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Study shows variability in cinacalcet prescriptions across the US
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Researchers with the Dialysis Outcomes and Practice Patterns Study found greater use of calcimimetics – drugs used to treat ESRD in patients with secondary hyperparathyroidism – among black and younger patients and those on dialysis for 3 years or more compared to the general ESRD population.
“Facilities treating more patients who are black, under age 65 years and having dialysis vintage of greater than 3 years have higher average levels of cinacalcet prescription,” wrote lead author Douglas S. Fuller, MS, and colleagues from the DOPPS study group and other research organizations. “However, these differences were strongly attenuated after accounting for the unbalanced distributions of these patient case-mix variables.”
Calcimimetic treatments are separately reimbursed under Medicare Part B payments for at least the next 2 years. Utilization and cost data are being collected and analyzed by CMS to determine needed revisions to the bundled payment, including calcimimetics. “Understanding of utilization patterns of calcimimetics across dialysis facilities may help align financial incentives with clinical objectives,” the authors wrote.
DOPPS gathers data for its research projects via a sampling of clinics around the United States and abroad. Fuller and colleagues reviewed data from 2014 obtained from 203 U.S. facilities and involving 10,521 patients. After determining parathyroid hormone levels from patient-level analyses, the researchers used linear mixed-effects regressions to estimate the associations between three facility level exposures (black race, age younger than 65 years and being on dialysis for 3 years or more) and the prevalence of cinacalcet prescription. Data were adjusted for facility- and patient-level potential confounders.
During 2014, the median percentage of patients in facilities with cinacalcet prescription increased steadily, but only from 22% to 24%.
“By contrast, we observed large variability in cinacalcet prescription across facilities within each month, with absolute differences between the 25th and 75th percentiles (interquartile range [IQR]) varying from 16% to 20% across months in 2014,” the authors wrote. “Adjusted for facility-level and nonexposure patient-level variables, the difference in prevalence of cinacalcet prescription between facilities with the highest and lowest quartiles of percentage of black patients was 7.8% ... The adjusted prevalence difference was 7.3% for the percentage of patients aged [younger than] 65 years ... and 11.9% for the percentage of patients with [at least] 3 years of dialysis ... These associations changed appreciably, becoming much weaker or even reversing, after further adjusting for the patient-level exposure variables,” the authors noted.
The considerable variability in the percentage of patients prescribed cinacalcet – and the notably higher levels of cinacalcet prescriptions for black patients, younger than age 65 years, and patients on dialysis 3 years or more – is worth further study, the authors wrote. “These differences were only slightly influenced by facility situational factors but were strongly attenuated after accounting for the unbalanced distributions of these patient-level case-mix variables,” they wrote. “Existing ESRD PPS adjustments may not fully account for these imbalances, and thus additional studies evaluating the clinical and financial effects on facilities of adding calcimimetics to the bundle with respect to these three factors are warranted.”
Disclosures: The study was funded by Amgen Inc. Please see the study for a complete list of relevant financial disclosures.
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