In a recent "Viewpoint" written by Jay Wish, MD in the August 2006 issue of Nephrology News and Issues, Dr. Wish addresses the 'Should patients get EPO subcutaneously?' Dr. Wish cites the recent publication of Thamer et al. (Am J Kidney Dis. 2006 Jul;48(1):77-87) to discuss this crucial issue. "The authors point out that in parts of Europe, a substantial majority of hemodialysis patients receive their epoetin SC, and they cite the data from a meta-analysis by Besarab (2002) that SC epoetin administration could result in an annual per-patient savings of $1,761 versus intravenous administration." As to why the majority of patients in the U.S. continue to receive IV epoetin, Dr. Wish cites the following explanations found in the MTPPI study: I.V. is more profitable, CMS has agreed to pay for the higher volume of drug used and patients may prefer the less painful IV route of administration.
The following abstract has been reprinted from the study
BACKGROUND:
Published
clinical guidelines advocate subcutaneous (SC) administration for
epoetin therapy, although this is practiced among only 7% of all
hemodialysis patients. Despite this disparity, few studies have
examined factors associated with route of epoetin administration in
hemodialysis patients. METHODS: Data from the Centers for Medicare &
Medicaid Services End-Stage Renal Disease Clinical Performance
Measures Project were used to identify 13,854 patients receiving
hemodialysis in 3,069 dialysis facilities from October to December in
1999 and 2000. Unadjusted associations were examined by using t-test
and chi-square test. Adjusted associations were estimated by using
generalized estimating equations to control for clustering of patients
within the same dialysis facility. RESULTS: In the United States, use
of the SC route of epoetin administration varies widely across the
country. After adjusting for patient sociodemographics and
comorbidities, the greatest rates of SC therapy are found in the
Midwest and West, in providers not affiliated with chains, and in
hospital-based and not-for-profit freestanding units. Previous
exposure to SC administration (as a predialysis or peritoneal dialysis
patient) predicted subsequent SC use, for-profit and large chains were
significantly less likely to use SC administration, and increased use
of injectable drugs overall (to maximize income) was associated with
less SC use. CONCLUSION: In addition to regional variation in SC use,
study findings indicate that physician decision making for epoetin
administration route is influenced primarily by type of ownership and
financial incentives. Adherence to published clinical guidelines was
not a consistent predictor of SC use. Given the similar effectiveness,
but significantly decreased dose associated with SC epoetin, these
findings suggest an enormous opportunity for cost savings for the
Medicare program.
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