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Johansen KL, Gilbertson DT, Li S, Li S, Liu J, Roetker NS, Ku E, Schulman IH, Greer RC, Chan K, Abbott KC, Butler CR, O'Hare AM, Powe NR, Reddy YNV, Snyder J, St Peter W, Taylor JS, Weinhandl ED, Wetmore JB. US Renal Data System 2023 Annual Data Report: Epidemiology of Kidney Disease in the United States. Am J Kidney Dis 2024; 83:A8-A13. [PMID: 38519262 DOI: 10.1053/j.ajkd.2024.01.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/24/2024]
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2
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Rope R, Ryan E, Weinhandl ED, Abra GE. Home-Based Dialysis: A Primer for the Internist. Annu Rev Med 2024; 75:205-217. [PMID: 38039393 DOI: 10.1146/annurev-med-050922-051415] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2023]
Abstract
Home-based dialysis modalities offer both clinical and practical advantages to patients. The use of the home-based modalities, peritoneal dialysis and home hemodialysis, has been increasing over the past decade after a long period of decline. Given the increasing frequency of use of these types of dialysis, it is important for clinicians to be familiar with how these types of dialysis are performed and key clinical aspects of care related to their use in patients with end-stage kidney disease.
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Affiliation(s)
- Robert Rope
- Division of Nephrology and Hypertension, Oregon Health & Science University, Portland, Oregon, USA;
| | - Eric Ryan
- Division of Nephrology and Hypertension, Oregon Health & Science University, Portland, Oregon, USA;
| | - Eric D Weinhandl
- DaVita Clinical Research, Minneapolis, Minnesota, USA
- Department of Pharmaceutical Care and Health Systems, University of Minnesota, Minneapolis, Minnesota, USA
| | - Graham E Abra
- Division of Nephrology, Department of Medicine, Stanford University, Stanford, California, USA;
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Weinhandl ED. Kidney Failure in the Court of Chronic Diseases. Am J Kidney Dis 2024; 83:6-8. [PMID: 37952143 DOI: 10.1053/j.ajkd.2023.08.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Revised: 08/23/2023] [Accepted: 08/26/2023] [Indexed: 11/14/2023]
Affiliation(s)
- Eric D Weinhandl
- Satellite Healthcare, San Jose, California; and Department of Pharmaceutical Care and Health Systems, University of Minnesota, Minneapolis, Minnesota.
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Weinhandl ED, Eggert W, Hwang Y, Gilbertson DT, Petersen J. Contemporary Practice of Anemia Treatment Among Dialysis Patients in the United States. Kidney Int Rep 2023; 8:2616-2624. [PMID: 38106574 PMCID: PMC10719594 DOI: 10.1016/j.ekir.2023.09.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Revised: 08/28/2023] [Accepted: 09/04/2023] [Indexed: 12/19/2023] Open
Abstract
Introduction The treatment of anemia is a major activity in the care of patients undergoing maintenance hemodialysis (HD). The comparative effectiveness of new pharmacologic treatments, relative to erythropoiesis-stimulating agents (ESAs), should be anticipated on the bases of controlled trials and current practice. We describe the contemporary practice of anemia treatment in a national cohort of patients undergoing maintenance HD. Methods We analyzed the United States Renal Data System (USRDS) data to identify adult patients undergoing in-facility HD in 2016 to 2019. Using the Consolidated Renal Operations in a Web-Enabled Network (CROWNWeb) dataset, we identified hemoglobin and ESA utilization (agent and cumulative dose) during each patient-month, as well as intravenous (IV) iron utilization, ferritin, and transferrin saturation. We compared ESA dosing during the study era to dosing in the Normal Hematocrit Cardiac Trial (NHCT), conducted in the 1990s. We assessed ESA hyporesponsiveness by estimating the prevalence of the following: (i) high erythropoietin resistance index (ERI) and (ii) either 3 or 6 consecutive months with hemoglobin <10 g/dl. Results Nearly two-thirds of patient-months had hemoglobin of 10.0 to 11.9 g/dl. Mean ESA utilization was 76.7% per month, with increasing use of pegylated epoetin beta. ESA dosing was stable; epoetin alfa dosing was slightly lower than in the low-target arm of the NHCT. The prevalence of ESA hyporesponsiveness was 22.2% if defined by high ERI, but only 2.1% to 6.0% if defined by 3 to 6 consecutive months with hemoglobin <10 g/dl. Median transferrin saturation was 22.3% with high ERI and persistently low hemoglobin. Conclusion Hemoglobin and ESA dosing distributions are stable, with epoetin alfa dosing below the low-target arm of the NHCT. Persistently low hemoglobin occurs infrequently and may reflect iron depletion.
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Affiliation(s)
- Eric D. Weinhandl
- Department of Pharmaceutical Care and Health Systems, University of Minnesota, Minneapolis, Minnesota, USA
- Chronic Disease Research Group, Hennepin Healthcare Research Institute, Minneapolis, Minnesota, USA
| | - William Eggert
- Chronic Disease Research Group, Hennepin Healthcare Research Institute, Minneapolis, Minnesota, USA
| | | | - David T. Gilbertson
- Chronic Disease Research Group, Hennepin Healthcare Research Institute, Minneapolis, Minnesota, USA
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Knapp CD, Li S, Kou C, Gilbertson DT, Weinhandl ED, Wetmore JB, Hart A, Johansen KL. Increased Access, Persistent Disparities: Trends in Disparities in Peritoneal Dialysis (PD) Use, 2009-2019. Clin J Am Soc Nephrol 2023; 18:1483-1489. [PMID: 37499680 PMCID: PMC10637445 DOI: 10.2215/cjn.0000000000000222] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Accepted: 07/21/2023] [Indexed: 07/29/2023]
Abstract
Peritoneal dialysis (PD) use has increased in the United States since 2009, but how this has affected disparities in PD use is unclear. We used data from the United States Renal Data System to identify a cohort of incident dialysis patients from 2009 to 2019. We used logistic regression models to examine how odds of PD use changed by demographic characteristics. The incident PD population increased by 203% from 2009 to 2019, and the odds of PD use increased in every subgroup. PD use increased more among older people because the odds for those aged 75 years or older increased 15% more per 5-year period compared with individuals aged 18-44 years (odds ratio [OR] 1.68, 95% confidence interval [CI], 1.64 to 1.73 versus OR 1.46, 95% CI, 1.42 to 1.50). The odds of PD use increased 5% more per 5-year period among Hispanic people compared with White people (OR 1.58, 95% CI, 1.53 to 1.63 versus OR 1.51, 95% CI, 1.48 to 1.53). There was no difference in odds of PD initiation among people who were Black, Asian, or of another race. The odds of PD use increased 5% more for people living in urban areas compared with people living in nonurban areas (5-year OR 1.54, 95% CI, 1.52 to 1.56 versus 5-year OR 1.46, 95% CI, 1.42 to 1.50). The odds of PD use increased 7% more for people living in socioeconomically advantaged areas compared with people living in more deprived areas (5-year OR 1.60, 95% CI, 1.56 to 1.63 for neighborhoods with lowest Social Deprivation Index versus 5-year OR 1.50, 95% CI, 1.48 to 1.53 in the most deprived areas). Expansion of PD use led to a reduction in disparities for older people and for Hispanic people. Although PD use increased across all strata of socioeconomic deprivation, the gap in PD use between people living in the least deprived areas and those living in the most deprived areas widened.
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Affiliation(s)
- Christopher D. Knapp
- Chronic Disease Research Group, Hennepin Healthcare Research Institute, Minneapolis, Minnesota
| | - Shuling Li
- Chronic Disease Research Group, Hennepin Healthcare Research Institute, Minneapolis, Minnesota
| | - Chuanyu Kou
- Chronic Disease Research Group, Hennepin Healthcare Research Institute, Minneapolis, Minnesota
| | - David T. Gilbertson
- Chronic Disease Research Group, Hennepin Healthcare Research Institute, Minneapolis, Minnesota
- Department of Medicine, University of Minnesota, Minneapolis, Minnesota
| | - Eric D. Weinhandl
- Chronic Disease Research Group, Hennepin Healthcare Research Institute, Minneapolis, Minnesota
- University of Minnesota School of Pharmacy, Minneapolis, Minnesota
- Satellite Healthcare, San Jose, California
| | - James B. Wetmore
- Chronic Disease Research Group, Hennepin Healthcare Research Institute, Minneapolis, Minnesota
- Department of Medicine, University of Minnesota, Minneapolis, Minnesota
| | - Allyson Hart
- Chronic Disease Research Group, Hennepin Healthcare Research Institute, Minneapolis, Minnesota
- Department of Medicine, University of Minnesota, Minneapolis, Minnesota
| | - Kirsten L. Johansen
- Chronic Disease Research Group, Hennepin Healthcare Research Institute, Minneapolis, Minnesota
- Department of Medicine, University of Minnesota, Minneapolis, Minnesota
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Abra GE, Weinhandl ED, Hussein WF. Setting Up Home Dialysis Programs: Now and in the Future. Clin J Am Soc Nephrol 2023; 18:1490-1496. [PMID: 37603364 PMCID: PMC10637466 DOI: 10.2215/cjn.0000000000000284] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Accepted: 08/09/2023] [Indexed: 08/22/2023]
Abstract
Home dialysis utilization has been growing in the United States over the past decade but still lags behind similar socioeconomic nations. More than half of dialysis facilities in the United States either are not licensed to offer home dialysis or, despite a license, have no patients dialyzing at home, and many programs have a relatively small census. Multiple stakeholders, including patients, health care providers, and payers, have identified increased home dialysis use as an important goal. To realize these goals, nephrologists and kidney care professionals need a sound understanding of the key considerations in home dialysis center operation. In this review, we outline the core domains required to set up and operate a home dialysis program in the United States now and in the future.
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Affiliation(s)
- Graham E. Abra
- Satellite Healthcare, San Jose, California
- Division of Nephrology, Stanford University, Palo Alto, California
| | - Eric D. Weinhandl
- Satellite Healthcare, San Jose, California
- Department of Pharmaceutical Care and Health Systems, University of Minnesota, Minneapolis, Minnesota
| | - Wael F. Hussein
- Satellite Healthcare, San Jose, California
- Division of Nephrology, Stanford University, Palo Alto, California
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Meyer M, Wetmore JB, Weinhandl ED, Roetker NS. Association of Nondihydropyridine Calcium Channel Blockers Versus β-Adrenergic Receptor Blockers With Risk of Heart Failure Hospitalization. Am J Cardiol 2023; 197:68-74. [PMID: 37150720 DOI: 10.1016/j.amjcard.2023.04.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Revised: 03/13/2023] [Accepted: 04/10/2023] [Indexed: 05/09/2023]
Abstract
Heart failure (HF) with preserved ejection fraction (HFpEF) and atrial fibrillation (AF) are interrelated and often coexisting conditions in older adults. Although equally recommended, nondihydropyridine calcium channel blockers (non-DHP CCBs), such as diltiazem and verapamil, are less often used than β blockers. Because recent studies suggested that β-blocker use in both HFpEF and AF may increase the risk for HF, we tested whether non-DHP CCBs were associated with lower HF hospitalization risk than β blockers. We examined fee-for-service Medicare beneficiaries who were aged ≥66 years, had HFpEF or AF, and newly initiated a β blocker (n = 83,458) or non-DHP CCB (n = 18,924) from 2014 to 2018. The outcomes of HF hospitalization and all-cause mortality were analyzed using multivariable-adjusted Cox regression in the full cohort and, separately, in the subset without a recent hospital or skilled nursing discharge. Follow-up was analyzed using 2 frameworks: intention-to-treat and censored-at-drug-switch-or-discontinuation. There was a modestly protective association of non-DHP CCBs for the risk of HF hospitalization. Before drug switch or discontinuation, the use of diltiazem or verapamil was associated with decreased risk of HF hospitalization in the full cohort (hazard ratio [HR] 0.90, 95% confidence interval [CI] 0.81 to 1.00, p = 0.05) and in the subgroup (HR 0.70, 95% CI 0.56 to 0.89, p = 0.003). However, the association with all-cause mortality tended to favor β blockers, including in the intention-to-treat analysis (HR 1.21, 95% CI 1.17 to 1.25, p <0.001). In conclusion, compared with β blockers, the initiation of diltiazem or verapamil in patients with HFpEF or AF may be associated with fewer HF hospitalization events but also with more all-cause deaths.
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Affiliation(s)
- Markus Meyer
- Lillehei Heart Institute, Department of Medicine, University of Minnesota College of Medicine, Minneapolis, Minnesota
| | - James B Wetmore
- Chronic Disease Research Group, Hennepin Healthcare Research Institute, Hennepin Healthcare, Minneapolis, Minnesota; Division of Nephrology, Hennepin County Medical Center and dDepartment of Medicine, University of Minnesota, Minneapolis, Minnesota; Satellite Healthcare, San Jose, California
| | - Eric D Weinhandl
- Satellite Healthcare, San Jose, California; Department of Pharmaceutical Care and Health Systems, University of Minnesota, Minneapolis, Minnesota
| | - Nicholas S Roetker
- Chronic Disease Research Group, Hennepin Healthcare Research Institute, Hennepin Healthcare, Minneapolis, Minnesota.
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Maliha G, Weinhandl ED, Reddy YNV. Deprescribing the Kt/V Target for Peritoneal Dialysis in the United States: The Path Toward Adopting International Standards for Dialysis Adequacy. J Am Soc Nephrol 2023; 34:751-754. [PMID: 36787755 PMCID: PMC10125636 DOI: 10.1681/asn.0000000000000101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Accepted: 01/31/2023] [Indexed: 02/16/2023] Open
Affiliation(s)
- George Maliha
- Department of Internal Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Eric D. Weinhandl
- Satellite Healthcare, San Jose, California
- Department of Pharmaceutical Care and Health Systems, University of Minnesota, Minneapolis, Minnesota
| | - Yuvaram N. V. Reddy
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania
- Renal-Electrolyte and Hypertension Division, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
- Center for Health Equity Research and Promotion, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania
- ASN Quality Committee, American Society of Nephrology, Washington, District of Columbia
- ASN Home Dialysis Steering Committee, American Society of Nephrology, Washington, District of Columbia
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Naljayan MV, Schiller B, Watnick S, Weinhandl ED, Perl J. How the COVID-19 Pandemic Hit Home in North America: Lessons Learned in Improving Home Dialysis Utilization and Outcomes. Clin J Am Soc Nephrol 2023; 18:01277230-990000000-00085. [PMID: 36758152 PMCID: PMC10356155 DOI: 10.2215/cjn.0000000000000117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Accepted: 01/30/2023] [Indexed: 02/11/2023]
Affiliation(s)
- Mihran V. Naljayan
- Section of Nephrology and Hypertension, Louisiana State University School of Medicine, New Orleans, Louisiana
- DaVita Kidney Care, Denver, Colorado
| | - Brigitte Schiller
- Satellite Healthcare, San Jose, California
- Department of Medicine, Division of Nephrology, Stanford University School of Medicine, Palo Alto, California
| | - Suzanne Watnick
- Northwest Kidney Centers, Seattle, Washington
- Department of Medicine, University of Washington, Seattle, Washington
| | - Eric D. Weinhandl
- Satellite Healthcare, San Jose, California
- Department of Pharmaceutical Care and Health Systems, University of Minnesota, Minneapolis, Minnesota
| | - Jeffrey Perl
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
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Johansen KL, Li S, Liu J, Weinhandl ED, Gilbertson DT, Kou I, Knapp C, Wetmore JB. Association of the End-Stage Renal Disease Treatment Choices Payment Model With Home Dialysis Use at Kidney Failure Onset From 2016 to 2022. JAMA Netw Open 2023; 6:e230806. [PMID: 36848086 PMCID: PMC9972188 DOI: 10.1001/jamanetworkopen.2023.0806] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/01/2023] Open
Abstract
IMPORTANCE The Centers for Medicare & Medicaid Services designed a mandatory payment model to incentivize home dialysis use: the End-Stage Renal Disease Treatment Choices (ETC). Outpatient dialysis facilities and health care professionals providing nephrology services were randomly assigned to ETC participation at the hospital referral region level. OBJECTIVE To assess the association between ETC and home dialysis use in the incident dialysis population in its first 18 months of implementation. DESIGN, SETTING, AND PARTICIPANTS A cohort study with controlled, interrupted time series analysis of the US End-Stage Renal Disease Quality Reporting System database was conducted, using generalized estimating equations. All adults initiating home-based dialysis in the US between January 1, 2016, and June 30, 2022, without a prior kidney transplant were included in the analysis. EXPOSURES Prior to vs after ETC onset in January 1, 2021, and random assignment to ETC participation of facilities and health care professionals involved in patient care. MAIN OUTCOMES AND MEASURES Percentage of patients started on incident home dialysis and yearly change in percentage initiating home dialysis. RESULTS A total of 817 177 adults initiated home dialysis during the study period, of whom 750 314 were included in the study cohort. The cohort included 41.4% women; 26.2% of the patients were Black, 17.4% were Hispanic, and 49.1% were White. Approximately half (49.6%) of the patients were aged at least 65 years. A total of 31.2% received care from health care professionals assigned to ETC participation, and 33.6% had Medicare fee-for-service coverage. Overall, home dialysis use increased from 10.0% in January 2016 to 17.4% in June 2022. Home dialysis use increased more in ETC markets than in non-ETC markets after January 2021 (by 1.07%; 95% CI, 0.16%-1.97%). The rate of increase in home dialysis use in the entire cohort nearly doubled after January 2021 to 1.66% per year (95% CI, 1.14%-2.19%) compared with before 2021, when the rate was 0.86% per year (95% CI, 0.75%-0.97%), but the difference in rate of increase in home dialysis use was not significant between ETC and non-ETC markets. CONCLUSIONS AND RELEVANCE This study noted that, although the overall rate of dialysis use at home was greater after ETC implementation, the increase occurred more among patients in ETC markets than among those in non-ETC markets. These findings suggest that federal policy and financial incentives affected care for the entire incident dialysis population in the US.
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Affiliation(s)
- Kirsten L. Johansen
- Chronic Disease Research Group, Hennepin Healthcare Research Institute, Minneapolis, Minnesota
- Department of Nephrology, University of Minnesota, Minneapolis
| | - Shuling Li
- Chronic Disease Research Group, Hennepin Healthcare Research Institute, Minneapolis, Minnesota
| | - Jiannong Liu
- Chronic Disease Research Group, Hennepin Healthcare Research Institute, Minneapolis, Minnesota
| | - Eric D. Weinhandl
- Chronic Disease Research Group, Hennepin Healthcare Research Institute, Minneapolis, Minnesota
- Department of Nephrology, University of Minnesota, Minneapolis
- Satellite Healthcare, Crestwood, Illinois
| | - David T. Gilbertson
- Chronic Disease Research Group, Hennepin Healthcare Research Institute, Minneapolis, Minnesota
- Department of Nephrology, University of Minnesota, Minneapolis
| | - Iris Kou
- Chronic Disease Research Group, Hennepin Healthcare Research Institute, Minneapolis, Minnesota
| | - Christopher Knapp
- Chronic Disease Research Group, Hennepin Healthcare Research Institute, Minneapolis, Minnesota
| | - James B. Wetmore
- Chronic Disease Research Group, Hennepin Healthcare Research Institute, Minneapolis, Minnesota
- Department of Nephrology, University of Minnesota, Minneapolis
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Wetmore JB, Weinhandl ED, Yan H, Reyes JL, Herzog CA, Roetker NS. Apixaban Dosing Patterns Versus Warfarin in Patients With Nonvalvular Atrial Fibrillation Receiving Dialysis: A Retrospective Cohort Study. Am J Kidney Dis 2022; 80:569-579.e1. [PMID: 35469965 DOI: 10.1053/j.ajkd.2022.03.007] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2021] [Accepted: 03/01/2022] [Indexed: 02/02/2023]
Abstract
BACKGROUND & OBJECTIVES Comparison of clinical outcomes across anticoagulation regimens using different apixaban dosing or warfarin is not well-defined in patients with nonvalvular atrial fibrillation (AF) who are receiving dialysis. This study compared these outcomes in a US national cohort of patients with kidney failure receiving maintenance dialysis. STUDY DESIGN Retrospective cohort study. SETTING & PARTICIPANTS Patients receiving dialysis represented in the US Renal Data System database 2013-2018 who had AF and were treated with apixaban or warfarin. EXPOSURE First prescribed treatment with apixaban dosed according to the label, apixaban dosed below the label, or warfarin. OUTCOME Ischemic stroke/systemic embolism, major bleeding, and all-cause mortality. ANALYTICAL APPROACH Cox proportional hazards models with inverse probability of treatment weighting. Analyses simulating an intention-to-treat (ITT) approach as well as those incorporating censoring at drug switch or discontinuation (CAS) were also implemented. Inverse probability of censoring weighting was used to account for possible informative censoring. RESULTS Among 17,156 individuals, there was no difference in risk of stroke/systemic embolism among the label-concordant apixaban, below-label apixaban, and warfarin treatment groups. Both label-concordant (HR, 0.67 [95% CI, 0.55-0.81]) and below-label (HR, 0.68 [95% CI, 0.55-0.84]) apixaban dosing were associated with a lower risk of major bleeding compared with warfarin in ITT analyses. Compared with label-concordant apixaban, below-label apixaban was not associated with a lower bleeding risk (HR, 1.02 [95% CI, 0.78-1.34]). In the ITT analysis of mortality, label-concordant apixaban dosing was associated with a lower risk versus warfarin (HR, 0.85 [95% CI, 0.78-0.92]) while there was no significant difference in mortality between below-label dosing of apixaban and warfarin (HR, 0.97 [95% CI, 0.89-1.05]). Overall, results were similar for the CAS analyses. LIMITATIONS Study limited to US Medicare beneficiaries; reliance on administrative claims to ascertain outcomes of AF, stroke, and bleeding; likely residual confounding. CONCLUSIONS Among patients with nonvalvular AF undergoing dialysis, warfarin is associated with an increased risk of bleeding compared with apixaban. The risk of bleeding with below-label apixaban was not detectably less than with label-concordant dosing. Label-concordant apixaban dosing is associated with a mortality benefit compared to warfarin. Label-concordant dosing, rather than reduced-label dosing, may offer the most favorable benefit-risk trade-off for dialysis patients with nonvalvular AF.
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Affiliation(s)
- James B Wetmore
- Chronic Disease Research Group, Hennepin Healthcare Research Institute, Minneapolis, Minnesota; Division of Nephrology, University of Minnesota, Minneapolis, Minnesota.
| | - Eric D Weinhandl
- Chronic Disease Research Group, Hennepin Healthcare Research Institute, Minneapolis, Minnesota; Hennepin County Medical Center and Department of Medicine, and Department of Pharmaceutical Care and Health Systems, University of Minnesota, Minneapolis, Minnesota
| | - Heng Yan
- Chronic Disease Research Group, Hennepin Healthcare Research Institute, Minneapolis, Minnesota
| | - Jorge L Reyes
- Department of Internal Medicine, Hennepin County Medical Center, Minneapolis, Minnesota
| | - Charles A Herzog
- Chronic Disease Research Group, Hennepin Healthcare Research Institute, Minneapolis, Minnesota; Division of Cardiology, University of Minnesota, Minneapolis, Minnesota
| | - Nicholas S Roetker
- Chronic Disease Research Group, Hennepin Healthcare Research Institute, Minneapolis, Minnesota
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Lavenburg LMU, Kim Y, Weinhandl ED, Johansen KL, Harhay MN. Trends, Social Context, and Transplant Implications of Obesity Among Incident Dialysis Patients in the United States. Transplantation 2022; 106:e488-e498. [PMID: 35831929 PMCID: PMC9613499 DOI: 10.1097/tp.0000000000004243] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Kidney transplant programs have variable thresholds to accept obese candidates. This study aimed to examine trends and the social context of obesity among United States dialysis patients and implications for kidney transplant access. METHODS We performed a retrospective cohort study of 1 084 816 adults who initiated dialysis between January 2007 and December 2016 using the United States Renal Data System data. We estimated national body mass index (BMI) trends and 1-y cumulative incidence of waitlisting and death without waitlisting by BMI category (<18.5 kg/m 2 , ≥18.5 and <25 kg/m 2 [normal weight], ≥25 and <30 kg/m 2 [overweight], ≥30 and <35 kg/m 2 [class 1 obesity], ≥35 and <40 kg/m 2 [class 2 obesity], and ≥40 kg/m 2 [class 3 obesity]). We then used Fine-Gray subdistribution hazard regression models to examine associations between BMI category and 1-y waitlisting with death as a competing risk and tested for effect modification by End Stage Renal Disease (ESRD) network, patient characteristics, and neighborhood social deprivation index. RESULTS The median age was 65 (interquartile range 54-75) y, 43% were female, and 27% were non-Hispanic Black. From 2007 to 2016, the adjusted prevalence of class 1 obesity or higher increased from 31.9% to 38.2%. Class 2 and 3 obesity but not class 1 obesity were associated with lower waitlisting rates relative to normal BMI, especially for younger individuals, women, those of Asian race, or those living in less disadvantaged neighborhoods ( pinteraction < 0.001 for all). CONCLUSIONS Obesity prevalence is rising among US incident dialysis patients. Relative to normal BMI, waitlisting rates with class 2 and 3 obesity were lower and varied substantially by region, patient characteristics, and socioeconomic context.
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Affiliation(s)
- Linda-Marie U Lavenburg
- Renal and Electrolyte Division, Department of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Yuna Kim
- Department of Epidemiology and Biostatistics, Drexel University Dornsife School of Public Health, Philadelphia, PA
| | - Eric D Weinhandl
- Chronic Disease Research Group, Hennepin Healthcare Research Institute, Minneapolis, MN
- Department of Pharmaceutical Care and Health Systems, University of Minnesota, Minneapolis, MN
| | | | - Meera N Harhay
- Department of Epidemiology and Biostatistics, Drexel University Dornsife School of Public Health, Philadelphia, PA
- Department of Medicine, Drexel University College of Medicine, Philadelphia, PA
- Department of Medicine, University of Pennsylvania Transplant Institute, University of Pennsylvania, Philadelphia, PA
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Zhao JZ, Weinhandl ED, Carlson AM, St. Peter WL. Disparities in SGLT2 Inhibitor or Glucagon-Like Peptide 1 Receptor Agonist Initiation Among Medicare-Insured Adults With CKD in the United States. Kidney Med 2022; 5:100564. [PMID: 36593878 PMCID: PMC9803841 DOI: 10.1016/j.xkme.2022.100564] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Rationale & Objective Information regarding disparities in initiating sodium/glucose cotransporter 2 inhibitors (SGLT2i) and glucagon-like peptide 1 receptor agonists (GLP-1RA) in patients with chronic kidney disease (CKD) is limited. We examined sociodemographic and clinical factors associated with the initiation of SGLT2i, GLP-1RA, or second-generation sulfonylureas in a Medicare Fee-For-Service patient population with CKD and type 2 diabetes. Study Design Retrospective cohort study. Setting & Participants The 20% random sample of Medicare Fee-For-Service claims, 2012-2018. Exposures Patients' sociodemographic and clinical factors. Outcomes Use of SGLT2i, GLP-1RA, or sulfonylureas. Analytical Approach Patients with a newly initiated prescription of SGLT2i, GLP-1RA, or second-generation sulfonylureas from January 1, 2013, to December 31, 2018, were identified. Multinomial logistic regression model was used to evaluate demographic and clinical factors associated with the initiation of SGLT2i, GLP-1RA, or second-generation sulfonylureas. Results The study cohort comprised 53,029 adults (aged greater than or equal to 18 years) with CKD and type 2 diabetes, of whom 10.0%, 17.4%, and 72.6% had a first prescription for SGLT2i, GLP-1RA, and sulfonylurea, respectively. Patients aged greater than or equal to 75 years versus those aged 65-74 years had lower odds to start SGLT2i or GLP-1RA compared with sulfonylureas. Black patients were associated with lower odds of initiation of SGLT2i (OR, 0.67; 95% CI, 0.61-0.74) and GLP-1RA (OR, 0.73; 95% CI, 0.68-0.79), compared with White patients. Hispanic and Asian patients had lower odds of initiation of GLP-1RA. Patients with cardiovascular disease or hyperlipidemia had higher odds to start SGLT2i or GLP-1RA. Limitations CKD and type 2 diabetes diagnosis; CKD stage; and patient clinical status were identified with diagnosis or procedure codes. There is potential for residual confounding with the use of retrospective data. Conclusions The results of this study identified disparities in the use of SGLT2i and GLP-1RA in patients with CKD. Black and older patients were significantly less likely to be initiated on SGLT2i or GLP-1RA than on second-generation sulfonylureas.
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Affiliation(s)
- Julie Z. Zhao
- Department of Pharmaceutical Care & Health Systems, College of Pharmacy, University of Minnesota, Minneapolis, MN,Chronic Disease Research Group, Hennepin Healthcare Research Institute, Minneapolis, MN,Address for Correspondence: Julie Z. Zhao, MPH, PhD, Department of Pharmaceutical Care & Health Systems, College of Pharmacy, University of Minnesota, 7-164 Weaver-Densford Hall, 308 SE Harvard St, Minneapolis, MN 55455.
| | - Eric D. Weinhandl
- Department of Pharmaceutical Care & Health Systems, College of Pharmacy, University of Minnesota, Minneapolis, MN,Chronic Disease Research Group, Hennepin Healthcare Research Institute, Minneapolis, MN
| | - Angeline M. Carlson
- Department of Pharmaceutical Care & Health Systems, College of Pharmacy, University of Minnesota, Minneapolis, MN
| | - Wendy L. St. Peter
- Department of Pharmaceutical Care & Health Systems, College of Pharmacy, University of Minnesota, Minneapolis, MN,Chronic Disease Research Group, Hennepin Healthcare Research Institute, Minneapolis, MN
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14
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Weinhandl ED, Liu J, Gilbertson DT, Wetmore JB, Johansen KL. Associations of COVID-19 Outcomes with Dialysis Modalities and Settings. Clin J Am Soc Nephrol 2022; 17:1526-1534. [PMID: 36400565 PMCID: PMC9528267 DOI: 10.2215/cjn.03400322] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
How maintenance dialysis modality, dialysis setting, and residence in a nursing facility have jointly associated with coronavirus disease 2019 (COVID-19)-related outcomes in the United States is relevant to future viral outbreaks. Using Medicare claims, we determined the incidence of COVID-19-related infection, hospitalization, and death between March 15, 2020 and June 5, 2021. The exposure was one of five combinations of dialysis modality and care setting: in-facility hemodialysis without a recent history of skilled nursing facility care, in-facility hemodialysis with a recent history of skilled nursing facility care, hemodialysis in a skilled nursing facility, home hemodialysis, and (home) peritoneal dialysis. Patient-weeks were pooled to estimate the adjusted associations of event incidence with each dialysis modality/setting during four intervals in 2020-2021. Relative to in-facility hemodialysis without a recent history of skilled nursing facility care, home dialysis was associated with 36%-60% lower odds of all events during weeks 12-23 of 2020; 24%-37% lower odds of all events during weeks 24-37 of 2020; 20%-33% lower odds of infection and hospitalization during the winter of 2020-2021; and similar odds of all events thereafter. In contrast, exposure to skilled nursing facilities was associated with 570%-1140% higher odds of all events during spring of 2020, although excess risk attenuated as the pandemic transpired, especially among patients who received hemodialysis in skilled nursing facilities. In conclusion, home dialysis was associated with lower risks of COVID-19 diagnosis, hospitalization, and death until vaccines were available, whereas care in skilled nursing facilities was associated with higher risks.
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Affiliation(s)
- Eric D. Weinhandl
- Chronic Disease Research Group, Hennepin Healthcare Research Institute, Minneapolis, Minnesota
- Department of Pharmaceutical Care and Health Systems, University of Minnesota, Minneapolis, Minnesota
| | - Jiannong Liu
- Chronic Disease Research Group, Hennepin Healthcare Research Institute, Minneapolis, Minnesota
| | - David T. Gilbertson
- Chronic Disease Research Group, Hennepin Healthcare Research Institute, Minneapolis, Minnesota
| | - James B. Wetmore
- Chronic Disease Research Group, Hennepin Healthcare Research Institute, Minneapolis, Minnesota
- Division of Nephrology, Hennepin Healthcare and the University of Minnesota, Minneapolis, Minnesota
| | - Kirsten L. Johansen
- Chronic Disease Research Group, Hennepin Healthcare Research Institute, Minneapolis, Minnesota
- Division of Nephrology, Hennepin Healthcare and the University of Minnesota, Minneapolis, Minnesota
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15
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Zhao JZ, Weinhandl ED, Carlson AM, St. Peter WL. Hypoglycemia Risk With SGLT2 Inhibitors or Glucagon-Like Peptide 1 Receptor Agonists Versus Sulfonylureas Among Medicare Insured Adults With CKD in the United States. Kidney Med 2022; 4:100510. [PMID: 35898692 PMCID: PMC9310119 DOI: 10.1016/j.xkme.2022.100510] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Rationale & Objective Study Design Setting & Participants Exposures Outcomes Analytical Approach Results Limitations Conclusions
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Affiliation(s)
- Julie Z. Zhao
- Department of Pharmaceutical Care & Health Systems, College of Pharmacy, University of Minnesota, Minneapolis, MN
- Chronic Disease Research Group, Hennepin Healthcare Research Institute, Minneapolis, MN
- Address for Correspondence: Julie Z. Zhao, MPH, PhD, Department of Pharmaceutical Care & Health Systems, College of Pharmacy, University of Minnesota, 7-164 Weaver-Densford Hall, 308 SE Harvard St. Minneapolis, MN 55455.
| | - Eric D. Weinhandl
- Department of Pharmaceutical Care & Health Systems, College of Pharmacy, University of Minnesota, Minneapolis, MN
- Chronic Disease Research Group, Hennepin Healthcare Research Institute, Minneapolis, MN
| | - Angeline M. Carlson
- Department of Pharmaceutical Care & Health Systems, College of Pharmacy, University of Minnesota, Minneapolis, MN
| | - Wendy L. St. Peter
- Department of Pharmaceutical Care & Health Systems, College of Pharmacy, University of Minnesota, Minneapolis, MN
- Chronic Disease Research Group, Hennepin Healthcare Research Institute, Minneapolis, MN
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16
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Johansen KL, Wetmore JB, Peng Y, Liu J, Weinhandl ED, Gilbertson DT. Variation in Incidence of ESKD Among Individuals of Native Hawaiian/Pacific Islander Race Based on Data From the US Renal Data System. Am J Kidney Dis 2022; 80:295-296. [PMID: 34871699 DOI: 10.1053/j.ajkd.2021.09.027] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Accepted: 09/27/2021] [Indexed: 01/27/2023]
Affiliation(s)
- Kirsten L Johansen
- Chronic Disease Research Group, Hennepin Healthcare Research Institute, Minneapolis, Minnesota.
| | - James B Wetmore
- Chronic Disease Research Group, Hennepin Healthcare Research Institute, Minneapolis, Minnesota
| | - Yi Peng
- Chronic Disease Research Group, Hennepin Healthcare Research Institute, Minneapolis, Minnesota
| | - Jiannong Liu
- Chronic Disease Research Group, Hennepin Healthcare Research Institute, Minneapolis, Minnesota
| | - Eric D Weinhandl
- Chronic Disease Research Group, Hennepin Healthcare Research Institute, Minneapolis, Minnesota
| | - David T Gilbertson
- Chronic Disease Research Group, Hennepin Healthcare Research Institute, Minneapolis, Minnesota
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17
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Roetker NS, Gilbertson DT, Weinhandl ED. A Brief Introduction to Competing Risks in the Context of Kidney Disease Epidemiology. Kidney360 2022; 3:740-743. [PMID: 35721604 PMCID: PMC9136896 DOI: 10.34067/kid.0007382021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Accepted: 02/16/2022] [Indexed: 05/12/2023]
Affiliation(s)
- Nicholas S. Roetker
- Chronic Disease Research Group, Hennepin Healthcare Research Institute, Minneapolis, Minnesota
| | - David T. Gilbertson
- Chronic Disease Research Group, Hennepin Healthcare Research Institute, Minneapolis, Minnesota
| | - Eric D. Weinhandl
- Chronic Disease Research Group, Hennepin Healthcare Research Institute, Minneapolis, Minnesota
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18
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Wetmore JB, Herzog CA, Yan H, Reyes JL, Weinhandl ED, Roetker NS. Apixaban versus Warfarin for Treatment of Venous Thromboembolism in Patients Receiving Long-Term Dialysis. Clin J Am Soc Nephrol 2022; 17:693-702. [PMID: 35470214 PMCID: PMC9269579 DOI: 10.2215/cjn.14021021] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2021] [Accepted: 03/04/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND AND OBJECTIVES The association of apixaban compared with warfarin for the treatment of venous thromboembolism in patients receiving maintenance dialysis is not well studied. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS We conducted a retrospective cohort study of Medicare fee-for-service beneficiaries receiving dialysis using United States Renal Data System data from 2013 to 2018. The study included patients who received a new prescription for apixaban or warfarin following a venous thromboembolism diagnosis. The outcomes were recurrent venous thromboembolism, major bleeding, and death. Outcomes were analyzed using Cox proportional hazards regression for intention-to-treat and censored-at-drug-switch-or-discontinuation analyses. Models incorporated inverse probability of treatment and censoring weights to minimize confounding and informative censoring. RESULTS In 12,206 individuals, apixaban, compared with warfarin, was associated with lower risks of both recurrent venous thromboembolism (hazard ratio [HR], 0.58; 95% confidence interval [95% CI], 0.43 to 0.77) and major bleeding (HR, 0.78; 95% CI, 0.62 to 0.98) in the intention-to-treat analysis over 6 months of follow-up. However, there was no difference between apixaban and warfarin in terms of risk of all-cause death (HR, 1.04; 95% CI, 0.94 to 1.16). Corresponding hazard ratios for the 6-month censored-at-drug-switch-or-discontinuation analysis and for corresponding analyses limited to a shorter (3-month) follow-up were all highly similar to the primary analysis. CONCLUSIONS In a large group of US patients on dialysis with recent venous thromboembolism, we observed that apixaban was associated with lower risk of recurrent venous thromboembolism and of major bleeding than warfarin. There was no observed difference in mortality.
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Affiliation(s)
- James B Wetmore
- Chronic Disease Research Group, Hennepin Healthcare Research Institute, Minneapolis, Minnesota .,Division of Nephrology, Hennepin Healthcare and Department of Medicine, University of Minnesota, Minneapolis, Minnesota
| | - Charles A Herzog
- Chronic Disease Research Group, Hennepin Healthcare Research Institute, Minneapolis, Minnesota.,Division of Cardiology, Hennepin Healthcare, and Department of Medicine, University of Minnesota, Minneapolis, Minnesota
| | - Heng Yan
- Chronic Disease Research Group, Hennepin Healthcare Research Institute, Minneapolis, Minnesota
| | - Jorge L Reyes
- Division of Cardiology, University of Minnesota, Minneapolis, Minnesota
| | - Eric D Weinhandl
- Chronic Disease Research Group, Hennepin Healthcare Research Institute, Minneapolis, Minnesota.,Department of Pharmaceutical Care and Health Systems, University of Minnesota, Minneapolis, Minnesota
| | - Nicholas S Roetker
- Chronic Disease Research Group, Hennepin Healthcare Research Institute, Minneapolis, Minnesota
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19
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Johansen KL, Chertow GM, Gilbertson DT, Herzog CA, Ishani A, Israni AK, Ku E, Li S, Li S, Liu J, Obrador GT, O'Hare AM, Peng Y, Powe NR, Roetker NS, St Peter WL, Saeed F, Snyder J, Solid C, Weinhandl ED, Winkelmayer WC, Wetmore JB. US Renal Data System 2021 Annual Data Report: Epidemiology of Kidney Disease in the United States. Am J Kidney Dis 2022; 79:A8-A12. [PMID: 35331382 PMCID: PMC8935019 DOI: 10.1053/j.ajkd.2022.02.001] [Citation(s) in RCA: 112] [Impact Index Per Article: 56.0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
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20
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Weinhandl ED, Saffer TL, Aragon M. Hidden Costs Associated with Conversion from Peritoneal Dialysis to Hemodialysis. Kidney360 2022; 3:883-890. [PMID: 36128476 PMCID: PMC9438410 DOI: 10.34067/kid.0007692021] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Accepted: 02/28/2022] [Indexed: 01/10/2023]
Abstract
Background Increasing use of peritoneal dialysis (PD) will likely lead to increasing numbers of patients transitioning from PD to hemodialysis (HD). We describe the characteristics of patients who discontinued PD and converted to HD, trajectories of acute-care encounter rates and the total cost of care both before and after PD discontinuation, and the incidence of modality-related outcomes after PD discontinuation. Methods We analyzed data in the United States Renal Data System to identify patients aged ≥12 years who were newly diagnosed with ESKD in 2001-2017, initiated PD during the first year of ESKD, and discontinued PD in 2009-2018. We estimated monthly rates of hospital admissions, observation stays, emergency department encounters, and Medicare Parts A and B costs during the 12 months before and after conversion from PD to HD, and the incidence of home HD initiation, death, and kidney transplantation after conversion to in-facility HD. Results Among 232,699 patients who initiated PD, there were 124,213 patients who discontinued PD. Among them, 68,743 (55%) converted to HD. In this subgroup, monthly rates of acute-care encounters and total costs of care to Medicare sharply increased during the 6 months preceding PD discontinuation, peaking at 96.2 acute-care encounters per 100 patient-months and $20,701 per patient in the last month of PD. After conversion, rates decreased, but remained higher than before conversion. Among patients who converted to in-facility HD, the cumulative incidence of home HD initiation, death, and kidney transplantation at 24 months was 3%, 25%, and 7%, respectively. Conclusions The transition from PD to HD is characterized by high rates of acute-care encounters and health-care expenditures. Quality improvement efforts should be aimed at improving transitions and encouraging both home HD and kidney transplantation after PD discontinuation.
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Affiliation(s)
- Eric D. Weinhandl
- Chronic Disease Research Group, Hennepin Healthcare Research Institute, Minneapolis, Minnesota,Department of Pharmaceutical Care and Health Systems, University of Minnesota, Minneapolis, Minnesota
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21
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Johansen KL, Gilbertson DT, Wetmore JB, Peng Y, Liu J, Weinhandl ED. Catheter-Associated Bloodstream Infections among Patients on Hemodialysis: Progress before and during the COVID-19 Pandemic. Clin J Am Soc Nephrol 2022; 17:429-433. [PMID: 35110377 PMCID: PMC8975041 DOI: 10.2215/cjn.11360821] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Measures implemented to prevent transmission of severe acute respiratory syndrome coronavirus 2 in outpatient dialysis facilities may also help to prevent catheter-associated bloodstream infections in patients receiving hemodialysis. We used United States Renal Data System data to examine rates of antibiotic administration within dialysis facilities and rates of hospital admission for catheter-associated bloodstream infection from March 2018 through November 2020, and rates of hospitalization for sepsis, to address overall changes in hospitalization during the coronavirus disease 2019 (COVID-19) pandemic. Using logistic regression, we estimated year-over-year adjusted odds ratios of these events in 3-month intervals. During the first 6 months of the pandemic, rates of antibiotic administration were between 20% and 21% lower, and rates of hospitalization for catheter-associated bloodstream infection were between 17% and 24% lower than during corresponding periods in 2019, without significant changes in rates of hospitalization for sepsis. However, rates of catheter-associated events also decreased between 2018 and 2019, driven by reductions in facilities operated by a large dialysis provider. These data suggest that significant reductions in catheter-associated infections occurred during the pandemic, superimposed on nonpandemic-related reductions in some facilities before the pandemic. Even after the pandemic, it may be prudent to continue some COVID-19 mitigation measures to prevent catheter-associated bloodstream infections.
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Affiliation(s)
- Kirsten L. Johansen
- Chronic Disease Research Group, Hennepin Healthcare Research Institute, Minneapolis, Minnesota,Division of Nephrology, Hennepin Healthcare, Minneapolis, Minnesota,Department of Medicine, University of Minnesota, Minneapolis, Minnesota
| | - David T. Gilbertson
- Chronic Disease Research Group, Hennepin Healthcare Research Institute, Minneapolis, Minnesota
| | - James B. Wetmore
- Chronic Disease Research Group, Hennepin Healthcare Research Institute, Minneapolis, Minnesota,Division of Nephrology, Hennepin Healthcare, Minneapolis, Minnesota,Department of Medicine, University of Minnesota, Minneapolis, Minnesota
| | - Yi Peng
- Chronic Disease Research Group, Hennepin Healthcare Research Institute, Minneapolis, Minnesota
| | - Jiannong Liu
- Chronic Disease Research Group, Hennepin Healthcare Research Institute, Minneapolis, Minnesota
| | - Eric D. Weinhandl
- Chronic Disease Research Group, Hennepin Healthcare Research Institute, Minneapolis, Minnesota,Department of Pharmaceutical Care and Health Systems, University of Minnesota, Minneapolis, Minnesota
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22
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Weinhandl ED. The coronavirus disease 2019 pandemic: the disruptor that maintenance dialysis never anticipated. Curr Opin Nephrol Hypertens 2022; 31:185-190. [PMID: 35086986 DOI: 10.1097/mnh.0000000000000777] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW The novel coronavirus 2019 (COVID-19) pandemic has upended maintenance dialysis in the United States. I review changes in prevalence, incidence, mortality, and other clinical outcomes among patients undergoing dialysis since March 2020, highlighting vulnerabilities in the current system and opportunities for improved care in the future. RECENT FINDINGS The number of dialysis patients in the United States declined between March 2020 and March 2021, an unprecedented year-over-year drop in the census. Some of the decline can be attributed to an early drop in patients initiating dialysis but most of the decline can be attributed to excess mortality. Kidney transplants also declined during the early part of the pandemic. Home dialysis utilization increased during 2020 but that increase was largely in line with secular trends. The rate of hospitalization for causes other than COVID-19 fell significantly during 2020. SUMMARY The epidemiology of dialysis in the United States is clearly modifiable, as it reflects decisions to initiate treatment, prescribe home therapies, and hospitalize patients with acute medical needs. On the other hand, some outcomes are powerfully guided by health outcomes in the general population, thus limiting the ability of dialysis providers and nephrologists to influence outcomes.
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Affiliation(s)
- Eric D Weinhandl
- Chronic Disease Research Group, Hennepin Healthcare Research Institute
- Department of Pharmaceutical Care and Health Systems, University of Minnesota, Minneapolis, Minnesota
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23
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Wetmore JB, Johansen KL, Weinhandl ED. Authors' Reply. J Am Soc Nephrol 2022; 33:455-457. [PMID: 35101996 PMCID: PMC8819993 DOI: 10.1681/asn.2021111417] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Affiliation(s)
- James B. Wetmore
- Chronic Disease Research Group, Hennepin Healthcare Research Institute, Minneapolis, Minnesota,Division of Nephrology, Hennepin Healthcare, Minneapolis, Minnesota
| | - Kirsten L. Johansen
- Chronic Disease Research Group, Hennepin Healthcare Research Institute, Minneapolis, Minnesota,Division of Nephrology, Hennepin Healthcare, Minneapolis, Minnesota
| | - Eric D. Weinhandl
- Chronic Disease Research Group, Hennepin Healthcare Research Institute, Minneapolis, Minnesota,Department of Pharmaceutical Care and Health Systems, University of Minnesota, Minneapolis, Minnesota
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24
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Weinhandl ED, Forfang D. From Home Dialysis Access to Home Dialysis Quality. Adv Chronic Kidney Dis 2022; 29:52-58. [PMID: 35690405 DOI: 10.1053/j.ackd.2022.02.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2021] [Revised: 02/14/2022] [Accepted: 02/28/2022] [Indexed: 11/11/2022]
Abstract
The number and percentage of patients dialyzing at home has steadily increased during the past decade, and federal policy initiatives have driven interest to a new high. However, the mere utilization of home dialysis does not ensure better outcomes for patients and care partners. Although public reporting systems for dialysis quality are mature and robust, the incorporation of home dialysis quality in those systems is immature; the advent of the End-Stage Renal Disease Treatment Choices payment model brings this problem into sharp relief. The home dialysis modalities present both common and unique targets for quality measurement. For both modalities, therapy duration (or its inverse, technique failure) is a potential target. For peritoneal dialysis, peritonitis, catheter complications, and residual kidney function are additional targets; for home hemodialysis, vascular access infections, dialysis adequacy, and treatment adherence are targets. Patient-reported experience measures are also important; this domain is a long-standing disparity, as in-facility hemodialysis patients have been routinely surveyed for several years. The statistical aspect of quality measurement in home dialysis requires some adaptation, as the typical home dialysis program is small, thus presenting a threat to reliability; pooling programs may be necessary. Ultimately, promoting high-quality home dialysis will likely increase utilization of home dialysis.
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Affiliation(s)
- Eric D Weinhandl
- Satellite Healthcare, San Jose, CA; Department of Pharmaceutical Care and Health Systems, University of Minnesota, Minneapolis, MN.
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25
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Wetmore JB, Johansen KL, Liu J, Peng Y, Gilbertson DT, Weinhandl ED. Changes in Treatment of Patients with Incident ESKD during the Novel Coronavirus Disease 2019 Pandemic. J Am Soc Nephrol 2021; 32:2948-2957. [PMID: 34535558 PMCID: PMC8806095 DOI: 10.1681/asn.2021040579] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Accepted: 08/11/2021] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND The COVID-19 pandemic caused major disruptions to care for patients with advanced CKD. METHODS We investigated the incidence of documented ESKD, ESKD treatment modalities, changes in eGFR at dialysis initiation, and use of incident central venous catheters (CVCs) by epidemiologic week during the first half of 2020 compared with 2017-2019 historical trends, using Centers for Medicare and Medicaid Services data. We used Poisson and logistic regression for analyses of incidence and binary outcomes, respectively. RESULTS Incidence of documented ESKD dropped dramatically in 2020 compared with the expected incidence, particularly during epidemiologic weeks 15-18 (April, incidence rate ratio [IRR], 0.75; 95% CI, 0.73 to 0.78). The decrease was most pronounced for individuals aged ≥75 years (IRR, 0.69; 95% CI, 0.66 to 0.73). Pre-emptive kidney transplantation decreased markedly during weeks 15-18 (IRR, 0.56; 95% CI, 0.46 to 0.67). Mean eGFR at dialysis initiation decreased by 0.33 ml/min per 1.73 m2 in weeks 19-22; non-Hispanic Black patients exhibited the largest decrease, at 0.61 ml/min per 1.73 m2. The odds of initiating dialysis with eGFR <10 ml/min per 1.73 m2 were highest during weeks 19-22 (May, OR, 1.14; 95% CI, 1.05 to 1.17), corresponding to an absolute increase of 2.9%. The odds of initiating peritoneal dialysis (versus hemodialysis) were 24% higher (OR, 1.24; 95% CI, 1.14 to 1.34) in weeks 11-14, an absolute increase of 2.3%. Initiation with a CVC increased by 3.3% (OR, 1.30; 95% CI, 1.20 to 1.41). CONCLUSIONS During the first wave of the COVID-19 pandemic, the number of patients starting treatment for ESKD fell to a level not observed since 2011. Changes in documented ESKD incidence and other aspects of ESKD-related care may reflect differential access to care early in the pandemic.
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Affiliation(s)
- James B. Wetmore
- Chronic Disease Research Group, Hennepin Healthcare Research Institute, Minneapolis, Minnesota
- Division of Nephrology, Hennepin Healthcare, Minneapolis, Minnesota
| | - Kirsten L. Johansen
- Chronic Disease Research Group, Hennepin Healthcare Research Institute, Minneapolis, Minnesota
- Division of Nephrology, Hennepin Healthcare, Minneapolis, Minnesota
| | - Jiannong Liu
- Chronic Disease Research Group, Hennepin Healthcare Research Institute, Minneapolis, Minnesota
| | - Yi Peng
- Chronic Disease Research Group, Hennepin Healthcare Research Institute, Minneapolis, Minnesota
| | - David T. Gilbertson
- Chronic Disease Research Group, Hennepin Healthcare Research Institute, Minneapolis, Minnesota
| | - Eric D. Weinhandl
- Chronic Disease Research Group, Hennepin Healthcare Research Institute, Minneapolis, Minnesota
- Department of Pharmaceutical Care and Health Systems, University of Minnesota, Minneapolis, Minnesota
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26
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Abra G, Weinhandl ED. Pulling the goalie: What the United States and the world can learn from Canada about growing home dialysis. Perit Dial Int 2021; 41:437-440. [PMID: 34323152 DOI: 10.1177/08968608211034696] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
- Graham Abra
- Satellite Healthcare, San Jose, CA, USA.,Department of Medicine, Division of Nephrology, 6429Stanford University, Palo Alto, CA, USA
| | - Eric D Weinhandl
- Chronic Disease Research Group, Hennepin Healthcare Research Institute, Minneapolis, MN, USA.,Department of Pharmaceutical Care and Health Systems, 5635University of Minnesota, Minneapolis, MN, USA
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27
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Weinhandl ED, Gilbertson DT, Wetmore JB, Johansen KL. COVID-19-Associated Decline in the Size of the End Stage Kidney Disease Population in the United States. Kidney Int Rep 2021; 6:2698-2701. [PMID: 34337192 PMCID: PMC8302479 DOI: 10.1016/j.ekir.2021.07.019] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Accepted: 07/19/2021] [Indexed: 01/30/2023] Open
Affiliation(s)
- Eric D Weinhandl
- Chronic Disease Research Group, Hennepin Healthcare Research Institute, Minneapolis, Minnesota.,Department of Pharmaceutical Care and Health Systems, University of Minnesota, Minneapolis, Minnesota
| | - David T Gilbertson
- Chronic Disease Research Group, Hennepin Healthcare Research Institute, Minneapolis, Minnesota
| | - James B Wetmore
- Chronic Disease Research Group, Hennepin Healthcare Research Institute, Minneapolis, Minnesota.,Division of Nephrology, Hennepin Healthcare, Minneapolis, Minnesota
| | - Kirsten L Johansen
- Chronic Disease Research Group, Hennepin Healthcare Research Institute, Minneapolis, Minnesota.,Division of Nephrology, Hennepin Healthcare, Minneapolis, Minnesota
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Weinhandl ED, Wetmore JB, Peng Y, Liu J, Gilbertson DT, Johansen KL. Initial Effects of COVID-19 on Patients with ESKD. J Am Soc Nephrol 2021; 32:1444-1453. [PMID: 33833076 PMCID: PMC8259631 DOI: 10.1681/asn.2021010009] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Accepted: 03/05/2021] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Reports from around the world have indicated a fatality rate of patients with coronavirus disease 2019 (COVID-19) in the range of 20%-30% among patients with ESKD. Population-level effects of COVID-19 on patients with ESKD in the United States are uncertain. METHODS We identified patients with ESKD from Centers for Medicare and Medicaid Services data during epidemiologic weeks 3-27 of 2017-2020 and corresponding weeks of 2017-2019, stratifying them by kidney replacement therapy. Outcomes comprised hospitalization for COVID-19, all-cause death, and hospitalization for reasons other than COVID-19. We estimated adjusted relative rates (ARRs) of death and non-COVID-19 hospitalization during epidemiologic weeks 13-27 of 2020 (March 22 to July 4) versus corresponding weeks in 2017-2019. RESULTS Among patients on dialysis, the rate of COVID-19 hospitalization peaked between March 22 and April 25 2020. Non-Hispanic Black race and Hispanic ethnicity associated with higher rates of COVID-19 hospitalization, whereas peritoneal dialysis was associated with lower rates. During weeks 13-27, ARRs of death in 2020 versus 2017-2019 were 1.17 (95% confidence interval [95% CI], 1.16 to 1.19) and 1.30 (95% CI, 1.24 to 1.36) among patients undergoing dialysis or with a functioning transplant, respectively. Excess mortality was higher among non-Hispanic Black, Hispanic, and Asian patients. Among patients on dialysis, the rate of non-COVID-19 hospitalization during weeks 13-27 in 2020 was 17% lower versus hospitalization rates for corresponding weeks in 2017-2019. CONCLUSIONS During the first half of 2020, the clinical outcomes of patients with ESKD were greatly affected by COVID-19, and racial and ethnic disparities were apparent. These findings should be considered in prioritizing administration of COVID-19 vaccination.
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Affiliation(s)
- Eric D. Weinhandl
- Chronic Disease Research Group, Hennepin Healthcare Research Institute, Minneapolis, Minnesota
- Department of Pharmaceutical Care and Health Systems, University of Minnesota, Minneapolis, Minnesota
| | - James B. Wetmore
- Chronic Disease Research Group, Hennepin Healthcare Research Institute, Minneapolis, Minnesota
- Division of Nephrology, Hennepin Healthcare, Minneapolis, Minnesota
| | - Yi Peng
- Chronic Disease Research Group, Hennepin Healthcare Research Institute, Minneapolis, Minnesota
| | - Jiannong Liu
- Chronic Disease Research Group, Hennepin Healthcare Research Institute, Minneapolis, Minnesota
| | - David T. Gilbertson
- Chronic Disease Research Group, Hennepin Healthcare Research Institute, Minneapolis, Minnesota
| | - Kirsten L. Johansen
- Chronic Disease Research Group, Hennepin Healthcare Research Institute, Minneapolis, Minnesota
- Division of Nephrology, Hennepin Healthcare, Minneapolis, Minnesota
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Reddy YNV, Mendu ML, Weinhandl ED. Funding Innovative Dialysis Technology in the United States: Home Dialysis and the ESRD Transitional Add-on Payment for New and Innovative Equipment and Supplies (TPNIES). Am J Kidney Dis 2021; 78:892-896. [PMID: 34051309 DOI: 10.1053/j.ajkd.2021.03.025] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2020] [Accepted: 03/15/2021] [Indexed: 11/11/2022]
Abstract
Innovative, patient-centered, and pragmatic dialysis technologies are urgently needed to accommodate the growing national interest in home dialysis use. To help achieve this goal, the US Centers for Medicare & Medicaid Services (CMS) are expanding reimbursement for eligible home dialysis machines through an existing payment mechanism, the transitional add-on payment for new and innovative equipment and supplies (TPNIES). This mechanism incentivizes the early adoption of innovative equipment into practice by reimbursing dialysis providers up to 26% of the total cost of approved home dialysis machines. Machines are evaluated for TPNIES eligibility using prespecified substantial clinical improvement (SCI) criteria that are derived from the Inpatient Prospective Payment System (for non-nephrology technologies). Although the SCI criteria may be suitable for some non-nephrology technologies, they have not been adapted to consider the unique and complex care inherent in home dialysis. Thus, many of the SCI criteria appear unsuitable for home dialysis machines. To better incentivize innovation, CMS should develop nephrology-specific transparent and pragmatic criteria for TPNIES. In this perspective, we provide an overview of the TPNIES payment mechanism, highlight areas of concern within the policy, and offer solutions for improving TPNIES that could better promote the adoption of new home dialysis machines.
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Affiliation(s)
- Yuvaram N V Reddy
- Nephrology Division, Department of Medicine, Brigham and Women's Hospital, Boston, MA; Harvard Medical School, Boston, MA; Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA.
| | - Mallika L Mendu
- Nephrology Division, Department of Medicine, Brigham and Women's Hospital, Boston, MA; Harvard Medical School, Boston, MA
| | - Eric D Weinhandl
- Chronic Disease Research Group, Hennepin Healthcare Research Institute, Minneapolis, MN; Department of Pharmaceutical Care and Health Systems, University of Minnesota, Minneapolis, MN
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30
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Johansen KL, Chertow GM, Foley RN, Gilbertson DT, Herzog CA, Ishani A, Israni AK, Ku E, Kurella Tamura M, Li S, Li S, Liu J, Obrador GT, O'Hare AM, Peng Y, Powe NR, Roetker NS, St Peter WL, Abbott KC, Chan KE, Schulman IH, Snyder J, Solid C, Weinhandl ED, Winkelmayer WC, Wetmore JB. US Renal Data System 2020 Annual Data Report: Epidemiology of Kidney Disease in the United States. Am J Kidney Dis 2021; 77:A7-A8. [PMID: 33752804 DOI: 10.1053/j.ajkd.2021.01.002] [Citation(s) in RCA: 295] [Impact Index Per Article: 98.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Abstract
Home hemodialysis (HD) is growing in the United States, but the economics of the modality are largely unknown, especially considering the unique aspects of home HD in the United States . In this review, I focus on details of Medicare coverage, which directly applies to most patients on dialysis and influences the policies of private insurers. Key details in Medicare comprise the relationship between home dialysis training and initial Medicare eligibility, reimbursement for home HD training, coverage of additional HD treatments (ie., in excess of 3 treatments per week), and monthly capitated payments to nephrologists. The overarching narrative is that frequent home HD directly increases Medicare costs for outpatient dialysis, but these added costs can be mitigated by lower inpatient expenditures if increased HD treatment frequency lowers the risk of cardiovascular hospitalization and infection control is emphasized. I also review recent international literature; conventional home HD exhibits a superior cost profile, whereas frequent home HD is generally cost-effective over multiple treatment years (ie, if early technique failure is avoided). Out-of-pocket expenses for patients should be considered. The future economics of home HD in the United States will be determined by new equipment, new adaptations of the modality, and new payment models.
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Abstract
BACKGROUND Information regarding the use of glucose-lowering medications in patients with chronic kidney disease (CKD) is limited. STUDY DESIGN Retrospective cohort study. SETTING & PARTICIPANTS Medicare 5% random sample of patients with CKD with type 2 diabetes, 2007 to 2016. PREDICTORS Study year, CKD stage, low-income subsidy status, and demographic characteristics (age, sex, and race/ethnicity). OUTCOMES Trends in use of glucose-lowering medications. ANALYTICAL APPROACH Yearly cohorts of patients with CKD and type 2 diabetes were created. Descriptive statistics were used to report proportions of patients using glucose-lowering medications. To test overall trends in glucose-lowering medication classes, linear probability models with adjustment for age, sex, race/ethnicity, CKD stage, and low-income subsidy status were used. RESULTS Metformin use increased significantly from 32.7% in 2007 to 48.7% in 2016. Use of newer classes of glucose-lowering medications increased significantly, including dipeptidyl peptidase 4 inhibitors (5.6%, 2007; 21.7%, 2016), glucagon-like peptide 1 receptor agonists (2.3%, 2007; 6.1%, 2016), and sodium-glucose cotransporter 2 inhibitors (0.2%, 2013; 3.3%, 2016). Newer insulin analogue use increased from 37.2% in 2007 to 46.3% in 2013 and then remained steady. Use of sulfonylureas, thiazolidinediones, older insulins (human regular and neutral protamine Hagedorn), α-glucosidase inhibitors, amylin mimetics, and meglitinides decreased significantly. Insulin was the most highly used single medication class. Insulin use was higher among low-income subsidy than among non-low-income subsidy patients. Combination therapy was less common as CKD stage increased. LIMITATIONS Patients with CKD and type 2 diabetes and the CKD stages were identified with diagnosis codes and could not be verified through medical record review. Our results may not be generalizable to younger patients with CKD with type 2 diabetes. CONCLUSIONS Use of metformin and newer glucose-lowering medication classes is increasing in patients with CKD with type 2 diabetes. We anticipate that percentages of patients with CKD using these newer agents will increase.
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Affiliation(s)
- Julie Z. Zhao
- Department of Pharmaceutical Care & Health Systems, University of Minnesota, College of Pharmacy, Minneapolis, MN
- Chronic Disease Research Group, Hennepin Healthcare Research Institute, Minneapolis, MN
| | - Eric D. Weinhandl
- Department of Pharmaceutical Care & Health Systems, University of Minnesota, College of Pharmacy, Minneapolis, MN
- Chronic Disease Research Group, Hennepin Healthcare Research Institute, Minneapolis, MN
| | - Angeline M. Carlson
- Department of Pharmaceutical Care & Health Systems, University of Minnesota, College of Pharmacy, Minneapolis, MN
| | - Wendy L. St. Peter
- Department of Pharmaceutical Care & Health Systems, University of Minnesota, College of Pharmacy, Minneapolis, MN
- Chronic Disease Research Group, Hennepin Healthcare Research Institute, Minneapolis, MN
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33
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Monaghan CK, Larkin JW, Chaudhuri S, Han H, Jiao Y, Bermudez KM, Weinhandl ED, Dahne-Steuber IA, Belmonte K, Neri L, Kotanko P, Kooman JP, Hymes JL, Kossmann RJ, Usvyat LA, Maddux FW. Machine Learning for Prediction of Patients on Hemodialysis with an Undetected SARS-CoV-2 Infection. Kidney360 2021; 2:456-468. [PMID: 35369017 PMCID: PMC8786002 DOI: 10.34067/kid.0003802020] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Accepted: 01/12/2021] [Indexed: 02/04/2023]
Abstract
Background We developed a machine learning (ML) model that predicts the risk of a patient on hemodialysis (HD) having an undetected SARS-CoV-2 infection that is identified after the following ≥3 days. Methods As part of a healthcare operations effort, we used patient data from a national network of dialysis clinics (February-September 2020) to develop an ML model (XGBoost) that uses 81 variables to predict the likelihood of an adult patient on HD having an undetected SARS-CoV-2 infection that is identified in the subsequent ≥3 days. We used a 60%:20%:20% randomized split of COVID-19-positive samples for the training, validation, and testing datasets. Results We used a select cohort of 40,490 patients on HD to build the ML model (11,166 patients who were COVID-19 positive and 29,324 patients who were unaffected controls). The prevalence of COVID-19 in the cohort (28% COVID-19 positive) was by design higher than the HD population. The prevalence of COVID-19 was set to 10% in the testing dataset to estimate the prevalence observed in the national HD population. The threshold for classifying observations as positive or negative was set at 0.80 to minimize false positives. Precision for the model was 0.52, the recall was 0.07, and the lift was 5.3 in the testing dataset. Area under the receiver operating characteristic curve (AUROC) and area under the precision-recall curve (AUPRC) for the model was 0.68 and 0.24 in the testing dataset, respectively. Top predictors of a patient on HD having a SARS-CoV-2 infection were the change in interdialytic weight gain from the previous month, mean pre-HD body temperature in the prior week, and the change in post-HD heart rate from the previous month. Conclusions The developed ML model appears suitable for predicting patients on HD at risk of having COVID-19 at least 3 days before there would be a clinical suspicion of the disease.
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Affiliation(s)
| | - John W. Larkin
- Fresenius Medical Care, Global Medical Office, Waltham, Massachusetts
| | - Sheetal Chaudhuri
- Fresenius Medical Care, Global Medical Office, Waltham, Massachusetts,Division of Nephrology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Hao Han
- Fresenius Medical Care, Global Medical Office, Waltham, Massachusetts
| | - Yue Jiao
- Fresenius Medical Care, Global Medical Office, Waltham, Massachusetts
| | | | - Eric D. Weinhandl
- Fresenius Medical Care North America, Medical Office, Waltham, Massachusetts
| | | | - Kathleen Belmonte
- Nursing & Clinical Services, Fresenius Kidney Care, Waltham, Massachusetts
| | - Luca Neri
- Fresenius Medical Care Deutschland GmbH, EMEA Medical Office, Bad Homburg, Germany
| | - Peter Kotanko
- Research Division, Renal Research Institute, New York, New York,Division of Nephrology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Jeroen P. Kooman
- Division of Nephrology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Jeffrey L. Hymes
- Fresenius Medical Care North America, Medical Office, Waltham, Massachusetts
| | - Robert J. Kossmann
- Fresenius Medical Care North America, Medical Office, Waltham, Massachusetts
| | - Len A. Usvyat
- Fresenius Medical Care, Global Medical Office, Waltham, Massachusetts
| | - Franklin W. Maddux
- Fresenius Medical Care AG & Co. KGaA, Global Medical Office, Bad Homburg, Germany
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Affiliation(s)
- Eric D. Weinhandl
- Chronic Disease Research Group, Hennepin Healthcare Research Institute, Minneapolis, MN
- Department of Pharmaceutical Care and Health Systems, University of Minnesota, Minneapolis, MN
| | - David T. Gilbertson
- Chronic Disease Research Group, Hennepin Healthcare Research Institute, Minneapolis, MN
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35
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Gangaram V, Vilpakka M, Goffin E, Weinhandl ED, Kubisiak KM, Borman N. Nocturnal home hemodialysis with low-flow dialysate: Retrospective analysis of the first European patients. Hemodial Int 2019; 24:175-181. [PMID: 31820557 DOI: 10.1111/hdi.12808] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2019] [Revised: 10/31/2019] [Accepted: 11/23/2019] [Indexed: 12/19/2022]
Abstract
INTRODUCTION Despite mounting evidence that increased frequency and duration of hemodialysis (HD) improves outcomes, less than 1% of HD patients worldwide receive nocturnal hemodialysis (NHD). Many perceived barriers exist to providing NHD and increasing its provision. METHODS A retrospective analysis of nocturnal therapy using a low-flow dialysate system in 4 European centers for a minimum of 12 months, with data collected on patient demographics, training times, safety features, medications, and biochemical parameters at baseline and at 6 and 12 months. FINDINGS Data were collected on 21 patients, with 12-month analysis available for 20 patients. Mean dialysis duration was 28 hours per week, with most dialysis on an alternate night regimen using 50-60 L of dialysate per session. All vascular access types were represented, and low molecular weight heparin was used as a bolus. All biochemical parameters met European standards, with a trend for improvement in standardized Kt/V, phosphate, hemoglobin, and albumin. There was a significant reduction in phosphate binder usage and a reduction in blood pressure medication. Training time was 9.6 sessions for independence at home, with 2 additional sessions to transition to NHD. Additional safety features included an alarmed drip tray under the cycler and moisture sensors under the venous needle (all patients used dual-cannulation technique). No patient safety events were reported. DISCUSSION These data support the use of a low-flow dialysate system for provision of NHD at home. Biochemical parameters were good, medication burden was reduced at 12 months, and all patients received more than double the duration of HD provided in standard in-center units. While patient numbers were small, low-flow dialysis in this cohort was both effective and safe. Use of this alternative HD system could reduce some of the barriers to NHD, increasing the uptake of therapy in Europe, and improving long-term patient outcomes.
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Affiliation(s)
- Venkat Gangaram
- Queen Alexandra Hospital, Wessex Kidney Centre, Portsmouth, UK
| | | | - Eric Goffin
- Cliniques Universitaires Saint-Luc, Woluwe-Saint-Lambert, Belgium
| | - Eric D Weinhandl
- Fresenius Medical Care North America, Waltham, Massachusetts, USA
| | | | - Natalie Borman
- Queen Alexandra Hospital, Wessex Kidney Centre, Portsmouth, UK
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36
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Affiliation(s)
- Robert J. Kossmann
- Chief Medical Officer, Fresenius Medical Care North America, Waltham, Massachusetts; and
| | - Eric D. Weinhandl
- Chief Medical Officer, Fresenius Medical Care North America, Waltham, Massachusetts; and
- Department of Pharmaceutical Care and Health Systems, University of Minnesota, Minneapolis, Minnesota
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Leypoldt JK, Kraus MA, Jaber BL, Weinhandl ED, Collins AJ. Effect of dialysate potassium and lactate on serum potassium and bicarbonate concentrations during daily hemodialysis at low dialysate flow rates. BMC Nephrol 2019; 20:252. [PMID: 31288787 PMCID: PMC6617706 DOI: 10.1186/s12882-019-1450-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2019] [Accepted: 07/01/2019] [Indexed: 12/29/2022] Open
Abstract
Background Observational studies of hemodialysis patients treated thrice weekly have shown that serum and dialysate potassium and bicarbonate concentrations are associated with patient outcomes. The effect of more frequent hemodialysis on serum potassium and bicarbonate concentrations has rarely been studied, especially for treatments at low dialysate flow rate. Methods These post-hoc analyses evaluated data from patients who transferred from in-center hemodialysis (HD) to daily HD at low dialysate flow rates during the FREEDOM Study. The primary outcomes were the change in predialysis serum potassium and bicarbonate concentrations after transfer from in-center HD (mean during the last 3 months) to daily HD (mean during the first 3 months). Results After transfer from in-center HD to daily HD (data from 345 patients, 51 ± 15 years of age, mean ± standard deviation), predialysis serum potassium decreased (P < 0.001) by approximately 0.4 mEq/L when dialysate potassium concentration during daily HD was 1 mEq/L; no change occurred when dialysate potassium concentration during daily HD was 2 mEq/L. After transfer from in-center HD to daily HD (data from 284 patients, 51 ± 15 years of age), predialysis serum bicarbonate concentration decreased (P = 0.0022) by 1.0 ± 3.3 mEq/L when dialysate lactate concentration was 40 mEq/L but increased (P < 0.001) by 2.5 ± 3.5 mEq/L when dialysate lactate concentration was 45 mEq/L. These relationships were dependent on serum potassium and bicarbonate concentrations during in-center HD. Conclusions Control of serum potassium and bicarbonate concentrations during daily HD at low dialysate flow rates is readily achievable; the choice of dialysate potassium and lactate concentration can be informed when transfer is from in-center HD to daily HD. Electronic supplementary material The online version of this article (10.1186/s12882-019-1450-7) contains supplementary material, which is available to authorized users.
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Affiliation(s)
| | | | | | - Eric D Weinhandl
- NxStage Medical, Lawrence, MA, USA.,Department of Pharmaceutical Care and Health Systems, University of Minnesota, Minneapolis, MN, USA
| | - Allan J Collins
- NxStage Medical, Lawrence, MA, USA.,Medical School, University of Minnesota, Minneapolis, MN, USA
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Weinhandl ED, Kubisiak KM, Wetmore JB. Low Quality of International Classification of Diseases, 10th Revision, Procedural Coding System Data Undermines the Validity of the Standardized Transfusion Ratio: Time to Chart a New Course? Adv Chronic Kidney Dis 2019; 26:237-249. [PMID: 31477254 DOI: 10.1053/j.ackd.2019.04.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2019] [Revised: 04/24/2019] [Accepted: 04/30/2019] [Indexed: 11/11/2022]
Abstract
The validity of the standardized transfusion ratio, a quality measure for dialysis facilities, may have been affected by the transition from International Classification of Diseases, Ninth Revision (ICD-9) to International Classification of Diseases, Tenth Revision (ICD-10) procedure coding in October 2015. We analyzed Medicare Part A claims for inpatient care among dialysis patients in 2014-2017 and investigated billing patterns for blood transfusion during the last year of ICD-9 coding and the first and second years of ICD-10 coding. We identified 2205 hospitals with a steady volume of dialysis patient admissions. In nearly one-third (31.7%) of hospitals, the apparent incidence of blood transfusion during hospitalization fell >50% between the last year of ICD-9 coding and the first year of ICD-10 coding. Between the first and second years of ICD-10 coding, the apparent incidence of blood transfusion during hospitalization fell >20% in 24.5% of hospitals and rose >25% in 14.8% of hospitals. Furthermore, hospital-specific changes in the apparent incidence of blood transfusion among dialysis patients and all Medicare beneficiaries were highly correlated. These findings suggest that the standardized transfusion ratio reflects differential misclassification of transfusions among hospitals. Alternative measures to judge the quality of anemia management, such as attainment of hemoglobin within a target range, may be more appropriate.
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Weinhandl ED, Ray D, Kubisiak KM, Collins AJ. Contemporary Trends in Clinical Outcomes among Dialysis Patients with Medicare Coverage. Am J Nephrol 2019; 50:63-71. [PMID: 31203279 DOI: 10.1159/000500943] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Accepted: 04/30/2019] [Indexed: 11/19/2022]
Abstract
BACKGROUND The dialysis patient population in the United States continues to grow. Trends in rates of death and hospitalization among dialysis patients have important consequences for outpatient dialysis capacity and Medicare spending. OBJECTIVES To estimate contemporary trends in rates of death and hospitalization among dialysis patients in the United States, overall and within subgroups. METHODS We used Medicare Limited Data Sets (100% sample) in 2014-2017 to estimate trends in rates of death and hospitalization among dialysis patients with Medicare Parts A and B enrollment. We used seasonal autoregressive integrated moving average models to identify secular trends in the incidence of outcomes. RESULTS There were 631,075 unique patients; 222,924 deaths; and 1,876,779 hospital admissions. Weekly risks of both death and hospitalization exhibited strong seasonality. However, overall weekly risks of death were 34.9, 35.4, 35.2, and 35.7 deaths per 10,000 patients in 2014-2017, respectively (p = 0.47, from a likelihood ratio test of secular trend). The overall weekly risk of hospitalization was 3.08, 3.05, 3.11, and 3.11% in 2014, 2015, 2016, and 2017, respectively (p = 0.30). There were significant secular trends in risk of death in subgroups defined by black race and residency in South Atlantic states (p < 0.05). There were also secular trends in risk of hospitalization in subgroups defined by age 20-44 years, concurrent enrollment in Medicaid, and residency in South Central states. CONCLUSION For the first time since the beginning of this century, rates of both death and hospitalization among dialysis patients with Medicare fee-for-service coverage have stagnated. The reasons for this change are unknown and require detailed assessment. Persistent lack of change in clinical outcomes may alter the future expectations about dialysis patient population growth.
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Affiliation(s)
- Eric D Weinhandl
- NxStage Medical, Medical Affairs, Lawrence, Massachusetts, USA,
- Department of Pharmaceutical Care and Health Systems, University of Minnesota, Minneapolis, Minnesota, USA,
| | - Debabrata Ray
- NxStage Medical, Medical Affairs, Lawrence, Massachusetts, USA
| | | | - Allan J Collins
- NxStage Medical, Medical Affairs, Lawrence, Massachusetts, USA
- Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA
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Weinhandl ED. Piecing Together the Risk of Sudden Cardiac Death on Dialysis. J Am Soc Nephrol 2019; 30:521-523. [DOI: 10.1681/asn.2019020185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
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41
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Kansal SK, Morfin JA, Weinhandl ED. Survival and Kidney Transplant Incidence on Home versus In-Center Hemodialysis, following Peritoneal Dialysis Technique Failure. Perit Dial Int 2019; 39:25-34. [DOI: 10.3747/pdi.2017.00207] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2017] [Accepted: 05/09/2018] [Indexed: 02/01/2023] Open
Abstract
Background Peritoneal dialysis (PD) technique failure is often accompanied by complications that increase risks of hospitalization and death. Planned transition to hemodialysis may improve outcomes. Transitioning patients from PD to home hemodialysis (HHD) may improve continuity of lifestyle and facilitate delivery of more frequent treatment. Methods We analyzed United States Renal Data System (USRDS) data to compare the incidence of death and kidney transplant in patients who transferred from PD to HHD and matched patients who transferred from PD to in-center HD (IHD). We used Fine-Gray regression to estimate hazard ratios (HRs) of death and transplant for HHD versus IHD. Results We identified 521 patients who transferred from PD to HHD. Survival in HHD patients was 89.1% at 1 year and 80.5% at 2 years. In intention-to-treat analysis, the HR of death for HHD versus matched IHD patients was 0.76 (95% confidence interval [CI] 0.65 – 0.90). In subsets of non-Medicare and Medicare patients, corresponding HRs were 0.57 (95% CI 0.43 – 0.75) and 0.92 (95% CI 0.75 – 1.13), respectively. Kidney transplant incidence in HHD patients was 10.6% at 1 year and 21.0% at 2 years. In modified intention-to-treat analysis, the HR of transplant for HHD versus matched IHD patients was 1.36 (1.14 – 1.61). Conclusions Transfer to HHD after PD technique failure was rare, but associated with lower risk of death and higher incidence of transplant than transfer to IHD. Heterogeneity in relative risks by Medicare coverage suggests uncertainty about the magnitude of benefit. Still, these data suggest that clinical outcomes after PD technique failure can be improved.
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Affiliation(s)
- Sheru K. Kansal
- Division of Nephrology, University Hospitals, Cleveland, OH, United States
| | - Jose A. Morfin
- Division of Nephrology, UC Davis Health System, Sacramento, CA, United States
| | - Eric D. Weinhandl
- NxStage Medical, Inc., Lawrence, MA, United States
- Department of Pharmaceutical Care and Health Systems, University of Minnesota, Minneapolis, MN, United States
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42
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Affiliation(s)
- Eric D. Weinhandl
- Medical Affairs, NxStage Medical, Lawrence, Massachusetts; and
- Pharmaceutical Care and Health Systems, University of Minnesota, Minneapolis, Minnesota
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43
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Leypoldt JK, Weinhandl ED, Collins AJ. Volume of urea cleared as a therapy dosing guide for more frequent hemodialysis. Hemodial Int 2018; 23:42-49. [PMID: 30255600 DOI: 10.1111/hdi.12692] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2018] [Revised: 08/05/2018] [Indexed: 01/29/2023]
Abstract
INTRODUCTION With dialysis delivery systems that operate at low dialysate flow rates, prescriptions for more frequent hemodialysis (HD) employ dialysate volume as the primary parameter for small solute removal rather than blood-side urea dialyzer clearance (K). Such delivery systems, however, yield dialysate concentrations that almost completely saturate with blood (water), suggesting that the volume of urea cleared (the product of K and treatment time or Kt) can be readily estimated from the prescribed dialysate volume to target small solute removal. Methods For more frequent HD, we examined the volume of urea cleared per treatment required to achieve a minimal dose of small solute removal, comparing results based on body surface area (BSA) with those based on KDOQI clinical practice guidelines, that is, a weekly stdKt/V of 2.1. Estimates of the target volume of urea cleared were calculated for 4, 5, and 6 treatments per week, and compared for patients with different anthropometric estimates of total body water volume (Vant ). BSA was assumed proportional to Vant 0.8 , and residual kidney function was neglected. Findings Whether based on BSA or weekly stdKt/V of 2.1, the target volume of urea cleared per treatment required to achieve a minimal dose of small solute removal was lower at higher treatment frequency. As with conventional thrice-weekly HD, target volumes of urea cleared for more frequent HD based on BSA were larger for patients with small Vant and smaller for patients with large Vant than those based on a weekly stdKt/V of 2.1. Discussion Prescription of more frequent HD using the volume of urea cleared per treatment, calculated from the prescribed dialysate volume, is simple in principle and can be readily implemented in clinical practice when using dialysis delivery systems that operate at low dialysate flow rates. Other aspects of dialysis adequacy require additional consideration.
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Affiliation(s)
| | - Eric D Weinhandl
- NxStage Medical, Lawrence, Massachusetts, USA.,Department of Pharmaceutical Care and Health Systems, University of Minnesota, Minneapolis, Minnesota, USA
| | - Allan J Collins
- NxStage Medical, Lawrence, Massachusetts, USA.,Medical School, University of Minnesota, Minneapolis, Minnesota, USA
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Affiliation(s)
- Eric D Weinhandl
- Pharmaceutical Care and Health Systems, University of Minnesota, Minneapolis, Minnesota
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Westberg SM, Yarbrough A, Weinhandl ED, Adam TJ, Brummel AR, Reidt SL, Sick BT, St Peter WL. Drug Therapy Problem Severity Following Hospitalization and Association With 30-Day Clinical Outcomes. Ann Pharmacother 2018; 52:1195-1203. [PMID: 29888615 DOI: 10.1177/1060028018781919] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Improved understanding of how drug therapy problems (DTPs) contribute to rehospitalization is needed. OBJECTIVE The primary objectives were to assess the association of DTP likelihood of harm (LoH) severity score, as measured by comprehensive medication management (CMM) pharmacist after hospital discharge, with 30-day risk of hospital readmission, observation visit, or emergency department visit, and to determine whether resolution of DTPs reduces 30-day risk. Secondary objectives were to determine if any eventswere associated with DTPs and preventability of events. METHODS Data were collected for 365 patients who received CMM following hospitalization and had at least 1 DTP identified. Retrospective chart reviews were completed for 80 patients with subsequent events to assess associationg with a DTP and its preventability. RESULTS For each 1-point increment in maximum LoH score, there was 10% higher risk of the composite end point (hazard ratio [HR]=1.10; 95% CI:0.97-1.26; P=0.13). When DTPs were resolved by the CMM pharmacist, the association was attenuated, with a HR of 1.15 (95% CI:0.96-1.38; P=0.12) when the DTP was unresolved and HR of 1.09 (95% CI:0.96-1.25; P=0.52) when resolved; for hospital readmission alone, the corresponding HRs were 1.23 (95% CI:1.00-1.53; P=0.05) and 1.05 (95% CI:0.87-1.27; P=0.60). Of 80 subsequent events, 44 were associated with a medication; 22 were considered preventable. Conclusion and Relevance: The LoH severity score was associated with risk of 30-day events. The strength of association was attenuated when DTPs were resolved by the CMM pharmacist. However, because of statistical uncertainty, larger studies are needed to confirm these patterns.
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Affiliation(s)
- Sarah M Westberg
- 1 University of Minnesota College of Pharmacy, Minneapolis, MN, USA
| | | | - Eric D Weinhandl
- 1 University of Minnesota College of Pharmacy, Minneapolis, MN, USA
| | - Terrence J Adam
- 1 University of Minnesota College of Pharmacy, Minneapolis, MN, USA
| | | | - Shannon L Reidt
- 1 University of Minnesota College of Pharmacy, Minneapolis, MN, USA
| | - Brian T Sick
- 4 University of Minnesota School of Medicine, Minneapolis, MN, USA
| | - Wendy L St Peter
- 1 University of Minnesota College of Pharmacy, Minneapolis, MN, USA
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St. Peter WL, Wazny LD, Weinhandl ED. Phosphate-Binder Use in US Dialysis Patients: Prevalence, Costs, Evidence, and Policies. Am J Kidney Dis 2018; 71:246-253. [DOI: 10.1053/j.ajkd.2017.09.007] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2017] [Accepted: 09/19/2017] [Indexed: 01/15/2023]
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Abstract
INTRODUCTION Home hemodialysis (HHD) facilitates increased treatment frequency, which may improve patient outcomes. However, attrition due to technique failure limits the clinical effectiveness of the modality. Nx2me Connected Health is a telehealth platform that enables ongoing assessment of HHD patients using NxStage equipment, and that may reduce patient burden. We aimed to assess whether use of Nx2me was associated with risk of HHD attrition. METHODS We compared risks of all-cause attrition, dialysis cessation (i.e., death or transplant), and technique failure in Nx2me users and matched control patients, using a retrospective cohort study. We also compared the likelihood of HHD training graduation in patients who initiated use of Nx2me during training with the likelihood in matched control patients. Matching factors included date of HHD initiation, NxStage treatment duration at initiation of follow-up, and prescribed treatment frequency. We used stratified Fine-Gray and Cox regression to compare risks, with adjustment for demographic factors and vascular access modality, and stratification by matched cluster. FINDINGS We identified 606 Nx2me users; 49.5% initiated use of Nx2me in <3 months after initiation of HHD with NxStage equipment. Adjusted hazard ratios (AHRs) of all-cause attrition, dialysis cessation, and technique failure were 0.80 (95% confidence interval, 0.68-0.95), 1.10 (0.86-1.41), and 0.71 (0.57-0.87), respectively, for Nx2me users vs. matched controls. AHRs were similar in patients who initiated use of Nx2me in <3 months after initiation of HHD. The AHR of HHD training graduation was 1.61 (1.10-2.36) in patients who initiated use of Nx2me within 2 weeks of training initiation vs. matched controls. DISCUSSION Use of Nx2me was associated with lower risk of all-cause attrition, lower risk of technique failure, and higher likelihood of HHD training graduation. Further studies are needed to identify the mechanisms by which use of a telehealth platform may improve clinical outcomes and reduce patient burden.
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Affiliation(s)
- Eric D Weinhandl
- NxStage Medical, Inc., Lawrence, Massachusetts, USA.,Department of Pharmaceutical Care and Health Systems
| | - Allan J Collins
- NxStage Medical, Inc., Lawrence, Massachusetts, USA.,Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA
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Westberg SM, Derr SK, Weinhandl ED, Adam TJ, Brummel AR, Lahti J, Reidt SL, Sick BT, Skiermont KF, St. Peter WL. Drug Therapy Problems Identified by Pharmacists Through Comprehensive
Medication Management Following Hospital Discharge. J Pharm Technol 2017; 33:96-107. [PMCID: PMC5998417 DOI: 10.1177/8755122517698975] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/01/2023] Open
Abstract
Background: Pharmacists influence health care outcomes through the identification and resolution of drug therapy problems (DTPs). Objective: The objectives of this study were to describe number, type, and severity of DTPs based on clinical significance and likelihood of harm in patients transitioning from hospital to home as assessed during a comprehensive medication management (CMM) visit with a pharmacist. Secondary objectives were to assess intrarater reliability in severity ratings and assess likelihood of harm for adverse drug reactions (ADR) by drug classes. Methods: Retrospective review of 408 patients having a face-to-face, telephonic, or virtual CMM visit within the Fairview Health System. Teams of 3 investigators reviewed each DTP from the electronic medical record for each of the 408 patients and assigned a severity score (0-10) for clinical significance and likelihood of harm. Main Results: The highest severity DTP classes were adherence and ADR. The lowest severity DTP class was unnecessary drug therapy. An average of 2.5 DTPs was found per patient at the index CMM visit following hospital discharge. The most common DTP classes were needs additional therapy and dose too low. There were statistically significant differences in DTP severity scoring between reviewer types, though differences were <5%. Drug classes with the highest severity ADR included diabetes, cardiovascular, and anticoagulant/antiplatelet agents. Conclusions: The DTP severity ratings indicated that reviewers found ADR and adherence DTPs were potentially the most severe. There were differences in DTP ratings between reviewer types, though clinical significance of these differences is unclear.
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Affiliation(s)
| | | | | | | | | | - Joseph Lahti
- Fairview Pharmacy Services, Minneapolis,
MN, USA
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Kraus MA, Kansal S, Copland M, Komenda P, Weinhandl ED, Bakris GL, Chan CT, Fluck RJ, Burkart JM. Intensive Hemodialysis and Potential Risks With Increasing Treatment. Am J Kidney Dis 2017; 68:S51-S58. [PMID: 27772644 DOI: 10.1053/j.ajkd.2016.05.020] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2016] [Accepted: 05/25/2016] [Indexed: 12/27/2022]
Abstract
Although intensive hemodialysis (HD) can address important clinical problems, increasing treatment also introduces risks. In this review, we assess risks pertaining to 6 domains: vascular access complications, infection, mortality, loss of residual kidney function, solute balance, and patient and care partner burden. In the Frequent Hemodialysis Network (FHN) trials, short daily and nocturnal schedules increased the incidence of access complications, although the incidence of access loss was not statistically higher. Observational studies indicate that infection-related hospitalization is an ongoing challenge with short daily HD. Excess risk may be catalyzed by poor infection control practices in the home setting in which intensive HD is typically delivered, but with fixed probability of bacterial contamination per cannulation, greater treatment frequency necessarily increases the risk for infectious complications. Buttonhole cannulation may increase the risk for metastatic infections. However, intensive HD in the home setting is associated with lower risk for infection than peritoneal dialysis. Data regarding mortality are equivocal. With extended follow-up of individuals in the FHN trials, short daily HD was associated with lower risk relative to the usual schedule, whereas nocturnal HD was associated with higher risk. In many, but not all, observational studies, short daily HD has been associated with lower risk than both in-center HD and peritoneal dialysis; however, observational studies are subject to unmeasured confounding. Intensive HD can accelerate the loss of residual kidney function in new dialysis patients with substantial urine output and can deplete solutes (eg, phosphorus) to the extent that supplementation is necessary. Finally, intensive HD may increase burden on patients and caregivers, possibly leading to technique failure. Some of these problems might be addressed with careful monitoring, so that relevant interventions (eg, antibiotics, retraining, and respite care) can be delivered. Ultimately, intensive HD is not a panacea for end-stage renal disease. Potential benefits and risks of treatment should be jointly considered.
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Affiliation(s)
| | - Sheru Kansal
- Department of Nephrology and Hypertension, Cleveland Clinic, Cleveland, OH
| | - Michael Copland
- Division of Nephrology, University of British Columbia, Vancouver, Canada
| | - Paul Komenda
- Section of Nephrology, Department of Medicine, University of Manitoba, Winnipeg, Canada; Department of Community Health Sciences, University of Manitoba, Winnipeg, Canada; Seven Oaks General Hospital Renal Program, Winnipeg, Canada
| | - Eric D Weinhandl
- Department of Pharmaceutical Care and Health Systems, College of Pharmacy, University of Minnesota, Minneapolis, MN.
| | - George L Bakris
- American Society of Hypertension Comprehensive Hypertension Center, Section of Endocrinology, Diabetes, and Metabolism, Department of Medicine, University of Chicago Medicine, Chicago, IL
| | - Christopher T Chan
- Division of Nephrology, Department of Medicine, University Health Network, Toronto, Canada
| | - Richard J Fluck
- Department of Renal Medicine, Royal Derby Hospital, Derby, United Kingdom
| | - John M Burkart
- Wake Forest University Medical Center, Winston-Salem, NC
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Wetmore JB, Weinhandl ED, Zhou J, Gilbertson DT. Relative Incidence of Acute Adverse Events with Ferumoxytol Compared to Other Intravenous Iron Compounds: A Matched Cohort Study. PLoS One 2017; 12:e0171098. [PMID: 28135334 PMCID: PMC5279762 DOI: 10.1371/journal.pone.0171098] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2016] [Accepted: 01/16/2017] [Indexed: 01/23/2023] Open
Abstract
Concerns persist about adverse reactions to intravenous (IV) iron. We aimed to determine the relative safety of ferumoxytol compared to other IV iron compounds. This retrospective cohort study with propensity-score matching for patients and drug doses used the Medicare 20% random sample to identify patients (1) without chronic kidney disease (non-CKD) and (2) with non-dialysis-dependent chronic kidney disease (NDD-CKD) who received a first dose of IV iron in 2010–2012. Exposures were ferumoxytol, iron sucrose, sodium ferric gluconate, or iron dextran. Outcomes were hypersensitivity symptoms, anaphylaxis, emergency department (ED) encounters, hospitalizations, and death after acute IV iron exposure. In the primary analysis for reactions on the day of or following exposure, there was no difference in hypersensitivity symptoms (hazard ratio 1.04, 95% confidence interval 0.94–1.16) or hypotension (0.83, 0.52–1.34) between 4289 non-CKD ferumoxytol users and an equal number of users of other compounds; results were similar for 7358 NDD-CKD patients and an equal number of controls. All-cause ED encounters or hospitalizations were less common in both the non-CKD (0.56, 0.45–0.70) and NDD-CKD ferumoxytol-treated patients (0.83, 0.71–0.95). Fewer than 10 deaths occurred in both the non-CKD and NDD-CKD ferumoxytol users and in matched controls; the hazard for death did not differ significantly between ferumoxytol users and controls in the non-CKD patients (2.00, 0.33–11.97) or in the NDD-CKD patients (0.25, 0.04–1.52). Multiple sensitivity analyses showed similar results. Ferumoxytol did not appear to be associated with more adverse reactions than other compounds for the treatment of iron-deficiency anemia in both non-CKD and NDD-CKD patients.
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Affiliation(s)
- James B. Wetmore
- Chronic Disease Research Group, Minneapolis Medical Research Foundation, Minneapolis, Minnesota, United States of America
- Division of Nephrology, Hennepin County Medical Center, Minneapolis, Minnesota, United States of America
- * E-mail:
| | - Eric D. Weinhandl
- Chronic Disease Research Group, Minneapolis Medical Research Foundation, Minneapolis, Minnesota, United States of America
| | - Jincheng Zhou
- Chronic Disease Research Group, Minneapolis Medical Research Foundation, Minneapolis, Minnesota, United States of America
| | - David T. Gilbertson
- Chronic Disease Research Group, Minneapolis Medical Research Foundation, Minneapolis, Minnesota, United States of America
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