1
|
Awan AA, Zhao B, Anumudu SJ, Winkelmayer WC, Ho V, Erickson KF. Pre-ESKD Nephrology Care and Employment at the Start of Dialysis. Kidney Int Rep 2020; 5:821-830. [PMID: 32518864 PMCID: PMC7270719 DOI: 10.1016/j.ekir.2020.03.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Revised: 02/12/2020] [Accepted: 03/02/2020] [Indexed: 01/05/2023] Open
Abstract
Introduction Employment is associated with an improved sense of well-being and quality of life in patients with kidney disease. Earlier nephrology referral and longer duration of pre-end-stage kidney disease (ESKD) nephrology care are associated with improved health outcomes in patients with advanced kidney disease who initiate dialysis. It is unknown if pre-ESKD nephrology care helps patients stay employed leading up to dialysis initiation. Methods We used the US ESKD registry to identify adults aged 18-54 years who initiated dialysis between 2007 and 2014. Analyses were restricted to patients who reported being employed 6 months prior to ESKD. We used multivariable regression models with estimated average marginal effects to examine the independent association between ≥6 months of pre-ESKD nephrology care and employment at dialysis initiation. To reduce bias, we conducted an instrumental variable (IV) analysis based on geographic variation in pre-ESKD care. Results Of 75,700 patients included in study cohort, 49% reported receiving pre-ESKD nephrology care for ≥6 months, and 62% were employed at dialysis initiation. Although geographic variation in pre-ESKD nephrology care was strongly associated with the likelihood that working-aged patients in our analytic cohort received pre-ESKD care, the receipt of pre-ESKD nephrology care was not significantly associated with employment at dialysis initiation; estimated probability: 5%; 95% confidence interval (CI) -6% to 14%. Conclusions Pre-ESKD nephrology care 6 months prior to initiation of dialysis is not associated with the likelihood of remaining employed at the initiation of dialysis. Although nephrology care has potential to help patients remain employed, this benefit is not manifested in current practice.
Collapse
Affiliation(s)
- Ahmed A. Awan
- Selzman Institute for Kidney Health and Section of Nephrology, Baylor College of Medicine, Houston, Texas, USA
- Correspondence: Ahmed A. Awan, Baylor College of Medicine, 7200 Cambridge Street, Suite 8B, MS: BCM902, Houston, Texas 77030, USA.
| | - Bo Zhao
- Selzman Institute for Kidney Health and Section of Nephrology, Baylor College of Medicine, Houston, Texas, USA
| | - Samaya J. Anumudu
- Selzman Institute for Kidney Health and Section of Nephrology, Baylor College of Medicine, Houston, Texas, USA
| | - Wolfgang C. Winkelmayer
- Selzman Institute for Kidney Health and Section of Nephrology, Baylor College of Medicine, Houston, Texas, USA
| | - Vivian Ho
- Center for Innovations in Quality, Effectiveness, and Safety, Baylor College of Medicine, Houston Texas, USA
- Baker Institute for Public Policy, Rice University, Houston, Texas, USA
| | - Kevin F. Erickson
- Selzman Institute for Kidney Health and Section of Nephrology, Baylor College of Medicine, Houston, Texas, USA
- Center for Innovations in Quality, Effectiveness, and Safety, Baylor College of Medicine, Houston Texas, USA
- Baker Institute for Public Policy, Rice University, Houston, Texas, USA
| |
Collapse
|
2
|
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: 22] [Impact Index Per Article: 5.5] [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.
Collapse
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
| |
Collapse
|
3
|
Liu P, Quinn RR, Karim ME, Bello A, Tam-Tham H, Weaver R, Ronksley PE, Quan H, Strippoli GFM, Manns B, Hemmelgarn BR, Tonelli M, Ravani P. Nephrology consultation and mortality in people with stage 4 chronic kidney disease: a population-based study. CMAJ 2019; 191:E274-E282. [PMID: 30858183 DOI: 10.1503/cmaj.181372] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/15/2019] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Guidelines recommend nephrology referral for people with advanced non-dialysis-dependent chronic kidney disease, based mostly on survival benefits seen in retrospective studies of dialysis patients, which may not be generalizable to the broader population with chronic kidney disease. We aimed to examine the association between outpatient nephrology consultation and survival in adults with stage 4 chronic kidney disease. METHODS We linked population-based laboratory and administrative data from 2002 to 2014 in Alberta, Canada, on adults with stage 4 chronic kidney disease (sustained estimated glomerular filtration rate ≥ 15 to < 30 mL/min/1.73 m2 for > 90 d), who had never had kidney failure and had had no outpatient nephrology encounter in the 2 years preceding study entry. Participants who had never had an outpatient nephrology visit before renal replacement treatment were considered "unexposed." Participants who saw a nephrologist during follow-up were considered "unexposed" before the first outpatient nephrology visit and "exposed" thereafter. The primary outcome was all-cause mortality. RESULTS Of the 14 382 study participants (median follow-up 2.7 yr), 64% were aged ≥ 80 years, 35% saw a nephrologist and 66% died during follow-up. Nephrology consultation was associated with lower mortality (hazard ratio [HR] 0.88, 95% confidence interval [CI] 0.82-0.93). The association was strongest in people < 70 years (HR 0.78, 95% CI, 0.65-0.92), progressively weaker with increasing age, and absent in people ≥ 90 years (HR 1.05, 95% CI 0.88-1.25). INTERPRETATION The survival benefit of nephrology consultation in adults with stage 4 chronic kidney disease may be smaller than expected and appears to attenuate with increasing age. These findings should inform recommendations for nephrology referral considering the advanced age of the patient population meeting current referral criteria.
Collapse
Affiliation(s)
- Ping Liu
- Departments of Medicine and Community Health Sciences (Liu, Quinn, Tam-Tham, Weaver, Ronksley, Quan, Manns, Hemmelgarn, Tonelli, Ravani), University of Calgary, Calgary, Alta.; School of Population and Public Health (Karim), The University of British Columbia; Department of Medicine (Bello), University of Alberta, Edmonton, Alta.; Department of Emergency and Organ Transplantation (Strippoli), University of Bari, Bari, Italy
| | - Robert R Quinn
- Departments of Medicine and Community Health Sciences (Liu, Quinn, Tam-Tham, Weaver, Ronksley, Quan, Manns, Hemmelgarn, Tonelli, Ravani), University of Calgary, Calgary, Alta.; School of Population and Public Health (Karim), The University of British Columbia; Department of Medicine (Bello), University of Alberta, Edmonton, Alta.; Department of Emergency and Organ Transplantation (Strippoli), University of Bari, Bari, Italy
| | - Mohammad Ehsanul Karim
- Departments of Medicine and Community Health Sciences (Liu, Quinn, Tam-Tham, Weaver, Ronksley, Quan, Manns, Hemmelgarn, Tonelli, Ravani), University of Calgary, Calgary, Alta.; School of Population and Public Health (Karim), The University of British Columbia; Department of Medicine (Bello), University of Alberta, Edmonton, Alta.; Department of Emergency and Organ Transplantation (Strippoli), University of Bari, Bari, Italy
| | - Aminu Bello
- Departments of Medicine and Community Health Sciences (Liu, Quinn, Tam-Tham, Weaver, Ronksley, Quan, Manns, Hemmelgarn, Tonelli, Ravani), University of Calgary, Calgary, Alta.; School of Population and Public Health (Karim), The University of British Columbia; Department of Medicine (Bello), University of Alberta, Edmonton, Alta.; Department of Emergency and Organ Transplantation (Strippoli), University of Bari, Bari, Italy
| | - Helen Tam-Tham
- Departments of Medicine and Community Health Sciences (Liu, Quinn, Tam-Tham, Weaver, Ronksley, Quan, Manns, Hemmelgarn, Tonelli, Ravani), University of Calgary, Calgary, Alta.; School of Population and Public Health (Karim), The University of British Columbia; Department of Medicine (Bello), University of Alberta, Edmonton, Alta.; Department of Emergency and Organ Transplantation (Strippoli), University of Bari, Bari, Italy
| | - Robert Weaver
- Departments of Medicine and Community Health Sciences (Liu, Quinn, Tam-Tham, Weaver, Ronksley, Quan, Manns, Hemmelgarn, Tonelli, Ravani), University of Calgary, Calgary, Alta.; School of Population and Public Health (Karim), The University of British Columbia; Department of Medicine (Bello), University of Alberta, Edmonton, Alta.; Department of Emergency and Organ Transplantation (Strippoli), University of Bari, Bari, Italy
| | - Paul E Ronksley
- Departments of Medicine and Community Health Sciences (Liu, Quinn, Tam-Tham, Weaver, Ronksley, Quan, Manns, Hemmelgarn, Tonelli, Ravani), University of Calgary, Calgary, Alta.; School of Population and Public Health (Karim), The University of British Columbia; Department of Medicine (Bello), University of Alberta, Edmonton, Alta.; Department of Emergency and Organ Transplantation (Strippoli), University of Bari, Bari, Italy
| | - Hude Quan
- Departments of Medicine and Community Health Sciences (Liu, Quinn, Tam-Tham, Weaver, Ronksley, Quan, Manns, Hemmelgarn, Tonelli, Ravani), University of Calgary, Calgary, Alta.; School of Population and Public Health (Karim), The University of British Columbia; Department of Medicine (Bello), University of Alberta, Edmonton, Alta.; Department of Emergency and Organ Transplantation (Strippoli), University of Bari, Bari, Italy
| | - Giovanni F M Strippoli
- Departments of Medicine and Community Health Sciences (Liu, Quinn, Tam-Tham, Weaver, Ronksley, Quan, Manns, Hemmelgarn, Tonelli, Ravani), University of Calgary, Calgary, Alta.; School of Population and Public Health (Karim), The University of British Columbia; Department of Medicine (Bello), University of Alberta, Edmonton, Alta.; Department of Emergency and Organ Transplantation (Strippoli), University of Bari, Bari, Italy
| | - Braden Manns
- Departments of Medicine and Community Health Sciences (Liu, Quinn, Tam-Tham, Weaver, Ronksley, Quan, Manns, Hemmelgarn, Tonelli, Ravani), University of Calgary, Calgary, Alta.; School of Population and Public Health (Karim), The University of British Columbia; Department of Medicine (Bello), University of Alberta, Edmonton, Alta.; Department of Emergency and Organ Transplantation (Strippoli), University of Bari, Bari, Italy
| | - Brenda R Hemmelgarn
- Departments of Medicine and Community Health Sciences (Liu, Quinn, Tam-Tham, Weaver, Ronksley, Quan, Manns, Hemmelgarn, Tonelli, Ravani), University of Calgary, Calgary, Alta.; School of Population and Public Health (Karim), The University of British Columbia; Department of Medicine (Bello), University of Alberta, Edmonton, Alta.; Department of Emergency and Organ Transplantation (Strippoli), University of Bari, Bari, Italy
| | - Marcello Tonelli
- Departments of Medicine and Community Health Sciences (Liu, Quinn, Tam-Tham, Weaver, Ronksley, Quan, Manns, Hemmelgarn, Tonelli, Ravani), University of Calgary, Calgary, Alta.; School of Population and Public Health (Karim), The University of British Columbia; Department of Medicine (Bello), University of Alberta, Edmonton, Alta.; Department of Emergency and Organ Transplantation (Strippoli), University of Bari, Bari, Italy
| | - Pietro Ravani
- Departments of Medicine and Community Health Sciences (Liu, Quinn, Tam-Tham, Weaver, Ronksley, Quan, Manns, Hemmelgarn, Tonelli, Ravani), University of Calgary, Calgary, Alta.; School of Population and Public Health (Karim), The University of British Columbia; Department of Medicine (Bello), University of Alberta, Edmonton, Alta.; Department of Emergency and Organ Transplantation (Strippoli), University of Bari, Bari, Italy
| |
Collapse
|