Assessment of time and practice resources required to provide weekly or monthly erythropoiesis-stimulating protein therapy to chronic kidney disease patients in the physician office setting

BACKGROUND: There is an epidemic of chronic kidney disease (CKD) and a high prevalence of anemia (47%) observed in CKD patients. Little is known about the cost in physician office resources of routine erythropoiesis-stimulating protein (ESP) administration to treat patients with nondialysis CKD. OBJECTIVES: The objectives of this research were (1) to explore the patterns of care in physician offices where nondialysis CKD patients receive routine ESP injections, (2) to examine differences in the monthly resources and related costs incurred by physician offices in treating patients receiving either weekly (QW) or monthly (OM) ESP regimens, and (3) to identify opportunities to minimize the burden of CKD treatment on physician offices. METHODS: An observational, cross-sectional time and motion assessment was performed in 10 community-based outpatient nephrology practices (5 QW and 5 OM practices); each practice had 40 patients on routine ESP therapy for nondialysis CKD. Three observers trained in health care research documented injection-related tasks and time associated with 91 ESP injection procedures (47 QW and 44 QM) from patients' arrival to and departure from the physician office, office personnel follow-up on billing and documentation, and injection-related staff time. Monthly injection times for OM were calculated by summing the time required to perform the tasks associated with administering a single injection of ESP to subjects, as documented by observers. Total monthly per-patient medical practice costs for providing QM ESP injections were calculated, including labor costs (calculated by applying average wage rates of practice staff to time observed for the specific activities performed) and supply costs (based on average list prices found in medical supply catalogs). Monthly injection times and costs for the QW regimen were calculated by summing the same list of activities as for the QM regimen and multiplying by 4.3 (4.3 weeks per month). Nephrology practice personnel completed a questionnaire summarizing practice characteristics and estimated the time required for some of the injection-related activities. The time and cost associated with each task were analyzed using descriptive and comparative statistics (i.e., Fisher's exact test and t test), RESULTS: On average, patients spent 21 minutes in the clinic for a routine injection visit (QW: 17 minutes, QM: 25 minutes; P = 0.053), during which 11 minutes (52%) were spent interacting with clinic staff (QW: 8.9 minutes, QM: 13.4 minutes; P=0.005). In the time spent interacting with staff, 3 minutes (QW: 2.9 minutes, QM: 3.6 minutes; P=0.065) were for dose administration and 8 minutes (QW: 5.3 minutes, OM: 9.8 minutes; P=0.011) were for staff providing various services to the patients, including registering patients on arrival, examining patients (vital signs, weight, blood work), consulting with patients, and scheduling patients' next visits. Each month, clinic staff spent a total visit average of 38 minutes providing anemia-related treatment for each QW injection patient, compared with 13 minutes for each QM injection patient (P <0.001). After patients' departure, clinic staff spent additional time (not quantified) on billing, filing claims, and other administrative responsibilities most of which could not be observed during our 1-day observation. The average total monthly practice cost of providing ESP therapy to a QW patient ($17.00 [95% confidence interval (CI), 13.00-27.13]) was more than double that for a OM patient ($6.78 [95% Cl, 5.34-9.12]); (P=0.004). Differences in visit-related labor costs (QW: $8.34, QM: $3.43; P= 0.108) and injection supply costs (QW: $4.39, QM: $1.67; P <0.001) accounted for the largest portions of the total monthly cost differential between the treatment regimens. OM dosing would require, on average, 83 hours less staff time and $2,044 less estimated cost treating 200 patients per month compared with weekly administration per clinic. CONCLUSIONS: Administering routine ESP injections to nondialysis CKD patients for anemia using a QM regimen results in substantial time and cost savings compared with a QW therapy regimen. Managing patients on less-frequent ESP dosing schedules may alleviate medical practice burden by reducing the staff time and supplies related to providing injections in the office.