Employment among Patients Starting Dialysis in the United States.
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ABSTRACT:
SUBMITTER: Erickson KF
PROVIDER: S-EPMC5967428 | biostudies-literature | 2018 Feb
REPOSITORIES: biostudies-literature
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Project description:Aggressive pain treatment was advocated for ESRD patients, but new Centers for Disease Control and Prevention guidelines recommend cautious opioid prescription. Little is known regarding outcomes associated with ESRD opioid prescription. We assessed opioid prescriptions and associations between opioid prescription and dose and patient outcomes using 2006-2010 US Renal Data System information in patients on maintenance dialysis with Medicare Part A, B, and D coverage in each study year (n=671,281, of whom 271,285 were unique patients). Opioid prescription was confirmed from Part D prescription claims. In the 2010 prevalent cohort (n=153,758), we examined associations of opioid prescription with subsequent all-cause death, dialysis discontinuation, and hospitalization controlled for demographics, comorbidity, modality, and residence. Overall, >60% of dialysis patients had at least one opioid prescription every year. Approximately 20% of patients had a chronic (?90-day supply) opioid prescription each year, in 2010 usually for hydrocodone, oxycodone, or tramadol. In the 2010 cohort, compared with patients without an opioid prescription, patients with short-term (1-89 days) and chronic opioid prescriptions had increased mortality, dialysis discontinuation, and hospitalization. All opioid drugs associated with mortality; most associated with worsened morbidity. Higher opioid doses correlated with death in a monotonically increasing fashion. We conclude that opioid drug prescription is associated with increased risk of death, dialysis discontinuation, and hospitalization in dialysis patients. Causal relationships cannot be inferred, and opioid prescription may be an illness marker. Efforts to treat pain effectively in patients on dialysis yet decrease opioid prescriptions and dose deserve consideration.
| S-EPMC5698071 | biostudies-other
Project description:BackgroundWhile some prediction models have been developed for diabetic populations, prediction rules for mortality in diabetic dialysis patients are still lacking. Therefore, the objective of this study was to identify predictors for 1-year mortality in diabetic dialysis patients and use these results to develop a prediction model.MethodsData were used from the Netherlands Cooperative Study on the Adequacy of Dialysis (NECOSAD), a multicenter, prospective cohort study in which incident patients with end stage renal disease (ESRD) were monitored until transplantation or death. For the present analysis, patients with DM at baseline were included. A prediction algorithm for 1-year all-cause mortality was developed through multivariate logistic regression. Candidate predictors were selected based on literature and clinical expertise. The final model was constructed through backward selection. The model's predictive performance, measured by calibration and discrimination, was assessed and internally validated through bootstrapping.ResultsA total of 394 patients were available for statistical analysis; 82 (21%) patients died within one year after baseline (3 months after starting dialysis therapy). The final prediction model contained seven predictors; age, smoking, history of macrovascular complications, duration of diabetes mellitus, Karnofsky scale, serum albumin and hemoglobin level. Predictive performance was good, as shown by the c-statistic of 0.810. Internal validation showed a slightly lower, but still adequate performance. Sensitivity analyses showed stability of results.ConclusionsA prediction model containing seven predictors has been identified in order to predict 1-year mortality for diabetic incident dialysis patients. Predictive performance of the model was good. Before implementing the model in clinical practice, for example for counseling patients regarding their prognosis, external validation is necessary.
| S-EPMC3942369 | biostudies-literature
Project description:BACKGROUND AND OBJECTIVES:Veterans with ESKD initiate dialysis under the Veterans Health Administration (VHA), an integrated health system, or are outsourced to non-VHA providers. It is unknown whether outcomes differ according to their dialysis provider at initiation. We sought to evaluate the association between dialysis provider and mortality and hospitalization among United States veterans initiating dialysis. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS:Among 68,727 United States veterans who initiated dialysis in 2007-2014, we examined the association of dialysis provider (VHA versus non-VHA) at initiation with mortality and hospitalization rates in the first 12 months post-initiation. Associations were examined across adjusted models, accounting for demographics and comorbidities. RESULTS:Patients were 72±11 years, 5% were women, 24% were black, and 10% (n=7584) initiated at VHA dialysis centers. VHA dialysis center patients were younger, more likely to be black, had fewer cardiovascular comorbidities, and lower eGFR at dialysis initiation. VHA provider patients were more likely to be hospitalized in the first 12 months (adjusted incidence rate ratio, 1.10; 95% confidence interval, 1.07 to 1.14), but had lower all-cause mortality risk (adjusted hazard ratio, 0.87; 95% confidence interval, 0.83 to 0.93) in fully adjusted models. CONCLUSIONS:Veteran patients initiating dialysis with a VHA dialysis provider appear to have a lower mortality risk but higher hospitalization rates than veterans initiating dialysis at non-VHA dialysis units.
| S-EPMC6032569 | biostudies-literature
Project description:Very early withdrawal from treatment in patients undergoing peritoneal dialysis (PD) is an increasingly important, but poorly understood, issue. Here, we identified the reasons and risk factors for very early withdrawal from PD.Incident PD patients from The First Affiliated Hospital of Sun Yat-sen University above 18?years who started treatment between January 1 2006 and December 31 2011 were included. Cessation of PD therapy within the first 90?days after beginning dialysis was classified as very early withdrawal.Totally 1444 patients were enrolled. Of these, 71 (4.9%) withdrew from PD therapy during the first 90?days. Primary reasons for very early withdrawal included death (34 patients, 47.9%), transplantation (21 patients, 29.6%) and transfer to hemodialysis (14 patients, 19.7%). The leading reasons for death were cardiovascular and infectious disease, accounting for 41.2% (14 patients) and 23.5% (8 patients) of total deaths, respectively. Dialysate leakage (six patients, 42.9%) and catheter dysfunction (five patients, 35.7%) were the main reasons for transfer to hemodialysis. In multivariate analysis, predictors for very early PD withdrawal were older age (per decade increasing; hazard ratio [HR], 1.22; 95% confidence interval [CI], 1.03-1.45; p?=?.019), higher systolic blood pressure (per 10?mmHg increasing; HR, 1.35; 95% CI, 1.20-1.50; p?<?.001), lower hemoglobin (per 10?g/l increasing; HR, 0.67; 95% CI, 0.57-0.78; p?<?.001), lower high-density lipoprotein cholesterol (HR, 0.24; 95% CI, 0.10-0.54; p?=?.001) and lower residual urine volume (per 100?ml/d increasing; HR, 0.90; 95% CI, 0.84-0.95; p?=?.001).Death was the primary reason for very early withdrawal from PD. Risk factors for very early withdrawal from PD were older in age, had higher systolic blood pressure, lower hemoglobin, lower high-density lipoprotein cholesterol and lower residual urine volume.
| S-EPMC6014309 | biostudies-other
Project description:Objective This longitudinal study aimed to measure precarious employment in the US using a multidimensional indicator. Methods We used data from the National Longitudinal Survey of Youth (1988-2016) and the Occupational Information Network database to create a longitudinal precarious employment score (PES) among 7568 employed individuals over 18 waves (N=101 290 observations). We identified 13 survey indicators to operationalize 7 dimensions of precarious employment, which we included in our PES (range: 0-7, with 7 indicating the most precarious): material rewards, working-time arrangements, stability, workers' rights, collective organization, interpersonal relations, and training. Using generalized estimating equations, we estimated the mean PES and changes over time in the PES overall and by race/ethnicity, gender, education, income, and region. Results On average, the PES was 3.17 [standard deviation (SD) 1.19], and was higher among women (3.34, SD 1.20), people of color (Hispanics: 3.24, SD 1.23; non-Hispanic Blacks: 3.31, SD 1.23), those with less education (primary: 3.99, SD 1.07; high school: 3.43, SD 1.19), and with lower-incomes (3.84, SD 1.08), and those residing in the South (3.23, SD 1.17). From 1988 to 2016, the PES increased by 9% on average [0.29 points; 95% confidence interval (CI) 0.26-0.31]. While precarious employment increased over time across all subgroups, the increase was largest among males (0.35 points; 95% CI 0.33-0.39), higher-income (0.39 points; 95% CI 0.36-0.42) and college-educated (0.37 points; 95% CI 0.33-0.41) individuals. Conclusions Long-term decreases in employment quality are widespread in the US. Women and those from racialized and less-educated populations remain disproportionately precariously employed; however, we observed the largest increases among men, college graduates and higher-income individuals.
| S-EPMC8126438 | biostudies-literature
Project description:Precarious employment has increased in the United States and is now recognized as an important social determinant of health. Women are disproportionately employed in precarious jobs and are largely responsible for caretaking, which could deleteriously affect child weight. We utilized data from the National Longitudinal Survey of Youth adult and child cohorts (1996-2016; N = 4453) and identified 13 survey indicators to operationalize 7 dimensions of precarious employment (score range: 0-7, 7 indicating the most precarious): material rewards, working-time arrangements, stability, workers' rights, collective organization, interpersonal relations, and training. We estimated the association between maternal precarious employment and incident child overweight/obesity (BMI ≥85th percentile) using adjusted Poisson models. Between 1996 and 2016, the average age-adjusted precarious employment score among mothers was 3.7 (Standard Error [SE] = 0.02) and the average prevalence of children with overweight/obesity was 26.2% (SE = 0.5%). Higher maternal precarious employment was associated with a 10% higher incidence of children having overweight/obesity (Confidence Interval: 1.05, 1.14). A higher incidence of childhood overweight/obesity may have important implications at the population-level, due to the long-term health consequences of child obesity into adulthood. Policies to reduce employment precariousness should be considered and monitored for impacts on childhood obesity.
| S-EPMC10041450 | biostudies-literature
Project description:BACKGROUND:End-of-life care is a prominent consideration in patients on maintenance dialysis, especially when death appears imminent and quality of life is poor. To date, examination of race- and ethnicity-associated disparities in end-of-life care for patients with ESRD has largely been restricted to comparisons of white and black patients. METHODS:We performed a retrospective national study using United States Renal Data System files to determine whether end-of-life care in United States patients on dialysis is subject to racial or ethnic disparity. The primary outcome was a composite of discontinuation of dialysis and death in a nonhospital or hospice setting. RESULTS:Among 1,098,384 patients on dialysis dying between 2000 and 2014, the primary outcome was less likely in patients from any minority group compared with the non-Hispanic white population (10.9% versus 22.6%, P<0.001, respectively). We also observed similar significant disparities between any minority group and non-Hispanic whites for dialysis discontinuation (16.7% versus 31.2%), as well as hospice (10.3% versus 18.1%) and nonhospital death (34.4% versus 46.4%). After extensive covariate adjustment, the primary outcome was less likely in the combined minority group than in the non-Hispanic white population (adjusted odds ratio, 0.55; 95% confidence interval, 0.55 to 0.56; P<0.001). Individual minority groups (non-Hispanic Asian, non-Hispanic black, non-Hispanic Native American, and Hispanic) were significantly less likely than non-Hispanic whites to experience the primary outcome. This disparity was especially pronounced for non-Hispanic Native American and Hispanic subgroups. CONCLUSIONS:There appear to be substantial race- and ethnicity-based disparities in end-of-life care practices for United States patients receiving dialysis.
| S-EPMC6115657 | biostudies-literature
Project description:Background:People with end-stage kidney disease receiving peritoneal dialysis (PD) are generally physically inactive and frail. Exercise studies in PD are scarce and currently there are no PD exercise programs in the United States. The primary objective of this study was to test the feasibility of a combined resistance and cardiovascular exercise program for PD patients under the care of a dedicated home dialysis center in the United States. Study Design:Parallel randomized controlled feasibility study. Setting & Participants:PD patients were recruited from a single center and randomly assigned to the intervention (exercise; n = 18) or control (nonexercise; n = 18) group. Intervention:The intervention group received monthly exercise physiologist consultation, exercise prescription (resistance and aerobic exercise program using exercise bands), and 4 exercise support telephone calls over 12 weeks. The control group received standard care. Outcomes:The primary outcome was study feasibility as measured by eligibility rates, recruitment rates, retention rates, adherence rates, adverse events, and sustained exercise rates. Secondary outcome measures were changes in physical function (sit-to-stand test, timed-up-and-go test, and pinch-strength tests) and patient-reported outcome measures. Results:From a single center with 75 PD patients, 57 (76%) were deemed eligible, resulting in a recruitment rate of 36 (63%) patients. Participants were randomly assigned into 2 groups of 18 (1:1). 10 patients discontinued the study (5 in each arm), resulting in 26 (72%) patients, 13 in each arm, completing the study. 10 of 13 (77%) intervention patients were adherent to the exercise program. A t test analysis of covariance found a difference between the treatment groups for the timed-up-and-go test (P = 0.04) and appetite (P = 0.04). No serious adverse events caused by the exercise program were reported. Limitations:Single center, no blinded assessors. Conclusions:A resistance and cardiovascular exercise program appears feasible and safe for PD patients. We recommend that providers of PD therapy consider including exercise programs coordinated by exercise professionals to reduce the physical deterioration of PD patients. Funding:None. Trial Registration:NCT03980795.
| S-EPMC7380403 | biostudies-literature
Project description:Hemodialysis patients often do not attend their scheduled treatment session. We investigated factors associated with missed appointments and whether such nonadherence poses significant harm to patients and increases overall health care utilization in an observational analysis of 44 million hemodialysis treatments for 182,536 patients with ESRD in the United States. We assessed the risk of hospitalization, emergency room visit, or intensive-coronary care unit (ICU-CCU) admission in the 2 days after a missed treatment relative to the risk for patients who received hemodialysis. Over the 5-year study period, the average missed treatment rate was 7.1 days per patient-year. In covariate adjusted logistic regression, the risk of hospitalization (odds ratio [OR], 3.98; 95% confidence interval [95% CI], 3.93 to 4.04), emergency room visit (OR, 2.00; 95% CI, 1.87 to 2.14), or ICU-CCU admission (OR, 3.89; 95% CI, 3.81 to 3.96) increased significantly after a missed treatment. Overall, 0.9 missed treatment days per year associated with suboptimal transportation to dialysis, inclement weather, holidays, psychiatric illness, pain, and gastrointestinal upset. These barriers also associated with excess hospitalization (5.6 more events per patient-year), emergency room visits (1.1 more visits), and ICU-CCU admissions (0.8 more admissions). In conclusion, poor adherence to hemodialysis treatments may be a substantial roadblock to achieving better patient outcomes. Addressing systemic and patient barriers that impede access to hemodialysis care may decrease missed appointments and reduce patient morbidity.
| S-EPMC4214530 | biostudies-literature
Project description:ObjectiveThe purpose of this study was to determine psychiatrists' barriers, attitudes, and practices regarding cardiac screening prior to initiating stimulants in children with attention-deficit/hyperactivity disorder.BackgroundProfessional and federal oversight organizations recently have debated the evidence regarding sudden cardiac death (SCD) risk with stimulants, and have published guidelines recommending cardiac screening. It is not known how psychiatrists have responded.MethodsThis study was a cross-sectional survey of 1,600 randomly-selected U.S. members of the American Academy of Child and Adolescent Psychiatry. Analyses included descriptive statistics and logistic regression.ResultsResponse rate was 40%; 96% met eligibility criteria. Barriers to identifying cardiac disorders in general included ability to perform a routine physical examination (74%) and care coordination with primary care providers (35%). Only 27% agreed that SCD risk warranted cardiac assessment. Prior to starting a patient on stimulants, 95% of psychiatrists obtained a routine history. The majority either conducted (9%), or relied on primary care providers to conduct (67%) a physical examination; 26% did not obtain a physical examination. Nineteen percent of psychiatrists ordered an electrocardiogram (ECG), of those, non-mutually exclusive reasons for ordering an ECG included standard practice procedure (62%), clinical findings (27%), medicolegal considerations (25%), and guideline adherence (24%). On multivariate modeling, psychiatrists were less likely to conduct cardiac screening themselves if in private practice (referent: academic medical center), if >50% of their patients had private insurance, or if they believed their ability to perform a physical examination to be a barrier. When modeling cardiac screening performed by any healthcare professional (e.g., psychiatrist, primary care practitioner), screening was less likely if the psychiatrist was practicing in a community mental health center (referent: academic medical center), was male, or if >50% of that psychiatrist's patients had private insurance.ConclusionFindings suggest the tacit interplay between primary care and psychiatry for the assessment and management of medical risks associated with psychotropic medications should be improved, and solutions prioritized.
| S-EPMC3482376 | biostudies-literature