Author Interview: Dr. Manish M Sood
Assistant Professor of medicine at the University of Manitoba and Medical Director of Hemodialysis at St Boniface Hospital in Winnipeg, Manitoba.
Department of Medicine, Section of Nephrology, St Boniface Hospital, University of Manitoba, 409 Tache Avenue, Winnipeg, R2H 2A6, Canada
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Publication
International practice patterns and factors associated with non-conventional hemodialysis utilization
Nathan Allen, Daniel Schwartz, Paul Komenda, Robert P Pauly, Deborah Zimmerman, Gemini Tanna, Jeffery Schiff,Claudio Rigatto and Manish M Sood
BMC Nephrology 2011, 12:66 doi:10.1186/1471-2369-12-66
Department of Medicine, Section of Nephrology, St Boniface Hospital, University of Manitoba, 409 Tache Avenue, Winnipeg, R2H 2A6, Canada
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What are the main findings of the study? |
Recently research continues to provide evidence on the numerous
benefits of non-conventional hemodialysis therapies (defined as
nocturnal , short daily or long conventional hemodialysis) yet little
is known regrading barriers to their use.
We surveyed 311 international physicians to determine characteristics
that influence non-conventional hemodialysis utilization and attitudes
regarding the evidence for its use. We found physician training,
countries with government physician reimbursement and higher national
health care expenditure, practicing at an academic centre and an
increased number of ESRD patients per centre to be associated with
non-conventional hemodialysis utilization.
In general, physicians with patients on non-conventional hemodialysis were more favourableregarding the evidence of its benefits.
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Were any of the findings unexpected?
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The fact that national health care expenditure and number of ESRD
patients per centre were associated with non-conventional hemodialysis
was not that unusual however what was unexpected was that there
appears to be a "ceiling effect". Specifically, once a country's
health care expenditure exceeded the median, there was no additional
benefit witnessed with increases in expenditure. It suggests that from
a policymaker perspective, you cannot just increase expenditure and
hope for change in practice patterns, there are other factors
involved. A similar ceiling effect was observed with centre size.
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What should clinicians and patients take away from this study?
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Non-conventional hemodialysis therapy utilization and research is
likely going to steadily increase in the future as patients and
physicians want to individually tailored therapies. For physicians and
policy-makers understanding and overcoming barriers to its use are the
key to increasing its availability.
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What recommendations do you have for future studies as a result of your study?
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Our study was a online survey and captured large scale information.
Future assessments of more granular data regarding physician practices
and National health care programs are required.
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DOPPS Practice Monitor: Update on Trends in US Hemodialysis Care Following Launch of Bundled Payment System and Revisions to ESA Labels |
Emerging trends in hemodialysis care through August 2011, based on a sample of US dialysis facilities, are included in the latest update to the DOPPS Practice Monitor (DPM, at http://www.dopps.org/DPM), run by the Dialysis Outcomes and Practice Patterns Study (DOPPS) at Arbor Research Collaborative for Health.
Ongoing Changes in the US Dialysis Environment – Recent changes in dialysis payment and regulatory guidance are expected to affect hemodialysis practice. In January 2011, the Centers for Medicare & Medicaid Services (CMS) launched a new Prospective Payment System (PPS) with the intent to control dialysis costs through bundled payments. In June 2011, the FDA approved revised prescribing information for erythropoiesis-stimulating agents (ESAs), used to treat anemia in most dialysis patients. Previously, the label recommended a hemoglobin target range of 10-12 g/dL. The June 2011 update removed the target range, advising instead to start ESA therapy for dialysis patients at hemoglobin less than 10 g/dL, and to reduce or interrupt the dose when the hemoglobin approaches or exceeds 11 g/dL.
Most Recent Trends in Care – Over the August 2010 to August 2011 time period, many hemodialysis practices have remained stable; examples include nutrition measures and hemodialysis treatment time and dose. There have been notable trends in the following practice areas:
- Anemia: Hemoglobin levels have decreased since the June 2011 ESA label update. While the mean hemoglobin level declined by 0.12 g/dL over 12 months from August 2010 to July 2011, it declined in August 2011 by another 0.10 g/dL to 11.26 g/dL. The percentage of patients with hemoglobin levels greater than 12 g/dL declined sharply (from 28% to 23%) in July/August 2011, while the percentage with hemoglobin levels less than 10 g/dL increased slightly from 8.5% to 10% and the percentage with hemoglobin levels less than 9 g/dL remained under 3%.
Mean prescribed epoetin dose (among patients receiving epoetin) decreased by 15%, from 21,100 units/wk to 17,900 units/wk, from August 2010 to August 2011, with the greatest decline in June-August 2011. Epoetin doses at the higher end of the dose range have decreased most notably. IV iron use increased from August 2010 to August 2011 though has recently stabilized. In keeping with greater IV iron use, serum ferritin levels (indicative of iron stores) continue to rise. Serum ferritin concentration exceeded 500 ng/mL in 65% of patients, 800 ng/mL in 34% of patients, and 1,200 ng/mL in 11% of patients in August 2011.
- Mineral & Bone Disorder: In our last report, we noted a 29% increase in serum parathyroid hormone (PTH) levels through April 2011, and differences by race were described. Since then, PTH levels have remained stable or declined slightly in both black and non-black patients. In August 2011, 22% of black patients and 12% of non-black patients had very high PTH values (defined here as PTH >600 pg/mL). The percentage of hemodialysis patients for whom PTH is measured has declined slightly since August 2010. There have been no clear changes in serum calcium or serum phosphorus levels.
- Clinical Outcomes: Preliminary data indicate that the 30-day hospitalization rate has increased somewhat from August 2010 to August 2011. The DPM does not report yet on trends in red blood cell transfusions, as dialysis units are often unaware of transfusions occurring in the inpatient setting. Additional efforts to comprehensively monitor trends in transfusions are warranted. To date mortality rate has not changed appreciably, though further follow-up time is necessary as we continue to track this outcome.
Future monitoring of these trends, confirmation with national data when eventually available, and understanding their effect on clinical outcomes, if any, is required.
DPM data are aggregated across dialysis organizations and facilities. Aggregated trends may not reflect trends in individual dialysis organizations or facilities, and are not intended to provide oversight of performance in individual dialysis organizations or facilities.
Read the rest of the DOPPS Practice Monitor: Update on Trends in US Hemodialysis Care Following Launch of Bundled Payment System and Revisions to ESA Labels Press Release |
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Hemodialysis Research Interview of the Week |
Dr. Miklos Z Molnar MD, PhD and Dr. Kam Kalantar-Zadeh MD, MPH, PhD
Harold Simmons Center at Harbor-UCLA. |
Mortality Associated with Dose Response of Erythropoiesis-Stimulating Agents in Hemodialysis versus Peritoneal Dialysis Patients
Duong U, Kalantar-Zadeh K, Molnar MZ, Zaritsky JJ,
Teitelbaum I, Kovesdy CP, Mehrotra R:
Am J Nephrol 2012;35:198-208 (DOI: 10.1159/000335685)
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What are the main findings of the study? |
The analysis of the data was from a large and contemporary cohort of 10,527 peritoneal dialysis and 139,103 hemodialysis patients in a single dialysis provider with relatively uniform anemia management practice patterns between 7/2001 and 6/2006, i.e., during the era with the highest ESA dose administration in the United
States.
We found that peritoneal dialysis patients with the same achieved hemoglobin levels received substantially lower dose of ESA than hemodialysis patients, and the
differential was even wider among African Americans.
We also found that in peritoneal dialysis patients an ESA dose below 10,000 U/week was not associated with higher mortality, but a 28% higher death risk in those receiving significantly higher dose (>15,000 U/week).
In contrast, higher ESA dose was linearly and incrementally associated with higher all-cause and cardiovascular mortality in hemodialysis.
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Were any of the findings unexpected?
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While the administered ESA dose was linearly and incrementally associated with higher mortality in hemodialysis patients, the dose was used in everyday clinical practice in PD patients was not associated with mortality.
Only large doses (>15,000 U/week) were associated with higher mortality risk in PD
population.
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What should clinicians and patients take away from this study?
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PD patients require substantially lower ESA dose than hemodialysis to achieve same hemoglobin levels.
In both PD and hemodialysis patients Lower ESA dose (< 15,000 U/week) are safer than higher doses.
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