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Bhasin AA, Molnar AO, McArthur E, Nash DM, Busse JW, Cooper R, Heale E, Ip J, Pang J, Blake PG, Garg AX, Kurdyak P, Kim SJ, Sultan H, Walsh M. Mental health and addiction service utilization among people living with chronic kidney disease. Nephrol Dial Transplant 2024; 39:1115-1124. [PMID: 38017620 DOI: 10.1093/ndt/gfad240] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Indexed: 11/30/2023] Open
Abstract
BACKGROUND Mental health problems, particularly anxiety and depression, are common in patients with chronic kidney disease (CKD) and negatively impact quality of life, treatment adherence and mortality. However, the degree to which mental health and addiction services are utilized by those with CKD is unknown. We examined the history of mental health and addiction service use of individuals across levels of kidney function. METHODS We performed a population-based cross-sectional study using linked healthcare databases from Ontario, Canada from 2009 to 2017. We abstracted the prevalence of individuals with mental health and addiction service use within the previous 3 years across levels of kidney function [estimated glomerular filtration rate (eGFR) ≥60, 45 to <60, 30 to <45, 15 to <30, <15 ml/min/1.73 m2 and maintenance dialysis]. We calculated prevalence ratios (PRs) to compare prevalence across kidney function strata, while adjusting for age, sex, year of cohort entry, urban versus rural location, area-level marginalization and Charlson comorbidity index. RESULTS Of 5 956 589 adults, 9% (n = 534 605) had an eGFR <60 ml/min/1.73 m2 or were receiving maintenance dialysis. Fewer individuals with an eGFR <60 ml/min/1.73 m2 had a history of any mental health and addiction service utilization (crude prevalence range 28-31%) compared with individuals with an eGFR ≥60 ml/min/1.73 m2 (35%). Compared with an eGFR ≥60 ml/min/1.73 m2, the lowest prevalence of individuals with any mental health and addiction service utilization was among those with an eGFR of 15 to <30 ml/min/1.73 m2 {adjusted PR 0.86 [95% confidence interval (CI) 0.85 to 0.88]}, an eGFR <15 ml/min/1.73 m2 [adjusted PR 0.81 (95% CI 0.76-0.86)] and those receiving maintenance dialysis [adjusted PR 0.83 (95% CI 0.81-0.84)]. Less use of outpatient services accounted for differences in service utilization. CONCLUSIONS Mental health and addiction service utilization is common but less so in individuals with advanced CKD in Ontario, Canada.
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Affiliation(s)
- Arrti A Bhasin
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | - Amber O Molnar
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
- ICES, Toronto, ON, Canada
- Department of Medicine, McMaster University, Hamilton, ON, Canada
- St. Joseph's Healthcare Hamilton, Hamilton, ON, Canada
| | - Eric McArthur
- ICES, Toronto, ON, Canada
- Lawson Health Research Institute, London, ON, Canada
| | - Danielle M Nash
- ICES, Toronto, ON, Canada
- Lawson Health Research Institute, London, ON, Canada
| | - Jason W Busse
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
- Department of Anesthesia, McMaster University, Hamilton, ON, Canada
| | - Rebecca Cooper
- Ontario Renal Network, Ontario Health, Toronto, ON, Canada
| | - Esti Heale
- Ontario Renal Network, Ontario Health, Toronto, ON, Canada
| | - Jane Ip
- Ontario Renal Network, Ontario Health, Toronto, ON, Canada
| | - Jocelyn Pang
- Ontario Renal Network, Ontario Health, Toronto, ON, Canada
| | - Peter G Blake
- Lawson Health Research Institute, London, ON, Canada
- Ontario Renal Network, Ontario Health, Toronto, ON, Canada
- Department of Medicine, London Health Sciences Centre, London, ON, Canada
| | - Amit X Garg
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
- ICES, Toronto, ON, Canada
- Lawson Health Research Institute, London, ON, Canada
- Ontario Renal Network, Ontario Health, Toronto, ON, Canada
- Department of Medicine, London Health Sciences Centre, London, ON, Canada
| | - Paul Kurdyak
- ICES, Toronto, ON, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
- Department of Psychiatry, University of Toronto, Toronto, ON, Canada
- Centre for Addiction and Mental Health, Toronto, ON, Canada
| | - S Joseph Kim
- ICES, Toronto, ON, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
- Department of Medicine, University Health Network, Toronto, ON, Canada
| | - Heebah Sultan
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Michael Walsh
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
- Department of Medicine, McMaster University, Hamilton, ON, Canada
- St. Joseph's Healthcare Hamilton, Hamilton, ON, Canada
- Ontario Renal Network, Ontario Health, Toronto, ON, Canada
- Population Health Research Institute, Hamilton, ON, Canada
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Hall RK, Rutledge J, Lucas A, Liu CK, Clair Russell JS, Peter WS, Fish LJ, Colón-Emeric C. Stakeholder Perspectives on Factors Related to Deprescribing Potentially Inappropriate Medications in Older Adults Receiving Dialysis. Clin J Am Soc Nephrol 2023; 18:1310-1320. [PMID: 37499693 PMCID: PMC10578639 DOI: 10.2215/cjn.0000000000000229] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Accepted: 07/21/2023] [Indexed: 07/29/2023]
Abstract
BACKGROUND Potentially inappropriate medications, or medications that generally carry more risk of harm than benefit in older adults, are commonly prescribed to older adults receiving dialysis. Deprescribing, a systematic approach to reducing or stopping a medication, is a potential solution to limit potentially inappropriate medications use. Our objective was to identify clinicians and patient perspectives on factors related to deprescribing to inform design of a deprescribing program for dialysis clinics. METHODS We conducted rapid qualitative analysis of semistructured interviews and focus groups with clinicians (dialysis clinicians, primary care providers, and pharmacists) and patients (adults receiving hemodialysis aged 65 years or older and those aged 55-64 years who were prefrail or frail) from March 2019 to December 2020. RESULTS We interviewed 76 participants (53 clinicians [eight focus groups and 11 interviews] and 23 patients). Among clinicians, 24 worked in dialysis clinics, 18 worked in primary care, and 11 were pharmacists. Among patients, 13 (56%) were aged 65 years or older, 14 (61%) were Black race, and 16 (70%) reported taking at least one potentially inappropriate medication. We identified four themes (and corresponding subthemes) of contextual factors related to deprescribing potentially inappropriate medications: ( 1 ) system-level barriers to deprescribing (limited electronic medical record interoperability, time constraints and competing priorities), ( 2 ) undefined comanagement among clinicians (unclear role delineation, clinician caution about prescriber boundaries), ( 3 ) limited knowledge about potentially inappropriate medications (knowledge limitations among clinicians and patients), and ( 4 ) patients prioritize symptom control over potential harm (clinicians expect resistance to deprescribing, patient weigh risks and benefits). CONCLUSIONS Challenges to integration of deprescribing into dialysis clinics included siloed health systems, time constraints, comanagement behaviors, and clinician and patient knowledge and attitudes toward deprescribing.
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Affiliation(s)
- Rasheeda K. Hall
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina
- Medicine Service, Durham Veterans Affairs Medical Center, Durham, North Carolina
| | - Jeanette Rutledge
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina
| | - Anika Lucas
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina
- Medicine Service, Durham Veterans Affairs Medical Center, Durham, North Carolina
| | - Christine K. Liu
- Section of Geriatric Medicine, Stanford University School of Medicine, Stanford, California
- Geriatric Research Education and Clinical Center, Palo Alto VA Health Care System, Palo Alto, California
| | - Jennifer St. Clair Russell
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina
- Dimensions of Care, LLC, Rockville, Maryland
| | - Wendy St. Peter
- Department of Pharmaceutical Care and Health Systems, University of Minnesota College of Pharmacy, Minneapolis, Minnesota
| | - Laura J. Fish
- Department of Family Medicine and Community Health, Duke University School of Medicine, Durham, North Carolina
- Duke Cancer Institute, Duke University School of Medicine, Durham, North Carolina
| | - Cathleen Colón-Emeric
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina
- Medicine Service, Durham Veterans Affairs Medical Center, Durham, North Carolina
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Beaubien-Souligny W, Leclerc S, Verdin N, Ramzanali R, Fox DE. Bridging Gaps in Diabetic Nephropathy Care: A Narrative Review Guided by the Lived Experiences of Patient Partners. Can J Kidney Health Dis 2022; 9:20543581221127940. [PMID: 36246342 PMCID: PMC9558862 DOI: 10.1177/20543581221127940] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2022] [Accepted: 08/08/2022] [Indexed: 11/24/2022] Open
Abstract
PURPOSE OF REVIEW Diabetes affects almost a 10th of the Canadian population, and diabetic nephropathy is one of its main complications. It remains a leading cause of kidney failure despite the availability of effective treatments. SOURCES OF INFORMATION The sources of information are iterative discussions between health care professionals and patient partners and literature collected through the search of multiple databases. METHODS Major pitfalls related to optimal diabetic nephropathy care were identified through discussions between patient partners and clinician researchers. We identified underlying factors that were common between pitfalls. We then conducted a narrative review of strategies to overcome them, with a focus on Canadian initiatives. KEY FINDINGS We identified 5 pitfalls along the diabetic nephropathy trajectory, including a delay in diabetes diagnosis, suboptimal glycemic control, delay in the detection of kidney involvement, suboptimal kidney protection, and deficient management of advanced chronic kidney disease. Several innovative care models and approaches have been proposed to address these pitfalls; however, they are not consistently applied. To improve diabetic nephropathy care in Canada, we recommend focusing initiatives on improving awareness of diabetic nephropathy, improving access to timely evidence-based care, fostering inclusive patient-centered care environment, and generating new evidence that supports complex disease management. It is imperative that patients and their families are included at the center of these initiatives. LIMITATIONS This review was limited to research published in peer-reviewed journals. We did not perform a systematic review of the literature; we included articles that were relevant to the major pitfalls identified by our patient partners. Study quality was also not formally assessed. The combination of these factors limits the scope of our conclusions.
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Affiliation(s)
- William Beaubien-Souligny
- Division of Nephrology, Centre
Hospitalier de l’Université de Montréal, QC, Canada,Department of Medicine, University of
Montreal, QC, Canada
| | - Simon Leclerc
- Division of Nephrology, Department of
Medicine, The Research Institute of the McGill University Health Centre, Montreal,
QC, Canada,Division of Nephrology, Hôpital
Maisonneuve-Rosemont, Montreal, QC, Canada
| | - Nancy Verdin
- The Kidney Foundation of Canada,
London, ON, Canada
| | - Rizwana Ramzanali
- Patient and Community Engagement
Research Program, University of Calgary, AB, Canada
| | - Danielle E. Fox
- Department of Community Health
Sciences, University of Calgary, AB, Canada,Danielle E. Fox, Department of Community
Health Sciences, University of Calgary, TRW 3D44A, 3280 Hospital Drive
Northwest, Calgary, AB T2N 4Z6, Canada.
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4
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Walsh RL, Lofters A, Moineddin R, Krzyzanowska M, Grunfeld E. Primary Care Continuity and Wait Times to Receiving Breast Cancer Chemotherapy: A Population-Based Retrospective Cohort Study Using CanIMPACT Data. Curr Oncol 2021; 28:4786-4804. [PMID: 34898582 PMCID: PMC8628668 DOI: 10.3390/curroncol28060405] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Revised: 11/02/2021] [Accepted: 11/07/2021] [Indexed: 12/18/2022] Open
Abstract
(1) Background: Wait times to chemotherapy are associated with morbidity and mortality in breast cancer patients; however, it is unclear how primary care physician (PCP) continuity impacts these wait times, or whether this association is different in immigrants, who experience cancer care inequities. We assessed the association between PCP continuity and the contact-to-chemotherapy interval (wait time from when a patient first presents to healthcare to the first day of receiving breast cancer chemotherapy), with a specific look at the immigrant population. (2) Methods: Population-based, retrospective cohort study of women who were diagnosed with stage I–III breast cancer in Ontario who received surgery and adjuvant chemotherapy. We used quantile regression at the median and 90th percentile to quantify the effect of PCP continuity on the contact-to-chemotherapy interval, performing a separate analysis on the immigrant population. (3) Results: Among 12,781 breast cancer patients, including 1706 immigrants, the median contact-to-chemotherapy interval (126 days) was 3.21 days shorter (95% confidence interval (CI) 0.47–5.96) in symptom-detected patients with low PCP continuity, 10.68 days shorter (95% CI 5.36–16.00) in symptom-detected patients with no baseline PCP visits and 17.43 days longer (95% CI 0.90–34.76) in screen-detected immigrants with low PCP continuity compared to the same groups with high PCP continuity. (4) Conclusions: Higher PCP continuity was not associated with a change in the contact-to-chemotherapy interval for most of our study population, but was associated with a marginally longer interval in our symptom-detected population and a shorter contact-to-chemotherapy interval in screen-detected immigrants. This highlights the importance of PCP continuity among immigrants with positive screening results. Additionally, having no PCP visits at baseline was associated with a shorter contact-to-chemotherapy interval in symptom-detected patients.
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Affiliation(s)
- Rachel Lin Walsh
- Department of Family & Community Medicine, Sunnybrook Health Sciences Centre, Toronto, ON M4N 3M5, Canada
- Department of Family & Community Medicine, University of Toronto, Toronto, ON M5G 1V7, Canada; (A.L.); (R.M.); (E.G.)
- Correspondence:
| | - Aisha Lofters
- Department of Family & Community Medicine, University of Toronto, Toronto, ON M5G 1V7, Canada; (A.L.); (R.M.); (E.G.)
- Department of Family & Community Medicine, Women’s College Hospital, Toronto, ON M5S 1B2, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON M5T 3M7, Canada
- Institute for Clinical Evaluative Sciences (ICES), Toronto, ON M4N 3M5, Canada
| | - Rahim Moineddin
- Department of Family & Community Medicine, University of Toronto, Toronto, ON M5G 1V7, Canada; (A.L.); (R.M.); (E.G.)
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON M5T 3M7, Canada
- Institute for Clinical Evaluative Sciences (ICES), Toronto, ON M4N 3M5, Canada
| | - Monika Krzyzanowska
- Princess Margaret Cancer Centre, Department of Medical Oncology & Hematology, University Health Network, Toronto, ON M5G 2C1, Canada;
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON M5T 3M6, Canada
| | - Eva Grunfeld
- Department of Family & Community Medicine, University of Toronto, Toronto, ON M5G 1V7, Canada; (A.L.); (R.M.); (E.G.)
- Ontario Institute for Cancer Research, Toronto, ON M5G 0A3, Canada
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5
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House TR, Wightman A, Rosenberg AR, Sayre G, Abdel-Kader K, Wong SPY. Challenges to Shared Decision Making About Treatment of Advanced CKD: A Qualitative Study of Patients and Clinicians. Am J Kidney Dis 2021; 79:657-666.e1. [PMID: 34673161 PMCID: PMC9016096 DOI: 10.1053/j.ajkd.2021.08.021] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Accepted: 08/25/2021] [Indexed: 11/11/2022]
Abstract
RATIONALE AND OBJECTIVE Greater understanding of the challenges to shared decision-making about treatment of advanced CKD is needed to support implementation of shared decision-making in clinical practice. STUDY DESIGN Qualitative study. SETTING AND PARTICIPANTS Patients aged ≥65 years with advanced CKD and their clinicians recruited from 3 medical centers participated in semi-structured interviews. In-depth review of patients' electronic medical records was also performed. ANALYTICAL APPROACH Interview transcripts and medical record notes were analyzed using inductive thematic analysis. RESULTS Twenty-nine patients (age 73±6 years, 66% male, 59% Caucasian) and 10 of their clinicians (age 52±12 years, 30% male, 70% Caucasian) participated in interviews. Four themes emerged from qualitative analysis: 1) Competing priorities - patients and their clinicians tended to differ on when to prioritize CKD and dialysis planning above other personal or medical problems; 2) Focusing on present or future -patients were more focused on living well now while clinicians were more focused on preparing for dialysis and future adverse events; 3) Standardized versus individualized approach to CKD - although clinicians tried to personalize care recommendations to their patients, patients perceived their clinicians as taking a monolithic approach to CKD that was predicated on clinical practice guidelines and medical literature rather than patients' lived experiences with CKD and personal values and goals; and 4) Power dynamics - while patients described cautiously navigating a power differential in their therapeutic relationship with their clinicians, clinicians seemed less attuned to these power dynamics. LIMITATIONS Thematic saturation was based on patient interviews. Themes presented might incompletely reflect clinicians' perspectives. CONCLUSIONS Efforts to improve shared decision-making for treatment of advanced CKD will likely need to explicitly address differences in approaches to decision-making about treatment of advanced CKD between patients and their clinicians and perceived power imbalances in the therapeutic relationship.
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Affiliation(s)
- Taylor R House
- Pediatric Nephrology Fellow, Department of Pediatrics, University of Washington, Seattle Children's Hospital, 4800 Sandpoint Way NE, O.C. 9.820, Seattle, WA 98105.
| | - Aaron Wightman
- Associate Professor, Department of Pediatrics, University of Washington, Seattle Children's Hospital
| | - Abby R Rosenberg
- Associate Professor, Department of Pediatrics, University of Washington
| | - George Sayre
- Clinical Assistant Professor, Department of Health Services, University of Washington, HSR&D Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System
| | | | - Susan P Y Wong
- Assistant Professor of Medicine, University of Washington, VA Puget Sound Health Care System
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6
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Beers KH, Sperati CJ, Weisman DS, Abdel-Kader K, Soman S, Plantinga L, Choi MJ, Jaar BG, Greer RC. Improving Primary Care Delivery for Patients Receiving Maintenance Hemodialysis. Am J Kidney Dis 2021; 78:886-891. [PMID: 33992728 DOI: 10.1053/j.ajkd.2021.02.340] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Accepted: 02/27/2021] [Indexed: 12/26/2022]
Abstract
The beneficial impact of primary care, focused on all aspects of a patient's health (rather than a disease-specific focus) is well established. Recognized benefits include greater receipt of preventive care and counseling, lower use of emergency care and hospitalization for ambulatory care-sensitive conditions, and decreased early mortality. Although the importance of primary care and care coordination at the primary care/specialty interface is well recognized, the role of primary care within traditional and emerging care models for patients receiving in-center maintenance hemodialysis remains ill-defined. In this perspective article, we will describe: (1) the role of primary care for patients receiving maintenance hemodialysis and the current evidence regarding the receipt of primary care among these patients; (2) the key challenges to delivery of primary care in these complex cases, including suboptimal care coordination between nephrology and primary care providers, the intensity of dialysis care, and the limited capacity of nephrologists and primary care providers to meet the broad health needs of hemodialysis patients; (3) potential strategies for improving the delivery of primary care for patients receiving hemodialysis; and (4) future research requirements to improve primary care delivery for this high-risk population.
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Affiliation(s)
- Kelly H Beers
- Division of Nephrology and Hypertension, Department of Medicine, Albany Medical College, Albany, NY
| | - C John Sperati
- Division of Nephrology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - David S Weisman
- Department of Medicine, MedStar Good Samaritan Hospital, Baltimore, MD
| | - Khaled Abdel-Kader
- Vanderbilt Center for Kidney Disease and Division of Nephrology, Vanderbilt University Medical Center, Nashville, TN
| | - Sandeep Soman
- Division of Nephrology and Hypertension, Henry Ford Hospital, Detroit, MI
| | | | - Michael J Choi
- Division of Nephrology and Hypertension, MedStar Georgetown University Hospital, Washington DC
| | - Bernard G Jaar
- Division of Nephrology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD; Department of Medicine, MedStar Good Samaritan Hospital, Baltimore, MD; Nephrology Center of Maryland, Baltimore, MD; The Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins Medical Institutions, Baltimore, MD.
| | - Raquel C Greer
- Division of General Internal Medicine, Department of Medicine, Johns Hopkins University, Baltimore, MD.
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Sloan CE, Zhong J, Mohottige D, Hall R, Diamantidis CJ, Boulware LE, Wang V. Fragmentation of care as a barrier to optimal ESKD management. Semin Dial 2020; 33:440-448. [PMID: 33128300 DOI: 10.1111/sdi.12929] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2020] [Accepted: 10/04/2020] [Indexed: 12/15/2022]
Abstract
Caring for patients with end-stage kidney disease (ESKD) in the United States is challenging, due in part to the complex epidemiology of the disease's progression as well as the ways in which care is delivered. As CKD progresses toward ESKD, the number of comorbidities increases and care involves multiple healthcare providers from multiple subspecialties. This occurs in the context of a fragmented US healthcare delivery system that is traditionally siloed by provider specialty, organization, as well as systems of payment and administration. This article describes the role of care fragmentation in the delivery of optimal ESKD care and identifies research gaps in the evidence across the continuum of care. We then consider the impact of care fragmentation on ESKD care from the patient and health system perspectives and explore opportunities for system-level interventions aimed at improving care for patients with ESKD.
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Affiliation(s)
- Caroline E Sloan
- Durham Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, NC, USA.,Department of Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Judy Zhong
- Duke University Trinity College of Arts & Sciences, Durham, NC, USA
| | | | - Rasheeda Hall
- Department of Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Clarissa J Diamantidis
- Department of Medicine, Duke University School of Medicine, Durham, NC, USA.,Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA
| | - Leight E Boulware
- Department of Medicine, Duke University School of Medicine, Durham, NC, USA.,Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA
| | - Virginia Wang
- Durham Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, NC, USA.,Department of Medicine, Duke University School of Medicine, Durham, NC, USA.,Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA
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8
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Klomjit N, Leung N, Fervenza F, Sethi S, Zand L. Rate and Predictors of Finding Monoclonal Gammopathy of Renal Significance (MGRS) Lesions on Kidney Biopsy in Patients with Monoclonal Gammopathy. J Am Soc Nephrol 2020; 31:2400-2411. [PMID: 32747354 DOI: 10.1681/asn.2020010054] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2020] [Accepted: 07/04/2020] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Little is known about the rate and predictors of finding lesions of monoclonal gammopathy (MG) of renal significance (MGRS) on kidney biopsy specimens among patients with MG. METHODS We reviewed the medical records from 2013 to 2018 at the Mayo Clinic in Rochester, Minnesota, to identify patients with MG and whether they had undergone a kidney biopsy. In a more select group of patients with MG from 2017 to 2018, we conducted a review of records to determine how many had underlying CKD, which of those with CKD had undergone a kidney biopsy, and reasons for deferring a kidney biopsy. RESULTS Between 2013 and 2018, we identified 6300 patients who had MG, 160 (2.5%) of whom had undergone a kidney biopsy. Of the 160 patients, 64 (40%) had an MGRS lesion; amyloid light chain amyloidosis, the most common finding, accounted for nearly half of these lesions. In the non-MGRS group comprising 96 patients, 23 had arteriosclerosis, the most common finding. In multivariate analysis, strong predictors of finding an MGRS lesion included the presence of an elevated free light chain ratio, proteinuria, and hematuria. Among 596 patients with CKD and MG from 2017 to 2018, 62 (10.4%) underwent a kidney biopsy. Kidney biopsy was deferred for 70 patients (20%); for 62 of the 70, the diagnosis was already known, and eight were not candidates for therapy. Younger age and higher proteinuria and serum creatinine levels increased the likelihood that the patient would undergo a kidney biopsy. CONCLUSIONS Proteinuria ≥1.5 g/d, hematuria, and an elevated free light chain ratio increase the likelihood of finding MGRS, and a kidney biopsy should be highly considered in such patients.
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Affiliation(s)
- Nattawat Klomjit
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota
| | - Nelson Leung
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota.,Division of Hematology, Mayo Clinic, Rochester, Minnesota
| | - Fernando Fervenza
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota
| | - Sanjeev Sethi
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota
| | - Ladan Zand
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota
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9
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Ahmed S, Mendu ML. The Value of Primary Care Provider Involvement in the Care of Kidney Failure Patients on Dialysis. Clin J Am Soc Nephrol 2020; 15:450-452. [PMID: 32149723 PMCID: PMC7133141 DOI: 10.2215/cjn.01370220] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Affiliation(s)
- Salman Ahmed
- Renal Division, Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts; and
| | - Mallika L. Mendu
- Renal Division, Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts; and
- Department of Quality and Safety, Brigham and Women’s Hospital, Boston, Massachusetts
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