Blood Transfusion Practices in Dialysis Patients in a Dynamic Regulatory Environment

Market Competition and Anemia Management in the United States Following Dialysis Payment Reform

BACKGROUND

Whether market competition influences health care provider responses to national reimbursement reforms is unknown.

OBJECTIVES

We examined whether changes in anemia management after the expansion of Medicare's dialysis payment bundle varied with market competition.

RESEARCH DESIGN

With data from the US dialysis registry, we used a difference-in-differences (DID) design to estimate the independent associations of market competition with changes in anemia management after dialysis reimbursement reform.

SUBJECTS

A total of 326,150 patients underwent in-center hemodialysis in 2009 and 2012, representing periods before and after reimbursement reform.

MEASURES

Outcomes were erythropoiesis-stimulating agent (ESA) and intravenous iron dosage, the probability of hemoglobin <9 g/dL, hospitalizations, and mortality. We also examined serum ferritin concentration, an indicator of body iron stores. We used a dichotomous market competition index, with less competitive areas defined as effectively having <2 competing dialysis providers.

RESULTS

Compared with areas with more competition, patients in less competitive areas had slightly more pronounced declines in ESA dose (60% vs. 57%) following reimbursement reform (DID estimate: -3%; 95% CI, -5% to -1%) and less pronounced declines in intravenous iron dose (-14% vs. -19%; DID estimate: 5%; 95% CI, 1%-9%). The likelihoods of hemoglobin <9 g/dL, hospitalization, and mortality did not vary with market competition. Serum ferritin concentrations in 2012 were 4% (95% CI, 3%-6%) higher in less competitive areas.

CONCLUSIONS

After the expansion of Medicare's dialysis payment bundle, ESA use declined by more, and intravenous iron use declined by less in concentrated markets. More aggressive cost-reduction strategies may be implemented in less competitive markets.

Medicare Bundled Payment Policy on Anemia Care, Major Adverse Cardiovascular Events, and Mortality among Adults Undergoing Hemodialysis

BACKGROUND AND OBJECTIVES

In 2011, the Centers for Medicare & Medicaid Services implemented bundling of all services for patients receiving dialysis, including erythropoietin-stimulating agents use, and the Food and Drug Administration recommended conservative erythropoietin-stimulating agent dosing.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

This retrospective cohort study investigated anemia care and clinical outcomes before and after the Centers for Medicare & Medicaid Services bundled payment and the revised Food and Drug Administration-recommended erythropoietin-stimulating agent labeling for Medicare-insured adults receiving hemodialysis using data from the United States Renal Data System from January 1, 2006 to December 31, 2016. Clinical outcomes included major adverse cardiovascular event (stroke, acute myocardial infarction, and all-cause mortality), cardiovascular mortality, and heart failure. Measurements were compared between prepolicy (2006-2010) and postpolicy (2012-2016) implementation using interrupted time series and Cox proportional hazards regression models.

RESULTS

Of 481,564 patients, erythropoietin-stimulating agent use immediately decreased by 84.8 per 1000 persons (P<0.001), with a significant decrease in the slope of the trend line (both P=0.001). Blood transfusion use rapidly increased by 8.34 per 1000 persons in April 2012 and then gradually decreased (both P=0.001). The percentage of patients with hemoglobin >11 g/dl decreased from 68% in January 2006 to 28% in December 2016, whereas those with hemoglobin <9 g/dl increased from 5% to 9%. Overall major adverse cardiovascular event (adjusted hazard ratio, 0.95; 95% confidence interval, 0.94 to 0.96), stroke (adjusted hazard ratio, 0.83; 95% confidence interval, 0.80 to 0.86), all-cause mortality (adjusted hazard ratio, 0.87; 95% confidence interval, 0.86 to 0.89), cardiovascular mortality (adjusted hazard ratio, 0.81; 95% confidence interval, 0.79 to 0.83), and heart failure (adjusted hazard ratio, 0.86; 95% confidence interval, 0.84 to 0.88) risks were lower. Acute myocardial infarction risk (adjusted hazard ratio, 1.04; 95% confidence interval, 1.01 to 1.06) was higher after policies changed.

CONCLUSIONS

The Medicare reimbursement policy and Food and Drug Administration-recommended erythropoietin-stimulating agent dosing changes were associated with lower erythropoietin-stimulating agent use and lower hemoglobin levels. These changes in anemia care were associated with lower risks of major adverse cardiovascular event, stroke, mortality, and heart failure but higher risk of acute myocardial infarction among adults receiving hemodialysis.

Cost Barriers to More Widespread Use of Peritoneal Dialysis in the United States

The United States Department of Health and Human Services launched the Advancing American Kidney Health Initiative in 2019, which included a goal of transforming dialysis care from an in-center to a largely home-based dialysis program. A substantial motivator for this transition is the potential to reduce costs of ESKD care with peritoneal dialysis. Studies demonstrating that peritoneal dialysis is less costly than in-center hemodialysis have often focused on the perspective of the payer, whereas less consideration has been given to the costs of those who are more directly involved in treatment decision making, including patients, caregivers, physicians, and dialysis facilities. We review comparisons of peritoneal dialysis and in-center hemodialysis costs, focusing on costs incurred by the people and organizations making decisions about dialysis modality, to highlight the financial barriers toward increased adoption of peritoneal dialysis. We specifically address misaligned economic incentives, underappreciated costs for key stakeholders involved in peritoneal dialysis delivery, differences in provider costs, and transition costs. We conclude by offering policy suggestions that include improving data collection to better understand costs in peritoneal dialysis, and sharing potential savings among all stakeholders, to incentivize a transition to peritoneal dialysis.

Trends in Dialysis Industry Consolidation After Medicare Payment Reform, 2006-2016

Question

Findings

Meaning

Importance

Objective

Design, Setting, and Participants

Exposures

Main Outcomes and Measures

Results

Conclusions and Relevance

High prevalence of hepatitis E among regular hemodialysis patients in South of Iran

OBJECTIVE

Hepatitis E virus (HEV) is one of the prevalent nosocomially transmitted agents among patients on maintenance hemodialysis due to parenteral transmission of HEV and immunocompromised condition of chronic hemodialysis patients. Therefore, this study aimed to investigate prevalence, risk factors, and genotypic pattern of HEV infection among hemodialysis patients in South of Iran.

METHODS

All patients on maintenance hemodialysis attending the hemodialysis centers of Bushehr, Borazjan, and Genaveh cities for regular hemodialysis were enrolled in this study. Serum samples were tested for the presence of anti-HEV antibodies using ELISA kit. The serum samples were further tested for detection of HEV RNA using nested RT-PCR.

RESULTS

Of 226 hemodialysis patients, 155 patients (68.6%, 95% CI: 62.3%-74.3%) were positive for anti-HEV IgG antibody, of which 33 patients (14.6%, 95% CI: 10.6%-19.8%) had anti-HEV IgM antibody. The prevalence of anti-HEV IgG and anti-IgM antibodies in non-hemodialysis controls were 65.1% and 9.6%, respectively. Although the hemodialysis patients had higher prevalence of HEV than the controls, the difference was not significant. All samples were negative for HEV RNA. HEV seroprevalence among hemodialysis patients was not significantly associated with place of residency, ethnicity, level of education, gender distribution, hemodialysis duration, and levels of liver enzymes. HEV seropositive patients had significantly higher mean age compared to seronegative patients.

CONCLUSION

This study reports the highest seroprevalence of HEV among hemodialysis patients in Iran. Inapparent HEV infection in the dialysis setting calls for regular screening of hemodialysis patients regardless of the hemodialysis duration, clinical symptoms, and liver function parameters.

Development and Validation of a Transfusion Risk Score for Patients Receiving Maintenance Hemodialysis

BACKGROUND

In patients on dialysis with anemia, avoiding red blood cell transfusions is preferable. We sought to develop and validate a novel transfusion prediction risk score for patients receiving maintenance hemodialysis.

METHODS

This retrospective cohort study used United States Renal Data System data to create a model development cohort (patients who were point prevalent and on hemodialysis on November 1, 2012) and a validation cohort (patients who were point prevalent and on hemodialysis on August 1, 2013). We characterized comorbidity, inflammatory conditions, hospitalizations, anemia and anemia management, iron parameters, intravenous iron use, and vitamin D use during a 6-month baseline period to predict subsequent 3-month transfusion risk. We used logistic least absolute shrinkage and selection operator regression. In an exploratory analysis, model results were used to calculate a score to predict 6- and 12-month hospitalization and mortality.

RESULTS

Variables most predictive of transfusion were prior transfusion, hemoglobin, ferritin, and number of hospital days in the baseline period. The resulting c-statistic in the validation cohort was 0.74, indicating relatively good predictive power. The score was associated with a significantly increased risk of subsequent mortality (hazard ratios 1.0, 1.22, 1.26, 1.54, 1.71, grouped from lowest to highest score), but not with hospitalization.

CONCLUSIONS

We developed a transfusion prediction risk score with good performance characteristics that was associated with mortality. This score could be further developed into a clinically useful application, allowing clinicians to identify patients on hemodialysis most likely to benefit from a timely, proactive anemia treatment approach, with the goal of avoiding red blood cell transfusions and attendant risks of adverse clinical outcomes.

A Randomized Trial of Strategies Using Darbepoetin Alfa To Avoid Transfusions in CKD

BACKGROUND

Exposure to high doses or a high cumulative dose of erythropoiesis-stimulating agents (ESAs) may contribute to cardiovascular events in patients with CKD and anemia. Whether using a low fixed ESA dose versus dosing based on a hemoglobin-based, titration-dose algorithm in such patients might reduce risks associated with high ESA doses and decrease the cumulative exposure-while reducing the need for red blood cell transfusions-is unknown.

METHODS

In this phase-3, randomized trial involving 756 adults with stage-3 to -5 CKD and anemia, we evaluated incidence of red blood cell transfusions for participants randomized to receive darbepoetin given as a fixed dose (0.45 µg/kg every 4 weeks) versus administered according to a hemoglobin-based, titration-dose algorithm, for up to 2 years. Participants received transfusions as deemed necessary by the treating physician.

RESULTS

There were 379 patients randomized to the fixed-dose group, and 377 to the titration-dose group. The percentage of participants transfused did not differ (24.1% and 24.4% for the fixed-dose and titration-dose group, respectively), with similar time to first transfusion. The titration-dose group achieved significantly higher median hemoglobin (9.9 g/dl) compared with the fixed-dose group (9.4 g/dl). The fixed-dose group had a significantly lower median cumulative dose of darbepoetin (median monthly dose of 30.9 µg) compared with the titration-dose group (53.6 µg median monthly dose). The FD and TD group received a median (Q1, Q3) cumulative dose per 4 weeks of darbepoetin of 30.9 (21.8, 40.0) µg and 53.6 (31.1, 89.9) µg, respectively; the median of the difference between treatment groups was -22.1 (95% CI, -26.1 to -18.1) µg.

CONCLUSIONS

These findings indicate no evidence of difference in incidence of red blood cell transfusion for a titration-dose strategy versus a fixed-dose strategy for darbepoetin. This suggests that a low fixed dose of darbepoetin may be used as an alternative to a dose-titration approach to minimize transfusions, with less cumulative dosing.

Changes in hemodialysis catheter management after introduction of the end-stage renal disease prospective payment system

Background

We investigated whether implementation of the end-stage renal disease prospective payment system (ESRD PPS) was associated with changes in thrombolytic therapy use and other aspects of catheter management in hemodialysis (HD) patients.

Methods

Using quarterly, period prevalent cohorts of patients undergoing maintenance HD with a catheter in the US Renal Data System (2008–2015), we studied rates of claims for within- and outside-HD-unit thrombolytic use, and thrombus/fibrin sheath removal, and rates of delayed HD treatment after ESRD PPS implementation, January 1, 2011. Associations between PPS implementation and change in trend of rates of each outcome were assessed using covariate-adjusted Poisson regression, using a piecewise linear function for quarter-time (with breakpoint at PPS implementation).

Results

Among an average of 69,428 quarterly catheter users, rates of claims for within-HD-unit thrombolytic use declined from 236.6 (Q1–2008) to 81.4 (Q4–2012) per 100 person-years (P < 0.0001, PPS association with change in trend); rates of claims for thrombus/fibrin sheath removal procedures increased from 3.9 (Q1–2008) to 8.8 (Q3–2015) per 100 person-years (P = 0.0001, PPS association with change in trend). Rates of delayed HD treatment increased from 1.6 (Q2–2008) to 2.3 (Q3–2015) per patient-quarter, although PPS implementation was associated with a decrease in this rising trend (1.6% increase per quarter pre-PPS, 1.2% post-PPS; P < 0.0001, change in trend).

Conclusions

After PPS implementation, thrombolytic use decreased and thrombus/fibrin sheath removal increased. The increasing trend in delayed HD treatment appeared to slow after PPS implementation, but delayed sessions continued to increase year over year for unclear reasons.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12882-020-02222-9.

Does One Size Fit All With the Effects of Payment Reform? Dialysis Facility Payer Mix and Anemia Management Under the Expanded Medicare Prospective Payment System

BACKGROUND

The effects of Medicare payment reforms aiming to improve the efficiency and quality of care by establishing greater financial accountability for providers may vary based on the extent and types of other coverage for their patient populations. Providers who are more resource constrained due to a less favorable payer mix face greater financial risks under such reforms. The impact of the expanded Medicare dialysis prospective payment system (PPS) on quality of care in independent dialysis facilities may vary based on the extent of higher payments from private insurers available for managing increased risks.

OBJECTIVES

To evaluate whether anemia outcomes for dialysis patients in independent facilities differ under the Medicare PPS based on facility payer mix.

DESIGN

We examined changes in anemia outcomes for 122,641 Medicare dialysis patients in 921 independent facilities during 2009-2014 among facilities with differing levels of employer insurance (EI). We performed similar analyses of facilities affiliated with large dialysis organizations, whose practices were not expected to change based on facility-specific payer mix.

RESULTS

Among independent facilities, similar modeled trends in low hemoglobin for all 3 facility EI groups in 2009-2010 were followed by increased low hemoglobin during 2012-2014 for facilities with lower EI (P<0.01). Post-PPS standardized blood transfusion ratios were 9% higher for lower EI versus higher EI independent facilities (P<0.01). Among large dialysis organizations facilities, there was no divergence in low hemoglobin by payer mix under the PPS.

CONCLUSIONS

There is evidence of poorer quality of care for anemia under the PPS in independent facilities with lower versus higher EI. Provider responses to payment reform may vary based on attributes such as payer mix that could have implications for health disparities.

Validation of Algorithms Used to Identify Red Blood Cell Transfusion Related Admissions in Veteran Patients with End Stage Renal Disease

Background:

The goal of this study was to compare the performance of several database algorithms designed to identify red blood cell (RBC) Transfusion Related hospital Admissions (TRAs) in Veterans with end stage renal disease (ESRD).

Methods:

Hospitalizations in Veterans with ESRD and evidence of dialysis between 01/01/2008 and 12/31/2013 were screened for TRAs using a clinical algorithm (CA) and four variations of claims-based algorithms (CBA 1–4). Criteria were implemented to exclude patients with non-ESRD-related anemia (e.g., injury, surgery, bleeding, medications known to produce anemia). Diagnostic performance of each algorithm was delineated based on two clinical representations of a TRA: RBC transfusion required to treat ESRD-related anemia on admission regardless of the reason for admission (labeled as TRA) and hospitalization for the primary purpose of treating ESRD-related anemia (labeled TRA-Primary). The performance of all algorithms was determined by comparing each to a reference standard established by medical records review. Population-level estimates of classification agreement statistics were calculated for each algorithm using inverse probability weights and bootstrapping procedures. Due to the low prevalence of TRAs, the geometric mean was considered the primary measure of algorithm performance.

Results:

After application of exclusion criteria, the study consisted of 12,388 Veterans with 26,672 admissions. The CA had a geometric mean of 90.8% (95% Confidence Interval: 81.8, 95.6) and 94.7% (95% CI: 80.5, 98.7) for TRA and TRA-Primary, respectively. The geometric mean for the CBAs ranged from 60.3% (95% CI: 53.2, 66.9) to 91.8% (95% CI: 86.9, 95) for TRA, and from 80.7% (95% CI: 72.9, 86.7) to 96.7% (95% CI: 94.1, 98.2) for TRA-Primary. The adjusted proportions of admissions classified as TRAs was 3.2% (95% CI: 2.8, 3.8) and TRA-Primary was 1.3% (95% CI: 1.1, 1.7).

Conclusions:

The CA and select CBAs were able to identify TRAs and TRA-primary with high levels of accuracy and can be used to examine anemia management practices in ESRD patients.

Low Quality of International Classification of Diseases, 10th Revision, Procedural Coding System Data Undermines the Validity of the Standardized Transfusion Ratio: Time to Chart a New Course?

The validity of the standardized transfusion ratio, a quality measure for dialysis facilities, may have been affected by the transition from International Classification of Diseases, Ninth Revision (ICD-9) to International Classification of Diseases, Tenth Revision (ICD-10) procedure coding in October 2015. We analyzed Medicare Part A claims for inpatient care among dialysis patients in 2014-2017 and investigated billing patterns for blood transfusion during the last year of ICD-9 coding and the first and second years of ICD-10 coding. We identified 2205 hospitals with a steady volume of dialysis patient admissions. In nearly one-third (31.7%) of hospitals, the apparent incidence of blood transfusion during hospitalization fell >50% between the last year of ICD-9 coding and the first year of ICD-10 coding. Between the first and second years of ICD-10 coding, the apparent incidence of blood transfusion during hospitalization fell >20% in 24.5% of hospitals and rose >25% in 14.8% of hospitals. Furthermore, hospital-specific changes in the apparent incidence of blood transfusion among dialysis patients and all Medicare beneficiaries were highly correlated. These findings suggest that the standardized transfusion ratio reflects differential misclassification of transfusions among hospitals. Alternative measures to judge the quality of anemia management, such as attainment of hemoglobin within a target range, may be more appropriate.

Hospital-Volume Effects on Perioperative Outcomes in Peritoneal Dialysis Catheter Implantation: Analysis of 2,505 Cases

BACKGROUND

Evidence regarding volume-outcome effects on peritoneal dialysis (PD) catheter implantation is limited. This study aimed to investigate associations between hospital volume (annual caseload of catheter implantation) and perioperative outcomes.

METHODS

Clinical data for patients who underwent PD catheter implantation from 2007 to 2012 were extracted from the Japanese nationwide Diagnosis Procedure Combination database. Hospital volume was divided into tertiles: low-volume (1 - 6 cases/year), medium-volume (7 - 13 cases/year), and high-volume (≥ 14 cases/year). Multivariate logistic regression analysis for the occurrence of any adverse events and blood transfusion, and gamma-distributed log-linked linear regression analysis for postoperative length of stay were conducted with explanatory variables of hospital volume, age, sex, Charlson comorbidity index, history of hemodialysis, type of anesthesia, and type of hospital.

RESULTS

Among 906, 855, and 744 cases in the low-volume, medium-volume, and high-volume groups, overall adverse events were 10.0%, 7.6%, and 6.0%, transfusion rates were 1.3%, 1.1%, and 0.9%, and median postoperative stays were 12, 10, and 9 days, respectively. In multivariate analyses, compared with the low-volume group, medium-volume and high-volume groups were associated with a lower incidence of overall adverse events (odds ratio [OR] = 0.71, p = 0.058, and OR = 0.59, p = 0.013, respectively) and shorter postoperative stay (% difference = -10.5%, p = 0.023, and % difference = -18.5%, p = 0.001, respectively), while no significant association was detected for transfusion.

CONCLUSIONS

Less frequent adverse events and shorter stays were observed in higher-volume centers. Inverse volume-outcome relationships in PD catheter implantation were confirmed.

The Role of Big Data in the Development and Evaluation of US Dialysis Care

Rapid growth in electronic communications and digitalization, combined with advances in data management, analysis, and storage, have led to an era of "Big Data." The Social Security Amendments of 1972 turned end-stage renal disease (ESRD) care into a single-payer system for most patients requiring dialysis in the United States. As a result, there are few areas of medicine that have been as influenced by Big Data as dialysis care, for which Medicare's large administrative data sets have had a central role in the evaluation and development of public policy for several decades. In the 1970/1980s, Medicare data helped identify concerning trends in costs, access to dialysis care, and quality of care delivered. As the research community and policymakers made Medicare's administrative data increasingly accessible for investigation, analyses of Medicare claims have had a large role in facilitating policy synthesis and refinement. Efforts to address the skyrocketing cost of injectable drugs in the 1990s and 2000s exemplify this expanded role of Big Data. Although there are opportunities for large government and nongovernmental administrative data sets to continue serving a critical role in the evaluation and development of ESRD policies, it is important to understand challenges and limitations associated with their use.

Improving Outcomes in Patients Receiving Dialysis: The Peer Kidney Care Initiative

The past decade has witnessed a marked reduction in mortality rates among patients receiving maintenance dialysis. However, the reasons for this welcome development are uncertain, and greater understanding is needed to translate advances in care into additional survival gains. To fill important knowledge gaps and to enable dialysis provider organizations to learn from one another, with the aim of advancing patient care, the Peer Kidney Care Initiative (Peer) was created in 2014 by the chief medical officers of 14 United States dialysis provider organizations and the Chronic Disease Research Group. Areas of particular clinical importance were targeted to help shape the public health agenda in CKD and ESRD. Peer focuses on the effect of geographic variation on outcomes, the implications of seasonality for morbidity and mortality, the clinical significance of understudied disorders affecting dialysis patients, and the debate about how best to monitor and evaluate progress in care. In the realm of geovariation, Peer has provided key observations on regional variation in the rates of ESRD incidence, hospitalization, and pre-ESRD care. Regarding seasonality, Peer has reported on variation in both infection-related and non-infection-related hospitalizations, suggesting that ambient environmental conditions may affect a range of health outcomes in dialysis patients. Specific medical conditions that Peer highlights include Clostridium difficile infection, which has become strikingly more common in patients in the year after dialysis initiation, and chronic obstructive pulmonary disease, the treatments for which have the potential to contribute to sudden cardiac death. Finally, Peer challenges the nephrology community to consider alternatives to standardized mortality ratios in assessing progress in care, positing that close scrutiny of trends over time may be the most effective way to drive improvements in patient care.

Effects of the prospective payment system on anemia management in maintenance dialysis patients: implications for cost and site of care

Background

The 2011 expanded Prospective Payment System (PPS) and contemporaneous Food and Drug Administration label revision for erythropoiesis-stimulating agents (ESAs) were associated with changes in ESA use and mean hemoglobin levels among patients receiving maintenance dialysis. We aimed to investigate whether these changes coincided with increased red blood cell transfusions or changes to Medicare-incurred costs or sites of anemia management care in the period immediately before and after the introduction of the PPS, 2009–2011.

Methods

From US Medicare end-stage renal disease (ESRD) data (Parts A and B claims), maintenance hemodialysis patients from facilities that initially enrolled 100 % into the ESRD PPS were identified. Dialysis and anemia-related costs per-patient-per-month (PPPM) were calculated at the facility level, and transfusion rates were calculated overall and by site of care (outpatient, inpatient, emergency department, observation stay).

Results

More than 4100 facilities were included. Transfusions in both the inpatient and outpatient environments increased. In the inpatient environment, PPPM use increased by 11–17 % per facility in each quarter of 2011 compared with 2009; in the outpatient environment, PPPM use increased overall by 5.0 %. Site of care for transfusions appeared to have shifted. Transfusions occurring in emergency departments or during observation stays increased 13.9 % and 26.4 %, respectively, over 2 years.

Conclusions

Inpatient- and emergency-department-administered transfusions increased, providing some evidence for a partial shift in the cost and site of care for anemia management from dialysis facilities to hospitals. Further exploration into the economic implications of this increase is necessary.

Has dialysis payment reform led to initial racial disparities in anemia and mineral metabolism management?

Implementation of the Medicare ESRD prospective payment system (PPS) and changes to dosing guidelines for erythropoiesis-stimulating agents (ESAs) in 2011 appear to have influenced use of injectable medications among dialysis patients. Given historically higher ESA and vitamin D use among black patients, we assessed the effect of these policy changes on racial disparities in the management of anemia and mineral metabolism. Analyses used cross-sectional monthly cohorts for a period-prevalent sample of 7384 maintenance hemodialysis patients at 132 facilities from the Dialysis Outcomes and Practice Patterns Study (DOPPS) Practice Monitor. Linear splines with knots at each policy change were used in survey-weighted regressions to estimate time trends in hemoglobin (Hgb), erythropoietin (EPO) dose, intravenous (IV) iron dose, ferritin, transferrin saturation (TSAT) concentration, parathyroid hormone (PTH), IV vitamin D dose, cinacalcet use, and phosphate binder use. From August 2010 to December 2011, mean Hgb declined from 11.5 to 11.0 g/dl (P<0.001), mean EPO dose declined from 20,506 to 14,777 U/wk (P<0.001), and mean serum PTH increased from 340 to 435 pg/ml (P<0.001). No meaningful differences by race were observed regarding the rates of change of management practices or laboratory measures (all P>0.21). Mean EPO and vitamin D dose and serum PTH levels remained higher in blacks. Despite evidence that anemia and mineral metabolism management practices have changed significantly over time, there was no immediate indication of racial disparities resulting from implementation of the PPS or ESA label change. Further studies are needed to examine effects among patient and facility subgroups.