Treatment Center and Geographic Variability in Pre-ESRD Care Associate with Increased Mortality

Late referral of patients with chronic kidney disease is associated with increased morbidity and mortality, but the contribution of center-to-center and geographic variability of pre-ESRD nephrology care to mortality of patients with ESRD is unknown. We evaluated the pre-ESRD care of >30,000 incident hemodialysis patients, 5088 (17.8%) of whom died during follow-up (median 365 d). Approximately half (51.3%) of incident patients had received at least 6 mo of pre-ESRD nephrology care, as reported by attending physicians. Pre-ESRD nephrology care was independently associated with survival (odds ratio 1.54; 95% confidence interval 1.45 to 1.64). There was substantial center-to-center variability in pre-ESRD care, which was associated with increased facility-specific death rates. As the proportion of patients who were in a treatment center and receiving pre-ESRD nephrology care increased from lowest to highest quintile, the mortality rate decreased from 19.6 to 16.1% (P = 0.0031). In addition, treatment centers in the lowest quintile of pre-ESRD care were clustered geographically. In conclusion, pre-ESRD nephrology care is highly variable among treatment centers and geographic regions. Targeting these disparities could have substantial clinical impact, because the absence of ≥6 mo of pre-ESRD care by a nephrologist is associated with a higher risk for death.Nephrology care before starting hemodialysis (HD) is an important determinant of health status of patients with ESRD^1,2 and is associated with hypoalbuminemia,³ anemia,⁴ absence of a functioning arteriovenous vascular access,⁵ reduced quality of life,⁶ and decreased kidney transplantation.⁷ Delayed care is associated with progression of kidney disease^8,9 and increased mortality after start of HD.^10–13 Early nephrology referral for individuals with chronic kidney disease (CKD) is recommended^14,15 for creation of an arteriovenous fistula (AVF) 6 mo before the anticipated start of HD.¹⁶Despite these guidelines, incident patients with ESRD frequently present without antecedent nephrology care.¹⁷ Differences between treatment center and geographic areas, similar to variations reported for the care of prevalent patients with ESRD, are possible factors that might contribute to variable pre-ESRD care.^17–19 If clinically relevant center-to-center and geographic variations in pre-ESRD care exist, then interventions might be designed to reduce the risk for delayed or absent care. This report describes the variable prevalence and clinical consequences for both individual patients and their treatment center populations of delayed pre-ESRD nephrology care in a large population-based sample of incident patients with ESRD.     

Radiation Dose Associated with Dialysis Vascular Access Interventional Procedures in the Interventional Nephrology Facility

The number of dialysis access procedures performed by interventional nephrologists using a mobile C‐arm fluoroscopy machine in freestanding centers continues to rise. With this activity comes the risk of radiation exposure to patients being treated and staff. This study was conducted to assess the levels of radiation dosage involved with these procedures. Dosimetry information including kerma area product (KAP), reference point air kerma (RPAK) and fluoroscopy time (FT) was collected prospectively. Radiation dosage data were collected from 24 centers in various parts of the United States and reflected cases managed by 69 different interventional nephrologists. The data were tabulated separately for eight procedures – fistula angioplasty and thrombectomy, graft angioplasty and thrombectomy, tunneled catheter placement and exchange, vein mapping and cases in which only angiographic evaluation was performed. The range for all of the measured parameters was large. Additionally there was considerable inter‐operator variability. The dosage levels noted in this series were well below the threshold for deterministic effects. FT for AVF procedures was higher than for other types of access. The highest values were observed for thrombectomies. The highest KAP values were recorded for venous mapping. Thrombectomy procedures were associated with the highest RPAK levels. All dosage metrics were considerably lower than those previously reported.     

Impact of Training in Interventional Nephrology on Hemodialysis Vascular Access Types

Vascular access has been a major problem in the management of end stage renal disease (ESRD) patients on chronic hemodialysis (HD). Native arteriovenous fistulas (AVFs) are the preferred vascular access for ESRD patients on HD. Multiple factors have been evaluated as causes for poor AVF rates. The purpose of this retrospective analysis was to assess the impact of training of nephrologist in interventional nephrology (IN) on vascular access outcomes. We studied the rates of different types of vascular access amongst patients on chronic HD under the care of two nephrology groups over 25 months in a community dialysis unit. In group A, all vascular access were managed directly by an interventional nephrologist, while in group B they were managed by general nephrologist with no exposure to IN during their training. A total of 129 patients received dialysis for at least 4 months at the unit during those 25 months. The rate of AVFs in group A was 56.6%, while in group B the rate of AVFs was 40.8% ( p  = 0.059). The rate of AVGs in group A was 22.9% and in group B it was 27.6% ( p  = 0.647). The tunneled HD catheter rate in group A was 20.4% and in group B it was 31.6% ( p  = 0.098). The results of this study demonstrate that training of nephrologists in IN leads to increased use of AVF as HD vascular access. We suggest that training programs in nephrology should consider incorporating IN into their programs to increase the prevalence of AVFs.     

Delivery of Predialysis Care in an Academic Referral Nephrology Practice

The purpose of this study was to obtain a detailed picture of the delivery of all aspects of pre-end stage renal disease (ESRD) care in an academic nephrology practice. The study consisted of a cross-sectional review of the charts of 111 patients with chronic kidney disease (CKD) (Creatinine > 1.5 mg/dL for males, Creatinine > 1.3 mg/dL for females) followed either in a private practice or a public hospital clinic. Charts were reviewed for evidence of a number of quality of care items including the degree of blood pressure control, the use of angiotensin II blockade, treatment of anemia, bone disease, and cardiovascular risk factors, as well as evidence of dialysis orientation and vascular access placement. Compared with previous published studies, this study shows encouraging trends towards better outcomes in at least two areas with evidence of improvement in hemoglobin levels, use of angiotensin II blockade, and degree of blood pressure control. However it also reveals many areas where care could be improved. This was particularly true in the areas of access placement, bone and mineral metabolism, and cardiovascular disease. It will be interesting to see whether the recent introduction of CKD guidelines by the National Kidney Foundation (NKF) and the associated educational initiatives for primary care physicians and nephrologists that are planned will further serve to improve the management of CKD patients in the years to come.     

Access to Care and Satisfaction in Colorectal Cancer Patients

This study described the various components of access to care for resectable colorectal cancer, and correlated the timeliness of these components with patient satisfaction. With a prospective/retrospective cohort design, all patients undergoing surgical resection for primary colorectal cancer from 2/1/01 to 15/12/01, were identified during their admission for surgery. A comprehensive, standardized method of ascertaining specific time intervals, which included a patient interview, was used. A patient satisfaction questionnaire was developed, tested, and used in consenting patients. Over the study period, 118 patients underwent colorectal cancer resection. Of these, 110 (93%) consented to participate and 101 (86%) completed the satisfaction questionnaire, including test-retest. The median time intervals (interquartile range) for the various components of access to care were as follows: symptoms to first physician visit, 32 days (10-75); first physician visit to diagnosis, 88 days (44-218); diagnosis to surgery, 19 days (10-44); surgery to chemotherapy (where applicable), 54 days (47-72). On multivariate analysis, tumor location in the rectum was associated with longer prediagnosis intervals, whereas increasing tumor stage was associated with shorter intervals from diagnosis to surgery. Variation in the time interval from diagnosis to surgery was associated with patient satisfaction (r = 0.49; P < 0.0001). Substantially less correlation was identified between patient satisfaction and the time from first physician visit to diagnosis (r = 0.25, P = 0.04). No significant correlation was identified between patient satisfaction scores and the time interval from symptoms to first physician visit (r = 0.11; P = 0.7). Despite concerns regarding surgical waitlists, the longest time intervals experienced by colorectal cancer patients precede diagnosis. However, variations in the relatively short time period from diagnosis to surgery appeared to have the most impact on patient satisfaction. Interventions which improve the timeliness of specific components of access to care may not necessarily result in improved patient satisfaction.     

Variability in Surgical Caseload and Access to Intensive Care Services

Background: Variability in the demand for any service is a significant barrier to efficient distribution of limited resources. In health care, demand is often highly variable and access may be limited when peaks cannot be accommodated in a downsized care delivery system. Intensive care units may frequently present bottlenecks to patient flow, and saturation of these services limits a hospital's responsiveness to new emergencies.

Methods: Over a 1-yr period, information was collected prospectively on all requests for admission to the intensive care unit of a large, urban children's hospital. Data included the nature of each request, as well as each patient's final disposition. The daily variability of requests was then analyzed and related to the unit's ability to accommodate new admissions.

Results: Day-to-day demand for intensive care services was extremely variable. This variability was particularly high among patients undergoing scheduled surgical procedures, with variability of scheduled admissions exceeding that of emergencies. Peaks of demand were associated with diversion of patients both within the hospital (to off-service care sites) and to other institutions (ambulance diversions). Although emergency requests for admission outnumbered scheduled requests, diversion from the intensive care unit was better correlated with scheduled caseload (r = 0.542, P < 0.001) than with unscheduled volume (r = 0.255, P < 0.001). During the busiest periods, nearly 70% of all diversions were associated with variability in the scheduled caseload.     

Determinants of Racial and Ethnic Disparities in Surgical Care

Racial and ethnic disparities are a pervasive and persistent problem in health care. This article has three main objectives: 1) To highlight key studies related to racial disparities in cardiovascular care and outcomes; 2) To explore determinants of disparities specifically related to access to renal transplantation as a model for understanding racial disparities in greater depth; and 3) To present promising approaches to eliminate racial disparities in care. Performance reports of the quality of medical and surgical care by race and ethnicity will be a crucial and expanding tool as more organizations ascertain complete data on their patients’ race, ethnicity, language, and socioeconomic characteristics. Efforts to improve the quality of care and health outcomes of underserved racial and ethnic groups will also require effective coordination of care, patient-centered communication, and constructive engagement with communities to eliminate disparities in health care and health.     

Racial and Socioeconomic Disparities in Access and Utilization of Adrenal Metastasectomy

World Journal of Surgery - There is substantial evidence that resecting adrenal metastases can be safely accomplished and extend overall survival in select patients. However, patient access to this...     

Racial and Ethnic Differences in Pediatric Access to Preemptive Kidney Transplantation in the United States

Preemptive kidney transplantation is the optimal treatment for pediatric end stage renal disease patients to avoid increased morbidity and mortality associated with dialysis. It is unknown how race/ethnicity and poverty influence preemptive transplant access in pediatric. We examined the incidence of living donor or deceased donor preemptive transplantation among all black, white, and Hispanic children (<18 years) in the United States Renal Data System from 2000 to 2009. Adjusted risk ratios for preemptive transplant were calculated using multivariable‐adjusted models and examined across health insurance and neighborhood poverty levels. Among 8,053 patients, 1117 (13.9%) received a preemptive transplant (66.9% from LD, 33.1% from DD). In multivariable analyses, there were significant racial/ethnic disparities in access to LD preemptive transplant where blacks were 66% (RR = 0.34; 95% CI: 0.28–0.43) and Hispanics 52% (RR = 0.48; 95% CI: 0.35–0.67) less likely to receive a LD preemptive transplant versus whites. Blacks were 22% less likely to receive a DD preemptive transplant versus whites (RR = 0.78, 95% CI: 0.57–1.05), although results were not statistically significant. Future efforts to promote equity in preemptive transplant should address the critical issues of improving access to pre‐ESRD nephrology care and overcoming barriers in living donation, including obstacles partially driven by poverty.