Exploring the Local Context from Multiple Perspectives

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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

Effect of a pedometer-based walking intervention on body composition in patients with ESRD: a randomized controlled trial.

BackgroundA randomized trial of a pedometer-based intervention with weekly activity goals led to a modest increase in step count among dialysis patients. In a secondary analysis, we investigated the effect of this intervention on body composition.MethodsSixty dialysis patients were randomized to standard care or a 6-month program consisting of 3 months of pedometers and weekly step count targets and 3 months of post-intervention follow-up. We obtained bioelectrical impedance spectroscopy (BIS) data on 54 of these patients (28 control, 26 intervention) and used linear mixed-modeling (adjusted for sex and dialysis modality) to estimate differences in change in total-body muscle mass (TBMM) adjusted for height2, fat mass (kg), and body mass index (BMI) (kg/m2) between control and intervention groups.ResultsThe median age of participants was 57.5 years (53-66), and 76% were men. At baseline, there was no significant difference between groups in age, BMI, race, or body composition, but there were more men in the intervention group. After 3 months, patients in the intervention group increased their average daily steps by 2414 (95% CI 1047, 3782) more than controls (p < 0.001), but there were no significant differences in body composition. However, at 6 months, participants in the intervention had a significantly greater increase from baseline in TBMM of 0.7 kg/m2 (95% CI 0.3, 1.13), decrease in fat mass (- 4.3 kg [95% CI -7.1, - 1.5]) and decrease in BMI (- 1.0 kg/m2 [95% CI -1.8, - 0.2]) relative to controls. In post-hoc analysis, each increase of 1000 steps from 0 to 3 months was associated with a 0.3 kg decrease in fat mass (95% CI 0.05, 0.5) from 0 to 6 months, but there was no dose-response relationship with TBMM/ht2 or BMI.ConclusionA pedometer-based intervention resulted in greater decreases in fat mass with relative preservation of muscle mass, leading to a greater decrease in BMI over time compared with patients not in the intervention. These differences were driven as much by worsening in the control group as by improvement in the intervention group. Step counts had a dose-response relationship with decrease in fat mass.Trial registrationClinicalTrials.gov (NCT02623348). 02 December 2015

Use of Antihypertensive Agents and Association With Risk of Adverse Outcomes in Chronic Kidney Disease: Focus on Angiotensin-Converting Enzyme Inhibitors and Angiotensin Receptor Blockers.

Background Our objective was to determine patterns of antihypertensive agent use by stage of chronic kidney disease (CKD) and to evaluate the association between different classes of antihypertensive agents with nonrenal outcomes, especially in advanced CKD . Methods and Results We studied 3939 participants of the CRIC (Chronic Renal Insufficiency Cohort) study. Predictors were time-dependent angiotensin-converting enzyme inhibitor or angiotensin receptor blocker , β-blocker, and calcium channel blocker use (versus nonuse of agents in each class). Outcomes were adjudicated heart failure events or death. Adjusted Cox models were used to determine the association between predictors and outcomes. We also examined whether the associations differed based on the severity of CKD (early [stage 2-3 CKD ] versus advanced disease [stage 4-5 CKD ]). During median follow-up of 7.5 years, renin-angiotensin-aldosterone system inhibitor use plateaued during CKD stage 3 (75%) and declined to 37% by stage 5, while β-blocker, calcium channel blocker, and diuretic use increased steadily with advancing CKD . Renin-angiotensin-aldosterone system inhibitor use was associated with lower risk of heart failure (hazard ratio, 0.79; 95% confidence interval, 0.67-0.97) and death (hazard ratio, 0.78; 95% confidence interval, 0.67-0.90), regardless of severity of CKD . Calcium channel blocker use was not associated with risk of heart failure or death, regardless of the severity of CKD . β-Blocker use was associated with higher risk of heart failure (hazard ratio, 1.62; 95% confidence interval, 1.29-2.04) and death (hazard ratio, 1.22; 95% confidence interval, 1.03-1.43), especially during early CKD ( P<0.05 for interaction). Conclusions Angiotensin-converting enzyme inhibitor and angiotensin receptor blocker use decreased, while use of other agents increased with advancing CKD . Use of agents besides angiotensin-converting enzyme inhibitors or angiotensin receptor blockers may be associated with suboptimal outcomes in patients with CKD

Timing of preemptive vascular access placement: do we understand the natural history of advanced CKD?: an observational study

BACKGROUND: Little is known about the targets and expectations of practicing nephrologists with regard to timing of preemptive AV access surgery and how these relate to actual observed practice patterns in clinical care. METHODS: We administered a 8-question survey to assess nephrologists’ expectations for preemptive vascular access placement to 53 practicing nephrologists in California. We performed a retrospective chart review of 116 patients who underwent preemptive vascular access placement at a large academic medical center and examined progression to ESRD. RESULTS: According to our survey of nephrologists, most aimed to have preemptive vascular access created about 6 months prior to start of ESRD or when the chances of ESRD within the next year is two-thirds or greater. The estimated GFR level at which they believe match these conditions is approximately 18 ml/min/1.73 m(2). Among the 116 patients with CKD who underwent preemptive vascular access creation, the mean estimated GFR at the time of access creation was 16.1 (6.8) ml/min/1.73 m(2). Only 57 out of the 116 patients (49.1%) patients initiated maintenance HD within 1 year after surgery. CONCLUSIONS: In our study, most nephrologists aim for preemptive vascular access surgery approximately 6 months prior to the start of HD. However in fact, only approximately 50% of patients who underwent preemptive vascular access surgery started HD within 1 year. Better tools are needed to predict the natural history of advanced CKD

Parental mental health, socioeconomic position and the risk of asthma in children—a nationwide Danish register study

BACKGROUND: Parental mental illness affects child health. However, less is known about the impact of different severities of maternal depression and anxiety as well as other mental health conditions. The objective of this study was to examine the impact of different severities of maternal and paternal mental health conditions on child asthma. METHODS: This nationwide, register-based cohort study included all children in Denmark born from 2000 to 2014. Exposure was parental mental health conditions categorized in three severities: minor (treated at primary care settings), moderate (all ICD-10 F-diagnoses given at psychiatric hospital) and severe (diagnoses of severe mental illness). The children were followed from their third to sixth birthday. Child asthma was identified by prescribed medication and hospital-based diagnoses. Incidence rate ratios were calculated using negative binomial regression analyses. RESULTS: The analyses included 925 288 children; 26% of the mothers and 16% of the fathers were classified with a mental health condition. Exposed children were more likely to have asthma (10.6–12.0%) compared with unexposed children (8.5–9.0%). The three severities of mental health conditions of the mother and the father increased the risk of child asthma, most evident for maternal exposure. Additive interaction between maternal mental health conditions and disadvantaged socioeconomic position was found. CONCLUSION: We found an increased risk of asthma in exposed children, highest for maternal exposure. Not only moderate and severe, but also minor mental health conditions increased the risk of child asthma. The combination of mental health condition and disadvantaged socioeconomic position for mothers revealed a relative excess risk