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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
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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.
RESULTS

We identified 5530 patients meeting inclusion criteria, 90% of whom came from 2 large Kaiser Permanente regions (Northern California and Southern California). The initial renal replacement modality was hemodialysis via CVC for 2600 (47.0%) patients, hemodialysis via AVF for 1534 (27.7%) patients, and hemodialysis via AVG for 183 (3.3%) patients. A total of 1072 (19.4%) patients began renal replacement therapy via peritoneal dialysis and 141 (2.2%) patients received pre-emptive transplants. Of 2930 patients with an optimal start, 1826 patients were successfully matched to 1826 patients with a nonoptimal start.

In unadjusted comparisons of utilization in the year before starting renal replacement therapy, patients with optimal starts had fewer inpatient visits and days than patients with nonoptimal starts. Patients with optimal starts also had more visits to nephrologists, vascular surgeons, and other types of specialty care before starting renal replacement therapy (Table 2). Primary care and ED visits did not differ. In the analysis of utilization in the year after starting renal replacement therapy, which was adjusted for prior-year utilization, propensity score, region, and education, patients with optimal starts had lower utilization of all types except nephrology visits, which did not differ between groups (Table 3). The largest absolute between-group differences in annualized rates were observed for total inpatient days, which were 9.4 for patients with optimal starts versus 27.5 for patients with nonoptimal starts (relative rate [RR], 0.45; 95% CI, 0.38-0.52), and specialty care outpatient visits, which were 12.5 for optimal starts versus 18.0 for nonoptimal starts (RR, 0.62; 95% CI, 0.53-0.74). The largest relative differences in annualized rates were for vascular surgery outpatient visits, which were 1.3 for optimal starts versus 3.6 for nonoptimal starts (RR, 0.31; 95% CI, 0.29-0.34). The rate of nephrology visits did not differ between groups.

In analyses adjusted for propensity score, region, and education, optimal starts were associated with lower morbidity and mortality in the first 12 months after starting renal replacement therapy. The sepsis rate per person-year for patients with optimal starts was 0.16 versus 0.44 for patients with nonoptimal starts (OR, 0.35; 95% CI, 0.29-0.42; P <.001); the per person-year mortality rate was 0.10 for patients with optimal starts versus 0.30 for patients with nonoptimal starts (OR, 0.37; 95% CI, 0.29-0.46; P <.001). The 12-month HR for mortality, adjusted for propensity score, region, and education, among patients with optimal starts was 0.44 (95% CI, 0.29-0.46).

DISCUSSION

In an integrated healthcare delivery system, optimal ESRD starts were associated with improved clinical outcomes and lower utilization in the year after initiating renal replacement therapy. Patients with optimal starts were less likely to die or to develop sepsis than were patients with nonoptimal starts. They had lower inpatient and outpatient utilization, except for nephrology visits.

Comparing our results with the existing literature is challenging due to variations in study methodologies. Previous reports often focus on comparing mortality associated with starting hemodialysis via CVC with mortality for AVG and AVF starts. Using propensity score matching in a national cohort, Malas et al found an HR for mortality among patients starting hemodialysis with an AVF or AVG of 0.68 (95% CI, 0.67-0.69) compared with those starting with a CVC.12 However, variations in study periods and covariates may account for the differences between observed HRs. Although our optimal start population also included patients whose initial modality was peritoneal dialysis, recent evidence suggests that short-term mortality is equivalent between patients starting renal replacement therapy with hemodialysis via an AVF or AVG and those starting with peritoneal dialysis.22-24

A 2013 meta-analysis identified a relative mortality risk of 1.53 (95% CI, 1.41-1.67) over a median follow-up period of 18 months for patients starting hemodialysis via CVC compared with those starting hemodialysis with an AVF.6 In the same report, catheter use was associated with 80 to 134 additional deaths per 1000 person-years compared with AVF use and 60 to 125 additional deaths per 1000 person-years compared with AVG use. Reference annual event risks for all-cause mortality for AVF and AVG starts, drawn from an annual US Renal Data System report, were 0.20 and 0.24, respectively.25 In contrast, the annual event rate for all-cause mortality for all optimal start types in our study was 0.10, and CVC use for hemodialysis was associated with 200 additional deaths per 1000 person-years.

Potential explanations for the difference in the annual reference risks include the possibility that starting renal replacement therapy in the integrated healthcare delivery system studied here confers survival benefits beyond those that have been reported in the literature. Although we did not assess mortality risk by type of optimal start, it is unlikely that any mortality benefits for the minority of patients in our population who received a pre-emptive transplant or started renal replacement therapy with peritoneal dialysis accounted for the difference in reference annual event risks. Reviews and meta-analyses comparing outcomes for incident hemodialysis and peritoneal dialysis and for patients undergoing dialysis and transplantation suggest that mortality benefits are time-dependent and vary across groups of patients defined by age and comorbidities.26-28 We found no reports comparing outcomes for incident hemodialysis via CVC and the range of optimal start modalities.


 
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