Special treatment--the story of Medicare's ESRD entitlement

Chronic kidney disease and value-based care: Lessons from innovation, iteration, and ideation in primary care

Value-based primary care has reduced health care costs, improved the quality of rendered care, and enhanced the patient experience. Value-based care emphasizes prevention, outreach, follow-up, patient engagement, and comprehensive, whole-person health. Primary care Accountable Care Organizations have leveraged technology-enabled workflows, practice transformation, and cutting-edge data and analytics to achieve success. These efforts are increasingly aided by predictive modeling used in the context of patient identification and prioritization algorithms. Value-based kidney care programs can glean salient takeaways from successful value-based primary care methods and models. The kidney care community is experiencing unprecedented transformation as novel payer programs and financial models burgeon. The authors contend these efforts can be accelerated by the adoption of techniques honed in value-based primary care. To optimize value-based kidney care, though, nephrology thought leaders must transcend the archetype of value-based primary care. To do so, the nephrology community must: (1) impel behavioral change among fee-for-service adherents; (2) harness emerging policy, guidelines, and quality measures; (3) adopt innovative tools, technologies, and therapies. In aggregating lessons from value-based primary care-and leveraging novel methodologies and approaches-the kidney care community will be better equipped to achieve the quadruple aim for kidney care.

Advocating for in-center hemodialysis patients via anonymous survey

We conducted an anonymous survey in 9 of our university affiliated outpatient dialysis units to address the concern that many in-center hemodialysis patients may not feel comfortable sharing their experiences. Major goals of this study: Investigating level of patient satisfaction with their care; Evaluating the subjective perception of the level of understanding of patients regarding pertinent issues of their disease and its management; Identifying potential avenues for care improvement. Survey was conducted in English, paper-based, with answer choices to individual questions for patient satisfaction and education graded using a 5-point Likert scale. Regarding potential areas of improvement, patients were asked to choose as many areas as deemed appropriate. To ensure anonymity, the completed surveys were folded and dropped into a box. Overall, 253 out of 516 (49%) screened patients were eligible and completed the survey. Patients expressed favorable responses regarding satisfaction (mean rating > 4 in each of 14 questions) and education (mean rating > 4 in 8 questions, > 3.5 in 2 questions) regarding hemodialysis. About 62% of overall study participants identified at least one area where they felt additional information would result in improvement of care. Our results indicate that patients undergoing outpatient hemodialysis were overall satisfied and had a good perceptive understanding about their health. Based on the patients' input, strategies focused on addressing pain and discomfort, privacy, providing information about palliative care/hospice, mental health resources, and the process of kidney transplantation may promote improvement in overall quality of care.

You Can't Have One Without the Other: Innovation and Ethical Dilemmas in Gastroenterology and Hepatology

Medical innovation and ethical dilemmas are intertwined in gastroenterology and hepatology. This narrative review explores direct-acting antiviral (DAA) therapy for hepatitis C virus (HCV) as a touchstone example of how medical innovation breeds ethical dilemmas. A few quandaries-informed consent as well as informed deferral during the first wave of DAA approvals, sobriety restrictions from payors, and high DAA costs for patients-are addressed through the lens of the foundational principles of clinical medical ethics: autonomy, beneficence, non-maleficence, justice, and utility. By placing these issues within a medical ethics framework, we hope not only to focus on the solutions that the gastroenterology and hepatology community developed in the advent of DAA therapy, but to highlight an ethical paradigm that can be applied to similar dilemmas that will be faced as new therapies for other gastrointestinal diseases are approved.

Priority Setting as an Ethical Imperative in Managing Global Dialysis Access and Improving Kidney Care

Priority-setting dilemmas arise when trade-offs must be made regarding the kinds of services that should be provided and to whom, thereby withholding other services from individuals or groups that could benefit from them. Currently, it is practically impossible for lower-income countries to provide dialysis for all patients with kidney failure; however, the fundamental premise of the human right to health, while acknowledging the current resource constraints, is the progressive realization of access to care for all. In this article we outline the rationale for priority setting, starting with the global goal of achieving universal health coverage, the prerequisites for fair and transparent priority setting, and discuss how these may apply to expensive care such as dialysis. Priority is inherently a value-laden process, and cannot be whittled down to technical considerations of clinical or cost effectiveness alone. Fair and transparent priority setting should originate from population health needs, be based on evidence, and be associated with ethical values or principles. This requires effective engagement with relevant stakeholders. Once policies are developed and implemented, good oversight is crucial to ensure accountability and to provide iterative feedback such that the goals of universal health coverage may be progressively realized.

Health Policy for Dialysis Care in Canada and the United States

Contemporary dialysis treatment for chronic kidney failure is complex, is associated with poor clinical outcomes, and leads to high health costs, all of which pose substantial policy challenges. Despite similar policy goals and universal access for their kidney failure programs, the United States and Canada have taken very different approaches to dealing with these challenges. While US dialysis care is primarily government funded and delivered predominantly by private for-profit providers, Canadian dialysis care is also government funded but delivered almost exclusively in public facilities. Differences also exist for regulatory mechanisms and the policy incentives that may influence the behavior of providers and facilities. These differences in health policy are associated with significant variation in clinical outcomes: mortality among patients on dialysis is consistently lower in Canada than in the United States, although the gap has narrowed in recent years. The observed heterogeneity in policy and outcomes offers important potential opportunities for each health system to learn from the other. This article compares and contrasts transnational dialysis-related health policies, focusing on key levers including payment, finance, regulation, and organization. We also describe how policy levers can incentivize favorable practice patterns to support high-quality/high-value, person-centered care and to catalyze the emergence of transformative technologies for alternative kidney replacement strategies.

Increasing access to integrated ESKD care as part of universal health coverage

The global nephrology community recognizes the need for a cohesive strategy to address the growing problem of end-stage kidney disease (ESKD). In March 2018, the International Society of Nephrology hosted a summit on integrated ESKD care, including 92 individuals from around the globe with diverse expertise and professional backgrounds. The attendees were from 41 countries, including 16 participants from 11 low- and lower-middle-income countries. The purpose was to develop a strategic plan to improve worldwide access to integrated ESKD care, by identifying and prioritizing key activities across 8 themes: (i) estimates of ESKD burden and treatment coverage, (ii) advocacy, (iii) education and training/workforce, (iv) financing/funding models, (v) ethics, (vi) dialysis, (vii) transplantation, and (viii) conservative care. Action plans with prioritized lists of goals, activities, and key deliverables, and an overarching performance framework were developed for each theme. Examples of these key deliverables include improved data availability, integration of core registry measures and analysis to inform development of health care policy; a framework for advocacy; improved and continued stakeholder engagement; improved workforce training; equitable, efficient, and cost-effective funding models; greater understanding and greater application of ethical principles in practice and policy; definition and application of standards for safe and sustainable dialysis treatment and a set of measurable quality parameters; and integration of dialysis, transplantation, and comprehensive conservative care as ESKD treatment options within the context of overall health priorities. Intended users of the action plans include clinicians, patients and their families, scientists, industry partners, government decision makers, and advocacy organizations. Implementation of this integrated and comprehensive plan is intended to improve quality and access to care and thereby reduce serious health-related suffering of adults and children affected by ESKD worldwide.

Hemodialysis care for undocumented immigrants with end-stage renal disease in the United States

PURPOSE OF REVIEW

Across the United States, significant variation exists in the provision of care of undocumented immigrants with end-stage renal disease (ESRD), with some states providing standard dialysis, and other states providing emergency-only hemodialysis (EoHD).

RECENT FINDINGS

EoHD is associated with higher morbidity and mortality compared with standard hemodialysis. EoHD is also associated with higher healthcare utilization, resulting in more emergency department visits, more days spent in the hospital, and higher healthcare costs. Undocumented immigrants with ESRD who rely on EoHD also experience crippling and potentially fatal physical symptoms as well as psychosocial suffering, with some patients describing recurrent near-death experiences. Clinicians who provide EoHD to undocumented patients report experiencing moral distress and symptoms of professional burnout because of providing care that they perceive as unethical and far below the standard of care.

SUMMARY

Undocumented immigrants with ESRD who rely on EoHD have worse health outcomes and quality of life compared with patients who receive standard hemodialysis. EoHD is also more costly to the healthcare system. Healthcare policy reform is critical as more research demonstrates the worse clinical outcomes and higher costs of EoHD.

Rationale and design of a multicenter Chronic Kidney Disease (CKD) and at-risk for CKD electronic health records-based registry: CURE-CKD

BACKGROUND

Chronic kidney disease (CKD) is a global public health problem, exhibiting sharp increases in incidence, prevalence, and attributable morbidity and mortality. There is a critical need to better understand the demographics, clinical characteristics, and key risk factors for CKD; and to develop platforms for testing novel interventions to improve modifiable risk factors, particularly for the CKD patients with a rapid decline in kidney function.

METHODS

We describe a novel collaboration between two large healthcare systems (Providence St. Joseph Health and University of California, Los Angeles Health) supported by leadership from both institutions, which was created to develop harmonized cohorts of patients with CKD or those at increased risk for CKD (hypertension/HTN, diabetes/DM, pre-diabetes) from electronic health record data.

RESULTS

The combined repository of candidate records included more than 3.3 million patients with at least a single qualifying measure for CKD and/or at-risk for CKD. The CURE-CKD registry includes over 2.6 million patients with and/or at-risk for CKD identified by stricter guide-line based criteria using a combination of administrative encounter codes, physical examinations, laboratory values and medication use. Notably, data based on race/ethnicity and geography in part, will enable robust analyses to study traditionally disadvantaged or marginalized patients not typically included in clinical trials.

DISCUSSION

CURE-CKD project is a unique multidisciplinary collaboration between nephrologists, endocrinologists, primary care physicians with health services research skills, health economists, and those with expertise in statistics, bio-informatics and machine learning. The CURE-CKD registry uses curated observations from real-world settings across two large healthcare systems and has great potential to provide important contributions for healthcare and for improving clinical outcomes in patients with and at-risk for CKD.

Drive Times to Opioid Treatment Programs in Urban and Rural Counties in 5 US States

This study characterizes driving distances to opioid treatment programs in urban vs rural counties in states with the highest rates of opioid mortality and compares them with distances to methadone-prescribing federally qualified health centers and dialysis centers.

Renal Replacement Therapy for Undocumented Immigrants: Current Models with Medical, Financial, and Physician Perspectives-a Narrative Review

Renal replacement therapy is guaranteed for all US citizens with end-stage renal disease (ESRD). Undocumented immigrants with ESRD are a particularly vulnerable subset of renal failure patients. There is no federal legislation for these patients except for the requirement to treat them during "emergency medical conditions" and federal legislation excluding them from the guarantee of renal replacement therapy described above. Different states have developed different methods for dealing with this problem, with variation in management even addressed on a center by center basis. This review of the original studies published in the literature reveals the medical, ethical, and financial problems with this situation. These patients frequently have delayed presentation to care, poor access to routine care, increased complications, increased utilization of services, and increased morbidity and mortality in an emergent dialysis model compared to chronic outpatient care. They present an ethical dilemma for practitioners who know they are providing substandard care and occasionally making decisions on how to allocate resources. Emergent dialysis is associated with inadequate reimbursement, increased threat to sustained unemployment, and an overburdening of our healthcare infrastructure. This practice puts patients at risk, places an unfair ethical burden on providers and is financially unsustainable. Special considerations described for kidney transplant and peritoneal dialysis are considered and considerations for a new model are reviewed in the paper. Ultimately accommodations must be made with the input of government, healthcare practitioners, and facilities needs to be reached to protect these vulnerable patients.

Association of Scheduled vs Emergency-Only Dialysis With Health Outcomes and Costs in Undocumented Immigrants With End-stage Renal Disease

IMPORTANCE

In 40 of 50 US states, scheduled dialysis is withheld from undocumented immigrants with end-stage renal disease (ESRD); instead, they receive intermittent emergency-only dialysis to treat life-threatening manifestations of ESRD. However, the comparative effectiveness of scheduled dialysis vs emergency-only dialysis and the influence of treatment on health outcomes, utilization, and costs is uncertain.

OBJECTIVE

To compare the effectiveness of scheduled vs emergency-only dialysis with regard to health outcomes, utilization, and costs in undocumented immigrants with ESRD.

DESIGN, SETTING, AND PARTICIPANTS

Observational cohort study of 181 eligible adults with ESRD receiving emergency-only dialysis in Dallas, Texas, who became newly eligible and applied for private commercial health insurance in February 2015; 105 received coverage and were enrolled in scheduled dialysis; 76 were not enrolled in insurance for nonclinical reasons (eg, lack of capacity at a participating outpatient dialysis center) and remained uninsured, receiving emergency-only dialysis. We examined data on eligible persons during a 6-month period prior to enrollment (baseline period, August 1, 2014-January 31, 2015) until 12 months after enrollment (follow-up period, March 1, 2015-February 29, 2016), with an intervening 1-month washout period (February 2015). All participants were undocumented immigrants; self-reported data on immigration status was collected from Parkland Hospital electronic health records.

EXPOSURES

Enrollment in private health insurance coverage and scheduled dialysis.

MAIN OUTCOMES AND MEASURES

We used enrollment in health insurance and scheduled dialysis to estimate the influence of scheduled dialysis on 1-year mortality, utilization, and health care costs, using a propensity score-adjusted, intention-to-treat approach, including time-to-event analyses for mortality, difference-in-differences (DiD) negative binomial regression analyses for utilization, and DiD gamma generalized linear regression for health care costs.

RESULTS

Of 181 eligible adults with ESRD, 105 (65 men, 40 women; mean age, 45 years) received scheduled dialysis and 76 (38 men, 38 women; mean age, 52 years) received emergency-only dialysis. Compared with emergency-only dialysis, scheduled dialysis was significantly associated with reduced mortality (3% vs 17%, P = .001; absolute risk reduction, 14%; number needed to treat, 7; adjusted hazard ratio, 4.6; 95% CI, 1.2-18.2; P = .03), adjusted emergency department visits (-5.2 vs +1.1 visits/mo; DiD, -6.2; P < .001), adjusted hospitalizations (-2.1 vs -0.5 hospitalizations/6 months; DiD, -1.6; P < .001), adjusted hospital days (-9.2 vs +0.8 days/6 months; DiD, -9.9; P = .007), and adjusted costs (-$4316 vs +$1452 per person per month; DiD, -$5768; P < .001).

CONCLUSIONS AND RELEVANCE

In this study, scheduled dialysis was significantly associated with reduced 1-year mortality, health care utilization, and costs compared with emergency-only dialysis. Scheduled dialysis should be the universal standard of care for all individuals with ESRD in the United States.

Effects of Medicare coverage for the chronically ill on health insurance, utilization, and mortality: Evidence from coverage expansions affecting people with end-stage renal disease

I study the effect of the 1973 expansions of Medicare coverage among individuals with end-stage renal disease (ESRD) on insurance coverage, health care utilization, and mortality. I find that the expansions increased insurance coverage by between 22 and 30 percentage points, in models that include trends in age, with the increase explained by Medicare coverage, and increased physician visits by 25-35 percent. These expansions also decreased mortality due to kidney disease in the under 65 population by between 0.5 and 1.0 deaths per 100,000. Lastly, I provide evidence for two mechanisms that affected mortality: an increase in access to and use of treatment, which may be due to changes in insurance coverage; and an increase in entry of dialysis clinics and transplant programs.

Association of Medicare's Bundled Payment Reform With Changes in Use of Vitamin D Among Patients Receiving Maintenance Hemodialysis: An Interrupted Time-Series Analysis

BACKGROUND & RATIONALE

Medicare's 2011 prospective payment system (PPS) was introduced to curb overuse of separately billable injectable drugs. After epoietin, intravenous (IV) vitamin D analogues are the biggest drug cost drivers in hemodialysis (HD) patients, but the association between PPS introduction and vitamin D therapy has been scarcely investigated.

STUDY DESIGN

Interrupted time-series analyses.

SETTING & PARTICIPANTS

Adult US HD patients represented in the US Renal Data System between 2008 and 2013.

EXPOSURES

PPS implementation.

OUTCOMES

The cumulative dose of IV vitamin D analogues (paricalcitol equivalents) per patient per calendar quarter in prevalent HD patients. The average starting dose of IV vitamin D analogues and quarterly rates of new vitamin D use (initiations/100 person-months) in incident HD patients within 90 days of beginning HD therapy.

ANALYTICAL APPROACH

Segmented linear regression models of the immediate change and slope change over time of vitamin D use after PPS implementation.

RESULTS

Among 359,600 prevalent HD patients, IV vitamin D analogues accounted for 99% of the total use, and this trend was unchanged over time. PPS resulted in an immediate 7% decline in the average dose of IV vitamin D analogues (average baseline dose = 186.5 μg per quarter; immediate change = -13.5 μg [P < 0.001]; slope change = 0.43 per quarter [P = 0.3]) and in the starting dose of IV vitamin D analogues in incident HD patients (average baseline starting dose = 5.22 μg; immediate change = -0.40 μg [P < 0.001]; slope change = -0.03 per quarter [P = 0.03]). The baseline rate of vitamin D therapy initiation among 99,970 incident HD patients was 44.9/100 person-months and decreased over time, even before PPS implementation (pre-PPS β = -0.46/100 person-months [P < 0.001]; slope change = -0.19/100 person-months [P = 0.2]). PPS implementation was associated with an immediate change in initiation levels (by -4.5/100 person-months; P < 0.001).

LIMITATIONS

Incident HD patients were restricted to those 65 years or older.

CONCLUSION

PPS implementation was associated with a 7% reduction in the average dose and starting dose of IV vitamin D analogues and a 10% reduction in the rate of vitamin D therapy initiation.

Ethical Challenges in the Provision of Dialysis in Resource-Constrained Environments

The number of patients requiring dialysis by 2030 is projected to double worldwide, with the largest increase expected in low- and middle-income countries (LMICs). Dialysis is seldom considered a high priority by health care funders, consequently, few LMICs develop policies regarding dialysis allocation. Dialysis facilities may exist, but access remains highly inequitable in LMICs. High out-of-pocket payments make dialysis unsustainable and plunge many families into poverty. Patients, families, and clinicians suffer significant emotional and moral distress from daily life-and-death decisions imposed by dialysis. The health system's obligation to provide financial risk protection is an important component of global and national strategies to achieve universal health coverage. An ethical imperative therefore exists to develop transparent dialysis priority-setting guidelines to facilitate public understanding and acceptance of the realistic limits within the health system, and facilitate fair allocation of scarce resources. In this article, we present ethical challenges faced by patients, families, clinicians, and policy makers where dialysis is not universally accessible and discuss the potential ethical consequences of various dialysis allocation strategies. Finally, we suggest an ethical framework for use in policy development for priority setting of dialysis care. The accountability for reasonableness framework is proposed as a procedurally fair decision-making, priority-setting process.

Employment among Patients Starting Dialysis in the United States

BACKGROUND AND OBJECTIVES

Patients with ESRD face significant challenges to remaining employed. It is unknown when in the course of kidney disease patients stop working.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

We examined employment trends over time among patients ages 18-54 years old who initiated dialysis in the United States between 1996 and 2013 from a national ESRD registry. We compared unadjusted trends in employment at the start of dialysis and 6 months before ESRD and used linear probability models to estimate changes in employment over time after adjusting for patient characteristics and local unemployment rates in the general population. We also examined employment among selected vulnerable patient populations and changes in employment in the 6 months preceding dialysis initiation.

RESULTS

Employment was low among patients starting dialysis throughout the study period at 23%-24%, and 38% of patients who were employed 6 months before ESRD stopped working by dialysis initiation. However, after adjusting for observed characteristics, the probability of employment increased over time; patients starting dialysis between 2008 and 2013 had a 4.7% (95% confidence interval, 4.3% to 5.1%) increase in the absolute probability of employment at the start of dialysis compared with patients starting dialysis between 1996 and 2001. Black and Hispanic patients were less likely to be employed than other patients starting dialysis, but this gap narrowed during the study period.

CONCLUSIONS

Although working-aged patients in the United States starting dialysis have experienced increases in the adjusted probability of employment over time, employment at the start of dialysis has remained low.

What the non-nephrologist needs to know about dialysis

The End-Stage Renal Disease (ESRD) program now serves approximately 675,000 individuals in the United States at a cost of $26.1 billion to the Medicare system. Given the size of this population, healthcare providers from all disciplines will deliver care to patients on dialysis. Mortality remains high among patients on chronic dialysis, with 42.3% surviving 5 years. As this is a vulnerable population, it is important in the care of ESRD patients that non-nephrologists have a working knowledge of issues germane to dialysis. This review examines the physiology, mechanics, complications, and care delivery concerns of kidney dialysis modalities relevant to the non-nephrologist. The majority of patients receive in-center hemodialysis thrice weekly, with a small proportion on home-based therapies such as peritoneal dialysis or home hemodialysis. Inpatients may undergo hemodialysis or peritoneal dialysis, and in critically ill patients, continuous renal replacement therapies are utilized. Practical aspects of each of these modalities are discussed.

Association of Citizenship Status With Kidney Transplantation in Medicaid Patients

BACKGROUND

Although individuals classified as nonresident aliens, including undocumented immigrants, are entitled to receive emergency dialysis in the United States regardless of their ability to pay, most states do not provide them with subsidized care for maintenance dialysis or kidney transplantation. We explored whether nonresident aliens have similar outcomes to US citizens after receiving kidney transplants covered by Medicaid, a joint federal and state health insurance program.

STUDY DESIGN

Retrospective observational cohort study.

SETTING & PARTICIPANTS

All adult Medicaid patients in the US Renal Data System who received their first kidney transplant from 1990 to 2011.

PREDICTOR

Citizenship status, categorized as US citizen, nonresident alien, or permanent resident.

OUTCOME

All-cause transplant loss.

MEASUREMENTS

HRs and 95% CIs estimated by applying Cox proportional hazards frailty models with transplantation center as a random effect.

RESULTS

Of 10,495 patients, 8,660 (82%) were US citizens, 1,489 (14%) were permanent residents, and 346 (3%) were nonresident aliens, whom we assumed were undocumented immigrants. Nonresident aliens were younger, healthier, receiving dialysis longer, and more likely to have had a living donor. 71% underwent transplantation in California, and 61% underwent transplantation after 2005. Nonresident aliens had a lower unadjusted risk for transplant loss compared with US citizens (HR, 0.48; 95% CI, 0.35-0.65). Results were attenuated but still significant when adjusted for demographics, comorbid conditions, dialysis, and transplant-related factors (HR, 0.67; 95% CI, 0.46-0.94).

LIMITATIONS

Citizenship status was self-reported, possible residual confounding.

CONCLUSIONS

Our study suggests that the select group of insured nonresident aliens who undergo transplantation with Medicaid do just as well as US citizens with Medicaid. Policymakers should consider expanding coverage for kidney transplantation in nonresident aliens, including undocumented immigrants, given the associated high-quality outcomes in these patients.

Palliation Versus Dialysis for End-Stage Renal Disease in the Oldest Old: What are the Considerations?

As the US population continues to age, new cases of end-stage renal disease (ESRD) in individuals, aged 85 years or older (the oldest old), are increasing. Many patients who begin hemodialysis despite questionable benefit may struggle with high symptom burden and rapid functional decline. This article reviews the history regarding the funding and development of the Medicare ESRD program, reviews current approaches to the oldest old with ESRD, and considers strategies to improve the management approach of this vulnerable population.

Survival analysis of conservative vs. dialysis treatment of elderly patients with CKD stage 5

Elderly patients represent a growing population among people suffering from ESRD. So far only limited data on actual survival benefits of elderly adults initiating dialysis have been published. Besides the high burden of preexisting comorbidities, dialysis treatment itself may be associated with a further deterioration in functional status in this population. We retrospectively analyzed the Austrian Dialysis and Transplant Registry and identified 8,622 patients who started maintenance hemodialysis after the age of 65 years between 2002 and 2009. We compared this data set to a cohort of 174 patients aged over 65 years with CKD stage 5 who progressed to an eGFR < 10ml/min/ and were managed conservatively in the same era. All patients who died of malignant disease were excluded from this analysis. The risk of mortality was analyzed using multivariable Cox proportional hazards models. Furthermore, a parametric model of time to event analysis was used for visualization of changing risk over time and precise calculation of time to equal risk assuming a Weibull distribution. Hemodialysis treatment was associated with a decreased risk for death with a HR of 0.23 (95% CI 0.18 to 0.29; p<0.001) compared to conservative treatment. The time to event analysis however showed, that although survival was initially superior in the hemodialysis group, hazards crossed thereafter. Time to equal risk was 2.9 months and 1.9 months for female and male patient aged 65, respectively, and decreased to one month in the very elderly aged 95. Elderly patients with ERSD did benefit from initiation of hemodialysis, as the conservative group showed a very high initial mortality rate. This survival benefit of dialysis treatment however did not persist beyond the first two months compared to survivors of the conservative group.

Regional Variations in the Interpretation of the End-Stage Renal Disease Thirty-Month Coordination Period: Potential Implications for Patient Care

Chronic kidney disease is a non-communicable disease that is now well recognized as a major source of premature morbidity and mortality. In general, racial/ethnic minorities in the United States are more likely than non-minority groups to develop end-stage renal disease (ESRD), but paradoxically most have a lower mortality risk. Unlike most minorities, dialysis patients in Puerto Rico have a mortality risk nearly 50% higher than the national average. Multiple factors such as medical conditions, socioeconomic, environmental, and health system factors can influence health outcomes for patients with ESRD. We describe one potential health system factor that may contribute to this finding, a unique interpretation and implementation of the ESRD Medicare Secondary Payer provision in the Commonwealth of Puerto Rico. We conducted a search of regulatory documents and key stakeholder interviews to help envision the potential implications of these differences for dialysis facilities, health care providers, and patients with ESRD.

The Evolving Ethics of Dialysis in the United States: A Principlist Bioethics Approach

Throughout the history of dialysis, four bioethical principles - beneficence, nonmaleficence, autonomy and justice - have been weighted differently based upon changing forces of technologic innovation, resource limitation, and societal values. In the 1960s, a committee of lay people in Seattle attempted to fairly distribute a limited number of maintenance hemodialysis stations guided by considerations of justice. As technology advanced and dialysis was funded under an amendment to the Social Security Act in 1972, focus shifted to providing dialysis for all in need while balancing the burdens of treatment and quality of life, supported by the concepts of beneficence and nonmaleficence. At the end of the last century, the importance of patient preferences and personal values became paramount in medical decisions, reflecting a focus on the principle of autonomy. More recently, greater recognition that health care financial resources are limited makes fair allocation more pressing, again highlighting the importance of distributive justice. The varying application and prioritization of these four principles to both policy and clinical decisions in the United States over the last 50 years makes the history of hemodialysis an instructive platform for understanding principlist bioethics. As medical technology evolves in a landscape of changing personal and societal values, a comprehensive understanding of an ethical framework for evaluating appropriate use of medical interventions enables the clinician to systematically negotiate and optimize difficult ethical situations.

Is Surgery Warranted for Oligometastatic Disease?

The development of metastases after curative treatment can be seen as a failure. A common justification for the removal of metastases is that the knowledge that they are there may cause psychological distress, a real symptom that may be relieved by their removal. Although it is a commonly used justification for metastasectomy, the authors are unaware of any studies confirming or quantifying the health gain. This article strongly challenges the belief in clinical effectiveness and demonstrates that it is supported neither by a sound biological rationale nor by any good evidence. Reasons are suggested why this unfounded belief has become so prevalent.

A Matter of Choice: Opportunities and Obstacles Facing People with ESRD

Kidney failure is an overwhelming, life-shattering event, but patients with ESRD do not see themselves as being at the end stage of their lives. On the contrary, patients opting for kidney dialysis are choosing to live. Ideally, then, public policy would support patients' choices about how to live-specifically, the choice to continue working. Many patients with ESRD faced with the limitations of their health status and the demands of their treatment understandably choose to leave their jobs, a choice that is facilitated by the availability of public disability and health insurance. However, other patients who have the desire and opportunity to continue working may not get the guidance and support that can actually make their employment possible. Specifically, current disability and health insurance may fail to provide timely treatment and employment counseling to help patients with ESRD remain in their jobs. We, therefore, propose that the Center for Medicare and Medicaid Services support ESRD Networks to initiate more timely employment and treatment counseling in both the ESRD and the late-stage pre-ESRD setting. Although it is too late to require such counseling in the new network scope of work for 2016-2020, active experimentation in the next few years can lay the groundwork for a subsequent contract.

The Ethics of Chronic Dialysis for the Older Patient: Time to Reevaluate the Norms

Recent research highlights the potential burdens of hemodialysis for older patients with significant comorbidities, for whom there is clinical equipoise regarding the net benefits. With the advent of accountable care and bundled payment, previous incentives to offer hemodialysis to as many patients as possible are being replaced with a disincentive to dialyze high-risk patients. While this may offset the harm of overtreatment for some elderly patients, some voice concerns that the pendulum will swing too far back, with a return to ageist rationing of hemodialysis. Nephrologists should ensure that the patient's rights to be informed about the potential benefits and burdens of hemodialysis are respected, particularly because age, functional status, nutritional status, and comorbidities affect the net balance between benefits and burdens. Nephrologists are also called on to help patients make a decision, for which the patient's goals of care guide determination of potential benefit from hemodialysis. This article addresses concerns about present overtreatment and future risk of undertreatment of older adults with ESRD. It also discusses ways in which providers can ethically approach the question of initiation of hemodialysis in the elderly patient by including patient-specific estimates of prognosis, shared decision-making, and the use of specialist palliative care clinicians or ethics consultants for complex cases.

Patient-centered care: an opportunity to accomplish the "Three Aims" of the National Quality Strategy in the Medicare ESRD program

In light of mounting federal government debt and levels of Medicare spending that are widely viewed as unsustainable, commentators have called for a transformation of the United States health care system to deliver better care at lower costs. This article presents the priorities of the Coalition for Supportive Care of Kidney Patients for how clinicians might achieve this transformation for patients with advanced CKD and their families. The authors suspect that much of the high-intensity, high-cost care currently delivered to patients with advanced kidney disease may be unwanted and that the "Three Aims" put forth by the National Quality Strategy of better care for the individual, better health for populations, and reduced health care costs may be within reach for patients with CKD and ESRD. This work describes the coalition's vision for a more patient-centered approach to the care of patients with kidney disease and argues for more concerted efforts to align their treatments with their goals, values, and preferences. Key priorities to achieve this vision include using improved prognostic models and decision science to help patients, their families, and their providers better understand what to expect in the future; engaging patients and their families in shared decision-making before the initiation of dialysis and during the course of dialysis treatment; and tailoring treatment strategies throughout the continuum of their care to address what matters most to individual patients.

Pulmonary Metastasectomy for Colorectal Cancer: Recent Reports Prompt a Review of the Available Evidence

Pulmonary metastasectomy for colorectal cancer is commonplace surgery, but the practice has grown on the basis of follow-up studies. These studies base their conclusion on the effectiveness of metastasectomy on the survival rates at 5 years of very highly selected patients. Three publications in the last year, a registry study, a meta-analysis and a randomised controlled trial of monitoring and early detection of cancer recurrence, prompted a review of the evidence. A critical examination of the evidence suggests that much of the apparent benefit may be due to selection of patients most likely to survive on the basis of well-known prognostic features, explicitly stated in the clinical record. Clinicians also assess their patients over time and do not offer surgery to those with faster progression. Such clinical judgements are of their nature often subtle and undocumented and thus cannot be retrieved from the clinical record. Although some patients may have long survival following pulmonary metastasectomy, and indeed their survival might be believed to be due to resection of pulmonary metastases, how many patients must be operated on to find these survivors? What is the number 'needed to treat'? It may be that of the patients having metastasectomy, for the greater proportion it does not materially alter their survival. A randomised controlled trial to resolve this uncertainty is in progress. The Pulmonary Metastasectomy in Colorectal Cancer (PulMiCC) trial is recruiting in Britain and Europe.

Survival trends in ESRD patients compared with the general population in the United States

BACKGROUND

Health care resources expended on patients with end-stage renal disease (ESRD) have increased extensively, with uncertain changes in outcomes. In this study, we examined survival trends in the United States in patients with ESRD receiving renal replacement therapy with long-term dialysis or transplantation relative to the general population.

STUDY DESIGN

Secondary analysis of records from the US Renal Data System.

SETTING & PARTICIPANTS

American adults receiving renal replacement therapy in 1977, 1987, 1997, and 2007.

PREDICTOR

Year.

OUTCOME

1-year survival.

MEASUREMENTS

Abridged period life tables were created for each cross-sectional patient group and were compared with general US population life tables to measure relative survival, calculated as differences in average survival between the general US and the ESRD populations.

RESULTS

From 1977 to 2007, ESRD patient groups became significantly older (mean age increased from 47 to 58 years) and sicker (ESRD due to diabetes increased from 9.1% to 38.2%; patients with a high death risk increased from 36.8% to 50.7%). Unadjusted age-specific survival improved (for 50-year-olds, average life expectancy increased 8% from 7.3 years in 1977 to 7.9 years in 2007), but age-specific survival increased more extensively in the general US population (from 27.5 years in 1977 to 30.9 years in 2007; 12% improvement). Accounting for this, age-specific relative survival in patients with ESRD decreased (for 50-year-olds, 20.2 life-years lost in 1977 vs 23.0 life-years lost in 2007).

LIMITATIONS

Our analysis controlled for neither patient comorbid conditions nor initial glomerular filtration rate at the start of renal replacement therapy.

CONCLUSIONS

Over the past 4 decades, age-specific survival in patients with ESRD has improved, but has not kept pace with that of the general US population. To be complete, future survival studies in patients with ESRD should focus on both temporal changes in survival within this group and changes relative to the general population.

Dialysis in the frail elderly--a current ethical problem, an impending ethical crisis

The current practice of hemodialysis for the frail elderly frequently ignores core bioethical principles. Lack of transparency and shared decision making coupled with financial incentives to treat have resulted in problems of overtreatment near the end of life. Imminent changes in reimbursement for hemodialysis will reverse the financial incentives to favor not treating high-risk patients. In this article, we describe what is empirically known about the approach to hemodialysis today, and how it violates four core ethical principles. We then discuss how the new financial system turns physician and organizational incentives upside down in ways that may exacerbate the ethical dilemmas, but in the opposite direction.

Reduced use of erythropoiesis-stimulating agents and intravenous iron with ferric citrate: a managed care cost-offset model

Background

Ferric citrate (FC) is a phosphate binder in development for the treatment of hyperphosphatemia in patients with end-stage renal disease (ESRD). In clinical trials, FC improved patient serum phosphorus levels and increased serum ferritin and percent transferrin saturation. Because nephrologists respond to increases in these iron measures by reducing intravenous (IV) iron and erythropoiesis-stimulating agent (ESA) doses, the decreased use of iron and ESA associated with FC may reduce costs.

Objectives

To develop a cost-offset model from a managed care perspective estimating the cost savings associated with FC use.

Methods

We created a cost-offset model from the managed care payer perspective that compared the treatment costs of ESRD for patients given FC. The model considered the number of dialysis sessions per month; number of ESRD patients enrolled in the health plan; cost of ESAs, iron, and dialysis sessions; and the proportion of patients on phosphate binder therapy. The model assumed equivalent efficacy and cost neutrality between FC and other phosphate binders. Monte Carlo simulations were conducted by varying model inputs.

Results

When FC was compared to other phosphate binders, the monthly cost of ESA and IV iron per 500 patients with ESRD (85% treated with phosphate binders) was reduced by 8.15% and 33.2%, respectively. When incorporated into the total cost of dialysis for patients with ESRD (dialysis, ESA, and IV iron), the decrease in the monthly cost of dialysis care was US$80,214 per 500 ESRD patients. Monte Carlo simulations suggest that a plan serving 500 dialysis patients could save between US$626,000 and US$1,106,000 annually with the use of FC.

Conclusion

The use of FC in ESRD patients with hyperphosphatemia may help reduce treatment costs.

Dialysis by the book? Treatment of renal failure in a 101-year-old patient

While dialysis historically began as treatment intended for younger patients, it has, over time, increasingly been extended to treat elderly patients with a high comorbidity burden. Data on the outcomes of dialysis in these patients show that in some cases it confers no benefit and may be associated with functional decline. We describe a 101-year-old male patient with chronic kidney disease (CKD), admitted to the intensive care unit (ICU) with exacerbation of heart failure and sepsis. He experienced acute deterioration of renal function, with oliguria and acidosis. The patient's healthcare proxy insisted that dialysis be initiated despite his extremely advanced age, citing the patient's devout religious beliefs. He underwent 56 dialysis treatments over the course of ∼4 months after which he died as a result of septic and cardiogenic shock. Our case is unique, in that it may represent the oldest individual ever reported to start haemodialysis. It illustrates the ever-growing clinical and ethical challenges posed by the treatment of renal failure in the geriatric population.

Comparing mandated health care reforms: the Affordable Care Act, accountable care organizations, and the Medicare ESRD program

In addition to extending health insurance coverage, the Affordable Care Act of 2010 aims to improve quality of care and contain costs. To this end, the act allowed introduction of bundled payments for a range of services, proposed the creation of accountable care organizations (ACOs), and established the Centers for Medicare and Medicaid Innovation to test new care delivery and payment models. The ACO program began April 1, 2012, along with demonstration projects for bundled payments for episodes of care in Medicaid. Yet even before many components of the Affordable Care Act are fully in place, the Medicare ESRD Program has instituted legislatively mandated changes for dialysis services that resemble many of these care delivery reform proposals. The ESRD program now operates under a fully bundled, case-mix adjusted prospective payment system and has implemented Medicare's first-ever mandatory pay-for-performance program: the ESRD Quality Incentive Program. As ACOs are developed, they may benefit from the nephrology community's experience with these relatively novel models of health care payment and delivery reform. Nephrologists are in a position to assure that the ACO development will benefit from the ESRD experience. This article reviews the new ESRD payment system and the Quality Incentive Program, comparing and contrasting them with ACOs. Better understanding of similarities and differences between the ESRD program and the ACO program will allow the nephrology community to have a more influential voice in shaping the future of health care delivery in the United States.

Successful disease-specific induced pluripotent stem cell generation from patients with kidney transplantation

Introduction

End-stage renal disease (ESRD) is a major public health problem. Although kidney transplantation is a viable therapeutic option, this therapy is associated with significant limitations, including a shortage of donor organs. Induced pluripotent stem (iPS) cell technology, which allows derivation of patient-specific pluripotent stem cells, could provide a possible alternative modality for kidney replacement therapy for patients with ESRD.

Methods

The feasibility of iPS cell generation from patients with a history of ESRD was investigated using lentiviral vectors expressing pluripotency-associated factors.

Results

In the present article we report, for the first time, generation of iPS cells from kidney transplant recipients with a history of autosomal-dominant polycystic kidney disease (ADPKD), systemic lupus erythematosus, or Wilms tumor and ESRD. Lentiviral transduction of OCT4, SOX2, KLF4 and c-MYC, under feeder-free conditions, resulted in reprogramming of skin-derived keratinocytes. Keratinocyte-derived iPS cells exhibited properties of human embryonic stem cells, including morphology, growth properties, expression of pluripotency genes and surface markers, spontaneous differentiation and teratoma formation. All iPS cell clones from the ADPKD patient retained the conserved W3842X mutation in exon 41 of the PKD1 gene.

Conclusions

Our results demonstrate successful iPS cell generation from patients with a history of ESRD, PKD1 gene mutation, or chronic immunosuppression. iPS cells from autosomal kidney diseases, such as ADPKD, would provide unique opportunities to study patient-specific disease pathogenesis in vitro.