Effect of facility-level hemoglobin concentration on dialysis patient risk of transfusion

Background Changes in anemia management practices due to concerns about erythropoiesis-stimulating agent safety and Medicare payment changes may increase patient risk of transfusion. We examined anemia management trends in hemodialysis patients and risk of red blood cell (RBC) transfusion according to dialysis facility-level hemoglobin concentration. Study Design Retrospective follow-up study; 6-month study period (January to June), 3-month exposure/follow-up. Setting & Participants For each year in 2007-2011, annual cohorts of point-prevalent Medicare primary payer patients receiving hemodialysis on January 1 with one or more hemoglobin measurements during the study period. Annual cohorts averaged 170,000 patients, with 130,000 patients and 3,100 facilities for the risk analysis. Predictor Percentage of facility patient-months with hemoglobin level < 10 g/dL. Outcome Patient-level RBC transfusion rates. Measurements Monthly epoetin alfa and intravenous iron doses, mean hemoglobin levels, and RBC transfusion rates; percentage of facility patient-months with hemoglobin levels < 10 g/dL (exposure) and patient-level RBC transfusion rates (follow-up). Results Percentages of patients with hemoglobin levels < 10 g/dL increased every year from 2007 (6%) to 2011 (∼11%). Epoetin alfa doses, iron doses, and transfusion rates remained relatively stable through 2010 and changed in 2011. Median monthly epoetin alfa and iron doses decreased 25% and 43.8%, respectively, and monthly transfusion rates increased from 2.8% to 3.2% in 2011, a 14.3% increase. Patients in facilities with the highest prevalence of hemoglobin levels < 10 g/dL over 3 months were at ∼30% elevated risk of receiving RBC transfusions within the next 3 months (relative risk, 1.28; 95% CI, 1.22-1.34). Limitations Possibly incomplete claims data; smaller units excluded; hemoglobin levels reported monthly for patients receiving epoetin alfa; transfusions usually not administered in dialysis units. Conclusions Dialysis facility treatment practices, as assessed by percentage of patient-months with hemoglobin levels < 10 g/dL over 3 months, were associated significantly with risk of transfusions in the next 3 months for all patients in the facility, regardless of patient case-mix.