Dialysis Patients: A Standardized Transfusion Ratio to Evaluate Anemia Management

MedicalResearch.com Interview with:
David T. Gilbertson, Ph.D.
Chronic Disease Research Group
Center for Observational Research, Amgen, Inc, Thousand Oaks, CA

MedicalResearch: What were the main findings of the study?

Dr. Gilbertson: Since transfusion avoidance is important in patients receiving maintenance hemodialysis, development of a measure of red blood cell transfusion use to assess dialysis facility anemia management is reasonable. Because dialysis facility size varies widely, calculation of a standardized transfusion ratio (STfR) using standard methods is possible, but these methods result in significant instability in estimates for small dialysis facilities. Use of more advanced statistical methods results in standardized transfusion ratio estimates that are considerably more stable and more consistently precise across dialysis facilities of all sizes.

MedicalResearch: Were any of the findings unexpected?

Dr. Gilbertson: Because of the large variability in dialysis facility size, standard methods to calculate dialysis facility standardized transfusion ratio produce widely variable estimates that are essentially uninformative for small facilities. The modified Bayesian approach produces STfR estimates that are much more stable than those produced with the standard method and are useful across the entire range of dialysis facility sizes.

MedicalResearch: What should clinicians and patients take away from the report?

Dr. Gilbertson: A number of factors, including the reimbursement bundle implemented in January 2011 by CMS and safety signals with hemoglobin values higher than 12 g/dL, led to decreased use of ESAs in dialysis patients. Concomitant with the resulting decrease in hemoglobin levels, transfusion use has increased. Since transfusion avoidance is the primary goal of anemia management, development of a measure to assess dialysis facility anemia management is important. The method we developed for STfR estimation is feasible, and it is appropriate for measuring dialysis facility anemia management. Application of a similar modified Bayesian approach to other metrics may also improve the usability of such measures.

MedicalResearch: What recommendations do you have for future research as a result of this study?

Dr. Gilbertson: Several next steps are important. Transfusion reporting in Medicare billing data is complex, and transfusions may be coded differently in different geographic regions, leading to additional variability in observed transfusion rates. The impact of this geographic variability should be assessed, with the goal of improving consistency of transfusion billing. Also, some transfusions are clearly unavoidable and outside the control of dialysis facilities. Further work to eliminate these from consideration may be important.

Citation:

Development of a Standardized Transfusion Ratio as a Metric for Evaluating Dialysis Facility Anemia Management Practices
Jiannong Liu, Suying Li, David T. Gilbertson, Keri L. Monda, Brian D. Bradbury, Allan J. Collins

American Journal of Kidney Diseases
DOI: http://dx.doi.org/10.1053/j.ajkd.2014.04.012
Publication stage: In Press Corrected Proof
Published online: May 9, 2014