Factors influencing route of administration for epoetin treatment among hemodialysis patients in the United States

Am J Kidney Dis. 2006 Jul;48(1):77-87. doi: 10.1053/j.ajkd.2006.03.040.


Background: Published clinical guidelines advocate subcutaneous (SC) administration for epoetin therapy, although this is practiced among only 7% of all hemodialysis patients. Despite this disparity, few studies have examined factors associated with route of epoetin administration in hemodialysis patients.

Methods: Data from the Centers for Medicare & Medicaid Services End-Stage Renal Disease Clinical Performance Measures Project were used to identify 13,854 patients receiving hemodialysis in 3,069 dialysis facilities from October to December in 1999 and 2000. Unadjusted associations were examined by using t-test and chi-square test. Adjusted associations were estimated by using generalized estimating equations to control for clustering of patients within the same dialysis facility.

Results: In the United States, use of the SC route of epoetin administration varies widely across the country. After adjusting for patient sociodemographics and comorbidities, the greatest rates of SC therapy are found in the Midwest and West, in providers not affiliated with chains, and in hospital-based and not-for-profit freestanding units. Previous exposure to SC administration (as a predialysis or peritoneal dialysis patient) predicted subsequent SC use, for-profit and large chains were significantly less likely to use SC administration, and increased use of injectable drugs overall (to maximize income) was associated with less SC use.

Conclusion: In addition to regional variation in SC use, study findings indicate that physician decision making for epoetin administration route is influenced primarily by type of ownership and financial incentives. Adherence to published clinical guidelines was not a consistent predictor of SC use. Given the similar effectiveness, but significantly decreased dose associated with SC epoetin, these findings suggest an enormous opportunity for cost savings for the Medicare program.

Publication types

  • Research Support, N.I.H., Extramural

MeSH terms

  • Adult
  • Aged
  • Cohort Studies
  • Cost Savings
  • Decision Making
  • Drug Prescriptions / economics
  • Epoetin Alfa
  • Erythropoietin / administration & dosage*
  • Erythropoietin / economics*
  • Erythropoietin / therapeutic use
  • Female
  • Hematinics / administration & dosage*
  • Hematinics / economics*
  • Hematinics / therapeutic use
  • Humans
  • Injections, Subcutaneous
  • Male
  • Medicare / economics
  • Middle Aged
  • Ownership
  • Physician Incentive Plans
  • Practice Patterns, Physicians' / statistics & numerical data
  • Recombinant Proteins
  • Renal Dialysis*
  • United States


  • Hematinics
  • Recombinant Proteins
  • Erythropoietin
  • Epoetin Alfa