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Niu J, Rosales O, Oluyomi A, Lew SQ, Winkelmayer WC, Chertow GM, Erickson KF. The Use of Telemedicine by US Nephrologists for In-Center Hemodialysis Care During the Pandemic: An Analysis of National Medicare Claims. Kidney Med 2024; 6:100798. [PMID: 38645734 PMCID: PMC11026969 DOI: 10.1016/j.xkme.2024.100798] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/23/2024] Open
Abstract
Rationale & Objective Because of coronavirus disease 2019 (COVID-19), the US government issued emergency waivers in March 2020 that removed regulatory barriers around the use of telemedicine. For the first time, nephrologists were reimbursed for telemedicine care delivered during in-center hemodialysis. We examined the use of telemedicine for in-center hemodialysis during the first 16 months of the pandemic. Study Design We ascertained telemedicine modifiers on nephrologist claims. We used multivariable regression to examine time trends and patient, dialysis facility, and geographic correlates of telemedicine use. We also examined whether the estimated effects of predictors of telemedicine use changed over time. Setting & Participants US Medicare beneficiaries receiving in-center hemodialysis between March 1, 2020, and June 30, 2021. Exposures Patient, geographic, and dialysis facility characteristics. Outcomes The use of telehealth for in-center hemodialysis care. Analytic Approach Retrospective cohort analysis. Results Among 267,434 Medicare beneficiaries identified, the reported use of telemedicine peaked at 9% of patient-months in April 2020 and declined to 2% of patient-months by June 2021. Telemedicine use varied geographically and was more common in areas that were remote and socioeconomically disadvantaged. Patients were more likely to receive care by telemedicine in areas with higher incidence of COVID-19, although the predictive value of COVID-19 diminished later in the pandemic. Patients were more likely to receive care using telemedicine if they were at facilities with more staff, and the use of telemedicine varied by facility ownership type. Limitations Limited reporting of telemedicine on claims could lead to underestimation of its use. Reported telemedicine use was higher in an analysis designed to address this limitation by focusing on patients whose physicians used telemedicine at least once during the pandemic. Conclusions Some US nephrologists continued to use telemedicine for in-center hemodialysis throughout the pandemic, even as the association between COVID-19 incidence and telemedicine use diminished over time. These findings highlight unique challenges and opportunities to the future use of telemedicine in dialysis care.
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Affiliation(s)
- Jingbo Niu
- Section of Nephrology, Baylor College of Medicine, Houston, Texas
| | - Omar Rosales
- Center for Epidemiology and Population Health, Baylor College of Medicine, Houston, Texas
| | - Abiodun Oluyomi
- Center for Epidemiology and Population Health, Baylor College of Medicine, Houston, Texas
| | - Susie Q. Lew
- Division of Renal Diseases and Hypertension, George Washington University, Washington, DC
| | | | - Glenn M. Chertow
- Division of Nephrology, Stanford University School of Medicine, Palo Alto, California
| | - Kevin F. Erickson
- Section of Nephrology, Baylor College of Medicine, Houston, Texas
- Baker Institute for Public Policy, Rice University, Houston, Texas
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2
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Brady BM, Zhao B, Dang BN, Winkelmayer WC, Chertow GM, Erickson KF. Patient-Reported Experiences with Dialysis Care and Provider Visit Frequency. Clin J Am Soc Nephrol 2021; 16:1052-1060. [PMID: 34597265 PMCID: PMC8425623 DOI: 10.2215/cjn.16621020] [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: 10/22/2020] [Accepted: 04/19/2021] [Indexed: 02/04/2023]
Abstract
BACKGROUND AND OBJECTIVES New payment models resulting from the Advancing American Kidney Health initiative may create incentives for nephrologists to focus less on face-to-face in-center hemodialysis visits. This study aimed to understand whether more frequent nephrology practitioner dialysis visits improved patient experience and could help inform future policy. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS In a cross-sectional study of patients receiving dialysis from April 1, 2015 through January 31, 2016, we linked patient records from a national kidney failure registry to patient experience data from the In-Center Hemodialysis Consumer Assessment of Healthcare Providers and Systems survey. We used a multivariable mixed effects linear regression model to examine the association between nephrology practitioner visit frequency and patient-reported experiences with nephrologist care. RESULTS Among 5125 US dialysis facilities, 2981 (58%) had ≥30 In-Center Hemodialysis Consumer Assessment of Healthcare Providers and Systems surveys completed between April 2015 and January 2016, and 243,324 patients receiving care within these facilities had Medicare Parts A/B coverage. Face-to-face practitioner visits per month were 71% with four or more visits, 17% with two to three visits, 4% with one visit, and 8% with no visits. Each 10% absolute greater proportion of patients seen by their nephrology practitioner(s) four or more times per month was associated with a modestly but statistically significant lower score of patient experience with nephrologist care by -0.3 points (95% confidence interval, -0.5 to -0.1) and no effect on experience with other domains of dialysis care. CONCLUSIONS In an analysis of patient experiences at the dialysis facility level, frequent nephrology practitioner visits to facilities where patients undergo outpatient hemodialysis were not associated with better patient experiences.
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Affiliation(s)
- Brian M. Brady
- Division of Nephrology, Stanford University School of Medicine, Stanford, California
| | - Bo Zhao
- Selzman Institute for Kidney Health and Section of Nephrology, Baylor College of Medicine, Houston, Texas
| | - Bich N. Dang
- Section of Infectious Diseases, Baylor College of Medicine, Houston, Texas
| | - Wolfgang C. Winkelmayer
- Selzman Institute for Kidney Health and Section of Nephrology, Baylor College of Medicine, Houston, Texas
| | - Glenn M. Chertow
- Division of Nephrology, Stanford University School of Medicine, Stanford, California
| | - Kevin F. Erickson
- Selzman Institute for Kidney Health and Section of Nephrology, Baylor College of Medicine, Houston, Texas,Baker Institute for Public Policy, Rice University, Houston, Texas,Correspondence: Dr. Kevin F. Erickson, Baylor College of Medicine, 2002 Holcombe Boulevard, Mail Code 152, Houston, TX 77030.
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3
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Kelly DM, Anders HJ, Bello AK, Choukroun G, Coppo R, Dreyer G, Eckardt KU, Johnson DW, Jha V, Harris DCH, Levin A, Lunney M, Luyckx V, Marti HP, Messa P, Mueller TF, Saad S, Stengel B, Vanholder RC, Weinstein T, Khan M, Zaidi D, Osman MA, Ye F, Tonelli M, Okpechi IG, Rondeau E. International Society of Nephrology Global Kidney Health Atlas: structures, organization, and services for the management of kidney failure in Western Europe. Kidney Int Suppl (2011) 2021; 11:e106-e118. [PMID: 33981476 DOI: 10.1016/j.kisu.2021.01.007] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2020] [Revised: 12/09/2020] [Accepted: 01/06/2021] [Indexed: 01/08/2023] Open
Abstract
Populations in the high-income countries of Western Europe are aging due to increased life expectancy. As the prevalence of diabetes and obesity has increased, so has the burden of kidney failure. To determine the global capacity for kidney replacement therapy and conservative kidney management, the International Society of Nephrology conducted multinational, cross-sectional surveys and published the findings in the International Society of Nephrology Global Kidney Health Atlas. In the second iteration of the International Society of Nephrology Global Kidney Health Atlas, we aimed to describe the availability, accessibility, quality, and affordability of kidney failure care in Western Europe. Among the 29 countries in Western Europe, 21 (72.4%) responded, representing 99% of the region's population. The burden of kidney failure prevalence varied widely, ranging from 760 per million population (pmp) in Iceland to 1612 pmp in Portugal. Coverage of kidney replacement therapy from public funding was nearly universal, with the exceptions of Germany and Liechtenstein where part of the costs was covered by mandatory insurance. Fourteen (67%) of 21 countries charged no fees at the point of care delivery, but in 5 countries (24%), patients do pay some out-of-pocket costs. Long-term dialysis services (both hemodialysis and peritoneal dialysis) were available in all countries in the region, and kidney transplantation services were available in 19 (90%) countries. The incidence of kidney transplantation varied widely between countries from 12 pmp in Luxembourg to 70.45 pmp in Spain. Conservative kidney care was available in 18 (90%) of 21 countries. The median number of nephrologists was 22.9 pmp (range: 9.47-55.75 pmp). These data highlight the uniform capacity of Western Europe to provide kidney failure care, but also the scope for improvement in disease prevention and management, as exemplified by the variability in disease burden and transplantation rates.
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Affiliation(s)
- Dearbhla M Kelly
- Wolfson Centre for the Prevention of Stroke and Dementia, University of Oxford, John Radcliffe Hospital, Oxford, UK.,Department of Nephrology, Beaumont Hospital, Dublin, Ireland
| | - Hans-Joachim Anders
- Division of Nephrology, Department of Internal Medicine IV, University Hospital of the Ludwig Maximilians University Munich, Munich, Germany
| | - Aminu K Bello
- Division of Nephrology and Immunology, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Gabriel Choukroun
- Nephrology Dialysis Transplantation Department, CHU Amiens, MP3CV Research Unit, Amiens University, Amiens, France
| | - Rosanna Coppo
- Fondazione Ricerca Molinette, Regina Margherita Hospital, Turin, Italy
| | - Gavin Dreyer
- Department of Nephrology, Barts Health National Health Service Trust, London, UK
| | - Kai-Uwe Eckardt
- Department of Nephrology and Medical Intensive Care, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - David W Johnson
- Department of Nephrology, Metro South and Ipswich Nephrology and Transplant Services (MINTS), Princess Alexandra Hospital, Brisbane, Queensland, Australia.,Centre for Kidney Disease Research, University of Queensland at Princess Alexandra Hospital, Brisbane, Queensland, Australia.,Translation Research Institute, Brisbane, Queensland, Australia
| | - Vivekanand Jha
- George Institute for Global Health, University of New South Wales (UNSW), New Delhi, India.,School of Public Health, Imperial College, London, UK.,Manipal Academy of Higher Education, Manipal, India
| | - David C H Harris
- Centre for Transplantation and Renal Research, The Westmead Institute for Medical Research, University of Sydney, Westmead, New South Wales, Australia
| | - Adeera Levin
- Division of Nephrology, Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Meaghan Lunney
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Valerie Luyckx
- Nephrology, Cantonal Hospital Graubunden, Chur, Switzerland.,Renal Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA.,Department of Child Health and Paediatrics, University of Cape Town, Cape Town, South Africa
| | - Hans-Peter Marti
- Department of Clinical Medicine, University of Bergen, Bergen, Norway.,Division of Nephrology, Department of Medicine, Haukeland University Hospital, Bergen, Norway
| | - Piergiorgio Messa
- Nephrology, Dialysis and Renal Transplant Unit, Fondazione IRCCS Ca'Granda Ospedale Maggiore Policlinico, Milan, Italy.,Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Thomas F Mueller
- Nephrology Clinic, University Hospital Zurich, Zürich, Switzerland
| | - Syed Saad
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Benedicte Stengel
- Center for Research in Epidemiology and Population Health (CESP), National Institute of Health and Medical Research (INSERM), Villejuif, France.,University Paris Saclay, Villejuif, France
| | - Raymond C Vanholder
- Department of Internal Medicine and Pediatrics, Nephrology Section, Ghent University Hospital, Ghent, Belgium.,European Kidney Health Alliance, Brussels, Belgium
| | - Talia Weinstein
- Department of Nephrology, Tel Aviv Medical Center, Sackler Medical School, Tel Aviv University, Tel Aviv, Israel
| | - Maryam Khan
- Faculty of Science, University of Alberta, Edmonton, Alberta, Canada
| | - Deenaz Zaidi
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Mohamed A Osman
- Department of Family Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Feng Ye
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Marcello Tonelli
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada.,Pan-American Health Organization/World Health Organization's Collaborating Centre in Prevention and Control of Chronic Kidney Disease, University of Calgary, Calgary, Alberta, Canada
| | - Ikechi G Okpechi
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada.,Division of Nephrology and Hypertension, University of Cape Town, Cape Town, South Africa.,Kidney and Hypertension Research Unit, University of Cape Town, Cape Town, South Africa
| | - Eric Rondeau
- Intensive Care Nephrology and Transplantation Department, Hopital Tenon, Assistance Publique-Hopitaux de Paris, Paris, France.,Sorbonne Université, Paris, France
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Davis J, Zuber K. The changing landscape of PAs and NPs in nephrology. JAAPA 2021; 34:1-8. [PMID: 33332839 DOI: 10.1097/01.jaa.0000723944.52480.d8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Physician assistants (PAs) and NPs have expanded roles in nephrology as both the patient load and acuity of care needed for this population have increased. PURPOSE To evaluate the workforce patterns of PAs and NPs working in nephrology over the past decade. METHODS Using the biannual survey from the National Kidney Foundation Council of Advanced Practitioners, data were collected and analyzed over the past decade. RESULTS Surveys of nephrology practitioners show the evolution of the dialysis-focused practitioner to one encompassing all aspects of nephrology: hospital, ICU, research, office, and all types of dialysis. Salaries and benefits have increased to compensate for the expansion of responsibilities. CONCLUSIONS PAs and NPs in nephrology have the opportunity to use their skills and training in caring for this high-risk population.
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Affiliation(s)
- Jane Davis
- Jane Davis is an NP in the Division of Nephrology at the University of Alabama at Birmingham. Kim Zuber is executive director of the American Academy of Nephrology PAs in St. Petersburg, Fla. Ms. Davis is on the Amgen Speakers Bureau and the ANNA-Amgen chapter programs bureau. The authors have disclosed no other potential conflicts of interest, financial or otherwise
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5
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Davis J, Zuber K. The changing landscape of nephrology physician assistants and nurse practitioners. J Am Assoc Nurse Pract 2021; 33:51-56. [PMID: 33395030 DOI: 10.1097/jxx.0000000000000490] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Accepted: 06/15/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND Physician assistants (PAs) and nurse practitioners (NPs) have expanded roles in nephrology as both the patient load and acuity of care needed for this population have increased. PURPOSE To evaluate workforce patterns of PAs and NPs working in nephrology over the past decade. METHODS Using the biannual survey from the National Kidney Foundation Council of Advanced Practitioners, data were collected and analyzed over the past decade. RESULTS Surveys of nephrology practitioners show the evolution of the dialysis-centralized practitioner to one encompassing all aspects of nephrology: hospital, intensive care unit, research, office, and all types of dialysis. Salaries and benefits have increased to compensate for the expansion of responsibilities. IMPLICATIONS FOR PRACTICE Physician assistants and NPs in nephrology have the opportunity to use their skills and training in caring for this high-risk population.
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Affiliation(s)
- Jane Davis
- Division of Nephrology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Kim Zuber
- American Academy of Nephrology PAs, St Petersburg, Florida JAANP and JAAPA have arranged to publish this article simultaneously in their January 2021 issues. Although the two articles may have minor style differences, they are essentially the same
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6
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Magua W, Basu M, Pastan SO, Kim JJ, Smith K, Gander J, Mohan S, Escoffery C, Plantinga LC, Melanson T, Garber MD, Patzer RE. Effect of the ASCENT Intervention to Increase Knowledge of Kidney Allocation Policy Changes Among Dialysis Providers. Kidney Int Rep 2020; 5:1422-1431. [PMID: 32954067 PMCID: PMC7486341 DOI: 10.1016/j.ekir.2020.06.027] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2020] [Revised: 05/29/2020] [Accepted: 06/23/2020] [Indexed: 11/26/2022] Open
Abstract
INTRODUCTION The Allocation System Changes for Equity in Kidney Transplantation (ASCENT) trial was a cluster-randomized pragmatic, effectiveness-implementation study designed to test whether a multicomponent educational intervention targeting leadership, clinic staff, and patients in dialysis facilities improved knowledge and awareness of the 2014 Kidney Allocation System (KAS) change. METHODS Participants included 690 dialysis facility medical directors, nephrologists, social workers, and other staff within 655 US dialysis facilities, with 51% (n = 334) in the intervention group and 49% (n = 321) in the control group. Intervention activities included a webinar targeting medical directors and facility staff, an approximately 10-minute educational video targeting dialysis staff, an approximately 10-minute educational video targeting patients, and a facility-specific audit and feedback report of transplant performance. The control group received a standard United Network for Organ Sharing brochure. Provider knowledge was a secondary outcome of the ASCENT trial and the primary outcome of this study; knowledge was assessed as a cumulative score on a 5-point Likert scale (higher score = greater knowledge). Intention-to-treat analysis was used. RESULTS At baseline, nonintervention providers had a higher mean knowledge score (mean ± SD, 2.45 ± 1.43) than intervention providers (mean ± SD, 2.31 ± 1.46). After 3 months, the average knowledge score was slightly higher in the intervention (mean ± SD, 3.14 ± 1.28) versus nonintervention providers (mean ± SD, 3.07 ± 1.24), and the estimated mean difference in knowledge scores between the groups at follow-up minus the mean difference at baseline was 0.25 (95% confidence interval [CI], 0.11-0.48; P = 0.039). The effect size (0.41) was low to moderate. CONCLUSION Dialysis facility provider education could help extend the impact of a national policy change in organ allocation.
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Affiliation(s)
- Wairimu Magua
- Department of Surgery, Division of Transplantation, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Mohua Basu
- Department of Surgery, Division of Transplantation, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Stephen O. Pastan
- Department of Medicine, Renal Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Joyce J. Kim
- Department of Surgery, Division of Transplantation, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Kayla Smith
- Department of Surgery, Division of Transplantation, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Jennifer Gander
- Center for Research and Evaluation, Kaiser Permanente Georgia, Atlanta, Georgia, USA
| | - Sumit Mohan
- Department of Medicine, Division of Nephrology, College of Physicians and Surgeons, Columbia University, New York, New York, USA
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York, USA
| | - Cam Escoffery
- Department of Behavioral Sciences and Health Education, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Laura C. Plantinga
- Department of Medicine, Renal Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
- Department of Epidemiology, Rollins School of Public Health, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Taylor Melanson
- Department of Surgery, Division of Transplantation, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Michael D. Garber
- Department of Epidemiology, Rollins School of Public Health, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Rachel E. Patzer
- Department of Surgery, Division of Transplantation, Emory University School of Medicine, Atlanta, Georgia, USA
- Department of Medicine, Renal Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
- Department of Epidemiology, Rollins School of Public Health, Emory University School of Medicine, Atlanta, Georgia, USA
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Awan AA, Zhao B, Anumudu SJ, Winkelmayer WC, Ho V, Erickson KF. Pre-ESKD Nephrology Care and Employment at the Start of Dialysis. Kidney Int Rep 2020; 5:821-830. [PMID: 32518864 PMCID: PMC7270719 DOI: 10.1016/j.ekir.2020.03.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Revised: 02/12/2020] [Accepted: 03/02/2020] [Indexed: 01/05/2023] Open
Abstract
Introduction Employment is associated with an improved sense of well-being and quality of life in patients with kidney disease. Earlier nephrology referral and longer duration of pre-end-stage kidney disease (ESKD) nephrology care are associated with improved health outcomes in patients with advanced kidney disease who initiate dialysis. It is unknown if pre-ESKD nephrology care helps patients stay employed leading up to dialysis initiation. Methods We used the US ESKD registry to identify adults aged 18-54 years who initiated dialysis between 2007 and 2014. Analyses were restricted to patients who reported being employed 6 months prior to ESKD. We used multivariable regression models with estimated average marginal effects to examine the independent association between ≥6 months of pre-ESKD nephrology care and employment at dialysis initiation. To reduce bias, we conducted an instrumental variable (IV) analysis based on geographic variation in pre-ESKD care. Results Of 75,700 patients included in study cohort, 49% reported receiving pre-ESKD nephrology care for ≥6 months, and 62% were employed at dialysis initiation. Although geographic variation in pre-ESKD nephrology care was strongly associated with the likelihood that working-aged patients in our analytic cohort received pre-ESKD care, the receipt of pre-ESKD nephrology care was not significantly associated with employment at dialysis initiation; estimated probability: 5%; 95% confidence interval (CI) -6% to 14%. Conclusions Pre-ESKD nephrology care 6 months prior to initiation of dialysis is not associated with the likelihood of remaining employed at the initiation of dialysis. Although nephrology care has potential to help patients remain employed, this benefit is not manifested in current practice.
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Affiliation(s)
- Ahmed A. Awan
- Selzman Institute for Kidney Health and Section of Nephrology, Baylor College of Medicine, Houston, Texas, USA
- Correspondence: Ahmed A. Awan, Baylor College of Medicine, 7200 Cambridge Street, Suite 8B, MS: BCM902, Houston, Texas 77030, USA.
| | - Bo Zhao
- Selzman Institute for Kidney Health and Section of Nephrology, Baylor College of Medicine, Houston, Texas, USA
| | - Samaya J. Anumudu
- Selzman Institute for Kidney Health and Section of Nephrology, Baylor College of Medicine, Houston, Texas, USA
| | - Wolfgang C. Winkelmayer
- Selzman Institute for Kidney Health and Section of Nephrology, Baylor College of Medicine, Houston, Texas, USA
| | - Vivian Ho
- Center for Innovations in Quality, Effectiveness, and Safety, Baylor College of Medicine, Houston Texas, USA
- Baker Institute for Public Policy, Rice University, Houston, Texas, USA
| | - Kevin F. Erickson
- Selzman Institute for Kidney Health and Section of Nephrology, Baylor College of Medicine, Houston, Texas, USA
- Center for Innovations in Quality, Effectiveness, and Safety, Baylor College of Medicine, Houston Texas, USA
- Baker Institute for Public Policy, Rice University, Houston, Texas, USA
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8
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Anumudu SJ, Erickson KF. Physician reimbursement for outpatient dialysis care: Past, present, and future. Semin Dial 2020; 33:68-74. [DOI: 10.1111/sdi.12853] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2019] [Accepted: 12/20/2019] [Indexed: 11/30/2022]
Affiliation(s)
| | - Kevin F. Erickson
- Section of Nephrology Baylor College of Medicine Houston Texas
- Baylor College of Medicine Center for Innovations in Quality, Effectiveness, and Safety Houston Texas
- Baker Institute for Public Policy Rice University Houston Texas
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9
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Plantinga LC, Jones B, Johnson J, Lambeth A, Lea JP, Nadel L, Vandenberg AE, Bowling CB. Delivery of a patient-friendly functioning report to improve patient-centeredness of dialysis care: a pilot study. BMC Health Serv Res 2019; 19:891. [PMID: 31771573 PMCID: PMC6880368 DOI: 10.1186/s12913-019-4733-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2019] [Accepted: 11/11/2019] [Indexed: 01/22/2023] Open
Abstract
Background Provider recognition of level of functioning may be suboptimal in the dialysis setting, and this lack of recognition may lead to less patient-centered care. We aimed to assess whether delivery of an app-based, individualized functioning report would improve patients’ perceptions of patient-centeredness of care. Methods In this pre-post pilot study at three outpatient dialysis facilities in metropolitan Atlanta, an individualized functioning report—including information on physical performance, perceived physical functioning, and community mobility—was delivered to patients receiving hemodialysis (n = 43) and their providers. Qualitative and quantitative approaches were used to gather patient and provider feedback to develop and assess the report and app. Paired t test was used to test for differences in patient perception of patient-centeredness of care (PPPC) scores (range, 1 = most patient-centered to 4 = least patient-centered) 1 month after report delivery. Results Delivery of the reports to both patients and providers was not associated with a subsequent change in patients’ perceptions of patient-centeredness of their care (follow-up vs. baseline PPPC scores of 2.35 vs. 2.36; P > 0.9). However, patients and providers generally saw the potential of the report to improve the patient-centeredness of care and reacted positively to the individualized reports delivered in the pilot. Patients also reported willingness to undergo future assessments. However, while two-thirds of surveyed providers reported always or sometimes discussing the reports they received, most (98%) participating patients reported that no one on the dialysis care team had discussed the report with them within 1 month. Conclusions Potential lack of fidelity to the intervention precludes definitive conclusions about effects of the report on patient-centeredness of care. The disconnect between patients’ and providers’ perceptions of discussions of the report warrants future study. However, this study introduces a novel, individualized, multi-domain functional report that is easily implemented in the setting of hemodialysis. Our pilot study provides guidance for improving its use both clinically and in future pragmatic research studies, both within and beyond the dialysis population.
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Affiliation(s)
- Laura C Plantinga
- Department of Medicine, Emory University, Atlanta, Georgia, USA. .,Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA.
| | - Brian Jones
- Interactive Media Technology Center, Georgia Institute of Technology, Atlanta, Georgia, USA
| | - Jeremy Johnson
- Interactive Media Technology Center, Georgia Institute of Technology, Atlanta, Georgia, USA
| | - Amelia Lambeth
- Interactive Media Technology Center, Georgia Institute of Technology, Atlanta, Georgia, USA
| | - Janice P Lea
- Department of Medicine, Emory University, Atlanta, Georgia, USA
| | - Leigh Nadel
- Department of Medicine, Emory University, Atlanta, Georgia, USA
| | | | - C Barrett Bowling
- Durham Veterans Affairs Geriatric Research Education and Clinical Center, Durham Veterans Affairs Medical Center, Durham, North Carolina, USA.,Department of Medicine, Duke University, Durham, North Carolina, USA
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10
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Brady BM, Ragavan MV, Simon M, Chertow GM, Milstein A. Exploring Care Attributes of Nephrologists Ranking Favorably on Measures of Value. J Am Soc Nephrol 2019; 30:2464-2472. [PMID: 31727849 DOI: 10.1681/asn.2019030219] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Accepted: 09/15/2019] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND Despite growth in value-based payment, attributes of nephrology care associated with payer-defined value remains unexplored. METHODS Using national health insurance claims data from private preferred provider organization plans, we ranked nephrology practices using total cost of care and a composite of common quality metrics. Blinded to practice rankings, we conducted site visits at four highly ranked and three average ranked practices to identify care attributes more frequently present in highly ranked practices. A panel of nephrologists used a modified Delphi method to score each distinguishing attribute on its potential to affect quality and cost of care and ease of transfer to other nephrology practices. RESULTS Compared with average-value peers, high-value practices were located in areas with a relatively higher proportion of black and Hispanic patients and a lower proportion of patients aged >65 years. Mean risk-adjusted per capita monthly total spending was 24% lower for high-value practices. Twelve attributes comprising five general themes were observed more frequently in high-value nephrology practices: preventing near-term costly health crises, supporting patient self-care, maximizing effectiveness of office visits, selecting cost-effective diagnostic and treatment options, and developing infrastructure to support high-value care. The Delphi panel rated four attributes highly on effect and transferability: rapidly adjustable office visit frequency for unstable patients, close monitoring and management to preserve kidney function, early planning for vascular access, and education to support self-management at every contact. CONCLUSIONS Findings from this small-scale exploratory study may serve as a starting point for nephrologists seeking to improve on payer-specified value measures.
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Affiliation(s)
- Brian M Brady
- Division of Nephrology, .,Clinical Excellence Research Center, and.,Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - Meera V Ragavan
- Clinical Excellence Research Center, and.,Department of Medicine, Stanford University School of Medicine, Stanford, California
| | | | - Glenn M Chertow
- Division of Nephrology.,Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - Arnold Milstein
- Clinical Excellence Research Center, and.,Department of Medicine, Stanford University School of Medicine, Stanford, California
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11
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Erickson KF, Zhao B, Niu J, Winkelmayer WC, Bhattacharya J, Chertow GM, Ho V. Association of Hospitalization and Mortality Among Patients Initiating Dialysis With Hemodialysis Facility Ownership and Acquisitions. JAMA Netw Open 2019; 2:e193987. [PMID: 31099872 PMCID: PMC6537810 DOI: 10.1001/jamanetworkopen.2019.3987] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE Mergers and acquisitions among health care institutions are increasingly common, and dialysis markets have undergone several decades of mergers and acquisitions. OBJECTIVE To examine the outcomes of hemodialysis facility acquisitions independent of associated changes in market competition resulting from acquisitions. DESIGN, SETTING, AND PARTICIPANTS Cohort study using difference-in-differences (DID) analyses to compare changes in health outcomes over time among in-center US dialysis facilities that were acquired by a hemodialysis chain with facilities located nearby but not acquired. Multivariable Cox proportional hazards regression models and negative binomial models with predicted marginal effects were developed to examine health outcomes, controlling for patient, facility, and geographic characteristics. All facility ownership types were examined together and stratified analyses were conducted of facilities that were independently owned and chain owned prior to acquisitions. The study was conducted from January 2001 to September 2015; 174 905 patients starting in-center dialysis in the 3 years before and following dialysis facility acquisitions were included. Data were analyzed from March 2017 to December 2018. EXPOSURES Acquisition by a hemodialysis chain. MAIN OUTCOMES AND MEASURES Twelve-month hazard of death and hospital days per patient-year were the primary outcomes. RESULTS Of the 174 905 patients included in the study, 79 705 were women (45.6%), 24 409 (14.0%) were of Hispanic ethnicity, 61 815 (35.3%) were black, 105 272 (60.2%) were white, and 1247 (0.7%) were Native American. Mean (SD) age was 65 (15) years. Before acquisitions, adjusted mortality and hospitalization rates were 10% (95% CI, -16% to -5%) and 2.9 days per patient-year (95% CI, -3.8 to -2.0) lower, respectively, at independently owned facilities that were acquired compared with those that were not acquired, while hospitalization rates were 0.7 days (95% CI, -1.2 to -2.0) lower at chain-owned facilities that were acquired compared with those that were not acquired. In stratified analyses of independently owned facilities, mortality decreases were smaller at acquired (-8.4%; 95% CI, -14% to -25%) vs nonacquired (-20.3%; 95% CI, -25.8% to -14.3%) facilities (DID P < .001). Similarly, hospitalization rates did not change at acquired facilities and decreased by 2.6 days per patient-year (95% CI, -3.6 to -1.7 days) at nonacquired facilities (DID P < .001). Acquisitions were not associated with changes in health outcomes at chain-owned facilities. Slower reductions in mortality and hospitalization rates at independently owned facilities contributed to significant differences in hospitalizations (-2.0 days; 95% CI, -2.5 to -1.6, at nonacquired vs 0.9 days; 95% CI, -1.3 to -0.5, at acquired facilities; DID, P < .001) across all ownership types but not mortality (DID, P = .28) with regard to acquisitions. CONCLUSIONS AND RELEVANCE Acquisition of independently owned dialysis facilities by larger dialysis organizations was associated with slower decreases in mortality and hospitalization rates, as nonacquired facilities appeared to experience more rapid improvements in outcomes over time.
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Affiliation(s)
- Kevin F Erickson
- Section of Nephrology, Baylor College of Medicine, Houston, Texas
- Center for Innovations in Quality, Effectiveness, and Safety, Baylor College of Medicine, Houston, Texas
- Baker Institute for Public Policy, Rice University, Houston, Texas
| | - Bo Zhao
- Section of Nephrology, Baylor College of Medicine, Houston, Texas
| | - Jingbo Niu
- Section of Nephrology, Baylor College of Medicine, Houston, Texas
| | | | - Jay Bhattacharya
- Center for Primary Care and Outcomes Research, Stanford University School of Medicine, Stanford, California
| | - Glenn M Chertow
- Division of Nephrology, Stanford University School of Medicine, Palo Alto, California
| | - Vivian Ho
- Center for Innovations in Quality, Effectiveness, and Safety, Baylor College of Medicine, Houston, Texas
- Baker Institute for Public Policy, Rice University, Houston, Texas
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12
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Yao YH, Chou YJ, Huang N. Facility size and mortality in hospital-based and freestanding haemodialysis units: A nationwide retrospective cohort study. Nephrology (Carlton) 2018; 24:1157-1164. [PMID: 30499206 DOI: 10.1111/nep.13543] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/27/2018] [Indexed: 11/29/2022]
Abstract
AIM Existing studies on the association between haemodialysis facility size/volume and patient survival are mostly limited to freestanding dialysis units in the United States. This study in Taiwan explored the facility size - mortality association in both hospital-based and freestanding haemodialysis (HD) units. METHODS In this nationwide population-based retrospective cohort study, we used the Taiwan National Health Insurance Research Database to include patients who began maintenance (HD) between 2008 and 2012. Facility size was categorized according to the number of stations in the HD unit. The 5 years mortality rate was analyzed using a frailty model for Cox regression. The patients in hospital-based and freestanding HD units were examined separately. RESULTS Among the 39 506 patients, 24 597 (62.3%) and 14 909 (37.7%) patients received HD in hospital-based and freestanding facilities, respectively. After the 4th month of dialysis initiation, the 5 years survival rates of patients in hospital-based and freestanding HD units were 50.7% and 52.3%, respectively. When patient and other facility characteristics were adjusted, patients in the smallest facility category (1-15 stations) showed the highest mortality risk (hazard ratio, 1.36; 95% confidence interval, 1.11-1.67) among all the patients treated in hospital-based units. The patients treated in freestanding units with 1-15, 16-30 and 31-45 stations showed 31%, 33% and 36%, respectively, higher mortality risks than those of patients treated in units with more than 45 stations. CONCLUSION A small facility size was associated with an increased mortality risk in HD patients, and the threshold size was higher in freestanding units.
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Affiliation(s)
- Yen-Hung Yao
- Division of Nephrology, Department of Medicine, National Yang-Ming University Hospital, Taipei, Taiwan.,Institute of Public Health, National Yang-Ming University, Taipei, Taiwan
| | - Yiing-Jenq Chou
- Institute of Public Health, National Yang-Ming University, Taipei, Taiwan.,School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Nicole Huang
- Institute of Hospital and Health Administration, National Yang-Ming University, Taipei, Taiwan
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13
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Erickson KF, Winkelmayer WC. Evaluating the Evidence behind Policy Mandates in US Dialysis Care. J Am Soc Nephrol 2018; 29:2777-2779. [PMID: 30389727 DOI: 10.1681/asn.2018090905] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Affiliation(s)
- Kevin F Erickson
- Department of Medicine, Selzman Institute for Kidney Health, Section of Nephrology, and .,Department of Medicine, Center for Innovations in Quality, Effectiveness, and Safety, Baylor College of Medicine, Houston, Texas; and.,Baker Institute for Public Policy, Rice University, Houston, Texas
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14
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Grubbs V. Meeting the Palliative Care Needs of Maintenance Hemodialysis Patients: Beyond the Math. Clin J Am Soc Nephrol 2018; 13:1138-1139. [PMID: 30026284 PMCID: PMC6086696 DOI: 10.2215/cjn.07390618] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Affiliation(s)
- Vanessa Grubbs
- University of California, San Francisco, California; and
- Zuckerberg San Francisco General Hospital, San Francisco, California
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15
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Mu Y, Chin AI, Kshirsagar AV, Zhang Y, Bang H. Regional and Temporal Variations in Comorbidity Among US Dialysis Patients: A Longitudinal Study of Medicare Claims Data. INQUIRY: The Journal of Health Care Organization, Provision, and Financing 2018; 55:46958018771163. [PMID: 29745284 PMCID: PMC5952281 DOI: 10.1177/0046958018771163] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Medicare claims data are commonly used to query comorbidities for case-mix adjustment in research of patients with end-stage renal disease (ESRD) in the United States. These adjustments may affect reimbursement and quality rating through comparative profiling and ranking of dialysis facilities. We studied regional and temporal variations in comorbidity from claims data in the United States Renal Data System. Patients with a previous 1-year Medicare history who initiated dialysis therapy between 2006 and 2009 were examined with a follow-up period until 2012. By linking pre- and post-ESRD Medicare claims with the Dartmouth Atlas, we carried out a longitudinal data analysis with multivariable adjustment to investigate regional and temporal variations in the Liu comorbidity index. We identified 23 336 incident hemodialysis patients who were covered by Medicare the year prior to dialysis initiation and had survived with complete 3 years of follow-up data. With the United States divided into 4 geographic regions, the Western region was found to have the lowest Liu index over all 3 follow-up years, compared with the respective years in the other regions (Midwest, Northeast, and South). In comparison with the first year, the Liu index dropped significantly during the second and third years of follow-up across all 4 regions. Significant regional and temporal variations observed in the comorbidity index cannot be explained by differences in reimbursement (average per state) or predialysis comorbidity. Based on our exploratory study, future studies should focus on identifying the factors and reasons for these variations which have the potential to affect health care policy and research.
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Affiliation(s)
- Yi Mu
- 1 Department of Public Health Sciences, University of California, Davis, CA, USA
| | - Andrew I Chin
- 2 Division of Nephrology, University of California, Davis School of Medicine, Sacramento, CA, USA.,3 Division of Nephrology, Sacramento VA Medical Center, VA Northern California Health Care Systems, Mather Field, CA, USA
| | - Abhijit V Kshirsagar
- 4 UNC Kidney Center, Chapel Hill, NC, USA.,5 Division of Nephrology and Hypertension, University of North Carolina, Chapel Hill, NC, USA
| | - Yi Zhang
- 6 Medical Technology and Practice Patterns Institute, Bethesda, MD, USA
| | - Heejung Bang
- 1 Department of Public Health Sciences, University of California, Davis, CA, USA.,2 Division of Nephrology, University of California, Davis School of Medicine, Sacramento, CA, USA
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16
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Kurella Tamura M, O'Hare AM, Lin E, Holdsworth LM, Malcolm E, Moss AH. Palliative Care Disincentives in CKD: Changing Policy to Improve CKD Care. Am J Kidney Dis 2018; 71:866-873. [PMID: 29510920 DOI: 10.1053/j.ajkd.2017.12.017] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2017] [Accepted: 12/14/2017] [Indexed: 01/03/2023]
Abstract
The dominant health delivery model for advanced chronic kidney disease (CKD) and end-stage renal disease (ESRD) in the United States, which focuses on provision of dialysis, is ill-equipped to address many of the needs of seriously ill patients. Although palliative care may address some of these gaps in care, its integration into advanced CKD care has been suboptimal due to several health system barriers. These barriers include uneven access to specialty palliative care services, underdeveloped models of care for seriously ill patients with advanced CKD, and misaligned policy incentives. This article reviews policies that affect the delivery of palliative care for this population, discusses reforms that could address disincentives to palliative care, identifies quality measurement issues for palliative care for individuals with advanced CKD and ESRD, and considers potential pitfalls in the implementation of new models of integrated palliative care. Reforming health care delivery in ways that remove policy disincentives to palliative care for patients with advanced CKD and ESRD will fill a critical gap in care.
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Affiliation(s)
- Manjula Kurella Tamura
- Geriatric Research and Education Clinical Center, VA Palo Alto Health Care System, Palo Alto, CA; Division of Nephrology, Stanford University School of Medicine, Palo Alto, CA.
| | - Ann M O'Hare
- Division of Nephrology, University of Washington School of Medicine and VA Puget Sound Healthcare System, Seattle, WA
| | - Eugene Lin
- Division of Nephrology, Stanford University School of Medicine, Palo Alto, CA; Centers for Health Policy, Stanford University School of Medicine, Palo Alto, CA; Primary Care Outcomes Research, Stanford University School of Medicine, Palo Alto, CA
| | - Laura M Holdsworth
- Division of Primary Care and Population Health, Stanford University School of Medicine, Palo Alto, CA
| | - Elizabeth Malcolm
- Division of Primary Care and Population Health, Stanford University School of Medicine, Palo Alto, CA
| | - Alvin H Moss
- Sections of Nephrology, West Virginia University School of Medicine, Morgantown, WV; Supportive Care, West Virginia University School of Medicine, Morgantown, WV
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17
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Golestaneh L. Decreasing hospitalizations in patients on hemodialysis: Time for a paradigm shift. Semin Dial 2018; 31:278-288. [DOI: 10.1111/sdi.12675] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Affiliation(s)
- Ladan Golestaneh
- Nephrology Division; Department of Medicine; Montefiore Medical Center; Albert Einstein College of Medicine; Bronx NY USA
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18
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Plantinga LC, King L, Patzer RE, Lea JP, Burkart JM, Hockenberry JM, Jaar BG. Early hospital readmission among hemodialysis patients in the United States is associated with subsequent mortality. Kidney Int 2017; 92:934-941. [PMID: 28532710 DOI: 10.1016/j.kint.2017.03.025] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2017] [Revised: 03/10/2017] [Accepted: 03/16/2017] [Indexed: 10/19/2022]
Abstract
Dialysis providers in the United States may soon be held accountable for their patients' 30-day hospital readmissions. However, few studies have evaluated the timing of readmissions, which determines the window in which dialysis providers could act to prevent readmission. We therefore examined the timing of readmissions of hemodialysis patients in the United States and its association with mortality among 285,795 prevalent adult Medicare-primary hemodialysis patients from a national registry. Patients had at least one hospitalization in 2010-2013 (first index) and survived for 30 days or more. Readmission timing was defined as 0-7, 8-14, or 15-30 days after the index discharge. Multivariable Cox proportional hazards models were used to estimate the association between readmission timing (referent no readmission) and mortality, censored at one year. Overall, 23.1% of patients had readmissions within 30 days of the index discharge, of which over one-third (35.9%) were within the first week. Regardless of timing, patients with readmissions had a higher risk of death within one year, compared to those with no readmissions, with hazard ratios of 2.04 (95% confidence interval 2.00-2.09) for being readmitted within 15-30 days; 1.98 (1.93-2.04) for being readmitted within 8-14 days; and 1.76 (1.71-1.80) for being readmitted within 0-7 days. Thus, opportunities for dialysis providers to intervene and prevent early readmission may be limited. Regardless of the timing, readmission appears independently associated with a substantially increased risk of mortality in this population.
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Affiliation(s)
- Laura C Plantinga
- Department of Medicine, Emory University, Atlanta, Georgia, USA; Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA.
| | - Laura King
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Rachel E Patzer
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA; Department of Surgery, Emory University, Atlanta, Georgia, USA
| | - Janice P Lea
- Department of Medicine, Emory University, Atlanta, Georgia, USA
| | - John M Burkart
- Wake Forest Baptist Medical Center, Winston-Salem, North Carolina, USA
| | - Jason M Hockenberry
- Department of Health Policy and Management, Emory University, Atlanta, Georgia, USA
| | - Bernard G Jaar
- Department of Medicine Johns Hopkins School of Medicine, Baltimore, Maryland, USA; Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA; Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins University, Baltimore, Maryland, USA; Nephrology Center of Maryland Baltimore, Maryland, USA
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19
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Erickson KF, Winkelmayer WC, Chertow GM, Bhattacharya J. Hemodialysis Hospitalizations and Readmissions: The Effects of Payment Reform. Am J Kidney Dis 2017; 69:237-246. [PMID: 27856087 PMCID: PMC5263112 DOI: 10.1053/j.ajkd.2016.08.033] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2016] [Accepted: 08/11/2016] [Indexed: 02/04/2023]
Abstract
BACKGROUND In 2004, the Centers for Medicare & Medicaid Services changed reimbursement for physicians and advanced practitioners caring for patients receiving hemodialysis from a capitated to a tiered fee-for-service system, encouraging increased face-to-face visits. This early version of a pay-for-performance initiative targeted a care process: more frequent provider visits in hemodialysis. Although more frequent provider visits in hemodialysis are associated with fewer hospitalizations and rehospitalizations, it is unknown whether encouraging more frequent visits through reimbursement policy also yielded these benefits. STUDY DESIGN We used a retrospective cohort interrupted time-series study design to examine whether the 2004 nephrologist reimbursement reform led to reduced hospitalizations and rehospitalizations. We also used published data to estimate a range of annual economic costs associated with more frequent visits. SETTING & PARTICIPANTS Medicare beneficiaries in the United States receiving hemodialysis in the 2 years prior to and following reimbursement reform. PREDICTOR The 2 years following nephrologist reimbursement reform. OUTCOMES Odds of hospitalization and 30-day hospital readmission for all causes and fluid overload; US dollars. RESULTS We found no significant change in all-cause hospitalization or rehospitalization and slight reductions in fluid overload hospitalization and rehospitalization following reimbursement reform; the estimated economic cost associated with additional visits ranged from $13 to $87 million per year, depending on who (physicians or advanced practitioners) spent additional time visiting patients and how much additional effort was involved. LIMITATIONS Due to limited information about how much additional time providers spent seeing patients after reimbursement reform, we could only examine a range of potential economic costs associated with the reform. CONCLUSIONS A Medicare reimbursement policy designed to encourage more frequent visits during outpatient hemodialysis may have been costly. The policy was associated with fewer hospitalizations and rehospitalizations for fluid overload, but had no effect on all-cause hospitalizations or rehospitalizations.
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Affiliation(s)
- Kevin F Erickson
- Section of Nephrology, Selzman Institute for Kidney Health, Baylor College of Medicine, Houston, TX; Center for Innovations in Quality, Effectiveness and Safety, Baylor College of Medicine, Houston, TX.
| | - Wolfgang C Winkelmayer
- Section of Nephrology, Selzman Institute for Kidney Health, Baylor College of Medicine, Houston, TX
| | - Glenn M Chertow
- Division of Nephrology, Department of Medicine, Stanford University School of Medicine, Palo Alto, CA
| | - Jay Bhattacharya
- Center for Primary Care and Outcomes Research, Department of Medicine, Stanford University School of Medicine, Stanford, CA
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20
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Wetmore JB, Liu J, Dluzniewski PJ, Ishani A, Block GA, Collins AJ. Geographic variation of parathyroidectomy in patients receiving hemodialysis: a retrospective cohort analysis. BMC Surg 2016; 16:77. [PMID: 27899108 PMCID: PMC5129232 DOI: 10.1186/s12893-016-0193-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2016] [Accepted: 11/24/2016] [Indexed: 11/24/2022] Open
Abstract
Background Secondary hyperparathyroidism (SHPT) is associated with adverse outcomes in patients receiving maintenance dialysis. Parathyroidectomy is a treatment for SHPT; whether parathyroidectomy utilization varies geographically in the US is unknown. Methods A retrospective cohort analysis was undertaken to identify all patients aged 18 years or older who were receiving in-center hemodialysis between 2007 and 2009, were covered by Medicare Parts A and B, and had been receiving hemodialysis for at least 1 year. Parathyroidectomy was identified from inpatient claims using relevant International Classification of Diseases, Ninth Revision, Clinical Modification procedure codes. Patient characteristics and End-Stage Renal Disease Network (a proxy for geography) were ascertained. Adjusted odds ratios for parathyroidectomy were estimated from a logistic model. Results A total of 286,569 patients satisfied inclusion criteria, of whom 4435 (1.5%) underwent PTX. After adjustment for a variety of patient characteristics, there was a 2-fold difference in adjusted odds of parathyroidectomy between the most- and least-frequently performing regions. Adjusted odds ratios were more than 20% higher than average in four networks, and more than 20% lower in four networks. Conclusions Parathyroidectomy use varies substantially by geography in the US; the factors responsible should be further investigated.
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Affiliation(s)
- James B Wetmore
- Chronic Disease Research Group, Minneapolis Medical Research Foundation, 914 South 8th Street, Suite S4.100, Minneapolis, MN, 55404, USA. .,Division of Nephrology, Hennepin County Medical Center, Minneapolis, MN, USA. .,Department of Medicine, University of Minnesota, Minneapolis, MN, USA.
| | - Jiannong Liu
- Chronic Disease Research Group, Minneapolis Medical Research Foundation, 914 South 8th Street, Suite S4.100, Minneapolis, MN, 55404, USA
| | | | - Areef Ishani
- Chronic Disease Research Group, Minneapolis Medical Research Foundation, 914 South 8th Street, Suite S4.100, Minneapolis, MN, 55404, USA.,Department of Medicine, University of Minnesota, Minneapolis, MN, USA.,Section of Renal Diseases and Hypertension, Minneapolis Veterans Administration Health Care System, Minneapolis, MN, USA
| | | | - Allan J Collins
- Chronic Disease Research Group, Minneapolis Medical Research Foundation, 914 South 8th Street, Suite S4.100, Minneapolis, MN, 55404, USA.,Department of Medicine, University of Minnesota, Minneapolis, MN, USA
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21
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Wetmore JB, Liu J, Wirtz HS, Gilbertson DT, Cooper K, Nieman KM, Collins AJ, Bradbury BD. Geovariation in Fracture Risk among Patients Receiving Hemodialysis. Clin J Am Soc Nephrol 2016; 11:1413-1421. [PMID: 27269611 PMCID: PMC4974888 DOI: 10.2215/cjn.11651115] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2015] [Accepted: 04/04/2016] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND OBJECTIVES Fractures are a major source of morbidity and mortality in patients receiving dialysis. We sought to determine whether rates of fractures and tendon ruptures vary geographically. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS Data from the US Renal Data System were used to create four yearly cohorts, 2007-2010, including all eligible prevalent patients on hemodialysis in the United States on January 1 of each year. A secondary analysis comprising patients in a large dialysis organization conducted over the same period permitted inclusion of patient-level markers of mineral metabolism. Patients were grouped into 10 regions designated by the Centers for Medicare and Medicaid Services and divided by latitude into one of three bands: south, <35°; middle, 35° to <40°; and north, ≥40°. Poisson regression was used to calculate unadjusted and adjusted region-level rate ratios for events. RESULTS Overall, 327,615 patients on hemodialysis were included. Mean (SD) age was 61.8 (15.0) years old, 52.7% were white, and 55.0% were men. During 716,962 person-years of follow-up, 44,014 fractures and tendon ruptures occurred, the latter being only 0.3% of overall events. Event rates ranged from 5.36 to 7.83 per 100 person-years, a 1.5-fold rate difference across regions. Unadjusted region-level rate ratios varied from 0.83 (95% confidence interval, 0.81 to 0.85) to 1.20 (95% confidence interval, 1.18 to 1.23), a 1.45-fold rate difference. After adjustment for a wide range of case mix variables, a 1.33-fold variation in rates remained. Rates were higher in north and middle bands than the south (north rate ratio, 1.18; 95% confidence interval, 1.13 to 1.23; middle rate ratio, 1.13; 95% confidence interval, 1.10 to 1.17). Latitude explained 11% of variation, independent of region. A complementary analysis of 87,013 patients from a large dialysis organization further adjusted for circulating mineral metabolic parameters and protein energy wasting yielded similar results. CONCLUSIONS Rates of fractures vary geographically in the United States dialysis population, even after adjustment for known patient characteristics. Latitude seems to contribute to this phenomenon, but additional analyses exploring whether other factors might influence variation are warranted.
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Affiliation(s)
- James B. Wetmore
- Chronic Disease Research Group, Minneapolis Medical Research Foundation, Minneapolis, Minnesota
| | - Jiannong Liu
- Chronic Disease Research Group, Minneapolis Medical Research Foundation, Minneapolis, Minnesota
| | | | - David T. Gilbertson
- Chronic Disease Research Group, Minneapolis Medical Research Foundation, Minneapolis, Minnesota
| | - Kerry Cooper
- Global Medical Organization, Amgen, Inc., Thousand Oaks, California; and
| | - Kimberly M. Nieman
- Chronic Disease Research Group, Minneapolis Medical Research Foundation, Minneapolis, Minnesota
| | - Allan J. Collins
- Chronic Disease Research Group, Minneapolis Medical Research Foundation, Minneapolis, Minnesota
- Department of Medicine, University of Minnesota, Minneapolis, Minnesota
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22
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Shen JI, Saxena AB, Montez-Rath ME, Leng L, Chang TI, Winkelmayer WC. Comparative effectiveness of angiotensin receptor blockers vs. angiotensin-converting enzyme inhibitors on cardiovascular outcomes in patients initiating peritoneal dialysis. J Nephrol 2016; 30:281-288. [PMID: 27485007 DOI: 10.1007/s40620-016-0340-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2016] [Accepted: 07/28/2016] [Indexed: 12/01/2022]
Abstract
BACKGROUND There is evidence that angiotensin-converting enzyme inhibitors (ACEI) and angiotensin-II receptor blockers (ARB) may reduce cardiovascular (CV) risk in patients undergoing peritoneal dialysis (PD), but no studies have compared the effectiveness between these drug classes. In this observational cohort study, we compared the association of ARB vs. ACEI use on CV outcomes in patients initiating PD. METHODS We identified from the US Renal Data System all adult patients who initiated PD from 2007 to 2011 and participated in Medicare Part D, a federal prescription drug benefits program, for the first 90 days of dialysis. Patients who filled a prescription for an ACEI or ARB in those 90 days were considered users. We excluded patients who used both ACEI and ARB. We applied Cox proportional hazards regression to an inverse probability of treatment-weighted cohort to estimate the hazard ratios (HR) for the combined outcome of all-cause death, ischemic stroke, or myocardial infarction; all-cause mortality; and CV death. RESULTS Among 1892 patients using either drug class, 39 % were ARB users. We observed 624 events over 2,898 person-years of follow-up, for a composite event rate of 22 events per 100 person-years. We observed no differences between ARB vs. ACEI users: composite outcome HR 0.94, 95 % confidence interval (CI) 0.79-1.11; all-cause mortality HR 0.92, 95 % CI 0.76-1.10; CV death HR: 1.06, 95 % CI 0.80-1.41. CONCLUSION We identified no significant difference in the risks of CV events or death between users of ARBs vs. ACEIs in patients initiating PD, thus supporting their mostly interchangeable use in this population.
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Affiliation(s)
- Jenny I Shen
- Division of Nephrology and Hypertension, Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center, 1000 W. Carson St., Box 406, Torrance, CA, 90509, USA. .,Division of Nephrology, Department of Medicine, Stanford University School of Medicine, Palo Alto, CA, USA.
| | - Anjali B Saxena
- Division of Nephrology, Department of Medicine, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Maria E Montez-Rath
- Division of Nephrology, Department of Medicine, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Lynn Leng
- Division of Nephrology and Hypertension, Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center, 1000 W. Carson St., Box 406, Torrance, CA, 90509, USA
| | - Tara I Chang
- Division of Nephrology, Department of Medicine, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Wolfgang C Winkelmayer
- Division of Nephrology, Department of Medicine, Stanford University School of Medicine, Palo Alto, CA, USA.,Selzman Institute for Kidney Health, Section of Nephrology, Department of Medicine, Baylor College of Medicine, Houston, TX, USA
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23
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Erickson KF, Winkelmayer WC, Chertow GM, Bhattacharya J. Effects of physician payment reform on provision of home dialysis. THE AMERICAN JOURNAL OF MANAGED CARE 2016; 22:e215-23. [PMID: 27355909 PMCID: PMC5055389] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
OBJECTIVES Patients with end-stage renal disease can receive dialysis at home or in-center. In 2004, CMS reformed physician payment for in-center hemodialysis care from a capitated to a tiered fee-for-service model, augmenting physician payment for frequent in-center visits. We evaluated whether payment reform influenced dialysis modality assignment. STUDY DESIGN Cohort study of patients starting dialysis in the United States in the 3 years before and the 3 years after payment reform. METHODS We conducted difference-in-difference analyses comparing patients with traditional Medicare coverage (who were affected by the policy) to others with Medicare Advantage (who were unaffected by the policy). We also examined whether the policy had a more pronounced influence on dialysis modality assignment in areas with lower costs of traveling to dialysis facilities. RESULTS Patients with traditional Medicare coverage experienced a 0.7% (95% CI, 0.2%-1.1%; P = .003) reduction in the absolute probability of home dialysis use following payment reform compared with patients with Medicare Advantage. Patients living in areas with larger dialysis facilities (where payment reform made in-center hemodialysis comparatively more lucrative for physicians) experienced a 0.9% (95% CI, 0.5%-1.4%; P < .001) reduction in home dialysis use following payment reform compared with patients living in areas with smaller facilities (where payment reform made in-center hemodialysis comparatively less lucrative for physicians). CONCLUSIONS The transition from a capitated to a tiered fee-for-service payment model for in-center hemodialysis care resulted in fewer patients receiving home dialysis. This area of policy failure highlights the importance of considering unintended consequences of future physician payment reform efforts.
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Affiliation(s)
- Kevin F Erickson
- Center for Innovations in Quality, Effectiveness, and Safety, Baylor College of Medicine, 2002 Holcombe Blvd, Mail Code 152, Houston, TX 77030. E-mail:
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Harel Z, Wald R, McArthur E, Chertow GM, Harel S, Gruneir A, Fischer HD, Garg AX, Perl J, Nash DM, Silver S, Bell CM. Rehospitalizations and Emergency Department Visits after Hospital Discharge in Patients Receiving Maintenance Hemodialysis. J Am Soc Nephrol 2015; 26:3141-50. [PMID: 25855772 PMCID: PMC4657827 DOI: 10.1681/asn.2014060614] [Citation(s) in RCA: 59] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2014] [Accepted: 02/20/2015] [Indexed: 12/13/2022] Open
Abstract
Clinical outcomes after a hospital discharge are poorly defined for patients receiving maintenance in-center (outpatient) hemodialysis. To describe the proportion and characteristics of these patients who are rehospitalized, visit an emergency department, or die within 30 days after discharge from an acute hospitalization, we conducted a population-based study of all adult patients receiving maintenance in-center hemodialysis who were discharged between January 1, 2003, and December 31, 2011, from 157 acute care hospitals in Ontario, Canada. For patients with more than one hospitalization, we randomly selected a single hospitalization as the index hospitalization. Of the 11,177 patients included in the final cohort, 1926 (17%) were rehospitalized, 2971 (27%) were treated in the emergency department, and 840 (7.5%) died within 30 days of discharge. Complications of type 2 diabetes mellitus were the most common reason for rehospitalization, whereas heart failure was the most common reason for an emergency department visit. In multivariable analysis using a cause-specific Cox proportional hazards model, the following characteristics were associated with 30-day rehospitalization: older age, the number of hospital admissions in the preceding 6 months, the number of emergency department visits in the preceding 6 months, higher Charlson comorbidity index score, and the receipt of mechanical ventilation during the index hospitalization. Thus, a large proportion of patients receiving maintenance in-center hemodialysis will be readmitted or visit an emergency room within 30 days of an acute hospitalization. A focus on improving care transitions from the inpatient setting to the outpatient dialysis unit may improve outcomes and reduce healthcare costs.
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Affiliation(s)
- Ziv Harel
- Division of Nephrology, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada; Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada; Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada;
| | - Ron Wald
- Division of Nephrology, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada; Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada; Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | - Eric McArthur
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | - Glenn M Chertow
- Division of Nephrology, Stanford University School of Medicine, Palo Alto, California
| | - Shai Harel
- Division of Nephrology, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Andrea Gruneir
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada; Women's College Research Institute, Toronto, Ontario, Canada; Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Hadas D Fischer
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | - Amit X Garg
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada; Division of Nephrology, London Health Sciences Centre, Western University, London, Ontario, Canada; and
| | - Jeffrey Perl
- Division of Nephrology, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada; Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Danielle M Nash
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | - Samuel Silver
- Division of Nephrology, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Chaim M Bell
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada; Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada; Department of Medicine, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
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Gomez AT, Kiberd BA, Royston JP, Alfaadhel T, Soroka SD, Hemmelgarn BR, Tennankore KK. Comorbidity burden at dialysis initiation and mortality: A cohort study. Can J Kidney Health Dis 2015; 2:34. [PMID: 26351568 PMCID: PMC4562341 DOI: 10.1186/s40697-015-0068-3] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2015] [Accepted: 07/24/2015] [Indexed: 11/14/2022] Open
Abstract
Background A high level of comorbidity at dialysis initiation is associated with an increased risk of death. However, contemporary assessments of the validity and prognostic value of comorbidity indices are lacking. Objectives To assess the validity of two comorbidity indices and to determine if a high degree of comorbidity is associated with mortality among dialysis patients. Design Cohort study. Setting QEII Health Sciences Centre (Halifax, Nova Scotia, Canada). Patients Incident, chronic dialysis patients between 01 Jan 2006 and 01 Jul 2013. Measurements Exposure: The Charlson Comorbidity Index (CCI) and End-Stage Renal Disease Comorbidity Index (ESRD-CI) were used to classify individual comorbid conditions into an overall score. Comorbidities were classified using patient charts and electronic records. Outcome: All-cause mortality. Confounders: Patient demographics, dialysis access, cause of ESRD and baseline laboratory data. Methods Regression coefficients were estimated on the CCI and ESRD-CI. Discrimination for death was assessed using Harrell’s c-index. Adjusted Cox proportional hazard models were used to calculate relative hazards and 95 % confidence intervals for each category of the CCI and ESRD-CI. Results The cohort consisted of 771 ESRD patients from 01 Jan 2006 to 01 Jul 2013. Most were male (62 %) and Caucasian (91 %). The cohort had a high proportion of diabetes (48 %), history of previous myocardial infarction (31 %) and heart failure (22 %). Regression coefficients on the CCI and ESRD-CI were 0.55 and 0.52, respectively. The c-index, for the prediction of death, was 0.61 for the CCI and 0.63 for the ESRD-CI. ESRD-CI scores of 4, 5 and ≥6 were associated with a similar mortality risk (adjusted relative hazard of 1.95, 1.89 and 1.99, respectively). There was a small increased mortality risk for CCI scores of 4, 5 and ≥6 (adjusted relative hazard of 1.86, 2.38 and 2.71, respectively). Limitations Classification of comorbidities for each patient was determined by clinical impression. Conclusions The CCI and ESRD-CI have a limited ability to discriminate mortality risk for incident dialysis patients. Acknowledging the frequency with which they are used, this study emphasizes the need to re-examine the usefulness of previously derived comorbidity indices in contemporary dialysis cohorts.
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Affiliation(s)
- Alwyn T Gomez
- Faculty of Medicine, Dalhousie University, Halifax, NS Canada
| | - Bryce A Kiberd
- Department of Medicine (Division of Nephrology), Dalhousie University, Halifax, NS Canada ; Nova Scotia Health Authority, 5820 University Avenue, Halifax, NS Canada B3H 1V8
| | | | - Talal Alfaadhel
- Department of Medicine (Division of Nephrology), Dalhousie University, Halifax, NS Canada
| | - Steven D Soroka
- Department of Medicine (Division of Nephrology), Dalhousie University, Halifax, NS Canada ; Nova Scotia Health Authority, 5820 University Avenue, Halifax, NS Canada B3H 1V8
| | - Brenda R Hemmelgarn
- Department of Medicine, University of Calgary, Calgary, AB Canada ; Department of Community Health Sciences, University of Calgary, Calgary, AB Canada
| | - Karthik K Tennankore
- Department of Medicine (Division of Nephrology), Dalhousie University, Halifax, NS Canada ; Nova Scotia Health Authority, 5820 University Avenue, Halifax, NS Canada B3H 1V8
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Erickson KF, Mell MW, Winkelmayer WC, Chertow GM, Bhattacharya J. Provider visit frequency and vascular access interventions in hemodialysis. Clin J Am Soc Nephrol 2015; 10:269-77. [PMID: 25587105 DOI: 10.2215/cjn.05540614] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND AND OBJECTIVES Medicare reimbursement policy encourages frequent provider visits to patients with ESRD undergoing hemodialysis. This study sought to determine whether more frequent face-to-face provider (physician and advanced practitioner) visits lead to more procedures and therapeutic interventions aimed at preserving arteriovenous fistulas and grafts, improved vascular access outcomes, and fewer related hospitalizations. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS Multivariable regression was used to evaluate the association between provider (physician and advanced practitioner) visit frequency and interventions aimed at preserving vascular access, vascular access survival, hospitalization for vascular access infection, and outpatient antibiotic use in a cohort of 63,488 Medicare beneficiaries receiving hemodialysis in the United States. Medicare claims were used to identify the type of vascular access used, access-related events, and vascular access failure. RESULTS One additional provider (physician and advanced practitioner) visit per month was associated with a 13% higher odds of receiving an intervention to preserve vascular access (95% confidence interval [95% CI], 12% to 14%) but was not associated with vascular access survival (hazard ratio, 1.01; 95% CI, 0.99 to 1.03). One additional provider visit was associated with a 9% (95% CI, 5% to 14%) lower odds of hospitalization for vascular access infection and a corresponding 9% (95% CI, 5% to 14%) higher odds of outpatient intravenous antibiotic administration. However, the associated changes in absolute probabilities of hospitalization and antibiotic administration were small. CONCLUSIONS More frequent face-to-face provider (physician and advanced practitioner) visits were associated with more procedures and therapeutic interventions aimed at preserving vascular accesses, but not with prolonged vascular access survival and only a small decrease in hospitalization for vascular access.
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Affiliation(s)
- Kevin F Erickson
- Division of Nephrology, Department of Medicine, Center for Primary Care and Outcomes Research, Department of Medicine, and
| | - Matthew W Mell
- Division of Vascular Surgery, Department of Surgery, Stanford University School of Medicine, Palo Alto, California; and
| | | | | | - Jay Bhattacharya
- Center for Primary Care and Outcomes Research, Department of Medicine, and
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Erickson KF, Mell M, Winkelmayer WC, Chertow GM, Bhattacharya J. Provider Visits and Early Vascular Access Placement in Maintenance Hemodialysis. J Am Soc Nephrol 2014; 26:1990-7. [PMID: 25452668 DOI: 10.1681/asn.2014050464] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2014] [Accepted: 10/27/2014] [Indexed: 11/03/2022] Open
Abstract
Medicare reimbursement policy encourages frequent provider visits for patients with ESRD undergoing hemodialysis. We hypothesize that patients seen more frequently by their nephrologist or advanced practitioner within the first 90 days of hemodialysis are more likely to undergo surgery to create an arteriovenous (AV) fistula or place an AV graft. We selected 35,959 patients aged ≥67 years starting hemodialysis in the United States from a national registry. We used multivariable regression to evaluate the associations between mean visit frequency and AV fistula creation or graft placement in the first 90 days of hemodialysis. We conducted an instrumental variable analysis to test the sensitivity of our findings to potential bias from unobserved characteristics. One additional visit per month in the first 90 days of hemodialysis was associated with a 21% increase in the odds of AV fistula creation or graft placement during that period (95% confidence interval, 19% to 24%), corresponding to an average 4.5% increase in absolute probability. An instrumental variable analysis demonstrated similar findings. Excluding visits in months when patients were hospitalized, one additional visit per month was associated with a 10% increase in odds of vascular access surgery (95% confidence interval, 8% to 13%). In conclusion, patients seen more frequently by care providers in the first 90 days of hemodialysis undergo earlier AV fistula creation or graft placement. Payment policies that encourage more frequent visits to patients at key clinical time points may yield more favorable health outcomes than policies that operate irrespective of patients' health status.
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Affiliation(s)
- Kevin F Erickson
- Division of Nephrology and Center for Primary Care and Outcomes Research, Department of Medicine, and
| | - Matthew Mell
- Division of Vascular Surgery, Department of Surgery, Stanford University School of Medicine, Palo Alto, California; and
| | | | | | - Jay Bhattacharya
- Center for Primary Care and Outcomes Research, Department of Medicine, and
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Erickson KF, Winkelmayer WC, Chertow GM, Bhattacharya J. Physician visits and 30-day hospital readmissions in patients receiving hemodialysis. J Am Soc Nephrol 2014; 25:2079-87. [PMID: 24812168 DOI: 10.1681/asn.2013080879] [Citation(s) in RCA: 74] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
A focus of health care reform has been on reducing 30-day hospital readmissions. Patients with ESRD are at high risk for hospital readmission. It is unknown whether more monitoring by outpatient providers can reduce hospital readmissions in patients receiving hemodialysis. In nationally representative cohorts of patients in the United States receiving in-center hemodialysis between 2004 and 2009, we used a quasi-experimental (instrumental variable) approach to assess the relationship between frequency of visits to patients receiving hemodialysis following hospital discharge and the probability of rehospitalization. We then used a multivariable regression model and published hospitalization data to estimate the cost savings and number of hospitalizations that could be prevented annually with additional provider visits to patients in the month following hospitalization. In the main cohort (n=26,613), one additional provider visit in the month following hospital discharge was estimated to reduce the absolute probability of 30-day hospital readmission by 3.5% (95% confidence interval, 1.6% to 5.3%). The reduction in 30-day hospital readmission ranged from 0.5% to 4.9% in an additional four cohorts tested, depending on population density around facilities, facility profit status, and patient Medicaid eligibility. At current Medicare reimbursement rates, the effort to visit patients one additional time in the month following hospital discharge could lead to 31,370 fewer hospitalizations per year, and $240 million per year saved. In conclusion, more frequent physician visits following hospital discharge are estimated to reduce rehospitalizations in patients undergoing hemodialysis. Incentives for closer outpatient monitoring following hospital discharge could lead to substantial cost savings.
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Affiliation(s)
- Kevin F Erickson
- Division of Nephrology, Stanford University School of Medicine, Palo Alto, California; and Center for Primary Care and Outcomes Research, Stanford University School of Medicine, Stanford, California
| | - Wolfgang C Winkelmayer
- Division of Nephrology, Stanford University School of Medicine, Palo Alto, California; and
| | - Glenn M Chertow
- Division of Nephrology, Stanford University School of Medicine, Palo Alto, California; and
| | - Jay Bhattacharya
- Center for Primary Care and Outcomes Research, Stanford University School of Medicine, Stanford, California
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Rosansky SJ. Early dialysis initiation, a look from the rearview mirror to what's ahead. Clin J Am Soc Nephrol 2014; 9:222-4. [PMID: 24436479 PMCID: PMC3913248 DOI: 10.2215/cjn.12231213] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Affiliation(s)
- Steven J Rosansky
- Dorn Research Institute, William Jennings Bryan Dorn Veterans Affairs Medical Center, Columbia, South Carolina
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Erickson KF, Winkelmayer WC, Chertow GM, Bhattacharya J. Medicare Reimbursement Reform for Provider Visits and Health Outcomes in Patients on Hemodialysis. Forum Health Econ Policy 2014; 17:53-77. [PMID: 26180520 DOI: 10.1515/fhep-2012-0018] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
The relation between the quantity of many healthcare services delivered and health outcomes is uncertain. In January 2004, the Centers for Medicare and Medicaid Services introduced a tiered fee-for-service system for patients on hemodialysis, creating an incentive for providers to see patients more frequently. We analyzed the effect of this change on patient mortality, transplant wait-listing, and costs. While mortality rates for Medicare beneficiaries on hemodialysis declined after reimbursement reform, mortality declined more - or was no different - among patients whose providers were not affected by the economic incentive. Similarly, improved placement of patients on the kidney transplant waitlist was no different among patients whose providers were not affected by the economic incentive; payments for dialysis visits increased 13.7% in the year following reform. The payment system designed to increase provider visits to hemodialysis patients increased Medicare costs with no evidence of a benefit on survival or kidney transplant listing.
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Affiliation(s)
- Kevin F Erickson
- Division of Nephrology and Centers for Health Policy and Primary Care and Outcomes Research, Departments of Medicine and Health Research and Policy, Stanford University School of Medicine, Palo Alto, CA
| | - Wolfgang C Winkelmayer
- Division of Nephrology and Centers for Health Policy and Primary Care and Outcomes Research, Departments of Medicine and Health Research and Policy, Stanford University School of Medicine, Palo Alto, CA
| | - Glenn M Chertow
- Division of Nephrology and Centers for Health Policy and Primary Care and Outcomes Research, Departments of Medicine and Health Research and Policy, Stanford University School of Medicine, Palo Alto, CA
| | - Jay Bhattacharya
- Division of Nephrology and Centers for Health Policy and Primary Care and Outcomes Research, Departments of Medicine and Health Research and Policy, Stanford University School of Medicine, Palo Alto, CA
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Sherman RA. Briefly Noted. Semin Dial 2013. [DOI: 10.1111/sdi.12136] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Young B. Geography and ESRD Care: What Contributes Most to Hemodialysis Patient-Provider Visit Variation? Clin J Am Soc Nephrol 2013; 8:898-900. [DOI: 10.2215/cjn.03970413] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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