Kevin F. Erickson

Physician Visits and 30-Day Hospital Readmissions in Patients Receiving Hemodialysis

A focus of health care reform has been on reducing 30-day hospital readmissions. Patients with ESRD are at high risk for hospital readmission. It is unknown whether more monitoring by outpatient providers can reduce hospital readmissions in patients receiving hemodialysis. In nationally representative cohorts of patients in the United States receiving in-center hemodialysis between 2004 and 2009, we used a quasi-experimental (instrumental variable) approach to assess the relationship between frequency of visits to patients receiving hemodialysis following hospital discharge and the probability of rehospitalization. We then used a multivariable regression model and published hospitalization data to estimate the cost savings and number of hospitalizations that could be prevented annually with additional provider visits to patients in the month following hospitalization. In the main cohort (n=26,613), one additional provider visit in the month following hospital discharge was estimated to reduce the absolute probability of 30-day hospital readmission by 3.5% (95% confidence interval, 1.6% to 5.3%). The reduction in 30-day hospital readmission ranged from 0.5% to 4.9% in an additional four cohorts tested, depending on population density around facilities, facility profit status, and patient Medicaid eligibility. At current Medicare reimbursement rates, the effort to visit patients one additional time in the month following hospital discharge could lead to 31,370 fewer hospitalizations per year, and

Provider Visit Frequency and Vascular Access Interventions in Hemodialysis

240 million per year saved. In conclusion, more frequent physician visits following hospital discharge are estimated to reduce rehospitalizations in patients undergoing hemodialysis. Incentives for closer outpatient monitoring following hospital discharge could lead to substantial cost savings.

Overlooked Care Transitions: An Opportunity to Reduce Acute Care Use in ESRD

BACKGROUND AND OBJECTIVES Medicare reimbursement policy encourages frequent provider visits to patients with ESRD undergoing hemodialysis. This study sought to determine whether more frequent face-to-face provider (physician and advanced practitioner) visits lead to more procedures and therapeutic interventions aimed at preserving arteriovenous fistulas and grafts, improved vascular access outcomes, and fewer related hospitalizations. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS Multivariable regression was used to evaluate the association between provider (physician and advanced practitioner) visit frequency and interventions aimed at preserving vascular access, vascular access survival, hospitalization for vascular access infection, and outpatient antibiotic use in a cohort of 63,488 Medicare beneficiaries receiving hemodialysis in the United States. Medicare claims were used to identify the type of vascular access used, access-related events, and vascular access failure. RESULTS One additional provider (physician and advanced practitioner) visit per month was associated with a 13% higher odds of receiving an intervention to preserve vascular access (95% confidence interval [95% CI], 12% to 14%) but was not associated with vascular access survival (hazard ratio, 1.01; 95% CI, 0.99 to 1.03). One additional provider visit was associated with a 9% (95% CI, 5% to 14%) lower odds of hospitalization for vascular access infection and a corresponding 9% (95% CI, 5% to 14%) higher odds of outpatient intravenous antibiotic administration. However, the associated changes in absolute probabilities of hospitalization and antibiotic administration were small. CONCLUSIONS More frequent face-to-face provider (physician and advanced practitioner) visits were associated with more procedures and therapeutic interventions aimed at preserving vascular accesses, but not with prolonged vascular access survival and only a small decrease in hospitalization for vascular access.

Medicare Reimbursement Reform for Provider Visits and Health Outcomes in Patients on Hemodialysis

A major goal of United States health care reform is to reduce hospital readmissions. In 2012, approximately 18% of Medicare patients discharged from the hospital were readmitted within 30 days ([1][1]). According to one estimate, readmissions cost the Medicare program >

Interaction between GFR and Risk Factors for Morbidity and Mortality in African Americans with CKD

17 billion in 2004 ([2][2]).

Hemodialysis treatment center early mortality rates for incident hemodialysis patients are associated with the quality of care prior to starting but not following onset of dialysis.

Abstract The relation between the quantity of many healthcare services delivered and health outcomes is uncertain. In January 2004, the Centers for Medicare and Medicaid Services introduced a tiered fee-for-service system for patients on hemodialysis, creating an incentive for providers to see patients more frequently. We analyzed the effect of this change on patient mortality, transplant wait-listing, and costs. While mortality rates for Medicare beneficiaries on hemodialysis declined after reimbursement reform, mortality declined more – or was no different – among patients whose providers were not affected by the economic incentive. Similarly, improved placement of patients on the kidney transplant waitlist was no different among patients whose providers were not affected by the economic incentive; payments for dialysis visits increased 13.7% in the year following reform. The payment system designed to increase provider visits to hemodialysis patients increased Medicare costs with no evidence of a benefit on survival or kidney transplant listing.

Correlates and variance decomposition analysis of heparin dosing for maintenance hemodialysis in older US patients.

BACKGROUND AND OBJECTIVES The African American Study of Kidney Disease Trial identified risk factors for CKD progression and suggested that GFR level may modify the association between these risk factors and CKD progression or death. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS Enrollment in the African American Study of Kidney Disease Trial occurred between June of 1995 and September of 2001, with median follow-up of 48.6 months. Among 1094 patients with hypertensive kidney disease in the trial, this study tested whether the association between six previously identified risk factors for CKD progression (or death) and a composite clinical outcome (progression of CKD, ESRD, or death) depends on level of GFR. Multivariate Cox regression was used to control for other baseline risk factors. RESULTS After controlling for baseline risk factors, only proteinuria was more closely associated with the composite clinical outcome at lower levels of GFR (P value for interaction term=0.002); increased hazards of the clinical composite outcome associated with a doubling of proteinuria ranged from 30% (95% confidence interval=21%-39%) with a GFR of 50 to 55% (95% confidence interval=40%-72%) with a GFR of 25. CONCLUSIONS The magnitude of the association between proteinuria and CKD progression, ESRD, or death in the African American Study of Kidney Disease Trial cohort depends on the level of GFR; proteinuria is a stronger independent predictor of the composite clinical outcome at lower levels of GFR. This finding reinforces that African Americans with proteinuria and lower GFR represent a population at particularly high risk for adverse outcomes.

A Case for More Frequent, Not Just Earlier, Nephrology Care of Patients Approaching ESRD?

Background: We examined the independent contribution of pre-ESRD (end-stage renal disease) care and care after starting hemodialysis (post-HD) with facility-specific mortality among incident patients. Methods: We studied 6,217 incident patients treated at 311 dialysis facilities. A pre-ESRD care score was assessed as the sum of quality measures met on the Centers for Medicare and Medicaid Services Form 2728, including predialysis nephrology and dietary care, having a fistula, hemoglobin and serum albumin. A post-HD care score was evaluated by the sum of quality targets attained, including HD adequacy, anemia, serum albumin and hemoglobin measured on an annual quality survey. A fifth post-HD care measure was having obtained an influenza vaccination during the current year. Results: Individual patient mortality was associated with both pre-ESRD (p < 0.001) and post-HD (p < 0.001) care scores. Linear regression models including both pre-ESRD and post-HD care scores showed that a 1-point increase in the pre-ESRD care score resulted in a 0.30 (95% CI: –0.47, –0.12) decreased facility standardized mortality ratio; no association for post-HD care score was noted (–0.11; 95% CI: –0.26, 0.04). Conclusion: Pre-ESRD and post-HD care are both strongly associated with individual patient mortality. In contrast, only pre-ESRD care is associated with facility mortality, suggesting that early mortality reflects differences in pre-ESRD care in the community.

The Challenges of Cost-Effectiveness Analyses for the Clinician

Heparin is commonly used to anticoagulate the hemodialysis (HD) circuit. Despite the bleeding risk, no American standards exist for its administration. We identified correlates and quantified sources of variance in heparin dosing for HD.

Cost-effectiveness of statins for primary cardiovascular prevention in chronic kidney disease.

In addition to initiating patients on dialysis treatment or assisting in the management of kidney transplantation, nephrologists have a crucial role in managing patients with progressive chronic kidney disease (CKD) and preparing them for the transition to end-stage renal disease (ESRD). Patients with earlier nephrology referral survive longer after starting dialysis. Earlier nephrology referral is also associated with higher likelihoods of arteriovenous fistula or graft use among those initiating hemodialysis, of selecting home dialysis modalities, and of wait listing for a kidney transplant. Almost 15 years ago, the NKF-KDOQI (National Kidney Foundation–Kidney Disease Outcomes Quality Initiative) clinical practice guideline for CKD recommended that patients be referred to a nephrologist when the glomerular filtration rate was ,30 mL/min/1.73 m (CKD stage 4). Similarly, recognizing the important role of timely nephrology care in patients with CKD, the Centers for Disease Control and Prevention (CDC) Healthy People 2020 CKD initiatives included a goal of increasing the proportion of patients with CKD who receive nephrology care at least 12 months before starting kidney replacement therapy. Although laudable in establishing a focus on this important matter, the monodimensional focus on when patients should be referred may be rather simplistic. In particular, considerations other than just duration of predialysis follow-up may be equally important, including what constitutes the optimal frequency and intensity of interactions between patients with CKD and their nephrologists. However, relatively few data on this aspect of predialysis care are currently available. In the current issue of AJKD, Yang et al explore the relationship between the frequency and intensity of predialysis nephrology care and major adverse cardiovascular events (MACEs) among patients initiating long-term dialysis in an observational cohort study using the National Health Insurance Research Database, a large database of Taiwan residents’ health care use. The investigators randomly selected 60,329 patients from this vast database who were 20 years or older and initiated maintenance dialysis in Taiwan between 1999 and 2010 and survived at least 3 months. The primary outcome of interest was occurrence of a composite outcome of MACE: