Laura C. Plantinga

Clinical Information Technologies and Inpatient Outcomes: A Multiple Hospital Study

BACKGROUNDnDespite speculation that clinical information technologies will improve clinical and financial outcomes, few studies have examined this relationship in a large number of hospitals.nnnMETHODSnWe conducted a cross-sectional study of urban hospitals in Texas using the Clinical Information Technology Assessment Tool, which measures a hospitals level of automation based on physician interactions with the information system. After adjustment for potential confounders, we examined whether greater automation of hospital information was associated with reduced rates of inpatient mortality, complications, costs, and length of stay for 167 233 patients older than 50 years admitted to responding hospitals between December 1, 2005, and May 30, 2006.nnnRESULTSnWe received a sufficient number of responses from 41 of 72 hospitals (58%). For all medical conditions studied, a 10-point increase in the automation of notes and records was associated with a 15% decrease in the adjusted odds of fatal hospitalizations (0.85; 95% confidence interval, 0.74-0.97). Higher scores in order entry were associated with 9% and 55% decreases in the adjusted odds of death for myocardial infarction and coronary artery bypass graft procedures, respectively. For all causes of hospitalization, higher scores in decision support were associated with a 16% decrease in the adjusted odds of complications (0.84; 95% confidence interval, 0.79-0.90). Higher scores on test results, order entry, and decision support were associated with lower costs for all hospital admissions (-

Prevalence of Chronic Kidney Disease in US Adults with Undiagnosed Diabetes or Prediabetes

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Patient Awareness of Chronic Kidney Disease Trends and Predictors

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Association of residual urine output with mortality, quality of life, and inflammation in incident hemodialysis patients: the Choices for Healthy Outcomes in Caring for End-Stage Renal Disease (CHOICE) Study.

538, respectively; P < .05).nnnCONCLUSIONnHospitals with automated notes and records, order entry, and clinical decision support had fewer complications, lower mortality rates, and lower costs.

The association of sudden cardiac death with inflammation and other traditional risk factors

BACKGROUND AND OBJECTIVESnPrevalence of chronic kidney disease (CKD) in people with diagnosed diabetes is known to be high, but little is known about the prevalence of CKD in those with undiagnosed diabetes or prediabetes. We aimed to estimate and compare the community prevalence of CKD among people with diagnosed diabetes, undiagnosed diabetes, prediabetes, or no diabetes.nnnDESIGN, SETTING, PARTICIPANTS, & MEASUREMENTSnThe 1999 through 2006 National Health and Nutrition Examination Survey is a representative survey of the civilian, noninstitutionalized US population. Participants who were aged > or =20 years; responded to the diabetes questionnaire; and had fasting plasma glucose (FPG), serum creatinine, and urinary albumin-creatinine ratio measurements were included (N = 8188). Diabetes status was defined as follows: Diagnosed diabetes, self-reported provider diagnosis (n = 826); undiagnosed diabetes, FPG > or =126 mg/dl without self-reported diagnosis (n = 299); prediabetes, FPG > or =100 and <126 mg/dl (n = 2272); and no diabetes, FPG <100 mg/dl (n = 4791). Prevalence of CKD was defined by estimated GFR 15 to 59 ml/min per 1.73 m(2) or albumin-creatinine ratio > or =30 mg/g; adjustment was performed with multivariable logistic regression.nnnRESULTSnFully 39.6% of people with diagnosed and 41.7% with undiagnosed diabetes had CKD; 17.7% with prediabetes and 10.6% without diabetes had CKD. Age-, gender-, and race/ethnicity-adjusted prevalence of CKD was 32.9, 24.2, 17.1, and 11.8%, for diagnosed, undiagnosed, pre-, and no diabetes, respectively. Among those with CKD, 39.1% had undiagnosed or prediabetes.nnnCONCLUSIONSnCKD prevalence is high among people with undiagnosed diabetes and prediabetes. These individuals might benefit from interventions aimed at preventing development and/or progression of both CKD and diabetes.

Cerebrovascular disease incidence, characteristics, and outcomes in patients initiating dialysis: the choices for healthy outcomes in caring for ESRD (CHOICE) study.

BACKGROUNDnThe impact of recent guidelines for early detection and prevention of chronic kidney disease (CKD) on patient awareness of disease and factors that might be associated with awareness have not been well described.nnnMETHODSnAwareness rates were assessed in 2992 adults (age, > or =20 years) with CKD stages 1 to 4 from a nationally representative, cross-sectional survey (National Health and Nutrition Examination Survey 1999-2004). Awareness of CKD was defined by an answer of yes to Have you ever been told you have weak or failing kidneys? Potential predictors of awareness included demographics, access to care, and clinical and lifestyle factors, which were assessed by standardized interviewer-administered questionnaires and physical examinations. We examined independent associations of patient characteristics with awareness in those with CKD stage 3 (n = 1314) over 6 years using multivariable logistic regression.nnnRESULTSnAwareness improved over time in those with CKD stage 3 only (4.7% [95% confidence interval {CI}, 2.6%-8.5%], 8.9% [95% CI, 7.1%-11.2%], and 9.2% [95% CI, 6.1%-13.8%] for 1999-2000, 2001-2002, and 2003-2004, respectively; P = .04, adjusted for age, sex, and race). Having proteinuria (odds ratio, 3.04 [95% CI, 1.62-5.70]), diabetes (OR, 2.19 [95% CI, 1.03-4.64]), and hypertension (OR, 2.92 [95% CI, 1.57-5.42]) and being male (OR, 2.06 [95% CI, 1.15-3.69]) were all statistically significantly associated with greater awareness among persons with CKD stage 3 after adjustment. Chronic kidney disease awareness increased almost 2-fold for those with CKD stage 3 over recent years but remains low. Persons with risk factors for CKD (proteinuria, diabetes, hypertension, and male sex) were more likely to be aware of their stage 3 disease.nnnCONCLUSIONnRenewed and innovative efforts should be made to increase CKD awareness among patients and health care providers.

Prevalence of Chronic Kidney Disease in Persons With Undiagnosed or Prehypertension in the United States

BACKGROUNDnResidual kidney function (RKF) is associated with improved survival in peritoneal dialysis patients, but its role in hemodialysis patients is less well known. Urine output may provide an estimate of RKF. The aim of our study is to determine the association of urine output with mortality, quality of life (QOL), and inflammation in incident hemodialysis patients.nnnSTUDY DESIGNnNationally representative prospective cohort study.nnnSETTING & PARTICIPANTSn734 incident hemodialysis participants treated in 81 clinics; enrollment, 1995-1998; follow-up until December 2004.nnnPREDICTORnUrine output, defined as producing at least 250 mL (1 cup) of urine daily, ascertained using questionnaires at baseline and year 1.nnnOUTCOMES & MEASUREMENTSnPrimary outcomes were all-cause and cardiovascular mortality, analyzed using Cox regression adjusted for demographic, clinical, and treatment characteristics. Secondary outcomes were QOL, inflammation (C-reactive protein and interleukin 6 levels), and erythropoietin (EPO) requirements.nnnRESULTSn617 of 734 (84%) participants reported urine output at baseline, and 163 of 579 (28%), at year 1. Baseline urine output was not associated with survival. Urine output at year 1, indicating preserved RKF, was independently associated with lower all-cause mortality (HR, 0.70; 95% CI, 0.52-0.93; P = 0.02) and a trend toward lower cardiovascular mortality (HR, 0.69; 95% CI, 0.45-1.05; P = 0.09). Participants with urine output at baseline reported better QOL and had lower C-reactive protein (P = 0.02) and interleukin 6 (P = 0.03) levels. Importantly, EPO dose was 12,000 U/wk lower in those with urine output at year 1 compared with those without (P = 0.001).nnnLIMITATIONSnUrine volume was measured in only a subset of patients (42%), but agreed with self-report (P < 0.001).nnnCONCLUSIONSnRKF in hemodialysis patients is associated with better survival and QOL, lower inflammation, and significantly less EPO use. RKF should be monitored routinely in hemodialysis patients. The development of methods to assess and preserve RKF is important and may improve dialysis care.

Chronic Kidney Disease Awareness Among Individuals with Clinical Markers of Kidney Dysfunction

Despite the frequency of cardiovascular death in dialysis patients, few studies have prospectively measured sudden cardiac death in these individuals. Here, we sought to determine the frequency of sudden cardiac death and its association with inflammation and other risk factors among the CHOICE (Choices for Healthy Outcomes In Caring for ESRD) cohort of 1,041 incident dialysis patients. Sudden cardiac death was defined as that occurring outside of the hospital with an underlying cardiac cause from death certificate data. Over a median 2.5 years of follow-up, 22% of all mortality in this cohort was due to sudden cardiac death. Using Cox proportional hazards, we found that the highest tertiles of high-sensitivity C-reactive protein and of IL-6 were each associated with twice the risk of sudden cardiac death compared to their lowest tertiles when adjusted for demographics, comorbidities and laboratory factors. A decrement in serum albumin was associated with a 1.35 times increased risk for sudden cardiac death in the highest compared to the lowest tertile. These findings were robust and consistent when accounting for competing risks of death from other causes. Hence, we found that sudden cardiac death is common among patients with end stage renal disease and that inflammation and malnutrition significantly increased its occurrence independent of traditional cardiovascular risk factors.

Blood Pressure Control Among Persons Without and With Chronic Kidney Disease: US Trends and Risk Factors 1999―2006

BACKGROUNDnStroke is the third most common cause of cardiovascular disease death in patients on dialysis therapy; however, characteristics of cerebrovascular disease, including clinical subtypes and subsequent consequences, have not been well described.nnnSTUDY DESIGNnProspective national cohort study, the Choices for Healthy Outcomes in Caring for End-Stage Renal Disease (CHOICE) Study.nnnSETTINGS & PARTICIPANTSn1,041 incident dialysis patients treated in 81 clinics enrolled from October 1995 to July 1998, followed up until December 31, 2004.nnnPREDICTORnTime from dialysis therapy initiation.nnnOUTCOMES & MEASUREMENTSnCerebrovascular disease events were defined as nonfatal (hospitalized stroke and carotid endarterectomy) and fatal (stroke death) events after dialysis therapy initiation. Stroke subtypes were classified by using standardized criteria from the Trial of ORG 10172 in Acute Stroke Treatment (TOAST) system. The incidence of cerebrovascular event subtypes was analyzed by using time-to-event analyses accounting for competing risk of death. Clinical outcomes after stroke were abstracted from medical records.nnnRESULTSn165 participants experienced a cerebrovascular event with an overall incidence of 4.9 events/100 person-years. Ischemic stroke was the most common (76% of all 200 events), with cardioembolism subtype accounting for 28% of the 95 abstracted ischemic events. Median time from onset of symptoms to first stroke evaluation was 8.5 hours (25th and 75th percentiles, 1 and 42), with only 56% of patients successfully escaping death, nursing home, or skilled nursing facility.nnnLIMITATIONSnRelatively small sample size limits power to determine risk factors.nnnCONCLUSIONSnCerebrovascular disease is common in dialysis patients, is identified late, and carries a significant risk of morbidity and mortality. Stroke etiologic subtypes on dialysis therapy are multifactorial, suggesting risk factors may change the longer one has end-stage renal disease. Additional studies are needed to address the poor prognosis through prevention, early identification, and treatment.

Correlates and Outcomes of Fatigue among Incident Dialysis Patients

Hypertension is both a cause and a consequence of chronic kidney disease, but the prevalence of chronic kidney disease throughout the diagnostic spectrum of blood pressure has not been established. We determined the prevalence of chronic kidney disease within blood pressure categories in 17 794 adults surveyed by the National Health and Nutrition Examination Survey during 1999–2006. Diagnosed hypertension was defined as self-reported provider diagnosis (n=5832); undiagnosed hypertension was defined as systolic blood pressure ≥140 mm Hg or diastolic blood pressure ≥90 mm Hg, without report of provider diagnosis (n=3046); prehypertension was defined as systolic blood pressure ≥120 and <140 mm Hg or diastolic blood pressure ≥80 and <90 mm Hg (n=3719); and normal was defined as systolic blood pressure <120 mm Hg and diastolic blood pressure <80 mm Hg (n=5197). Chronic kidney disease was defined as estimated glomerular filtration rate <60 mL/min per 1.73 m2 or urinary albumin:creatinine ratio >30 mg/g. Prevalences of chronic kidney disease among those with prehypertension and undiagnosed hypertension were 17.3% and 22.0%, respectively, compared with 27.5% with diagnosed hypertension and 13.4% with normal blood pressure, after adjustment for age, sex, and race in multivariable logistic regression. This pattern persisted with varying definitions of kidney disease; macroalbuminuria (urinary albumin:creatinine ratio >300 mg/g) had the strongest association with increasing blood pressure category (odds ratio: 2.37 [95% CI: 2.00 to 2.81]). Chronic kidney disease is prevalent in undiagnosed and prehypertension. Earlier identification and treatment of both these conditions may prevent or delay morbidity and mortality from chronic kidney disease.