Dataset Information

Dialysis Provider and Outcomes among United States Veterans Who Transition to Dialysis.

ABSTRACT: 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.

SUBMITTER: Streja E

PROVIDER: S-EPMC6032569 | biostudies-literature | 2018 Jul

REPOSITORIES: biostudies-literature

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Dialysis Provider and Outcomes among United States Veterans Who Transition to Dialysis.

Streja Elani E Kovesdy Csaba Pal CP Kovesdy Csaba Pal CP Soohoo Melissa M Obi Yoshitsugu Y Rhee Connie M CM Park Christina C Chen Joline L T JLT Nakata Tracy T Nguyen Danh V DV Amin Alpesh N AN Jacobsen Steven J SJ Sim John J JJ Kalantar-Zadeh Kamyar K

Clinical journal of the American Society of Nephrology : CJASN 20180614 7

<h4>Background and objectives</h4>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.<h4>Design, setting, participants, & measurements</h4>Among 68,727 United S ...[more]

PMID: 29903898

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Project description:Rationale & objectiveDuring the coronavirus disease 2019 (COVID-19) pandemic, patients receiving maintenance dialysis are a highly vulnerable population due to their comorbidities and circumstances that limit physical distancing during treatment. This study sought to characterize the risk factors for and outcomes following COVID-19 in this population.Study designRetrospective cohort study.Setting & participantsMaintenance dialysis patients in clinics of a midsize national dialysis provider that had at least 1 patient who tested positive for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) from February to June 2020.PredictorsDemographics, dialysis characteristics, residence in a congregated setting, comorbid conditions, measurements of frailty, and use of selected medications.OutcomesCOVID-19, defined as having a positive SARS-CoV-2 test result, and all-cause mortality among those with COVID-19.Analytical approachLogistic regression analyses conducted to identify clinical characteristics associated with COVID-19 and risk factors associated with mortality among patients following COVID-19.Results438 of 7948 (5.5%) maintenance dialysis patients developed COVID-19. Male sex, Black race, in-center dialysis (vs home dialysis), treatment at an urban clinic, residence in a congregate setting, and greater comorbidity were associated with contracting COVID-19. Odds of COVID-19 were 17-fold higher for those residing in a congregated setting (odds ratio [OR], 17.10 [95% CI, 13.51-21.54]). Of the 438 maintenance dialysis patients with COVID-19, 109 (24.9%) died. Older age, heart disease, and markers of frailty were associated with mortality.LimitationsNo distinction was detected between symptomatic and asymptomatic SARS-CoV-2 positivity, with asymptomatic screening limited by testing capacity during this initial COVID-19 surge period.ConclusionsCOVID-19 is common among patients receiving maintenance dialysis, particularly those residing in congregate settings. Among maintenance dialysis patients with COVID-19, mortality is high, exceeding 20%.

Project description:Rationale & objectiveTransitions between dialysis modalities can be disruptive to care. Our goals were to evaluate rates of transition from peritoneal dialysis (PD) to in-center hemodialysis (HD), mortality, and transplantation among incident PD patients in the US Renal Data System from 1996 to 2015 and identify factors associated with these outcomes.Study designObservational registry-based retrospective cohort study.Setting & participantsMedicare patients incident to end-stage renal disease (ESRD) from January 1, 1996, through December 31, 2011 (for adjusted analyses; through December 31, 2014, for unadjusted analyses), and treated with PD 1 or more days within 180 days of ESRD incidence (n = 173,533 for adjusted analyses; n = 219,787 for unadjusted analyses).Exposure & predictorsExposure: 1 or more days of PD. Predictors: patient- and facility-level characteristics obtained from Centers for Medicare & Medicaid Services Form 2728 and other data sources.OutcomesPatients were followed up for 3 years until transition to in-center HD, death, or transplantation.Analytical approachMultivariable Cox regression was used to estimate hazards over time and associations with predictors.ResultsCompared with earlier cohorts, recent incident PD patient cohorts had lower rates of death (48% decline) and transition to in-center HD (13% decline). Among many other findings, we found that: (1) rates of transition to in-center HD and death were lowest in the 2008 to 2011 cohort, (2) longer time receiving PD was associated with higher mortality risk but lower risk for transition to in-center HD, and (3) larger PD programs (≥25 vs ≤6 patients) displayed lower risks for death and transition to in-center HD.LimitationsData collected on Form 2728 are only at the time of ESRD incidence and do not provide information at the time of transition to in-center HD, death, or transplantation.ConclusionsRates of transition from PD to in-center HD and death rates for PD patients decreased over time and were lowest in PD programs with 25 or more patients. Implications of the observed improved technique survival warrant further investigation, focusing on modifiable factors of center-level performance to create opportunities for improved patient outcomes.

Project description:BackgroundIn end-stage kidney disease, patients may undergo parathyroidectomy if secondary hyperparathyroidism cannot be managed medically. This study was designed to estimate the parathyroidectomy rate in the United States (US) and to quantify changes in costs and other outcomes after parathyroidectomy.MethodsThis was a retrospective observational cohort study using US Renal Data System data for 2015-2018. Parathyroidectomy rates were estimated for adult hemodialysis and peritoneal dialysis patients alive at the beginning of 2016, 2017, and 2018 who were followed for a year or until parathyroidectomy, death, or transplant. Incremental differences in economic and clinical outcomes were compared before and after parathyroidectomy in adult hemodialysis and peritoneal dialysis patients who received a parathyroidectomy in 2016 and 2017.ResultsThe rate of parathyroidectomy per 1,000 person-years decreased from 6.5 (95% CI 6.2-6.8) in 2016 to 5.3 (95% CI 5.0-5.6) in 2018. The incremental increase in 12-month cost after versus before parathyroidectomy was $25,314 (95% CI $23,777-$27,078). By the second month after parathyroidectomy, 58% of patients had a corrected calcium level < 8.5 mg/dL. In the year after parathyroidectomy (versus before), hospitalizations increased by 1.4 per person-year (95% CI 1.3-1.5), hospital days increased by 12.1 per person-year (95% CI 11.2-13.0), dialysis visits decreased by 5.2 per person-year (95% CI 4.4-5.9), and office visits declined by 1.3 per person-year (95% CI 1.0-1.5). The incremental rate per 1,000 person years for hematoma/bleed was 224.4 (95% CI 152.5-303.1), for vocal cord paralysis was 124.6 (95% CI 59.1-232.1), and for seroma was 27.4 (95% CI 0.4-59.0).ConclusionsParathyroidectomy was a relatively uncommon event in the hemodialysis and peritoneal dialysis populations. The incremental cost of parathyroidectomy was mostly attributable to the cost of the parathyroidectomy hospitalization. Hypocalcemia occurred in over half of patients, and calcium and phosphate levels were reduced. Clinicians, payers, and patients should understand the potential clinical and economic outcomes when considering parathyroidectomy.

Project description:BackgroundThe COVID 19 pandemic adversely impacted delivery of preventive, routine, urgent, and essential care worldwide. Dialysis access care was particularly affected due to the lack of specific guidelines regarding procedures for its creation and maintenance. Early guidance by Centers for Medicare and Medicaid was inadvertently interpreted as guidance to stop dialysis access procedures. Prompt action by professional societies was needed to furnish detailed guidance to establish essential nature of these procedures.MethodsThe American Society of Diagnostic and Interventional Nephrology (ASDIN) issued a joint statement with Vascular Access Society of the Americas (VASA) - "Maintaining Lifelines for ESKD Patients" to clearly establish the role of vascular access as a lifeline for ESKD (End Stage Kidney Disease) patients and the importance and urgency of its timely management. ASDIN also conducted a survey in mid-2020, that was administered to the ASDIN database as well as shared with the general public via the organization's social media platforms. The respondents reported their experiences in the care of dialysis access, practice patterns and the utility of the ASDIN-VASA statement during the COVID 19 pandemic.ResultsOf the 2030 individual surveys sent, 581 were opened and 53 (9.1%) responses were received from different parts of the country and from different practice settings. ASDIN COVID 19 triage document was frequently utilized and 83% of respondents found the document valuable. The survey also revealed multiple obstacles, including logistical and financial issues that led to significant disruption of services.ConclusionsThe care of dialysis access was significantly affected in the United States during the COVID 19 pandemic due to multiple reasons. ASDIN actions provided valuable specific guidance regarding and explored barriers to dialysis access care. We describe those results and discuss strategies to prevent COVID 19 transmission with innovative strategies of providing access care. Individualized decision making is of essence when considering dialysis access procedures.

Dataset Information

Dialysis Provider and Outcomes among United States Veterans Who Transition to Dialysis.

Publications

Dialysis Provider and Outcomes among United States Veterans Who Transition to Dialysis.

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