The Marginal Cost of Frailty Among Medicare Patients on Hemodialysis.

Introduction:Dialysis patients incur disproportionately high costs compared with other Medicare beneficiaries. Care for frail individuals may be even more costly. We examined the extent to which frailty contributes to higher costs among dialysis patients. Methods:We used ACTIVE/ADIPOSE (A Cohort to Investigate the Value of Exercise/Analyses Designed to Investigate the Paradox of Obesity and Survival in ESRD) enrollees (adult hemodialysis patients evaluated from June 2009 to August 2011) in a retrospective cohort analysis. Individuals using Medicare as the primary payer were included. Fried's frailty phenotype was evaluated at baseline, 12, and 24 months. Costs were derived from linkage with the US Renal Data System (USRDS) and Medicare claims data. We used generalized estimating equations (GEEs) incorporating time-updated frailty and costs to evaluate adjusted point estimates and the marginal cost associated with being frail. We also investigated if frail patients who died during the study incurred higher costs than those who survived. Results:Among 771 enrollees in ACTIVE/ADIPOSE, 425 met inclusion criteria. Mean age was 56 ± 13 years, body mass index (BMI) 29.2 ± 7.1 kg/m2, 42.4% were women, and 29.0% were frail at baseline. Over a mean follow-up of 2.3 years, frail individuals incurred 22% (95% confidence interval [CI] 9.6%-35.8%) higher costs compared with nonfrail individuals ($87,600 per patient per year [pppy], 95$71,800 pppy, 95% CI 64,800-79,600), the difference was driven primarily by higher inpatient expenditures. The difference between frail and nonfrail patients' inpatient expenditures was even more pronounced among those who died during the study compared with those who survived. Conclusions:Frail dialysis patients incur a significantly higher cost relative to their nonfrail counterparts, primarily driven by higher inpatient costs. Frail patients near end of life incur even higher costs

Implementing Wellness into Mental Health and Addiction Recovery: The Addressing Wellness Through Organizational Change (AWTOC) Approach [English and Spanish versions]

A Spanish translation of this publication is available to download under Additional Files below. There are many opportunities for clinicians and leaders in mental health and addiction treatment programs to champion more discussion about wellness and integrate evidence-based treatments that can decrease patient morbidity and mortality. However, many clinicians and staff may not feel trained and prepared to help individuals adequately address wellness goals, to integrate wellness into their routine clinical practice, or to make appropriate referrals to community resources. To address this service and training gap, the UMass Department of Psychiatry developed the Addressing Wellness Through Organization Change (AWTOC) approach, based upon the Addressing Problems Through Organizational Change (APTOC) model developed by Douglas Ziedonis, M.D., M.P.H. which has been used previously to address tobacco cessation (Ziedonis et al., 2007)

Association Between Blood Pressure and Adverse Renal Events in Type 1 Diabetes.

ObjectiveTo compare different blood pressure (BP) levels in their association with the risk of renal outcomes in type 1 diabetes and to determine whether an intensive glycemic control strategy modifies this association.Research design and methodsWe included 1,441 participants with type 1 diabetes between the ages of 13 and 39 years who had previously been randomized to receive intensive versus conventional glycemic control in the Diabetes Control and Complications Trial (DCCT). The exposures of interest were time-updated systolic BP (SBP) and diastolic BP (DBP) categories. Outcomes included macroalbuminuria (>300 mg/24 h) or stage III chronic kidney disease (CKD) (sustained estimated glomerular filtration rate <60 mL/min/1.73 m2).ResultsDuring a median follow-up time of 24 years, there were 84 cases of stage III CKD and 169 cases of macroalbuminuria. In adjusted models, SBP in the <120 mmHg range was associated with a 0.59 times higher risk of macroalbuminuria (95% CI 0.37-0.95) and a 0.32 times higher risk of stage III CKD (95% CI 0.14-0.75) compared with SBPs between 130 and 140 mmHg. DBP in the <70 mmHg range were associated with a 0.73 times higher risk of macroalbuminuria (95% CI 0.44-1.18) and a 0.47 times higher risk of stage III CKD (95% CI 0.21-1.05) compared with DBPs between 80 and 90 mmHg. No interaction was noted between BP and prior DCCT-assigned glycemic control strategy (all P > 0.05).ConclusionsA lower BP (<120/70 mmHg) was associated with a substantially lower risk of adverse renal outcomes, regardless of the prior assigned glycemic control strategy. Interventional trials may be useful to help determine whether the currently recommended BP target of 140/90 mmHg may be too high for optimal renal protection in type 1 diabetes

The pursuit of prosperity and blessing : social life and symbolic action on Buru Island, Eastern Indonesia

This thesis is an ethnographic analysis based on fieldwork among the 'mountain people' of the interior of Burn, an island located in the present-day province of Maluku in the Republic of Indonesia. Interested in 'metaphors for living' I found important Burn metaphors refer to botanic 'roots’ and 'tips'. The conceptualization of botanic growth as the consequence of life being transmitted from roots to new leaf-tips also applies to the Burn social world. This study details the Burn 'quest for life', a quest concerned with maintaining proper relationships with sources of life to ensure the transmission of 'prosperity and blessing' (berkona tu berkate). After the Introduction, Part One provides the setting. Chapter Two examines the history of Bum's relations with the outside world. Chapter Three describes the island as a culturally constructed inside world. Part Two concerns Bum social life. Chapter Four focuses on the noro, exogamous groups (clans) defined in terms of common origins. When they marry, women leave their natal noro and their children subsequently belong to the noro of their husband. Yet Bum concerns about the source of life connect children to their mother's brothers in a relationship between 'source uncles' and 'life children'. To maintain 'connections' between noro, ideally men return to their 'source uncle' to marry their emdaa (MBD). Chapter Five provides the details of marriage and the regeneration of human life. While the Bum kinship terminology is asymmetric, marriages are symmetric, involving simultaneous sister exchange and other bidirectional marriages. Sister exchange allows an immediate substitution for the bride, but, alternatively, there can be bridewealth, or the return of a child to replace its mother. Whenever a noro loses a person through the agency of another noro, Bum people are strict accountants. There must be a replacement for sisters lost in marriage as well as for members lost through death at the hands of another noro. Chapter Six describes the effort that goes into maintaining equality between noro, an effort that falls largely to 'entitled men' and warriors. Through their negotiating skills, 'entitled men' obtain a replacement for any life taken, while warriors guard the balance between noro through their fighting skills and the possibility of 'revenge killing' (kalungan). Part Three focuses on symbolic action. Chapter Seven examines the Bum symbols intertwined with the concept of 'prosperity and blessing'. The dyadic categories of Bum symbolism are used to transform the state of things in the world. Chapter Eight describes a variety of taboos, constmcted in terms of symbolic action intended to create distinction and to avoid undesired consequences. Chapter Nine details various rituals and the role of symbolic actions in transforming experience as people seek to restore prosperity when they encounter difficulty. The conclusion consider the implications of this study for the comparative effort. In reference to hierarchy, alliance, exchange, gender, the cultural construction of the body, illness, and childbirth, Burn presents a useful vantage point for the comparison of societies in eastern Indonesia and Melanesia

Affiliation and alliance on Buru

On the island of Burn in the Indonesian province of Maluku certain social groups, called noro, play a very prominent role in society as do similar groups in many other societies of eastern Indonesia.1 Every individual in Buru society belongs to a noro and at any given point in time he or she can only belong to one noro. The noro an individual belongs to is the primary source of his or her social identity and prescribes relationships and interaction with other individuals and groups in society. Because of the significance of these social groups I began inquiring more about them and soon came to the question which eventually led to this study and provided a key which opened up a broader understanding of Buru society: "How is it determined to which noro an individual belongs?

Magnitude of the Difference Between Clinic and Ambulatory Blood Pressures and Risk of Adverse Outcomes in Patients With Chronic Kidney Disease.

Background Obtaining 24-hour ambulatory blood pressure ( BP ) is recommended for the detection of masked or white-coat hypertension. Our objective was to determine whether the magnitude of the difference between ambulatory and clinic BP s has prognostic implications. Methods and Results We included 610 participants of the AASK (African American Study of Kidney Disease and Hypertension) Cohort Study who had clinic and ambulatory BPs performed in close proximity in time. We used Cox models to determine the association between the absolute systolic BP ( SBP ) difference between clinic and awake ambulatory BPs (primary predictor) and death and end-stage renal disease. Of 610 AASK Cohort Study participants, 200 (32.8%) died during a median follow-up of 9.9 years; 178 (29.2%) developed end-stage renal disease. There was a U-shaped association between the clinic and ambulatory SBP difference with risk of death, but not end-stage renal disease. A 5- to <10-mm Hg higher clinic versus awake SBP (white-coat effect) was associated with a trend toward higher (adjusted) mortality risk (adjusted hazard ratio, 1.84; 95% CI, 0.94-3.56) compared with a 0- to <5-mm Hg clinic-awake SBP difference (reference group). A ≥10-mm Hg clinic-awake SBP difference was associated with even higher mortality risk (adjusted hazard ratio, 2.31; 95% CI, 1.27-4.22). A ≥-5-mm Hg clinic-awake SBP difference was also associated with higher mortality (adjusted hazard ratio, 1.82; 95% CI, 1.05-3.15) compared with the reference group. Conclusions A U-shaped association exists between the magnitude of the difference between clinic and ambulatory SBP and mortality. Higher clinic versus ambulatory BPs (as in white-coat effect) may be associated with higher risk of death in black patients with chronic kidney disease