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Ernecoff NC, Robinson MT, Motter EM, Bursic AE, Lagnese K, Taylor R, Lupu D, Schell JO. Concurrent Hospice and Dialysis Care: Considerations for Implementation. J Gen Intern Med 2024; 39:798-807. [PMID: 37962726 PMCID: PMC11043284 DOI: 10.1007/s11606-023-08504-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Accepted: 10/20/2023] [Indexed: 11/15/2023]
Abstract
IMPORTANCE Hospice positively impacts care at the end of life for patients and their families. However, compared to the general Medicare population, patients on dialysis are half as likely to receive hospice. Concurrent hospice and dialysis care offers an opportunity to improve care for people living with end-stage kidney disease (ESKD). OBJECTIVE We sought to (1) develop a conceptual model of the Program and (2) identify key components, resources, and considerations for further implementation. DESIGN We conducted a template analysis of qualitative interviews and convened a community advisory panel (CAP) to get feedback on current concurrent care design and considerations for dissemination and implementation. PARTICIPANTS Thirty-nine patients with late-stage chronic kidney disease (CKD), family caregivers, bereaved family caregivers, hospice clinicians, nephrology clinicians, administrators, and policy experts participated in interviews. A purposive subset of 19 interviewees composed the CAP. MAIN MEASURES Qualitative feedback on concurrent care design refinements, implementation, and resources. KEY RESULTS Participants identified four themes that define an effective model of concurrent hospice and dialysis: it requires (1) timely goals-of-care conversations and (2) an interdisciplinary approach; (3) clear guidelines ensure smooth transitions for patients and families; and (4) hospice payment policy must support concurrent care. CAP participants provided feedback on the phases of an effective model of concurrent hospice and dialysis, and resources, including written and interactive educational materials, communication tools, workflow processes, and order sets. CONCLUSIONS We developed a conceptual model for concurrent hospice and dialysis care and a corresponding resource list. In addition to policy changes, clinical implementation and educational resources can facilitate scalable and equitable dissemination of concurrent care. Concurrent hospice and dialysis care must be systematically evaluated via a hybrid implementation-effectiveness trial that includes the resources outlined herein, based on our conceptual model of concurrent care delivery.
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Affiliation(s)
| | - Mayumi T Robinson
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Erica M Motter
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Alexandra E Bursic
- Division of Renal-Electrolyte, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Keith Lagnese
- Optum Home & Community Care, Landmark Health, Huntington Beach, CA, USA
| | | | - Dale Lupu
- School of Nursing, George Washington University, Washington, DC, USA
| | - Jane O Schell
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Division of Renal-Electrolyte, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Dialysis Clinic, Inc, Nashville, TN, USA
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Griffin SM, Marr J, Kapke A, Jin Y, Pearson J, Esposito D, Young EW. Mortality Risk of Patients Treated in Dialysis Facilities with Payment Reductions under ESRD Quality Incentive Program. Clin J Am Soc Nephrol 2023; 18:356-362. [PMID: 36763812 PMCID: PMC10103248 DOI: 10.2215/cjn.0000000000000079] [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: 08/17/2022] [Accepted: 01/03/2023] [Indexed: 02/05/2023]
Abstract
BACKGROUND The Centers for Medicare & Medicaid Services End-Stage Renal Disease Quality Incentive Program (ESRD QIP) measures quality of care delivered by dialysis facilities and imposes Medicare payment reductions for quality lapses. We assessed the association between payment reductions and patient mortality, a quality indicator not included in the ESRD QIP measure set. METHODS Association between mortality and ESRD QIP facility payment reduction based on the year of performance was expressed as the unadjusted rate and patient case-mix-adjusted hazard ratio. We also measured association between mortality and 1-year changes in payment reductions. Retrospective patient cohorts were defined by their treating dialysis facility on the first day of each year (2010-2018). RESULTS Facility performance resulted in payment reductions for 5%-42% of dialysis facilities over the 9 study years. Patients experienced progressively higher mortality at each payment reduction level. Across all years, unadjusted mortality was 17.3, 18.1, 18.9, 20.3, and 23.9 deaths per 100 patient-years for patients in facilities that received 0%, 0.5%, 1%, 1.5%, and 2% payment reductions, respectively. The adjusted hazard ratio showed a similar stepwise pattern by the level of payment reduction: 1.0 (reference), 1.08 (95% confidence interval [CI], 1.07 to 1.09), 1.15 (95% CI, 1.13 to 1.16), 1.19 (95% CI, 1.16 to 1.21), and 1.34 (95% CI, 1.29 to 1.39). Strength of the association increased from 2010 to 2016. Patients treated in facilities that improved over 1 year generally experienced lower mortality; patients in facilities that performed worse on ESRD QIP measures generally experienced higher mortality. CONCLUSIONS Patient mortality was associated with ESRD QIP facility payment reductions in dose-response and temporal patterns.
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Affiliation(s)
| | | | - Alissa Kapke
- Arbor Research Collaborative for Health, Ann Arbor, Michigan
| | - Yan Jin
- Arbor Research Collaborative for Health, Ann Arbor, Michigan
| | - Jeffrey Pearson
- Arbor Research Collaborative for Health, Ann Arbor, Michigan
| | | | - Eric W Young
- Arbor Research Collaborative for Health, Ann Arbor, Michigan
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Adler JT, Xiang L, Weissman JS, Rodrigue JR, Patzer RE, Waikar SS, Tsai TC. Association of Public Reporting of Medicare Dialysis Facility Quality Ratings With Access to Kidney Transplantation. JAMA Netw Open 2021; 4:e2126719. [PMID: 34559227 PMCID: PMC8463939 DOI: 10.1001/jamanetworkopen.2021.26719] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE Improving the quality of dialysis care and access to kidney transplantation for patients with end-stage kidney disease is a national clinical and policy priority. The role of dialysis facility quality in increasing access to kidney transplantation is not known. OBJECTIVE To determine whether patient, facility, and kidney transplant waitlisting characteristics are associated with variations in dialysis center quality. DESIGN, SETTING, AND PARTICIPANTS This population-based cohort study is an analysis of US Renal Data System data and Medicare Dialysis Facility Compare (DFC) data from 2013 to 2018. Participants included all adult (aged ≥18 years) patients in the US Renal Data System beginning long-term dialysis in the US from 2013 to 2017 with follow-up through the end of 2018. Patients with a prior kidney transplant and matched Medicare DFC star ratings to each annual cohort of recipients were excluded. Patients at facilities without a star rating in that year were also excluded. Data analysis was performed from January to April 2021. EXPOSURES Dialysis center quality, as defined by Medicare DFC star ratings. MAIN OUTCOMES AND MEASURES The primary outcome was the proportion of patients undergoing incident dialysis who were waitlisted within 1 year of dialysis initiation. Secondary outcomes were patient and facility characteristics. RESULTS Of 507 581 patients beginning long-term dialysis in the US from 2013 to 2017, 291 802 (57.4%) were male, 266 517 (52.5%) were White, and the median (interquartile range) age was 65 (55-75) years. Of 5869 dialysis facilities in 2017, 132 (2.2%) were 1-star, 436 (7.4%) were 2-star, 2047 (34.9%) were 3-star, 1660 (28.3%) were 4-star, and 1594 (27.2%) were 5-star. Higher-quality dialysis facilities were associated with 47% higher odds of transplant waitlisting (odds ratio [OR], 1.47; 95% CI, 1.39-1.57 for 5-star facilities vs 1-star facilities; P < .001). Black patients were less likely than White patients to be waitlisted for transplantation (OR, 0.74; 95% CI, 0.72-0.76). In addition, patients at for-profit (OR, 0.78; 95% CI, 0.74-0.81) and rural (OR, 0.63; 95%, CI 0.58-0.68) facilities were less likely to be waitlisted for transplantation compared with those at nonprofit and urban facilities, respectively. CONCLUSIONS AND RELEVANCE In this cohort study, patients at higher-quality dialysis facilities had higher odds than patients at lower-quality facilities of being waitlisted for kidney transplantation within 1 year. Waitlisting rates for kidney transplantation should be considered for integration into the current Centers for Medicare & Medicaid Services DFC star ratings to incentivize dialysis facility referral to transplant centers, inform patient choice, and drive quality improvement by increasing transplant waitlisting rates.
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Affiliation(s)
- Joel T. Adler
- Department of Surgery, Brigham and Women’s Hospital, Boston, Massachusetts
- Center for Surgery and Public Health, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Lingwei Xiang
- Center for Surgery and Public Health, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Joel S. Weissman
- Center for Surgery and Public Health, Brigham and Women’s Hospital, Boston, Massachusetts
| | - James R. Rodrigue
- Department of Surgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Rachel E. Patzer
- Department of Surgery, Emory Medical School, Atlanta, Georgia
- Department of Medicine, Emory Medical School, Atlanta, Georgia
| | - Sushrut S. Waikar
- Department of Medicine, Boston Medical Center, Boston, Massachusetts
| | - Thomas C. Tsai
- Department of Surgery, Brigham and Women’s Hospital, Boston, Massachusetts
- Center for Surgery and Public Health, Brigham and Women’s Hospital, Boston, Massachusetts
- Department of Health Policy and Management, Harvard T. H. Chan School of Public Health, Boston, Massachusetts
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Gupta N. Strategic Planning for Starting or Expanding a Home Hemodialysis Program. Adv Chronic Kidney Dis 2021; 28:143-148. [PMID: 34717860 DOI: 10.1053/j.ackd.2021.02.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Revised: 12/23/2020] [Accepted: 02/05/2021] [Indexed: 01/08/2023]
Abstract
The American Advancing Kidney Health Initiative has renewed interest in home hemodialysis (HHD). Many perceived barriers exist for adoption of HHD despite well-reported clinical benefits. A well-designed program ensures patient success further engaging more patients. The initial planning regarding the surrounding patient population, stakeholders, economics, and physical location is essential. The services offered including modality education and different kinds of HHD modalities depend on local expertise and economics. The program should fulfill conditions for coverage requirements for personnel, physical infrastructure, and quality metrics to begin operations. The patient recruitment is facilitated by a patient-centric modality education program developed by the multidisciplinary team. If the patient is interested, a training schedule should be discussed with the patient and caregiver. A system to ensure remote patient monitoring, respite care, and 24 hours on-call availability should be established. These practical considerations ensure initial success and future growth of the program.
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Drummond M, Federici C, Busink E, Apel C, Kendzia D, Brouwer W. Performance-based risk-sharing agreements in renal care: current experience and future prospects. Expert Rev Pharmacoecon Outcomes Res 2021; 21:197-209. [PMID: 33439090 DOI: 10.1080/14737167.2021.1876566] [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] [Indexed: 10/22/2022]
Abstract
INTRODUCTION Performance-based risk-sharing agreements (PBRSAs), between payers, health care providers, and technology manufacturers can be useful when there is uncertainty about the (cost-) effectiveness of a new technology or service. However, they can be challenging to design and implement. AREAS COVERED A total of 18 performance-based agreements were identified through a literature review. All but two of the agreements identified were pay-for-performance schemes, agreed between providers and payers at the national level. No examples were found of agreements between health care providers and manufacturers at the local level. The potential for these local agreements was illustrated by hypothetical case studies of water quality management and an integrated chronic kidney disease program. EXPERT OPINION Performance-based risk-sharing agreements can work to the advantage of patients, health care providers, payers, and technology manufacturers, particularly if they facilitate the introduction of technologies or systems of care that might not have been introduced otherwise. However, the design, conduct, and implementation of PBRSAs in renal care pose a number of challenges. Efforts should be made to overcome these challenges so that more renal care patients can benefit from technological advances and new models of care.
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Affiliation(s)
- Michael Drummond
- Centre for Health Economics, University of York, York, UK.,Center for Research in Health and Social Care, Bocconi University, Milan, Italy
| | - Carlo Federici
- Center for Research in Health and Social Care, Bocconi University, Milan, Italy
| | - Ellen Busink
- Health Economics and Market Access EMEA, Fresenius Medical Care, Bad Homburg, Germany
| | - Christian Apel
- Health Economics and Market Access EMEA, Fresenius Medical Care, Bad Homburg, Germany
| | - Dana Kendzia
- Health Economics and Market Access EMEA, Fresenius Medical Care, Bad Homburg, Germany
| | - Werner Brouwer
- Erasmus School of Health Policy and Management, Erasmus University, Rotterdam, The Netherlands
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Salerno S, Dahlerus C, Messana J, Wisniewski K, Tong L, Hirth RA, Affholter J, Gremel G, Wu Y, Zhu J, Roach J, Balovlenkov Rn E, Andress J, Li Y. Evaluating national trends in outcomes after implementation of a star rating system: Results from dialysis facility compare. Health Serv Res 2020; 56:123-131. [PMID: 33184854 DOI: 10.1111/1475-6773.13600] [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] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVE To examine which factors are driving improvement in the Dialysis Facility Compare (DFC) star ratings and to test whether nonclinical facility characteristics are associated with observed longitudinal changes in the star ratings. DATA SOURCES Data were collected from eligible patients in over 6,000 Medicare-certified dialysis facilities from three annual star rating and individual measure updates, publicly released on DFC in October 2015, October 2016, and April 2018. STUDY DESIGN Changes in the star rating and individual quality measures were investigated across three public data releases. Year-to-year changes in the star ratings were linked to facility characteristics, adjusting for baseline differences in quality measure performance. DATA COLLECTION Data from publicly reported quality measures, including standardized mortality, hospitalization, and transfusion ratios, dialysis adequacy, type of vascular access for dialysis, and management of mineral and bone disease, were extracted from annual DFC data releases. PRINCIPAL FINDINGS The proportion of four- and five-star facilities increased from 30.0% to 53.4% between October 2015 and April 2018. Quality improvement was driven by the domain of care containing the dialysis adequacy and hypercalcemia measures. Additionally, independently owned facilities and facilities belonging to smaller dialysis organizations had significantly lower odds of year-to-year improvement than facilities belonging to either of the two large dialysis organizations (Odds Ratio [OR]: 0.736, 95% Confidence Interval [CI]: 0.631-0.856 and OR: 0.797, 95% CI: 0.723-0.879, respectively). CONCLUSIONS The percentage of four- and five-star facilities has increased markedly over a three-year time period. These changes were driven by improvement in the specific quality measures that may be most directly under the control of the dialysis facility.
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Affiliation(s)
- Stephen Salerno
- Kidney Epidemiology and Cost Center, University of Michigan, Ann Arbor, Michigan, USA
| | - Claudia Dahlerus
- Kidney Epidemiology and Cost Center, University of Michigan, Ann Arbor, Michigan, USA
| | - Joseph Messana
- Kidney Epidemiology and Cost Center, University of Michigan, Ann Arbor, Michigan, USA
| | - Karen Wisniewski
- Kidney Epidemiology and Cost Center, University of Michigan, Ann Arbor, Michigan, USA
| | - Lan Tong
- Kidney Epidemiology and Cost Center, University of Michigan, Ann Arbor, Michigan, USA
| | - Richard A Hirth
- Kidney Epidemiology and Cost Center, University of Michigan, Ann Arbor, Michigan, USA
| | - Jordan Affholter
- Kidney Epidemiology and Cost Center, University of Michigan, Ann Arbor, Michigan, USA
| | - Garrett Gremel
- Kidney Epidemiology and Cost Center, University of Michigan, Ann Arbor, Michigan, USA
| | - YiFan Wu
- Kidney Epidemiology and Cost Center, University of Michigan, Ann Arbor, Michigan, USA
| | - Ji Zhu
- Kidney Epidemiology and Cost Center, University of Michigan, Ann Arbor, Michigan, USA
| | - Jesse Roach
- The Centers for Medicare & Medicaid Services, Baltimore, Maryland, USA
| | | | - Joel Andress
- The Centers for Medicare & Medicaid Services, Baltimore, Maryland, USA
| | - Yi Li
- Kidney Epidemiology and Cost Center, University of Michigan, Ann Arbor, Michigan, USA
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Gupta N, Wish JB. Are Dialysis Facility Quality Incentive Program Scores Associated With Patient Survival? Am J Kidney Dis 2020; 75:155-157. [DOI: 10.1053/j.ajkd.2019.09.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2019] [Accepted: 09/11/2019] [Indexed: 11/11/2022]
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Crews DC, Novick TK. Achieving equity in dialysis care and outcomes: The role of policies. Semin Dial 2020; 33:43-51. [PMID: 31899828 DOI: 10.1111/sdi.12847] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Socially disadvantaged persons, including racial and ethnic minorities, individuals with low incomes, homeless persons, and non-US citizens bear a disproportionate burden of end-stage kidney disease (ESKD). Inequities in nephrology referral, vascular access, use of home dialysis modalities, kidney transplantation, and mortality are prominent. Public policies, including the Patient Protection and Affordable Care Act, end-stage renal disease Quality Incentive Program, and the Prospective Payment System, were enacted to improve healthcare access and dialysis care. Here, we highlight inequities in dialysis care and outcomes, how current ESKD and other public policies may influence or exacerbate these inequities, and gaps in the literature needed to inform future policies toward achieving equity in ESKD. We give special attention to the 2019 Advancing American Kidney Health Executive Order, which has high potential to radically transform dialysis care.
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Affiliation(s)
- Deidra C Crews
- Division of Nephrology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA.,Johns Hopkins Center for Health Equity, Johns Hopkins Medical Institutions, Baltimore, MD, USA.,Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Tessa K Novick
- Division of Nephrology, Department of Internal Medicine, Dell Medical School, University of Texas at Austin, Austin, TX, USA
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Plantinga LC, Jones B, Johnson J, Lambeth A, Lea JP, Nadel L, Vandenberg AE, Bowling CB. Delivery of a patient-friendly functioning report to improve patient-centeredness of dialysis care: a pilot study. BMC Health Serv Res 2019; 19:891. [PMID: 31771573 PMCID: PMC6880368 DOI: 10.1186/s12913-019-4733-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2019] [Accepted: 11/11/2019] [Indexed: 01/22/2023] Open
Abstract
Background Provider recognition of level of functioning may be suboptimal in the dialysis setting, and this lack of recognition may lead to less patient-centered care. We aimed to assess whether delivery of an app-based, individualized functioning report would improve patients’ perceptions of patient-centeredness of care. Methods In this pre-post pilot study at three outpatient dialysis facilities in metropolitan Atlanta, an individualized functioning report—including information on physical performance, perceived physical functioning, and community mobility—was delivered to patients receiving hemodialysis (n = 43) and their providers. Qualitative and quantitative approaches were used to gather patient and provider feedback to develop and assess the report and app. Paired t test was used to test for differences in patient perception of patient-centeredness of care (PPPC) scores (range, 1 = most patient-centered to 4 = least patient-centered) 1 month after report delivery. Results Delivery of the reports to both patients and providers was not associated with a subsequent change in patients’ perceptions of patient-centeredness of their care (follow-up vs. baseline PPPC scores of 2.35 vs. 2.36; P > 0.9). However, patients and providers generally saw the potential of the report to improve the patient-centeredness of care and reacted positively to the individualized reports delivered in the pilot. Patients also reported willingness to undergo future assessments. However, while two-thirds of surveyed providers reported always or sometimes discussing the reports they received, most (98%) participating patients reported that no one on the dialysis care team had discussed the report with them within 1 month. Conclusions Potential lack of fidelity to the intervention precludes definitive conclusions about effects of the report on patient-centeredness of care. The disconnect between patients’ and providers’ perceptions of discussions of the report warrants future study. However, this study introduces a novel, individualized, multi-domain functional report that is easily implemented in the setting of hemodialysis. Our pilot study provides guidance for improving its use both clinically and in future pragmatic research studies, both within and beyond the dialysis population.
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Affiliation(s)
- Laura C Plantinga
- Department of Medicine, Emory University, Atlanta, Georgia, USA. .,Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA.
| | - Brian Jones
- Interactive Media Technology Center, Georgia Institute of Technology, Atlanta, Georgia, USA
| | - Jeremy Johnson
- Interactive Media Technology Center, Georgia Institute of Technology, Atlanta, Georgia, USA
| | - Amelia Lambeth
- Interactive Media Technology Center, Georgia Institute of Technology, Atlanta, Georgia, USA
| | - Janice P Lea
- Department of Medicine, Emory University, Atlanta, Georgia, USA
| | - Leigh Nadel
- Department of Medicine, Emory University, Atlanta, Georgia, USA
| | | | - C Barrett Bowling
- Durham Veterans Affairs Geriatric Research Education and Clinical Center, Durham Veterans Affairs Medical Center, Durham, North Carolina, USA.,Department of Medicine, Duke University, Durham, North Carolina, USA
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Mathew AT, Fishbane S. Introduction to unresolved issues in the care of dialysis patients. Semin Dial 2018; 31:313-314. [PMID: 29978602 DOI: 10.1111/sdi.12736] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Anna T Mathew
- Division of Nephrology, McMaster University, Hamilton, ON, Canada
| | - Steven Fishbane
- Division of Kidney Diseases and Hypertension, Northwell Health, New Hyde Park, NY, USA
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