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Wang AX, Liu S, Montez-Rath ME, Chertow GM, Lenihan CR. Parathyroidectomy and Cinacalcet Use in Medicare-Insured Kidney Transplant Recipients. Am J Kidney Dis 2023; 81:270-280.e1. [PMID: 36162617 PMCID: PMC10354231 DOI: 10.1053/j.ajkd.2022.07.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Accepted: 07/24/2022] [Indexed: 12/30/2022]
Abstract
RATIONALE & OBJECTIVE Posttransplant hyperparathyroidism is common, and treatment practices are poorly characterized. The goal of this study was to examine the incidence, associations, and outcomes of posttransplant parathyroidectomy and calcimimetic use in a cohort of Medicare-insured US kidney transplant recipients. STUDY DESIGN Retrospective observational cohort study. SETTING & PARTICIPANTS We used the US Renal Data System to extract demographic, clinical, and prescription data from Medicare Parts A, B, and D-insured patients who received their first kidney transplant in 2007-2013. We excluded patients with pretransplant parathyroidectomy. PREDICTORS Calendar year of transplantation and pretransplant patient characteristics. OUTCOME (1) Incidence of and secular trends in parathyroidectomy and cinacalcet use in the 3 years after transplant; (2) 90-day outcomes after posttransplant parathyroidectomy and cinacalcet initiation. ANALYTICAL APPROACH Temporal trends and pretransplant correlates of parathyroidectomy and cinacalcet use were assessed using proportional hazards models and multivariable Poisson regression, respectively. RESULTS The inclusion criteria were met by 30,127 patients, of whom 10,707 used cinacalcet before transplant, 551 underwent posttransplant parathyroidectomy, and 5,413 filled≥1 prescription for cinacalcet. The rate of posttransplant parathyroidectomy was stable over time. By contrast, cinacalcet use increased during the period studied. Long dialysis vintage and pretransplant cinacalcet use were strongly associated with posttransplant parathyroidectomy and cinacalcet use. Roughly 1 in 4 patients were hospitalized within 90 days of posttransplant parathyroidectomy, with hypocalcemia-related diagnoses being the most common complication. Parathyroidectomy (vs cinacalcet initiation) was not associated with an increase in acute kidney injury. LIMITATIONS We lacked access to laboratory data to help assess the severity of secondary/tertiary hyperparathyroidism. The cohort was limited to Medicare beneficiaries. CONCLUSIONS Almost one-fifth of our study cohort was treated with parathyroidectomy and/or cinacalcet. Further studies are needed to establish the optimal treatment for posttransplant hyperparathyroidism.
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Affiliation(s)
- Aileen X Wang
- Division of Nephrology, Department of Medicine, School of Medicine, Stanford University, Stanford, California.
| | - Sai Liu
- Division of Nephrology, Department of Medicine, School of Medicine, Stanford University, Stanford, California
| | - Maria E Montez-Rath
- Division of Nephrology, Department of Medicine, School of Medicine, Stanford University, Stanford, California
| | - Glenn M Chertow
- Division of Nephrology, Department of Medicine, School of Medicine, Stanford University, Stanford, California
| | - Colin R Lenihan
- Division of Nephrology, Department of Medicine, School of Medicine, Stanford University, Stanford, California
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Kendrick JB, Zhou M, Ficociello LH, Parameswaran V, Mullon C, Anger MS, Coyne DW. Serum Phosphorus and Pill Burden Among Hemodialysis Patients Prescribed Sucroferric Oxyhydroxide: One-Year Follow-Up on a Contemporary Cohort. Int J Nephrol Renovasc Dis 2022; 15:139-149. [PMID: 35431567 PMCID: PMC9012313 DOI: 10.2147/ijnrd.s353213] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Accepted: 03/19/2022] [Indexed: 11/23/2022] Open
Abstract
Purpose In prior analyses of real-world cohorts of hemodialysis patients switched from one phosphate binder (PB) to sucroferric oxyhydroxide (SO), SO therapy has been associated with improvements in serum phosphorus (sP) and reductions in daily PB pill burden. To characterize how SO initiation patterns have changed over time, we examined the long-term effectiveness of SO in a contemporary (2018–2019) cohort. Patients and Methods Adult Fresenius Kidney Care hemodialysis patients first prescribed SO monotherapy as part of routine care between May 2018 and May 2019 (N = 1792) were followed for 1 year. All patients received a non-SO PB during a 91-day baseline period before SO prescription. Mean PB pills/day and laboratory parameters were compared before and during SO treatment. Results were divided into consecutive 91-day intervals (Q1–Q4) and analyzed using linear mixed-effects regression and Cochran’s Q test. These results were contrasted with findings from a historical (2014–2015) cohort (N = 530). Results The proportion of patients achieving sP ≤5.5 mg/dl increased after switching to SO (from 27.0% at baseline to 37.8%, 45.1%, 44.7%, and 44.0% at Q1, Q2, Q3, and Q4, respectively; P < 0.0001 for all). The mean daily PB pill burden decreased from a baseline of 7.7 to 4.4, 4.6, 4.8, and 4.9, respectively, across quarters (P < 0.0001 for all). Patients in the contemporary cohort had improved sP control (27.0% achieving sP ≤5.5 mg/dl vs 17.7%) and lower daily PB pill burden (mean 7.7 vs 8.5 pills/day) at baseline than those in the historical cohort. Overall use of active vitamin D was similar between cohorts, although higher use of oral active vitamin D (63.9% vs 15.7%) and lower use of IV active vitamin D lower (23.4% vs 74.2%) was observed in the contemporary cohort. Conclusion Despite evolving treatment patterns, switching to SO resulted in improved sP control with fewer pills per day in this contemporary hemodialysis cohort.
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Affiliation(s)
| | - Meijiao Zhou
- Fresenius Medical Care Global Medical Office, Waltham, MA, USA
| | | | | | - Claudy Mullon
- Fresenius Medical Care Global Medical Office, Waltham, MA, USA
| | - Michael S Anger
- Fresenius Medical Care Global Medical Office, Waltham, MA, USA
- Unversity of Colorado School of Medicine, Denver, CO, USA
| | - Daniel W Coyne
- Washington University School of Medicine, St. Louis, MO, USA
- Correspondence: Daniel W Coyne, Washington University School of Medicine, 660 S. Euclid Ave, St. Louis, MO, 63110, USA, Tel +1 314-362-7603, Fax +1 314-747-5213, Email
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Stephens JM, Fox KM, Desai P, Cheng S, Goodman WG, Kendrick JB. Calcimimetic use in US hemodialysis facilities in first 2 years after the launch of etelcalcetide: A descriptive analysis of real-world clinical practice and outcomes. Hemodial Int 2021; 26:243-254. [PMID: 34931443 DOI: 10.1111/hdi.12996] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Revised: 12/08/2021] [Accepted: 12/09/2021] [Indexed: 11/28/2022]
Abstract
INTRODUCTION This study described control of parathyroid hormone (PTH), phosphorus, and corrected calcium in adults initiating calcimimetics in small dialysis organizations after the introduction of etelcalcetide. METHODS This retrospective study using Visonex Clarity electronic health records between October 1, 2017, and December 31, 2019, identified adults ≥ 18 years of age receiving in-center hemodialysis as either a cinacalcet or etelcalcetide initiator based on their first calcimimetic use in 2018 (index date) with no prior calcimimetic use in the 3 months preindex date. Patients were stratified by PTH at index date and were followed for 15 months. Subcohorts of patients who were persistent on a single calcimimetic for 15 months and of patients who had their calcimimetic changed from cinacalcet to etelcalcetide were also analyzed. FINDINGS A total of 677 patients initiated cinacalcet and 711 initiated etelcalcetide. Mean PTH (pg/ml), phosphorus, and corrected calcium (mg/dl) at baseline were 864, 5.9, and 9.3 for cinacalcet and 804, 5.9, and 9.4 for etelcalcetide, respectively. During follow-up, the proportion of initiators considered in-target (monthly average PTH < 600) increased from 48% to 62% with cinacalcet and from 56% to 86% with etelcalcetide in the baseline PTH 600 to < 800 subgroup; increased from 30% to 64% with cinacalcet and 31% to 59% with etelcalcetide among those with baseline PTH 800 to < 1000; and increased from 14% to 41% with cinacalcet and 12% to 58% with etelcalcetide among those with baseline PTH ≥1000. A similar pattern was observed for persistent users (n = 646). For patients changed from cinacalcet to etelcalcetide (n = 183), the proportion of patients considered in-target increased from 22% in the month prior to the treatment change to 51% in Month 6 postchange. DISCUSSION Patients initiating calcimimetics at lower baseline PTH had better biochemical control than patients starting at higher PTH. Patients changed from cinacalcet to etelcalcetide had improvements in PTH control postchange.
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Karaboyas A, Muenz D, Fuller DS, Desai P, Lin TC, Robinson BM, Rossetti S, Pisoni RL. Etelcalcetide Utilization, Dosing Titration, and Chronic Kidney Disease-Mineral and Bone Disease (CKD-MBD) Marker Responses in US Hemodialysis Patients. Am J Kidney Dis 2021; 79:362-373. [PMID: 34273436 DOI: 10.1053/j.ajkd.2021.05.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Accepted: 05/23/2021] [Indexed: 01/09/2023]
Abstract
RATIONALE AND OBJECTIVE Clinical trial data have demonstrated the efficacy of etelcalcetide for reducing parathyroid hormone (PTH) levels in hemodialysis (HD) patients. We provide a real-world summary of etelcalcetide utilization, dosing, effectiveness, and discontinuation since its US introduction in April 2017. STUDY DESIGN New-user design within prospective cohort. SETTING PARTICIPANTS 2596 new users of etelcalcetide from April 2017 through August 2019 in a national sample of adult, chronic HD patients in the US Dialysis Outcomes and Practice Patterns Study (DOPPS). PREDICTORS Baseline PTH, prior cinacalcet use, initial etelcalcetide dose. OUTCOME(S) Trajectories of etelcalcetide dose, use of mineral bone disorder (MBD) medications, and levels of PTH, serum calcium, and phosphorus in the 12 months following etelcalcetide initiation. ANALYTICAL APPROACH Cumulative incidence methods for etelcalcetide discontinuation and linear generalized estimating equations for trajectory analyses. RESULTS By August 2019 etelcalcetide prescriptions increased to 6% of HD patients from their first use in April 2017. Starting etelcalcetide dose was 15 mg/week in 70% of patients and 7.5 mg/week in 27% of patients; 49% of new users were prescribed cinacalcet in the prior 3 months. Etelcalcetide discontinuation was 9%, 17%, and 27% by 3, 6, and 12 months post-initiation. One year after etelcalcetide initiation, mean PTH levels declined by 40%, from 948 to 566 pg/mL, and the proportion of patients with PTH within target (150-599 pg/mL) increased from 33% to 64% overall, from 0% to 60% among patients with baseline PTH ≥600 pg/mL, and from 30% to 63% among patients with prior cinacalcet use. The proportion of patients with serum phosphorus >5.5 mg/dL decreased from 55% to 45%, while the prevalence of albumin-corrected serum calcium <7.5 mg/dL remained at 1%-2%. Use of active vitamin D (from 77% to 87%) and Ca-based phosphate binders (from 41% to 50%) increased in the 12 months following etelcalcetide initiation. LIMITATIONS Data unavailable for provider dosing protocols, dose holds, or reasons for discontinuation. CONCLUSIONS In the 12 months following etelcalcetide initiation, patients had large and sustained reductions in PTH levels. These results support the utility of etelcalcetide as an effective therapy to achieve the KDIGO recommended guidelines for CKD-MBD markers in HD patients.
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Affiliation(s)
| | - Daniel Muenz
- Arbor Research Collaborative for Health, Ann Arbor, MI, USA
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Gooding M, Desai P, Owens H, Petrilla AA, Kambhampati M, Levine Z, Young J, Fagan J, Rubin R. Calcimimetic Use in Dialysis-Dependent Medicare Fee-for-Service Beneficiaries and Implications for Bundled Payment. KIDNEY360 2020; 1:1091-1098. [PMID: 35368776 PMCID: PMC8815481 DOI: 10.34067/kid.0003042020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Accepted: 08/21/2020] [Indexed: 06/14/2023]
Abstract
BACKGROUND Patients who are dialysis dependent and have secondary hyperparathyroidism (SHPT) may require calcimimetics to reduce parathyroid hormone levels to treatment goals. Medicare currently uses the Transitional Drug Add-on Payment Adjustment (TDAPA) designation under the ESKD Prospective Payment System ("bundled payment") to pay for calcimimetics (the first products eligible for the adjustment); this payment designation for calcimimetics is expected to conclude after 2020. This study explores variability in calcimimetic use across key patient characteristics and its potential effect on policy options for incorporating calcimimetics permanently into the bundle. METHODS This descriptive analysis used the 100% sample of Medicare FFS Part B (outpatient) 2018 claims to describe national-, regional-, and patient-level variation (including race, dual eligibility, and dialysis vintage) in calcimimetic use among beneficiaries who are dialysis dependent. RESULTS A total of 373,874 beneficiaries were analyzed, 28% had ≥90 days of calcimimetic use during 2018. At the national level, the proportion of patients on dialysis using calcimimetics was roughly 80% higher in Black versus non-Black patients on dialysis, 30% higher in patients on dialysis who were dual eligible versus non-dual eligible, and three times higher in patients with a dialysis vintage ≥3 years versus <3 years (all results unadjusted). Calcimimetic use was similar across census regions, however, substantial variation in calcimimetic use was observed at the facility level. Medicare spending for calcimimetic therapies as a proportion of total Medicare dialysis spending was >10% in approximately 20% of dialysis facilities. CONCLUSIONS Although less than a third of beneficiaries use calcimimetics, certain patient-level characteristics are associated with higher rates of maintenance calcimimetic use. Due to the financial pressure many dialysis facilities face, how calcimimetics are incorporated into the bundle may have a direct effect on facility reimbursement for, and patient access to, therapy. Careful consideration will be required to ensure patients who are vulnerable and require treatment for SHPT do not face barriers to appropriate care.
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Affiliation(s)
| | - Pooja Desai
- Global Health Economics, Amgen, Inc., Thousand Oaks, California
| | - Holly Owens
- US Government Affairs and Policy, Amgen, Inc., Washington, DC
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Fuller DS, Xing S, Belozeroff V, Yehoshua A, Morgenstern H, Robinson BM, Rubin RJ, Bhatt N, Pisoni RL. Variability in Cinacalcet Prescription across US Hemodialysis Facilities. Clin J Am Soc Nephrol 2019; 14:241-249. [PMID: 30665922 PMCID: PMC6390908 DOI: 10.2215/cjn.09550818] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2018] [Accepted: 12/12/2018] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND OBJECTIVES Calcimimetic drugs used to treat secondary hyperparathyroidism are being considered for inclusion in the Medicare ESRD Prospective Payment System bundle after an evaluation period. Understanding of utilization patterns of calcimimetics across dialysis facilities may help align financial incentives with clinical objectives. Our study's purpose was to describe the distribution of cinacalcet prescription across United States hemodialysis facilities and to explore factors that may influence cinacalcet utilization. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS We used monthly cross-sectional data from the Dialysis Outcomes and Practice Patterns Study in 2014 to characterize the distribution of cinacalcet prescription across 203 United States hemodialysis facilities (10,521 patients). On the basis of associations with parathyroid hormone levels from patient-level analyses, we used linear mixed-effects regressions to estimate the associations between three facility-level exposures (black race, <65 years old, and having ≥3 years on dialysis [vintage]) and the prevalence of cinacalcet prescription, adjusting for facility- and patient-level potential confounders. RESULTS The mean percentage of patients in each facility with cinacalcet prescription was 23% in June 2014 (median, 22%; interquartile range, 13%-30%). 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% (95% confidence interval [95% CI], 0.8% to 14.8%; P for trend =0.03). The adjusted prevalence difference was 7.3% for the percentage of patients aged <65 years (95% CI, -0.1% to 14.7%; P for trend =0.06) and 11.9% for the percentage of patients with ≥3 years of dialysis (95% CI, 2.4% to 21.4%; P for trend =0.02). These associations changed appreciably, becoming much weaker or even reversing, after further adjusting for the patient-level exposure variables. CONCLUSIONS Facilities treating more patients who are black, under age 65 years, and having dialysis vintage ≥3 years have higher average levels of cinacalcet prescription. However, these differences were strongly attenuated after accounting for the unbalanced distributions of these patient case-mix variables.
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Affiliation(s)
| | - Shan Xing
- Global Health Economics, Amgen, Inc., Thousand Oaks, California
| | | | - Alon Yehoshua
- Global Health Economics, Amgen, Inc., Thousand Oaks, California
| | - Hal Morgenstern
- Departments of Epidemiology and.,Environmental Health Sciences, School of Public Health, and.,Department of Urology, Medical School, University of Michigan, Ann Arbor, Michigan; and
| | | | - Robert J Rubin
- Division of Nephrology and Hypertension, Georgetown University, Washington, DC
| | - Nisha Bhatt
- Global Health Economics, Amgen, Inc., Thousand Oaks, California
| | - Ronald L Pisoni
- Arbor Research Collaborative for Health, Ann Arbor, Michigan
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Reams BD, Dluzniewski PJ, Do TP, Yue SV, Bradbury BD, Kshirsagar AV, Brookhart MA. Dynamics of cinacalcet use and biochemical control in hemodialysis patients: a retrospective New-user cohort design. BMC Nephrol 2015; 16:175. [PMID: 26510587 PMCID: PMC4625889 DOI: 10.1186/s12882-015-0174-6] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2015] [Accepted: 10/19/2015] [Indexed: 01/18/2023] Open
Abstract
Background Cinacalcet is used to treat secondary hyperparathyroidism among hemodialysis patients. Large-scale epidemiologic studies describing patterns of cinacalcet use, effects on parathyroid hormone (PTH), calcium, and phosphorous levels, and predictors of discontinuation have not been previously reported. Methods This retrospective cohort study used a clinical database of a large U.S. dialysis provider (2007–2010) merged with administrative data from the United States Renal Data System. Among new users of cinacalcet with Medicare coverage, trends in PTH, calcium, and phosphorus were measured in 30-day intervals following cinacalcet initiation. Results Seventeen thousand seven hundred sixty-three eligible initiators contributed 111,047 30-day follow-up intervals. Of these, 56 % discontinued cinacalcet by month 4. Of those discontinuing, 76.3 % reinitiated. Mean values of PTH, calcium, and phosphorus decreased to recommended levels within 4 months following initiation. Proximal PTH levels <150 pg/mL were associated with discontinuation: HR = 1.23 (95 % CI: 1.12, 1.36), whereas low calcium (<7.5 mg/dL) was suggestive of an association, HR = 1.09 (95 % CI 0.91, 1.32). Being in the Part D gap period increased discontinuation risk: HR = 1.09 (95 % CI: 1.03, 1.16). Low-income subsidy status decreased discontinuation risk: HR = 0.77 (95 % CI 0.69, 0.86). Predictors of reinitiation included low-income subsidy, HR = 1.32 (95 % CI 1.22, 1.43); higher albumin level, HR = 1.23 (95 % CI 1.10, 1.36) and higher calcium level, HR = 1.26 (95 % CI 1.19, 1.33). Conclusions Substantial and expected declines in laboratory values occurred following cinacalcet initiation. Early discontinuation and reinitiation of cinacalcet were common and may have occurred for clinical and economic reasons. Electronic supplementary material The online version of this article (doi:10.1186/s12882-015-0174-6) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- B Diane Reams
- Cecil G. Sheps Center for Health Services Research, University of North Carolina, Chapel Hill, NC, USA.
| | | | - Thy P Do
- Amgen, Inc, Thousand Oaks, CA, USA.
| | | | | | - Abhijit V Kshirsagar
- University of North Carolina Kidney Center, UNC School of Medicine, Chapel Hill, NC, USA.
| | - M Alan Brookhart
- Department of Epidemiology, UNC Gillings School of Global Public Health, UNC Chapel Hill, Chapel Hill, NC, USA.
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Yusuf AA, Howell BL, Powers CA, St Peter WL. Utilization and costs of medications associated with CKD mineral and bone disorder in dialysis patients enrolled in Medicare Part D. Am J Kidney Dis 2014; 64:770-80. [PMID: 24833203 DOI: 10.1053/j.ajkd.2014.04.014] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2013] [Accepted: 04/08/2014] [Indexed: 11/11/2022]
Abstract
BACKGROUND Information is limited regarding utilization patterns and costs for chronic kidney disease-mineral and bone disorder (CKD-MBD) medications in Medicare Part D-enrolled dialysis patients. STUDY DESIGN Retrospective cohort study. SETTING & PARTICIPANTS Annual cohorts of dialysis patients, 2007-2010. PREDICTORS Cohort year, low-income subsidy status, and dialysis provider. OUTCOMES Utilization and costs of prescription phosphate binders, oral and intravenous vitamin D analogues, and cinacalcet. MEASUREMENTS Using logistic regression, we calculated adjusted odds of medication use for low-income subsidy versus non-low-income subsidy patients and for patients from various dialysis organizations, and we report per-member-per-month and average out-of-pocket costs. RESULTS Phosphate binders (∼83%) and intravenous vitamin D (77.5%-79.3%) were the most commonly used CKD-MBD medications in 2007 through 2010. The adjusted odds of prescription phosphate-binder, intravenous vitamin D, and cinacalcet use were significantly higher for low-income subsidy than for non-low-income subsidy patients. Total Part D versus CKD-MBD Part D medication costs increased 22% versus 36% from 2007 to 2010. For Part D-enrolled dialysis patients, CKD-MBD medications represented ∼50% of overall net Part D costs in 2010. LIMITATIONS Inability to describe utilization and costs of calcium carbonate, an over-the-counter agent not covered under Medicare Part D; inability to reliably identify prescriptions filled through a non-Part D reimbursement or payment mechanism; findings may not apply to dialysis patients without Medicare Part D benefits or with Medicare Advantage plans, or to pediatric dialysis patients; could identify only prescription drugs dispensed in the outpatient setting; inability to adjust for MBD laboratory values. CONCLUSIONS Part D net costs for CKD-MBD medications increased at a faster rate than costs for all Part D medications in dialysis patients despite relatively stable use within medication classes. In a bundled environment, there may be incentives to shift to generic phosphate binders and reduce cinacalcet use.
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Affiliation(s)
- Akeem A Yusuf
- Chronic Disease Research Group, Minneapolis Medical Research Foundation, Minneapolis, MN; University of Minnesota, College of Pharmacy, Minneapolis, MN
| | - Benjamin L Howell
- Center for Medicare and Medicaid Innovation, Centers for Medicare & Medicaid Services, Baltimore, MD
| | - Christopher A Powers
- Center for Strategic Planning, Centers for Medicare & Medicaid Services, Baltimore, MD
| | - Wendy L St Peter
- Chronic Disease Research Group, Minneapolis Medical Research Foundation, Minneapolis, MN; University of Minnesota, College of Pharmacy, Minneapolis, MN.
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