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Drewry K, Cummings JR, Patzer RE, Wilk AS. Characteristics of Nephrologists Participating in Medicare's Comprehensive ESRD Care Initiative. Am J Kidney Dis 2024; 83:836-839. [PMID: 38070589 DOI: 10.1053/j.ajkd.2023.09.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Revised: 09/18/2023] [Accepted: 09/30/2023] [Indexed: 01/27/2024]
Affiliation(s)
- Kelsey Drewry
- Department of Health Policy and Management, Rollins School of Public Health at Emory University, Atlanta, Georgia; Department of Surgery, Emory University School of Medicine, Atlanta, Georgia.
| | - Janet R Cummings
- Department of Health Policy and Management, Rollins School of Public Health at Emory University, Atlanta, Georgia
| | - Rachel E Patzer
- Department of Surgery, Emory University School of Medicine, Atlanta, Georgia; Department of Epidemiology, Rollins School of Public Health at Emory University, Atlanta, Georgia; Department of General Internal Medicine, Emory University School of Medicine, Atlanta, Georgia; Regenstrief Institute, Indianapolis, Indiana
| | - Adam S Wilk
- Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana
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2
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Crouch E, Yell N, Herbert L, Browne T, Hung P. Availability and Quality of Dialysis Care in Rural versus Urban US Counties. Am J Nephrol 2024; 55:361-368. [PMID: 38342081 DOI: 10.1159/000537763] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2024] [Accepted: 02/08/2024] [Indexed: 02/13/2024]
Abstract
INTRODUCTION Rural areas face significant disparities in dialysis care compared to urban areas due to limited access to dialysis facilities, longer travel distances, and a shortage of healthcare professionals. The objective of this study was to conduct a national examination of rural-urban differences in quality of dialysis care offered across counties in the USA. METHODS Data were gathered from Medicare-certified dialysis facilities in 2020 from the Centers for Medicare and Medicaid Services website. To identify high-need counties, county-level estimated crude prevalence of diabetes in adults was obtained from the 2022 CDC PLACES data portal. Our analysis reviewed 3,141 counties in the USA. The primary outcome measured was whether the county had a dialysis facility. Among those counties that had a dialysis facility, additional outcomes were the average star rating, whether peritoneal dialysis was offered, and whether home dialysis was offered. RESULTS The type of services offered by dialysis facilities varied significantly, with peritoneal dialysis being the most commonly offered service (50.8%), followed by home hemodialysis (28.5%) and late-shift services (16.0%). These service availabilities are more prevalent in urban facilities than in rural facilities. The Centers for Medicare and Medicaid Services Five Star Quality ratings were quite different between urban and rural facilities, with 40.4% of rural facilities having a ranking of five, compared to 27.1% in urban. CONCLUSION The majority of rural counties lack a single dialysis facility. Counties with high rates of chronic kidney disease, diabetes, and blood pressure, deemed high need, were less likely to have a highly rated dialysis facility. The findings can be used to further inform targeted efforts to increase diabetes educational programming and design appropriate interventions to those residing in rural communities and high-need counties who may need it the most.
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Affiliation(s)
- Elizabeth Crouch
- Arnold School of Public Health, University of South Carolina, Columbia, South Carolina, USA
| | - Nick Yell
- Arnold School of Public Health, University of South Carolina, Columbia, South Carolina, USA
| | - Laura Herbert
- College of Nursing, University of South Carolina, Columbia, South Carolina, USA
| | - Teri Browne
- College of Social Work, University of South Carolina, Columbia, South Carolina, USA
| | - Peiyin Hung
- Arnold School of Public Health, University of South Carolina, Columbia, South Carolina, USA
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Çankaya E, Altunok M, Yağanoğlu AM. The effect of rural and urban life on peritonitis rates in chronic peritoneal patients. Ren Fail 2023; 45:2163504. [PMID: 36645062 PMCID: PMC9848302 DOI: 10.1080/0886022x.2022.2163504] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
BACKGROUND It has been reported that living far from the peritoneal dialysis (PD) unit is a risk factor for peritonitis. Considering that PD units are urban located; the question of whether living in a rural area compared to an urban area is a risk factor for peritonitis has arisen. METHODS From March 2010 to August 2020, 335 episodes of peritonitis in 202 PD patients followed in a single center were evaluated retrospectively. People living in areas with a population <1000 were defined as living in rural areas regardless of their distance from the PD center. Cox regression analysis was used to identify independent factors associated with peritonitis. RESULTS A total of 202 PD patients were followed during 791 patient-years (mean follow-up of 3.9 years per patient). Total patients had 335 episodes of peritonitis and the rate of peritonitis was 0.42 episodes per year (episodes/patient-year). Cox regression analysis revealed that living environment (urban vs. rural) was not a risk factor for peritonitis (p = 0.57). CONCLUSIONS In Turkey, we report that living in a rural area in our region is not a risk factor for peritonitis. It is not the right approach for both the physician and the patient to be reluctant in the choice of PD due to the concern of peritonitis in rural areas.
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Affiliation(s)
- Erdem Çankaya
- Department of Nephrology, Medical Faculty, Atatürk University, Erzurum, Turkey,CONTACT Erdem Çankaya Department of Nephrology, Medical Faculty, Atatürk University, Erzurum25240, Turkey
| | - Murat Altunok
- Department of Nephrology, Medical Faculty, Atatürk University, Erzurum, Turkey
| | - Aycan Mutlu Yağanoğlu
- Department of Animal Science, Faculty of Agrıculture, Atatürk University, Erzurum, Turkey
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4
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Rizzolo K, Cervantes L, Wilhalme H, Vasilyev A, Shen JI. Differences in Outcomes by Place of Origin among Hispanic Patients with Kidney Failure. J Am Soc Nephrol 2023; 34:2013-2023. [PMID: 37755821 PMCID: PMC10703086 DOI: 10.1681/asn.0000000000000239] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Accepted: 09/14/2023] [Indexed: 09/28/2023] Open
Abstract
SIGNIFICANCE STATEMENT Hispanic patients are known to have a higher risk of kidney failure and lower rates of home dialysis use and kidney transplantation than non-Hispanic White patients. However, it is unknown whether these outcomes differ within the Hispanic community, which is heterogeneous in its members' places of origins. Using United States Renal Data System data, the authors found similar adjusted rates of home dialysis use for patients originating from places outside the United States and US-born Hispanic patients, whereas the adjusted risk of mortality and likelihood of transplantation differed depending on place (country or territory) of origin. Understanding the heterogeneity in kidney disease outcomes and treatment within the Hispanic community is crucial in designing interventions and implementation strategies to ensure that Hispanic individuals with kidney failure have equitable access to care. BACKGROUND Compared with non-Hispanic White groups, Hispanic individuals have a higher risk of kidney failure yet lower rates of living donor transplantation and home dialysis. However, how home dialysis, mortality, and transplantation vary within the Hispanic community depending on patients' place of origin is unclear. METHODS We identified adult Hispanic patients from the United States Renal Data System who initiated dialysis in 2009-2017. Primary exposure was country or territory of origin (the United States, Mexico, US-Puerto Rico, and other countries). We used logistic regression to estimate differences in odds of initiating home dialysis and competing risk models to estimate subdistribution hazard ratios (SHR) of mortality and kidney transplantation. RESULTS Of 137,039 patients, 44.4% were US-born, 30.9% were from Mexico, 12.9% were from US-Puerto Rico, and 11.8% were from other countries. Home dialysis rates were higher among US-born patients, but not significantly different after adjusting for demographic, medical, socioeconomic, and facility-level factors. Adjusted mortality risk was higher for individuals from US-Puerto Rico (SHR, 1.04; 95% confidence interval [CI], 1.01 to 1.08) and lower for Mexico (SHR, 0.80; 95% CI, 0.78 to 0.81) and other countries (SHR, 0.83; 95% CI, 0.81 to 0.86) compared with US-born patients. The adjusted rate of transplantation for Mexican or US-Puerto Rican patients was similar to that of US-born patients but higher for those from other countries (SHR, 1.22; 95% CI, 1.15 to 1.30). CONCLUSIONS Hispanic people from different places of origin have similar adjusted rates of home dialysis but different adjusted rates of mortality and kidney transplantation. Further research is needed to understand the mechanisms underlying these observed differences in outcomes.
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Affiliation(s)
- Katherine Rizzolo
- Section of Nephrology, Boston University Chobanian and Avedisian School of Medicine and Boston Medical Center, Boston, Massachusetts
| | - Lilia Cervantes
- Department of Medicine, University of Colorado Anschutz Campus, Denver, Colorado
| | - Holly Wilhalme
- David Geffen School of Medicine at University of California, Los Angeles, California, Los Angeles, California
| | - Arseniy Vasilyev
- David Geffen School of Medicine at University of California, Los Angeles, California, Los Angeles, California
| | - Jenny I. Shen
- David Geffen School of Medicine at University of California, Los Angeles, California, Los Angeles, California
- The Lundquist Institute at Harbor-UCLA Medical Center, Torrance, California
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5
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Knapp CD, Li S, Kou C, Gilbertson DT, Weinhandl ED, Wetmore JB, Hart A, Johansen KL. Increased Access, Persistent Disparities: Trends in Disparities in Peritoneal Dialysis (PD) Use, 2009-2019. Clin J Am Soc Nephrol 2023; 18:1483-1489. [PMID: 37499680 PMCID: PMC10637445 DOI: 10.2215/cjn.0000000000000222] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Accepted: 07/21/2023] [Indexed: 07/29/2023]
Abstract
Peritoneal dialysis (PD) use has increased in the United States since 2009, but how this has affected disparities in PD use is unclear. We used data from the United States Renal Data System to identify a cohort of incident dialysis patients from 2009 to 2019. We used logistic regression models to examine how odds of PD use changed by demographic characteristics. The incident PD population increased by 203% from 2009 to 2019, and the odds of PD use increased in every subgroup. PD use increased more among older people because the odds for those aged 75 years or older increased 15% more per 5-year period compared with individuals aged 18-44 years (odds ratio [OR] 1.68, 95% confidence interval [CI], 1.64 to 1.73 versus OR 1.46, 95% CI, 1.42 to 1.50). The odds of PD use increased 5% more per 5-year period among Hispanic people compared with White people (OR 1.58, 95% CI, 1.53 to 1.63 versus OR 1.51, 95% CI, 1.48 to 1.53). There was no difference in odds of PD initiation among people who were Black, Asian, or of another race. The odds of PD use increased 5% more for people living in urban areas compared with people living in nonurban areas (5-year OR 1.54, 95% CI, 1.52 to 1.56 versus 5-year OR 1.46, 95% CI, 1.42 to 1.50). The odds of PD use increased 7% more for people living in socioeconomically advantaged areas compared with people living in more deprived areas (5-year OR 1.60, 95% CI, 1.56 to 1.63 for neighborhoods with lowest Social Deprivation Index versus 5-year OR 1.50, 95% CI, 1.48 to 1.53 in the most deprived areas). Expansion of PD use led to a reduction in disparities for older people and for Hispanic people. Although PD use increased across all strata of socioeconomic deprivation, the gap in PD use between people living in the least deprived areas and those living in the most deprived areas widened.
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Affiliation(s)
- Christopher D. Knapp
- Chronic Disease Research Group, Hennepin Healthcare Research Institute, Minneapolis, Minnesota
| | - Shuling Li
- Chronic Disease Research Group, Hennepin Healthcare Research Institute, Minneapolis, Minnesota
| | - Chuanyu Kou
- Chronic Disease Research Group, Hennepin Healthcare Research Institute, Minneapolis, Minnesota
| | - David T. Gilbertson
- Chronic Disease Research Group, Hennepin Healthcare Research Institute, Minneapolis, Minnesota
- Department of Medicine, University of Minnesota, Minneapolis, Minnesota
| | - Eric D. Weinhandl
- Chronic Disease Research Group, Hennepin Healthcare Research Institute, Minneapolis, Minnesota
- University of Minnesota School of Pharmacy, Minneapolis, Minnesota
- Satellite Healthcare, San Jose, California
| | - James B. Wetmore
- Chronic Disease Research Group, Hennepin Healthcare Research Institute, Minneapolis, Minnesota
- Department of Medicine, University of Minnesota, Minneapolis, Minnesota
| | - Allyson Hart
- Chronic Disease Research Group, Hennepin Healthcare Research Institute, Minneapolis, Minnesota
- Department of Medicine, University of Minnesota, Minneapolis, Minnesota
| | - Kirsten L. Johansen
- Chronic Disease Research Group, Hennepin Healthcare Research Institute, Minneapolis, Minnesota
- Department of Medicine, University of Minnesota, Minneapolis, Minnesota
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Mohamed KA, Ghabril M, Desai A, Orman E, Patidar KR, Holden J, Rawl S, Chalasani N, Kubal CS, D. Nephew L. Neighborhood poverty is associated with failure to be waitlisted and death during liver transplantation evaluation. Liver Transpl 2022; 28:1441-1453. [PMID: 35389564 PMCID: PMC9545792 DOI: 10.1002/lt.26473] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2021] [Revised: 03/16/2022] [Accepted: 03/29/2022] [Indexed: 01/13/2023]
Abstract
Liver transplantation (LT) is the final step in a complex care cascade. Little is known about how race, gender, rural versus urban residence, or neighborhood socioeconomic indicators impact a patient's likelihood of LT waitlisting or risk of death during LT evaluation. We performed a retrospective cohort study of adults referred for LT to the Indiana University Academic Medical Center from 2011 to 2018. Neighborhood socioeconomic status indicators were obtained by linking patients' addresses to their census tract defined in the 2017 American Community Survey. Descriptive statistics were used to describe completion of steps in the LT evaluation cascade. Multivariable analyses were performed to assess the factors associated with waitlisting and death during LT evaluation. There were 3454 patients referred for LT during the study period; 25.3% of those referred were waitlisted for LT. There was no difference seen in the proportion of patients from vulnerable populations who progressed to the steps of financial approval or evaluation start. There were differences in waitlisting by insurance type (22.6% of Medicaid vs. 34.3% of those who were privately insured; p < 0.01) and neighborhood poverty (quartile 1 29.6% vs. quartile 4 20.4%; p < 0.01). On multivariable analysis, neighborhood poverty was independently associated with waitlisting (odds ratio 0.56, 95% confidence interval [CI] 0.38-0.82) and death during LT evaluation (hazard ratio 1.49, 95% CI 1.09-2.09). Patients from high-poverty neighborhoods are at risk of failing to be waitlisted and death during LT evaluation.
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Affiliation(s)
- Kawthar A. Mohamed
- Department of MedicineIndiana University School of MedicineIndianapolisIndianaUSA
| | - Marwan Ghabril
- Department of MedicineIndiana University School of MedicineIndianapolisIndianaUSA,Division of Gastroenterology and HepatologyDepartment of MedicineIndiana University School of MedicineIndianapolisIndianaUSA
| | - Archita Desai
- Department of MedicineIndiana University School of MedicineIndianapolisIndianaUSA,Division of Gastroenterology and HepatologyDepartment of MedicineIndiana University School of MedicineIndianapolisIndianaUSA
| | - Eric Orman
- Department of MedicineIndiana University School of MedicineIndianapolisIndianaUSA,Division of Gastroenterology and HepatologyDepartment of MedicineIndiana University School of MedicineIndianapolisIndianaUSA
| | - Kavish R. Patidar
- Department of MedicineIndiana University School of MedicineIndianapolisIndianaUSA
| | - John Holden
- Department of MedicineIndiana University School of MedicineIndianapolisIndianaUSA
| | - Susan Rawl
- Indiana University School of NursingIndianapolisIndianaUSA,Indiana University Simon Comprehensive Cancer CenterIndianapolisIndianaUSA
| | - Naga Chalasani
- Department of MedicineIndiana University School of MedicineIndianapolisIndianaUSA,Division of Gastroenterology and HepatologyDepartment of MedicineIndiana University School of MedicineIndianapolisIndianaUSA,Indiana University Simon Comprehensive Cancer CenterIndianapolisIndianaUSA
| | - Chandra Shekhar Kubal
- Division of Organ TransplantationDepartment of SurgeryIndiana University School of MedicineIndianapolisIndianaUSA
| | - Lauren D. Nephew
- Department of MedicineIndiana University School of MedicineIndianapolisIndianaUSA,Division of Gastroenterology and HepatologyDepartment of MedicineIndiana University School of MedicineIndianapolisIndianaUSA,Indiana University Simon Comprehensive Cancer CenterIndianapolisIndianaUSA
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7
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Scholes-Robertson N, Gutman T, Howell M, Craig JC, Chalmers R, Tong A. Patients’ Perspectives on Access to Dialysis and Kidney Transplantation in Rural Communities in Australia. Kidney Int Rep 2022; 7:591-600. [PMID: 35257071 PMCID: PMC8897297 DOI: 10.1016/j.ekir.2021.11.010] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Revised: 11/04/2021] [Accepted: 11/08/2021] [Indexed: 11/30/2022] Open
Abstract
Introduction This study aimed to describe the perspectives of patients from rural communities on access to all forms of kidney replacement therapy to inform strategies to address such inequity. Methods Semistructured interviews were conducted. Transcripts were thematically analyzed. Results There were 28 participants, of whom, 14 (50%) were female and 5 (17%) Aboriginal or Torres Strait Islander. The mean distance to a nephrologist was 107 km, and transplant center was 447 km. We identified the following 5 themes: encumbered by transportation hardship (burdening of family and friends, frustration at lack of transportation options, heightened vulnerability to road trauma, unrelenting financial strain); deprived of treatment and care (isolated from centralized services, unresolved psychological distress, vulnerable without care, disadvantaged by limited options); confused by multiple information sources (despair at fragmented care, fear of unfamiliar health settings and treatments); compounding economic consequences (depletion of income/leave, coping with unexpected expenses); and the looming threat of relocation (devastated by displacement, resigned to periods of separation, uncertainty in sourcing appropriate accommodation). Conclusion Patients with chronic kidney disease (CKD) in rural communities face profound economic, logistical, and psychological obstacles to accessing dialysis and transplant, leaving them feeling vulnerable and confused. To achieve equity of access and improved health outcomes for rural patients with CKD, barriers to dialysis, transplantation, and psychological services in this population require addressing through policy and alternate models of health service delivery, in consultation with rural communities and those families affected by CKD.
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8
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Scholes-Robertson NJ, Gutman T, Howell M, Craig J, Chalmers R, Dwyer KM, Jose M, Roberts I, Tong A. Clinicians' perspectives on equity of access to dialysis and kidney transplantation for rural people in Australia: a semistructured interview study. BMJ Open 2022; 12:e052315. [PMID: 35177446 PMCID: PMC8860044 DOI: 10.1136/bmjopen-2021-052315] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVES People with chronic kidney disease requiring dialysis or kidney transplantation in rural areas have worse outcomes, including an increased risk of hospitalisation and mortality and encounter many barriers to accessing kidney replacement therapy. We aim to describe clinicians' perspectives of equity of access to dialysis and kidney transplantation in rural areas. DESIGN Qualitative study with semistructured interviews. SETTING AND PARTICIPANTS Twenty eight nephrologists, nurses and social workers from 19 centres across seven states in Australia. RESULTS We identified five themes: the tyranny of distance (with subthemes of overwhelming burden of travel, minimising relocation distress, limited transportation options and concerns for patient safety on the roads); supporting navigation of health systems (reliance on local champions, variability of health literacy, providing flexible models of care and frustrated by gatekeepers); disrupted care (without continuity of care, scarcity of specialist services and fluctuating capacity for dialysis); pervasive financial distress (crippling out of pocket expenditure and widespread socioeconomic disadvantage) and understanding local variability (lacking availability of safe and sustainable resources for dialysis, sensitivity to local needs and dependence on social support). CONCLUSIONS Clinicians identified geographical barriers, dislocation from homes and financial hardship to be major challenges for patients in accessing kidney replacement therapy. Strategies such as telehealth, outreach services, increased service provision and patient navigators were suggested to improve access.
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Affiliation(s)
- Nicole Jane Scholes-Robertson
- Sydney School of Public Health, The University of Sydney, Sydney, New South Wales, Australia
- Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, New South Wales, Australia
| | - Talia Gutman
- Sydney School of Public Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Martin Howell
- Sydney School of Public Health, The University of Sydney, Sydney, New South Wales, Australia
- Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, New South Wales, Australia
| | - Jonathan Craig
- College of Medicine and Public Health, Flinders University Faculty of Medicine Nursing and Health Sciences, Adelaide, South Australia, Australia
| | - Rachel Chalmers
- Faculty of Medicine and Health, University of New England, Armidale, New South Wales, Australia
| | - Karen M Dwyer
- School of Medicine, Faculty of Health, Deakin University-Geelong Campus at Waurn Ponds, Geelong, Victoria, Australia
| | - Matthew Jose
- Hobart Clinical School, University of Tasmania School of Medicine, Hobart, Tasmania, Australia
- Department of Nephrology, Royal Hobart Hospital, Hobart, Tasmania, Australia
| | - Ieyesha Roberts
- Sydney School of Public Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Allison Tong
- Sydney School of Public Health, The University of Sydney, Sydney, New South Wales, Australia
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9
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Walker RC, Hay S, Walker C, Tipene-Leach D, Palmer SC. Exploring rural and remote patients' experiences of health services for kidney disease in Aotearoa New Zealand: An in-depth interview study. Nephrology (Carlton) 2022; 27:421-429. [PMID: 34985814 DOI: 10.1111/nep.14018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Revised: 12/16/2021] [Accepted: 12/28/2021] [Indexed: 11/30/2022]
Abstract
AIMS People with chronic kidney disease (CKD) living in rural communities have increased risks of death, morbidity, hospitalization and poorer quality of life compared with people with CKD living in urban areas. This study explores the experiences and perceptions of rural and remote patients and families in relation to accessing health services for kidney disease in Aotearoa New Zealand. METHODS We conducted an In-depth interview study. We purposively sampled adult patients with CKD and their caregivers who lived further than 100 km (62 miles) or more than 1 h drive from their nearest dialysis or transplant centre. Qualitative data were analyzed inductively to generate themes, subthemes and a conceptual framework. RESULTS Of 35 participants, including 26 patients and nine caregivers, 51% were female, 71% travelled between 1 and 3 h to their nearest renal unit, and the remainder, between 3 and 6 h. We identified five themes and related subthemes: intense psychological impact of rurality; pressure of extended periods away from home; services not designed for rural and remote living; suffering from financial losses; and poor communication. CONCLUSION Rural and remote patients with CKD and their caregivers face the added challenges of separation from family, social and community support and financial burden, which can have profound consequences on their psychological and physical well-being and that of their families.
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Affiliation(s)
- Rachael C Walker
- Research Innovation Centre, Eastern Institute of Technology, Hawke's Bay, New Zealand
| | - Sandra Hay
- Department of Nephrology, Canterbury District Health Board, Christchurch, New Zealand
| | - Curtis Walker
- Department of Medicine, Midcentral District Health Board, Palmerston North, New Zealand
| | - David Tipene-Leach
- Research Innovation Centre, Eastern Institute of Technology, Hawke's Bay, New Zealand
| | - Suetonia C Palmer
- Department of Nephrology, Canterbury District Health Board, Christchurch, New Zealand.,Department of Medicine, University of Otago Christchurch, Christchurch, New Zealand
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10
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Al Ammary F, Concepcion BP, Yadav A. The Scope of Telemedicine in Kidney Transplantation: Access and Outreach Services. Adv Chronic Kidney Dis 2021; 28:542-547. [PMID: 35367022 DOI: 10.1053/j.ackd.2021.10.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Revised: 09/29/2021] [Accepted: 10/12/2021] [Indexed: 12/23/2022]
Abstract
Access to transplant centers is a key barrier for kidney transplant evaluation and follow-up care for both the recipient and donor. Potential kidney transplant recipients and living kidney donors may face geographic, financial, and logistical challenges in engaging with a transplant center and maintaining post-transplant continuity of care. Telemedicine via synchronous video visits has the potential to overcome the access barrier to transplant centers. Transplant centers can start the evaluation process for potential recipients and donors via telemedicine, especially for those who have challenges to come for an in-person visit or when there are restrictions on clinic capacities, such as during a pandemic. Similarly, transplant centers can use telemedicine to sustain post-transplant follow-up care while avoiding the burden of travel and its associated costs. However, expansion to telemedicine-based kidney transplant services is substantially dependent on telemedicine infrastructure, insurer policy, and state regulations. In this review, we discuss the practice of telemedicine in kidney transplantation and its implications for expanding access to kidney transplant services and outreach from pretransplant evaluation to post-transplant follow-up care for the recipient and donor.
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11
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Pattharanitima P, El Shamy O, Chauhan K, Saha A, Wen HH, Sharma S, Uribarri J, Chan L. The Association between Prevalence of Peritoneal Dialysis versus Hemodialysis and Patients' Distance to Dialysis-Providing Facilities. KIDNEY360 2021; 2:1908-1916. [PMID: 35419529 PMCID: PMC8986048 DOI: 10.34067/kid.0004762021] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Accepted: 10/14/2021] [Indexed: 02/04/2023]
Abstract
Background Accessibility to dialysis facilities plays a central role when deciding on a patient's long-term dialysis modality. Studies investigating the effect of distance to nearest dialysis-providing unit on modality choice have yielded conflicting results. We set out to investigate the association between patients' dialysis modality and both the driving and straight-line distances to the closest HD- and PD-providing units. Methods All patients with ESKD who initiated in-center HD and PD in 2017, were 18-90 years old, and were on dialysis for ≥30 days were included. Patients in residence zip codes in nonconterminous United States or lived >90 miles from the nearest HD-providing unit were excluded. Results A total of 102,247 patients in the United States initiated in-center HD and PD in 2017. Compared with patients on HD, patients on PD had longer driving distances to their nearest PD unit (4.4 versus 3.4 miles; P<0.001). Patients who lived >30 miles from the nearest HD unit were more likely to be on PD if the nearest PD unit was a distance equal to/less than that of the HD unit. PD utilization increased with increasing distance from patients' homes to the nearest HD unit. No change in this association was found regardless of if the PD unit was farther from/closer than the nearest HD unit. This association was not seen with straight-line distance analysis. Conclusions With increasing distances from the nearest dialysis-providing units (HD or PD), PD utilization increased. Using driving distance rather than straight-line distance affects data analysis and outcomes. Increasing the number of PD units may have a limited effect on increasing PD utilization.
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Affiliation(s)
- Pattharawin Pattharanitima
- Division of Nephrology, Department of Internal Medicine, Faculty of Medicine, Thammasat University, Pathum Thani, Thailand,Division of Nephrology, Icahn School of Medicine, Mount Sinai, New York
| | - Osama El Shamy
- Department of Medicine, Division of Nephrology and Hypertension, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Kinsuk Chauhan
- Division of Nephrology, Icahn School of Medicine, Mount Sinai, New York
| | - Aparna Saha
- Charles Bronfman Institute of Personalized Medicine, Icahn School of Medicine, Mount Sinai, New York
| | - Huei Hsun Wen
- Division of Nephrology, Icahn School of Medicine, Mount Sinai, New York
| | - Shuchita Sharma
- Division of Nephrology, Icahn School of Medicine, Mount Sinai, New York
| | - Jaime Uribarri
- Division of Nephrology, Icahn School of Medicine, Mount Sinai, New York
| | - Lili Chan
- Division of Nephrology, Icahn School of Medicine, Mount Sinai, New York,Charles Bronfman Institute of Personalized Medicine, Icahn School of Medicine, Mount Sinai, New York
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12
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Woodside KJ, Repeck KJ, Mukhopadhyay P, Schaubel DE, Shahinian VB, Saran R, Pisoni RL. Arteriovenous Vascular Access-Related Procedural Burden Among Incident Hemodialysis Patients in the United States. Am J Kidney Dis 2021; 78:369-379.e1. [PMID: 33857533 DOI: 10.1053/j.ajkd.2021.01.019] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Accepted: 01/26/2021] [Indexed: 11/11/2022]
Abstract
RATIONALE & OBJECTIVE As the proportion of arteriovenous fistulas (AVFs) compared with arteriovenous grafts (AVGs) in the United States has increased, there has been a concurrent increase in interventions. We explored AVF and AVG maturation and maintenance procedural burden in the first year of hemodialysis. STUDY DESIGN Observational cohort study. SETTING & PARTICIPANTS Patients initiating hemodialysis from July 1, 2012, to December 31, 2014, and having a first-time AVF or AVG placement between dialysis initiation and 1 year (N = 73,027), identified using the US Renal Data System (USRDS). PREDICTORS Patient characteristics. OUTCOME Successful AVF/AVG use and intervention procedure burden. ANALYTICAL APPROACH For each group, we analyzed interventional procedure rates during maturation maintenance phases using Poisson regression. We used proportional rate modeling for covariate-adjusted analysis of interventional procedure rates during the maintenance phase. RESULTS During the maturation phase, 13,989 of 57,275 patients (24.4%) in the AVF group required intervention, with therapeutic interventional requirements of 0.36 per person. In the AVG group 2,904 of 15,572 patients (18.4%) required intervention during maturation, with therapeutic interventional requirements of 0.28 per person. During the maintenance phase, in the AVF group 12,732 of 32,115 patients (39.6%) required intervention, with a therapeutic intervention rate of 0.93 per person-year. During maintenance phase, in the AVG group 5,928 of 10,271 patients (57.7%) required intervention, with a therapeutic intervention rate of 1.87 per person-year. For both phases, the intervention rates for AVF tended to be higher on the East Coast while those for AVG were more uniform geographically. LIMITATIONS This study relies on administrative data, with monthly recording of access use. CONCLUSIONS During maturation, interventions for both AVFs and AVGs were relatively common. Once successfully matured, AVFs had lower maintenance interventional requirements. During the maturation and maintenance phases, there were geographic variations in AVF intervention rates that warrant additional study.
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Affiliation(s)
- Kenneth J Woodside
- Kidney Epidemiology and Cost Center, University of Michigan, Ann Arbor, MI; Department of Surgery, University of Michigan, Ann Arbor, MI.
| | | | | | - Douglas E Schaubel
- Kidney Epidemiology and Cost Center, University of Michigan, Ann Arbor, MI; Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Philadelphia, PA
| | - Vahakn B Shahinian
- Kidney Epidemiology and Cost Center, University of Michigan, Ann Arbor, MI; Division of Nephrology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI
| | - Rajiv Saran
- Kidney Epidemiology and Cost Center, University of Michigan, Ann Arbor, MI; Division of Nephrology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI; Department of Epidemiology, University of Michigan, Ann Arbor, MI
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13
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Stavropoulou E, Kantartzi K, Tsigalou C, Konstantinidis T, Romanidou G, Voidarou C, Bezirtzoglou E. Focus on the Gut-Kidney Axis in Health and Disease. Front Med (Lausanne) 2021; 7:620102. [PMID: 33553216 PMCID: PMC7859267 DOI: 10.3389/fmed.2020.620102] [Citation(s) in RCA: 42] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Accepted: 12/16/2020] [Indexed: 12/11/2022] Open
Abstract
The recent new developments in technology with culture-independent techniques including genome sequencing methodologies shed light on the identification of microbiota bacterial species and their role in health and disease. Microbiome is actually reported as an important predictive tool for evaluating characteristic shifts in case of disease. Our present review states the development of different renal diseases and pathologies linked to the intestinal dysbiosis, which impacts on host homeostasis. The gastrointestinal–kidney dialogue provides intriguing features in the pathogenesis of several renal diseases. Without any doubt, investigation of this interconnection consists one of the most cutting-edge areas of research with potential implications on our health.
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Affiliation(s)
- Elisavet Stavropoulou
- Centre Hospitalier Universitaire Vaudois (CHUV), Lausanne, Switzerland.,Department of Infectious Diseases, Central Institute, Valais Hospital, Sion, Switzerland
| | - Konstantia Kantartzi
- Department of Medicine, Democritus University of Thrace, Alexandroupolis, Greece
| | - Christina Tsigalou
- Department of Medicine, Democritus University of Thrace, Alexandroupolis, Greece
| | | | | | | | - Eugenia Bezirtzoglou
- Department of Medicine, Democritus University of Thrace, Alexandroupolis, Greece
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14
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Education Strategies in Dialysis Centers Associated With Increased Transplant Wait-listing Rates. Transplantation 2020; 104:335-342. [PMID: 31335777 DOI: 10.1097/tp.0000000000002781] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Transplant education in dialysis centers can increase access to kidney transplant; however, dialysis center transplant barriers are common, and limited research identifies the most effective transplant education approaches. METHODS We surveyed transplant educators in 1694 US dialysis centers about their transplant knowledge, use of 12 education practices, and 8 identified education barriers. Transplant wait-listing rates were calculated using US Renal Data System data. RESULTS Fifty-two percent of educators orally recommended transplant to patients, 31% had in-center transplant discussions with patients, 17% distributed print educational resources, and 3% used intensive education approaches. Distribution of print education (incident rate ratio: 1.021.151.30) and using >1 intensive education practice (1.001.111.23) within dialysis centers were associated with increased wait-listing rates. Several dialysis center characteristics were associated with reduced odds of using education strategies leading to increased wait-listing. Centers with greater percentages of uninsured patients (odds ratio [OR]: 0.960.970.99), in rural locations (OR: 0.660.790.95), with for-profit ownership (OR: 0.640.770.91), and with more patients older than 65 years (OR: 0.050.110.23) had lower odds of recommending transplant, while centers with a higher patient-to-staff ratio were more likely to do so (OR: 1.011.031.04). Language barriers (OR: 0.480.640.86) and having competing work priorities (OR: 0.400.530.70) reduced the odds of distributing print education. Providers with greater transplant knowledge were more likely to use >1 intensive educational strategy (OR: 1.011.271.60) while providers who reported competing work priorities (OR: 0.510.660.84) and poor communication with transplant centers (OR: 0.580.760.98) were less likely to do so. CONCLUSIONS Educators should prioritize transplant education strategies shown to be associated with increasing wait-listing rates.
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15
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Scholes-Robertson NJ, Howell M, Gutman T, Baumgart A, SInka V, Tunnicliffe DJ, May S, Chalmers R, Craig J, Tong A. Patients' and caregivers' perspectives on access to kidney replacement therapy in rural communities: systematic review of qualitative studies. BMJ Open 2020; 10:e037529. [PMID: 32967878 PMCID: PMC7513603 DOI: 10.1136/bmjopen-2020-037529] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE Patients with chronic kidney disease (CKD) requiring kidney replacement therapy (KRT) in rural communities encounter many barriers in accessing equitable care and have worse outcomes compared with patients in urban areas. This study aims to describe the perspectives of patients and caregivers on access to KRT in rural communities to inform strategies to maximise access to quality care, and thereby reduce disadvantage, inequity and improve health outcomes. SETTING 18 studies (n=593 participants) conducted across eight countries (Australia, Canada, the UK, New Zealand, Ghana, the USA, Tanzania and India). RESULTS We identified five themes: uncertainty in navigating healthcare services (with subthemes of struggling to absorb information, without familiarity and exposure to options, grieving former roles and yearning for cultural safety); fearing separation from family and home (anguish of homesickness, unable to fulfil family roles and preserving sense of belonging in community); intense burden of travel and cost (poverty of time, exposure to risks and hazards, and taking a financial toll); making life-changing sacrifices; guilt and worry in receiving care (shame in taking resources from others, harbouring concerns for living donor, and coping and managing in isolation). CONCLUSION Patients with CKD in rural areas face profound and inequitable challenges of displacement, financial burden and separation from family in accessing KRT, which can have severe consequences on their well-being and outcomes. Strategies are needed to improve access and reduce the burden of obtaining appropriate KRT in rural communities.
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Affiliation(s)
- Nicole Jane Scholes-Robertson
- Sydney School of Public Health, The University of Sydney, Sydney, New South Wales, Australia
- Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, New South Wales, Australia
| | - Martin Howell
- Sydney School of Public Health, The University of Sydney, Sydney, New South Wales, Australia
- Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, New South Wales, Australia
| | - Talia Gutman
- Sydney School of Public Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Amanda Baumgart
- Sydney School of Public Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Victoria SInka
- Sydney School of Public Health, The University of Sydney, Sydney, New South Wales, Australia
| | - David J Tunnicliffe
- Sydney School of Public Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Stephen May
- School of Rural Medicine, University of New England, Armidale, New South Wales, Australia
| | - Rachel Chalmers
- School of Rural Medicine, University of New England, Armidale, New South Wales, Australia
| | - Jonathan Craig
- College of Medicine and Public Health, Flinders University Faculty of Medicine Nursing and Health Sciences, Adelaide, South Australia, Australia
| | - Allison Tong
- Sydney School of Public Health, The University of Sydney, Sydney, New South Wales, Australia
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16
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Palmer NR, Avis NE, Fino NF, Tooze JA, Weaver KE. Rural cancer survivors' health information needs post-treatment. PATIENT EDUCATION AND COUNSELING 2020; 103:1606-1614. [PMID: 32147307 PMCID: PMC7311274 DOI: 10.1016/j.pec.2020.02.034] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/30/2019] [Revised: 02/03/2020] [Accepted: 02/26/2020] [Indexed: 06/10/2023]
Abstract
OBJECTIVE This study describes the most common cancer-related health information needs among rural cancer survivors and characteristics associated with reporting more information needs. METHODS Rural breast, prostate, and colorectal cancer survivors, two to five years post-diagnosis, identified from an institutional cancer registry, completed a mailed/telephone-administered survey. Respondents were asked about 23 health information needs in eight domains (tests and treatment, side effects and symptoms, health promotion, fertility, interpersonal, occupational, emotional, and insurance). Poisson regression models were used to assess relationships between number of health information needs and demographic and cancer characteristics. RESULTS Participants (n = 170) reported an average of four health information needs, with the most common domains being: side effects and symptoms (58 %), health promotion (54 %), and tests and treatment (41 %). Participants who were younger (compared to 5-year increase, rate ratio [RR] = 1.11, 95 % CI = 1.02-1.21), ethnic minority (RR = 1.89, 95 % CI = 1.17-3.06), less educated (RR = 1.49, 95 % CI = 1.00-2.23), and financially stressed (RR = 1.87, 95 % CI = 1.25-2.81) had a greater number of information needs. CONCLUSIONS Younger, ethnic minority, less educated, and financially strained rural survivors have the greatest need for informational support. PRACTICE IMPLICATIONS The provision of health information for rural cancer survivors should consider type of cancer, treatments received, and sociocultural differences to tailor information provided.
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Affiliation(s)
- Nynikka R Palmer
- Department of Medicine, University of California San Francisco, San Francisco, CA, USA.
| | - Nancy E Avis
- Department of Social Sciences and Health Policy, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Nora F Fino
- Department of Biostatistical Sciences, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Janet A Tooze
- Department of Biostatistical Sciences, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Kathryn E Weaver
- Department of Social Sciences and Health Policy, Wake Forest School of Medicine, Winston-Salem, NC, USA
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17
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Use of Telehealth to Expand Living Kidney Donation and Living Kidney Donor Transplantation. CURRENT TRANSPLANTATION REPORTS 2020. [DOI: 10.1007/s40472-020-00276-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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18
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Reed RD, Shelton BA, Mustian MN, MacLennan PA, Sawinski D, Locke JE. Geographic Differences in Population Health and Expected Organ Supply in the Gulf Coast Region of the United States Compared to Non-Gulf States. Transplantation 2020; 104:421-427. [PMID: 32004235 PMCID: PMC7000133 DOI: 10.1097/tp.0000000000002831] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The Final Rule aimed to reduce geographic disparities in access to transplantation by prioritizing the need for transplant over donor proximity. However, disparities in waiting times persist for deceased donor kidney transplantation. The kidney allocation system implemented in 2014 does not account for potential local supply based on population health characteristics within a donation service area (DSA). We hypothesized that regions with traditionally high rates of comorbid disease, such as the states located along the Gulf of Mexico (Gulf States), may be disadvantaged by limited local supply secondary to poor population health. METHODS Using data from the Robert Wood Johnson Foundation County Health Rankings, the United States Renal Data System, and the Scientific Registry of Transplant Recipients, we compared population-level characteristics and expected kidney donation rates by Gulf States location. RESULTS Prevalence of African American ethnicity, end-stage renal disease, diabetes, fair/poor self-rated health, physical inactivity, food insecurity, and uninsurance were higher among Gulf State DSAs. On unadjusted analyses, Gulf State DSAs were associated with 3.52 fewer expected kidney donors per 100 eligible deaths than non-Gulf States. After adjustment, there was no longer a statistically significant difference in expected kidney donation rate. CONCLUSIONS Although Gulf State DSAs have lower expected donation rates, these differences appear to be driven by the prevalence of health factors negatively associated with donation rate. These data suggest the need to discuss population health characteristics when examining kidney allocation policy, to account for potential lower supply of donors and to further address geographic disparities in access to kidney transplantation.
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Affiliation(s)
- Rhiannon D. Reed
- Department of Surgery, University of Alabama at Birmingham Comprehensive Transplant Institute, Birmingham, AL
| | - Brittany A. Shelton
- Department of Surgery, University of Alabama at Birmingham Comprehensive Transplant Institute, Birmingham, AL
| | - Margaux N. Mustian
- Department of Surgery, University of Alabama at Birmingham Comprehensive Transplant Institute, Birmingham, AL
| | - Paul A. MacLennan
- Department of Surgery, University of Alabama at Birmingham Comprehensive Transplant Institute, Birmingham, AL
| | - Deirdre Sawinski
- Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Jayme E. Locke
- Department of Surgery, University of Alabama at Birmingham Comprehensive Transplant Institute, Birmingham, AL
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Cabacungan A, Diamantidis C, St. Clair Russell J, Strigo T, Pounds I, Alkon A, Riley J, Falkovic M, Pendergast J, Davenport C, Ellis M, Sudan D, Hill-Briggs F, Browne T, Ephraim P, Boulware L. Development of a Telehealth Intervention to Improve Access to Live Donor Kidney Transplantation. Transplant Proc 2019; 51:665-675. [DOI: 10.1016/j.transproceed.2018.12.032] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2018] [Accepted: 12/05/2018] [Indexed: 01/07/2023]
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20
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Chan CT, Wallace E, Golper TA, Rosner MH, Seshasai RK, Glickman JD, Schreiber M, Gee P, Rocco MV. Exploring Barriers and Potential Solutions in Home Dialysis: An NKF-KDOQI Conference Outcomes Report. Am J Kidney Dis 2018; 73:363-371. [PMID: 30545707 DOI: 10.1053/j.ajkd.2018.09.015] [Citation(s) in RCA: 54] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2018] [Accepted: 09/27/2018] [Indexed: 11/11/2022]
Abstract
Home dialysis therapy, including home hemodialysis and peritoneal dialysis, is underused as a modality for the treatment of chronic kidney failure. The National Kidney Foundation-Kidney Disease Outcomes Quality Initiative sponsored a home dialysis conference in late 2017 that was designed to identify the barriers to starting and maintaining patients on home dialysis therapy. Clinical, operational, policy, and societal barriers were identified that need to be overcome to ensure that dialysis patients have the freedom to choose their treatment modality. Education of patients and patient partners, as well as health care providers, about home dialysis therapy, if offered at all, is often provided in a cursory manner. Lack of exposure to home dialysis therapies perpetuates a lack of familiarity and thus a hesitancy to refer patients to home dialysis therapies. Patient and care partner support, both psychosocial and financial, is also critical to minimize the risk for burnout leading to dropout from a home dialysis modality. Thus, the facilitation of home dialysis therapy will require a systematic change in chronic kidney disease education and the approach to dialysis therapy initiation, the creation of additional incentives for performing home dialysis, and breakthroughs to simplify the performance of home dialysis modalities. The home dialysis work group plans to develop strategies to overcome these barriers to home dialysis therapy, which will be presented at a follow-up home dialysis conference.
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Affiliation(s)
| | - Eric Wallace
- University of Alabama at Birmingham, Birmingham, AL
| | | | | | | | - Joel D Glickman
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | | | - Patrick Gee
- Quality Insights Renal Network 5, Mid-Atlantic Renal Coalition, North Chesterfield, VA
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21
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Wang V, Coffman CJ, Sanders LL, Lee SYD, Hirth RA, Maciejewski ML. Medicare's New Prospective Payment System on Facility Provision of Peritoneal Dialysis. Clin J Am Soc Nephrol 2018; 13:1833-1841. [PMID: 30455323 PMCID: PMC6302340 DOI: 10.2215/cjn.05680518] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2018] [Accepted: 08/31/2018] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND OBJECTIVES Peritoneal dialysis is a self-administered, home-based treatment for ESKD associated with equivalent mortality, higher quality of life, and lower costs compared with hemodialysis. In 2011, Medicare implemented a comprehensive prospective payment system that makes a single payment for all dialysis, medication, and ancillary services. We examined whether the prospective payment system increased dialysis facility provision of peritoneal dialysis services and whether changes in peritoneal dialysis provision were more common among dialysis facilities that are chain affiliated, located in nonurban areas, and in regions with high dialysis market competition. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS We conducted a longitudinal retrospective cohort study of n=6433 United States nonfederal dialysis facilities before (2006-2010) and after (2011-2013) the prospective payment system using data from the US Renal Data System, Medicare, and Area Health Resource Files. The outcomes of interest were a dichotomous indicator of peritoneal dialysis service availability and a discrete count variable of dialysis facility peritoneal dialysis program size defined as the annual number of patients on peritoneal dialysis in a facility. We used general estimating equation models to examine changes in peritoneal dialysis service offerings and peritoneal dialysis program size by a pre- versus post-prospective payment system effect and whether changes differed by chain affiliation, urban location, facility size, or market competition, adjusting for 1-year lagged facility-, patient with ESKD-, and region-level demographic characteristics. RESULTS We found a modest increase in observed facility provision of peritoneal dialysis and peritoneal dialysis program size after the prospective payment system (36% and 5.7 patients in 2006 to 42% and 6.9 patients in 2013, respectively). There was a positive association of the prospective payment system with peritoneal dialysis provision (odds ratio, 1.20; 95% confidence interval, 1.13 to 1.18) and PD program size (incidence rate ratio, 1.27; 95% confidence interval, 1.22 to 1.33). Post-prospective payment system change in peritoneal dialysis provision was greater among nonurban (P<0.001), chain-affiliated (P=0.002), and larger-sized facilities (P<0.001), and there were higher rates of peritoneal dialysis program size growth in nonurban facilities (P<0.001). CONCLUSIONS Medicare's 2011 prospective payment system was associated with more facilities' availability of peritoneal dialysis and modest growth in facility peritoneal dialysis program size. PODCAST This article contains a podcast at https://www.asn-online.org/media/podcast/CJASN/2018_11_19_CJASNPodcast_18_12_.mp3.
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Affiliation(s)
- Virginia Wang
- Departments of Population Health Sciences and
- Division of General Internal Medicine, Department of Medicine, Duke University School of Medicine, Durham, North Carolina
- Health Services Research and Development Center of Innovation, Durham Veterans Affairs Health Care System, Durham, North Carolina; and
| | - Cynthia J. Coffman
- Biostatistics and Bioinformatics and
- Health Services Research and Development Center of Innovation, Durham Veterans Affairs Health Care System, Durham, North Carolina; and
| | - Linda L. Sanders
- Division of General Internal Medicine, Department of Medicine, Duke University School of Medicine, Durham, North Carolina
| | - Shoou-Yih D. Lee
- Department of Health Management and Policy, University of Michigan, Ann Arbor, Michigan
| | - Richard A. Hirth
- Department of Health Management and Policy, University of Michigan, Ann Arbor, Michigan
| | - Matthew L. Maciejewski
- Departments of Population Health Sciences and
- Division of General Internal Medicine, Department of Medicine, Duke University School of Medicine, Durham, North Carolina
- Health Services Research and Development Center of Innovation, Durham Veterans Affairs Health Care System, Durham, North Carolina; and
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22
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Brady BM, Zhao B, Niu J, Winkelmayer WC, Milstein A, Chertow GM, Erickson KF. Patient-Reported Experiences of Dialysis Care Within a National Pay-for-Performance System. JAMA Intern Med 2018; 178:1358-1367. [PMID: 30208398 PMCID: PMC6233760 DOI: 10.1001/jamainternmed.2018.3756] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
IMPORTANCE Medicare's End-Stage Renal Disease Quality Incentive Program incorporates measures of perceived value into reimbursement calculations. In 2016, patient experience became a clinical measure in the Quality Incentive Program scoring system. Dialysis facility performance in patient experience measures has not been studied at the national level to date. OBJECTIVE To examine associations among dialysis facility performance with patient experience measures and patient, facility, and geographic characteristics. DESIGN In this cross-sectional analysis, patients from a national end-stage renal disease registry receiving in-center hemodialysis in the United States on December 31, 2014, were linked with dialysis facility scores on the In-Center Hemodialysis Consumer Assessment of Healthcare Providers and Systems (ICH-CAHPS) survey. Of 4977 US dialysis facilities, 2939 (59.1%) reported ICH-CAHPS scores from April 8, 2015, through January 11, 2016. Multivariable linear regression models with geographic random effects were used to examine associations of facility ICH-CAHPS scores with patient, dialysis facility, and geographic characteristics and to identify the amount of total between-facility variation in patient experience scores explained by these categories. Data were analyzed from September 15, 2017, through June 1, 2018. EXPOSURES Dialysis facility, geographic characteristic, and 10% change in patient characteristics. MAIN OUTCOMES AND MEASURES Dialysis facility ICH-CAHPS scores and the total between-facility variation explained by different categories of characteristics. RESULTS Of the 2939 facilities included in the analysis, adjusted mean ICH-CAHPS scores were 2.6 percentage points (95% CI, 1.5-3.7) lower in for-profit facilities, 1.6 percentage points (95% CI, 0.9-2.2) lower in facilities owned by large dialysis organizations, and 2.3 percentage points (95% CI, 0.5-4.2) lower in free-standing facilities compared with their counterparts. More nurses per patient was associated with 0.2 percentage points (95% CI, 0.03-0.3) higher scores; a privately insured patient population was associated with 1.2 percentage points (95% CI, 0.2-2.2) higher scores. Facilities with higher proportions of black patients had 0.95 percentage points (95% CI, 0.78-1.12) lower scores; more Native American patients, 1.00 percentage point (95% CI, 0.39-1.60) lower facility scores. Geographic location and dialysis facility characteristics explained larger proportions of the overall between-facility variation in ICH-CAHPS scores than did patient characteristics. CONCLUSIONS AND RELEVANCE This study suggests that for-profit operation, free-standing status, and large dialysis organization designation were associated with less favorable patient-reported experiences of care. Patient experience scores varied geographically, and black and Native American populations reported less favorable experiences. The study findings suggest that perceived quality of care delivered in these settings are of concern, and that there may be opportunities for improved implementation of patient experience surveys as is highlighted.
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Affiliation(s)
- Brian M Brady
- Division of Nephrology, Stanford University School of Medicine, Stanford, California.,Clinical Excellence Research Center, Stanford University School of Medicine, Stanford, California
| | - Bo Zhao
- Selzman Institute for Kidney Health, Section of Nephrology, Baylor College of Medicine, Houston, Texas
| | - Jingbo Niu
- Selzman Institute for Kidney Health, Section of Nephrology, Baylor College of Medicine, Houston, Texas
| | - Wolfgang C Winkelmayer
- Selzman Institute for Kidney Health, Section of Nephrology, Baylor College of Medicine, Houston, Texas
| | - Arnold Milstein
- Clinical Excellence Research Center, Stanford University School of Medicine, Stanford, California
| | - Glenn M Chertow
- Division of Nephrology, Stanford University School of Medicine, Stanford, California
| | - Kevin F Erickson
- Selzman Institute for Kidney Health, Section of Nephrology, Baylor College of Medicine, Houston, Texas.,Baker Institute for Public Policy, Rice University, Houston, Texas
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Turenne M, Baker R, Pearson J, Cogan C, Mukhopadhyay P, Cope E. Payment Reform and Health Disparities: Changes in Dialysis Modality under the New Medicare Dialysis Payment System. Health Serv Res 2017; 53:1430-1457. [PMID: 28560726 DOI: 10.1111/1475-6773.12713] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE To evaluate the effect of the Medicare dialysis payment reform on potential disparities in the selection of peritoneal dialysis (PD) for the treatment of end-stage renal disease (ESRD). DATA SOURCES Centers for Medicare & Medicaid Services (CMS) ESRD Medical Evidence Form, Medicare claims, and other CMS data for 2008-2013. STUDY DESIGN We examined the association of patient age, race/ethnicity, urban/rural location, pre-ESRD care, comorbidities, insurance, and other factors with the selection of PD as initial dialysis modality across prereform (2008-2009), interim (2010), and postreform (2011-2013) time periods. PRINCIPAL FINDINGS Selection of PD increased among diverse patient subgroups following the payment reform. However, the lower PD selection observed with older age, black race, Hispanic ethnicity, less pre-ESRD care, and Medicaid insurance before the reform largely remained in the initial postreform years. CONCLUSIONS Despite recent growth in PD, there may be ongoing disparities in access to PD that have largely not been mitigated by the payment reform. There is potential for modifying provider financial incentives to achieve policy goals related to cost and quality of care. However, even with a substantial shift in financial incentives, separate initiatives to reduce existing disparities in care may be needed.
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Affiliation(s)
- Marc Turenne
- Arbor Research Collaborative for Health, Ann Arbor, MI
| | - Regina Baker
- Arbor Research Collaborative for Health, Ann Arbor, MI
| | | | - Chad Cogan
- Arbor Research Collaborative for Health, Ann Arbor, MI
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Crowley ST, Belcher J, Choudhury D, Griffin C, Pichler R, Robey B, Rohatgi R, Mielcarek B. Targeting Access to Kidney Care Via Telehealth: The VA Experience. Adv Chronic Kidney Dis 2017; 24:22-30. [PMID: 28224939 DOI: 10.1053/j.ackd.2016.11.005] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2016] [Revised: 11/13/2016] [Accepted: 11/14/2016] [Indexed: 01/22/2023]
Abstract
The Veterans Affairs (VA) is the largest integrated health care system in the United States and is responsible for the care of a population with a disproportionately high rate of CKD. As such, ensuring access to kidney health services is a VA imperative. One facet of the VA's strategy to reduce CKD is to leverage the use of teletechnology to expand the VA's outreach to Veterans with kidney disease. A wide array of teletechnology services have been deployed to both pull in Veterans and push out kidney health services to Veterans in their preferred health care venue. Teletechnology, thus, expands Veteran choice, facilitates their access to care, and furthers the goal of delivering patient-centered kidney specialty care. The VA has demonstrated the feasibility of virtual delivery of kidney specialty care services and education via synchronous and asynchronous approaches. The challenges ahead include determining the relative health care value of kidney telehealth services, identifying Veterans most likely to benefit from specific technologies and optimizing the adoption of effective kidney telehealth services by both providers and patients alike to ensure optimal and timely kidney health care delivery.
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Wallace EL, Lea J, Chaudhary NS, Griffin R, Hammelman E, Cohen J, Sloand JA. Home Dialysis Utilization Among Racial and Ethnic Minorities in the United States at the National, Regional, and State Level. Perit Dial Int 2016; 37:21-29. [PMID: 27680759 DOI: 10.3747/pdi.2016.00025] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2016] [Accepted: 03/05/2016] [Indexed: 11/15/2022] Open
Abstract
♦ BACKGROUND: United States Renal Data System (USRDS) data from 2014 show that African Americans (AA) are underrepresented in the home dialysis population, with 6.4% versus 9.2% utilization in the general populace. This racial disparity may be inaccurately ascribed to the nation as a whole if regional and inter-state variability exists. This investigation sought to examine home dialysis utilization by minority Medicare beneficiary populations across the US nationally, regionally, and by individual state. ♦ METHODS: The 2012 Medicare 100% Outpatient Standard Analytic File was used to identify all Medicare fee-for-service (FFS) patients, with state of residence and race, receiving an outpatient dialysis facility bill type. Peritoneal dialysis (PD) and home hemodialysis (HHD) patients were identified using revenue and condition codes and were defined by having at least one claim during the year that met criteria for the category. Beneficiaries were counted once for each modality used that year. A home dialysis utilization ratio (UR) was calculated as the ratio of the proportion of a minority on PD or HHD within a geographic division to the proportion of Caucasians on PD or HHD within the same geographic division. A UR less than 1.00 indicated under-representation while a UR over 1.00 indicated over-representation. Utilization ratios were compared using a Poisson regression model. ♦ RESULTS: A total of 369,164 Medicare FFS dialysis patients were identified. Within the total cohort, AA were the most underrepresented minority on PD (UR 0.586; 95% confidence interval [CI]: 0.585 - 0.586; p < 0.0001), followed by Hispanics (UR 0.744; 95% CI 0.743 - 0.744; p < 0.0001). The underutilization of PD by AA and Hispanics could not be ascribed to any region of the US, as all regions of the US had UR < 1.00. Only Massachusetts had a UR > 1.00 for AA on PD. Peritoneal dialysis UR values for Asians and those self-identified as Other were 0.954; 95% CI 0.953 - 0.954 and 0.932; 95% CI 0.931 - 0.932, respectively. Nationally, all minorities utilized HHD less than Caucasians. However, more variability existed, with Asians utilizing more HHD than Caucasians in the Midwest. ♦ CONCLUSIONS: Although regional and interstate variability exists, there is near universal under-representation of AA and Hispanics in the home dialysis population, while Asians and Other demonstrate more interregional and interstate variability.
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Affiliation(s)
- Eric L Wallace
- Department of Medicine, Division of Nephrology, University of Alabama at Birmingham, Birmingham, AL, USA
| | | | - Ninad S Chaudhary
- Department of Epidemiology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Russell Griffin
- Department of Epidemiology, University of Alabama at Birmingham, Birmingham, AL, USA
| | | | | | - James A Sloand
- Baxter Healthcare Corporation, Deerfield, IL, United States
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26
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Ajmal F, Bennett KJ, Probst JC. Geographic disparities in mortality among the end stage renal disease patients: an analysis of the United States Renal Data System, 2007-08. J Nephrol 2016; 29:817-826. [PMID: 27312990 DOI: 10.1007/s40620-016-0324-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2016] [Accepted: 05/30/2016] [Indexed: 11/30/2022]
Abstract
The study was conducted to determine the association between mortality, rurality, and distance from the treatment facility of the patients with ESRD. The United States Renal Data System (USRDS) for the year 2007-08 was utilized to conduct analysis of 181,349 subjects. After adjusting for all other covariates, the odds of mortality were higher among patients in urban and isolated areas (18.1 miles or more from the dialysis facility), compared with those who were living closer (≤3.3 miles, OR 1.08, 95 % CI 1.05-1.12). Conversely, patients living in isolated rural (0-≤3.3 miles, OR 0.95, 95 % CI 0.81-0.96), small adjacent rural (8.1-≤18.1 miles, OR 0.90, 95 % CI 0.77-0.96) and Micropolitan rural quartiles (>18.1 miles, OR 0.96, 95 % CI 0.92-0.97) had lower odds of mortality than their urban counterparts. The Accountable Care Organizations must devise strategies to cater ESRD patients living in remote areas.
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Affiliation(s)
- Fozia Ajmal
- Department of Health Policy and Management, Arnold School of Public Health, University of South Carolina, 220 Stoneridge Drive, Suite 204, Columbia, SC, 29208, USA. .,South Carolina Rural Health Research Center, Arnold School of Public Health, University of South Carolina, 220 Stoneridge Drive, Suite 204, Columbia, SC, 29208, USA.
| | - Kevin J Bennett
- Department of Family and Preventive Medicine, University of South Carolina School of Medicine, 3209 Colonial Drive, Columbia, SC, 29203, USA.,South Carolina Rural Health Research Center, Arnold School of Public Health, University of South Carolina, 220 Stoneridge Drive, Suite 204, Columbia, SC, 29208, USA
| | - Janice C Probst
- Department of Health Policy and Management, Arnold School of Public Health, University of South Carolina, 220 Stoneridge Drive, Suite 204, Columbia, SC, 29208, USA.,South Carolina Rural Health Research Center, Arnold School of Public Health, University of South Carolina, 220 Stoneridge Drive, Suite 204, Columbia, SC, 29208, USA
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27
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Kihal-Talantikite W, Vigneau C, Deguen S, Siebert M, Couchoud C, Bayat S. Influence of Socio-Economic Inequalities on Access to Renal Transplantation and Survival of Patients with End-Stage Renal Disease. PLoS One 2016; 11:e0153431. [PMID: 27082113 PMCID: PMC4833352 DOI: 10.1371/journal.pone.0153431] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2015] [Accepted: 03/29/2016] [Indexed: 11/18/2022] Open
Abstract
Background Public and scientific concerns about the social gradient of end-stage renal disease and access to renal replacement therapies are increasing. This study investigated the influence of social inequalities on the (i) access to renal transplant waiting list, (ii) access to renal transplantation and (iii) patients’ survival. Methods All incident adult patients with end-stage renal disease who lived in Bretagne, a French region, and started dialysis during the 2004–2009 period were geocoded in census-blocks. To each census-block was assigned a level of neighborhood deprivation and a degree of urbanization. Cox proportional hazards models were used to identify factors associated with each study outcome. Results Patients living in neighborhoods with low level of deprivation had more chance to be placed on the waiting list and less risk of death (HR = 1.40 95%CI: [1.1–1.7]; HR = 0.82 95%CI: [0.7–0.98]), but this association did not remain after adjustment for the patients’ clinical features. The likelihood of receiving renal transplantation after being waitlisted was not associated with neighborhood deprivation in univariate and multivariate analyses. Conclusions In a mixed rural and urban French region, patients living in deprived or advantaged neighborhoods had the same chance to be placed on the waiting list and to undergo renal transplantation. They also showed the same mortality risk, when their clinical features were taken into account.
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Affiliation(s)
| | - Cécile Vigneau
- CHU Pontchaillou, Service de néphrologie, Rennes, France
- Université de Rennes 1, UMR 6290, équipe Kyca, Rennes, France
| | - Séverine Deguen
- EHESP School of Public Health, Sorbonne Paris Cité, Rennes, France
| | - Muriel Siebert
- CHU Pontchaillou, Service de néphrologie, Rennes, France
| | - Cécile Couchoud
- REIN Registry, Agence de la biomédecine, Saint Denis La Plaine, France
| | - Sahar Bayat
- EHESP School of Public Health, Sorbonne Paris Cité, EA MOS, Rennes, France
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Wang V, Maciejewski ML, Coffman CJ, Sanders LL, Lee SYD, Hirth R, Messana J. Impacts of Geographic Distance on Peritoneal Dialysis Utilization: Refining Models of Treatment Selection. Health Serv Res 2016; 52:35-55. [PMID: 27060855 DOI: 10.1111/1475-6773.12489] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
OBJECTIVE To examine the relationship between distance to dialysis provider and patient selection of dialysis modality, informed by the absolute distance from a patient's home and relative distance of alternative modalities. DATA SOURCES U.S. Renal Data System. STUDY DESIGN About 70,131 patients initiating chronic dialysis and 4,795 dialysis facilities in 2006. The primary outcome was patient utilization of peritoneal dialysis (PD). Independent variables included absolute distance between patients' home and the nearest hemodialysis (HD) facility, relative distance between patients' home and nearest PD versus nearest HD facilities, and their interaction. Logistic regression was used to model distance on PD use, controlling for patient and market characteristics. PRINCIPAL FINDINGS Nine percent of incident dialysis patients used PD in 2006. There was a positive, nonlinear relationship between absolute distance to HD services and PD use (p < .0001), with the magnitude of the effect increasing at greater distances. In terms of relative distance, odds of PD use increased if a PD facility was closer or the same distance as the nearest HD facility (p = .006). Interaction of distance measures to dialysis facilities was not significant. CONCLUSIONS Analyses of patient choice between alternative treatments should model distance to reflect all relevant dimensions of geographic access to treatment options.
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Affiliation(s)
- Virginia Wang
- Division of General Internal Medicine, Department of Medicine, Duke University School of Medicine, Durham, NC.,Center for Health Services Research in Primary Care, Durham Veterans Affairs Medical Center, Durham, NC
| | - Matthew L Maciejewski
- Division of General Internal Medicine, Department of Medicine, Duke University School of Medicine, Durham, NC.,Center for Health Services Research in Primary Care, Durham Veterans Affairs Medical Center, Durham, NC
| | - Cynthia J Coffman
- Center for Health Services Research in Primary Care, Durham Veterans Affairs Medical Center, Durham, NC.,Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, NC
| | - Linda L Sanders
- Division of General Internal Medicine, Department of Medicine, Duke University School of Medicine, Durham, NC
| | - Shoou-Yih Daniel Lee
- Department of Health Policy and Management, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Richard Hirth
- Department of Health Management and Policy, University of Michigan, Ann Arbor, MI
| | - Joseph Messana
- Division of Nephrology, Department of Internal Medicine, University of Michigan, Internal Medicine-Nephrology, Ann Arbor, MI
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29
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Jia P, Xierali IM. Disparities in Patterns of Health Care Travel Among Inpatients Diagnosed With Congestive Heart Failure, Florida, 2011. Prev Chronic Dis 2015; 12:E150. [PMID: 26378896 PMCID: PMC4576422 DOI: 10.5888/pcd12.150079] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Introduction Congestive heart failure (CHF) is a major public health problem in the United States and is a leading cause of hospitalization in the elderly population. Understanding the health care travel patterns of CHF patients and their underlying cause is important to balance the supply and demand for local hospital resources. This article explores the nonclinical factors that prompt CHF patients to seek distant instead of local hospitalization. Methods Local hospitalization was defined as inpatients staying within hospital service areas, and distant hospitalization was defined as inpatients traveling outside hospital service areas, based on individual hospital discharge data in 2011 generated by a Dartmouth–Swiss hybrid approach. Multiple logistic and linear regression models were used to compare the travel patterns of different groups of inpatients in Florida. Results Black patients, no-charge patients, patients living in large metropolitan areas, and patients with a low socioeconomic status were more likely to seek local hospitalization than were white patients, those who were privately insured, those who lived in rural areas, and those with a high socioeconomic status, respectively. Conclusion Findings indicate that different populations diagnosed with CHF had different travel patterns for hospitalization. Changes or disruptions in local hospital supply could differentially affect different groups in a population. Policy makers could target efforts to CHF patients who are less likely to travel to seek treatment.
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Affiliation(s)
- Peng Jia
- Department of Epidemiology and Environmental Health, University at Buffalo, Buffalo, NY 14214. Telephone: 716-829-5354.
| | - Imam M Xierali
- Louisiana State University, Baton Rouge, Louisiana, and Association of American Medical Colleges, Washington, DC
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30
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Ferguson TW, Zacharias J, Walker SR, Collister D, Rigatto C, Tangri N, Komenda P. An Economic Assessment Model of Rural and Remote Satellite Hemodialysis Units. PLoS One 2015; 10:e0135587. [PMID: 26284357 PMCID: PMC4540589 DOI: 10.1371/journal.pone.0135587] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2015] [Accepted: 07/24/2015] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Kidney Failure is epidemic in many remote communities in Canada. In-centre hemodialysis is provided within these settings in satellite hemodialysis units. The key cost drivers of this program have not been fully described. Such information is important in informing the design of programs aimed at optimizing efficiency in providing dialysis and preventative chronic kidney disease care in remote communities. DESIGN, SETTING, PARTICIPANTS, AND MEASUREMENTS We constructed a cost model based on data derived from 16 of Manitoba, Canada's remote satellite units. We included all costs for operation of the unit, transportation, treatment, and capital costs. All costs were presented in 2013 Canadian dollars. RESULTS The annual per-patient cost of providing hemodialysis in the satellite units ranged from $80,372 to $215,918 per patient, per year. The median per patient, per year cost was $99,888 (IQR $89,057-$122,640). Primary cost drivers were capital costs related to construction, human resource expenses, and expenses for return to tertiary care centres for health care. Costs related to transport considerably increased estimates in units that required plane or helicopter transfers. CONCLUSIONS Satellite hemodialysis units in remote areas are more expensive on a per-patient basis than hospital hemodialysis and satellite hemodialysis available in urban areas. In some rural, remote locations, better value for money may reside in local surveillance and prevention programs in addition support for home dialysis therapies over construction of new satellite hemodialysis units.
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Affiliation(s)
- Thomas W. Ferguson
- Department of Community Health Sciences, University of Manitoba; Winnipeg, Canada
| | - James Zacharias
- Department of Medicine, Section of Nephrology, University of Manitoba; Winnipeg, Canada
- Department of Community Health Sciences, University of Manitoba; Winnipeg, Canada
| | - Simon R. Walker
- Department of Medicine, Section of Nephrology, University of Manitoba; Winnipeg, Canada
| | - David Collister
- Department of Medicine, Section of Nephrology, University of Manitoba; Winnipeg, Canada
| | - Claudio Rigatto
- Department of Medicine, Section of Nephrology, University of Manitoba; Winnipeg, Canada
| | - Navdeep Tangri
- Department of Medicine, Section of Nephrology, University of Manitoba; Winnipeg, Canada
- Department of Community Health Sciences, University of Manitoba; Winnipeg, Canada
| | - Paul Komenda
- Department of Medicine, Section of Nephrology, University of Manitoba; Winnipeg, Canada
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31
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Waterman AD, Morgievich M, Cohen DJ, Butt Z, Chakkera HA, Lindower C, Hays RE, Hiller JM, Lentine KL, Matas AJ, Poggio ED, Rees MA, Rodrigue JR, LaPointe Rudow D. Living Donor Kidney Transplantation: Improving Education Outside of Transplant Centers about Live Donor Transplantation--Recommendations from a Consensus Conference. Clin J Am Soc Nephrol 2015; 10:1659-69. [PMID: 26116651 DOI: 10.2215/cjn.00950115] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Living donor kidney transplantation (LDKT) offers better quality of life and clinical outcomes, including patient survival, compared with remaining on dialysis or receiving a deceased donor kidney transplant. Although LDKT education within transplant centers for both potential recipients and living donors is very important, outreach and education to kidney patients in settings other than transplant centers and to the general public is also critical to increase access to this highly beneficial treatment. In June 2014, the American Society of Transplantation's Live Donor Community of Practice, with the support of 10 additional sponsors, convened a consensus conference to determine best practices in LDKT, including a workgroup focused on developing a set of recommendations for optimizing outreach and LDKT education outside of transplant centers. Members of this workgroup performed a structured literature review, conducted teleconference meetings, and met in person at the 2-day conference. Their efforts resulted in consensus around the following recommendations. First, preemptive transplantation should be promoted through increased LDKT education by primary care physicians and community nephrologists. Second, dialysis providers should be trained to educate their own patients about LDKT and deceased donor kidney transplantation. Third, partnerships between community organizations, organ procurement organizations, religious organizations, and transplant centers should be fostered to support transplantation. Fourth, use of technology should be improved or expanded to better educate kidney patients and their support networks. Fifth, LDKT education and outreach should be improved for kidney patients in rural areas. Finally, a consensus-driven, evidence-based public message about LDKT should be developed. Discussion of the effect and potential for implementation around each recommendation is featured, particularly regarding reducing racial and socioeconomic disparities in access to LDKT. To accomplish these recommendations, the entire community of professionals and organizations serving kidney patients must work collaboratively toward ensuring accurate, comprehensive, and up-to-date LDKT education for all patients, thereby reducing barriers to LDKT access and increasing LDKT rates.
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Affiliation(s)
- Amy D Waterman
- Due to the number of contributing authors,the affiliations are provided in the Supplemental Material.
| | - Marie Morgievich
- Due to the number of contributing authors,the affiliations are provided in the Supplemental Material
| | - David J Cohen
- Due to the number of contributing authors,the affiliations are provided in the Supplemental Material
| | - Zeeshan Butt
- Due to the number of contributing authors,the affiliations are provided in the Supplemental Material
| | - Harini A Chakkera
- Due to the number of contributing authors,the affiliations are provided in the Supplemental Material
| | - Carrie Lindower
- Due to the number of contributing authors,the affiliations are provided in the Supplemental Material
| | - Rebecca E Hays
- Due to the number of contributing authors,the affiliations are provided in the Supplemental Material
| | - Janet M Hiller
- Due to the number of contributing authors,the affiliations are provided in the Supplemental Material
| | - Krista L Lentine
- Due to the number of contributing authors,the affiliations are provided in the Supplemental Material
| | - Arthur J Matas
- Due to the number of contributing authors,the affiliations are provided in the Supplemental Material
| | - Emilio D Poggio
- Due to the number of contributing authors,the affiliations are provided in the Supplemental Material
| | - Michael A Rees
- Due to the number of contributing authors,the affiliations are provided in the Supplemental Material
| | - James R Rodrigue
- Due to the number of contributing authors,the affiliations are provided in the Supplemental Material
| | - Dianne LaPointe Rudow
- Due to the number of contributing authors,the affiliations are provided in the Supplemental Material
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32
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Kotwal S, Webster A, Cass A, Gallagher M. Rural Versus Urban Health Service Utilization and Outcomes for Renal Patients in New South Wales: Protocol for a Data Linkage Study. JMIR Res Protoc 2015; 4:e73. [PMID: 26082088 PMCID: PMC4526941 DOI: 10.2196/resprot.3299] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2015] [Accepted: 04/03/2015] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Kidney disease is a significant burden on health systems globally, with the rising prevalence of end stage kidney disease in Australia mirrored in many other countries. Approximately 25% of the Australian population lives in regional and rural areas and accessing complex tertiary services is challenging. OBJECTIVE We aim to compare the burden and outcomes of chronic kidney disease and end stage kidney disease in rural and urban regions of New South Wales (Australia's most populous state) using linked health data. METHODS This is a retrospective cohort study and we have defined two cohorts: one with end stage kidney disease and one with chronic kidney disease. The end stage kidney disease cohort was defined using the Australia and New Zealand Dialysis and Transplant Registry, identifying all patients living in NSW receiving renal replacement therapy at any time between 01/07/2000 and 31/07/2010. The chronic kidney disease cohort used the NSW Admitted Patient Data Collection (APDC) to identify patients with a diagnostic code relating to chronic renal failure during any admission between 01/07/2000 and 31/07/2010. Both cohorts were linked to the NSW APDC, the Registry of Births, Deaths and Marriages, and the Central Cancer Registry allowing derivation of outcomes by categories of geographical remoteness. RESULTS To date, we have identified 10,505 patients with 2,384,218 records in the end stage kidney disease cohort and 159,033 patients with 1,599,770 records in the chronic kidney disease cohort. CONCLUSIONS This study will define the geographical distribution of end stage and chronic kidney disease and compare the health service utilization between rural and urban renal populations.
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Affiliation(s)
- Sradha Kotwal
- The George Institute for Global Health, Sydney Medical School, University of Sydney, Sydney, Australia.
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Saunders MR, Lee H, Alexander GC, Tak HJ, Thistlethwaite JR, Ross LF. Racial disparities in reaching the renal transplant waitlist: is geography as important as race? Clin Transplant 2015; 29:531-8. [PMID: 25818547 DOI: 10.1111/ctr.12547] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/23/2015] [Indexed: 11/29/2022]
Abstract
BACKGROUND In the United States, African Americans and whites differ in access to the deceased donor renal transplant waitlist. The extent to which racial disparities in waitlisting differ between United Network for Organ Sharing (UNOS) regions is understudied. METHODS The US Renal Data System (USRDS) was linked with US census data to examine time from dialysis initiation to waitlisting for whites (n = 188,410) and African Americans (n = 144,335) using Cox proportional hazards across 11 UNOS regions, adjusting for potentially confounding individual, neighborhood, and state characteristics. RESULTS Likelihood of waitlisting varies significantly by UNOS region, overall and by race. Additionally, African Americans face significantly lower likelihood of waitlisting compared to whites in all but two regions (1 and 6). Overall, 39% of African Americans with ESRD reside in Regions 3 and 4--regions with a large racial disparity and where African Americans comprise a large proportion of the ESRD population. In these regions, the African American-white disparity is an important contributor to their overall regional disparity. CONCLUSIONS Race remains an important factor in time to transplant waitlist in the United States. Race contributes to overall regional disparities; however, the importance of race varies by UNOS region.
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Affiliation(s)
- Milda R Saunders
- Department of Medicine, Section of Hospital Medicine, University of Chicago Medical Center, Chicago, IL, USA.,MacLean Center for Clinical Medical Ethics, University of Chicago Medical Center, Chicago, IL, USA
| | - Haena Lee
- Department of Medicine, Section of Hospital Medicine, University of Chicago Medical Center, Chicago, IL, USA.,Department of Sociology, University of Chicago, Chicago, IL, USA
| | - G Caleb Alexander
- Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, MD, USA
| | - Hyo Jung Tak
- Department of Health Management and Policy, University of North Texas Health Science Center School of Public Health, Fort Worth, TX, USA
| | - J Richard Thistlethwaite
- Section of Transplantation, Department of Surgery, University of Chicago Medical Center, Chicago, IL, USA
| | - Lainie Friedman Ross
- MacLean Center for Clinical Medical Ethics, University of Chicago Medical Center, Chicago, IL, USA.,Section of Transplantation, Department of Surgery, University of Chicago Medical Center, Chicago, IL, USA.,Department of Pediatrics, University of Chicago Hospitals, Chicago, IL, USA
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34
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Zhang Y. The Association Between Dialysis Facility Quality and Facility Characteristics, Neighborhood Demographics, and Region. Am J Med Qual 2015; 31:358-63. [DOI: 10.1177/1062860615580429] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Yue Zhang
- The University of Toledo, Toledo, OH
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35
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Prakash S, Coffin R, Schold J, Lewis SA, Gunzler D, Stark S, Howard M, Rodgers D, Einstadter D, Sehgal AR. Travel distance and home dialysis rates in the United States. Perit Dial Int 2014; 34:24-32. [PMID: 24525595 DOI: 10.3747/pdi.2012.00234] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
UNLABELLED INTRODUCTION Rural residence is associated with increased peritoneal dialysis (PD) utilization. The influence of travel distance on rates of home dialysis utilization has not been examined in the United States. The purpose of this study was to determine whether travel distances to the closest home and in-center hemodialysis (IHD) facilities are a barrier to home dialysis. ♢ METHODS This was a retrospective cohort study of patients aged ≥ 18 years initiating dialysis between 2005 and 2011. Unadjusted PD and home hemodialysis (HHD) rates were compared by travel distances to both the closest home dialysis and closest IHD facilities. Adjusted PD and HHD utilization rates were examined using multivariable logistic regression models. ♢ RESULTS There were 98,608 patients in the adjusted analyses. 55.5% of the dialysis facilities offered home dialysis. IHD, PD and HHD patients traveled median distances of 5.4, 3.5 and 6.6 miles respectively to their initial dialysis facilities. Unadjusted analyses showed an increase in PD rates and decrease in HHD rates with increased travel distances. Adjusted odds of PD and HHD were 1.6 and 1.2 respectively for a ten mile increase in distance to the closest home dialysis facility, while for distances to the closest IHD facility the odds ratios for both PD and HHD were 0.7 (all p < 0.01). ♢ CONCLUSIONS In metropolitan areas, PD and HHD generally increased with increased travel distance to the closest home dialysis facility and decreased with greater distance to an IHD facility. Examination of travel distances to PD and HHD facilities separately may provide further insight on specific barriers to these modalities which can serve as targets for future studies examining expansion of home dialysis utilization.
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Affiliation(s)
- Suma Prakash
- Case Western Reserve University,1 Cleveland, Ohio, USA
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36
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Castledine C, Caskey FJ. Dialysis modality after renal transplant failure. Perit Dial Int 2014; 33:600-3. [PMID: 24335121 DOI: 10.3747/pdi.2013.00087] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
- Clare Castledine
- Nephrology1 Royal London Hospital London, UK Nephrology2 Richard Bright Renal Unit Bristol UK
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Proximity Does Not Equal Access: Racial Disparities in Access to High Quality Dialysis Facilities. J Racial Ethn Health Disparities 2014; 1:291-299. [PMID: 25419509 DOI: 10.1007/s40615-014-0036-0] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
BACKGROUND For patients receiving hemodialysis, distance to their dialysis facility may be particularly important due to the need for thrice weekly dialysis. We sought to determine whether African-Americans and Whites differ in proximity and access to high quality dialysis facilities. METHODS We analyzed urban, Whites and African-Americans aged 18-65 receiving in-center hemodialysis linked to data on neighborhood and dialysis facility quality measures. In multivariable analyses, we examined the association between individual and neighborhood characteristics, and our outcomes: distance from home zip code to nearest dialysis facility, their current facility and the nearest high quality facility, as well as likelihood of receiving dialysis in a high quality facility. RESULTS African-Americans lived a half mile closer to a dialysis facility (B=-0.52) but traveled the same distance to their own dialysis facility compared to Whites. In initial analysis, African-Americans are 14% less likely than their White counterparts to attend a high quality dialysis facility (OR 0.86); and those disparities persist, though are reduced, even after adjusting for region, neighborhood poverty and percent African-American. In predominately African-American neighborhoods, individuals lived closer to high quality facilities (B=--5.92), but were 53% less likely to receive dialysis there (OR 0.47, highest group versus lowest, p<0.05). Living in a predominately African-American neighborhood explains 24% of racial disparity in attending a high quality facility. CONCLUSIONS African-Americans' proximity to high quality facilities does not lead to receiving care there. Institutional and social barriers may also play an important role in where people receive dialysis.
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Goldfarb-Rumyantzev AS, Syed W, Patibandla BK, Narra A, Desilva R, Chawla V, Hod T, Vin Y. Geographic disparities in arteriovenous fistula placement in patients approaching hemodialysis in the United States. Hemodial Int 2014; 18:686-94. [DOI: 10.1111/hdi.12141] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Alexander S. Goldfarb-Rumyantzev
- Division of Nephrology; Beth Israel Deaconess Medical Center and Harvard Medical School; Boston Massachusetts USA
- Transplant Institute; Beth Israel Deaconess Medical Center; Boston Massachusetts USA
| | - Wajih Syed
- Metrowest Medical Center; Framingham Massachusetts USA
| | - Bhanu K. Patibandla
- Transplant Institute; Beth Israel Deaconess Medical Center; Boston Massachusetts USA
| | - Akshita Narra
- Transplant Institute; Beth Israel Deaconess Medical Center; Boston Massachusetts USA
| | - Ranil Desilva
- Transplant Institute; Beth Israel Deaconess Medical Center; Boston Massachusetts USA
| | - Varun Chawla
- Transplant Institute; Beth Israel Deaconess Medical Center; Boston Massachusetts USA
| | - Tammy Hod
- Division of Nephrology and Center for Vascular Biology Research; Department of Medicine; Beth Israel Deaconess Medical Center and Harvard Medical School; Boston Massachusetts USA
| | - Yael Vin
- Section of Interventional Radiology; Beth Israel Deaconess Medical Center and Harvard Medical School; Boston Massachusetts USA
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Rhee CM, Lertdumrongluk P, Streja E, Park J, Moradi H, Lau WL, Norris KC, Nissenson AR, Amin AN, Kovesdy CP, Kalantar-Zadeh K. Impact of age, race and ethnicity on dialysis patient survival and kidney transplantation disparities. Am J Nephrol 2014; 39:183-94. [PMID: 24556752 PMCID: PMC4024458 DOI: 10.1159/000358497] [Citation(s) in RCA: 54] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2013] [Accepted: 01/08/2014] [Indexed: 01/19/2023]
Abstract
BACKGROUND Prior studies show that African-American and Hispanic dialysis patients have lower mortality risk than whites. Recent age-stratified analyses suggest this survival advantage may be limited to younger age groups, but did not concurrently compare Hispanic, African-American, and white patients, nor account for differences in nutritional and inflammatory status as potential confounders. Minorities experience inequities in kidney transplantation access, but it is unknown whether these racial/ethnic disparities differ across age groups. METHODS The associations between race/ethnicity with all-cause mortality and kidney transplantation were separately examined among 130,909 adult dialysis patients from a large national dialysis organization (entry period 2001-2006, follow-up through 2009) within 7 age categories using Cox proportional hazard models adjusted for case-mix and malnutrition and inflammatory surrogates. RESULTS African-Americans had similar mortality versus whites in younger age groups (18-40 years), but decreased mortality in older age groups (>40 years). In contrast, Hispanics had lower mortality versus whites across all ages. In sensitivity analyses using competing risk regression to account for differential kidney transplantation rates across racial/ethnic groups, the African-American survival advantage was limited to >60-years age categories. African-Americans and Hispanics were less likely to undergo kidney transplantation from all donor types versus whites across all ages, and these disparities were even more pronounced for living donor kidney transplantation (LDKT). CONCLUSIONS Hispanic dialysis patients have greater survival versus whites across all ages; in African-Americans, this survival advantage is limited to patients >40 years of age. Minorities are less likely to undergo kidney transplantation, particularly LDKT, across all ages.
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Affiliation(s)
- Connie M. Rhee
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine Medical Center, Orange, CA
| | - Paungpaga Lertdumrongluk
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine Medical Center, Orange, CA
- Royal Irrigation Hospital, Srinakharinwirot University, Nonthaburi, Thailand
| | - Elani Streja
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine Medical Center, Orange, CA
| | - Jongha Park
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine Medical Center, Orange, CA
- Division of Nephrology, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Republic of Korea
| | - Hamid Moradi
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine Medical Center, Orange, CA
| | - Wei Ling Lau
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine Medical Center, Orange, CA
| | - Keith C. Norris
- Drew University of Medicine, Los Angeles, CA
- David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Allen R. Nissenson
- David Geffen School of Medicine at UCLA, Los Angeles, CA
- DaVita Inc., El Segundo, CA
| | - Alpesh N. Amin
- Department of Medicine, University of California Irvine Medical Center, Irvine, CA
| | - Csaba P. Kovesdy
- Division of Nephrology, Memphis Veterans Affairs Medical Center, Memphis, TN
- Division of Nephrology, University of Tennessee Health Science Center, Memphis, TN
| | - Kamyar Kalantar-Zadeh
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine Medical Center, Orange, CA
- David Geffen School of Medicine at UCLA, Los Angeles, CA
- Department of Epidemiology, Fielding School of Public Health at UCLA, Los Angeles, CA
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Gray NA, Grace BS, McDonald SP. Peritoneal dialysis in rural Australia. BMC Nephrol 2013; 14:278. [PMID: 24359341 PMCID: PMC3913839 DOI: 10.1186/1471-2369-14-278] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2013] [Accepted: 11/26/2013] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Australians living in rural areas have lower incidence rates of renal replacement therapy and poorer dialysis survival compared with urban dwellers. This study compares peritoneal dialysis (PD) patient characteristics and outcomes in rural and urban Australia. METHODS Non-indigenous Australian adults who commenced chronic dialysis between 1 January 2000 and 31 December 2010 according to the Australia and New Zealand Dialysis and Transplant Registry (ANZDATA) were investigated. Each patient's residence was classified according to the Australian Bureau of Statistics remote area index as major city (MC), inner regional (IR), outer regional (OR), or remote/very remote (REM). RESULTS A total of 7657 patients underwent PD treatment during the study period. Patient distribution was 69.0% MC, 19.6% IR, 9.5% OR, and 1.8% REM. PD uptake increased with increasing remoteness. Compared with MC, sub-hazard ratios [95% confidence intervals] for commencing PD were 1.70 [1.61-1.79] IR, 2.01 [1.87-2.16] OR, and 2.60 [2.21-3.06] REM. During the first 6 months of PD, technique failure was less likely outside MC (sub-hazard ratio 0.47 [95% CI: 0.35-0.62], P < 0.001), but no difference was seen after 6 months (sub-hazard ratio 1.05 [95% CI: 0.84-1.32], P = 0.6). Technique failure due to technical (sub-hazard ratio 0.57 [95% CI: 0.38-0.84], P = 0.005) and non-medical causes (sub-hazard ratio 0.52 [95% CI: 0.31-0.87], P = 0.01) was less likely outside MC. Time to first peritonitis episode was not associated with remoteness (P = 0.8). Patient survival while on PD or within 90 days of stopping PD did not differ by region (P = 0.2). CONCLUSIONS PD uptake increases with increasing remoteness. In rural areas, PD technique failure is less likely during the first 6 months and time to first peritonitis is comparable to urban areas. Mortality while on PD does not differ by region. PD is therefore a good dialysis modality choice for rural patients in Australia.
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Affiliation(s)
- Nicholas A Gray
- Department of Renal Medicine, Nambour General Hospital, Nambour, Queensland, Australia.
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Schold JD, Heaphy ELG, Buccini LD, Poggio ED, Srinivas TR, Goldfarb DA, Flechner SM, Rodrigue JR, Thornton JD, Sehgal AR. Prominent impact of community risk factors on kidney transplant candidate processes and outcomes. Am J Transplant 2013; 13:2374-83. [PMID: 24034708 PMCID: PMC3775281 DOI: 10.1111/ajt.12349] [Citation(s) in RCA: 70] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2013] [Revised: 04/20/2013] [Accepted: 05/21/2013] [Indexed: 01/25/2023]
Abstract
Numerous factors impact patients' health beyond traditional clinical characteristics. We evaluated the association of risk factors in kidney transplant patients' communities with outcomes prior to transplantation. The primary exposure variable was a community risk score (range 0-40) derived from multiple databases and defined by factors including prevalence of comorbidities, access and quality of healthcare, self-reported physical and mental health and socioeconomic status for each U.S. county. We merged data with the Scientific Registry of Transplant Recipients (SRTR) and utilized risk-adjusted models to evaluate effects of community risk for adult candidates listed 2004-2010 (n = 209 198). Patients in highest risk communities were associated with increased mortality (adjusted hazard ratio [AHR] = 1.22, 1.16-1.28), decreased likelihood of living donor transplantation (adjusted odds ratio [AOR] = 0.90, 0.85-0.94), increased waitlist removal for health deterioration (AHR = 1.36, 1.22-1.51), decreased likelihood of preemptive listing (AOR = 0.85, 0.81-0.88), increased likelihood of inactive listing (AOR = 1.49, 1.43-1.55) and increased likelihood of listing for expanded criteria donor kidneys (AHR = 1.19, 1.15-1.24). Associations persisted with adjustment for rural-urban location; furthermore the independent effects of rural-urban location were largely eliminated with adjustment for community risk. Average community risk varied widely by region and transplant center (median = 21, range 5-37). Community risks are powerful factors associated with processes of care and outcomes for transplant candidates and may be important considerations for developing effective interventions and measuring quality of care of transplant centers.
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Affiliation(s)
- JD Schold
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio,Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland, Ohio,Center for Health Disparities, MetroHealth Medical Center and Case Western Reserve University, Cleveland, Ohio
| | - ELG Heaphy
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio
| | - LD Buccini
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio,Digestive Disease Institute, Cleveland Clinic, Cleveland, Ohio
| | - ED Poggio
- Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland, Ohio,Glickman Urological and Kidney Institute, Cleveland, Ohio
| | - TR Srinivas
- Department of Nephrology, Medical University of South Carolina, Charleston, South Carolina
| | - DA Goldfarb
- Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland, Ohio,Glickman Urological and Kidney Institute, Cleveland, Ohio
| | - SM Flechner
- Glickman Urological and Kidney Institute, Cleveland, Ohio
| | - JR Rodrigue
- Transplant Institute, Beth Israel Deaconess Medical Center, Harvard University, Boston, Massachusetts
| | - JD Thornton
- Center for Health Disparities, MetroHealth Medical Center and Case Western Reserve University, Cleveland, Ohio
| | - AR Sehgal
- Center for Health Disparities, MetroHealth Medical Center and Case Western Reserve University, Cleveland, Ohio
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Geographic information systems and chronic kidney disease: racial disparities, rural residence and forecasting. J Nephrol 2013; 26:3-15. [PMID: 23065915 DOI: 10.5301/jn.5000225] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/23/2012] [Indexed: 11/20/2022]
Abstract
The dynamics of health and health care provision in the United States vary substantially across regions, and there is substantial regional heterogeneity in population density, age distribution, disease prevalence, race and ethnicity, poverty and the ability to access care. Geocoding and geographic information systems (GIS) are important tools to link patient or population location to information regarding these characteristics. In this review, we provide an overview of basic GIS concepts and provide examples to illustrate how GIS techniques have been applied to the study of kidney disease, and in particular to understanding the interplay between race, poverty, rural residence and the planning of renal services for this population. The interplay of socioeconomic status and renal disease outcomes remains an important area for investigation and recent publications have explored this relationship utilizing GIS techniques to incorporate measures of socioeconomic status and racial composition of neighborhoods. In addition, there are many potential challenges in providing care to rural patients with chronic kidney disease including long travel times and sparse renal services such as transplant and dialysis centers. Geospatially fluent analytic approaches can also inform system level analyses of health care systems and these approaches can be applied to identify an optimal distribution of dialysis facilities. GIS analysis could help untangle the complex interplay between geography, socioeconomic status, and racial disparities in chronic kidney disease, and could inform policy decisions and resource allocation as the population ages and the prevalence of renal disease increases.
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Yoder LAG, Xin W, Norris KC, Yan G. Patient care staffing levels and facility characteristics in U.S. hemodialysis facilities. Am J Kidney Dis 2013; 62:1130-40. [PMID: 23810689 DOI: 10.1053/j.ajkd.2013.05.007] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2013] [Accepted: 05/15/2013] [Indexed: 11/11/2022]
Abstract
BACKGROUND Higher numbers of registered nurses (RNs) per patient have been associated with improved patient outcomes in acute-care facilities. Variation in and associations of patient care staffing levels and hemodialysis facility characteristics have not been examined previously. STUDY DESIGN Cross-sectional study using Poisson regression to examine associations between patient care staffing levels and hemodialysis facility characteristics. SETTING & PARTICIPANTS 4,800 US hemodialysis facilities in the 2009 Centers for Medicare & Medicaid (CMS) End-Stage Renal Disease Annual Facility Survey (CMS-2744 form). PREDICTORS Facility characteristics, including profit status, freestanding status, chain affiliation, and geographic region, adjusted for facility size, capacity, functional type, and urbanicity. OUTCOMES Patient care staffing levels, including ratios of RNs, licensed practical nurses (LPNs), patient care technicians (PCTs), composite staff (RN + LPN + PCT), social workers, and dietitians to in-center hemodialysis patients. RESULTS After adjusting for background facility characteristics, ratios of RNs and LPNs to patients were 35% (P < 0.001) and 42% (P < 0.001) lower, respectively, but the PCT to patient ratio was 16% (P < 0.001) higher in for-profit than nonprofit facilities (rate ratios of 0.65 [95% CI, 0.63-0.68], 0.58 [95% CI, 0.51-0.65], and 1.16 [95% CI, 1.12-1.19], respectively). Regionally, compared to the Northeast, the adjusted RN to patient ratio was 14% (P < 0.001) lower in the Midwest, 25% (P < 0.001) lower in the South, and 18% (P < 0.001) lower in the West. Even after additional adjustments, the large for-profit chains had significantly lower RN and LPN to patient ratios than the largest nonprofit chain, but a significantly higher PCT to patient ratio. Overall composite staffing levels also were lower in for-profit and chain-affiliated facilities. The patterns hold when hospital-based units were excluded. LIMITATIONS Nursing hours were not available. Two part-time staff were counted as one full-time equivalent, which may not always be accurate. CONCLUSIONS The significant variation in patient care staffing levels and its associations with facility characteristics warrants inclusion in future large-scale hemodialysis outcomes studies. End-stage renal disease networks and hemodialysis facilities should attend to quality assurance and performance improvement initiatives that maximize licensed nurse staffing levels in hemodialysis facilities.
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Affiliation(s)
- Laura A G Yoder
- University of Virginia School of Nursing, Charlottesville, VA
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Abstract
BACKGROUND We examined whether dialysis facility characteristics, neighborhood demographics, and region are associated with Centers for Medicare and Medicaid Services (CMS) dialysis facility quality measures in order to determine the most important targets for intervention. METHODS We linked US census data to the CMS Dialysis Compare File which contains information for facility outcomes for all CMS-certified dialysis facilities in 2007 (n=5616). We then used linear and logistic regression to characterize the association between dialysis facility quality--worse than expected patient survival, and the proportion of individuals in a facility achieving dialysis adequacy (urea reduction rate >65) or target hemoglobin (10<Hgb<12 g/dL)--and dialysis facility characteristics, neighborhood demographics, and region. RESULTS Only an increasing proportion of African Americans in the neighborhood is consistently associated with worse dialysis facility outcomes, even after controlling for neighborhood poverty. Facilities with the highest proportion of African Americans in the neighborhood had worse patient survival [odds ratio (OR) 4.6; 95% confidence interval (CI), 2.8-7.6], were less likely to have adequate dialysis (β -1.4; 95% CI, -2.3 to -0.6), and achieve targeted hemoglobin (β -3.1; 95% CI, -4.7 to -1.6) compared to those with the lowest proportion. No other predictor-facility, neighborhood, or region--was consistently associated with dialysis facility quality. CONCLUSIONS The proportion of African Americans in the dialysis facility neighborhood is strongly and consistently associated with lower facility quality. Quality improvement efforts are particularly needed for dialysis facilities in minority communities.
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Stephens JM, Brotherton S, Dunning SC, Emerson LC, Gilbertson DT, Harrison DJ, Kochevar JJ, McClellan AC, McClellan WM, Wan S, Gitlin M. Geographic Disparities in Patient Travel for Dialysis in the United States. J Rural Health 2013; 29:339-48. [DOI: 10.1111/jrh.12022] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
| | | | | | | | | | | | | | - Ann C. McClellan
- Rollins School of Public Health Emory University Atlanta Georgia
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Abbott KC, Nee R, Yuan CM. Making the Crooked Way Straight: Interpreting Geography and Health Care Delivery in CKD. Clin J Am Soc Nephrol 2013; 8:518-9. [DOI: 10.2215/cjn.01830213] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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van de Luijtgaarden MW, Jager KJ, Stel VS, Kramer A, Cusumano A, Elliott RF, Geue C, MacLeod AM, Stengel B, Covic A, Caskey FJ. Global differences in dialysis modality mix: the role of patient characteristics, macroeconomics and renal service indicators. Nephrol Dial Transplant 2013; 28:1264-75. [DOI: 10.1093/ndt/gft053] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Maripuri S, Ikizler TA, Cavanaugh KL. Prevalence of pre-end-stage renal disease care and associated outcomes among urban, micropolitan, and rural dialysis patients. Am J Nephrol 2013; 37:274-80. [PMID: 23548738 DOI: 10.1159/000348377] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2012] [Accepted: 01/24/2013] [Indexed: 11/19/2022]
Abstract
BACKGROUND/AIMS Pre-end-stage renal disease (ESRD) care is associated with improved outcomes among patients receiving dialysis. It is unknown what proportion of US micropolitan and rural dialysis patients receive pre-ESRD care and benefit from such care when compared to urban. METHODS A retrospective cohort study was performed using data from the US Renal Data System. Patients ≥18 years old who initiated dialysis in 2006 and 2007 were classified as rural, micropolitan or urban and the prevalence of pre-ESRD care (early nephrology care >6 months, permanent vascular access, -dietary education) was determined using the medical evidence report. The association of pre-ESRD care with dialysis mortality and transplantation was assessed using Cox regression with stratification for geographic residence. RESULTS Of 204,463 dialysis patients, 80% were urban, 10.2% were micropolitan and 9.8% were rural. Overall attainment of pre-ESRD care was poor. After adjustment, there were no significant geographic differences in attainment of early nephrology care or permanent dialysis access. Receiving care reduced all-cause mortality and increased the likelihood of transplantation to a similar degree regardless of geographic residence. Both micropolitan and rural patients received less dietary education (relative risk = 0.80, 95% CI = 0.76-0.84 and relative risk = 0.85, 95% CI = 0.80-0.89, respectively). CONCLUSION Among patients who receive dialysis, the prevalence of early nephrology care and permanent dialysis access is poor and does not vary by geographic residence. Micropolitan and rural patients receive less dietary education despite an observed mortality benefit, suggesting that barriers may exist to quality dietary care in more remote locations.
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Affiliation(s)
- Saugar Maripuri
- Division of Nephrology and Hypertension, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN 37232, USA
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Rao MK, Morris CD, O'Malley JP, Davis MM, Mori M, Anderson S. Documentation and management of CKD in rural primary care. Clin J Am Soc Nephrol 2013; 8:739-48. [PMID: 23371962 DOI: 10.2215/cjn.02410312] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND OBJECTIVES Recognition of CKD by primary care practitioners is essential in rural communities where nephrology access is limited. This study determined the prevalence of undocumented CKD in patients cared for in rural primary care practices and evaluated characteristics associated with undocumented CKD as well as CKD management. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS A retrospective cohort study, conducted within the Oregon Rural Practice Based Research Network, consisted of 865 CKD patients with serum creatinine≥1.5 mg/dl in males and ≥1.3 mg/dl in females and an estimated GFR<60 ml/min per 1.73 m(2). Documentation of a CKD diagnosis and laboratory values were abstracted by chart review. RESULTS Of CKD patients, 51.9% had no documentation of CKD. Undocumented CKD occurred more frequently in female patients (adjusted odds ratio=2.93, 95% confidence interval=2.04, 4.21). The association of serum creatinine reporting versus automating reporting of estimated GFR on CKD documentation was dependent on patient sex, years of practitioner experience, and practitioner clinical training. Hypertensive patients with documented CKD were more likely to have a BP medication change than patients with undocumented CKD (odds ratio=2.07, 95% confidence interval=1.15, 3.73). Only 2 of 449 patients with undocumented CKD were comanaged with a nephrologist compared with 20% of patients with documented CKD (odds ratio=53.20, 95% confidence interval=14.90, 189.90). CONCLUSIONS Undocumented CKD in a rural primary care setting is frequent, particularly in female patients. Depending on practitioner characteristics, automatic reporting of estimated GFR might improve documentation of CKD in this population.
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Affiliation(s)
- Maya K Rao
- Department of Medicine, Division of Nephrology and Hypertension, Oregon Health and Science University, Portland, Oregon, USA.
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Harwood L, Clark AM. Understanding pre-dialysis modality decision-making: A meta-synthesis of qualitative studies. Int J Nurs Stud 2013; 50:109-20. [DOI: 10.1016/j.ijnurstu.2012.04.003] [Citation(s) in RCA: 58] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2011] [Revised: 03/01/2012] [Accepted: 04/06/2012] [Indexed: 10/28/2022]
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