Nephrol Dial Transplant (2003) 18: 147-152
© 2003 European Renal Association-European Dialysis and Transplant Association
Regional variability in anaemia management and haemoglobin in the US
1 Duke Institute of Renal Outcomes Research and Health Policy, Duke University Medical Center, Durham, NC, 2 Center for Beneficiary Choices, Centers for Medicare & Medicaid Services, Baltimore, MD, 3 University of Wisconsin School of Pharmacy, Madison, WI, 4 West Virginia University, Morgantown, WV, 5 Wake Forest University School of Medicine, Winston-Salem, NC, 6 Emory University, Atlanta, GA and 7 University Hospitals of Cleveland, Cleveland, OH, USA
Background. Regional differences in haemoglobin values and process care measures were examined using data from the Centers for Medicare & Medicaid Services' End-Stage Renal Disease (ESRD) Clinical Performance Measures Project. It was posited that regional differences in haemoglobin values are consequent upon differences in components of clinical practice.
Methods. A national random sample of 8336 adult, in-centre haemodialysis patients, stratified by the 18 regional ESRD Networks, was drawn. Information was collected for October–December 1998. Multivariable stepwise linear and logistic regression analyses were performed to identify variables associated with haemoglobin. Linear regression analysis was used to identify variables associated with Epo/Hb index (mean weight-adjusted treatment level erythropoietin (Epo) dose divided by mean haemoglobin).
Results. The percentage of patients with haemoglobin concentration <11 g/dl ranged from 34 to 52% across ESRD Networks. In addition to haemoglobin there was significant, non-random variation among ESRD Networks with regard to prescribed Epo dose and administration route, intravenous (IV) iron prescription and dialyser flux (high flux=KUf 
20 ml/mmHg/h) (all P-values <0.001). Higher haemoglobin was associated with older age, male gender, higher serum albumin, higher transferrin saturation, higher Kt/V, lower serum ferritin and lower prescribed Epo dose (all P-values <0.01). Diabetes mellitus as cause of ESRD, high-flux dialyser use, IV iron prescription or subcutaneous Epo prescription were not associated with haemoglobin. Male gender, diabetes as cause of ESRD, older age, higher transferrin saturation and higher albumin concentrations were associated with lower Epo/Hb index. Prescription of IV iron and IV Epo were associated with higher Epo/Hb index.
Conclusions. Regional mean haemoglobin levels vary considerably across the US and the variation in haemoglobin is explained by both non-modifiable factors and modifiable clinical practice-derived variables.
Keywords: anaemia; Centers for Medicare & Medicaid Services; end-stage renal disease; erythropoietin; haemodialysis; iron
Correspondence and offprint requests to: Dr Donal Reddan, Duke Institute of Renal Outcomes Research and Health Policy, Box 3646, Duke University Medical Center, Durham, NC 27710, USA. Email: redda001{at}mc.duke.edu
The authors wish it to be known that, in their opinion, the first two authors contributed equally to this work. The views expressed in this manuscript are those of the authors and do not necessarily reflect official policy of the Centers for Medicare & Medicaid Services.
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