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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
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Stephen M. Shortell, PhD, MPH, MBA; Patricia P. Ramsay, MPH; Laurence C. Baker, PhD; Michael F. Pesko, PhD; and Lawrence P. Casalino, MD, 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
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Hsueh-Fen Chen, PhD; J. Mick Tilford, PhD; Fei Wan, PhD; and Robert Schuldt, MA
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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.

Our analysis has several limitations. Its retrospective observational design and the use of pre-existing data create the potential for misclassification of measured confounders and outcomes and for selection biases related to unmeasured confounders. Examples of the latter include adherence, self-care ability, and social support; they could have affected outcomes to an unknown degree. Additionally, a predialysis fistula attempt, successful or not, may be associated with lower mortality for patients younger than 65 years because healthier patients are more likely to have the option of fistula placement.29,30 We did not assess whether any patients included in the nonoptimal start group were ineligible for fistula placement; their inclusion may have led us to overstate the benefits of optimal starts to an unknown degree, although any mortality benefit of predialysis fistula attempts in the older population we studied is unknown.29,30 We controlled for the presence of CHF and fluid overload, which could have mitigated against a predialysis fistula placement and is independently associated with increased mortality31 but not CHF severity. Similarly, we assessed only the modality used at the time of initiation, which may have differed from planned renal replacement modalities.30 We did not directly assess for fistula failure, but it is associated with severe peripheral artery disease, CAD, and diabetes, all of which were included as covariates.32 Nevertheless, we may have missed an unknown number of failed fistulae. Standard organizational coding audits give us confidence that miscoding of diagnoses did not affect our results to an appreciable extent. We did not assess costs, although the utilization differences we reported strongly suggest that optimal starts reflect value-based healthcare decision making that occurs before the care on which the CMS ESRD Quality Incentive Program focuses.33 We did not assess patient satisfaction or quality of life.34,35


Our findings underscore the well-established importance of identifying primary care patients at risk for ESRD and initiating timely referrals to nephrology care. In addition, they suggest that late-stage CKD and ESRD care delivered in an integrated healthcare system may confer benefits beyond those reported in the literature. We also note that the Optimal ESRD Starts measure can currently be used to assess performance over time within a single healthcare organization or system; the proportion of optimal renal replacement therapy starts at Kaiser Permanente improved from 46.0% at first use in 2011 to 56.4% in June 2015. With broad use that enables benchmarking, the measure can also be used to compare performance across organizations and systems.


The authors thank the Permanente Federation leadership for their support of the Optimal ESRD Starts measure and the Kaiser Permanente Renal Care Teams for their dedication. This work would not have been possible without the commitment of the Kaiser Permanente Interregional Nephrology Work Group to improving the transition to renal replacement therapy: Karen Ching, MD; Mark Rutkowski, MD; Nirvan Mukerji, MD; Diane Lanese, MD; Tina Cushing, MD; Alan Lau, MD; Leonid Pravoverov, MD; Jignesh Patel, MD; Brent Arnold, MD; Joanna Mroz, MS, MPH; and Oscar Cairoli, RN. Jenni Green, a Kaiser Permanente employee, provided manuscript editing and preparation.

Author Affiliations: Southern California Permanente Medical Group (PWC), Pasadena, CA; Northwest Permanente, PC (COT), Milwaukie, OR; Providence Health & Services (AC-P), Portland, OR; Northwest Permanente, PC (WL, YYZ), Portland, OR; The Permanente Federation, Inc (AS), Oakland, CA; Workers’ Compensation Insurance Rating Bureau (LR), Oakland, CA.

Source of Funding: None.

Author Disclosures: Dr Crooks was a member of the NQF Renal Standing Committee but was recused during consideration of the Optimal ESRD Starts measure. The remaining authors report no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.

Authorship Information: Concept and design (PWC, AC-P, YYZ, LR); acquisition of data (COT, AS); analysis and interpretation of data (PWC, COT, AC-P, WL, AS, YYZ, LR); drafting of the manuscript (PWC); critical revision of the manuscript for important intellectual content (COT, AC-P, WL, AS, YYZ, LR); statistical analysis (WL, AS); administrative, technical, or logistic support (LR); and supervision (YYZ, LR).

Address Correspondence to: Peter W. Crooks, MD, Southern California Permanente Medical Group, 393 E Walnut St, Pasadena, CA 91188. Email:

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