Dataset Information

Trends in the Medical Complexity and Outcomes of Medicare-insured Patients Undergoing Kidney Transplant in the Years 1998-2014.

ABSTRACT: BACKGROUND:Graft and patient survival following kidney transplant are improving. However, the drivers of this trend are unclear. To gain further insight, we set out to examine concurrent changes in pretransplant patient complexity, posttransplant survival, and cause-specific hospitalization. METHODS:We identified 101?332 Medicare-insured patients who underwent their first kidney transplant in the United States between the years 1998 and 2014. We analyzed secular trends in (1) posttransplant patient and graft survival and (2) posttransplant hospitalization for cardiovascular disease, infection, and cancer using Cox models with year of kidney transplant as the primary exposure of interest. RESULTS:Age, dialysis vintage, body mass index, and the prevalence of a number of baseline medical comorbidities increased during the study period. Despite these adverse changes in case mix, patient survival improved: the unadjusted and multivariable-adjusted hazard ratios (HRs) for death in 2014 (versus 1998) were 0.61 (confidence interval [CI], 0.52-0.73) and 0.46 (CI, 0.39-0.55), respectively. For graft failure excluding death with a functioning graft, the unadjusted and multivariable adjusted subdistribution HRs in 2014 versus 1998 were 0.4 (CI, 0.25-0.55) and 0.45 (CI, 0.3-0.6), respectively. There was a marked decrease in hospitalizations for cardiovascular disease following transplant between 1998 and 2011, subdistribution HR 0.51 (CI, 0.43-0.6). Hospitalization for infection remained unchanged, while cancer hospitalization increased modestly. CONCLUSIONS:Medicare-insured patients undergoing kidney transplant became increasingly medically complex between 1998 and 2014. Despite this, both patient and graft survival improved during this period. A marked decrease in serious cardiovascular events likely contributed to this positive trend.

SUBMITTER: Lenihan CR

PROVIDER: S-EPMC7688011 | biostudies-literature | 2019 Nov

REPOSITORIES: biostudies-literature

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Trends in the Medical Complexity and Outcomes of Medicare-insured Patients Undergoing Kidney Transplant in the Years 1998-2014.

Lenihan Colin R CR Liu Sai S Montez-Rath Maria E ME Winkelmayer Wolfgang C WC

Transplantation 20191101 11

<h4>Background</h4>Graft and patient survival following kidney transplant are improving. However, the drivers of this trend are unclear. To gain further insight, we set out to examine concurrent changes in pretransplant patient complexity, posttransplant survival, and cause-specific hospitalization.<h4>Methods</h4>We identified 101 332 Medicare-insured patients who underwent their first kidney transplant in the United States between the years 1998 and 2014. We analyzed secular trends in (1) post ...[more]

PMID: 30801531

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Project description:Importance:Studies demonstrating improved survival after allogeneic hematopoietic cell transplant generally exclude infants. Objective:To analyze overall survival trends and other outcomes among infants who undergo allogeneic hematopoietic cell transplant. Design, Setting, and Participants:In this cohort study, we used time-trend analysis to evaluate 3 periods: 2000 through 2004, 2005 through 2009, and 2010 through 2014. The study was conducted in a multicenter setting through the Center for International Blood and Marrow Transplant Research, which is made up of a voluntary working group of more than 450 transplant centers worldwide. Two groups of infants aged 1 year or younger in 2 cohorts were included: those with malignant conditions, such as leukemia, and those with nonmalignant disorders, including immunodeficiencies. Data analysis was conducted from July 2017 to December 2018. Exposures:Allogeneic hematopoietic cell transplant. Main Outcomes and Measures:Survival trends, disease relapse, and toxicity. Results:A total of 2498 infants with a median age of 7 months (range, <1-12 months) were included. In the nonmalignant cohort (n = 472), survival rates improved from the first to the second period (hazard ratio, 0.77 [95% CI, 0.63-0.93]; P = .007) but did not change after 2004. Compared with infants with nonmalignant diseases (n = 2026; 3-year overall survival: 2000-2004, 375/577 [65.0%]; 2005-2009, 503/699 [72.0%]; and 2010-2014, 555/750 [74.0%]), those with malignant conditions had poorer survival rates, without improvement over time (3-year overall survival: 2000-2004, 109/199 [54.8%]; 2005-2009, 104/161 [64.6%]; and 2010-2014, 66/112 [58.9%]). From 2000 through 2014, relapse rates increased in infants with malignant conditions (3-year relapse rate: 2000-2004, 19% [95% CI, 14%-25%]; 2005-2009, 23% [95% CI, 17%-30%]; 2010-2014, 36% [95% CI, 27%-46%]; P = .01). Sinusoidal obstruction syndrome was frequent, occurring with a cumulative incidence of 13% (95% CI, 11%-16%) of infants with nonmalignant diseases and 32% (95% CI, 22%-42%) of those with malignant diseases. Generally, recipients of human leukocyte antigen-identical sibling bone marrow grafts had the best outcomes. Conclusions and Relevance:Survival rates have not improved for infants with malignant diseases over the 15-year study period. Infants with nonmalignant diseases had improved survival rates in the earlier but not the later study period. Higher relapses for the malignant cohort and toxicities for all infants remain significant challenges. Strategies to reduce relapse and toxicity and optimize donor and graft selection may improve outcomes in the future.

Project description:ObjectiveTo describe trends in the rate and daily dose of opioids used among commercial and Medicare Advantage beneficiaries from 2007 to 2016.DesignRetrospective cohort study of administrative claims data.SettingNational database of medical and pharmacy claims for commercially insured and Medicare Advantage beneficiaries in the United States.Participants48 million individuals with any period of insurance coverage between 1 January 2007 and 31 December 2016, including commercial beneficiaries, Medicare Advantage beneficiaries aged 65 years and over, and Medicare Advantage beneficiaries under age 65 years (eligible owing to permanent disability).Main endpointsProportion of beneficiaries with any opioid prescription per quarter, average daily dose in milligram morphine equivalents (MME), and proportion of opioid use episodes that represented long term use.ResultsAcross all years of the study, annual opioid use prevalence was 14% for commercial beneficiaries, 26% for aged Medicare beneficiaries, and 52% for disabled Medicare beneficiaries. In the commercial beneficiary group, quarterly prevalence of opioid use changed little, starting and ending the study period at 6%; the average daily dose of 17 MME remained unchanged since 2011. For aged Medicare beneficiaries, quarterly use prevalence was also relatively stable, ranging from 11% at the beginning of the study period to 14% at the end. Disabled Medicare beneficiaries had the highest rates of opioid use, the highest rate of long term use, and the largest average daily doses. In this group, both quarterly use rates (39%) and average daily dose (56 MME) were higher at the end of 2016 than the low points observed in 2007 for each endpoint (26% prevalence and 53 MME).ConclusionsOpioid use rates were high during the study period of 2007-16, with the highest rates in disabled Medicare beneficiaries versus aged Medicare beneficiaries and commercial beneficiaries. Opioid use and average daily dose have not substantially declined from their peaks, despite increased attention to opioid abuse and awareness of their risks.

Dataset Information

Trends in the Medical Complexity and Outcomes of Medicare-insured Patients Undergoing Kidney Transplant in the Years 1998-2014.

Publications

Trends in the Medical Complexity and Outcomes of Medicare-insured Patients Undergoing Kidney Transplant in the Years 1998-2014.

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