CSCI Joe Doupe Lecture: End stage renal disease among Aboriginal people

Aboriginal people in Canada have an increased prevalence of ESRD, are more likely to initiate renal-replacement therapy on hemodialysis, and are much less likely to receive a kidney transplant compared to non-Aboriginals. Once established on dialysis quality of care and survival is similar for Aboriginal and non-Aboriginal people with ESRD. Understanding issues central to the health and outcomes of Aboriginal patients with ESRD, and documenting potential inequities in care, is essential to guide strategies to develop a new model for delivery of services for management of ESRD among Aboriginal people. Two areas in particular require further investigation for Aboriginal people with ESRD, namely the need to further investigate potential barriers to kidney transplantation, and reasons for lower rates of peritoneal dialysis as a form of renal replacement therapy. Research in this area will enable targeted interventions to be developed in partnership with the Aboriginal communities, with a goal to increase the health outcomes and quality of life for Aboriginal people with ESRD.     

The cost-effectiveness of irbesartan in the treatment of hypertensive patients with type 2 diabetic nephropathy

BACKGROUND: End-stage renal disease (ESRD)-related health care costs are substantial. Improving clinical outcomes in patients at risk of progression to ESRD could lead to considerable health care savings. OBJECTIVE: We estimated the cost-effectiveness of irbesartan compared with placebo or amlodipine in the treatment of patients with type 2 diabetes mellitus, hypertension, and overt nephropathy. METHODS: Three treatments for hypertension patients with type 2 diabetes mellitus and nephropathy were assessed: (1) irbesartan, (2) amlodipine, and (3) placebo. A Markov model was developed based on primary data from the Irbesartan in Diabetic Nephropathy Trial and the United States Renal Data System. Projected survival and costs were compared for each treatment at 3-, 10-, and 25-year time horizons. Different assumptions of treatment benefits and costs were tested with use of sensitivity analyses. RESULTS: At 10 and 25 years, the model projected irbesartan to be both the least costly and most effective (ie, demonstrating a survival advantage) strategy. At 25     

Economic burden of chronic kidney disease

Objectives To define the cost of care and evaluate interventions associated with improving outcomes and delaying the progression of chronic kidney disease (CKD). Methods Using the PubMed database, a systematic review of the literature was conducted describing (i) the cost of care associated with treating earlier stages of CKD, and (ii) the role of early referral, erythropoiesis‐stimulating proteins and anti‐hypertensive agents in improving clinical outcomes and reducing the cost of CKD. Results The higher costs associated with treatment of the CKD population are largely due to higher rates and duration of comorbidity‐driven hospitalizations. Studies suggest that early referral to a nephrologist, use of erythropoiesis‐stimulating proteins and anti‐hypertensive agents may be associated with better outcomes and lower costs. In some instances, however, higher target haemoglobin levels could have harmful effects in CKD patients. Conclusion The substantial costs incurred during earlier stages of CKD increase markedly during the transition to renal replacement and remain elevated thereafter. An increase in awareness among health care providers may result in more timely interventions. More proactive management, in turn, can lead to improved clinical and economic outcomes through the slowing of disease progression and prevention of comorbidities.     

Does the addition of functional status indicators to case-mix adjustment indices improve prediction of hospitalization, institutionalization, and death in the elderly?

BACKGROUND: Case-mix adjustment is widely used in health services research to ensure that groups being compared are equivalent on variables predicting outcome. There has been considerable development and testing of comorbidity indices derived from diagnostic codes recorded in administrative databases, but increasingly, the benefit of clinical information and patient reported ratings of health and functional status is being recognized. One type of information that is highly valued but has so far not been captured by administrative health databases is functional status indicators (FSI). OBJECTIVE: The purpose of this study was to estimate the extent to which prediction of health outcomes can be improved on by including information on functional status indicators (FSI). RESEARCH DESIGN: The data for the current study was obtained from a clustered randomized trial evaluating computerized decision support for managing drug therapy in the elderly, conducted from 1997 to 1998. A total of 107 primary care physicians participated in this trial and 6465 of their patients (51%) completed a generic health status measure-the SF-12-before the intervention. C statistics and R were used to compare the predictive value of sociodemographic factors, 2 comorbidity indices, and 11 FSI predictor variables derived from the SF-12 and coded (possible for 8) using the International Classification of Functioning (ICF). RESULTS: Using stepwise logistic regression, FSI, particularly limitation in stair climbing or doing moderate activities like housework, were found to be strong and independent predictors of all outcomes, even after controlling for sociodemographics and comorbidity. CONCLUSION: This study indicates that FSI provided as robust a prediction of health events as did complex comorbidity indices. Additionally, the ICF coding system provides a mechanism whereby information on FSI could be incorporated into administrative databases through the use of electronic health records that include a health or functional status measure.     

Nursing informatics. Applications for long-term care

Long-term care (LTC) settings, specifically nursing homes, have found it difficult to manage the regulatory process and provide quality resident care without computerization. Clinical information systems in the current health care environment, including LTC, need to provide five functions. These five functions are providing the legal record of care; supporting clinical decision-making; capturing costs for financial purposes; accumulating a database for administrative queries, quality assurance, and research; and supporting data exchange between systems. While computerization may have occurred in LTC, the application of the informatics concepts with nursing standardized languages and financial and database usage may not have occurred. To succeed in the current health care environment, nursing informatics concepts need to be implemented in LTC. As a result, the quality of care for older adults in nursing homes will be improved. The purpose of this article is to identify application for nursing informatics use in the LTC setting.     

End-stage renal disease-associated managed care costs among patients with and without diabetes

OBJECTIVE: To examine the direct costs of care before and after onset of end-stage renal disease (ESRD) for patients with and without diabetes based on analyses of retrospective healthcare claims data. RESEARCH DESIGN AND METHODS: Patients with onset of ESRD between January 1998 though June 2002 were identified based on use of dialysis, renal transplantation, or other ESRD-related services. Continuous health plan enrollment > or =12 months before and > or =1 month after ESRD onset was required. The costs calculated include both observed and adjusted estimates; the latter were calculated using generalized linear models, controlling for demographic and clinical characteristics, "onset" period, and duration of follow-up. Analyses focus on the diabetic ESRD patient and include a comparison with ESRD patients without diabetes. RESULTS: The study included 2,020 patients with diabetes and 2,170 without diabetes; 63% of patients were >50 years of age. Average costs were relatively stable before ESRD ($1,535 to $4,357 for diabetes, $1,082 to $2,447 for no diabetes) but more than doubled in the month preceding onset ($9,152 and $8,211, respectively). Postonset, average monthly per-patient costs escalated sharply in the 1st month ($26,507 and $26,789), declined steadily through month 6, and remained flat but elevated thereafter. Adjusted annual costs per patient pre- and postonset of ESRD were significantly higher for diabetes (P <0.0001); annual costs were 69% ($38,041 vs. $22,538) and 79% ($96,014 vs. $53,653) higher pre- and postonset, respectively. CONCLUSIONS: The economic burden of ESRD in the year after onset is substantial, particularly among patients with diabetes.     

Detailed cost analysis of care for survivors of severe sepsis

OBJECTIVES: The objectives of our study were to accurately describe the costs and resources required to treat survivors of severe sepsis subsequent to hospital discharge and to determine what factors influenced these costs. DESIGN: Observational cohort study. SETTING: Three regional intensive care units. PATIENTS: Patients with severe sepsis admitted to one of three regional intensive care units in southern Alberta between April 1, 1996, and March 31, 1999. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Patients were identified using an intensive care unit research database; all survivors were followed prospectively for 3 yrs. Information on baseline patient characteristics, including acuity of illness (Acute Physiology and Chronic Health Evaluation II scores) and Charlson comorbidity scores, was collected. Costs considered included all episodes of inpatient and outpatient care and all physician claims. Of 787 patients who were admitted with severe sepsis, 502 survived to hospital discharge and were followed. Subsequent mean cost of care for years 1, 2, and 3 was CAN$20,855, $7,139 and $7,091, respectively. Using various regression models, the Acute Physiology and Chronic Health Evaluation II score and the Charlson comorbidity score were the only factors that consistently predicted higher healthcare costs in the first year after hospital discharge. Diabetes was the comorbid condition that best predicted subsequent cost. CONCLUSIONS: Cost of care for survivors of severe sepsis was highest in the first year after hospital discharge. Acuity of illness and patient comorbidity were the main determinants of cost. In assessing whether new therapeutic innovations for intensive care unit patients with severe sepsis are cost-effective, an accurate estimate of the cost of subsequent health care for survivors treated with and without the new intervention will be important.     

Improving the utilization of clinical laboratory tests

Reimbursement policies for health care services are greatly diminishing in the U.S. and Western Europe. Hence, there is an increasing need for doctors and other care givers to reduce costs without compromising the quality of the care being delivered. The clinical laboratory is viewed as an area of high costs where significant reductions have been targeted. Efficient utilization of laboratory services can be achieved by elimination of the general health panel, removal of old tests or those that provide redundant information, a reduction in the use of standing orders, more judicious use of drug assays, acceptance of clinical practice guidelines, and use of reflex testing algorithms. New technologies such as DNA probes can substantially improve diagnostic efficiency. Point-of-care testing devices which have higher costs than incremental central laboratory expenses should only be used if they reduce overall operating expenses. Implementation of expert systems can make remaining tests more effective. Doctors and laboratorians must collaborate to achieve more efficient utilization practices.     

Impact of Postherpetic Neuralgia and Painful Diabetic Peripheral Neuropathy on Health Care Costs

Knowledge of the health care costs associated with neuropathic pain is limited. Existing studies have not directly compared the health care costs of different neuropathic pain conditions, and patients with neuropathic pain have not been compared with control subjects with the same underlying conditions (for example, diabetes). To determine health care costs associated with postherpetic neuralgia (PHN) and painful diabetic peripheral neuropathy (DPN), patients with these conditions were selected from 2 different administrative databases of health care claims and respectively matched to control subjects who had a diagnosis of herpes zoster without persisting pain or a diagnosis of diabetes without neurological complications using propensity scores for demographic and clinical factors. Total excess health care costs attributable to PHN and painful DPN and excess costs for inpatient care, outpatient/professional services, and pharmacy expenses were calculated. The results indicated that the annual excess health care costs associated with peripheral neuropathic pain in patients of all ages range from approximately $1600 to $7000, depending on the specific pain condition. Total excess health care costs associated with painful DPN were substantially greater than those associated with PHN, which might reflect the great medical comorbidity associated with DPN.PerspectiveThe data demonstrate that the health care costs associated with 1 peripheral neuropathic pain condition cannot be extrapolated to other neuropathic pain conditions. The results also increase understanding of the economic burden of PHN and painful DPN and provide a basis for evaluating the impact on health care costs of new interventions for their treatment and prevention.     

The impact of reducing dose frequency on health outcomes

BACKGROUND: Dosing schedules may be one important factor determining whether patients take their prescribed medication. Schedules may influence whether a patient stays on the prescribed therapy and, if so, the degree to which the regimen is followed. Both factors are important determinants of health outcomes and health care costs. OBJECTIVE: The goal of this study was to investigate the impact of reducing dose frequency on health outcomes and health care costs. METHODS: Articles from peer-reviewed journals were identified from the medical literature databases MEDLINE, International Pharmaceutical Abstracts, and HealthSTAR for the years 1985 through 2002. The search included all references that reported on the impact of a change of dose frequency on chronic disease. Search terms used were combinations of dose frequency, dose schedule, and dosing and efficacy, safety, clinical effectiveness, preferences, adherence, compliance, persistence, health-related quality of life, patient satisfaction, resource use, and costs. RESULTS: Reducing the number of daily doses through extended-release formulations or newer drugs has frequently been shown to provide the patient with better symptom control in a number of disease states. Overall improvements were seen in adherence, patient quality of life, patient satisfaction, and costs. However, results of some studies indicate that not all patients, medications, or diseases may be candidates for reduced dosing due to the potential effects on symptom control, incidence of adverse events, and overcompensation for missed doses. CONCLUSION: Where feasible, reducing dose frequency may offer benefits for the patient in terms of health outcomes and for the health care budget holder in terms of costs.     

Identification of patients receiving peritoneal dialysis using health insurance claims data

Objective: The aim of this analysis was to assess alternative methods of identification of patients treated with peritoneal dialysis (PD) in health care claims databases for possible use in future analyses of costs of this treatment modality.Methods: Using a US health insurance claims database spanning January 1, 2004, to December 31, 2006, we identified all patients with renal failure who satisfied a case-finding algorithm for PD anticipated to be highly specific, but not necessarily sensitive—namely, ≥2 claims for PD-related physician services (algorithm 1). All claims from these patients were assessed to identify additional PD-related codes, from which 6 additional algorithms were developed, each of which focused on specific categories of billing codes (eg, diagnostic, procedural/service, equipment). Patient selection was then reimplemented using these alternative algorithms. Concordance between the various algorithms and the extent to which resulting samples were similar in terms of patient characteristics, health care resource utilization, and costs were assessed.Results: We identified a total of 132,274 patients in the database with ≥1 claim for renal failure and valid enrollment data. Among these patients, a total of 2329 satisfied case-selection criteria for algorithm 1, and 4031 patients met criteria for at least 1 of the 7 algorithms for PD. The most sensitive algorithm identified 2859 patients who might have received PD; the least sensitive, 211. Concordance between algorithms was relatively poor. Patients identified using each algorithm were similar, however, with respect to mean age (45–50 years), sex (54%–56% male), and the prevalence of selected comorbidities. Annualized median health care costs were similar across the various algorithms (range, US $80,967-$118,668).Conclusions: Based on the results from this analysis, it seems that health care providers bill insurers for PD-related care using a variety of codes. Investigators using health insurance claims data for analyses of patients treated with PD need to take this into account.     

Economic evaluation in critical care medicine

Scarce resources are a reality in all health care systems. There is a constant challenge to maximize health benefits within the resources available. This is particularly relevant when caring for critically ill patients, given the resource-intensive technologies and medicines used and the highly specialized professionals required. Moreover, given the high acuity of illness, decision makers and health care providers in critical care units must constantly assess the value derived from therapies and resources used. Economic evaluation is the comparative analysis of alternative health care interventions in their relative costs (resource use) and effectiveness (health effects). Economic evaluations have been increasingly published in critical care journals and read by clinicians. This article illustrates how the basic principles of health economics can be applied to health care decision making through the use of economic evaluation. We demonstrate how economic evaluation can link medical outcomes, quality of life, and costs in a common index, even for therapies for different medical conditions and with different health outcomes. This article highlights the need for randomized clinical trials and economic evaluations of therapies in critical care medicine for which the effect of the therapy on health outcomes and/or costs are unknown.     

Appropriateness in programs for continuous quality improvement in clinical laboratories

BACKGROUND: External reviews and the accreditation of medical laboratories involve more than the mere assessment of conformance with standards for organisational processes. The new approaches to quality improvement suggest that, rather than using inspection to correct unusual errors, there should be more emphasis on improving the processes of health care to ensure that desired outcomes are produced. Appropriateness plays a key role in programs for quality improvement. METHODS: Appropriateness in laboratory medicine can be assessed, and improved, through the governance of the entire testing process. This begins with test selection, proceeds through valuable pre-, intra- and post-analytical procedures, and concludes by assuring the correct interpretation and utilization of laboratory information. RESULTS: The International Standard, specifically developed for medical laboratories (ISO 15189) recognizes the value of appropriate interpretation and advisory services, although it does not specify requirements for assessing appropriateness, requesting tests and interpreting results. The effectiveness of clinical laboratories can be assessed by using surrogate markers, which indicate physicians' satisfaction, and clinical audits. Effectiveness is also enhanced by stressing the importance of the technical and professional competence of evaluators. CONCLUSIONS: Inappropriate laboratory utilization unjustifiably increases health care costs, can harm patients and perpetuates the vision of laboratory testing as a commodity. Improvement in laboratory appropriateness can be achieved by seeking a better relationship with physicians and by stressing the role of laboratory specialists in providing clinical advice for the selection of laboratory tests, and the interpretation and utilization of their results, thus leading to more satisfactory clinical outcomes.     

Quality assurance and technology assessment: pieces of a larger puzzle

Increasing integration of health care and health services research has resulted in an overlap between disciplines involved in the evaluation of clinical practice. We have examined the relationships of quality assurance (QA), medical technology assessment (TA), clinical epidemiology (CE) and evidence-based medicine (EBM) from an historical perspective. Clinicians, patients and administrators need local information on effectiveness of routine care. Information from trials alone, efficacy data, will not suffice nor can it be culled from administrative databases designed for other purposes. The current activities of QA should be therefore be expanded to include the study of the effectiveness of interventions in terms of appropriateness of use, patient outcomes and study of the determinants of outcomes, as seen from the perspective of doctors, patients, administrators and policy makers, using data collected during the course of routine patient care. With the assistance of information technology, with methodological support and multidisciplinary cooperation, clinicians can do this as part of a more broadly defined clinical research. Quality assurance and TA both evolved with the objective of studying clinical care but have quite different historical roots, complementary perspectives and objectives, use different methods and involve a different set of practitioners. Quality assurance is a type of 'formative' evaluation conducted in the clinical setting using indicators as flags of process or outcome events of interest, simple surveys and audit studies. Its primary aim is to achieve incremental improvement rather than to simply pass judgement. An important underlying assumption is that health care behaves as a complex dynamic system. Technology assessment, a form of summative evaluation with an orientation towards policy, synthesises information from formal scientific studies of efficacy in the form of clinical trials and studies of cost-effectiveness. For the evaluation of the impact of any technology more complex than a drug, the complementary contributions of both of these disciplines is needed, and QA and TA should work cooperatively in tandem with the support of CE and EBM.     

Quality and the nursing workforce: APNs, patient outcomes and health care costs

Quality in health care requires access, appropriate and acceptable treatment plans, responsible patient follow through, a workforce of sufficient numbers and qualification and agreement on health care quality indicators. The purpose of this article is to describe APN workforce and dose effects on quality, reflected in patient outcomes and health care costs with current quality indicators. Stakeholders measure “quality indicators” differently. Nursing practices are often absent in databases and systems of reimbursement. Research overwhelmingly indicates equal outcomes for physician and APN care plus value-added APN effects on use of preventive services, adjustment to illness, stress management, treatment compliance, satisfaction, and reduced emergency room visits and rehospitalizations. APN dose has an important positive effect on patient outcomes and healthcare costs. Research is needed on the level of APN dose, staff mix and use of APNs, and balance of physician and APN dose in different stages of patient health, illness, and recovery to achieve quality outcomes.     

Computer-based documentation and bedside terminals

Rising health care costs and the need for enhancing the quality of clinical care are concerns of hospitals throughout the world. Documentation consumes excessive amounts of nursing time and directly influences the quality of clinical practice, research, administration and education. Recent developments in information technology have offered many alternatives to traditional systems of documentation. Many hospitals have installed bedside terminals, but only few have conducted and published studies regarding their implementation. Most of the studies come from the US and report improved quality of care and reduction of nursing expenses. All the relevant studies have design, sample and methodological problems. There is a need for additional systematic studies to prove the actual benefits of the bedside terminals and link them with the outcomes of care. This paper intends to review the literature and discuss the installation, use, results and future directions of the bedside terminals.     

Ambulatory testing for capitation and fee-for-service patients in the same practice setting: relationship to outcomes.

Previous studies of the impact of varying reimbursement incentives on physician behavior have not explored the simultaneous implications for patients' health outcomes. Using a single group of physicians who provided care for hypertensive patients with either capitation (N = 99) or fee-for-service (N = 66) health insurance plans, physicians' test-ordering behavior and patients' subsequent health outcomes were examined. After controlling for patients' age, severity of hypertension, and level of comorbidity, it was found that patients with capitation health insurance had fewer laboratory tests and lower overall charges than the fee-for-service patients, with no clinical or statistically significant differences in 1-year health outcomes, specifically blood pressure control. The study concludes that capitation can result in reduction in charges associated with management of hypertension, without apparent compromise in proximate health outcomes.     

The illness trajectory of end-stage renal disease dialysis patients

Chronic illness is the number one health problem in the United States. As a consequence, health care professionals have assumed an increasingly important role in helping patients and families manage illness over an extended period of time. Familiarity with the evolution of chronic illness is needed to increase the effectiveness of these efforts. The concept of a trajectory provides a way for clinicians to gain a fuller understanding of the changing nature of chronic illness. The trajectory model has not yet been used to define the experience of end-stage renal disease (ESRD). ESRD is typically viewed as the static end point of chronic renal failure. The new paradigm suggests that the experience of ESRD continues to evolve from the time of diagnosis until death and that it follows a trajectory that can be described. This article represents the first attempt to delineate the ESRD illness trajectory, including the characteristics of each phase relative to the dimensions of life. The significance of the trajectory for clinical practice is discussed as well as the need for further research to validate and refine the model.