Treatment bias in the management of end-stage renal disease

Processes and outcomes of care for diabetic acute myocardial infarction patients in Ontario: do physicians undertreat?

OBJECTIVE

To compare the health service utilization and long-term outcomes of acute myocardial infarction (AMI) patients with and without diabetes in Ontario.

RESEARCH DESIGN AND METHODS

We examined 25,697 patients from Ontario (6,052 and 19,645 patients with and without diabetes, respectively) who were hospitalized because of AMI between 1 April 1992 and 31 December 1993. Using linked administrative databases, we determined the use of invasive cardiac procedures at 1 year as well as the intensity of specialty follow-up care and use of evidence-based pharmacotherapies (among elderly individuals) within the first 90 days of hospital discharge. Outcomes examined included mortality and recurrent cardiac admissions at 30 days and 5 years post AMI. Multivariable analyses adjusted for sociodemographic and case-mix characteristics, attending physician specialty, and admitting hospital characteristics.

RESULTS

Despite being at significantly higher risk for death at baseline, diabetic patients were less likely to be followed-up by a cardiologist (22.2 vs. 25.6%, P < 0.001), to receive myocardial revascularization (12.6 vs. 14.9%, P < 0.001), to receive beta-blockers (34.2 vs. 44.0%, P < 0.001), and to receive aspirin therapy (59.7 vs. 63.5%, P < 0.001) after AMI than their nondiabetic counterparts. Diabetes was an important independent predictor of 5-year morbidity (adjusted hazard ratio 1.52, 95% CI 1.45-1.59) and 5-year mortality outcomes (1.57, 1.50-1.63). Variations in processes of care were marginally associated with higher nonfatal complication rates for diabetic patients.

CONCLUSIONS

When managing AMI patients with diabetes in Ontario, physician treatment aggressiveness does not correspond appropriately to the baseline risk of patients.

Competition under fixed prices: effects on patient selection and service strategies by hemodialysis providers

Dialysis services for patients with end-stage renal disease (ESRD) are delivered by predominantly private providers competing in local markets. Because prices are fixed by Medicare, providers can only compete on product quality. Using 1990 data and multiple competition measures, this study examines how competition under fixed prices influences hemodialysis providers' strategies for patient selection and service levels. It finds that provider strategies vary with competition, but competitive effects are not dominant and they differ by provider type. Providers with greater competition accept more costly patients, suggesting that competition may be contributing to changes in the Medicare ESRD population to an older and sicker patient mix. Only hospital-based facilities use richer staffing in more competitive markets. For-profit, free-standing facilities in all markets have lean staffing. Rural facilities have higher staff productivity than facilities in concentrated urban markets.

Psychological factors affecting end-stage renal disease. A review

This review summarizes recent systematic research literature regarding psychological factors as they affect chronic renal disease. Special attention is devoted to depression, quality of life, noncompliance, outcome studies, withdrawal from dialysis, and directions for future research.

Geographic access to health care services: the case of maintenance hemodialysis

A longitudinal study of the system for delivering maintenance hemodialysis services in St Louis, Missouri was conducted to determine the significance of geographic access in the selection and continued utilization of a treatment facility. Historically, center hemodialysis patients in this metropolitan area received care at four centrally located facilities. In 1981, two new, independent facilities were constructed; a satellite of an existing unit was opened in 1983. The data obtained in this study demonstrated that end-stage renal disease (ESRD) patients generally did not change their mode of maintenance therapy, their treatment facility, or the location of their personal residence. When such changes occurred, they were rarely precipitated by a desire to reduce travel time to treatment. Furthermore, the opportunity to improve geographic access by transferring to a closer unit was perceived by patients to be viable only if they could retain their physician. It was concluded, therefore, that travel time to treatment is a relatively unimportant aspect of the chronic care of center hemodialysis patients in a metropolitan area.

Does social support determine the treatment setting for hemodialysis patients?

The availability of an adequate system of social support has been suggested to be significant in determining whether an end-stage renal disease (ESRD) patient is dialyzed in a center or at home. To evaluate this hypothesis more completely, we conducted a study of social support among 257 home and center hemodialysis patients receiving maintenance therapy at four facilities in a midwestern, metropolitan area. A statistically significant difference, chi 2(3) = 14.031, P = 0.0029, was observed in the percentage of patients with social support available to them across the four facilities. The distribution of patients between home and center hemodialysis at the facilities also differed significantly, chi 2(3) = 14.919, P = 0.0019. An adequate social support system was present among 96.4% of the 55 home hemodialysis patients and 85.6% of the 202 center hemodialysis patients, a difference that was statistically significant, chi 2(1) = 4.684, P = 0.0305. However, a more detailed analysis of these findings revealed that the presence of social support was not significant, chi 2(1) = 1.080, P = 0.2995, in determining whether and ESRD patient was dialyzed at home or in a center after accounting for the facility differences. The facility differences remained significant in determining the setting of hemodialysis even after correcting for social support, chi 2(3) = 10.740, P = 0.0132. We concluded, therefore, that the attitudes of clinical staff toward home and center hemodialysis and the willingness of staff to develop those resources that facilitate a specific treatment setting are the principal elements in the therapy selection process.

The quality of maintenance therapy for end-stage renal disease. A review of social adjustment and rehabilitation

Prior to 1972, ESRD patients selected for maintenance dialysis or renal transplantation were generally young, emotionally and socially well-adjusted, and physically healthy except for their renal disease. Following the enactment of Public Law 92-603 (1972), which extended Medicare coverage to virtually all ESRD patients, the criteria for the selection of patients were substantially liberalized. During the past decade, maintenance therapy has increasingly been provided for severely debilitated ESRD patients whose reported levels of rehabilitation have been less than desired. While the majority of the current ESRD patient population have not been restored to their premorbid levels of individual and social functioning, recent studies suggest this may be the result of initiating rehabilitation efforts too late in the disease process. For optimal social functioning to be achieved by ESRD patients, it is concluded that psychosocial intervention and support must be initiated at the time ESRD is diagnosed and be focused on the maintenance, rather than rehabilitation, of the patient's functioning.