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Patients with chronic kidney disease often need synthetic erythropoietin to prevent anaemia and keep transfusions to a minimum. But evidence is emerging of systematic overtreatment by some dialysis facilities in the United States. The problem seems to be linked to a perverse reimbursement arrangement with Medicare, whereby facilities can and do profit from treating patients with epoetin, the leading agent.
Four out of five American patients on dialysis are treated in profit making facilities, usually large corporate chains. A careful comparison of these facilities with “not for profit” dialysis units such as those affiliated with hospitals showed a clear difference in treatment patterns. At the end of 2004 (the most recent data available), profit making facilities used more erythropoietin per patient each week, chased and achieved higher haematocrit values, and adjusted patients' doses more aggressively than not for profit units. Patients treated in profit making facilities were more likely to have haematocrit levels higher than the 36% target level recommended at the time by national guidelines and by the Food and Drugs Administration (54% v 47%).
None of these differences were explained by differences in case mix, and at least one commentator questions whether some units are overtreating patients for profit (pp 1713-6). Last year, the two largest dialysis chains made 21% and 25% of their revenue from epoetin.