Dialysis. Epidemiology, Outcome Research, Health Services 2

  • Bornstein J
  • McCullough K
  • Combe C
 et al. 
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Abstract

Introduction and Aims: Psychiatric and neurological disorders are highly prevalent in the dialysis population. We postulated that because the presence of serious psychiatric and neurological disorders may have a negative impact on patient self-care, these conditions may be associated with higher rates of vascular access (VA) infections.Methods: DOPPS phase 4 (2009-2011) demographic, comorbid, hospitalization, and VA data were used from 367 facilities in 12 countries. Data on comorbid conditions including psychiatric and neurological disorders were collected by chart review at enrollment. Infection rates were modeled for each VA as time to first VA-related infection from the time of either VA placement or study enrollment, using Cox proportional hazards models containing these psychological and neurological covariates simultaneously and controlling for country, age, BMI, time on dialysis, and 12 comorbid factors; sandwich estimators were used to account for patient-level clustering. Models were run overall and separately for central venous catheter (CVC) patients (n=4,451) and for arteriovenous fistula (AVF) and arteriovenous graft (AVG) patients (n=12,425).Results: The sampled population at study entry had the following characteristics: average follow-up time per patient 1.08 years, mean age 64 years; mean BMI 26.5, diabetes (47%), depression (13%), other psychiatric disorders (4%, includes bipolar, schizophrenia, and alcohol or substance abuse), cognitive impairment or dementia (7%), and other neurological disorders (4%, includes multiple sclerosis, seizure disorder, and Parkinson’s disease). On average, the prevalence of these diagnoses was lowest in Japan and highest in Europe.Catheter use was higher among these patients, with total time during follow-up on a catheter exceeding 30 days for 27% of patients with depression, 30% for cognitive disorders or dementia, 25% for other psychiatric or neurological disorders, and 23% for patients with none of these diagnoses. Neurologic and psychiatric conditions were associated with overall hazard ratios (with 95% confidence limit) of infection as follows: depression 1.08 (0.84-1.38), other psych 1.53 (1.08-2.16), cognitive impairment/dementia 1.54 (1.06-2.22), and other neuro 0.77 (0.47-1.26). Results of separate models by vascular access type are shown (Figure).Conclusions: As postulated, certain serious neurological and psychiatric conditions are associated with substantially higher infection rates. This finding is possibly mediated by a more profound impact of these conditions on patient ability to self-care. Recognition of this elevated risk represents an opportunity to potentially improve outcomes among these patients.
Introduction and Aims: Mortality during first 90 days on HD has been marked as an indicator of predialysis care and patient status at HD initiation. We explored the association between early predictors i.e. factors captured in the first 30 days on HD and survival during first year in a large international sample of incident HD patients.Methods: The MONitoring Dialysis Outcomes [MONDO] initiative is an international consortium of hemodialysis (HD) databases [Usvyat, Blood Purif 2013; von Gersdorff, Blood Purif 2014]. Databases from Renal Research Institute in the US and Fresenius Medical Care Europe [17 countries] were queried to identify all incident patients with in-center treatments [01/2006-12/2012] who survived at least 30 days on HD. Clinical and laboratory parameters were computed over the first 30 days (baseline), deaths were observed in days 31 to 365 (follow up period). Cox regression model was set up to analyze associations of baseline parameters and mortality in the follow up period.Results: We studied 31,870 patients [RRI 8,330; FMC Europe 23,540]: 59% male, 88% white, mean age 64.0 years and 57% starting HD using a non-definitive vascular access. Factors increasing mortality risk during first year were (HR, 95CI) age [years] (1.03, 1.029-1.038), use of catheter (1.8, 1.5-2.04), preexisting cancer (1.33, 1.036-1.708), hospitalization during first 30 days (1.55, 1.39-1.72), preSBP below 100 mmHg (2.59, 1.95-3.44), Interdialytic weight gain [IDWG%] (1.08, 1.034-1.128) and neutrophil to lymphocyte ratio [NLR] (1.015, 1.009-1.021) while preSBP above 140 mmHg (0.68, 0.59-0.77), Albumin [g/dL] (0.45, 0.41-0.50) and Serum Na [mmol/L] (0.97, 0.956-0.984) showed a protective effect during the same time window. Gender, race, DBT status or Hemoglobin level in first 30 days were not associated to first year mortality.Conclusions: Several modifiable factors in the first 30 days of dialysis showed a marked effect on patient mortality during first year of dialysis. Efforts towards improved pre-dialysis care and planned dialysis start using fistulas as vascular access should be made to achive better outcomes in this population.Introduction and Aims: Outpatient dialysis global budget payment (ODGB) under Taiwanese National Health Insurance was implemented in 2003 in order to cap the growing expenditure. The unit price was decreased from 1 NT dollar per point in 2003 to NT .94 per point in 2007. This may be as results of increasing market competition. The purpose of this study is to examine the association between the cuts of dialysis global budget payment, market competition and first-Year mortality in incident ESRD Dialysis Patients.Methods: This study used retrospective longitudinal data to examine the study question. The unit of analysis is at patient level. Study patients were incident end-stage renal disease (ESRD) patients (including HD and PD patients) between Jan 1st, 1999 and Dec 31st, 2007. Data source was from the NHI population-based claim data. The dependent variable was incident ESRD patient first-year mortality. Market competition was measured by using Herfindahl-Hirschman Index (HHI). HHI was calculated based on predicated patient volume given the concern of endogenous issue. Quarterly mean monetary value per 100 points under outpatient dialysis global budgeting was used to measure cuts in reimbursement. In addition, we also include interaction terms between point value and market competition. Multi-level logistic regression model was used as the primary statistical analytical tool.Results: During 1999 to 2007, number of dialysis facilities increased from 364 to 529 (45.33%) and the mean value of predicted HHI at zipcode level decreased about 7.08%, indicating markets became less concentration and more competitive. We then categorized markets into high, moderate and low competitive markets. Our results indicated that large reimbursement cuts were associated with higher mortality, in particular in a high competitive market. Specifically, for every NT$1 decrease per 100 points, which corresponded to every 1% reduction in average dialysis facility revenue, the odds of first-year mortality rate were 98% higher in high competitive market. On the contrary, in low competitive market, the odds of mortality were about 3.1% higher.Conclusions: The first-year mortality of ESRD patients increased under increased financial constrain from cuts in reimbursement. In addition, the findings indicated dialysis facilities in a high competitive market confronted with more financial pressure as a result of payment reductions may reduce their quality of care because they have fewer resources compared to those in low competitive market. Policy makers and stakeholders often concern whether the global budgeting payment policy affect the patient quality in a positive or negative way, especially when dialysis markets became more competitive. It is important to continuously monitor ESRD patients' quality of care as cuts in reimbursement under global budget system are implemented.Introduction and Aims: Renal Patient View (RPV) is an established patient-facing Electronic Health Record (EHR) that enables patients to access their test results and information about their condition. Evaluation has shown high patient satisfaction and that some patients feel empowered by fuller more current information, but it is not known if such patient engagement has health care benefits.Hyperphosphatemia and Urea Reduction Ratio (URR) are two measures of haemodialysis quality collected by the UK Renal Registry for all haemodialysis patients in the UK. Whereas effective serum phosphate control requires substantial patient action (principally through diet selection and consumption of phosphate binders), the URR is mostly managed by health care professionals.In this study we examined phosphate and URR control in haemodialysis patients with or without concomitant utilisation of RPV to test the hypothesis that more active users of RPV achieve better phosphate control.Methods: The RPV user database extant on January 25th 2012 was linked by patient CHI / NHS number with the UK renal registry and anonymised data extracted for analysis. For the current study we identified patients that had registered for RPV during a period when their treatment with haemodialysis had been continuous extending at least 6 months before and 12 months after registration. To assess any impact of RPV on phosphate control we selected the subgroup with serum phosphate reported to the registry during the 6 months pre-registration as greater than the upper limit of the UK target range (1.1 - 1.7mmol/L). Similarly to assess URR we selected patients with URR < 65. Selected patients were stratified by frequency of RPV use assessed by the number of logons per month in the first year after registration. A comparable group of patients not involved with RPV was constructed from the UK Registry by matching for modality of treatment, age, sex, ethnicity, deprivation, renal centre and start date of RRT. Statistical analysis was by T- and Chi-squared tests as appropriate and utilised SAS v 9.3.Results: All the patient groups had similarly elevated phosphate (2.10-2.18 mmol/L) and depressed URR (56.9-58.7) during the 6 month lead

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Authors

  • Josh Bornstein

  • Keith P McCullough

  • Christian Combe

  • Brian Bieber

  • Michel Jadoul

  • Ronald L Pisoni

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