Economic evaluation of a pre-ESRD pay-for-performance programme in advanced chronic kidney disease patients

Effects of AST-120 on mortality in patients with chronic kidney disease modeled by artificial intelligence or traditional statistical analysis

Chronic kidney disease (CKD) imposes a substantial burden, and patient prognosis remains grim. The impact of AST-120 (AST-120) on the survival of CKD patients lacks a consensus. This study aims to investigate the effects of AST-120 usage on the survival of CKD patients and explore the utility of artificial intelligence models for decision-making. We conducted a retrospective analysis of CKD patients receiving care in the pre-end-stage renal disease (ESRD) program at Taichung Veterans General Hospital from 2000 to 2019. We employed Cox regression models to evaluate the relationship between AST-120 use and patient survival, both before and after propensity score matching. Subsequently, we employed Deep Neural Network (DNN) and Extreme Gradient Boosting (XGBoost) models to assess their performance in predicting AST-120's impact on patient survival. Among the 2584 patients in our cohort, 2199 did not use AST-120, while 385 patients received AST-120. AST-120 users exhibited significantly lower mortality rates compared to non-AST-120 users (13.51% vs. 37.88%, p < 0.0001) and a reduced prevalence of ESRD (44.16% vs. 53.17%, p = 0.0005). Propensity score matching at 1:1 and 1:2 revealed no significant differences, except for dialysis and all-cause mortality, where AST-120 users exhibited significantly lower all-cause mortality (p < 0.0001), with a hazard ratio (HR) of 0.395 (95% CI = 0.295-0.522). This difference remained statistically significant even after propensity matching. In terms of model performance, the XGBoost model demonstrated the highest accuracy (0.72), specificity (0.90), and positive predictive value (0.48), while the logistic regression model showed the highest sensitivity (0.63) and negative predictive value (0.84). The area under the curve (AUC) values for logistic regression, DNN, and XGBoost were 0.73, 0.73, and 0.69, respectively, indicating similar predictive capabilities for mortality. In this cohort of CKD patients, the use of AST-120 is significantly associated with reduced mortality. However, the performance of artificial intelligence models in predicting the impact of AST-120 is not superior to statistical analysis using the current architecture and algorithm.

A quality improvement initiative for patients with chronic kidney disease to promote their smoking cessation

Cigarette smoking is a critical issue in caring for patients of chronic kidney disease (CKD). However, there is no routine care program designed for combining both smoking cessation and CKD care. The process of our quality improvement (QI) collaboration used data under our routine payment-for-performance for pre-end-stage renal disease (P4P Pre-ESRD) in Taichung Veterans General hospital from 2020 to 2022. We share our experience with a QI project that integrates the Ottawa model for smoking cessation (OMSC) with the Pre-ESRD care program as part of routine CKD care. The electronic health information systems were improved to reduce workload of medical staff. The number was more for both qualified CKD educators and nephrologists for smoking cessation. The access and availability for smoking cessation were immediate and convenient for patients. Specifically, all the actions were performed by CKD educators, with nephrologists overseeing the process in routine care. By combining OMSC with the Pre-ESRD program, we were able to provide smokers with satisfactory access and availability to smoking cessation services within our healthcare facility. The smoker cases found were more in number (206 in 2020, 344 in 2021, and 421 in 2022). Before the integrated OSTC-Pre-ESRD program (in 2020), the proportion of smokers was 3.88%. After implementing the integrated program, smokers increased significantly on a yearly basis (9.69% in 2021 and 9.82% in 2022). Finally, case numbers of on-site smoking cessations increased significantly after implementing the integrated system (0 in 2020, 17 in 2021, and 20 in 2022). All CKD patients for smoking cessation were also more (8 in 2020, 46 in 2021, and 38 in 2022). After implementing the QI program, focusing on the integrated OMSC-Pre-ESRD program, we found more smokers undergoing smoking cessation. This QI program highlighted the importance of better access and availability for smoking cessation.

Air Pollution Alleviation During COVID-19 Pandemic is Associated with Renal Function Decline in Stage 5 CKD Patients

Introduction

Methods

Results

Conclusion

Effect of a Pay-for-Performance Program on Renal Outcomes Among Patients With Early-Stage Chronic Kidney Disease in Taiwan

BACKGROUND

With the promising outcomes of the pre-ESRD (end-stage renal disease) pay-for-performance (P4P) program, the National Health Insurance Administration (NHIA) of Taiwan launched a P4P program for patients with early chronic kidney disease (CKD) in 2011, targeting CKD patients at stages 1, 2, and 3a. This study aimed to examine the long-term effect of the early-CKD P4P program on CKD progression.

METHODS

We conducted a matched cohort study using electronic medical records from a large healthcare delivery system in Taiwan. The outcome of interest was CKD progression to estimated glomerular filtration rate (eGFR) <45 mL/min/1.73 m2 between P4P program enrolees and non-enrolees. The difference in the cumulative incidence of CKD progression between the P4P and non-P4P groups was tested using Gray's test. We adopted a cause-specific (CS) hazard model to estimate the hazard in the P4P group as compared to non-P4P group, adjusting for age, sex, baseline renal function, and comorbidities. A subgroup analysis was further performed in CKD patients with diabetes to evaluate the interactive effects between the early-CKD P4P and diabetes P4P programs.

RESULTS

The incidence per 100 person-months of disease progression was significantly lower in the P4P group than in the non-P4P group (0.44 vs. 0.69, P<.0001), and the CS hazard ratio (CS-HR) for P4P program enrolees compared with non-enrolees was 0.61 (95% CI: 0.58-0.64, P<.0001). The results of the subgroup analysis further revealed an additive effect of the diabetes P4P program on CKD progression; compared to none of both P4P enrolees, the CS-HR for CKD disease progression was 0.60 (95% CI: 0.54-0.67, P<.0001) for patients who were enrolled in both early-CKD P4P and diabetes P4P programs.

CONCLUSION

The present study results suggest that the early-CKD P4P program is superior to usual care to decelerate CKD progression in patients with early-stage CKD.

Association of pre-ESRD care education with patient outcomes in a 10-year longitudinal study of patients with CKD stages 3-5 in Taiwan

There is little comprehensive education for people with end-stage renal disease (ESRD) progress. We investigated the differences in terms of outcomes between patients with CKD stages 3-5 who enrolled and did not enroll in the pre-ESRD care education in Taiwan. This retrospective cohort study was conducted using data from the National Health Insurance Research Database (NHIRD). All patients diagnosed with CKD stages 3-5 who received the pre-ESRD care education through the pay for performance (P4P) program were enrolled. Based on whether or not they participated in the program, they were categorized into P4P or non-P4P groups. All analyses were performed from January 2006 through December 2015. Study outcomes were risk of hemodialysis dependency, hospitalization, and all-cause mortality. In this study of 29,337 patients, those with CKD stages 3-5 in the P4P group had lower events of hemodialysis, hospitalization, and all-cause mortality compared to patients in the non-P4P group. This study suggested that pre-ESRD care education is associated with increased patient outcomes, resulting in lower hemodialysis and hospitalization events and a higher overall survival rate in patients with CKD stages 3-5. Patient education could raise opportunities to improve pre-ESRD care by reaching patients outside the traditional health care setting.

Effectiveness of Nationwide COPD Pay-for-Performance Program on COPD Exacerbations in Taiwan

Background

Chronic obstructive pulmonary disease (COPD) is a leading cause of morbidity and mortality worldwide. It has also imposed a substantial economic and social burden on the health care system. In Taiwan, a nationwide COPD pay-for-performance (P4P) program was designed to improve the quality of COPD-related care by introducing financial incentives for health care providers and employing a multidisciplinary team to deliver guideline-based, integrated care for patients with COPD, reducing adverse outcomes, especially COPD exacerbation. However, the results of a survey of the effectiveness of the pay-for-performance program in COPD management were inconclusive. To address this knowledge gap, this study evaluated the effectiveness of the COPD P4P program in Taiwan.

Methods

This retrospective cohort study used data from Taiwan’s National Health Insurance claims database and nationwide COPD P4P enrollment program records from June 2016 to December 2018. Patients with COPD were classified into P4P and non-P4P groups. Patients in the P4P group were matched at a ratio of 1:1 based on age, gender, region, accreditation level, Charlson Comorbidity Index (CCI), and inhaled medication prescription type to create the non-P4P group. A difference-in-difference analysis was used to evaluate the influence of the P4P program on the likelihood of COPD exacerbation, namely COPD-related emergency department (ED) visit, intensive care unit (ICU) admission, or hospitalization.

Results

The final sample of 14,288 patients comprised 7144 in each of the P4P and non-P4P groups. The prevalence of COPD-related ED visits, ICU admissions, and hospitalizations was higher in the P4P group than in the non-P4P group 1 year before enrollment. After enrollment, the P4P group exhibited a greater decrease in the prevalence of COPD-related ED visits and hospitalizations than the non-P4P group (ED visit: −2.98%, p<0.05, 95% confidence interval [CI]: −0.277 to −0.086; hospitalization: −1.62%, p<0.05, 95% CI: −0.232 to −0.020), whereas no significant difference was observed between the groups in terms of the changes in the prevalence of COPD-related ICU admissions.

Conclusion

The COPD P4P program exerted a positive net effect on reducing the likelihood of COPD exacerbation, namely COPD-related ED visits and hospitalizations. Future studies should examine the long-term cost-effectiveness of the COPD P4P program.

Development and application of a chronic kidney disease-specific health literacy, knowledge and disease awareness assessment tool for patients with chronic kidney disease in Taiwan

OBJECTIVES

This study aims to develop an assessment tool for health literacy and knowledge specific to chronic kidney disease (CKD) for use in examining the associations between health literacy, disease-specific knowledge and disease awareness among patients with CKD in Taiwan.

DESIGN

An assessment tool in Mandarin and Taiwanese was developed based on patient input, panel discussions with experts and a literature review, and checked for validity and reliability in a pilot test. Formal data were collected through population-based sampling with a set quota according to region and hospital accreditation level. Cross-sectional data were collected to confirm the reliability and validity of the assessment tool. Levels of health literacy, disease knowledge, and disease awareness were then reported and analysed.

SETTING

Sample hospitals included 10 medical centres, 18 regional hospitals and 15 local hospitals in Taiwan. Researchers were granted Internal Review Board approval and obtained agreement to collect data in all study settings.

PARTICIPANTS

Patients at least 20 years old who had been diagnosed with CKD of any stage were eligible to participate. The formal assessment collected 1155 valid questionnaires, yielding an 87.3% response rate. The mean age of participants was 67.48 years (SD=12.87, range 22-98), while 484 (41.95%) were female and 78% were aware they had CKD.

RESULTS

The self-devised instrument proved to have excellent reliability and validity. Use of the instrument in the main study showed that CKD-specific health literacy was significantly associated with age (β=-0.33, p<0.00), educational attainment and disease awareness (β=0.13, p<0.00). CKD-specific knowledge was also significantly associated with age (β=-0.18, p<0.00), educational attainment and disease awareness (β=0.19, p<0.00).

CONCLUSIONS

This CKD-specific health literacy and knowledge assessment tool developed for Mandarin and Taiwanese-speaking patients is reliable and well validated. Patients with CKD who are aware of and understand their disease performed better in the assessment.

Factors influencing self-management among Indonesian patients with early-stage chronic kidney disease: A cross-sectional study

AIMS AND OBJECTIVES

The purpose of this study was to explore the self-management of patients with early-stage chronic kidney disease (CKD) and its influencing factors.

METHODS

A convenient sample of 226 patients with early-stage CKD was recruited from 63 Public Health Centers in Indonesia, from June to September 2020. Demographic characteristics, health literacy, illness perception, self-efficacy and self-management were assessed using self-reported questionnaires. Stepwise multiple linear regression analysis was performed to identify the factors influencing self-management. This study adhered to the EQUATOR checklist, STROBE.

RESULTS

The mean estimated glomerular filtration rate was 63.45 ml/min/1.73 m² (standard deviation [SD] = 15.34). The average scores for health literacy, illness perception, self-efficacy and self-management were 32.11 (SD = 4.46), 4.57 (SD = 1.46), 183.64 (SD = 38.23) and 76.92 (SD = 9.45), respectively. The influencing factors were education level, monthly income, family history of comorbidity, health literacy and self-efficacy, which accounted for 45% of total self-management score.

CONCLUSIONS

Indonesian patients with early-stage CKD showed low level of health literacy, but positive illness perception and self-efficacy; these factors significantly affected CKD self-management. Health literacy was found to influence all dimensions of self-management: self-integration, problem-solving, seeking social support and adherence to the recommended regimen.

RELEVANCE TO CLINICAL PRACTICE

Adherence to the recommended regimen is the most challenging dimension of CKD self-management. Health literacy was found to be a major determinant of self-management. Improving health literacy and motivation of patients with early-stage CKD may help sustain positive illness perception and self-efficacy, and improve self-management.

Prediction of non-responsiveness to pre-dialysis care program in patients with chronic kidney disease: a retrospective cohort analysis

The responsiveness of patients with chronic kidney disease (CKD) to nephrologists’ care is unpredictable. We defined the longitudinal stages (LSs) 1–5 of estimated glomerular filtration rate (eGFR) by group-based trajectory modeling for repeated eGFR measurements of 7135 patients with CKD aged 20–90 years from a 13-year pre-end-stage renal disease (ESRD) care registry. Patients were considered nonresponsive to the pre-dialysis care if they had a more advanced eGFR LS compared with the baseline. Conversely, those with improved or stable eGFR LS were considered responsive. The proportion of patients with CKD stage progression increased with the increase in the baseline CKD stage (stages 1–2: 29.2%; stage 4: 45.8%). The adjusted times to ESRD and all-cause mortality in patients with eGFR LS-5 were 92% (95% confidence interval [CI] 86–96%) and 57% (95% CI 48–65%) shorter, respectively, than in patients with eGFR LS-3A. Among patients with baseline CKD stages 3 and 4, the adjusted times to ESRD and all-cause death in the nonresponsive patients were 39% (95% CI 33–44%) and 20% (95% CI 14–26%) shorter, respectively, than in the responsive patients. Our proposed Renal Care Responsiveness Prediction (RCRP) model performed significantly better than the conventional Kidney Failure Risk Equation in discrimination, calibration, and net benefit according to decision curve analysis. Non-responsiveness to nephrologists’ care is associated with rapid progression to ESRD and all-cause mortality. The RCRP model improves early identification of responsiveness based on variables collected during enrollment in a pre-ESRD program. Urgent attention should be given to characterize the underlying heterogeneous responsiveness to pre-dialysis care.

Association of glomerular filtration rate slope with timely creation of vascular access in incident hemodialysis

The factors associated with the timely creation of distal vascular access for hemodialysis initiation are unclear. We aimed to explore the association between the slope of estimated glomerular filtration rate (eGFR) and the successful usage of vascular access upon hemodialysis initiation. This single center retrospective cohort study enrolled chronic kidney disease patients who undertook a multidisciplinary care program from 2003 to 2016. Using eGFR slope as predictor, we evaluated the vascular access created timely upon hemodialysis initiation. Among the 987 patients, vascular access was created at a median eGFR of 5.8 min/ml/1.73 m², with a median duration of 3.1 months before hemodialysis. The proportions of vascular access created timely, created not timely (vascular access immature), and not created were 68.5%, 8.8%, and 22.7%, respectively. There was a significant negative association of eGFR upon vascular access creation with eGFR slope (r = − 0.182, P < 0.001). The fastest eGFR slope patients (the first quartile or < − 10 min/ml/1.73 m²/year) had the lowest percentage of vascular access created timely. In the multivariable logistic regression analysis, only higher eGFR upon vascular access creation (P = 0.001) and eGFR slope (P = 0.009) were significantly associated with vascular access created timely. The adjusted odds ratios of each quartile of eGFR slopes for vascular access created timely were 0.46 (95% confidence interval 0.27–0.86), 1.30 (0.62, 2.72), 1.00 (reference), and 0.95 (0.48–1.87), respectively. eGFR slope is associated with the timely creation of vascular access for the initiation of hemodialysis in a reverse-J-shaped pattern and may help determine the time of vascular access creation.

Continuity of care: evaluating a multidisciplinary care model for people with early CKD via a nationwide population-based longitudinal study

OBJECTIVES

To control and prevent the burdens associated with chronic kidney disease (CKD), Taiwan's National Health Insurance Administration (NHIA) launched the 'early-CKD programme' in 2011 to extend care and education to patients with CKD. This study aims to evaluate the effectiveness of the early-CKD programme in terms of continuity of care (COC).

DESIGN AND PARTICIPANTS

This study used secondary data from 2010 to 2014 provided by the NHIA to identify 86 581 participants each for the intervention and control groups. Patients with CKD who participated in the early-CKD programme between 2011 and 2013 were defined as the intervention group. For the control group, propensity score matching was used to select patients with CKD who did not participate in the programme, but were seen by the same group of physicians.

INTERVENTION

A multidisciplinary care model for patients with early CKD launched in 2011.

PRIMARY OUTCOME MEASURES

Outcome variables included the continuity of care index (COCI), which measures a physician's COC; number of essential examinations; and resource utilisation. To better identify the difference between groups, we separated COCI into two groups based on mean: high (above mean) and low (below mean). A generalised estimating equation model was used to examine the effects of the early-CKD programme.

RESULTS

The programme significantly increased the number of essential examinations/tests administered to patients (β=0.61, p<0.001) and improved COCI between physicians and patients (OR=4.18, p<0.001). Medical expenses (β=1.03, p<0.001) and medication expenses (β=0.23, p<0.001) significantly increased after the programme was implemented, but patients' kidney-related hospitalisations and emergency department visits decreased (β=-0.13, p<0.001).

CONCLUSION

From the COC viewpoint, the programme in Taiwan showed a positive effect on COCI, number of essential examinations and resource utilisation.

The Impact of a Social Networking Service-Enhanced Smart Care Model on Stage 5 Chronic Kidney Disease: Quasi-Experimental Study

Background

Stage 5 chronic kidney disease (CKD) presents a high risk for dialysis initiation and for complications such as uremic encephalopathy, uremic symptoms, gastrointestinal bleeding, and infection. One of the most common barriers to health care for patients with stage 5 CKD is poor continuity of care due to unresolved communication gaps.

Objective

Our aim was to establish a powerful care model that includes the use of a social networking service (SNS) to improve care quality for patients with CKD and safely delay dialysis initiation.

Methods

We used a retrospective cohort of CKD patients aged 20-85 years who received care between 2007 and 2017 to evaluate the efficacy of incorporating an SNS into the health care system. In 2014, author F-JY, a nephrologist at the National Taiwan University Hospital Yunlin Branch, started to use an SNS app to connect with stage 5 CKD patients and their families. In cases of emergency, patients and families could quickly report any condition to F-JY. Using this app, F-JY helped facilitate productive interactions between these patients and the health care system. The intention was to safely delay the initiation of dialysis therapy. We divided patients into four groups: group 1 (G1) included patients at the study hospital during the 2007-2014 period who had contact only with nephrologists other than F-JY; group 2 (G2) included patients who visited F-JY during the 2007-2014 period before he began using the SNS app; group 3 (G3) included patients who visited nephrologists other than F-JY during the 2014-2017 period and had no interactions using the SNS; and group 4 (G4) included patients who visited F-JY during the 2014-2017 period and interacted with him using the SNS app.

Results

We recruited 209 patients with stage 5 CKD who had been enrolled in the study hospital’s CKD program between 2007 and 2017. Each of the four groups initiated dialysis at different times. Before adjusting for baseline estimated glomerular filtration rate (eGFR), the G4 patients had a longer time to dialysis (mean 761.7 days, SD 616.2 days) than the other groups (G1: mean 403.6 days, SD 409.4 days, P=.011 for G4 vs G1; G2: 394.8 days, SD 318.8 days, P=.04; G3: 369.1 days, SD 330.8 days, P=.049). After adjusting for baseline eGFR, G4 had a longer duration for each eGFR drop (mean 84.8 days, SD 65.1 days) than the other groups (G1: mean 43.5 days, SD 45.4 days, P=.005; G2: mean 42.5 days, SD 26.5 days, P=.03; G3: mean 3.8.7 days, SD 33.5 days, P=.002).

Conclusions

The use of an SNS app between patients with stage 5 CKD and their physicians can reduce the communication gap between them and create benefits such as prolonging time-to-dialysis initiation. The role of SNSs and associated care models should be further investigated in a larger population.

Direct medical costs of end-stage kidney disease and renal replacement therapy: a cohort study in Guangzhou City, southern China

BACKGROUND

Renal replacement therapy was a lifesaving yet high-cost treatment for people with end-stage kidney disease (ESKD). This study aimed to estimate the direct medical costs per capita of ESKD by different treatment strategies: haemodialysis (HD); peritoneal dialysis (PD); kidney transplantation (KT) (in the first year); KT (in the second year), and by two urban health insurance schemes.

METHODS

This was a retrospective observational cohort study. Data were obtained from outpatient and inpatient claims database of two urban health insurance from Guangzhou City, Southern China. Adult patients with HD (n = 3765; mean age 58 years), PD (n = 1237; 51 years), KT (first year) (n = 117; 37 years) and KT (second year) (n = 41; 39 years) were identified between 2010 and 2012. The primary outcome was the annual per patient medical costs in 2013 Chinese Yuan (CNY) incurred in the outpatient and inpatient sectors. Secondary outcomes were annual outpatient visits and inpatient admissions, length of stay per admission. Generalized linear regression and bootstrapping statistical methods were used for analysis.

RESULTS

The estimated average annual medical costs for patients on HD were CNY 94,760.5 (US$15,066.0), 95% Confidence Interval (CI): CNY85,166.6-106,972.2, which was higher than those for patients on PD [CNY80,762.9 (US$12,840.5), 95% CI: CNY 76,249.8-85,498.9]. The estimated annual cost ratio of HD versus PD was 1.17 (95% CI: 1.12-1.25). Among the transplanted patients, the estimated average annual medical costs in the first year were CNY132,253.0 (US$21,026.9), 95%CI: CNY114,009.9-153,858.6, and in the second year were CNY93,155.3 (US$14,810.8), 95%CI: CNY61,120.6-101,989.1. The mean annual medical costs for dialysis patients under Urban Employee-based Basic Medical Insurance scheme were significantly higher than those for patients under Urban Resident-based Basic Medical Insurance scheme (P < 0.001).

CONCLUSIONS

The direct medical costs of ESKD patients were high and different by types of renal replacement therapy and insurance. The findings can be used to conduct cost-effectiveness research on different types of RRT for ESKD patients that provides economic evidence for health policy design in China.

Economic Evaluations Informed Exclusively by Real World Data: A Systematic Review

Economic evaluations using Real World Data (RWD) has been increasing in the very recent years, however, this source of information has several advantages and limitations. The aim of this review was to assess the quality of full economic evaluations (EE) developed using RWD. A systematic review was carried out through articles from the following databases: PubMed, Embase, Web of Science and Centre for Reviews and Dissemination. Included were studies that employed RWD for both costs and effectiveness. Methodological quality of the studies was assessed using the Consolidated Health Economic Evaluation Reporting Standards (CHEERS) checklist. Of the 14,011 studies identified, 93 were included. Roughly half of the studies were carried out in a hospital setting. The most frequently assessed illnesses were neoplasms while the most evaluated interventions were pharmacological. The main source of costs and effects of RWD were information systems. The most frequent clinical outcome was survival. Some 47% of studies met at least 80% of CHEERS criteria. Studies were conducted with samples of 100-1000 patients or more, were randomized, and those that reported bias controls were those that fulfilled most CHEERS criteria. In conclusion, fewer than half the studies met 80% of the CHEERS checklist criteria.

Patient and provider factors associated with enrolment in the pre-end-stage renal disease pay-for-performance programme in Taiwan: a cross-sectional study

OBJECTIVE

The incidence and prevalence of end-stage renal disease (ESRD) in Taiwan have been ranked the highest worldwide. Therefore, the National Health Insurance Administration has implemented the pre-ESRD pay-for-performance (P4P) programme since November 2006, which had significantly reduced the incidence of dialysis and all-cause mortality. This study aimed to identify the factors associated with the enrolment in the pre-ESRD P4P programme.

DESIGN

Cross-sectional study.

SETTING

The National Health Insurance research database 2007-2012 in Taiwan.

PARTICIPANTS

Patients with prevalent pre-ESRD aged more than 18 years between January 2007 and December 2012 were enrolled. Patient demographics and hospital characteristics between P4P and non-P4P groups were compared. A logistic regression model was used to analyse the factors associated with P4P enrolment, and a generalised estimating equation was used to verify the results.

PRIMARY OUTCOME MEASURE

Enrolment in the pre-ESRD P4P programme.

RESULTS

In total, 82 991 patients were enrolled in the programme, with a 45.6% participation rate. Patients who were males (adjusted OR (AOR)=0.89, 95% CI=0.86 to 0.91) and employed (AOR=0.95, 95% CI=0.92 to 0.97) had a significantly lower probability to be enrolled in the programme. Older patients (66-75 years old, AOR=1.23, 95% CI=1.14 to 1.33) and those with higher Charlson Comorbidities Index (CCI 5+, AOR=4.01, 95% CI=3.55 to 4.53) tended to be enrolled in the programme, while those in the 76+ years age group were not (AOR=1.03, 95% CI=0.95 to 1.13). Hospitals located in the central (AOR=1.48, 95% CI=1.05 to 2.08) and Kao-Ping regions (AOR=1.62, 95% CI=1.18 to 2.22) also tended to enrol patients in the pre-ESRD P4P programme. Enrolment rates increased over time.

CONCLUSION

Pre-ESRD patients of the female gender, greater age and more comorbidities were more likely to be enrolled in the pre-ESRD P4P programme. Healthcare providers and health authorities should focus attention on patients who are male, younger and with less comorbidities to improve the healthcare quality and equality for all pre-ESRD patients.

Impact of pay for performance on access at first dialysis in Queensland

AIM

Commencement of haemodialysis with an arteriovenous fistula (AVF) or arteriovenous graft (AVG) is associated with improved survival compared with commencement with a central venous catheter. In 2011-2012, Queensland Health made incentive payments to renal units for early referred patients who commenced peritoneal dialysis (PD), or haemodialysis with an AVF/AVG. The aim of this study was to determine if pay for performance improved clinical care.

METHODS

All patients who commenced dialysis in Australia between 2009 and 2014 and were registered with the Australia and New Zealand Dialysis and Transplant Registry (ANZDATA) were included. A multivariable regression model was used to compare rates of commencing dialysis with a PD catheter or permanent AVF/AVG during the pay-for-performance period (2011-2012) with periods prior (2009-2010) and after (2013-2014).

RESULTS

A total of 10 858 early referred patients commenced dialysis during the study period, including 2058 in Queensland. In Queensland, PD as first modality increased with time (P < 0.001) but there was no change in AVF/AVG rate at first haemodialysis (P = 0.5). In a multivariate model using the pay-for-performance period as reference, the odds ratio for commencement with PD or haemodialysis with an AVF/AVG in Queensland was 1.02 (95% CI 0.81-1.29) in 2009-2010 and 1.28 (95% CI 1.01-1.61) in 2013-2014. There was no change for the rest of Australia (0.97 95% CI 0.87-1.09 in 2009-2010 and 1.00 95% CI 0.90-1.11 in 2013-14).

CONCLUSION

Pay for performance did not improve rates of commencement of dialysis with PD or an AVF/AVG during the payment period. A lag effect on clinical care may explain the improvement in later years.

Effect of national pre-ESRD care program on expenditures and mortality in incident dialysis patients: A population-based study

Inadequate care of chronic kidney disease (CKD) is common and may be associated with adverse outcomes after dialysis. The nationwide pre-end-stage renal disease pay for performance program (P4P) has been implemented in Taiwan to improve quality of CKD care. However, the effectiveness of the P4P program in improving the outcomes of pre-dialysis care and dialysis is uncertain. We conducted a longitudinal cohort study. Patients who newly underwent long-term dialysis (≥3 mo) between 2007 and 2009 were identified from the Taiwan National Health Insurance Research Database. Based on the patient enrolment of the P4P program, they were categorized into P4P or non-P4P groups. We analysed pre-dialysis care, healthcare expenditures, and mortality between two groups. Among the 26 588 patients, 25.5% participated in the P4P program. The P4P group received significantly better quality of care, including a higher frequency of glomerular filtration rate measurement and CKD complications survey, a higher rate of vascular access preparation, and more frequent use of arteriovenous fistulas than the non-P4P group did. The P4P group had a 68.4% reduction of the 4-year total healthcare expenditure (excluding dialysis fee), which is equivalent to US$345.7 million, and a significant 22% reduction in three-year mortality after dialysis (hazard ratio 0.78, 95% confidence interval: 0.75–0.82, P < 0.001) compared with the non-P4P group. P4P program improves quality of pre-dialysis CKD care, and provide survival benefit and a long-term cost saving for dialysis patients.

Role of resilience and social support in alleviating depression in patients receiving maintenance hemodialysis

BACKGROUND

Patients who undergo hemodialysis encounter challenges including role changes, physical degeneration, and difficulty in performing activities of daily living (ADLs) and self-care. These challenges deteriorate their physiological and psychosocial conditions, resulting in depression. High resilience (RES) and social support can alleviate stress and depression. This study evaluated the importance of RES and social support in managing depression in elderly patients undergoing maintenance hemodialysis (HD).

PATIENTS AND METHODS

In this descriptive, correlational study, 194 older patients undergoing HD were enrolled from the HD centers of three hospitals in northern Taiwan. The Barthel ADL Index, RES scale, Inventory of Socially Supportive Behavior, and Beck Depression Inventory-II were used. Hierarchical regression analysis was applied to evaluate the interaction of RES and social support with illness severity, demographics, and ADLs.

RESULTS

Of the total participants, 45.9% experienced depressive symptoms. Demographic analysis showed that men and those with high educational level and income and financial independence had less depression (p<0.01). Patients with a higher Barthel Index (n=103), RES scale (n=33), and social support (n=113) showed less depressive symptoms (p<0.01). We found a significant negative correlation between depressive symptoms and social support (r=-0.506, p<0.01) and RES (r=-0.743, p<0.01). Hierarchical regression analysis showed that RES could buffer the effects of symptom severity on depression (b=-0.436, p<0.01), but social support did not exert a buffering effect.

CONCLUSION

The severity of illness symptoms and ADLs were the major determinants of depressive symptoms. High RES could alleviate depressive symptoms in the older patients undergoing HD.

Bcl-3 is a novel biomarker of renal fibrosis in chronic kidney disease

Progressive renal fibrosis in chronic kidney disease (CKD) greatly contributes to end-stage renal failure and is associated with high mortality. The identification of renal fibrosis biomarkers for the diagnosis and the monitoring of disease progression in CKD is urgently needed. Whole-transcriptomic analysis of renal tissues in a unilateral ureteral obstruction (UUO) mouse model revealed that the mRNA level of Bcl-3, an atypical member of the IκB family, was induced 6.3-fold 2 days after UUO. Compared with renal tissues in sham-operated mice, increases in Bcl-3 mRNA and protein in the renal tissues in the UUO model were accompanied with increases in other markers of renal fibrosis, including human epididymis protein 4 (HE4), a recently identified biomarker of renal fibrosis. Immunohistochemical analysis revealed that both Bcl-3 and HE4 were located in the plasma of renal tubule cells. Serum protein levels of Bcl-3 and HE4 rose with the development of renal fibrosis in UUO mouse model. We found that the serum protein levels of both HE4 and Bcl-3 were elevated in CKD patients compared with healthy controls. Moreover, a significant positive correlation between Bcl-3 and HE4 (r = 0.939, p < 0.0001) was observed in CKD patients. These data suggest that Bcl-3 can serve as a novel valuable biomarker of renal fibrosis in CKD.