Effect of hospital setting and volume on clinical outcomes in women with gestational and type 2 diabetes mellitus

OBJECTIVE

Efforts to improve health care outcomes in the United States have led some organizations to recommend specific hospital settings or case volumes for complex medical diagnoses and procedures. But there are few studies of the effect of setting and volume on maternal outcomes, particularly in complicated conditions, such as diabetes. Our objective was to estimate the effect of hospital setting and volume on childbirth morbidity and length of stay in pregnancies complicated by type 2 and gestational diabetes.

METHODS

We analyzed Maryland hospital discharge data during 1999-2004. The dependent variables were primary cesarean delivery, episiotomy, a composite variable for severe maternal morbidity, and hospital length of stay. The independent variables were hospital setting (community, non-teaching hospitals, community, teaching hospitals, and academic medical centers) and tertiles of annual hospital diabetes delivery volume. Multivariable regression analysis was used to assess the relation of hospital setting with each outcome, adjusting for hospital volume and maternal case mix.

RESULTS

5,507 deliveries with type 2 (15%) and gestational (85%) diabetes were analyzed. Primary cesarean delivery rates among women with any diabetes did not vary across settings. After adjustment for volume and patient case mix, the likelihood of severe maternal morbidity was higher among deliveries at academic centers compared to community, non-teaching hospitals (odds ratio [OR], 2.1; 95% confidence interval: 1.0, 4.2). Academic centers had a protective effect (OR, 0.3; 95% CI: 0.2, 0.7) and community teaching hospitals had a borderline protective effect (OR, 0.8; 95% CI: 0.7, 1.0) on episiotomy, compared to community, non-teaching hospitals. Length of stay was greater at academic centers and community, teaching hospitals compared to community, non-teaching hospitals (5.4 days, 3.5 days vs. 2.8 days, respectively). We did not identify an independent association between hospital diabetes volume and clinical outcomes after adjustment for case mix.

CONCLUSIONS

Among women with type 2 and gestational diabetes, hospital setting is associated with a higher likelihood of severe maternal morbidity and length of stay, independent of volume. Patient case mix accounts for some of the variation across settings. The volume-outcome relationship found with other complex medical conditions or procedures was not found among diabetic pregnancies. Further investigations are needed to explain variations in outcomes across hospital settings and volumes.

Impact of Medicare coverage on disparities in access to simultaneous pancreas and kidney transplantation

In the setting of disparities in access to simultaneous pancreas and kidney transplantation (SPKT), Medicare coverage for this procedure was initiated July 1999. The impact of this change has not yet been studied. A national cohort of 22 190 type 1 diabetic candidates aged 18-55 for kidney transplantation (KT) alone or SPKT was analyzed. Before Medicare coverage, 57% of Caucasian, 36% of African American and 38% of Hispanic type 1 diabetics were registered for SPKT versus KT alone. After Medicare coverage, these proportions increased to 68%, 45% and 43%, respectively. The overall increase in SPKT registration rate was 27% (95% CI 1.16-1.38). As expected, the increase was more substantial in patients with Medicare primary insurance than those with private insurance (Relative Rate 1.18, 95% CI 1.09-1.28). However, racial disparities were unaffected by this policy change (African American vs. Caucasian: 0.97, 95% CI 0.87-1.09; Hispanic vs. Caucasian: 0.94, 95% CI 0.78-1.05). Even after Medicare coverage, African Americans and Hispanics had almost 30% lower SPKT registration rates than their Caucasian counterparts (95% CI 0.66-0.79 and 0.59-0.80, respectively). Medicare coverage for SPKT succeeded in increasing access for patients with Medicare, but did not affect the substantial racial disparities in access to this procedure.

The association of state and national legislation with living kidney donation rates in the United States: a national study

The effect of state legislation and federal policies supporting living donors on living kidney donation rates in the United States is unknown. We studied living kidney donation rates from 1988 to 2006, and we assessed changes in donation before and after the enactment of state legislation and the launch of federal initiatives supporting donors. During the study, 27 states enacted legislation. Among states enacting legislation, there was no statistically significant difference in the average rate of increase in overall living kidney donations after compared to before state legislation enactment (annual increase in donations per 1 000 000 population [95% confidence interval] 2.39 [1.94-2.84] compared to 1.68 [0.89-2.47] respectively, p > 0.05). Among states not enacting legislation, there was a statistically significantly greater annual increase in overall donation rates from 1997 to 2002 compared to before 1997 when federal initiatives commenced, but there was no growth in annual rates after 2002. State and federal legislation were associated with increases in living-unrelated donation. These findings suggest that although existing public policies were not associated with improvements in the majority of donations from living-related donors, they may have had a selective effect on barriers to living-unrelated kidney donation.

WITHDRAWN: Anticoagulants or antiplatelet therapy for non-rheumatic atrial fibrillation and flutter

BACKGROUND

Atrial fibrillation (AF) carries a high risk of stroke and other thromboembolic events. Appropriate use of drugs to prevent thromboembolism in patients with AF involves comparing the patient's risk of stroke to the risk of hemorrhage from medication use.

OBJECTIVES

To quantify risk of stroke, major hemorrhage and death from using medications that have been rigorously evaluated for prevention of thromboembolism in AF.

SEARCH STRATEGY

Articles were identified through the Cochrane Collaboration's CENTRAL database and MEDLINE until December 1999.

SELECTION CRITERIA

Included Randomized controlled trials of drugs to prevent thromboembolism in adults with non-postoperative AF. Excluded RCTS of patients with rheumatic valvular disease.

DATA COLLECTION AND ANALYSIS

Data were abstracted by two reviewers. Odds ratios from all qualitatively similar studies were combined, with weighting by study size, to yield aggregate odds ratios for stroke, major hemorrhage, and death for each drug.

MAIN RESULTS

Fourteen articles were included in this review. Warfarin was more efficacious than placebo for primary stroke prevention {aggregate odds ratio (OR) of stroke=0.30 [95% Confidence Interval (C.I.) 0.19,0.48]}, with moderate evidence of more major bleeding { OR= 1.90 [95% C.I. 0.89,4.04].}. Aspirin was inconclusively more efficacious than placebo for stroke prevention {OR=0.68 [95% C.I. 0.29,1.57]}, with inconclusive evidence regarding more major bleeds {OR=0.81[95% C.I. 0.37,1.78]}. For primary prevention, assuming a baseline risk of 45 strokes per 1000 patient-years, warfarin could prevent 30 strokes at the expense of only 6 additional major bleeds. Aspirin could prevent 17 strokes, without increasing major hemorrhage. In direct comparison, there was moderate evidence for fewer strokes among patients on warfarin than on aspirin {aggregate OR=0.64[95% C.I. 0.43,0.96]}, with only suggestive evidence for more major hemorrhage {OR =1.58 [95% C.I. 0.76,3.27]}. However, in younger patients, with a mean age of 65 years, the absolute reduction in stroke rate with warfarin compared to aspirin was low (5.5 per 1000 person-years) compared to an older group (15 per 1000 person-years). Low-dose warfarin or low-dose warfarin with aspirin was less efficacious for stroke prevention than adjusted-dose warfarin.

AUTHORS' CONCLUSIONS

The evidence strongly supports warfarin in AF for patients at average or greater risk of stroke, although clearly there is a risk of hemorrhage. Although not definitively supported by the evidence, aspirin may prove to be useful for stroke prevention in sub-groups with a low risk of stroke, with less risk of hemorrhage than with warfarin. Further studies are needed of low- molecular weight heparin and aspirin in lower risk patients.

Perceived transparency and fairness of the organ allocation system and willingness to donate organs: a national study

The influence of perceptions of organ allocation on willingness to donate organs is unclear. We performed a national study assessing the relation of public perceptions of organ allocation to willingness to donate organs, and we assessed the contribution of beliefs regarding discrimination in health care to observed associations. Among 845 participants, a majority (65%) reported that they less than "mostly" understand allocation, and most (71%) reported that they believe allocation is "unfair" or are "unsure" of its fairness. Participants reporting less understanding were less willing to donate (56%) than persons reporting greater understanding (67%) (p < 0.01). Participants believing allocation is "unfair" or who are "unsure" about fairness were less willing to donate (54%) than persons believing allocation is "fair" (68%) (p < 0.01). Associations were stronger among certain demographic subgroups. Participants with the least favorable perceptions of allocation were more likely than their counterparts to believe that race and income discrimination occur in transplantation and to believe that they personally experienced income discrimination in health care. Adjustment for these beliefs partially attenuated associations between perceptions regarding allocation and willingness to donate. Interventions enhancing transparency and perceived fairness of organ allocation may improve willingness to donate, particularly if they address concerns regarding discrimination in transplantation and health care.

Chronic kidney disease as a global public health problem: approaches and initiatives - a position statement from Kidney Disease Improving Global Outcomes

Chronic kidney disease (CKD) is increasingly recognized as a global public health problem. There is now convincing evidence that CKD can be detected using simple laboratory tests, and that treatment can prevent or delay complications of decreased kidney function, slow the progression of kidney disease, and reduce the risk of cardiovascular disease (CVD). Translating these advances to simple and applicable public health measures must be adopted as a goal worldwide. Understanding the relationship between CKD and other chronic diseases is important to developing a public health policy to improve outcomes. The 2004 Kidney Disease Improving Global Outcomes (KDIGO) Controversies Conference on 'Definition and Classification of Chronic Kidney Disease' represented an important endorsement of the Kidney Disease Outcome Quality Initiative definition and classification of CKD by the international community. The 2006 KDIGO Controversies Conference on CKD was convened to consider six major topics: (1) CKD classification, (2) CKD screening and surveillance, (3) public policy for CKD, (4) CVD and CVD risk factors as risk factors for development and progression of CKD, (5) association of CKD with chronic infections, and (6) association of CKD with cancer. This report contains the recommendations from the meeting. It has been reviewed by the conference participants and approved as position statement by the KDIGO Board of Directors. KDIGO will work in collaboration with international and national public health organizations to facilitate implementation of these recommendations.

Public attitudes toward incentives for organ donation: a national study of different racial/ethnic and income groups

Attitudes toward monetary and nonmonetary incentives for living (LD) and deceased donation (DD) among the U.S. general public and different racial/ethnic and income groups have not been systematically studied. We studied attitudes via a telephone questionnaire administered to persons aged 18-75 in the continental United States. Among 845 participants (85% of randomized households), less than one-fifth participants were in favor of incentives for DD (range 7-17%). Most persons were in favor of reimbursement of medical costs (91%), paid leave (84%) and priority on the waiting list (59%) for LD. African Americans and Hispanics were more likely than Whites to be in favor of some incentives for DD. African Americans were more likely than Whites to be in favor of monetary incentives for LD. Whites with incomes less than $20 000 were more likely than Whites with greater incomes to be in favor of reimbursement for deceased donors' funeral expenses or medical expenses. The U.S. public is not generally supportive of incentives for DD, but is supportive of limited incentives for LD. Racial/ethnic minorities are more supportive than Whites of some incentives. Persons with low income may be more accepting of certain monetary incentives.

Prevalence of immune thrombocytopenia: analyses of administrative data

BACKGROUND

The prevalence of immune thrombocytopenic purpura (ITP) in the USA is unknown. The paucity of data makes clinical trial design and resource allocation challenging.

OBJECTIVES

We aimed to quantify the prevalence of ITP in one state and to report on utilization of resources.

METHODS

The Maryland Health Care Commission supplied utilization data on all privately insured Maryland residents in 2002. We identified patients having two claims, separated by at least 30 days, for International Classification of Diseases, Ninth Revision, Clinical Modification code 287.3 (expected to be predominantly ITP). We excluded patients with concurrent diagnoses that made ITP unlikely. In sensitivity analyses, we varied the required visit interval between 14 and 180 days. We quantified ITP prevalence, resource utilization, and prevalence of concurrent autoimmune illnesses.

RESULTS

The age-adjusted prevalence of ITP was 9.5 per 100,000 persons (10.5 per 100,000 when requiring a minimum 14-day interval and 4.5 per 100,000 with a 180-day interval). There was a predominance of males in childhood and of females in the middle-adult years, with an overall prevalence rate ratio of 1.9 for females to males. Twenty per cent of these patients were hospitalized, but emergency department use was rare, as was splenectomy. A concurrent diagnosis of multiple sclerosis was 25 times more prevalent than anticipated.

CONCLUSIONS

We conclude that the prevalence of ITP in one populous state in the USA is comparable with that which has been reported in Europe. The suggested co-occurrence of ITP and multiple sclerosis in children merits further investigation.

Changes in serum calcium, phosphate, and PTH and the risk of death in incident dialysis patients: a longitudinal study

Elevated bone mineral parameters have been associated with mortality in dialysis patients. There are conflicting data about calcium, parathyroid hormone (PTH), and mortality and few data about changes in bone mineral parameters over time. We conducted a prospective cohort study of 1007 incident hemodialysis and peritoneal dialysis patients. We examined longitudinal changes in bone mineral parameters and whether their associations with mortality were independent of time on dialysis, inflammation, and comorbidity. Serum calcium, phosphate, and calcium-phosphate product (CaP) increased in these patients between baseline and 6 months (P<0.001) and then remained stable. Serum PTH decreased over the first year (P<0.001). In Cox proportional hazards models adjusting for inflammation, comorbidity, and other confounders, the highest quartile of phosphate was associated with a hazard ratio (HR) of 1.57 (1.07-2.30) using both baseline and time-dependent values. The highest quartiles of calcium, CaP, and PTH were associated with mortality in time-dependent models but not in those using baseline values. The lowest quartile of PTH was associated with an HR of 0.65 (0.44-0.98) in the time-dependent model with 6-month lag analysis. We conclude that high levels of phosphate both at baseline and over follow-up are associated with mortality in incident dialysis patients. High levels of calcium, CaP, and PTH are associated with mortality immediately preceding an event. Promising new interventions need to be rigorously tested in clinical trials for their ability to achieve normalization of bone mineral parameters and reduce deaths of dialysis patients.

Undertreatment of hyperlipidemia in a cohort of United States kidney dialysis patients

BACKGROUND

Application of national guidelines regarding cardiovascular disease risk reduction to kidney dialysis patients is complicated by the conflicting observations that dialysis patients have a high risk of atherosclerotic cardiovascular disease (ASCVD), but dialysis patients with higher serum cholesterol have lower mortality rates. Actual treatment patterns of hyperlipidemia are not well studied.

METHODS

We assessed the prevalence, treatment and control of hyperlipidemia in this high-risk patient population from 1995 - 1998. We measured low-density lipoprotein cholesterol, treatment with a lipid-lowering agent, and prevalence of hyperlipidemia as defined by the National Cholesterol Education Program (NCEP), Adult Treatment Panel (ATP) II guidelines in 812 incident hemodialysis (HD), and peritoneal dialysis (PD) patients from dialysis clinics in 19 states throughout the United States.

RESULTS

Hyperlipidemia was present in 40% of HD and 62% of PD patients. Among subjects with hyperlipidemia, 67% of HD and 63% of PD patients were untreated and only 22% of HD and 14% of PD patients were treated and controlled. Those who entered the study in 1997 or 1998, those with diabetes, males and Caucasians were more likely to be treated and controlled, whereas subjects on PD and those with ASCVD were less likely to be treated and controlled.

CONCLUSION

These data suggest that high rates of undertreatment exist in the United States ESRD dialysis population. Whether improved rates of treatment will result in decreased cardiovascular disease events needs to be tested in randomized clinical trials.

The contribution of sociodemographic, medical, and attitudinal factors to blood donation among the general public

BACKGROUND

Few studies have simultaneously assessed the relative importance of sociodemographic, medical, and attitudinal factors in explaining which individuals are more likely to donate blood.

STUDY DESIGN AND METHODS

A cross-sectional telephone survey of households in Maryland was conducted to identify the relation of sociodemographic, medical, and attitudinal factors to blood donation history among the general public. Random digit dialing was used to identify households; individuals aged 18 to 75 years were randomly selected within households. In multivariate analyses, the independent relationship of these factors with prior history of blood donation was assessed, and the amount of variation in prior history of blood donation among the study population that could be explained by these factors was determined.

RESULTS

Of 385 participants (84% of randomized homes), 228 (59%) had donated blood at least once in the past. After adjusting for potential confounders, women, black participants, and those agreeing with the statement "I am afraid of hospitals" had 60 to 80 percent lower odds of prior donation when compared with men, white participants, and those who did not agree with the statement (OR [95% CI]: 0.2 [0.1-0.4], 0.4 [0.2-0.8], and 0.3 [0.2-0.6], respectively). The effect of fear of hospitals was consistent across sex and race. Trust, fear, and suspicion of hospitals were among factors contributing most to variation in prior donation history.

CONCLUSION

Female sex, black race, and fear of hospitals are three major factors negatively associated with prior history of blood donation. Fear of hospitals affects blood donation patterns across race and sex groups. Future study is needed to determine whether recruitment of blood donors may be more efficient if focused toward women, minorities, and donors' fears of healthcare facilities or hospitals.

Managed care and primary care physicians' overall career satisfaction

Salaried employment among primary care physicians (PCPs) is becoming the rule rather than the exception. Because of this trend, the consequences of employment, types of practice revenues and overall career satisfaction will have the greatest impact on this group, their employers, and the populations they serve. This article examines the relationship between managed care contracts, managed care revenues and salaried PCP overall career satisfaction. Proportion of practice revenues from managed care and types of managed care contracts were associated with PCP overall career satisfaction. The implications of these findings and their importance to PCP turnover are discussed.

Autologous blood transfusion in the United States: clinical and nonclinical determinants of use

BACKGROUND

Preoperative donation of blood lowers the risk of allogeneic RBC transfusion. The use of autologous blood is not well quantified. This study aimed at identifying the frequency and determinants of use of autologous transfusion in the United States.

STUDY DESIGN AND METHODS

This national cross-sectional study, using the Nationwide Inpatient Sample, included all patients admitted to 900 hospitals in 19 states in 1996. Logistic regression with weighting yielded nationally representative results for the independent effects of clinical and nonclinical patient characteristics on autologous blood use.

RESULTS

Autologous transfusion was used in 19 of 1000 hospitalizations. The procedures using autologous blood most frequently were knee arthroplasty, hip replacement, prostatectomy, spinal fusion, and hysterectomy. Blacks and Hispanics were less likely to receive autologous transfusion than were whites (OR, 0. 64; 95% CI, 0.45-0.83); patients with Medicaid were less likely than the privately insured to receive autologous transfusions (OR, 0.29; 95% CI, 0.20-0.43), with racial differences greatest among the privately insured. Women received autologous blood for cardiovascular surgeries much less often than men (OR, 0.32; 95% CI, 0.20-0.49).

CONCLUSION

Ethnic minorities, women, and patients with Medicaid appear to receive fewer autologous blood transfusions than the rest of the population. Although this could reflect either better or worse quality of care, nonclinical determinants of transfusion practice warrant attention and further investigation.

The impact of practice guidelines in the management of Barrett esophagus: a national prospective cohort study of physicians

BACKGROUND

Surveillance of patients with Barrett esophagus (BE) is recommended to detect dysplasia and early cancer. In 1998, practice guidelines for the surveillance of patients with BE were developed under the auspices of the American College of Gastroenterology (ACG). Our objective is to assess physicians' awareness of agreement with and adherence to these guidelines.

METHODS

A national prospective cohort study of practicing gastroenterologists who completed a self-administered questionnaire containing case studies prior to the release of the guidelines and another survey 18 months later. Analysis of adherence to the guidelines was done using the McNemar chi(2) test.

RESULTS

Of the 154 gastroenterologists (66%) who responded to the follow-up survey, more than half (55%) were aware of the guidelines, and members of the ACG were more likely to know of their existence than nonmembers (61% vs 38%; P =.01). Overall, about 27% of physicians reported practicing in accordance with the guidelines at baseline; adherence increased modestly to 38% in the 18-month follow-up (P =.04) and was inversely related to fee-for-service reimbursement. Awareness was not associated with an increased likelihood of adherence, but agreement with the guidelines was strongly correlated with adherence (P<.001). The most frequent reasons for disagreement were concerns about liability, cancer risk, and inadequate evidence.

CONCLUSIONS

Awareness of the guidelines published by the ACG was low. Guideline awareness did not predict adherence. Improvement in guideline adherence will require steps beyond mere dissemination and promotion. Addressing disagreements about liability, disease risk, and scientific evidence as well as restructuring payment incentives may help achieve optimal practice.

Evidence-based practice centers: production of evidence report on management of atrial fibrillation

Healthcare practitioners are increasingly expected to understand and practice evidence-based healthcare. However, to apply evidence-based healthcare methods on an individual basis in a specific clinic or with a specific patient is rarely possible because it is time consuming and requires specialized skills. One way of facilitating evidence-based care is to use evidence-based products produced by others. In 1997, the Agency for Healthcare Research and Quality designated 12 evidence-based practice centers. Since their inception, these evidence-based practice centers have produced 40 evidence reports. This article provides an overview of the purpose and process of evidence-based practice centers using examples from the first evidence report produced by the Johns Hopkins Evidence-based Practice Center. The steps in the process of developing an evidence report include recruitment of experts, refinement of the questions, design of the literature search plan, quality assessment and data abstraction from identified articles, synthesis of evidence, peer review, and dissemination. Each step is defined and illustrated with examples from the development of an evidence report on atrial fibrillation.

An evidence-based review of patient-centered behavioral interventions for hypertension

INTRODUCTION

While behavioral interventions may be viewed as important strategies to improve blood pressure (BP), an evidence-based review of studies evaluating these interventions may help to guide clinical practice.

METHODS

We employed systematic review and meta-analysis of the literature (1970-1999) to assess the independent and additive effects of three behavioral interventions on BP control (counseling, self-monitoring of BP, and structured training courses).

RESULTS

Of 232 articles assessing behavioral interventions, 15 (4072 subjects) evaluated the effectiveness of patient-centered counseling, patient self-monitoring of BP, and structured training courses. Pooled results revealed that counseling was favored over usual care (3.2 mmHg [95% CI, 1.2-5.3] improvement in diastolic blood pressure [DBP] and 11.1 mmHg [95% CI, 4.1-18.1] improvement in systolic blood pressure [SBP]) and training courses (10 mmHg improvement in DBP [95% CI, 4.8-15.6]). Counseling plus training was favored over counseling (4.7 mmHg improvement in SBP [95% CI, 1.2-8.2]) and afforded more subjects hypertension control (95% [95% CI, 87-99]) than those receiving counseling (51% [95% CI, 34-66]) or training alone (64% [95% CI, 48-77]).

CONCLUSIONS

Evidence suggests that counseling offers BP improvement over usual care, and that adding structured training courses to counseling may further improve BP. However, there is not enough evidence to conclude whether self-monitoring of BP or training courses alone offer consistent improvement in BP over counseling or usual care. The magnitude of BP reduction offered by counseling indicates this may be an important adjunct to pharmacologic therapy.

Does growth retardation indicate suboptimal clinical care in children with chronic renal disease and those undergoing dialysis?

Growth failure is an important problem for children with end-stage renal disease (ESRD). Patients receiving replacement therapy for longstanding renal failure since childhood are likely to report dissatisfaction with certain aspects of their lives, especially with final adult height. Additionally, recent data suggest that growth failure in children with ESRD is associated with adverse clinical outcomes, including more frequent hospitalizations, and increased mortality. Although poor growth is unlikely to be the cause of this increased morbidity, growth failure may be a marker for a group of patients at high risk of adverse events. In this review, the authors describe the prevalence of growth retardation in children in the US with chronic renal disease, and present recent data on morbidity associated with growth failure. After reviewing published reports documenting available strategies to optimize growth, the authors conclude that despite vigilance and aggressive clinical management, a subset of children with long-term renal insufficiency and ESRD may still have poor linear growth. A discussion of "optimal care" leads one to consider evidence of current variability in the management of growth retardation in ESRD, and the strengths and limitations of developing practice guidelines to optimize growth in this population.

How important is intrinsic spirituality in depression care? A comparison of white and African-American primary care patients

We used a cross-sectional survey to compare the views of African-American and white adult primary care patients (N = 76) regarding the importance of various aspects of depression care. Patients were asked to rate the importance of 126 aspects of depression care (derived from attitudinal domains identified in focus groups) on a 5-point Likert scale. The 30 most important items came from 9 domains: 1) health professionals' interpersonal skills, 2) primary care provider recognition of depression, 3) treatment effectiveness, 4) treatment problems, 5) patient understanding about treatment, 6) intrinsic spirituality, 7) financial access, 8) life experiences, and 9) social support. African-American and white patients rated most aspects of depression care as similarly important, except that the odds of rating spirituality as extremely important for depression care were 3 times higher for African Americans than the odds for whites.

Timing of nephrologist referral and arteriovenous access use: the CHOICE Study

Recent clinical practice guidelines recommend the creation of an arteriovenous (AV) vascular access (ie, native fistula or synthetic graft) before the start of chronic hemodialysis therapy to prevent the need for complication-prone dialysis catheters. We report on the association of referral to a nephrologist with duration of dialysis-catheter use and type of vascular access used in the first 6 months of hemodialysis therapy. The study population is a representative cohort of 356 patients with questionnaire, laboratory, and medical record data collected as part of the Choices for Healthy Outcomes in Caring for End-Stage Renal Disease Center Study. Patients who reported being seen by a nephrologist at least 1 month before starting hemodialysis therapy (75%) were more likely than those referred later to use an AV access at initiation (39% versus 10%; P < 0.001) and 6 months after starting hemodialysis therapy (74% versus 56%; P < 0.01). Patients referred within 1 month of initiating hemodialysis therapy used a dialysis catheter for a median of 202 days compared with 64, 67, and 19 days for patients referred 1 to 4, 4 to 12, and greater than 12 months before initiating hemodialysis therapy, respectively (P trend < 0.001). Patients referred at least 4 months before initiating hemodialysis therapy were more likely than patients referred later to use an AV fistula, rather than a synthetic graft, as their first AV access (45% versus 31%; P < 0.01). These associations remained after adjustment for age, sex, race, marital status, education, insurance coverage, comorbid disease status, albumin level, body mass index, and underlying renal diagnosis. These data show that late referral to a nephrologist substantially increases the likelihood of dialysis-catheter use at the initiation of hemodialysis therapy and is associated with prolonged catheter use. Regardless of the time of referral, only a minority of patients used an AV access at the initiation of treatment, and greater than 25% had not used an AV access 6 months after initiation. Thus, further efforts to improve both referral patterns and preparation for dialysis after referral are needed.

Income-based disparities in outcomes for patients with chronic kidney disease

The impact of income on outcomes for patients with end-stage renal disease (ESRD), who are largely relieved of structural and financial barriers to care, is poorly understood. We conducted a prospective cohort study of 3,165 patients who developed ESRD in the early 1990s to examine whether low-income patients with ESRD have poorer health outcomes than their socioeconomically advantaged counterparts, and, if so, to determine whether greater health insurance can reduce this disparity. We found that increasing neighborhood income was associated with decreased mortality and an increased likelihood of placement on the renal transplant waiting list. The presence of private insurance coverage in addition to Medicare improved rates of listing for transplantation in a graded manner, with the greatest effect among those living in neighborhoods below the 10th percentile of income, but had no effect on socioeconomic disparities in mortality. Our results suggest that low-income patients with ESRD experience persistent financial barriers to transplantation that can be addressed with greater health benefits. However, they also experience higher mortality that is caused by personal and/or environmental factors that differ by social class. Clinicians, researchers, and policymakers must address these social, cultural, psychologic, and environmental determinants of health to improve the survival of patients with ESRD.

Factors influencing access to cardiovascular procedures in patients with chronic kidney disease: race, sex, and insurance

Blacks and women are less likely to undergo invasive cardiac procedures than whites and men in patients with chronic renal disease. We determined the relationship between ethnic and sex differences in access to cardiac procedures as patients progress to ESRD and acquire Medicare insurance. We performed a cohort study of a nationwide random sample of 4,987 patients who progressed to ESRD in 1986 to 1987 and were followed up for 7 years was used. Data were collected from medical charts and Medicare administrative records. Pre-ESRD, the odds of cardiac procedure use were much lower for white women (adjusted odds 0.67 [95% confidence interval (CI) 0.49-0.92]), black men (adjusted odds 0.32 [95% CI 0.20-0.49]), and black women (adjusted odds 0.30 [95%CI 0.18-0.50]) compared with white men. After initiating dialysis therapy, the ethnic and sex differences decreased with odds of receiving a cardiac procedure compared with white men 0.88 (95% CI 0.63-1.21) for white women, 0.66 (95% CI 0.47-0.92) for black men, and 0.75 (95% CI 0.53-1.08) for black women. Patients uninsured pre-ESRD had the largest increase in procedure rates at follow-up. The wide pre-ESRD disparities in cardiac procedure use between white women, black men, and black women compared with white men narrowed substantially with acquisition of Medicare and entry into comprehensive dialysis care. Health insurance contributed to the narrowing of differences. Procedure use for black men still lagged behind the other groups, suggesting the need for closer examination of health needs in this potentially vulnerable group.

Primary care physician job satisfaction and turnover

OBJECTIVE

To examine the relationship of personal characteristics, organizational characteristics, and overall job satisfaction to primary care physician (PCP) turnover.

SUBJECTS AND METHODS

A cohort of 507 postresident, nonfederally employed PCPs younger than 45 years of age, who completed their medical training between 1982 and 1985, participated in national surveys in 1987 and 1991. Psychological, economic, and sociological theories and constructs provided a conceptual framework. Primary care physician personal, organizational, and overall job satisfaction variables from 1987 were considered independent variables. Turnover-related responses from 1991 were dependent variables. Bivariate and multivariate analyses were conducted.

RESULTS

More than half (55%) of all PCPs in the cohort left at least 1 practice between 1987 and 1991. Twenty percent of the cohort left 2 employers. PCPs dissatisfied in 1987 were 2.38 times more likely to leave (P < .001). Primary care physicians who believed that third-party payer influence would decrease in 5 years were 1.29 times more likely to leave (P < .03). Non-board certified PCPs were 1.3 times more likely to leave (P < .003). Primary care physicians who believed that standardized protocols were overused were 1.18 times more likely to leave (P < .05). Specialty, gender, age, race, and practice setting were not associated with PCP turnover.

CONCLUSIONS

Turnover was an important phenomenon among PCPs in this cohort. The results of this study could enable policy makers, managed care organizations, researchers, and others to better understand the relationship between job satisfaction and turnover.

Profit-making in the treatment of chronic kidney disease: truth and consequences

Many have speculated that the quality of dialysis care differs for patients treated in for-profit and not-for-profit facilities. In 1999 we published a study that demonstrated poorer survival and lower rates of listing for renal transplant for patients in for-profit rather than not-for-profit, freestanding centers. While these findings generated substantial discussion, few have commented on their implications. In this article we first discuss potential sources of bias that could impact on the study's results and place the findings in context. We conclude that these disparities are likely to be real, as they are consistent with theorized differences between for-profit and not-for-profit health care organizations and with other evaluations of dialysis facility ownership. We then discuss several policy options for addressing the quality differences we identified. Reducing the outcome discrepancies will not be easy. Upon considering several policy alternatives, we conclude that a widespread effort to link processes of dialysis care to patient outcomes is best suited to reduce the quality differences between for-profit and not-for-profit dialysis units and improve outcomes in both types of facilities.

Reducing racial disparities in transplant activation: whom should we target?

Several studies have documented that blacks with end-stage renal disease (ESRD) are less likely than whites to be placed on the waiting list for a renal transplant. We examined trends in access over time to determine whether publication of these reports resulted in a reduction in disparity and identified those blacks who were most affected to focus future interventions. Three nationally representative groups of adult patients with ESRD (first dialysis in 1986 to 1987, 1990, or 1993) were followed up longitudinally to ascertain the date of first placement on the renal transplant waiting list. Cox proportional hazards models were used to characterize the magnitude of racial disparities in access to the waiting list with adjustment for clinical and sociodemographic factors. Lower rates of placement on the waiting list for blacks than whites persisted after adjustment for differences in both sociodemographic characteristics and health status (relative hazard [RH], 0.68; 95% confidence interval [CI], 0.59 to 0.79). The gap between blacks and whites did not narrow over time (blacks versus whites: 1986 to 1987 group, RH, 0.71; 95% CI, 0.59 to 0.86; 1990 group, RH, 0.69; 95% CI, 0.54 to 0.91; 1993 group, RH, 0.57; 0.43 to 0.77) and was greatest for the youngest and healthiest black patients, who were 50% and 40% less likely to be listed than corresponding whites, respectively. Interventions targeted toward young and healthy blacks, who are most likely to benefit from transplantation, are urgently needed to narrow black-white differences in transplant activation.

Validating billing data for RBC transfusions: a brief report

BACKGROUND

Administrative data are used often for research, but without validation of their accuracy. The validity of the billing for blood transfusion was assessed in one tertiary-care hospital.

MATERIALS AND METHODS

Patient discharge data were retrieved from a database containing demographics, diagnoses, and charges. There was random selection of 358 patients who were billed for RBC transfusion and 358 who were not, within a 2-month period. The blood bank's transfusion records were reviewed. Sensitivity was defined as the proportion of transfused patients who were billed, and specificity as the proportion of nontransfused patients who were not billed. Patient characteristics were compared by using Wilcoxon's rank sum test and the chi-square test.

RESULTS

Sixty-one transfused patients were not billed for the transfusion. No patient was billed without transfusion. Thus, the sensitivity and specificity were 83 percent (95% CI, 79-87%) and 100 percent, respectively. Nine patients who were not issued RBCs were appropriately not billed for RBCs, although the billing record suggests they had a procedure involving transfusion. These patients were called true-negative. The patients not billed were older (58 years vs. 55 years; p = 0.046) and less likely to have commercial insurance (5% vs. 15%; p = 0.035) than billed patients.

CONCLUSIONS

The billing for RBC transfusion in one large institution is reassuringly valid. The specificity is excellent, and the sensitivity is higher than that seen in other studies of coding validity.

Patterns of ambulatory care use for gynecologic conditions: A national study

OBJECTIVE

This study was undertaken to describe the site of ambulatory care visits for gynecologic conditions in the United States and to identify patient factors associated with the site of care for these conditions.

STUDY DESIGN

We conducted a national cross-sectional study using data from the 1995-1996 National Ambulatory Medical Care and National Hospital Ambulatory Medical Care Surveys. Visits to private physician offices, hospital outpatient departments, and emergency departments were selected if the principal diagnoses were consistent with 1 of 9 gynecologic categories. Multiple logistic regression was used for all diagnoses to identify factors associated with visits to emergency departments or hospital-based outpatient departments compared with factors associated with visits to private physician offices. Separate regression models were developed for individual diagnoses to test the hypothesis that the factors associated with the site of care would vary across different gynecologic conditions.

RESULTS

There were 23,194,000 visits for gynecologic conditions during the 2-year study period. Genital dysplasia, ovarian disorders, and uterine disorders were associated with greater use of hospital outpatient departments and emergency departments compared with physician offices. There was a 30% to 50% reduction in emergency room use for visits by women aged 45 years and older compared with visits by women aged 18 to 29 years. Emergency department use for several gynecologic conditions was 5 to 8 times greater for visits by women with household income <$29,000 than for visits by women with household income > or =$40,000.

CONCLUSION

Specific gynecologic diagnoses and patient factors are associated with greater use of emergency departments or hospital outpatient departments compared with physician offices. The association of these factors with the site of care varies across different gynecologic conditions.

Specialty of principal care physician and Medicare expenditures in patients with coronary artery disease: impact of comorbidity and severity

OBJECTIVE

To explore differences in expenditures for elderly patients with acute and chronic coronary artery disease according to the specialty of the principal care physician.

STUDY DESIGN

Retrospective analysis of Medicare claims.

PATIENTS AND METHODS

A total of 250,514 patients with coronary artery disease (International Classification of Diseases, Ninth Revision, Clinical Modification [ICD-9-CM] codes 410-414) were drawn from a national random sample of 1992 Medicare expenditures. Patients were classified by the physician type with the highest number of Medicare Part B outpatient claims into a cardiologist group and a generalist group. The outcome was mean total expenditures, stratifying (1) by comorbidity as measured by the modified Charlson Index and (2) by severity defined as the proportion of patients with acute myocardial infarction or unstable angina.

RESULTS

Those patients in the cardiologist group had lower comorbidity and higher severity than those in the generalist group. Overall mean expenditures were significantly higher for the cardiologist group than for the generalist group ($7658 vs $6047; P < .001). These differences in mean expenditures were evident at each level of comorbidity. However, when stratified by severity of diagnosis, differences were seen predominantly in those with acute diagnoses. For those with either acute myocardial infarction or unstable angina, the mean expenditures were higher for the cardiologist group than for the combined generalist group ($15,378 vs $12,260; P < .001); however, the mean expenditures for those with only chronic conditions were similar ($4856 vs $4745; P = .53).

CONCLUSION

Expenditures were higher when cardiologists were the principal care physicians treating patients with acute disease but not chronic disease.

Relation between pediatric experience and treatment recommendations for children and adolescents with kidney failure

CONTEXT

Children and adolescent patients with renal failure are frequently cared for by adult subspecialists. While peritoneal dialysis is used in less than 17% of adults with kidney failure, it is the preferred dialysis treatment for children. National data show that 45% of children receiving dialysis are treated with peritoneal dialysis and pediatric nephrologists report its use in 65% of patients receiving dialysis. Whether differences in peritoneal dialysis use among children are due to the pediatric experience of the clinician has not been examined.

OBJECTIVE

To assess whether the pediatric experience of nephrologists directly affects treatment recommendations for children with kidney failure.

DESIGN

Cross-sectional survey using 10 case vignettes per survey based on random combinations of 8 patient characteristics (age, sex, race, distance from facility, cause of renal failure, family structure, education, and compliance).

SETTING AND PARTICIPANTS

National random sample of office-, hospital-, and academic medical center-based adult and pediatric nephrologists, stratified by geographic region and conducted June to November 1999. Of 519 eligible physicians, 316 (61%) responded, including 191 adult and 125 pediatric nephrologists.

MAIN OUTCOME MEASURE

Treatment recommendations for peritoneal dialysis vs hemodialysis, compared based on nephrologists' pediatric experience.

RESULTS

After controlling for patient characteristics, pediatric nephrologists were 60% more likely than adult nephrologists to recommend peritoneal dialysis for identical patients (odds ratio, 1.61; 95% confidence interval, 1.35-1.92). This was true regardless of dialysis training, years in practice, practice setting, geography, or patient characteristics.

CONCLUSIONS

Our data indicate that pediatric specialization of clinicians influences treatment recommendations for children and adolescents with end-stage renal disease. Referring children to adult subspecialists may lead to differences in treatment choices and processes of care.

U.S. nephrologists' attitudes towards renal transplantation: results from a national survey

BACKGROUND

Renal transplantation is the optimal treatment for persons with end-stage renal disease (ESRD). A shortage of kidneys in the U.S. has focused increasing attention on the process by which kidneys are allocated. A national survey was undertaken to determine the relative importance of both clinical and nonclinical factors in the recommendation for renal transplantation by U.S. nephrologists.

METHODS

We conducted a national random survey of 271 U.S. nephrologists using hypothetical patient scenarios to determine their recommendation for renal transplantation based on demographic, clinical, and social factors. Specifically, eight unique patient scenarios were randomly distributed to each survey respondent.

RESULTS

According to responding nephrologists (response rate 53%), females were less likely than males to be recommended for renal transplantation [adjusted odds ratio (OR)=0.41; confidence interval (CI) 0.21, 0.79; for whites]. Asian males were less likely than white males to be recommended for transplantation (OR=0.46, CI 0.24, 0.91). Black-white differences in rates of recommendation were not found. Other factors associated with low rates of recommendation for renal transplantation included history of noncompliance (OR=0.17, CI 0.13, 0.23), <25% cardiac ejection fraction (OR=0.15, CI 0.10, 0.21), HIV infection (OR=0.01, CI 0.00, 0.01), and being >200 lbs (OR=0.73, CI 0.56, 0.95).

CONCLUSIONS

Female gender, and Asian but not black race, were associated with a decreased likelihood that nephrologists would recommend renal transplantation for patients with end stage renal disease. The well-documented black-white disparities in use of renal transplantation may be due to unaccounted for factors or may arise at a subsequent step in the transplantation process.

Anticoagulants or antiplatelet therapy for non-rheumatic atrial fibrillation and flutter

BACKGROUND

Atrial fibrillation (AF) carries a high risk of stroke and other thromboembolic events. Appropriate use of drugs to prevent thromboembolism in patients with AF involves comparing the patient's risk of stroke to the risk of hemorrhage from medication use.

OBJECTIVES

To quantify risk of stroke, major hemorrhage and death from using medications that have been rigorously evaluated for prevention of thromboembolism in AF.

SEARCH STRATEGY

Articles were identified through the Cochrane Collaboration's CENTRAL database and MEDLINE until December 1999.

SELECTION CRITERIA

Included Randomized controlled trials of drugs to prevent thromboembolism in adults with non-postoperative AF. Excluded RCTS of patients with rheumatic valvular disease.

DATA COLLECTION AND ANALYSIS

Data were abstracted by two reviewers. Odds ratios from all qualitatively similar studies were combined, with weighting by study size, to yield aggregate odds ratios for stroke, major hemorrhage, and death for each drug.

MAIN RESULTS

Fourteen articles were included in this review. Warfarin was more efficacious than placebo for primary stroke prevention [aggregate odds ratio (OR) of stroke=0.30 [95% Confidence Interval (C.I.) 0.19,0.48]], with moderate evidence of more major bleeding [ OR= 1.90 [95% C.I. 0.89,4.04].]. Aspirin was inconclusively more efficacious than placebo for stroke prevention [OR=0.68 [95% C.I. 0.29,1.57]], with inconclusive evidence regarding more major bleeds [OR=0.81[95% C.I. 0.37,1.78]]. For primary prevention, assuming a baseline risk of 45 strokes per 1000 patient-years, warfarin could prevent 30 strokes at the expense of only 6 additional major bleeds. Aspirin could prevent 17 strokes, without increasing major hemorrhage. In direct comparison, there was moderate evidence for fewer strokes among patients on warfarin than on aspirin [aggregate OR=0.64[95% C.I. 0.43,0.96]], with only suggestive evidence for more major hemorrhage [OR =1.58 [95% C.I. 0.76,3.27]]. However, in younger patients, with a mean age of 65 years, the absolute reduction in stroke rate with warfarin compared to aspirin was low (5.5 per 1000 person-years) compared to an older group (15 per 1000 person-years). Low-dose warfarin or low-dose warfarin with aspirin was less efficacious for stroke prevention than adjusted-dose warfarin.

REVIEWER'S CONCLUSIONS

The evidence strongly supports warfarin in AF for patients at average or greater risk of stroke, although clearly there is a risk of hemorrhage. Although not definitively supported by the evidence, aspirin may prove to be useful for stroke prevention in sub-groups with a low risk of stroke, with less risk of hemorrhage than with warfarin. Further studies are needed of low- molecular weight heparin and aspirin in lower risk patients.

A computerized tool for evaluating the effectiveness of preventive interventions

In identifying appropriate strategies for effective use of preventive services for particular settings or populations, public health practitioners employ a systematic approach to evaluating the literature. Behavioral intervention studies that focus on prevention, however, pose special challenges for these traditional methods. Tools for synthesizing evidence on preventive interventions can improve public health practice. The authors developed a literature abstraction tool and a classification for preventive interventions. They incorporated the tool into a PC-based relational database and user-friendly evidence reporting system, then tested the system by reviewing behavioral interventions for hypertension management. They performed a structured literature search and reviewed 100 studies on behavioral interventions for hypertension management. They abstracted information using the abstraction tool and classified important elements of interventions for comparison across studies. The authors found that many studies in their pilot project did not report sufficient information to allow for complete evaluation, comparison across studies, or replication of the intervention. They propose that studies reporting on preventive interventions should (a) categorize interventions into discrete components; (b) report sufficient participant information; and (c) report characteristics such as intervention leaders, timing, and setting so that public health professionals can compare and select the most appropriate interventions.

Developing a health-related quality-of-life measure for end-stage renal disease: The CHOICE Health Experience Questionnaire

The Choices for Healthy Outcomes in Caring for End-Stage Renal Disease ([ESRD] CHOICE) Study was designed to evaluate the effectiveness of alternative dialysis prescriptions. As part of CHOICE, we developed an instrument for measuring health-related quality of life (HRQOL) for patients with ESRD that would complement the Medical Outcomes Study 36-Item Short-Form Survey (SF-36) and be sensitive to differences in dialysis modality (hemodialysis [HD] and peritoneal dialysis [PD]) and dialysis dose. The selection of HRQOL domains to be included was based on: (1) a structured literature review of 47 articles describing 53 different instruments; (2) content analysis of five focus groups with HD and PD patients, nephrologists, and other providers; (3) a survey of 110 dialysis providers about features of different modalities that affect patient HRQOL; and (4) a semistructured survey of 25 patients with ESRD on the effects of dialysis on functioning and HRQOL. To help prioritize domains and items identified by these methods, a representative sample of 136 dialysis patients rated each item for frequency and bother. A panel of nephrologists provided advice about the salience of items to modality or dose. Items and scales were selected with a preference for existing measures tested in patients with ESRD and were tested for reliability and validity. The first four steps yielded 22 HRQOL domains that included 96 items: 8 generic domains in the SF-36 (health perceptions, physical, social, physical and emotional role function, pain, mental health, and energy); 8 additional generic domains (cognitive functioning, sexual functioning, sleep, work, recreation, travel, finances, and general quality of life); and 6 ESRD-specific domains (diet, freedom, time, body image, dialysis access [catheters and/or vascular], and symptoms). New items were developed or adapted to assess ESRD-specific domains. Scales for these items showed adequate internal consistency (Cronbach's alpha > 0.70, except for time [alpha = 0.57] and quality of life [alpha = 0.68]), as well as convergent and discriminant construct validity in a sample of 928 patients. The final questionnaire included 21 domains (time was deleted) and 83 items. We have designed a patient-centered instrument, the CHOICE Health Experience Questionnaire, that addresses domains that may be sensitive to differences in dialysis modality and dose and shows evidence for reliability and validity as a measure of HRQOL in ESRD.

Patients, populations and policy: patient outcomes in chronic kidney disease

Chronic kidney disease represents an interesting illustration for evaluating an epidemic of chronic illness, the impact of care processes and technology on health outcomes, the impact of financial incentives and cost containment on health outcomes, and the choices society must consider in responding to a chronic illness. The evidence suggests that strong economic pressures exist in the care of chronic kidney disease and that cost containment is important. The results in large part reflect the impact of economic pressures on clinical decision making in the absence of good evidence on outcomes. To improve clinical decision making we need valid evidence linking specific processes of care to patient outcomes. Specific processes amenable to study include the provision of preventive services, physician and nurse technical and interpersonal care and adherence to clinical practice guidelines. The ESRD Quality Study (EQUAL) currently underway and supported by the National Institutes of Diabetes and Digestive and Kidney Diseases, may help to guide physicians and centers in caring for their patients with chronic kidney disease. This investigation examines the relation between process of care and outcomes and expands outcomes measure to include disease-specific quality-of-life measures and patient satisfaction and accounts for case mix using the Index of Co-Existent Disease, a measure of the extent of different comorbid diseases as well as their severity (18,19,20). Better data on how processes of care are linked to health outcomes can inform decision making and allow educated cost cutting and quality maintenance.

Relation between prepublication release of clinical trial results and the practice of carotid endarterectomy

CONTEXT

Little is known about how clinical practice is affected by disseminating results of clinical trials prior to publication in peer-reviewed journals.

OBJECTIVE

To determine whether prepublication release of carotid endarterectomy (CEA) trial results via National Institutes of Health Clinical Alerts was associated with prompt changes in patient care that were consistent with the new medical evidence.

DESIGN, SETTING, AND PATIENTS

Longitudinal data series analysis using acute care hospital discharge data from the Healthcare Cost and Utilization Project for patients who had CEA performed in acute care hospitals in 7 states (New York, California, Pennsylvania, Florida, Colorado, Illinois, and Wisconsin). The trials were the North American Symptomatic Carotid Endarterectomy Trial (NASCET clinical alert released February 1991) and the Asymptomatic Carotid Atherosclerosis Study (ACAS clinical alert released September 1994).

MAIN OUTCOME MEASURE

Carotid endarterectomy rate during each month from 1989 (2 years before the NASCET clinical alert) to 1996 (2 years after the ACAS clinical alert), adjusted for age and sex. Because both trials were limited to patients 80 years or younger in hospitals with low mortality, we also stratified CEA rates by patient age and hospital mortality rate.

RESULTS

From 1989 through 1996, 272849 CEAs were performed in the acute care hospitals in these 7 states, with the annual number increasing from 22300 to 51 495. Afterthe NASCET clinical alert, the adjusted CEA rate increased 3.4% per month (95% confidence interval [CI], 1.6%-5.3%) during the following 6 months and then increased 0.5% per month (95% CI, 0.2%-0.8%; P<.04) after journal publication of the NASCET study. After the ACAS clinical alert, the CEA rate increased 7.3 % per month (95% CI, 6.0%-8.5%) during the following 7 months and then decreased by 0.44% per month (95% CI, -0.86% to -0.0002%; P<.04) after journal publication of the ACAS study. After the ACAS clinical alert, the CEA rate increased more in patients aged 80 years or older than in younger patients; whereas, after journal publication of ACAS, the CEA rate decreased more rapidly in the older population. The overall proportion of CEAs performed in low-mortality hospitals did not change substantially after release of the clinical alerts or after journal publication.

CONCLUSION

In this study, prepublication dissemination of CEA trial results with clinical alerts was associated with prompt and substantial changes in medical practice, but the observed changes suggest that the results were extrapolated to patients and settings not directly supported by the trials.

Relation between gender and vascular access complications in hemodialysis patients

Native arteriovenous (AV) fistulae for hemodialysis vascular access are believed to be associated with fewer complications than synthetic polytetrafluoroethylene (PTFE) grafts. We conducted a study among patients in the Dialysis Morbidity and Mortality Study to compare risk factors for complications of AV fistulae and PTFE grafts in men and women and to examine the effect of age on vascular access complications. We analyzed data from 833 incident patients with end-stage renal disease who had a PTFE graft (n = 621) or AV fistula (n = 212) in use 1 month after starting hemodialysis therapy. Follow-up using inpatient and outpatient Medicare administrative data identified a 1.8-times greater risk for a subsequent vascular access procedure for PTFE grafts (0.71 procedures/access-year) than for AV fistulae (0.39 procedures/access-year). Men with grafts and women with grafts or fistulae had a greater risk for a first subsequent access procedure than did men with fistulae (0.79, 0.65, and 0.59 versus 0.33 procedures/access-year, respectively). After adjustment for age, race, presence of diabetes mellitus, and history of smoking, peripheral vascular disease, and cardiovascular disease, use of a PTFE graft compared with an AV fistula was associated with a greater risk for a first subsequent procedure in men (relative hazard, 2.2; 95% confidence interval [CI], 1.6 to 2.9), but not in women (relative hazard, 1.0; 95% CI, 0.7 to 1.4). The excess risk associated with a PTFE graft compared with an AV fistula was limited to men in the lower three quartiles of age (ie, </=72 years). These data raise concern that the potential benefits of AV fistulae over PTFE grafts are not realized in women and older men. A better understanding of the determinants of successful access maturation and maintenance in these groups is needed.

US nephrologists' recommendation of dialysis modality: results of a national survey

Selection of a dialysis modality for persons with end-stage renal disease (ESRD) has important lifestyle and occupational implications. The factors affecting modality choice remain unclear, resulting in a low rate of peritoneal dialysis (PD) in the United States compared with other countries. A national survey of 271 US nephrologists was conducted from June 1997 to June 1998 to assess the relative importance of nonclinical and clinical factors related to dialysis modality selection for patients with ESRD. Hypothetical patient scenarios were randomly assigned to nephrologists to determine their recommendation for dialytic therapy based on patient demographic, clinical, and social factors. US nephrologists were more likely to recommend PD for men with ESRD compared with women (39% versus 33%; P: < 0.05; adjusted odds ratio, 1.44; 95% confidence interval, 1.15 to 1.80), as well as for patients with good compliance (adjusted odds ratio, 11.80; 95% confidence interval, 9.29 to 15.01), weight less than 200 lb (adjusted odds ratio, 2.3; 95% confidence interval, 1.8 to 2.9), residual renal function (adjusted odds ratio, 2.14; 95% confidence interval, 1.71 to 2.70), absence of diabetes (adjusted odds ratio, 2.0; 95% confidence interval, 1.6 to 2.5), and living with family (adjusted odds ratio, 1.7; 95% confidence interval, 1.4 to 2.1). Nephrologists in practice for 11 or more years were less likely to recommend PD. The association of male sex with PD therapy suggests a potential bias or sensitivity to women's perception of body image. Race was not associated with PD recommendations after controlling for other demographic and clinical characteristics. Because the incident US ESRD population is increasingly characterized by factors associated with not selecting PD (diabetes, obesity, malnourishment, living alone, and substance abuse problems), our results suggest that PD use may decrease over time.

Efficacy of agents for pharmacologic conversion of atrial fibrillation and subsequent maintenance of sinus rhythm: a meta-analysis of clinical trials

CONTEXT

Physicians have little evidentiary guidance for pharmacologic agent selection for atrial fibrillation (AF).

OBJECTIVE

To assess antiarrhythmic agent efficacy for AF conversion and subsequent maintenance of sinus rhythm (MSR).

DATA SOURCE

We searched the clinical trial database of the Cochrane Collaboration and MEDLINE encompassing literature from 1948 to May 1998.

STUDY SELECTION

We selected 36 (28%) articles eligible as randomized trials of nonpostoperative AF conversion or MSR in adults.

DATA EXTRACTION

Study quality; rates of conversion, MSR, and adverse events were extracted.

DATA SYNTHESIS

Compared with control treatment (placebo, verapamil, diltiazem, or digoxin), the odds ratio (OR) for conversion was greatest for ibutilide/dofetilide (OR=29.1; 95% confidence interval [CI], 9.8-86.1) and flecainide (OR=24.7; 95% CI, 9.0-68.3). Less strong but conclusive evidence existed for propafenone (OR=4.6; 95% CI, 2.6-8.2). Quinidine (OR=2.9; 95% CI, 1.2-7.0) had moderate evidence of efficacy for conversion. Disopyramide (OR=7.0; 95% CI, 0.3-153.0) and amiodarone (OR=5.7; 95% CI, 1.0-33.4) had suggestive evidence of efficacy. Sotalol (OR=0.4; 95% CI, 0.0-3.0) had suggestive evidence of negative efficacy. For MSR, strong evidence of efficacy existed for quinidine (OR=4.1; 95% CI, 2.5-6.7), disopyramide (OR=3.4; CI, 1.6-7.1), flecainide (OR=3.1; 95% CI, 1.5-6.2), propafenone (OR=3.7; 95% CI, 2.4-5.7), and sotalol (OR=7.1; 95% CI, 3.8-13.4). The only amiodarone data, from comparison with disopyramide, provided moderate evidence of efficacy for MSR. No trial evaluated procainamide. Direct agent comparisons and adverse event data were limited.

CONCLUSIONS

Although multiple antiarrhythmic agents had strong evidence of efficacy compared with control treatment for MSR, ibutilide/dofetilide and flecainide had particularly strong evidence of efficacy compared with control treatment for AF conversion. There is sparse and inconclusive evidence on direct agent comparisons and adverse event rates. Obtaining information regarding these relative efficacies should be a research priority.

Prescription drugs in Medicare and the ESRD program

Prescription drugs have improved the length and quality of life for many persons, particularly those with chronic disease. However, their contribution to total health care costs has been increasing, making it difficult for patients to afford necessary medications. Current Medicare policy, derived from statutory enactments by Congress, precludes payment for prescription medications with the exception a few medications for end-stage renal disease (ESRD) patients. A more comprehensive prescription drug benefit for Medicare has been proposed that might benefit ESRD patients. Design and implementation of a medication drug benefit involves several issues including what medications should be covered, under what circumstances, how cost should be shared, the payment structure, level of payment, and management of the benefit. This report describes the experience with Medicare coverage of prescription drugs for ESRD patients and explores issues in offering a general medication insurance benefit under Medicare.

Racial differences in access to the kidney transplant waiting list for children and adolescents with end-stage renal disease

CONTEXT

Renal transplantation is the treatment of choice for pediatric patients with end-stage renal disease (ESRD). Black patients wait longer for kidney transplants than do white patients.

OBJECTIVE

To determine whether the increased time to transplantation for black pediatric patients is attributable not only to a shortage of suitable donor organs, but also to racial differences in the time from a child's first treatment for ESRD until activation on the cadaveric kidney transplant waitlist.

DESIGN

National longitudinal cohort study.

SETTING

US Medicare-eligible, pediatric ESRD population.

PATIENTS

Children and adolescents </=19 years old at the time of their first dialysis for ESRD between 1988 and 1993, followed through 1996. Patients who received living donor renal transplants were excluded from study.

MAIN OUTCOME MEASURES

Time from first dialysis for ESRD until activation on the kidney transplant waiting list, relative hazard of activation on the waiting list for black compared with white pediatric patients.

RESULTS

Comparisons of the time from first dialysis for ESRD to waitlisting among the 2162 white (60.7%) and 1122 black (31.5%) patients studied using survival analysis revealed that blacks were less likely to be waitlisted at any given time in follow-up. In multivariate analysis, even after controlling for patient age, gender, socioeconomic status, geographic region, incident year of renal failure, and cause of ESRD, blacks were 12% less likely to be waitlisted than were whites at any point in time (relative hazard:. 88: 95% confidence interval:.79-.97).

CONCLUSIONS

Racial disparities in access to the renal transplant waiting list exist in pediatrics. Whether these disparities are attributable to differences in time of presentation to a nephrologist, physician bias in identification of transplant candidates, or patient preferences warrants further study.

Clinical review 115: effect of thyroxine therapy on serum lipoproteins in patients with mild thyroid failure: a quantitative review of the literature

The objective of our study was to estimate the expected change in serum lipoprotein concentrations after treatment with T4 in patients with mild thyroid failure (i.e. subclinical hypothyroidism). Our data sources included MEDLINE, between January 1966 and May 1999, and review of references from relevant articles. There were 1,786 published studies identified, 461 abstracts reviewed, 74 articles retrieved, 24 articles evaluated against predetermined entry criteria, and 13 studies systematically reviewed and abstracted. All studies reported serum total cholesterol concentration changes during T4 treatment, 12 reported triglyceride changes, 10 reported high-density lipoprotein (HDL) cholesterol changes, and 9 reported low-density lipoprotein (LDL) cholesterol changes. There were 247 patients in 13 studies. The mean decrease in the serum total cholesterol concentration was -0.20 mmol/L (-7.9 mg/ dL), with a 95% confidence interval of -0.09 to -0.34. The decline in serum total cholesterol was directly proportional to its baseline concentration. Studies enrolling hypothyroid participants receiving suboptimal T4 doses reported significantly larger decreases in serum total cholesterol after thyroid-stimulating hormone normalization than studies enrolling previously untreated individuals with mild thyroid failure [-0.44 mmol/L (-17 mg/dL) vs. -0.14 mmol/L (-5.6 mg/dL), P = 0.05]. The change in serum LDL cholesterol concentration was -0.26 mmol/L (-10 mg/dL), with a 95% confidence interval of -0.12 to -0.41. Serum HDL and triglyceride concentrations showed no change. These results, although based on fewer than 250 patients, suggest that T4 therapy in individuals with mild thyroid failure lowers mean serum total and LDL cholesterol concentrations. The reduction in serum total cholesterol may be larger in individuals with higher pretreatment cholesterol levels and in hypothyroid individuals taking suboptimal T4 doses. There do not seem to be significant effects of T4 on serum HDL or triglyceride concentrations.

Cost-utility analysis of the cochlear implant in children

CONTEXT

Barriers to the use of cochlear implants in children with profound deafness include device costs, difficulty assessing benefit, and lack of data to compare the implant with other medical interventions.

OBJECTIVE

To determine the quality of life and cost consequences for deaf children who receive a cochlear implant.

DESIGN

Cost-utility analysis using preintervention, postintervention, and cross-sectional surveys conducted from July 1998 to May 2000.

SETTING

Hearing clinic at a US academic medical center.

PARTICIPANTS

Parents of 78 profoundly deaf children (average age, 7.5 years) who received cochlear implants.

MAIN OUTCOME MEASURES

Direct and total cost to society per quality-adjusted life-year (QALY) using the time-trade-off (TTO), visual analog scale (VAS), and Health Utilities Index-Mark III (HUI), discounting costs and benefits 3% annually. Parents rated their child's health state at the time of the survey and immediately before and 1 year before implantation.

RESULTS

Recipients had an average of 1.9 years of implant use. Mean VAS scores increased by 0. 27, from 0.59 before implantation to 0.86 at survey. In a subset of participants, TTO scores increased by 0.22, from 0.75 to 0.97 (n = 40) and HUI scores increased by 0.39, from 0.25 to 0.64 (n = 22). Quality-of-life scores were no different 1 year before and immediately before implantation. Discounted direct costs were $60,228, yielding $9,029 per QALY using the TTO, $7,500 per QALY using the VAS, and $5,197 per QALY using the HUI. Including indirect costs such as reduced educational expenses, the cochlear implant provided a savings of $53,198 per child.

CONCLUSIONS

Cochlear implants in profoundly deaf children have a positive effect on quality of life at reasonable direct costs and appear to result in a net savings to society. JAMA. 2000;284:850-856

Formal literature review of quality-of-life instruments used in end-stage renal disease

Although quality-of-life assessment is an important complement to conventional clinical evaluation, there are limited opportunities for researchers in end-stage renal disease (ESRD) to examine evidence for a range of quality-of-life measures. To better understand how quality of life has been conceptualized, measured, and evaluated for ESRD, we conducted a structured literature review. Eligible articles were identified from a MEDLINE search, expert input, and review of references from eligible articles. A standardized instrument was created for article review and included type of measure, instrument development process, study sample characteristics, quality-of-life domains, and reliability and validity testing. From 436 citations, 78 articles were eligible for final review, and of those, 47 articles contained evidence of reliability or validity testing. Within this set, there were 113 uses of 53 different instruments: 82% were generic and 18% were disease specific. Only 32% defined quality of life. The most frequently assessed domains were depression (41%), social functioning (32%), positive affect (30%), and role functioning (27%). Testing was completed for test-retest reliability (20%), interrater reliability (13%), internal consistency (22%), content validity (24%), construct validity (41%), criterion validity (55%), and responsiveness (59%). Few articles measuring quality of life in ESRD defined quality-of-life domains or adequately described instrument development and testing. Generic measures, such as the Sickness Impact Profile, and disease-specific measures, such as the Kidney Disease Questionnaire, had been tested more thoroughly than others. Standardized reporting and more rigorous testing could help researchers make informed choices about instruments that would best serve their own and their patients' needs.

Economic burden of hospitalizations for preterm labor in the United States

OBJECTIVE

To determine patient factors associated with hospital care costs for preterm labor and to develop a clinically applicable cost model for evaluating economic consequences of interventions to reduce preterm-labor hospitalizations.

METHODS

Maryland state hospital discharge data from 1993-1996 were used to identify hospitalizations for preterm labor without delivery and preterm labor with early delivery. Median regression was used to determine the association between patient factors and hospital care costs in Maryland and to develop a model to estimate hospital care costs nationally. National estimates of hospitalizations for preterm labor were from the 1994 National Hospital Discharge Survey.

RESULTS

During the 4-year study period, there were 25,104 hospitalizations for preterm labor, undelivered, and preterm labor with early delivery in Maryland. Maternal comorbidity, antenatal procedures, types of insurance, and lengths of stay associated significantly with hospital costs for preterm labor. National costs for preterm labor, undelivered, were more than $360 million. Incremental costs for preterm labor with early delivery, compared with term delivery, ranged from $21 million to $191 million. Total expenditures for preterm-labor hospitalization for the United States were estimated in excess of $820 million.

CONCLUSION

Hospitalizations for preterm labor comprise a substantial portion of maternal cost of perinatal care in the United States. Maternal comorbidity and procedures account for major differences in costs per admission. Strategies to reduce hospitalizations for preterm labor should focus on economic and clinical outcomes in evaluating their overall values.