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Hatsek A, Hochberg I, Daoud Naccache D, Biderman A, Shahar Y. Design of a bi-directional methodology for automated assessment of compliance to continuous application of clinical guidelines, and its evaluation in the type 2 diabetes domain. PLoS One 2024; 19:e0303542. [PMID: 38768161 PMCID: PMC11104637 DOI: 10.1371/journal.pone.0303542] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Accepted: 04/25/2024] [Indexed: 05/22/2024] Open
Abstract
We introduce a new approach for automated guideline-based-care quality assessment, the bidirectional knowledge-based assessment of compliance (BiKBAC) method, and the DiscovErr system, which implements it. Our methodology compares the guideline's Asbru-based formal representation, including its intentions, with the longitudinal medical record, using a top-down and bottom-up approach. Partial matches are resolved using fuzzy temporal logic. The system was evaluated in the type 2 Diabetes management domain, comparing it to three expert clinicians, including two diabetes experts. The system and the experts commented on the management of 10 patients, randomly selected from 2,000 diabetes patients. On average, each record spanned 5.23 years; the data included 1,584 medical transactions. The system provided 279 comments. The experts made 181 different unique comments. The completeness (recall) of the system was 91% when the gold standard was comments made by at least two of the three experts, and 98%, compared to comments made by all three experts. The experts also assessed all of the 114 medication-therapy-related comments, and a random 35% of the 165 tests-and-monitoring-related comments. The system's correctness (precision) was 81%, compared to comments judged as correct by both diabetes experts, and 91%, compared to comments judged as correct by one diabetes expert and at least as partially correct by the other. 89% of the comments were judged as important by both diabetes experts, 8% were judged as important by one expert, and 3% were judged as less important by both experts. Adding the validated system comments to the experts' comments, the completeness scores of the experts were 75%, 60%, and 55%; the expert correctness scores were respectively 99%, 91%, and 88%. Thus, the system could be ranked first in completeness and second in correctness. We conclude that systems such as DiscovErr can effectively assess the quality of continuous guideline-based care.
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Affiliation(s)
- Avner Hatsek
- Department of Software and Information Systems Engineering, Ben Gurion University, Beer Sheva, Israel
| | - Irit Hochberg
- Endocrinology, Diabetes, and Metabolism Institute, Rambam Health Care Campus, Haifa, Israel
- Bruce Rappaport Faculty of Medicine, Technion—Israel Institute of Technology, Haifa, Israel
| | - Deeb Daoud Naccache
- Endocrinology, Diabetes, and Metabolism Institute, Rambam Health Care Campus, Haifa, Israel
| | - Aya Biderman
- Department of Family Medicine and the Siaal Research Center for Family Medicine and Primary Care, Faculty of Health Sciences, Ben‐Gurion University of the Negev and Clalit Health Care Services, Beer Sheva, Israel
| | - Yuval Shahar
- Department of Software and Information Systems Engineering, Ben Gurion University, Beer Sheva, Israel
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Bullock JE. Provider adherence to American Diabetes Association cardiovascular risk-reduction guidelines: An integrative review. J Am Assoc Nurse Pract 2024; 36:17-22. [PMID: 37494065 DOI: 10.1097/jxx.0000000000000920] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Accepted: 06/05/2023] [Indexed: 07/27/2023]
Abstract
BACKGROUND Diabetes mellitus (DM) requires comprehensive management to prevent end organ disease. Type 2 diabetes Mellitus (T2DM) effects more than 33.3 million individuals in the United States, the majority managed by primary care providers (PCPs). Type 2 diabetes Mellitus increases lifetime heart attack and stroke risk by 2-4 times. Adherence to the American Diabetes Association (ADA) cardiovascular disease reduction guidelines is associated with decreased morbidity and mortality. PURPOSE This integrative review highlights PCP adherence to ADA cardiovascular risk-reduction guidelines and explores interventions that address adherence. METHODOLOGY The integrative review approach demanded critical examination of the literature following extraction of findings obtained through a rigorous process involving clear inclusion and exclusion criteria. A comprehensive literature search was guided through Johns Hopkins Nursing Evidence-Based Practice Model. Data extraction was documented through Preferred Reporting Items for Systematic Reviews and Meta-Analysis. RESULTS Five articles met inclusion criteria. Articles ranged from 2017 to 2022 and occurred in the United States, Palestine, and one across Europe. Four areas of common content were identified and included the lack of adherence to statin prescribing, lack of adherence to blood pressure management, statin prescribing favoring male patients and those with existing atherosclerotic cardiovascular disease diagnoses, and varying methods to improve adherence. CONCLUSIONS Quality-improvement strategies focused on the improvement of PCP adherence to ADA cardiovascular risk-reduction guidelines are necessary. IMPLICATIONS Improved adherence would significantly improve morbidity and mortality outcomes in T2DM. Adherence interventions include education, electronic health record integration, and oversight by certified diabetes educator nurses. The time is now to reduce the negative sequelae from a disease that effects 11.3% of our population.
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Affiliation(s)
- Jamie Eve Bullock
- Johns Hopkins University School of Nursing, Baltimore, Maryland
- University of New England, Portland, Maine
- Martin's Point Health Care, Portland, Maine
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Jones RD, Abebe S, Distefano V, Mayer G, Poli I, Silvestri C, Slanzi D. Candidate composite biomarker to inform drug treatments for diabetic kidney disease. Front Med (Lausanne) 2023; 10:1271407. [PMID: 38020124 PMCID: PMC10646536 DOI: 10.3389/fmed.2023.1271407] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Accepted: 09/29/2023] [Indexed: 12/01/2023] Open
Abstract
Introduction Current guidelines recommend renin angiotensin system inhibitors (RASi) as key components of treatment of diabetic kidney disease (DKD). Additional options include sodium-glucose cotransporter-2 inhibitors (SGLT2i), glucagon-like peptide 1 receptor agonists (GLP1a), and mineralocorticoid receptor antagonists (MCRa). The identification of the optimum drug combination for an individual is difficult because of the inter-, and longitudinal intra-individual heterogeneity of response to therapy. Results Using data from a large observational study (PROVALID), we identified a set of parameters that can be combined into a meaningful composite biomarker that appears to be able to identify which of the various treatment options is clinically beneficial for an individual. It uses machine-earning techniques to estimate under what conditions a treatment of RASi plus an additional treatment is different from the treatment with RASi alone. The measure of difference is the annual percent change (ΔeGFR) in the estimated glomerular filtration rate (ΔeGFR). The 1eGFR is estimated for both the RASi-alone treatment and the add-on treatment. Discussion Higher estimated increase of eGFR for add-on patients compared with RASi-alone patients indicates that prognosis may be improved with the add-on treatment. The personalized biomarker value thus identifies which patients may benefit from the additional treatment.
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Affiliation(s)
- Roger D. Jones
- European Centre for Living Technology, Ca' Foscari University of Venice, Venice, Italy
- Department of Biology, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
- Systems Engineering and Research Center, Stevens Institute of Technology, Hoboken, NJ, United States
| | - Seyum Abebe
- European Centre for Living Technology, Ca' Foscari University of Venice, Venice, Italy
| | - Veronica Distefano
- European Centre for Living Technology, Ca' Foscari University of Venice, Venice, Italy
- Department of Economic Sciences, Università del Salento, Salento, Italy
| | - Gert Mayer
- Internal Medicine IV, Medical University Innsbruck, Innsbruck, Austria
| | - Irene Poli
- European Centre for Living Technology, Ca' Foscari University of Venice, Venice, Italy
| | - Claudio Silvestri
- European Centre for Living Technology, Ca' Foscari University of Venice, Venice, Italy
- Department of Environmental Sciences, Informatics and Statistics, Ca' Foscari University of Venice, Venice, Italy
| | - Debora Slanzi
- European Centre for Living Technology, Ca' Foscari University of Venice, Venice, Italy
- Department of Management, Ca' Foscari University of Venice, Venice, Italy
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Sun Z, Wang K, Yun C, Bai F, Yuan X, Lee Y, Lou Q. Correlation Between the Variability of Different Obesity Indices and Diabetic Kidney Disease: A Retrospective Cohort Study Based on Populations in Taiwan. Diabetes Metab Syndr Obes 2023; 16:2791-2802. [PMID: 37720422 PMCID: PMC10504903 DOI: 10.2147/dmso.s425198] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Accepted: 08/31/2023] [Indexed: 09/19/2023] Open
Abstract
Purpose To investigate the association of five obesity indices and the variability of these indices with diabetic kidney disease (DKD) in patients with type 2 diabetes and compare the predictive validity of these markers for the risk of DKD in this large longitudinal cohort study. Patients and Methods A total of 2659 patients with type 2 diabetes who did not have DKD were enrolled between 2006 and 2019 at Lee's United Clinic in Taiwan. Data were collected for each subject, including demographic data, personal medical history, clinical parameters and calculated Body mass index (BMI), visceral adiposity index (VAI), lipid accumulation product (LAP), body roundness index (BRI) and variability of five obesity indices. Cox regression analysis was performed to determine the relationship between different obesity indicators and DKD risk. Cox's proportional hazards model was evaluated the predictive effect of obesity indices on DKD. Results The risk of developing DKD increased with an increase in the BRI, LAP, VAI, WC and BMI (all P trend<0.05), and the variability of VAI was significantly associated with DKD [HR=1.132, 95% CI (1.001, 1.281)] after adjusting for corresponding variables. BRI had the strongest predictive effect on DKD. BRI had the best predictive performance, with AUC of 0.807, 0.663 and 0.673 at 1, 3 and 5 years, respectively. Cox regression analysis of risk factors for DKD in patients stratified by BRI quartiles showed that patients in the Q4 group had the highest risk of developing DKD [HR=1.356, 95% CI (1.131, 1.626)]. Conclusion BMI, WC, VAI, LAP, BRI and VAI variability were associated with a significant increase in the risk of DKD events, and BRI was superior and alternative obesity index for predicting DKD.
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Affiliation(s)
- Zhenzhen Sun
- The First Affiliated Hospital of Hainan Medical University, Hainan Clinical Research Center for Metabolic Disease, Haikou, Hainan, People’s Republic of China
| | - Kun Wang
- The First Affiliated Hospital of Hainan Medical University, Hainan Clinical Research Center for Metabolic Disease, Haikou, Hainan, People’s Republic of China
| | - Chuan Yun
- The First Affiliated Hospital of Hainan Medical University, Hainan Clinical Research Center for Metabolic Disease, Haikou, Hainan, People’s Republic of China
| | - Fang Bai
- The First Affiliated Hospital of Hainan Medical University, Hainan Clinical Research Center for Metabolic Disease, Haikou, Hainan, People’s Republic of China
| | - Xiaodan Yuan
- Affiliated Hospital of Integrated Traditional Chinese and Western Medicine, Nanjing University of Chinese Medicine, Nanjing, Jiangsu, People’s Republic of China
| | - Yaujiunn Lee
- Department of Endocrinology, Lee’s Clinic, Pingtung City, Pingtung County, Taiwan
| | - Qingqing Lou
- The First Affiliated Hospital of Hainan Medical University, Hainan Clinical Research Center for Metabolic Disease, Haikou, Hainan, People’s Republic of China
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胡 煜, 杜 晓. [Blood Lipid Indicators and Different Clinical Classifications of Dyslipidemia and Diabetic Kidney Disease: Correlation and Predictive Value]. SICHUAN DA XUE XUE BAO. YI XUE BAN = JOURNAL OF SICHUAN UNIVERSITY. MEDICAL SCIENCE EDITION 2023; 54:1013-1018. [PMID: 37866961 PMCID: PMC10579073 DOI: 10.12182/20230960103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Indexed: 10/24/2023]
Abstract
Objective To explore the relationship between blood lipid indicators and different clinical classifications of dyslipidemia and diabetic kidney disease (DKD) and to compare the value of different clinical classifications of dyslipidemia for predicting DKD. Methods Continuously enrollment of subjects was conducted at the First Affiliated Hospital of Chongqing Medical University and the Yongchuan Hospital of Chongqing Medical University between October 2020 and October 2021. A total of 356 type 2 diabetes mellitus (T2DM) patients admitted to the two hospitals were enrolled. They were divided into DKD group ( n=126) and simple T2DM group ( n=230) according to whether their T2DM was combined with DKD. In addition, 250 healthy individuals undergoing physical examination during the same period were enrolled for the control group. The blood pressure, blood lipid, blood glucose, and the kidney function indicators of the three groups were measured. The effects of different classifications of dyslipidemia on DKD were analyzed with unconditional logistic regression models, the receiver operating characteristic (ROC) curve was constructed, the area under the curve ( AUC) of ROC was calculated, and the value of different classifications of dyslipidemia for predicting DKD was analyzed. Results The diastolic blood pressure (DBP), systolic blood pressure (SBP), total cholesterol (TC), triacylglycerol (TG), low-density lipoprotein cholesterol (LDL-C), serum creatinine (Scr), uric acid (UA), and glycosylated hemoglobin A1c (HbA1c) of the DKD group and the simple T2DM group were significantly higher than those of the control group, while the high-density lipoprotein cholesterol (HDL-C) levels of the DKD group and the simple T2DM group were lower than that of the control group (all P<0.05). The disease course of T2DM, DBP, SBP, TC, TG, Scr, UA and HbA1c of the DKD group were significantly higher than those of the T2DM group (all P<0.05). After adjusting for the effects of T2DM disease course, DBP, SBP, Scr, UA and HbA1c, the results showed that TC ( OR=1.426, 95% CI: 1.088-1.868) and TG ( OR=1.404, 95% CI: 1.075-1.833) were independent risk factors for DKD, and that hypercholesterolemia ( OR=1.817, 95% CI: 1.040-3.177) and mixed hyperlipidemia ( OR=2.148, 95% CI: 1.110-4.159) were independent risk factors for DKD (all P<0.05). The AUC (95% CI) of hypercholesterolemia was 0.789 (0.729-0.871). The AUC (95% CI) of mixed hyperlipidemia was 0.671 (0.579-0.760). Hypercholesterolemia showed better predictive value for the diagnosis and prediction of DKD. Conclusion Among the blood lipid indicators, TC and TG are independent risk factors of DKD. In the clinical classifications of dyslipidemia, hypercholesterolemia and mixed hyperlipidemia are independent risk factors of DKD. Hypercholesterolemia can be used as a predictor to screen for DKD among T2DM patients and is well suited for extensive application in outpatient screening.
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Affiliation(s)
- 煜琳 胡
- 重庆医科大学附属永川医院 肾病风湿科 (重庆 402160)Department of Nephrology and Rheumatism, Yongchuan Hospital of Chongqing Medical University, Chongqing 402160, China
- 重庆医科大学附属第一医院 肾内科 (重庆 400016)Department of Nephrology, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China
| | - 晓刚 杜
- 重庆医科大学附属永川医院 肾病风湿科 (重庆 402160)Department of Nephrology and Rheumatism, Yongchuan Hospital of Chongqing Medical University, Chongqing 402160, China
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Alsalemi N, Lafrance JP, Sadowski CA. Older age, kidney concordant diseases and the dilemma of adherence to guidelines: A narrative review. Res Social Adm Pharm 2023; 19:1018-1024. [PMID: 37055315 DOI: 10.1016/j.sapharm.2023.04.115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Revised: 03/15/2023] [Accepted: 04/04/2023] [Indexed: 04/15/2023]
Abstract
Evidence-based medicine is pivotal to contemporary clinical practice, and the excellence of a healthcare institution is measured by the adherence of its clinical staff to the clinical practice guidelines (CPGs) among other standards and policies. Following the recommendations of CPGs in older adults poses different challenges to prescribers. In this narrative review we explore research studies that assessed clinicians' adherence to CPGs when prescribing to older adults with chronic kidney disease and its concordant disorders, and to discuss the potential barriers and facilitators to better adherence to CPGs. Our review of the literature found that the adherence level to CPGs differed according to country, disease condition and healthcare setting. Clinicians' attitudes toward older adults and the CPGs, the unfamiliarity with the CPGs, and the lack of time, were commonly cited barriers. Interventions suggested to improve adherence to CPGs include direct mentoring, educational activities, and the integration of CPGs recommendations within hospital protocols and policies.
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Affiliation(s)
- Noor Alsalemi
- Département de pharmacologie et physiologie, Université de Montréal, Montréal, QC, Canada; Centre de Recherche de l'Hôpital Maisonneuve-Rosemont, Montréal, QC, Canada
| | - Jean-Philippe Lafrance
- Département de pharmacologie et physiologie, Université de Montréal, Montréal, QC, Canada; Centre de Recherche de l'Hôpital Maisonneuve-Rosemont, Montréal, QC, Canada; Service de néphrologie, CIUSSS de l'Est-de-l'Île-de-Montréal, Montréal, QC, Canada
| | - Cheryl A Sadowski
- Faculty of Pharmacy and Pharmaceutical Sciences, University of Alberta, Edmonton, AB, Canada.
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Thöni S, Keller F, Denicolò S, Eder S, Buchwinkler L, Rosivall L, Wiecek A, Mark PB, Rossing P, Heerspink HL, Mayer G. International Variability of Renal and Cardiovascular Outcomes and Mortality in Patients with Type 2 Diabetes Mellitus in Europe. Kidney Blood Press Res 2023; 48:165-174. [PMID: 37015210 PMCID: PMC10077442 DOI: 10.1159/000528438] [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: 06/27/2022] [Accepted: 11/23/2022] [Indexed: 04/06/2023] Open
Abstract
INTRODUCTION Type 2 diabetes and its complications represent a huge burden to public health. With this prospective, observational cohort study, we aimed to estimate and to compare the incidence rate (IR) of renal and cardiovascular outcomes and all-cause mortality in patients with type 2 diabetes in different European countries. METHODS The renal endpoint was a composite of a sustained decline in estimated GFR of at least 40%, a sustained increase in albuminuria of at least 30% including a transition in albuminuria class, progression to kidney failure with replacement therapy, or death from renal causes. The cardiovascular endpoint was a composite of death from cardiovascular causes, nonfatal myocardial infarction, or nonfatal stroke. RESULTS 3,131 participants from four European countries (Austria, Hungary, The Netherlands, and Scotland) with a median follow-up time of 4.4 years were included. IRs were adjusted for several risk factors including sex, age, estimated GFR, albuminuria, HbA1c, blood pressure, and duration of type 2 diabetes. Across countries, the adjusted IR for the renal endpoint was significantly higher in Hungary and Austria, and the adjusted IR for the cardiovascular endpoint was significantly higher in Scotland and Austria. All-cause mortality was significantly higher in Scotland compared to all other countries. CONCLUSION Our findings show how the longitudinal outcome of patients with type 2 diabetes varies significantly across European countries even after accounting for the distribution of underlying risk factors.
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Affiliation(s)
- Stefanie Thöni
- Department of Internal Medicine IV (Nephrology and Hypertension), Medical University Innsbruck, Innsbruck, Austria,
| | - Felix Keller
- Department of Internal Medicine IV (Nephrology and Hypertension), Medical University Innsbruck, Innsbruck, Austria
| | - Sara Denicolò
- Department of Internal Medicine IV (Nephrology and Hypertension), Medical University Innsbruck, Innsbruck, Austria
| | - Susanne Eder
- Department of Internal Medicine IV (Nephrology and Hypertension), Medical University Innsbruck, Innsbruck, Austria
| | - Lukas Buchwinkler
- Department of Internal Medicine IV (Nephrology and Hypertension), Medical University Innsbruck, Innsbruck, Austria
| | - László Rosivall
- International Nephrology Research and Training Center, Institute of Pathophysiology, Semmelweis University, Budapest, Hungary
| | - Andrzej Wiecek
- Department of Nephrology, Transplantation and Internal medicine, Medical University of Silesia, Katowice, Poland
| | - Patrick Barry Mark
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Peter Rossing
- Steno Diabetes Center Copenhagen, Copenhagen, Denmark
- Department of Internal Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Hiddo L Heerspink
- Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Gert Mayer
- Department of Internal Medicine IV (Nephrology and Hypertension), Medical University Innsbruck, Innsbruck, Austria
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Sandelowsky H, Ställberg B, Wiklund F, Telg G, de Fine Licht S, Janson C. Annual and Post-Exacerbation Follow-Up of Asthma Patients in Clinical Practice – A Large Population-Based Study in Sweden. J Asthma Allergy 2022; 15:475-486. [PMID: 35444428 PMCID: PMC9014309 DOI: 10.2147/jaa.s357086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Accepted: 04/01/2022] [Indexed: 11/24/2022] Open
Abstract
Background Symptom control has not improved in Swedish asthma patients during the last two decades. Guidelines recommend annual reviews for asthma patients treated with maintenance inhaled corticosteroids (ICS). We aimed to describe how visit patterns in an ICS-treated asthma population in Sweden were related to applicable asthma guidelines. Methods Swedish electronic health data for incident asthma patients, ≥18 years, with at least one ICS collection (index date) between 2006 and 2017 were included. Exacerbations were defined as hospitalizations, emergency visits, or collection of oral corticosteroids (OCS). Probability of an asthma-related regular follow-up visit and probability of a follow-up visit after an exacerbation, both within 15 months, were estimated using the cumulative incidence function, time-to-event analysis, and incident rate ratios. Results In 51,349 asthma patients (mean age 47.6 years, 63% females), 17,573 had a regular asthma visit in primary or secondary care within 15 months after the index, yielding an overall probability of a visit of 37.4%. Patients with a follow-up visit had higher ICS collection and lower OCS collection than patients without regular visits. Among 22,097 patients with acute exacerbations, the probability of a visit within 15 months after an exacerbation was 31.0%. The probability of having a visit increased during the study period. Conclusion Only one-third of ICS-treated asthma patients, regardless of asthma severity, had a regular or post-exacerbation follow-up visit within a 15-month period. The consequences of this lack of adherence to guidelines need further evaluation to secure optimal asthma management.
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Affiliation(s)
- Hanna Sandelowsky
- Karolinska Institutet, Department of Medicine, Division of Clinical Epidemiology, Solna, Sweden
- Karolinska Institutet, Department of Neurobiology, Care Sciences and Society, Division of Family Medicine and Primary Care, Solna, Sweden
- Academic Primary Health Care Centre, Region Stockholm, Sweden
- Correspondence: Hanna Sandelowsky, Karolinska Institutet, Department of Medicine, Division of Clinical Epidemiology, Solna, Sweden, Tel +46738902565, Email
| | - Björn Ställberg
- Department of Public Health and Caring Sciences, Family Medicine and Preventive Medicine, Uppsala University, Uppsala, Sweden
| | | | | | | | - Christer Janson
- Department of Medical Sciences: Respiratory, Allergy and Sleep Research, Uppsala University, Uppsala, Sweden
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Mottl AK, Alicic R, Argyropoulos C, Brosius FC, Mauer M, Molitch M, Nelson RG, Perreault L, Nicholas SB. KDOQI US Commentary on the KDIGO 2020 Clinical Practice Guideline for Diabetes Management in CKD. Am J Kidney Dis 2022; 79:457-479. [PMID: 35144840 PMCID: PMC9740752 DOI: 10.1053/j.ajkd.2021.09.010] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Accepted: 09/15/2021] [Indexed: 12/14/2022]
Abstract
In October 2020, KDIGO (Kidney Disease: Improving Global Outcomes) published its first clinical practice guideline directed specifically to the care of patients with diabetes and chronic kidney disease (CKD). This commentary presents the views of the KDOQI (Kidney Disease Outcomes Quality Initiative) work group for diabetes in CKD, convened by the National Kidney Foundation to provide an independent expert perspective on the new guideline. The KDOQI work group believes that the KDIGO guideline takes a major step forward in clarifying glycemic targets and use of specific antihyperglycemic agents in diabetes and CKD. The purpose of this commentary is to carry forward the conversation regarding optimization of care for patients with diabetes and CKD. Recent developments for prevention of CKD progression and cardiovascular events in people with diabetes and CKD, particularly related to sodium/glucose cotransporter 2 (SGLT2) inhibitors, have filled a longstanding gap in nephrology's approach to the care of persons with diabetes and CKD. The multifaceted benefits of SGLT2 inhibitors have facilitated interactions between nephrology, cardiology, endocrinology, and primary care, underscoring the need for innovative approaches to multidisciplinary care in these patients. We now have more interventions to slow kidney disease progression and prevent or delay kidney failure in patients with diabetes and kidney disease, but methods to streamline their implementation and overcome barriers in access to care, particularly cost, are essential to ensuring all patients may benefit.
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Use of antihyperglycaemic therapy with cardiovascular benefit in patients with type 2 diabetes who require hospitalisation: A cross-sectional study. Rev Clin Esp 2021; 221:517-528. [PMID: 34752263 DOI: 10.1016/j.rceng.2019.12.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2019] [Accepted: 12/26/2019] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To evaluate the use of therapy with cardiovascular benefit in patients with type 2 diabetes mellitus admitted to internal medicine departments. METHODS One day, cross-sectional study of patients with type 2 diabetes mellitus hospitalised in internal medicine departments. We recorded demographic and anthropometric variables, laboratory data and use of antihyperglycaemic drugs. The endpoint was the proportion and determinants of the use of sodium-glucose cotransporter-2 inhibitors (SGLT2i) and glucagon-like peptide-1 receptor agonists (GLP1-RA). RESULTS We included 928 patients belonging to 74 hospitals, with a mean age of 78.9 years (SD, 10.86 years), 50% of whom were men. A total of 557 (60%) patients had ischaemic heart disease, 189 (20.4%) had cerebrovascular disease, 293 (31.6%) had heart failure, 274 (29.5%) had chronic kidney disease, and 129 (13.9%) had peripheral arterial disease. Prior to their hospital admission, the patients were taking sulfonylureas (5.7%), biguanides (49.1%), alpha-glucosidase inhibitors (0.2%), pioglitazone (0%), dipeptidyl peptidase 4 inhibitors (39%), SGLT2i (5.8%), GLP1-RA (2.6%) and basal insulin analogues (24%). An age over 75 years was the main determinant for not taking SGLT2i (adjusted OR, 0.28; 95% CI 0.10-0.74; p = .039) or GLP1-RA (adjusted OR, 0.09; 95% CI 0.02-0.46; p = .006). DISCUSSION A large proportion of elderly patients with type 2 diabetes mellitus at very high cardiovascular risk are not treated with antihyperglycemic drugs with proven cardiovascular benefit. The most commonly used drugs were metformin and DPP4i. There is room for improvement in the treatment of this very high-risk population.
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Lu J, Zhao W, Chen T, Xu Z, Sun X, Xie H, An Y, Zeng C, Hu G, Xie G, Liu Z. Influence of guideline adherence and parameter control on the clinical outcomes in patients with diabetic nephropathy. BMJ Open Diabetes Res Care 2020; 8:e001166. [PMID: 32675172 PMCID: PMC7368486 DOI: 10.1136/bmjdrc-2019-001166] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2019] [Revised: 03/27/2020] [Accepted: 05/30/2020] [Indexed: 12/29/2022] Open
Abstract
INTRODUCTION We assessed the association between guideline adherence and outcomes of clinical parameter control and end-stage kidney disease (ESKD), and further studied the effect of parameter control on ESKD for Chinese patients with diabetic nephropathy (DN). RESEARCH DESIGN AND METHODS In this retrospective study, 1128 patients with DN (15,374 patient-visit samples) diagnosed by renal biopsy were enrolled. Samples were classified as adherence and nonadherence based on whether prescribed drugs conformed to medication regimen and drug contraindication recommended by guidelines, including American Diabetes Association (ADA) and Chinese guidelines. Guideline adherence rate was calculated on all samples for antihyperglycemic, antihypertensive and lipid-lowering treatments. Clinical parameter control was compared after 3-6 months' therapy between two groups by generalized estimating equation models. Time-dependent Cox models were applied to evaluate the influence of guideline adherence on ESKD. Latent class mixed model was used to identify distinct trajectories for parameters and their ESKD risks were compared using Cox proportional-hazards models. RESULTS Guideline adherence rate of antihyperglycemic therapy was the highest, with 72.87% and 68.15% of samples meeting ADA and Chinese guidelines, respectively. Adherence was more likely to have good glycated hemoglobin A1c (HbA1c) control (ADA: OR 1.46, 95% CI 1.12 to 1.88; Chinese guideline: OR 1.42, 95% CI 1.09 to 1.85) and good blood pressure control (ADA: OR 1.35, 95% CI 1.03 to 1.78; Chinese guideline: OR 1.39, 95% CI 1.08 to 1.79) compared with nonadherence. The improvement of patient's adherence showed the potential to reduce ESKD risk. For proteinuria, low-density lipoprotein cholesterol (LDL-C), systolic blood pressure and uric acid, patients in higher-value trajectory group had higher ESKD risk. Proteinuria and LDL-C trajectories were most closely related to ESKD risk, while the risk was not significantly different in HbA1c trajectories. CONCLUSIONS Guideline adherence and good control of proteinuria and LDL-C in clinical practice are important and in need for improving clinical outcomes in patients with DN.
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Affiliation(s)
- Jingru Lu
- School of Medicine, Southeast University, National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing, China
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China
| | - Wei Zhao
- Department of Intelligent Clinical Decision Support, Ping An Healthcare Technology, Beijing, China
| | - Tingyu Chen
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China
| | - Zhuoyang Xu
- Department of Intelligent Clinical Decision Support, Ping An Healthcare Technology, Beijing, China
| | - Xingzhi Sun
- Department of Intelligent Clinical Decision Support, Ping An Healthcare Technology, Beijing, China
| | - Honglang Xie
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China
| | - Yu An
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China
| | - Caihong Zeng
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China
| | - Gang Hu
- Department of Intelligent Clinical Decision Support, Ping An Healthcare Technology, Beijing, China
| | - Guotong Xie
- Department of Intelligent Clinical Decision Support, Ping An Healthcare Technology, Beijing, China
| | - Zhihong Liu
- School of Medicine, Southeast University, National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing, China
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China
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12
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Ena J, Carretero-Gómez J, Zapatero-Gaviria A, Carrasco Sánchez FJ, Del Romero-Sánchez M, González-Becerra C, Blazquez-Encinar JC, Iguzquiza-Pellejero MJ, de Escalante Yangüela B, Gómez-Huelgas R. Use of antihyperglycaemic therapy with cardiovascular benefit in patients with type 2 diabetes who require hospitalisation: A cross-sectional study. Rev Clin Esp 2020; 221:S0014-2565(20)30059-X. [PMID: 32279949 DOI: 10.1016/j.rce.2019.12.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2019] [Revised: 12/18/2019] [Accepted: 12/26/2019] [Indexed: 10/24/2022]
Abstract
OBJECTIVE To evaluate the use of therapy with cardiovascular benefit in patients with type 2 diabetes mellitus admitted to internal medicine departments. METHODS One day, cross-sectional study of patients with type 2 diabetes mellitus hospitalised in internal medicine departments. We recorded demographic and anthropometric variables, laboratory data and use of antihyperglycaemic drugs. The endpoint was the proportion and determinants of the use of sodium-glucose cotransporter-2 inhibitors (SGLT2i) and glucagon-like peptide-1 receptor agonists (GLP1-RA). RESULTS We included 928 patients belonging to 74 hospitals, with a mean age of 78.9 years (SD, 10.86 years), 50% of whom were men. A total of 557 (60%) patients had ischaemic heart disease, 189 (20.4%) had cerebrovascular disease, 293 (31.6%) had heart failure, 274 (29.5%) had chronic kidney disease, and 129 (13.9%) had peripheral arterial disease. Prior to their hospital admission, the patients were taking sulfonylureas (5.7%), biguanides (49.1%), alpha-glucosidase inhibitors (0.2%), pioglitazone (0%), dipeptidyl peptidase 4 inhibitors (39%), SGLT2i (5.8%), GLP1-RA (2.6%) and basal insulin analogues (24%). An age over 75 years was the main determinant for not taking SGLT2i (adjusted OR, 0.28; 95% CI 0.10-0.74; P=.039) or GLP1-RA (adjusted OR, 0.09; 95% CI 0.02-0.46; P=.006). DISCUSSION A large proportion of elderly patients with type 2 diabetes mellitus at very high cardiovascular risk are not treated with antihyperglycemic drugs with proven cardiovascular benefit. The most commonly used drugs were metformin and DPP4i. There is room for improvement in the treatment of this very high-risk population.
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Affiliation(s)
- J Ena
- Servicio de Medicina Interna, Hospital Marina Baixa, Villajoyosa, Alicante, España.
| | - J Carretero-Gómez
- Servicio de Medicina Interna, Hospital de Zafra, Zafra, Badajoz, España
| | - A Zapatero-Gaviria
- Servicio de Medicina Interna, Hospital Universitario de Fuenlabrada, Fuenlabrada, Madrid, España
| | - F J Carrasco Sánchez
- Servicio de Medicina Interna, Hospital Universitario Juan Ramón Jiménez, Huelva, España
| | - M Del Romero-Sánchez
- Servicio de Medicina Interna, Hospital Universitario de Fuenlabrada, Fuenlabrada, Madrid, España
| | - C González-Becerra
- Servicio de Medicina Interna, Hospital San Juan de Dios, Tenerife, España
| | - J C Blazquez-Encinar
- Servicio de Medicina Interna, Hospital Universitario de Torrevieja, Torrevieja, Alicante, España
| | | | | | - R Gómez-Huelgas
- Servicio de Medicina Interna, Hospital Regional Universitario de Málaga, Málaga, España
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13
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Takala J, Ilmarinen P, Tuomisto LE, Vähätalo I, Niemelä O, Kankaanranta H. Planned primary health care asthma contacts during 12-year follow-up after Finnish National Asthma Programme: focus on spirometry. NPJ Prim Care Respir Med 2020; 30:8. [PMID: 32198357 PMCID: PMC7083866 DOI: 10.1038/s41533-020-0166-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2019] [Accepted: 02/28/2020] [Indexed: 01/08/2023] Open
Abstract
Primary health care (PHC) providers are at the front line of asthma management. To evaluate how planned asthma follow-up occurred in PHC and whether lung function tests were used, 203 patients were followed for 12 years as part of a real-life asthma cohort Seinäjoki Adult Asthma Study (SAAS). A total of 152 patients had visits in PHC attending on average to four planned contacts during 12-year follow-up corresponding to one visit every third year. National guideline recommends annual visits. Patients with ≥4 contacts seemed to have more difficult asthma and better adherence to inhaled corticosteroid medication. Lung function tests were performed on average in 87.5% of annual planned follow-up contacts. Spirometry was performed in 70%, 71% and 97% of all contacts depending on whether it was a contact to GP, nurse or both. Overall, the frequency of follow-up contacts was insufficient but PHC adherence to lung function testing was excellent.
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Affiliation(s)
- Jaana Takala
- Seinäjoki Health Care Centre, Seinäjoki, Finland.
- Department of Respiratory Medicine, Seinäjoki Central Hospital, Seinäjoki, Finland.
| | - Pinja Ilmarinen
- Department of Respiratory Medicine, Seinäjoki Central Hospital, Seinäjoki, Finland
| | - Leena E Tuomisto
- Department of Respiratory Medicine, Seinäjoki Central Hospital, Seinäjoki, Finland
| | - Iida Vähätalo
- Department of Respiratory Medicine, Seinäjoki Central Hospital, Seinäjoki, Finland
| | - Onni Niemelä
- Department of Laboratory Medicine, Seinäjoki Central Hospital, Seinäjoki, Finland
- Tampere University, Tampere, Finland
| | - Hannu Kankaanranta
- Department of Respiratory Medicine, Seinäjoki Central Hospital, Seinäjoki, Finland
- Department of Respiratory Medicine, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
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14
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Brimble KS, Boll P, Grill AK, Molnar A, Nash DM, Garg A, Akbari A, Blake PG, Perkins D. Impact of the KidneyWise toolkit on chronic kidney disease referral practices in Ontario primary care: a prospective evaluation. BMJ Open 2020; 10:e032838. [PMID: 32066603 PMCID: PMC7044871 DOI: 10.1136/bmjopen-2019-032838] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
OBJECTIVES Chronic kidney disease (CKD) is common; therefore, coordination of care between primary care and nephrology is important. Ontario Renal Network's KidneyWise toolkit was developed to provide guidance on the detection and management of people with CKD in primary care (www.kidneywise.ca). The aim of this study was to evaluate the impact of the April 2015 KidneyWise toolkit release on the characteristics of primary care referrals to nephrology. DESIGN AND SETTING The study was a prospective pre-post design conducted at two nephrology sites (community site: Trillium Health Partners in Mississauga, Ontario, Canada, and academic site: St Joseph's Healthcare in Hamilton, Ontario, Canada). Referrals were compared during the 3-month time period immediately prior to, and during a 3-month period 1 year after, the toolkit release. PRIMARY AND SECONDARY OUTCOME MEASURES The primary outcome was the change in proportion of referrals for CKD that met the KidneyWise criteria. Additional secondary referral and quality of care outcomes were also evaluated. Multivariable logistic regression was used to evaluate preselected variables for their independent association with referrals that met the KidneyWise criteria. RESULTS The proportion of referrals for CKD among people who met the KidneyWise referral criteria did not significantly change from pre-KidneyWise to post-KidneyWise implementation (44.7% vs 45.8%, respectively, adjusted OR 1.16, 95% CI 0.85 to 1.59, p=0.36). The proportion of referrals for CKD that provided a urine albumin-creatinine ratio significantly increased post-KidneyWise (25.8% vs 43.8%, adjusted OR 1.45, 95% CI 1.06 to 1.97, p=0.02). The significant independent predictors of meeting the KidneyWise referral criteria were academic site, increased age and use of the KidneyWise referral form. CONCLUSIONS We did not observe any change in the proportion of appropriate referrals for CKD at two large nephrology centres 1 year after implementation of the KidneyWise toolkit.
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Affiliation(s)
| | - Philip Boll
- Nephrology, Trillium Health Partners, Mississauga, Ontario, Canada
| | - Allan K Grill
- Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Amber Molnar
- Medicine, McMaster University, Hamilton, Ontario, Canada
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | - Danielle M Nash
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | - Amit Garg
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
- Medicine, University of Western Ontario, London, Ontario, Canada
| | - Ayub Akbari
- Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Peter G Blake
- Medicine, University of Western Ontario, London, Ontario, Canada
| | - David Perkins
- Nephrology, Trillium Health Partners, Mississauga, Ontario, Canada
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15
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Dorner TE, Wilfinger J, Hoffman K, Lackinger C. Association between physical activity and the utilization of general practitioners in different age groups. Wien Klin Wochenschr 2019; 131:278-287. [PMID: 31076889 PMCID: PMC6570780 DOI: 10.1007/s00508-019-1503-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2019] [Accepted: 04/24/2019] [Indexed: 11/28/2022]
Abstract
BACKGROUND Physical activity (PA) is an important tool in health promotion, prevention, curation, and rehabilitation and should be part of general practitioners (GP) consultations. For tailoring GP's service it is important to know the PA habits of the clients. METHODS Data from the Austrian Health Interview Survey 2014 with 15,770 subjects were analyzed. The association between PA, measured with the Physical Activity Questionnaire of the European Health Intervies Survey (EHIS-PAQ) and having visited a GP within the last 4 weeks was examined in different age groups (15-29, 30-64, and 65+ years). In multivariate analyses we adjusted for sociodemographic and health-related variables (body mass index, 17 chronic diseases, and the use of medication). RESULTS In subjects aged 15-29 years and 30-64 years fulfilling aerobic PA recommendations was significantly associated with a lower chance of having consulted the GP with unadjusted OR (95% CI) 0.82 (0.70-0.96) and 0.90 (0.82-0.99), respectively, whereas work-related PA was associated with a higher chance, with OR 1.21 (1.03-1.42) and 1.10 (1.00-1.20), respectively. Adjusting for sociodemographic and health-related factors led to loss of significance. In subjects aged 30-64 years, muscle strengthening PA was associated with a higher chance for GP consultation with OR 1.12 (1.00-1.24) in the fully adjusted model. In subjects aged 65+ years, PA was associated with a lower chance of having visited the GP with OR 0.74 (0.64-0.86) and 0.83 (0.71-0.97) for work related PA and total PA, respectively, in the fully adjusted model. CONCLUSION The association of PA and GP consultation is dependent on age and type of PA, and partly mediated by sociodemographic and health-related factors.
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Affiliation(s)
- Thomas E Dorner
- Department of Social and Preventive Medicine, Centre for Public Health, Medical University of Vienna, Kinderspitalgasse 15/1, 1090, Vienna, Austria.
| | - Julia Wilfinger
- Department for Health Promotion and Prevention, SPORTUNION Austria, Falkestraße 1, 1010, Vienna, Austria
| | - Kathryn Hoffman
- Department of General Practice and Family Medicine, Centre for Public Health, Medical University of Vienna, Kinderspitalgasse 15/I, 1090, Vienna, Austria
| | - Christian Lackinger
- Department of Social and Preventive Medicine, Centre for Public Health, Medical University of Vienna, Kinderspitalgasse 15/1, 1090, Vienna, Austria.,Department for Health Promotion and Prevention, SPORTUNION Austria, Falkestraße 1, 1010, Vienna, Austria
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16
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Woodell TB, Rifkin DE. Still Asking "Which Rate Is Right?" Years Later. Clin J Am Soc Nephrol 2018; 13:1783-1784. [PMID: 30498001 PMCID: PMC6302325 DOI: 10.2215/cjn.12371018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Affiliation(s)
- Tyler B. Woodell
- Division of Nephrology, Department of Medicine, University of California, San Diego, California; and
| | - Dena E. Rifkin
- Division of Nephrology, Department of Medicine, University of California, San Diego, California; and
- Veterans’ Administration Healthcare System, San Diego, California
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