Impact of eGFR reporting on health care utilization in Ontario

The objective of this thesis was to determine the impact of eGFR reporting on health care utilization in Ontario. There were two main aims of this thesis 1) to assess the impact or eGFR reporting on nephrology consults and 2) to assess the impact of eGFR reporting on kidney protective medication usage. Some clinicians believe chronic kidney disease (CKD) is under-recognized in the community. As a result, many outpatient laboratories now report the estimated glomerular filtration rate (eGFR) in addition to serum creatinine as a measure of kidney function. In January 2006, all outpatient laboratories in the province of Ontario, Canada began reporting eGFR. We linked health administrative data for more than 8 million adults of age 25 years or older from January, 1999 to September, 2007. We conducted a population-based intervention analysis with seasonal time-series modeling to examine secular trends in the number and type of patients seen by nephrologists. Compared to the pre-eGFR period, the number of patients seen in consultation by nephrologists increased after eGFR reporting [percentage increase of 24% (95% Cl 16 - 31%); absolute increase of 2.9 consults per 100,000 adult population (95% Cl 2.5 - 3.4)]. This translated into an increase of about 23 consults per nephrologist per year. The greatest increases were seen in women (percentage increase of 39%, 95% Cl 28 - 51%) and the elderly, age \u3e 80 years (percentage increase of 58%, 95% Cl 35 - 80%). eGFR reporting was associated with a sudden increase in the number of nephrology consults seen in Ontario. This increase was especially prominent amongst women and the elderly, populations who some believe are under-recognized as having CKD. Some patients with chronic kidney disease (CKD) in whom angiotensin converting enzyme inhibitors or angiotensin-ll receptor blockers are recommended do not receive these medications (collectively referred to as RAAS-Blockers). We considered whether RAAS-Blocker use increases amongst CKD patients after the introduction of eGFR reporting. In January 2006, all outpatient laboratories in the province of Ontario, Canada began reporting eGFR. We performed a population-based intervention analysis with seasonal time-series modeling for the period of January 2003 to April 2008. We linked health administrative data for adults living in south western Ontario. For our primary outcome we considered RAAS-Blocker usage amongst 45 361 ambulatory residents with CKD (eGFR \u3c 60 mL/min per 1.73m2). The introduction of eGFR reporting was associated with a significant increase in the use of RAAS-Blockers. Just prior to eGFR reporting the prescription rate was 571 per 1000 CKD patients; by early 2008 the rate had increased to 607 per 1000 CKD patients. According to the model, the increase in RAAS- Blocker use attributable to eGFR reporting was 19 per 1000 CKD patients (p=0.034). These iii results suggest eGFR reporting contributes to improved, guideline appropriate, care of patients with CKD. Estimating that 8% of the adult population has CKD, for every 10 million adults this means about 15 200 new patients are treated with RAAS Blockers by one year after the introduction of eGFR reporting in community laboratories. In summary, in Ontario eGFR reporting was associated with an increase in consults, particularly among elderly and female patients. Also, it was associated with more CKD patients using renal- protective medications. Although these two finding suggest that there may be benefit to its introduction, further studies are need to determine if these changes actually result in clinical improvements

The WISHED Trial: implementation of an interactive health communication application for patients with chronic kidney disease

Background: Despite many advantages over facility-based therapies, less than 25 % of prevalent dialysis patients in Ontario are on a home therapy. Interactive health communication applications, web-based packages for patients, have been shown to have a beneficial effect on knowledge, social support, self-efficacy, and behavioral and clinical outcomes but have not been evaluated in patients with chronic kidney disease (CKD). Web-based tools designed for patients with CKD exist but to our knowledge have not been assessed in their ability to influence dialysis modality decision-making. Objective: To determine if a web-based tool increases utilization of a home-based therapy in patients with CKD starting dialysis. Design: This is a multi-centered randomized controlled study. Setting: Participants will be recruited from sites in Canada. Participants: Two hundred and sixty-four consenting patients with an estimated glomerular filtration rate (eGFR) less than 20 ml/min/1.73 m 2 who have received modality education will be enrolled in the study. Measurements: The primary outcome will be the proportion of participants who are on dialysis using a home-based therapy within 3 months of dialysis initiation. Secondary outcomes will include the proportion of patients intending to perform a home-based modality and measures of dialysis knowledge, decision conflict, and social support. Methods: The between-group differences in frequencies will be expressed as either absolute risk differences and/or by calculating the odds ratio and its associated 95 % confidence interval. Conclusions: This study will assess whether access to a website dedicated to supporting and promoting home-based dialysis therapies will increase the proportion of patients with CKD who initiate a home-based dialysis therapy. Trial registration: ClinicalTrials.gov #NCT01403454, registration date: July 21, 2011

Association between angiotensin converting enzyme inhibitor or angiotensin receptor blocker use prior to major elective surgery and the risk of acute dialysis

Background: Some studies but not others suggest angiotensin converting enzyme inhibitor (ACEi) or angiotensin receptor blocker (ARB) use prior to major surgery associates with a higher risk of postoperative acute kidney injury (AKI) and death. Methods: We conducted a large population-based retrospective cohort study of patients aged 66 years or older who received major elective surgery in 118 hospitals in Ontario, Canada from 1995 to 2010 (n = 237,208). We grouped the cohort into ACEi/ARB users (n = 101,494) and non-users (n = 135,714) according to whether the patient filled at least one prescription for an ACEi or ARB (or not) in the 120 days prior to surgery. Our study outcomes were acute kidney injury treated with dialysis (AKI-D) within 14 days of surgery and all-cause mortality within 90 days of surgery. Results: After adjusting for potential confounders, preoperative ACEi/ARB use versus non-use was associated with 17% lower risk of post-operative AKI-D (adjusted relative risk (RR): 0.83; 95% confidence interval (CI): 0.71 to 0.98) and 9% lower risk of all-cause mortality (adjusted RR: 0.91; 95% CI: 0.87 to 0.95). Propensity score matched analyses provided similar results. The association between ACEi/ARB and AKI-D was significantly modified by the presence of preoperative chronic kidney disease (CKD) (P value for interaction < 0.001) with the observed association evident only in patients with CKD (CKD - adjusted RR: 0.62; 95% CI: 0.50 to 0.78 versus No CKD: adjusted RR: 1.00; 95% CI: 0.81 to 1.24). Conclusions: In this cohort study, preoperative ACEi/ARB use versus non-use was associated with a lower risk of AKI-D, and the association was primarily evident in patients with CKD. Large, multi-centre randomized trials are needed to inform optimal ACEi/ARB use in the peri-operative setting

The association of functional status with mortality and dialysis modality change : results from the Peritoneal Dialysis Outcomes and Practice Patterns Study (PDOPPS)

BACKGROUND: Little is known about the prevalence of functional impairment in peritoneal dialysis (PD) patients, its variation by country, and its association with mortality or transfer to hemodialysis. METHODS: A prospective cohort study was conducted in PD patients from 7 countries in the Peritoneal Dialysis Outcomes and Practice Patterns Study (PDOPPS) (2014 - 2017). Functional status (FS) was assessed by combining self-reports of 8 instrumental and 5 basic activities of daily living, using the Lawton-Brody and the Katz questionnaires. Summary FS scores, ranging from 1.25 (most dependent) to 13 (independent), were based on the patient's ability to perform each activity with or without assistance. Logistic regression was used to estimate the odds ratio (OR; 95% confidence interval [CI]) of a FS score < 11 comparing each country with the United States (US). Cox regression was used to estimate the hazard ratio (HR; 95% CI) for the effect of a low FS score on mortality and transfer to hemodialysis, adjusting for case mix. RESULTS: Of 2,593 patients with complete data on FS, 48% were fully independent (FS = 13), 32% had a FS score 11 to < 13, 14% had a FS score 8 to < 11, and 6% had a FS score < 8. Relative to the US, low FS scores (< 11; more dependent) were more frequent in Thailand (OR = 10.48, 5.90 - 18.60) and the United Kingdom (UK) (OR = 3.29, 1.77 - 6.08), but similar in other PDOPPS countries. The FS score was inversely and monotonically associated with mortality but not with transfer to hemodialysis; the HR, comparing a FS score < 8 vs 13, was 4.01 (2.44 - 6.61) for mortality and 0.91 (0.58 - 1.43) for transfer to hemodialysis. CONCLUSION: Regional differences in FS scores observed across PDOPPS countries may have been partly due to differences in regional patient selection for PD. Functional impairment was associated with mortality but not with permanent transfer to hemodialysis

Should Temporary Hemodialysis Catheter Insertion Remain a Requirement of Nephrology Residency Training?

Purpose of review: Recently, there has been much debate about the practicality and utility of training nephrology fellows in temporary hemodialysis catheter insertion. Sources of information: Literature review along with the authors' opinion. Findings: This skill can be taught easily, in a controlled fashion to maximize success and minimize complications. In order to achieve this training centres should be required to teach using simulation based mastery learning and ultrasound guidance. Employing these strategies makes the inexperienced operator perform at the level of an experienced operator. As a specialty, nephrologists have a responsibility to provide hemodialysis in a timely fashion during emergencies, meaning nephrologists should be able to insert temporary hemodialysis catheters. We should take ownership over this skill and depend on no other specialty. Limitations: Limited data has been published on this subject. Implications: Temporary hemodialysis catheter insertion should be maintained as a core competency by the Royal College

The Use of Incremental Peritoneal Dialysis in a Large Contemporary Peritoneal Dialysis Program

Background: The use of an incremental peritoneal dialysis (PD) strategy in a large contemporary patient population has not been described. Objective: We report the use of this strategy in clinical practice, the prescriptions required, and the clearances achieved in a large center which has routinely used this approach for more than 10 years. Design: This is a cross-sectional observational study. Setting: A single large Canadian academic center. Patients: This study collected data on 124 prevalent PD patients at a single Canadian academic center. Methods and Measurements: The proportion of patients who achieve the clearance target on a low clearance or incremental PD prescription; the actual PD prescriptions and consequent total, peritoneal, and renal urea clearances [Kt/V] achieved; and patient and technique survival and peritonitis rate in comparison with national and international reports. Results: Of the 124 prevalent PD patients in this PD unit, 106 (86%) were achieving the Kt/V target, and of these, 54 (44% of all patients) were doing so using incremental PD prescriptions. Fifty of these incremental PD patients were using automated PD (APD) with either no day dwell (68%) or less than 7 days a week treatment (12%) or both (20%). Patient survival in our PD unit was not different from that reported in Canada as a whole. Peritonitis rates were better than internationally recommended standards. Limitations: This is an observational study with no randomized control group. Conclusions: Incremental PD is feasible in a contemporary PD population treated mainly with APD. Almost half of the patients were able to achieve clearance targets while receiving less onerous and less costly low clearance prescriptions. We suggest that incremental PD should be widely used as a cost-effective strategy in PD

Frailty Severity and Hospitalization After Dialysis Initiation

Background: Frailty is associated with hospitalization and mortality among dialysis patients. To now, few studies have considered the degree of frailty as a predictor of hospitalization. Objective: We evaluated whether frailty severity was associated with hospitalization after dialysis initiation. Design: Retrolective cohort study. Setting: Nova Scotia, Canada. Patients: Consecutive adult, chronic dialysis patients who initiated dialysis from January 1, 2009 to June 30, 2014, (last follow-up June, 2015). Methods: Frailty Severity, as determined by the 7-point Clinical Frailty Scale (CFS, ranging from 1 = very fit to 7 = severely frail), was measured at dialysis initiation and treated as continuous and in categories (CFS scores of 1-3, 4/5, and 6/7). Hospitalization was characterized by cumulative time admitted to hospital (proportion of days admitted/time at risk) and by the joint risk of hospitalization and death. Time at risk included time in hospital after dialysis initiation and patients were followed until transplantation or death. Results: Of 647 patients (mean age: 62 ± 15), 564 (87%) had CFS scores. The mean CFS score was 4 (“corresponding to “vulnerable”) ± 2 (“well” to “moderately frail”). In an adjusted negative binomial regression model, moderate-severely frail patients (CFS 6/7) had a >2-fold increased risk of cumulative time admitted to hospital compared to the lowest CFS category (IRR = 2.18, 95% confidence interval [CI] = 1.31-3.63). In the joint model, moderate-severely frail patients had a 61% increase in the relative hazard for hospitalization (hazard ratio [HR] = 1.61, 95% CI = 1.29-2.02) and a 93% increase in the relative hazard for death compared to the lowest CFS category (HR = 1.93, 95% CI = 1.16-3.22). Limitations: Potential unknown confounders may have affected the association between frailty severity and hospitalization given observational study design. The CFS is subjective and different clinicians may grade frailty severity differently or misclassify patients on the basis of limited availability. Conclusions: Among incident dialysis patients, a higher frailty severity as defined by the CFS is associated with both an increased risk of cumulative time admitted to hospital and joint risk of hospitalization and death

Risk of hospitalization for community acquired pneumonia with renin-angiotensin blockade in elderly patients: a population-based study.

OBJECTIVE: To characterize the 90-day risk of hospitalization with pneumonia among patients treated with different anti-hypertensive drug classes. DESIGN: Population based cohort study using five linked databases. PARTICIPANTS: Individuals over the age of 65 who filled a new outpatient prescription for one of four anti-hypertensive medications: ACE inhibitors (n = 86 775), ARBs (n = 33,953), calcium channel blockers (CCB, n = 34,240), beta blockers (BB, n = 35,331) and thiazide diuretics (n = 64 186). PRIMARY OUTCOME: Hospitalization with pneumonia within 90 days of a qualifying prescription. We adjusted for ten a priori selected covariates, including age, sex, diabetes and number of visits to a family doctor. RESULTS: Baseline characteristics of the groups were relatively well matched, except for age, sex, diabetes and frequency of family doctor visits. 128 of the 86 775 patients (0.15%) initiated on an ACE inhibitor and 43 of the 33953 patients (0.13%) of patients initiated on an ARB were hospitalized with pneumonia in the subsequent 90 days. 135 of 64 186 patients (0.21%) initiated on a thiazide, 112 of 35 331 patients (.32%) initiated on a BB, and 89 of 34 240 (0.26%) patients initiated on a CCB achieved the primary outcome. Compared to calcium channel blockers, ACE inhibitors (adjusted OR 0.61, 95% CI 0.46 to 0.81) and ARBs (adjusted OR 0.52, 95% CI 0.36 to 0.76) were associated with a lower risk of pneumonia. No benefit was seen with thiazides (adjusted OR 0.87, 95% CI 0.66 to 1.14) or beta blockers (adjusted OR 1.21, 95% CI 0.91 to 1.60). CONCLUSION: Initiating medications that block the renin angiotensin system, compared to other anti-hypertensive medications, is associated with a small absolute reduction in the 90 day risk of hospitalization with pneumonia