Issue: August 2018
June 15, 2018
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ESRD payment bundle linked to reductions in vitamin D prescriptions

Issue: August 2018
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Changes made in the Medicare payment methodology for dialysis care in 2011 that bundled prescription drugs and treatment payment resulted in both a drop in initiation and in the dosage of vitamin D, according to a recently published study.

Perspective from Jay B. Wish, MD

Medicare introduced the Prospective Payment System for covering the costs of treating patients with end-stage renal disease to “curb overuse of separately billable injectable drugs,” wrote Julia Spoendlin, PhD, MPH, and colleagues from the Brigham and Women’s Hospital and Harvard Medical School in Boston. “After epoetin, intravenous (IV) vitamin D analogues are the biggest drug cost drivers in hemodialysis (HD) patients, but the association between PPS introduction and vitamin D therapy has been scarcely investigated.”

The researchers looked at vitamin D prescriptions among adults on hemodialysis (n=359,600 at the start of study) represented in the U.S. Renal Data System between 2008 and 2013. Researchers used models to adjust for seasonal variation of drug use and plotted the experience of vitamin D users after PPS implementation. They used predicted probabilities in the absence of PPS, extrapolated from pre-PPS trends, to compare the impact of PPS implementation. Researchers also performed subgroup analyses by product type (IV analogues or less expensive alternatives, such as calcitriol or oral vitamin D analogues), and noted the dialysis provider profit status.

The results of the review showed that in 2008, 88.9% of patients in the group were receiving vitamin D therapy. That dropped to 84.6% in the patient sample in 2013.

“PPS implementation was associated with a 7% reduction in the average dose and starting dose of IV vitamin D analogues and a 10% reduction in the rate of vitamin D therapy initiation,” the authors wrote. They also observed a shift from paricalcitol (69.4% in 2008 to 45% in 2013) to doxercalciferol (26.2% in 2008 to 54.7% in 2013).

“Use of phosphate binders was constant between 77.3% (in 2008) and 76.4% (in 2013), whereby sevelamer carbonate largely replaced sevelamer hydrochloride over time,” they wrote. Overall, IV vitamin D analogues accounted for 99% of the total use and this trend was unchanged during the study period, the researchers wrote.

 

Disclosures: Spoendlin reports support by an independent research grant by the Swiss National Science Foundation to conduct this project (P2BSP3-165324). The other authors reported no relevant financial disclosures.

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