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Supplements All-Cause Costs Increase Exponentially with Increased Chronic Kidney Disease Stage
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All-Cause Costs Increase Exponentially with Increased Chronic Kidney Disease Stage
Ladan Golestaneh, MD, MS; Paula J. Alvarez, RPh, MPH, MBA; Nancy L. Reaven, MA; Susan E. Funk, MBA, FACHE; Karen J. McGaughey, PhD; Alain Romero, PhD; Melanie S. Brenner, PharmD, BCPS; and Macaulay On

All-Cause Costs Increase Exponentially with Increased Chronic Kidney Disease Stage

Ladan Golestaneh, MD, MS; Paula J. Alvarez, RPh, MPH, MBA; Nancy L. Reaven, MA; Susan E. Funk, MBA, FACHE; Karen J. McGaughey, PhD; Alain Romero, PhD; Melanie S. Brenner, PharmD, BCPS; and Macaulay On
METHODS
Study Population and Cohorts
We queried the Humedica (Boston, Massachusetts) database EMRs covering approximately 7 million patients during 2007 to 2012 and selected patients with ≥1 RAASi prescription before July 1, 2009 (index date).21 Study patients were persons receiving care from providers in integrated health delivery networks across the United States, including those insured by private insurance, Medicare, Medicaid, other health insurance, or uninsured. The data were inclusive of services provided in hospitals as well as office and OP care. Medication data included written prescriptions and medication administrations that occurred in-clinic and/or in-hospital. We required postindex evidence of new, sustained, or progressive CKD (stages 2, 3a, 3b, or 4-5) or ESRD identified by estimated glomerular filtration rate (eGFR) or diagnosis code (definitions in Supplementary Item S1). Patients were included in the analysis of each postindex CKD stage lasting ≥90 days. Additionally, patients without evidence of CKD or ESRD during the study period (2007-2012) and with ≥90 days of postindex data were included as a no-CKD comparison group. Patients with ESRD before the index date and those receiving the above-recommended RAASi dosing at index were excluded from the current analyses.

Demographic and clinical characteristics (with the exception of sex, race, and region) were evaluated for each patient at the onset of each included CKD stage. Comorbidities were identified by single occurrence of any indicator in pre-stage data using diagnosis codes, laboratory values, or hypoglycemic medications (Supplementary Item S2). RAASi prescriptions were classified by dose level at the beginning of each CKD stage as “maximum” (recommended labeled dose; see Supplementary Item S3), “submaximum” (any lesser amount), or “discontinued” (>390 days elapsed since most recent prescription). OP diuretic therapy during the 12-month period before the stage start date was categorized hierarchically as loop diuretic, other diuretic, or none. Visit frequency was characterized as infrequent (0-1 visit) or frequent (≥2 visits) based on the number of office/clinic visits in the 12-month period concluding each stage.

Patients were assigned by pre-index age to 2 categories for modeling insurance coverage: Medicare (aged ≥65 years) and commercial (aged <65 years, or unspecified).

Classification of Services and Medications
In the EMR data, healthcare services were grouped by calendar day and classified as IP or emergency department (ED) visits or by type of OP services. OP prescriptions were identified by generic name of the primary ingredient, regardless of dose, brand, or formulation.



 
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