Braden Manns

Cause of Death in Patients with Reduced Kidney Function

Information on common causes of death in people with CKD is limited. We hypothesized that, as eGFR declines, cardiovascular mortality and mortality from infection account for increasing proportions of deaths. We calculated eGFR using the CKD Epidemiology Collaboration equation for residents of Alberta, Canada who died between 2002 and 2009. We used multinomial logistic regression to estimate unadjusted and age- and sex-adjusted differences in the proportions of deaths from each cause according to the severity of CKD. Cause of death was classified as cardiovascular, infection, cancer, other, or not reported using International Classification of Diseases codes. Among 81,064 deaths, the most common cause was cancer (31.9%) followed by cardiovascular disease (30.2%). The most common cause of death for those with eGFR≥60 ml/min per 1.73 m(2) and no proteinuria was cancer (38.1%); the most common cause of death for those with eGFR<60 ml/min per 1.73 m(2) was cardiovascular disease. The unadjusted proportion of patients who died from cardiovascular disease increased as eGFR decreased (20.7%, 36.8%, 41.2%, and 43.7% of patients with eGFR≥60 [with proteinuria], 45-59.9, 30-44.9, and 15-29.9 ml/min per 1.73 m(2), respectively). The proportions of deaths from heart failure and valvular disease specifically increased with declining eGFR along with the proportions of deaths from infectious and other causes, whereas the proportion of deaths from cancer decreased. In conclusion, we found an inverse association between eGFR and specific causes of death, including specific types of cardiovascular disease, infection, and other causes, in this cohort.

Canadian Society of Nephrology Commentary on the 2009 KDIGO Clinical Practice Guideline for the Diagnosis, Evaluation, and Treatment of CKD–Mineral and Bone Disorder (CKD-MBD)

Professional societies throughout the world, ncluding the Canadian Society of Nephrology CSN), agree there is a need for developing linical practice guidelines for patients with hronic kidney disease (CKD). However, as illusrated by the case of the plethora of anemia uidelines for CKD that have been completed and updated) by many national professional ocieties since 2000, creation of guidelines by ndividual professional societies results in signifiant duplication of effort. In this context, KDIGO Kidney Disease: Improving Global Outcomes) as established in 2003 with its stated mission to improve the care and outcomes of kidney disase patients worldwide through promoting coorination, collaboration, and integration of initiaives to develop and implement clinical practice uidelines.” The KDIGO Clinical Practice Guideline for he Diagnosis, Evaluation, Prevention, and Treatent of Chronic Kidney Disease–Mineral and

Patient, family physician and community pharmacist perspectives on expanded pharmacy scope of practice: a qualitative study

BACKGROUNDnThe RxEACH trial was a randomized trial to evaluate the efficacy of community pharmacy-based case finding and intervention in patients at high risk for cardiovascular (CV) events. Community-dwelling patients with poorly controlled risk factors were identified and their CV risk reduced through patient education, prescribing and follow-up by their pharmacist. Perspectives of patients, family physicians and community pharmacists were obtained regarding pharmacists identification and management of patients at high risk for CV events, to identify strategies to facilitate implementation of the pharmacists expanded role in routine patient care.nnnMETHODSnWe used a qualitative methodology (individual semistructured interviews) with conventional qualitative content analysis to describe perceptions about community pharmacists care of patients at high risk for CV events. Perceptions were categorized into macro (structure), meso (institution) and micro (practice) health system levels, based on a conceptual framework of care for optimizing scopes of practice.nnnRESULTSnWe interviewed 48 participants (14 patients, 13 family physicians and 21 community pharmacists). Patients were supportive of the expanded scope of practice of pharmacists. All participant groups emphasized the importance of communication, ability to share patient information, trust and better understanding of the roles, responsibilities, accountabilities and liabilities of the pharmacist within their expanded role.nnnINTERPRETATIONnDespite support from patients and changes to delivery of care in primary care settings, ongoing efforts are needed to understand how to best harmonize family physician and community pharmacist roles across the health system. This will require collaboration and input from professional associations, regulatory bodies, pharmacists, family physicians and patients.

Quality-of-care indicators among remote-dwelling hemodialysis patients: a cohort study.

BACKGROUNDnWe hypothesized that the higher mortality for hemodialysis patients who live farther from the closest attending nephrologist compared with patients living closer might be due to lower quality of care.nnnSTUDY DESIGNnPopulation-based longitudinal study.nnnSETTING & PARTICIPANTSnAll adult maintenance hemodialysis patients with measurements of quality-of-care indicators initiating hemodialysis therapy between January 2001 and June 2010 in Northern Alberta, Canada.nnnPREDICTORSnHemodialysis patients were classified into categories based on the distance by road from their residence to the closest nephrologist: ≤50 (referent), 50.1-150, 150.1-300, and >300 km.nnnOUTCOMESnQuality-of-care indicators were based on published guidelines.nnnMEASUREMENTSnQuality-of-care indicators at 90 days following initiation of hemodialysis therapy and, in a secondary analysis, at 1 year.nnnRESULTSnMeasurements were available for 1,784 patients. At baseline, the proportions of patients residing in each category were 69% for ≤50 km to closest nephrologist; 17%, 50.1-150 km; 7%, 150.1-300 km; and 7%, >300 km. Those who lived farther away from the closest nephrologist were less likely to have seen a nephrologist 90 days prior to the initiation of hemodialysis therapy (P for trend = 0.008) and were less likely to receive Kt/V of 1.2 (adjusted OR, 0.50; 95% CI, 0.30-0.84; P for trend = 0.01). Remote location also was associated with suboptimal levels of phosphate control (P for trend = 0.005). There were no differences in the prevalence of arteriovenous fistulas or grafts or hemoglobin levels across distance categories.nnnLIMITATIONSnRegistry data with limited data for non-guideline-based quality indicators.nnnCONCLUSIONSnAlthough several quality-of-care indicators were less common in remote-dwelling hemodialysis patients, these differences do not appear sufficient to explain the previously noted disparities in clinical outcomes by residence location.

Development of a conceptual framework for understanding financial barriers to care among patients with cardiovascular-related chronic disease: a protocol for a qualitative (grounded theory) study

BACKGROUNDnPatients with cardiovascular-related chronic diseases may face financial barriers to accessing health care, even in Canada, where universal health care insurance is in place. No current theory or framework is adequate for understanding the impact of financial barriers to care on these patients or how they experience financial barriers. The overall objective of this study is to develop a framework for understanding the role of financial barriers to care in the lives of patients with cardiovascular-related chronic diseases and the impact of such barriers on their health.nnnMETHODSnWe will perform an inductive qualitative grounded theory study to develop a framework to understand the effect of financial barriers to care on patients with cardiovascular-related chronic diseases. We will use semistructured interviews (face-to-face and telephone) with a purposive sample of adult patients from Alberta with at least 1 of hypertension, diabetes, heart disease or stroke. We will analyze interview transcripts in triplicate using grounded theory coding techniques, including open, focused and axial coding, following the principle of constant comparison. Interviews and analysis will be done iteratively to theoretical saturation. Member checking will be used to enhance rigour.nnnINTERPRETATIONnA comprehensive framework for understanding financial barriers to accessing health care is instrumental for both researchers and clinicians who care for patients with chronic diseases. Such a framework would enable a better understanding of patient behaviour and nonadherence to recommended medical therapies and lifestyle modifications.

The Role of Health Economics within Clinical Research

The pressure for health care systems to provide more resource-intensive health care and newer, more costly therapies is significant, despite limited health care budgets. It is not surprising, then, that demonstration that a new therapy is effective is no longer sufficient to ensure that it can be used in practice within publicly funded health care systems. The impact of the therapy on health care costs is also important and considered by decision makers, who must decide whether scarce resources should be invested in providing a new therapy. The impact of a therapy on both clinical benefits and costs can be estimated simultaneously using economic evaluation, the strengths and limitations of which are discussed. When planning a clinical trial, important economic outcomes can often be collected alongside the clinical outcome data, enabling consideration of the impact of the therapy on overall resource use, thus enabling performance of an economic evaluation, if appropriate.

Catheter-related blood stream infections in hemodialysis patients: a prospective cohort study

BackgroundFor people requiring hemodialysis, infectious mortality is independently associated with geographic distance from a nephrologist. We aimed to determine if differential management of catheter-related blood stream infections (CRBSIs) could explain poorer outcomes.MethodsWe prospectively collected data from adults initiating hemodialysis with a central venous catheter between 2005 and 2015 in Alberta, Canada. We collected indicators of CRBSI management (timely catheter removal, relapsing bacteremia); frequency of CRBSIs; hospitalizations; predictors of CRBSIs, and bacteremia. We evaluated indicators and infectious episodes as a function of the shortest distance by road to the closest nephrologist’s practice: <50 (referent); 50–99; and ≥100xa0km.ResultsOne thousand one hundred thirty-one participants were followed for a median of 755xa0days (interquartile range (IQR) 219, 1465) and used dialysis catheters for a median of 565xa0days (IQR 176, 1288). Compared to the referent group, there was no significant difference in the rate ratio (RR) of CRBSI in the 50–100 and >100xa0km distance categories: RR 1.63; 95% confidence interval (CI) (0.91, 2.91); RR 0.84 (95% CI 0.44, 1.58); pu2009=u20090.87, respectively or in bacteremia: RR 1.42; (95% CI 0.83, 2.45); RR 0.79 (95% CI 0.45,1.39) pu2009=u20090.74, respectively. There were no differences in indicators of appropriate CRBSI management or hospitalizations according to distance. The overall incidence of CRBSIs was low (0.19 per 1000 catheter days) as was the frequency of relapse. Only liver disease was independently associated with CRBSI (RR 2.11; 95% CI 1.15, 3.86).ConclusionsThe frequency and management of CRBSIs did not differ by location; however, event rates were low.