Dialysis facility ownership and epoetin dosing in patients receiving hemodialysis

JAMA. 2007 Apr 18;297(15):1667-74. doi: 10.1001/jama.297.15.1667.


Context: Epoetin therapy for dialysis-related anemia is the single largest Medicare drug expenditure. The type of facility (profit, chain, and affiliation status) at which a patient receives dialysis might affect epoetin dosing patterns and has implications for future epoetin policies.

Objective: To examine the association between dialysis facility ownership and the dose of epoetin administered.

Design, setting, and participants: Data from the US Renal Data System were used to identify 159,522 adult Medicare-eligible, end-stage renal disease patients receiving in-center hemodialysis during November and December 2004. Regression models were used to estimate the mean epoetin dose and dose adjustment by profit, chain, and affiliation status.

Main outcome measures: Weekly mean epoetin dose administered in December 2004 and the adjustment in dose between November and December 2004.

Results: Compared with patients in nonprofit dialysis facilities (n = 28,199), patients in large for-profit dialysis chain facilities (n = 106,116) were consistently administered the highest doses of epoetin regardless of anemia status. Compared with nonprofit facilities, for-profit facilities administered, on average, an additional 3306 U/wk of epoetin. Among the 6 large chain facilities with a similar patient case-mix, the average dose of epoetin ranged from 17,832 U/wk at chain 5 (nonprofit facilities with a mean hematocrit level of 34.6%) to 24,986 U/wk at chain 2 (for-profit facilities with a mean hematocrit level of 36.5%). Dosing adjustments also differed by type of facility. On average, compared with nonprofit facilities, for-profit facilities increased epoetin doses 3-fold for patients with hematocrit levels of less 33% and also increased the doses among patients with hematocrit levels in the recommended target of 33% to 36%, especially in the largest for-profit chain facilities. The greatest difference in dosing practice patterns between facilities was found among patients with hematocrit levels of less than 33%.

Conclusions: Dialysis facility organizational status and ownership are associated with variation in epoetin dosing in the United States. Different epoetin dosing patterns suggest that large for-profit chain facilities used larger dose adjustments and targeted higher hematocrit levels.

Publication types

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

MeSH terms

  • Adult
  • Aged
  • Ambulatory Care Facilities / economics
  • Ambulatory Care Facilities / organization & administration*
  • Ambulatory Care Facilities / standards
  • Anemia / drug therapy
  • Anemia / etiology
  • Drug Utilization / economics
  • Drug Utilization / statistics & numerical data*
  • Epoetin Alfa
  • Erythropoietin / administration & dosage*
  • Erythropoietin / economics
  • Erythropoietin / therapeutic use
  • Female
  • Health Facilities, Proprietary
  • Hematinics / administration & dosage*
  • Hematinics / economics
  • Hematinics / therapeutic use
  • Hematocrit
  • Humans
  • Male
  • Medicare
  • Middle Aged
  • Organizations, Nonprofit
  • Ownership / classification*
  • Private Sector
  • Recombinant Proteins
  • Renal Dialysis* / adverse effects
  • Renal Dialysis* / economics
  • Renal Dialysis* / standards
  • United States


  • Hematinics
  • Recombinant Proteins
  • Erythropoietin
  • Epoetin Alfa