T. Christopher Bond

Towards a common definition of global health

This commentary makes the argument for the necessity of a common definition of global health.

Mortality of Dialysis Patients According to Influenza and Pneumococcal Vaccination Status

BACKGROUND Data from an immunocompromised subpopulation in which both vaccine recipients and nonrecipients have frequent opportunities for vaccination can help determine the associations between vaccination against seasonal influenza and pneumococcal disease and all-cause mortality. STUDY DESIGN We surveyed dialysis centers and performed a retrospective analysis of health status at dialysis therapy initiation, vaccination for influenza and pneumococcal disease, laboratory results, and mortality associated with the 2005-2006 influenza season for patients in 3 End-Stage Renal Disease Networks across the United States. SETTING & PARTICIPANTS Of 1,033 dialysis facilities considered, 903 centers with a total patient population of 54,734 reported vaccination data. Analysis was limited to 36,966 patients on dialysis treatment for at least 1 year as of December 31, 2005. PREDICTOR Vaccination status. OUTCOMES OR for all-cause mortality (vaccinated vs unvaccinated patients). RESULTS The estimated adjusted OR for mortality was significantly less than 1.0 for patient who received either vaccination and was lower for patients who had received both vaccinations than for those who had received either. Survival analysis confirmed these findings. LIMITATIONS Possible misclassification due to self-report of vaccination for some patients. Lack of vaccination date. CONCLUSIONS Vaccination against influenza and pneumococcal disease is associated with improved survival in dialysis patients. The 2 vaccinations have independent effects on mortality.

Reduced use of erythropoiesis-stimulating agents and intravenous iron with ferric citrate: a managed care cost-offset model

Background Ferric citrate (FC) is a phosphate binder in development for the treatment of hyperphosphatemia in patients with end-stage renal disease (ESRD). In clinical trials, FC improved patient serum phosphorus levels and increased serum ferritin and percent transferrin saturation. Because nephrologists respond to increases in these iron measures by reducing intravenous (IV) iron and erythropoiesis-stimulating agent (ESA) doses, the decreased use of iron and ESA associated with FC may reduce costs. Objectives To develop a cost-offset model from a managed care perspective estimating the cost savings associated with FC use. Methods We created a cost-offset model from the managed care payer perspective that compared the treatment costs of ESRD for patients given FC. The model considered the number of dialysis sessions per month; number of ESRD patients enrolled in the health plan; cost of ESAs, iron, and dialysis sessions; and the proportion of patients on phosphate binder therapy. The model assumed equivalent efficacy and cost neutrality between FC and other phosphate binders. Monte Carlo simulations were conducted by varying model inputs. Results When FC was compared to other phosphate binders, the monthly cost of ESA and IV iron per 500 patients with ESRD (85% treated with phosphate binders) was reduced by 8.15% and 33.2%, respectively. When incorporated into the total cost of dialysis for patients with ESRD (dialysis, ESA, and IV iron), the decrease in the monthly cost of dialysis care was US

Association of standing-order policies with vaccination rates in dialysis clinics: a US-based cross-sectional study.

80,214 per 500 ESRD patients. Monte Carlo simulations suggest that a plan serving 500 dialysis patients could save between US

Form CMS-2728 Data Versus Erythropoietin Claims Data: Implications for Quality of Care Studies

626,000 and US

A Group-Randomized Evaluation of a Quality Improvement Intervention to Improve Influenza Vaccination Rates in Dialysis Centers

1,106,000 annually with the use of FC. Conclusion The use of FC in ESRD patients with hyperphosphatemia may help reduce treatment costs.

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.

BACKGROUND Patients with end-stage renal disease are at increased risk of morbidity and mortality because of infection. Quality improvement efforts for this patient population include assessment of institutional policies and practices that may increase vaccination rates for influenza, hepatitis B, and pneumococcal disease. STUDY DESIGN A survey of vaccination practices, beliefs, and attitudes was sent to all dialysis centers in End-Stage Renal Disease Networks 6, 11, and 15. SETTING & PARTICIPANTS Of 1,052 dialysis facilities considered, 683 returned the survey, reported vaccination rates for 2005 to 2006, and had 20 or more patients. PREDICTOR OR FACTOR Standing-order policy of the dialysis facility, categorized as facility-wide orders, preprinted admission orders for each patient (chart orders), physician-specific orders, and individual orders. OUTCOMES Vaccination rates for influenza, hepatitis B (full or partial series), hepatitis B, and pneumococcal vaccine. MEASUREMENTS Patient vaccination, given at or outside the center. RESULTS Overall vaccination rates were 76% +/- 18% (SD) for influenza, 73% +/- 22% for hepatitis B full or partial series, 62% +/- 25% for hepatitis B full series, and 44% +/- 34% for pneumococcal vaccine. Compared with individual orders, facility-wide standing orders and chart orders were not associated with greater vaccination rates for influenza (0.4%; confidence interval, -4 to 5; and 1.27%; confidence interval, -3 to 5, respectively), but were associated with greater vaccination rates for hepatitis B full or partial series (9%; confidence interval, 3 to 15; and 11%; confidence interval, 5 to 17, respectively), hepatitis B full series (11%; confidence interval, 4 to 17; and 13%; confidence interval, 7 to 19, respectively), and pneumococcal disease (21%; confidence interval, 14 to 29; and 20%; confidence interval, 13 to 27, respectively). LIMITATIONS Data are cross-sectional, and vaccinations outside the center were self-reported. CONCLUSIONS Existing facility-wide or chart-based order programs may be effective in promoting vaccination against hepatitis B and pneumococcal disease.

Real-world utilization of once-daily extended-release abuse deterrent formulation of hydrocodone: a comparison with the pre-approval randomized clinical trials

Medical Evidence Report Form CMS-2728 data is frequently used to study US dialysis patients, but the validity of these data have been called into question. We compared predialysis erythropoietin use as recorded on Form CMS-2728 with claims data as part of an assessment of quality of care among hemodialysis patients. Medicare claims were linked to Form CMS-2728 data for 18,870 patients. Dialysis patients, 67 years old or older, who started dialysis from 1 June 2005 to 31 May 2007 were eligible. Logistic and multivariate regressions were used to compare the use of either Form CMS-2728 or the corresponding claims data to predict mortality and the probability of meeting target hemoglobin levels. The sensitivity, specificity, and kappa coefficient for the predialysis erythropoietin indicator were 58.0%, 78.4%, and 0.36, respectively. Patients with a predialysis erythropoietin claim were less likely to die compared with patients without a claim (odds ratio = 0.80 and 95% confidence interval = 0.74–0.87), but there was no relationship observed between predialysis care and death using only Form CMS-2728 predictors. At the facility level, a predialysis erythropoietin claim was associated with a 0.085 increase in the rate of meeting target hemoglobin levels compared with patients without a claim (p = 0.041), but no statistically significant relationship was observed when using the Form CMS-2728 indicators. The agreement between Form CMS-2728 and claims data is poor and discordant results are observed when comparing the use of these data sources to predict health outcomes. Facilities with higher agreement between the two data sources may provide greater quality of care.

Towards a common defi nition of global health

BACKGROUND Patients with end-stage renal disease (ESRD) are at high risk of complications from influenza, but many dialysis centers report <50% influenza immunization coverage. STUDY DESIGN A group-randomized evaluation of a multicomponent intervention to increase influenza vaccination rates in poorly performing dialysis centers in ESRD Networks 6, 11, and 15. SETTING & PARTICIPANTS Facilities with the lowest immunization percentages in 2006-2007 were selected from each network and randomly assigned to a standard (n = 39) or intensive intervention (n = 38). INTERVENTION Standard intervention included a feedback report with comparison to other centers in their network and educational materials for staff and patients. Intensive-intervention centers also received 3 educational seminars, assistance with and review of center-specific action plans, and monthly monitoring of vaccination plan and rates. OUTCOMES Change in vaccination rate in following year. MEASUREMENTS Dialysis center records of patient vaccination status. RESULTS There was an 8.9% (P = 0.04) adjusted mean absolute difference in improvement between intensive- and standard-intervention centers. LIMITATIONS Some vaccinations were self-reported by patients. The vaccination data form does not have an option for patient data unavailable, which may have caused patients without data to be coded as unvaccinated. CONCLUSIONS Multicomponent interventions may serve as a successful strategy to increase influenza vaccination rates at poorly performing centers, with a benefit beyond that provided by usual oversight and support.

FERRIC CITRATE: AN IRON-BASED ORAL PHOSPHATE BINDER

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.