Wenke Hwang

More training needed in chronic care: A survey of U.S. physicians

Purpose. Although more than 125 million North Americans have one or more chronic conditions, medical training may not adequately prepare physicians to care for them. The authors evaluated physicians’ perceptions of the adequacy of their chronic illness care training to and the effects of training on their attitudes toward care of persons with chronic conditions. Method. In November 2000 through June 2001, the authors surveyed by telephone a random sample of U.S. physicians who had ≥20 hours of patient contact per week. The interview instrument examined demographics, career satisfaction, practice characteristics, perceived adequacy of chronic illness care training in ten competencies (geriatric syndromes, chronic pain, nutrition, developmental milestones, end-of-life care, psychosocial issues, patient education, assessment of caregiver needs, coordination of services, and interdisciplinary teamwork), and effect of training on attitudes toward chronic illness care. Results. Of 1,905 eligible physicians, 1,236 (65%) responded (270 family or general practitioners, 231 internists, 129 pediatricians, 335 nonsurgical specialists, and 271 surgeons). Most physicians reported their chronic disease training was less than adequate for all ten competencies. Family practitioners were more likely (p < .05) to report adequate training in seven competencies compared with internists, and in two to four competencies when compared with pediatricians, nonsurgical specialists, or surgeons. Most physicians reported that training had a positive effect on attitudes toward care of people with chronic conditions, including the ability to make a difference in their lives (74–84%). Conclusions. Physicians perceived their medical training for chronic illness care was inadequate. Medical schools and residencies may need to modify curricula to better prepare physicians to treat the growing number of people with chronic conditions.

Growth failure, risk of hospitalization and death for children with end-stage renal disease

Abstractu2002Growth failure remains a significant problem for children with chronic renal insufficiency and end-stage renal disease (ESRD). We examined whether growth failure is associated with more-frequent hospitalizations or higher mortality in children with kidney disease. We studied data on prevalent United States pediatric patients with ESRD in 1990 who were followed through 1995. Patients were categorized according to the standard deviation score (SDS) of their incremental growth during 1990: severe (<–3 SDS), moderate growth failure (>–3 and <–2 SDS), and normal growth (>–2 SDS). Among 1,112 prevalent pediatric dialysis and transplant patients (<17 years, Tanner I–IV), those with severe and moderate growth failure had higher hospitalization rates {relative risk (RR) 1.14 [95% confidence interval (CI) 1.1, 1.2] and 1.24 [95% CI 1.2, 1.3]} respectively than those with normal growth after adjustment for age, gender, race, cause and duration of ESRD, and treatment modality (dialysis or transplant) in 1990. Kaplan-Meier survival analysis showed 5-year survival of 85% and 90% for patients with severe and moderate growth failure, respectively, compared with 96% for patients with normal growth (P<0.001, log-rank). Cox proportional hazards analysis revealed that those with severe (RR 2.9, 95% CI 1.6, 5.3) and moderate growth failure (RR 2.01, 95% CI 1.1, 3.6) had an increased risk of death compared with youths with normal growth, after adjustment. A higher proportion of deaths in the severe and moderate growth failure groups were attributed to infectious causes (22% and 18.7%, respectively) than in the normal growth group (15.6%). We conclude that growth failure is associated with a more-complicated clinical course and increased risk of death for children with kidney failure.

Racial Differences in Access to the Kidney Transplant Waiting List for Children and Adolescents With End-Stage Renal Disease

Context. Renal transplantation is the treatment of choice for pediatric patients with end-stage renal disease (ESRD). Black patients wait longer for kidney transplants than do white patients. Objective. To determine whether the increased time to transplantation for black pediatric patients is attributable not only to a shortage of suitable donor organs, but also to racial differences in the time from a childs first treatment for ESRD until activation on the cadaveric kidney transplant waitlist. Design. National longitudinal cohort study. Setting. US Medicare-eligible, pediatric ESRD population. Patients. Children and adolescents ≤19 years old at the time of their first dialysis for ESRD between 1988 and 1993, followed through 1996. Patients who received living donor renal transplants were excluded from study. Main Outcome Measures. Time from first dialysis for ESRD until activation on the kidney transplant waiting list, relative hazard of activation on the waiting list for black compared with white pediatric patients. Results. Comparisons of the time from first dialysis for ESRD to waitlisting among the 2162 white (60.7%) and 1122 black (31.5%) patients studied using survival analysis revealed that blacks were less likely to be waitlisted at any given time in follow-up. In multivariate analysis, even after controlling for patient age, gender, socioeconomic status, geographic region, incident year of renal failure, and cause of ESRD, blacks were 12% less likely to be waitlisted than were whites at any point in time (relative hazard: .88: 95% confidence interval: .79–.97). Conclusions. Racial disparities in access to the renal transplant waiting list exist in pediatrics. Whether these disparities are attributable to differences in time of presentation to a nephrologist, physician bias in identification of transplant candidates, or patient preferences warrants further study.

U.S. nephrologists' attitudes towards renal transplantation: results from a national survey.

Background. Renal transplantation is the optimal treatment for persons with end-stage renal disease (ESRD). A shortage of kidneys in the U.S. has focused increasing attention on the process by which kidneys are allocated. A national survey was undertaken to determine the relative importance of both clinical and nonclinical factors in the recommendation for renal transplantation by U.S. nephrologists. Methods. We conducted a national random survey of 271 U.S. nephrologists using hypothetical patient scenarios to determine their recommendation for renal transplantation based on demographic, clinical, and social factors. Specifically, eight unique patient scenarios were randomly distributed to each survey respondent. Results. According to responding nephrologists (response rate 53%), females were less likely than males to be recommended for renal transplantation [adjusted odds ratio (OR)=0.41; confidence interval (CI) 0.21, 0.79; for whites]. Asian males were less likely than white males to be recommended for transplantation (OR=0.46, CI 0.24, 0.91). Black-white differences in rates of recommendation were not found. Other factors associated with low rates of recommendation for renal transplantation included history of noncompliance (OR=0.17, CI 0.13, 0.23), <25% cardiac ejection fraction (OR=0.15, CI 0.10, 0.21), HIV infection (OR=0.01, CI 0.00, 0.01), and being >200 lbs (OR=0.73, CI 0.56, 0.95). Conclusions. Female gender, and Asian but not black race, were associated with a decreased likelihood that nephrologists would recommend renal transplantation for patients with end stage renal disease. The well-documented black-white disparities in use of renal transplantation may be due to unaccounted for factors or may arise at a subsequent step in the transplantation process.

Association of Mortality and Hospitalization with Achievement of Adult Hemoglobin Targets in Adolescents Maintained on Hemodialysis

With the use of data from the Centers for Medicare & Medicaid Services ESRD Clinical Performance Measures Project (October through December 1999 and 2000) linked with US Renal Data System hospitalization and mortality records, whether achieving adult target hemoglobin (Hb) levels in adolescents who are on hemodialysis (HD) was associated with decreased risk for death or hospitalization was assessed. Of 677 adolescents, 238 were hospitalized and 54 died. In bivariate analysis, 11.7% with Hb <11 g/dl at study entry died versus 5% of those with initial Hb > or =11 g/dl (P = 0.001); 40.3% with baseline Hb <11 g/dl were hospitalized versus 31.1% with initial Hb > or =11 g/dl (P = 0.013). In multivariate analysis, Hb > or =11 g/dl was associated with decreased risk for death (hazard ratio [HR] 0.38; 95% confidence interval [CI] 0.20 to 0.72) but did not show a statistically significant association with decreased risk for hospitalization (HR 0.87; 95% CI 0.66 to 1.15). When Hb was recategorized as Hb <10, > or =10 and <11, > or =11 and < or =12, and >12 g/dl, risk of mortality declined as Hb level increased. At Hb 11 to 12 g/dl (versus Hb <10 g/dl), mortality risk decreased by 69% (HR 0.31; 95% CI 0.14 to 0.65). Risk for mortality was similar for Hb 11 to 12 and >12 g/dl. For hospitalization, no statistically significant difference in risk between Hb categories was found. This observational study of adolescents who are on HD is consistent with adult literature showing decreased mortality in patients who have ESRD and meet adult Hb targets. Further studies in the form of randomized, clinical trials are needed to assess optimal Hb levels for adolescents who are on HD.

Changes in physical and psychosocial functioning among adolescents with chronic kidney disease

Little research has been published assessing changes in the functional health status of children and adolescents with chronic kidney disease (CKD). We know little about which clinical parameters influence functional status or health-related quality of life in these young people. In a prospective study using data from semi-annual visits over a 4-year period from 78 adolescents with CKD aged 11 years to 18 years, we detail the impact of several clinical measures (i.e., kidney function, albumin, hematocrit, height) on short-term changes in health-related quality of life. The 50-item Child Health Questionnaire Parent Form, a validated health-related quality of life measure in children, was used to obtain physical and psychosocial functioning summary scores at each visit. After adjustment for the variables mentioned above, the physical summary score on the Child Health Questionnaire (CHQ) declined as glomerular filtration rate declined. Increasing height was associated with a positive change in physical and psychosocial summary scores. We conclude that decline in kidney function is associated with a subsequent decline in health-related quality of life, particularly in terms of physical activity.

Effects of Patient Compliance, Parental Education and Race on Nephrologists' Recommendations for Kidney Transplantation in Children

Transplantation is the treatment goal for youth with kidney failure. To assess the effects of compliance, parental education and race on nephrologists recommendations for transplantation in children, we surveyed a national random sample of adult and pediatric nephrologists. We elicited transplant recommendations for case vignettes created from random combinations of patient age, gender, race, cause of renal failure, family structure, parental education and compliance.

Patterns of Use of Vascular Catheters for Hemodialysis in Children in the United States

BACKGROUNDnArteriovenous fistulas (AVFs) and grafts (AVGs) have been associated with improved clinical outcomes in children and adults with end-stage renal disease (ESRD) on maintenance hemodialysis (HD) therapy, but use of vascular catheters is high. Identifying the reasons for the high prevalence of vascular catheters in children on HD therapy is necessary to assess whether targeted interventions may increase the prevalence of AVFs/AVGs.nnnSTUDY DESIGNnRetrospective cohort study.nnnSETTING & PARTICIPANTSnChildren younger than 18 years on HD therapy in the 2001 to 2003 ESRD Clinical Performance Measures (CPM) Projects followed up in the US Renal Data System transplant files through December 31, 2004.nnnPREDICTORnVascular access type and reasons for use of a vascular catheter.nnnOUTCOMES & MEASUREMENTSnDemographic/clinical characteristics, including the reason provided for use of a vascular catheter, and the association of type of vascular access and (1) patient size and (2) time to kidney transplantation.nnnRESULTSnOf 1,284 prevalent pediatric CPM patients examined, 529 (41%) had an AVF/AVG and 755 (59%) had a vascular catheter. Of 755 children with a catheter, small body size was a commonly listed reason (N = 142); 49% of these children weighed 20 kg or more. Of 53 patients with catheters described as having an AVF/AVG maturing and present in the consecutive ESRD CPM project year, 64% had a functioning AVF/AVG the following year. For those with transplantation scheduled listed as a reason for a vascular catheter (N = 83), 69% underwent transplantation within 1 year, and median time to transplantation was 115 days. Of all children with vascular catheters (N = 755), 32.2% underwent transplantation within 1 year, and median time to transplantation was 264 days compared with 21.7% and 347 days for those with AVFs/AVGs, respectively (N = 529). Of the 445 incident children in this cohort, 89% had a vascular catheter at dialysis therapy initiation.nnnLIMITATIONSnBecause of study design, only associations can be described.nnnCONCLUSIONSnVascular catheter use in children on HD therapy is high. This is partially explained by expeditious transplantation and technical barriers to AVF/AVG placement in small children; however, only one-third of patients with a vascular catheter underwent transplantation within 1 year. Interventions to decrease vascular catheter use in this population may be necessary.

Serum albumin level and risk for mortality and hospitalization in adolescents on hemodialysis

BACKGROUND AND OBJECTIVESnNational Kidney Foundation Dialysis Outcomes Quality Initiative practice guidelines recommend serum albumin > or = 4.0 g/dl for adults who are on hemodialysis. There is no established pediatric target for albumin and little evidence to support use of adult guidelines. This study examined the association between albumin and risk for death and hospitalization in adolescents who are on hemodialysis.nnnDESIGN, SETTING, PARTICIPANTS, & MEASUREMENTSnThis retrospective cohort study linked data on patients aged 12 to 18 yr in 1999 and 2000 from the Centers for Medicare and Medicaid Services End Stage Renal Disease Clinical Performance Measures Project with 4-yr hospitalization and mortality records in the United States Renal Data System. Albumin was categorized as < 3.5/3.2, > or = 3.5/3.2 and < 4.0/3.7, and > or = 4.0/3.7 g/dl.nnnRESULTSnOf 675 adolescents, 557 were hospitalized and 50 died. Albumin > or = 4.0/3.7 g/dl was associated with male gender, Hispanic ethnicity, and higher hemoglobin level. Those with albumin > or = 4.0/3.7 g/dl had fewer deaths per 100 patient-years and fewer hospitalizations per time at risk. In multivariate analysis, patients with albumin > or = 4.0/3.7 g/dl had 57% decreased risk for death. Poisson regression showed progressive decrease in hospitalization risk as albumin level increased; however, confidence intervals were similar between albumin > or = 4.0/3.7 g/dl and albumin > or = 3.5/3.2 and < 4.0/3.7 g/dl.nnnCONCLUSIONSnThis study demonstrates decreased mortality and hospitalization risk with albumin > or = 3.5/3.2 g/dl and suggests that adolescent hemodialysis patients who are able to achieve serum albumin > or = 4.0/3.7 g/dl may have the lowest mortality risk.

Clinical Course Associated with Vascular Access Type in a National Cohort of Adolescents Who Receive Hemodialysis: Findings from the Clinical Performance Measures and US Renal Data System Projects

Limited research has described clinical outcomes that are associated with the type of vascular access in pediatric patients who receive maintenance hemodialysis. This retrospective cohort study examined prevalent pediatric patients who were aged 12 to <18 yr and identified in the 2000 ESRD Clinical Performance Measures Project as receiving in-center hemodialysis. Vascular access type as of December 31, 1999, was identified. These patients were linked with 1 yr of data (January 1, 2000, through December 31, 2000) from US Renal Data System standard analytic files that allow for the comparison of rates of hospitalizations and access complications by access type. Of the 418 patients who met inclusion criteria, the mean age was 15.6 yr, 53% were male, 49% were white, the mean time on dialysis was 22 mo, and 42% had a structural/urologic cause of ESRD; 42% of patients had an arteriovenous graft or fistula, and 58% had a vascular catheter. Patients with a vascular catheter as compared with those with a graft or fistula had the following adjusted relative risks (95% confidence interval): 1.84 (1.38 to 2.44) for hospitalization for any cause, 4.74 (2.02 to 11.14) for hospitalization as a result of infection, and 2.72 (2.00 to 3.69) for a complication of vascular access. Vascular catheters are the predominant access type in adolescent patients who receive maintenance hemodialysis and are associated with significantly more hospitalizations and complications.