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      International Care Models for Chronic Kidney Disease: Methods and Economics – United States

      Blood Purification

      S. Karger AG

      Care models, Chronic kidney disease, Economics, Renal disease, United States

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          In the United States, there is a major chronic kidney disease (CKD) problem with over 8 million adults having stage 3 or 4 CKD. There is good medical evidence that many of these patients can benefit from focused interventions. And while there are strong theoretical reasons to believe these interventions are cost-effective, there are little published data to back up this assertion. However, despite the lack of financial data proving cost-effectiveness and against the background of a disorganized health care system in the US, some models of CKD care are being employed. At the present time, the most comprehensive models of care in the US are emerging in vertically integrated health care programs. Other models of care are developing in the setting of managed care health plans that employ CKD disease management programs, either developed internally or in partnership with renal disease management companies.

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          Most cited references 5

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          Impact of timing of nephrology referral and pre-ESRD care on mortality risk among new ESRD patients in the United States.

          Recent studies have suggested that early predialysis nephrological care is associated with lower mortality; however, this hypothesis has not been tested in a population-based study. We evaluated the impact of early nephrology referral and pre-end-stage renal disease (ESRD) care on mortality risk in a national cohort of new patients starting dialysis therapy in 1996 and 1997. Data were obtained on a subset of patients (n = 2,264; 56%) from the Dialysis Morbidity and Mortality Study Wave 2 who then were followed up for up to 2 years. Survival comparisons were made using log-rank test, then by Cox regression adjusting for demographics, comorbid medical conditions, and surrogate markers of pre-ESRD care. Adjusted mortality risks (relative risks [RRs]) were higher for late- (within 4 months of dialysis initiation) compared with early-referred patients at the end of 1 and 2 years of follow-up (RR, 1.68; confidence interval [CI], 1.31 to 2.15; RR, 1.23; CI, 1.02 to 1.47, respectively). Mortality risks were similarly high for the late-referred nondiabetic (RR, 2.10; CI, 1.49 to 2.94) and hemodialysis subgroups (RR, 1.72; CI, 1.25 to 2.38). Conversely, mortality risks were lower for patients who saw a nephrologist at least twice in the year before dialysis therapy initiation (RR, 0.80; CI, 0.62 to 1.03; P = 0.08] compared with those who did not. Late nephrology referral is associated with greater death risk in new patients with ESRD, and more frequent pre-ESRD care confers increased survival benefit. These findings stress the need for earlier referral of patients to nephrologists and improved pre-ESRD care for all patients approaching ESRD in the United States to improve survival. Am J Kidney Dis 41:310-318. Copyright 2003 by the National Kidney Foundation, Inc.
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            Delayed nephrologist referral and inadequate vascular access in patients with advanced chronic kidney failure.

            We sought to determine whether late referral to a nephrologist in patients with chronic renal failure influences the adequacy of vascular access for hemodialysis. We analyzed data describing all health care encounters for all Medicare and Medicaid patients with end-stage renal failure in New Jersey between January 1991 and June 1996. Patients were required to have been diagnosed with renal disease at least 1 year prior to onset of hemodialysis. In the resulting cohort of 2,398 incident hemodialysis patients, 35% had their first nephrologist consultation 90 days prior to onset of hemodialysis were 38% more likely to have undergone predialysis vascular access surgery than those who were referred to a nephrologist < or =90 days before dialysis [OR: 1.38; 95% CI (1.15; 1.64)]. Similarly, patients referred late were 42% more likely to require central venous access for hemodialysis compared to those seen by a nephrologist early [OR: 1.42; 95% CI (1.17; 1.71)]. Inadequate development of vascular access for renal replacement therapy in patients with late nephrologist referral unnecessarily contributes to the burden of disease experienced by this vulnerable patient population.
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              Association of serum albumin and atherosclerosis in chronic hemodialysis patients.

              Because cardiovascular disease is the leading cause of death and hypoalbuminemia predicts mortality, hypoalbuminemia may be associated with atherosclerosis. In 1,411 patients enrolled in the HEMO study, associations of albumin with the presence of coronary artery disease (CAD), cerebrovascular disease (CVD), peripheral vascular disease (PVD), and any one of the three conditions at baseline were examined using multivariable logistic regression models. In the two-slope model, when albumin level was 3.6 g/dL (36 g/L) or greater, with each 1-g/dL (10-g/L) increase in albumin level the odds for CAD (odds ratio [OR], 0.32; 95% confidence interval [CI], 0.17 to 0.59), PVD (OR, 0.39; 95% CI, 0.18 to 0.80), CVD (OR, 0.33; 95% CI, 0.15 to 0.73), and any one of the three conditions (OR, 0.23; 95% CI, 0.12 to 0.44) decreased. When albumin level was less than 3.6 g/dL (36 g/L), none of the conditions was statistically significantly associated with each 1-g/dL (10-g/L) increase in albumin level. When normal- and low-albumin groups were compared with each other, patients with albumin levels less than 3.6 g/dL (36 g/L) had a higher association with CAD (OR, 1.32; 95% CI, 1.03 to 1.70) and for any one of the three conditions (OR, 1.38; 95% CI, 1.07 to 1.78). The odds for atherosclerosis linearly decreased as albumin level increased in the normal-albumin group, and a plateau was seen in the low-albumin group; however, the low-albumin group had significantly greater CAD. The nonlinearity of association of albumin level with prevalence of atherosclerosis might be due to the cross-sectional nature of the study of higher mortality with hypoalbuminemia. Copyright 2002 by the National Kidney Foundation, Inc.

                Author and article information

                Blood Purif
                Blood Purification
                S. Karger AG
                July 2004
                20 January 2004
                : 22
                : 1
                : 13-20
                Kaiser Permanente Southern California, Los Angeles, Calif., and Optimal Renal Care, New York, N.Y., USA
                74919 Blood Purif 2004;22:13–20
                © 2004 S. Karger AG, Basel

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                Tables: 4, References: 20, Pages: 8
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