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The American Journal of Managed Care October 2018
Putting the Pieces Together: EHR Communication and Diabetes Patient Outcomes
Marlon P. Mundt, PhD, and Larissa I. Zakletskaia, MA
Primary Care Physician Resource Use Changes Associated With Feedback Reports
Eva Chang, PhD, MPH; Diana S.M. Buist, PhD, MPH; Matt Handley, MD; Eric Johnson, MS; Sharon Fuller, BA; Roy Pardee, JD, MA; Gabrielle Gundersen, MPH; and Robert J. Reid, MD, PhD
From the Editorial Board: Bruce W. Sherman, MD
Bruce W. Sherman, MD
Recent Study on Site of Care Has Severe Limitations
Lucio N. Gordan, MD, and Debra Patt, MD
The Authors Respond and Stand Behind Their Findings
Yamini Kalidindi, MHA; Jeah Jung, PhD; and Roger Feldman, PhD
The Characteristics of Physician Practices Joining the Early ACOs: Looking Back to Look Forward
Stephen M. Shortell, PhD, MPH, MBA; Patricia P. Ramsay, MPH; Laurence C. Baker, PhD; Michael F. Pesko, PhD; and Lawrence P. Casalino, MD, PhD
Nudging Physicians and Patients With Autopend Clinical Decision Support to Improve Diabetes Management
Laura Panattoni, PhD; Albert Chan, MD, MS; Yan Yang, PhD; Cliff Olson, MBA; and Ming Tai-Seale, PhD, MPH
Medicare Underpayment for Diabetes Prevention Program: Implications for DPP Suppliers
Amanda S. Parsons, MD; Varna Raman, MBA; Bronwyn Starr, MPH; Mark Zezza, PhD; and Colin D. Rehm, PhD
Currently Reading
Clinical Outcomes and Healthcare Use Associated With Optimal ESRD Starts
Peter W. Crooks, MD; Christopher O. Thomas, MD; Amy Compton-Phillips, MD; Wendy Leith, MS, MPH; Alvina Sundang, MBA; Yi Yvonne Zhou, PhD; and Linda Radler, MBA
CMS HCC Risk Scores and Home Health Patient Experience Measures
Hsueh-Fen Chen, PhD; J. Mick Tilford, PhD; Fei Wan, PhD; and Robert Schuldt, MA
An Early Warning Tool for Predicting at Admission the Discharge Disposition of a Hospitalized Patient
Nicholas Ballester, PhD; Pratik J. Parikh, PhD; Michael Donlin, MSN, ACNP-BC, FHM; Elizabeth K. May, MS; and Steven R. Simon, MD, MPH
Gatekeeping and Patterns of Outpatient Care Post Healthcare Reform
Michael L. Barnett, MD, MS; Zirui Song, MD, PhD; Asaf Bitton, MD, MPH; Sherri Rose, PhD; and Bruce E. Landon, MD, MBA, MSc

Clinical Outcomes and Healthcare Use Associated With Optimal ESRD Starts

Peter W. Crooks, MD; Christopher O. Thomas, MD; Amy Compton-Phillips, MD; Wendy Leith, MS, MPH; Alvina Sundang, MBA; Yi Yvonne Zhou, PhD; and Linda Radler, MBA
Optimal end-stage renal disease (ESRD) starts were associated with lower 12-month morbidity, mortality, and inpatient and outpatient utilization in an integrated healthcare delivery system.

Objectives: To assess the association between optimal end-stage renal disease (ESRD) starts and clinical and utilization outcomes in an integrated healthcare delivery system.

Study Design: Retrospective observational cohort study in 6 regions of an integrated healthcare delivery system, 2011-2013.

Methods: Propensity score techniques were used to match 1826 patients who experienced an optimal start of renal replacement therapy (initial therapy of hemodialysis via an arteriovenous fistula or graft, peritoneal dialysis, or pre-emptive transplant) to 1826 patients who experienced a nonoptimal start (hemodialysis via a central venous catheter). Outcomes included 12-month rates of sepsis, mortality, and utilization (inpatient stays, total inpatient days, emergency department visits, and outpatient visits to primary care and specialty care).

Results: Optimal starts were associated with a 65% reduction in sepsis (odds ratio, 0.35; 95% CI, 0.29-0.42) and a 56% reduction in 12-month mortality (hazard ratio, 0.44; 95% CI, 0.36-0.53). Optimal starts were also associated with lower utilization, except for nephrology visits. Large utilization differences were observed for total inpatient days (9.4 for optimal starts vs 27.5 for nonoptimal starts; relative rate [RR], 0.45; 95% CI, 0.38-0.52) and outpatient visits for specialty care other than nephrology or vascular surgery (12.5 vs 18.3, respectively; RR, 0.62; 95% CI, 0.53-0.74).

Conclusions: Compared with patients with nonoptimal starts, patients with optimal ESRD starts have lower morbidity and mortality and less use of inpatient and outpatient care. Late-stage chronic kidney disease and ESRD care in an integrated system may be associated with greater benefits than those previously reported in the literature.

Am J Manag Care. 2018;24(10):e305-e311
Takeaway Points

In an integrated healthcare delivery system, compared with patients with end-stage renal disease with nonoptimal starts of renal replacement therapy by hemodialysis via a central venous catheter, patients with optimal starts by hemodialysis via arteriovenous fistula/graft, peritoneal dialysis, or pre-emptive transplant had:
  • Reduced morbidity
  • Less inpatient utilization
  • Annual event rates for all-cause mortality lower than those reported in the largest systematic review to date
  • Fewer primary and specialty care outpatient visits, except for nephrology visits, which did not differ between those with optimal and nonoptimal starts
Clinical guidelines call for adequate planning before initiating renal replacement therapy in patients with chronic kidney disease (CKD) at risk for end-stage renal disease (ESRD).1-4 An important objective is to avoid the use of central venous catheters (CVCs) for hemodialysis access, which constitutes suboptimal initiation of renal replacement therapy.5 In a systematic review of 62 cohort studies, the relative risk of all-cause mortality for patients starting hemodialysis with a CVC, compared with those starting with an arteriovenous fistula (AVF), was 1.53.6 Patients starting hemodialysis with a CVC are also at increased risk of fatal infection and major cardiovascular events compared with patients starting dialysis with an AVF or arteriovenous graft (AVG).6 In addition, the median annual procedure and access costs of hemodialysis via CVC are more than 2.5 times higher than similar costs for either AVFs or AVGs.7

Other renal replacement therapy options include pre-emptive kidney transplant, peritoneal dialysis, and hemodialysis via AVF or AVG. In 1997, the National Kidney Foundation Kidney Disease Outcomes Quality Initiative first published practice guidelines recommending the use of an AVF in at least 50% of patients initiating renal replacement therapy.8 In 2005, the Fistula First (now Fistula First Catheter Last) Breakthrough Initiative established national guidelines based on these recommendations.9

However, remarkably little nationwide progress has been made toward achieving this goal. In 2013, among 117,162 individuals in the United States with incident ESRD, 70.9% began renal replacement therapy with hemodialysis via CVC.10 Under the direction of CMS, a national program of 18 ESRD networks is responsible for each state, territory, and the District of Columbia. No network has met the goal of 50% incident AVF use.11 Across networks, the proportion of patients with functional AVFs at the start of hemodialysis ranged from 11.1% to 22.2%, and nephrology care was significantly associated with increased odds of incident AVF use.11 One estimate places the potential annual US cost savings from using AVFs rather than CVCs for first hemodialysis access at $2 billion.12 Although this estimate is based on the faulty assumption that all those who start renal replacement therapy are both candidates for and want AVF placement, it illustrates the magnitude of the impact on healthcare costs of the slow progress toward meeting the Fistula First Catheter Last goals.

Suggestions for ameliorating widespread underperformance in late-stage CKD care include multidisciplinary teams that incorporate all stakeholders: engaged patients, primary care providers, nephrologists, and vascular surgeons.13 Early referrals from primary care to nephrology and from nephrology to vascular surgery are needed to ensure the timely placement of access.13 Care for patients with CKD stages 1 through 3 at Kaiser Permanente is managed by primary care providers in collaboration with nephrology specialty care as needed and according to clinical guidelines. In every region, patients are referred for nephrology specialty care by the time they reach CKD stage 4 if they have not been referred earlier for severe proteinuria or hypertension or at their request. Nephrologists refer patients for vascular access surgery. The effectiveness of pre-ESRD care is assessed using the National Quality Forum–endorsed Optimal ESRD Starts measure, which calculates the proportion of new patients with ESRD during the measurement period who avoid the use of a CVC for hemodialysis.14 Thus, it is an appropriate measure for assessing progress toward Fistula First Catheter Last goals.

Although the mortality and morbidity benefits of optimal starts are well documented, it is unclear whether equivalent benefits accrue within an integrated healthcare delivery system. The purpose of this analysis was to use propensity score–matching techniques to assess the association between optimal ESRD starts and clinical outcomes and utilization in an integrated healthcare delivery system facilitating proactive late-stage CKD care.


Design and Setting

We conducted a retrospective propensity score–matched analysis of patients who did and did not have an optimal ESRD start in 6 Kaiser Permanente regions between January 1, 2011, and December 31, 2013. Kaiser Permanente’s total membership is more than 12 million.

In 2013, across the regions participating in this analysis (Colorado, Georgia, Hawaii, Northwest, Northern California, and Southern California), 20,273 adult members were coded as having incident or prevalent stage 4 or 5 CKD; 13,760 were coded as having incident or prevalent ESRD; and 4421 were coded as having received a kidney transplant.

Approximately 230 Permanente Medical Group nephrologists and several hundred contracting nephrologists and nephrology groups care for patients with late-stage CKD. All renal replacement therapy options (home and in-center hemodialysis, peritoneal dialysis, and kidney transplant) are available to Kaiser Permanente members in all regions.

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