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Byeon H. Innovative approaches to managing chronic multimorbidity: A multidisciplinary perspective. World J Clin Cases 2025; 13:102484. [DOI: 10.12998/wjcc.v13.i19.102484] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2024] [Revised: 02/13/2025] [Accepted: 02/25/2025] [Indexed: 03/19/2025] Open
Abstract
The rising prevalence of chronic multimorbidity poses substantial challenges to healthcare systems, necessitating the development of innovative management strategies to optimize patient care and system efficiency. The study by Fontalba-Navas et al investigates the implementation of a novel high complexity unit (HCU) specifically designed to improve the management of patients with chronic complex conditions. By adopting a multidisciplinary approach, the HCU aims to provide comprehensive, patient-centered care that enhances health outcomes and alleviates the strain on traditional hospital services. Utilizing a longitudinal analysis of data from the Basic Minimum Data Set, this study compares hospitalization metrics among the HCU, Internal Medicine, and other departments within a regional hospital throughout 2022. The findings reveal that the HCU's integrated care model significantly reduces readmission rates and boosts patient satisfaction compared to conventional care practices. The study highlights the HCU's potential as a replicable model for managing chronic multimorbidity, emphasizing its effectiveness in minimizing unnecessary hospitalizations and enhancing the overall quality of patient care. This innovative approach not only addresses the complexities associated with chronic multimorbid conditions but also offers a sustainable framework for healthcare systems confronting similar challenges.
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Affiliation(s)
- Haewon Byeon
- Worker's Care and Digital Health Lab, Department of Future Technology, Korea University of Technology and Education, Cheonan 31253, South Korea
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2
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Subash A, Levinson M, Bonnet K, Hall RK, Saeed F, Liu CK, Chatterjee TS, Mixon AS, Gould ER, Horst SN, Umeukeje EM, Burdick RA, Taylor WD, Cavanaugh KL, Schlundt DG, Nair D. Interdisciplinary Care for Geriatric Syndromes in CKD: A Qualitative Study. Clin J Am Soc Nephrol 2025; 20:652-664. [PMID: 40085167 PMCID: PMC12097189 DOI: 10.2215/cjn.0000000658] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2024] [Accepted: 03/11/2025] [Indexed: 03/16/2025]
Abstract
Key Points Addressing geriatric syndromes in CKD likely requires implementation of an interdisciplinary model of care. Experts shared multilevel barriers to implementation of this model and strategies to mitigate each barrier. Experts felt that patient satisfaction and clinician burnout could improve with implementing interdisciplinary care in CKD. Background Despite their prevalence, prognostic significance, and prioritization by patients, key geriatric syndromes, such as cognitive impairment, frailty, and depression, are not routinely addressed in CKD care in the United States (US). In an interdisciplinary care model, health professionals with diverse expertise collaborate to address all symptoms and functional impairments occurring alongside a patient's chronic disease. Thus, routinely addressing geriatric syndromes in CKD may require implementing this evidence-based model of care and adapting it to the needs of patients with CKD. In a formative step to understanding how health systems could implement an interdisciplinary model of care to address geriatric syndromes in CKD, we interviewed health professionals around the world with relevant expertise. Methods We conducted a qualitative study informed by the Consolidated Framework for Implementation Research. We interviewed nephrologists, administrators, geriatricians, palliative medicine specialists, subspecialists, and allied health professionals working in other interdisciplinary clinics from the United States, United Kingdom, India, and Canada. We analyzed results using an inductive-deductive approach. Results Thematic saturation occurred at 42 experts. Three major domains emerged: barriers to implementation, strategies to mitigate barriers, and benefits of implementation. Barriers were categorized into overarching themes related to (1 ) aging-friendly policy and workforce availability, (2 ) organizational culture and structure, and (3 ) nephrologist and patient perceptions. Strategies to mitigate barriers were categorized into themes related to (1 ) demonstrating viability, (2 ) facilitating effective health communication, (3 ) soliciting support from administrators and clinicians, and (4 ) expanding the base for patient information and treatment evidence. Proposed benefits of implementation included improved shared decision making and reduced nephrologist burnout. Conclusions Implementing an interdisciplinary model of care that addresses geriatric syndromes in CKD is possible but will require overcoming policy-related, financial, cultural, and structural barriers. Such a model of care may ultimately benefit patients and nephrologists.
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Affiliation(s)
| | - Maya Levinson
- Department of Medicine, Health, and Society, Vanderbilt University, Nashville, Tennessee
| | - Kemberlee Bonnet
- Department of Psychology, Vanderbilt University, Nashville, Tennessee
| | - Rasheeda K. Hall
- Division of Nephrology, Duke University Medical Center, Durham, North Carolina
- Section of Nephrology, Durham Veterans Affairs Healthcare System, Durham, North Carolina
| | - Fahad Saeed
- Division of Nephrology, University of Rochester Medical Center, Rochester, New York
- Division of Palliative Care, University of Rochester Medical Center, Rochester, New York
| | - Christine K. Liu
- Division of Primary Care and Population Health, Stanford University Medical Center, Palo Alto, California
- Geriatric Research and Education Clinical Center, Veteran Affairs Palo Alto Health Care System, Palo Alto, California
| | | | - Amanda S. Mixon
- Division of General Internal Medicine and Public Health, Vanderbilt University Medical Center, Nashville, Tennessee
- Geriatric Research Education and Clinical Center, Veterans Affairs Tennessee Valley Healthcare System, Nashville, Tennessee
| | - Edward R. Gould
- Division of Nephrology and Hypertension, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Sara N. Horst
- Division of Gastroenterology, Hepatology, and Nutrition, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Ebele M. Umeukeje
- Division of Nephrology and Hypertension, Vanderbilt University Medical Center, Nashville, Tennessee
- Vanderbilt Center for Health Services Research, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Rachel A. Burdick
- Division of Nephrology and Hypertension, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Warren D. Taylor
- Division of General Internal Medicine and Public Health, Vanderbilt University Medical Center, Nashville, Tennessee
- Department of Psychiatry and Behavioral Sciences, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Kerri L. Cavanaugh
- Division of Nephrology and Hypertension, Vanderbilt University Medical Center, Nashville, Tennessee
- Vanderbilt Center for Health Services Research, Vanderbilt University Medical Center, Nashville, Tennessee
- Veterans Affairs Tennessee Valley Healthcare System, Nashville, Tennessee
- Veteran Wellbeing through Innovation Systems Science and Experience in Learning Health Systems (VETWISE-LHS) Center of Innovation, Nashville, Tennessee
| | - David G. Schlundt
- Department of Psychology, Vanderbilt University, Nashville, Tennessee
| | - Devika Nair
- Division of Nephrology and Hypertension, Vanderbilt University Medical Center, Nashville, Tennessee
- Vanderbilt Center for Health Services Research, Vanderbilt University Medical Center, Nashville, Tennessee
- Veterans Affairs Tennessee Valley Healthcare System, Nashville, Tennessee
- Veteran Wellbeing through Innovation Systems Science and Experience in Learning Health Systems (VETWISE-LHS) Center of Innovation, Nashville, Tennessee
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Mihala G, Hubbard RE, Logan B, Johnson DW, Viecelli AK, Forbes AB. Comprehensive geriatric assessment for frail older people with chronic kidney disease to increase attainment of patient-identified goals: Statistical analysis plan for a cluster-randomised controlled trial. Contemp Clin Trials 2025; 152:107881. [PMID: 40089148 DOI: 10.1016/j.cct.2025.107881] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2024] [Revised: 02/17/2025] [Accepted: 03/12/2025] [Indexed: 03/17/2025]
Abstract
BACKGROUND Frailty is highly prevalent in older people with chronic kidney disease (CKD) and associated with more complex healthcare needs. As part of person-centred care, healthcare planning should be tailored to the individual's needs and their desired outcomes. Comprehensive Geriatric Assessment (CGA) is an intervention which can help facilitate this by identifying a person's medical, functional, and psychosocial problems, and then tailoring a coordinated, targeted management plan. The GOAL trial was designed to establish whether, compared to usual care, a CGA would better enable a person to achieve their own set goals, as measured by Goal Attainment Scaling (GAS). This paper presents the statistical analysis plan (SAP) for the GOAL trial. METHODS The GOAL trial is a pragmatic, multi-centre, superiority, open-label, cluster-randomised controlled trial designed to enrol 500 frail, older people (Frailty Index >0.25, aged ≥65 or ≥ 55 years if First Nations people) with moderate to severe CKD (estimated glomerular filtration rate < 59 mL/min/1.73m2) across 16 hospital sites in Australia, and 12 months of follow-up. The primary question (effect of CGA on GAS at 3 months) will be modelled using mixed-effects linear regression. The SAP details the analysis and reporting methods. CONCLUSIONS The SAP described here resulted from an iterative, collaborative effort among statisticians and clinician leads of the GOAL trial. Specification of statistical methods prior to trial completion will contribute to unbiased analyses of the collected data. TRIAL REGISTRATION ClinicalTrials.govNCT04538157.
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Affiliation(s)
- Gabor Mihala
- Centre for Health Services Research, The University of Queensland, 34 Cornwall Street, Woollongabba, Queensland, Australia; Australasian Kidney Trials Network, The University of Queensland, 37 Kent Street, Woolloongabba, Queensland, Australia,.
| | - Ruth Eleanor Hubbard
- Centre for Health Services Research, The University of Queensland, 34 Cornwall Street, Woollongabba, Queensland, Australia; Department of Geriatric Medicine, Princess Alexandra Hospital, 199 Ipswich Road, Woolloongabba, Queensland, Australia,; Australian Frailty Network, The University of Queensland, 199 Ipswich Road, Woolloongabba, Queensland, Australia,.
| | - Benignus Logan
- Centre for Health Services Research, The University of Queensland, 34 Cornwall Street, Woollongabba, Queensland, Australia; Australian Frailty Network, The University of Queensland, 199 Ipswich Road, Woolloongabba, Queensland, Australia,.
| | - David Wayne Johnson
- Australasian Kidney Trials Network, The University of Queensland, 37 Kent Street, Woolloongabba, Queensland, Australia,; Department of Kidney and Transplant Services, Princess Alexandra Hospital, 199 Ipswich Road, Woolloongabba, Queensland, Australia,.
| | - Andrea Katharina Viecelli
- Australasian Kidney Trials Network, The University of Queensland, 37 Kent Street, Woolloongabba, Queensland, Australia,; Department of Kidney and Transplant Services, Princess Alexandra Hospital, 199 Ipswich Road, Woolloongabba, Queensland, Australia,.
| | - Andrew Benjamin Forbes
- School of Public Health and Preventative Medicine, Monash University, 553 St Kilda Road, Melbourne, Victoria, Australia.
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Ardavani A, Curtis F, Hopwood E, Highton P, Katapa P, Khunti K, Wilkinson TJ. Effect of pharmacist interventions in chronic kidney disease: a meta-analysis. Nephrol Dial Transplant 2025; 40:884-907. [PMID: 39384574 DOI: 10.1093/ndt/gfae221] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2024] [Indexed: 10/11/2024] Open
Abstract
BACKGROUND Pharmacists are uniquely placed with their therapeutic knowledge to manage people with chronic kidney disease (CKD). Data are limited regarding the impact of pharmacist interventions on economic, clinical and humanistic outcomes (ECHO). METHODS A systematic review and meta-analysis of randomized controlled trials (RCTs) of interventions with pharmacist input was conducted, which included adults with a diagnosis of CKD, including those with and without kidney replacement therapy. Data were extracted on ECHO: economic (e.g. healthcare-associated costs), clinical (e.g. mortality) and humanistic (e.g. patient satisfaction) outcomes. Where appropriate, a random-effects model meta-analysis generated a pooled estimate of effect. A direction of effect plot was used to summarize the overall effects for clinical outcome domains. RESULTS Thirty-two RCTs reported a total of 10 economic, 211 clinical and 18 humanistic outcomes. Pharmacist interventions resulted in statistically significant improvements in systolic blood pressure and hemoglobin levels, but not in diastolic blood pressure, estimated glomerular filtration rate, creatinine and low-density lipoprotein cholesterol levels. Mixed findings were reported for clinical and economic outcomes, whilst pharmacist interventions resulted in an improvement in humanistic outcomes such as patient satisfaction and patient knowledge. CONCLUSION Findings showed pharmacist interventions had mixed results for various outcomes. Future studies should be more robustly designed and take into consideration the role of the pharmacist in prescribing and deprescribing, the findings of which will help inform research and clinical practice. TRIAL REGISTRATION The review was prospectively registered on PROSPERO (CRD42022304902).
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Affiliation(s)
- Ashkon Ardavani
- NIHR Applied Research Collaboration East Midlands (ARC-EM), Leicester Diabetes Centre, University of Leicester, Leicester, UK
| | - Ffion Curtis
- Liverpool Reviews and Implementation Group (LRIG), Institute of Population Health, University of Liverpool, Liverpool, UK
| | - Ellen Hopwood
- NIHR Applied Research Collaboration East Midlands (ARC-EM), Leicester Diabetes Centre, University of Leicester, Leicester, UK
| | - Patrick Highton
- NIHR Applied Research Collaboration East Midlands (ARC-EM), Leicester Diabetes Centre, University of Leicester, Leicester, UK
| | - Priscilla Katapa
- NIHR Applied Research Collaboration East Midlands (ARC-EM), Leicester Diabetes Centre, University of Leicester, Leicester, UK
| | - Kamlesh Khunti
- NIHR Applied Research Collaboration East Midlands (ARC-EM), Leicester Diabetes Centre, University of Leicester, Leicester, UK
| | - Thomas J Wilkinson
- NIHR Leicester Biomedical Research Centre (BRC), Leicester Diabetes Centre, University of Leicester, Leicester, UK
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Hamroun A, Aymes E, Couchoud C, Béchade C, Moranne O, Beuscart JB, Gauthier V, Dauchet L, Amouyel P, Stengel B, Glowacki F. Older people predialysis care pathways and early morbidity-mortality upon start of dialysis. Nephrol Dial Transplant 2025; 40:768-780. [PMID: 39424602 DOI: 10.1093/ndt/gfae236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2024] [Indexed: 10/21/2024] Open
Abstract
BACKGROUND The ageing of the population with advanced chronic kidney disease (CKD) increases the complexity of care pathways. Our aim was to identify subgroups of older people according to predialysis care pathways and describe their association with early morbidity-mortality after transition to dialysis. METHODS This study included 22 128 incident dialysis patients aged ≥75 years during 2009-2017 from the French nationwide registry linked to the National Health Data System. Predialysis care pathways were identified by ascending hierarchical classification based on preselected healthcare use indicators in the previous year. Their association with a composite outcome of death or hospitalization ≥50% of the time off dialysis within the first year of dialysis was studied by multivariable logistic regression accounting for demographics, comorbidities, functional status, conditions of dialysis initiation, socioeconomic deprivation index and home-to-dialysis center travel time. RESULTS Five care pathway profiles were identified, characterized by limited healthcare use (Cluster 1, 28%), non-nephrology ambulatory care (Cluster 2, 17%), nephrology ambulatory care (Cluster 3, 37%) and a high level of non-nephrology or nephrology hospitalizations (Clusters 4 and 5, both 9%). Profile subgroups did not differ according to patient age and comorbidities, but Clusters 1, 2 and 4 displayed higher levels of social deprivation. Compared with Cluster 3, the odds ratios of primary composite outcome were significantly increased for Clusters 1, 4 and 5 [odds ratio (95% confidence interval) of 1.16 (1.08-1.25), 1.17 (1.05-1.32) and 1.12 (1.01-1.25), respectively]. Moreover, prolonged hospitalizations were also more common in all groups, compared with Cluster 3. CONCLUSION Despite a similar comorbidity profile, older people with advanced CKD experience very heterogeneous predialysis care pathways, some of which associated with higher burden of hospitalization after the transition to dialysis.
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Affiliation(s)
- Aghiles Hamroun
- Department of Public Health, Epidemiology, Health Economics and Prevention, Service de Santé Publique, Epidémiologie, Economie de la Santé et Prévention, CHU de Lille, Lille, France
- UMR1167 RID-AGE, Institut Pasteur de Lille, Inserm, Univ Lille, CHU Lille, Lille, France
| | - Estelle Aymes
- Department of Public Health, Epidemiology, Health Economics and Prevention, Service de Santé Publique, Epidémiologie, Economie de la Santé et Prévention, CHU de Lille, Lille, France
- UMR1167 RID-AGE, Institut Pasteur de Lille, Inserm, Univ Lille, CHU Lille, Lille, France
| | - Cécile Couchoud
- Coordination nationale Registre REIN, Agence de la biomédecine, Saint-Denis-La-Plaine cedex, France
| | - Clémence Béchade
- Department of Nephrology, Service de Néphrologie, Université de Normandie, UNICAEN, CHU de Caen Normandie, Caen, France
- ANTICIPE, U1086 INSERM-UCN, Centre François Baclesse, Caen, France
| | - Olivier Moranne
- Service de Néphrologie Dialyse Aphérèse, Nîmes Hôpital Universitaire, Nîmes, France
- IDESP, UMR-INSERM, Université de Montpellier, France
| | - Jean-Baptiste Beuscart
- Service de médecine gériatrique, CHU de Lille, F-59000 Lille, France
- Univ. Lille, CHU Lille, ULR 2694 METRICS-Evaluation des technologies de santé et des pratiques médicales, F-59000 Lille, France
| | - Victoria Gauthier
- Department of Public Health, Epidemiology, Health Economics and Prevention, Service de Santé Publique, Epidémiologie, Economie de la Santé et Prévention, CHU de Lille, Lille, France
- UMR1167 RID-AGE, Institut Pasteur de Lille, Inserm, Univ Lille, CHU Lille, Lille, France
| | - Luc Dauchet
- Department of Public Health, Epidemiology, Health Economics and Prevention, Service de Santé Publique, Epidémiologie, Economie de la Santé et Prévention, CHU de Lille, Lille, France
- UMR1167 RID-AGE, Institut Pasteur de Lille, Inserm, Univ Lille, CHU Lille, Lille, France
| | - Philippe Amouyel
- Department of Public Health, Epidemiology, Health Economics and Prevention, Service de Santé Publique, Epidémiologie, Economie de la Santé et Prévention, CHU de Lille, Lille, France
- UMR1167 RID-AGE, Institut Pasteur de Lille, Inserm, Univ Lille, CHU Lille, Lille, France
| | - Bénédicte Stengel
- Équipe d'épidémiologie clinique, CESP, Université Paris-Saclay, UVSQ, Université Paris-Sud, Inserm U1018, Villejuif, France
| | - François Glowacki
- Service de Néphrologie, CHU de Lille, F-59000 Lille, France
- Univ. Lille, CNRS, Inserm, CHU Lille, Institut Pasteur de Lille, UMR9020-U1277 - CANTHER - Cancer Heterogeneity, Plasticity and Resistance to Therapies, F-59000 Lille, France
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Li X, Yue X, Zhang L, Zheng X, Shang N. Pharmacist-led surgical medicines prescription optimization and prediction service improves patient outcomes - a machine learning based study. Front Pharmacol 2025; 16:1534552. [PMID: 40160467 PMCID: PMC11949800 DOI: 10.3389/fphar.2025.1534552] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2024] [Accepted: 02/25/2025] [Indexed: 04/02/2025] Open
Abstract
Background Optimizing prescription practices for surgical patients is crucial due to the complexity and sensitivity of their medication regimens. To enhance medication safety and improve patient outcomes by introducing a machine learning (ML)-based warning model integrated into a pharmacist-led Surgical Medicines Prescription Optimization and Prediction (SMPOP) service. Method A retrospective cohort design with a prospective implementation phase was used in a tertiary hospital. The study was divided into three phases: (1) Data analysis and ML model development (1 April 2019 to 31 March 2022), (2) Establishment of a pharmacist-led management model (1 April 2022 to 31 March 2023), and (3) Outcome evaluation (1 April 2023 to 31 March 2024). Key variables, including gender, age, number of comorbidities, type of surgery, surgery complexity, days from hospitalization to surgery, type of prescription, type of medication, route of administration, and prescriber's seniority were collected. The data set was divided into training set and test set in the form of 8:2. The effectiveness of the SMPOP service was evaluated based on prescription appropriateness, adverse drug reactions (ADRs), length of hospital stay, total hospitalization costs, and medication expenses. Results In Phase 1, 6,983 prescriptions were identified as potential prescription errors (PPEs) for ML model development, with 43.9% of them accepted by prescribers. The Random Forest (RF) model performed the best (AUC = 0.893) and retained high accuracy with 12 features (AUC = 0.886). External validation showed an AUC of 0.786. In Phase 2, SMPOP services were implemented, which effectively promoted effective communication between pharmacists and physicians and ensured the successful implementation of intervention measures. The SMPOP service was fully implemented. In Phase 3, the acceptance rate of pharmacist recommendations rose to 71.3%, while the length of stay, total hospitalization costs, and medication costs significantly decreased (p < 0.05), indicating overall improvement compared to Phase 1. Conclusion SMPOP service enhances prescription appropriateness, reduces ADRs, shortens stays, and lowers costs, underscoring the need for continuous innovation in healthcare.
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Affiliation(s)
- Xianlin Li
- Department of Pharmacy, The First Hospital of Shanxi Medical University, Taiyuan, Shanxi, China
- School of Pharmacy, Shanxi Medical University, Taiyuan, Shanxi, China
| | - Xiunan Yue
- School of Pharmacy, Shanxi Medical University, Taiyuan, Shanxi, China
| | - Lan Zhang
- School of Public Health, Capital Medical University, Beijing, China
| | - Xiaojun Zheng
- Department of Pharmacy, The First Hospital of Shanxi Medical University, Taiyuan, Shanxi, China
| | - Nan Shang
- Department of Pharmacy, The First Hospital of Shanxi Medical University, Taiyuan, Shanxi, China
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Masanneck L, Meuth SG, Pawlitzki M. Evaluating base and retrieval augmented LLMs with document or online support for evidence based neurology. NPJ Digit Med 2025; 8:137. [PMID: 40038423 DOI: 10.1038/s41746-025-01536-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2024] [Accepted: 02/21/2025] [Indexed: 03/06/2025] Open
Abstract
Effectively managing evidence-based information is increasingly challenging. This study tested large language models (LLMs), including document- and online-enabled retrieval-augmented generation (RAG) systems, using 13 recent neurology guidelines across 130 questions. Results showed substantial variability. RAG improved accuracy compared to base models but still produced potentially harmful answers. RAG-based systems performed worse on case-based than knowledge-based questions. Further refinement and improved regulation is needed for safe clinical integration of RAG-enhanced LLMs.
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Affiliation(s)
- Lars Masanneck
- Department of Neurology, Medical Faculty and University Hospital Düsseldorf, Heinrich Heine University Düsseldorf, Düsseldorf, Germany.
| | - Sven G Meuth
- Department of Neurology, Medical Faculty and University Hospital Düsseldorf, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Marc Pawlitzki
- Department of Neurology, Medical Faculty and University Hospital Düsseldorf, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
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Kanbay M, Copur S, Yilmaz ZY, Mallamaci F, Zoccali C. Ziltivekimab for anemia and atherosclerosis in chronic kidney disease: a new hope? J Nephrol 2025; 38:403-414. [PMID: 39453604 DOI: 10.1007/s40620-024-02117-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2024] [Accepted: 09/17/2024] [Indexed: 10/26/2024]
Abstract
Anemia of chronic kidney disease is a multifactorial condition secondary to various etiologies, including nutritional deficiencies, chronic inflammation, erythropoietin deficiency or resistance, bone marrow suppression, iron deficiency and adverse drug effects. The major therapeutic intervention for anemia among chronic kidney disease patients is erythropoiesis-stimulating agents. However, a limitation of erythropoiesis-stimulating agents is the risk for thromboembolic events, hypertension, seizures, solid organ malignancies and hyporesponsiveness. A novel interleukin-6 monoclonal antibody, ziltivekimab, has been evaluated for managing anemia in chronic kidney disease patients in pilot clinical trials with promising outcomes, including an improvement in hemoglobin levels and reduction of inflammatory parameters. These trials have shown that ziltivekimab does not increase the risk for cytopenia or infectious complications as has been described for other interleukin-6-targeting monoclonal antibodies, like tocilizumab. Furthermore, potentially beneficial effects on serum lipid profile have been reported, leading to the hypothesis of a favorable impact of the drug on atherosclerotic complications. In addition, ziltivekimab has shown efficacy in improving anemia parameters, including hemoglobin levels and iron studies. Ziltivekimab deserves full scale clinical development, and to this aim, large-scale clinical trials are under way.
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Affiliation(s)
- Mehmet Kanbay
- Division of Nephrology, Department of Medicine, Koc University School of Medicine, 34010, Istanbul, Turkey.
| | - Sidar Copur
- Department of Medicine, Koc University School of Medicine, Istanbul, Turkey
| | - Zeynep Y Yilmaz
- Department of Medicine, Koc University School of Medicine, Istanbul, Turkey
| | - Francesca Mallamaci
- Nephrology, Dialysis and Transplantation Unit Azienda Ospedaliera "Bianchi-Melacrino-Morelli" & CNR-IFC, Institute of Clinical Physiology, Research Unit of Clinical Epidemiology and Physiopathology of Renal Diseases and Hypertension of Reggio Calabria, Reggio Calabria, Italy
| | - Carmine Zoccali
- Renal Research Institute, New York, NY, USA
- Associazione Ipertensione Nefrologia Trapianto Renal (IPNET), C/O Nefrologia, Grande Ospedale Metropolitano, Reggio Calabria, Italy
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Butler CR, Nalatwad A, Cheung KL, Hannan MF, Hladek MD, Johnston EA, Kimberly L, Liu CK, Nair D, Ozdemir S, Saeed F, Scherer JS, Segev DL, Sheshadri A, Tennankore KK, Washington TR, Wolfgram D, Ghildayal N, Hall R, McAdams-DeMarco M. Establishing Research Priorities in Geriatric Nephrology: A Delphi Study of Clinicians and Researchers. Am J Kidney Dis 2025; 85:293-302. [PMID: 39603330 PMCID: PMC11846693 DOI: 10.1053/j.ajkd.2024.09.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2024] [Revised: 08/28/2024] [Accepted: 09/18/2024] [Indexed: 11/29/2024]
Abstract
RATIONALE & OBJECTIVE Despite substantial growth of the population of older adults with kidney disease, there remains a lack of evidence to guide clinical care for this group. The Kidney Disease and Aging Research Collaborative conducted a Delphi study to build consensus on research priorities for clinical geriatric nephrology. STUDY DESIGN Asynchronous modified Delphi study. SETTING & PARTICIPANTS Clinicians and researchers in the United States and Canada with clinical experience and/or research expertise in geriatric nephrology. OUTCOME Research priorities in geriatric nephrology. ANALYTICAL APPROACH In the first Delphi round, participants submitted free-text descriptions of research priorities considered important for improving the clinical care of older adults with kidney disease. Delphi moderators used inductive content analysis to group concepts into categories. In the second and third rounds, participants iteratively reviewed topics, selected their top 5 priorities, and offered comments used to revise categories. RESULTS Among 121 who were invited, 57 participants (47%) completed the first Delphi round and 48 (84% of enrolled participants) completed all rounds. After 3 rounds, the 5 priorities with the highest proportion of agreement were (1) communication and decision-making about treatment options for older adults with kidney failure (69% agreement), (2) quality of life, symptom management, and palliative care (67%), (3) frailty and physical function (54%), (4) tailoring therapies for kidney disease to specific needs of older adults (42%), and (5) caregiver and social support (35%). Health equity and person-centricity were identified as cross-cutting features that informed all topics. LIMITATIONS Relatively low response rate and limited participation by private practitioners and older clinicians and researchers. CONCLUSIONS Experts in geriatric nephrology identified clinical research priorities with the greatest potential to improve care for older adults with kidney disease. These findings provide a road map for the geriatric nephrology community to harmonize and maximize the impact of research efforts.
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Affiliation(s)
- Catherine R Butler
- Division of Nephrology, Department of Medicine, Kidney Research Institute, University of Washington, Seattle, Washington; Veterans Affairs Health Services Research and Development Center of Innovation for Veteran-Centered and Value-Driven Care, Seattle, Washington
| | - Akanksha Nalatwad
- Department of Surgery, New York University Grossman School of Medicine and Langone Health, New York, New York
| | - Katharine L Cheung
- Division of Nephrology, Department of Medicine, The University of Vermont Larner College of Medicine, Burlington, Vermont
| | - Mary F Hannan
- Department of Biobehavioral Nursing Science, College of Nursing, University of Illinois Chicago, Chicago, Illinois
| | - Melissa D Hladek
- School of Nursing, Johns Hopkins University, Baltimore, Maryland
| | - Emily A Johnston
- Division of Geriatrics and Palliative Care, Department of Medicine, New York University Grossman School of Medicine and Langone Health, New York, New York
| | - Laura Kimberly
- Hansjörg Wyss Department of Plastic Surgery, Department of Population Health, Division of Medical Ethics, New York University Grossman School of Medicine and Langone Health, New York, New York
| | - Christine K Liu
- Geriatric Research and Education Clinical Center, Veteran Affairs Palo Alto Health Care System, Palo Alto, California; Section of Geriatric Medicine, Division of Primary Care and Population Health, Stanford University School of Medicine, Stanford, California
| | - Devika Nair
- Division of Nephrology and Hypertension, Vanderbilt University Medical Center, Nashville, Tennessee; Tennessee Valley Veterans Affairs Health System, Nashville, Tennessee
| | - Semra Ozdemir
- Department of Population Health Sciences, Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - Fahad Saeed
- Divisions of Nephrology and Palliative Care, Departments of Medicine and Public Health, University of Rochester Medical Center, Rochester, New York
| | - Jennifer S Scherer
- Division of Geriatrics and Palliative Care, Division of Nephrology, Department of Internal Medicine, New York University Grossman School of Medicine and Langone Health, New York, New York
| | - Dorry L Segev
- Department of Surgery, New York University Grossman School of Medicine and Langone Health, New York, New York; Division of Nephrology and Hypertension, Vanderbilt University Medical Center, Nashville, Tennessee; Department of Population Health, New York University Grossman School of Medicine and Langone Health, New York, New York
| | - Anoop Sheshadri
- Division of Nephrology, Department of Medicine, University of California San Francisco, San Francisco, California; Nephrology Section, San Francisco Veterans Affairs Medical Center, San Francisco, California
| | - Karthik K Tennankore
- Division of Nephrology, Department of Medicine, Dalhousie University, Halifax, NS, Canada
| | | | - Dawn Wolfgram
- Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin; Medicine Division, Milwaukee Veterans Affairs Medical Center, Milwaukee, Wisconsin
| | - Nidhi Ghildayal
- Department of Surgery, New York University Grossman School of Medicine and Langone Health, New York, New York
| | - Rasheeda Hall
- Division of Nephrology, Department of Medicine, Duke University School of Medicine, Durham, North Carolina; Renal Section, Durham Veterans Affairs Healthcare System, Durham, North Carolina
| | - Mara McAdams-DeMarco
- Department of Surgery, New York University Grossman School of Medicine and Langone Health, New York, New York; Department of Population Health, New York University Grossman School of Medicine and Langone Health, New York, New York.
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Courtney M, Thompson S, Klarenbach S, Ye F, Zaidi D, Smith TJ, Bello AK. Virtual consultation in kidney care: a mixed-methods study on a model for safe and effective integration into routine clinical care. BMJ Open 2025; 15:e081651. [PMID: 39855659 PMCID: PMC11758694 DOI: 10.1136/bmjopen-2023-081651] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2023] [Accepted: 12/12/2024] [Indexed: 01/27/2025] Open
Abstract
RATIONALE AND OBJECTIVE Globally, the COVID-19 pandemic necessitated a rapid introduction of virtual care delivery via telephone or videoconference. The rapid advancements in e-health technology facilitated options for virtual care, including asynchronous data transfer in virtual clinic models and patient-facing smartphone applications for communications and self-care. However, the clinical benefits of virtual consultation have not been consistently demonstrated in all facets of kidney care, and the adoption of this innovation alters workflows and health professionals' perceptions of care delivery. This study evaluated the integration of virtual outpatient consultation safely and effectively into the kidney care programme in Alberta. STUDY DESIGN We leveraged a mixed-methods approach to collate data about clinicians' experiences and opinions, forming the basis for the qualitative part of the study. DATA EXTRACTION Data were collected through surveys, interviews and focus groups of nephrologists and home dialysis nurses. ANALYTICAL APPROACH Focus group/interview transcripts for nephrologists and nurses were used to generate initial codebooks, which were iteratively refined throughout the analysis. Codes were categorised and analysed thematically, and data collected from nephrologists and nurses were analysed separately. RESULTS The findings demonstrated that clinicians support the use of routine virtual care. Clinicians' opinions on implementation requirements emphasised logistics for routine virtual care integration, quality of care delivered, impacts on the therapeutic relationship and regulatory policy clarification. LIMITATION The generalisability of the findings is limited in scope, as the study was conducted in a single nephrology programme in Canada, and may not apply to other provinces or settings. CONCLUSIONS These findings inform recommendations for safe and effective virtual care delivery and can be leveraged to inform virtual care designs in kidney care programmes. Further study is required to clarify the impacts of virtual care on specific population demographics based on geography (rural vs urban) and age (elderly population) in the post-COVID-19 era, and determine how to effectively integrate patient perspectives into this model of care.
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Affiliation(s)
- Mark Courtney
- Nephrology, University of Alberta, Edmonton, Alberta, Canada
| | | | | | - Feng Ye
- University of Alberta, Edmonton, Alberta, Canada
- University of Alberta, Edmonton, Alberta, Canada
| | - Deenaz Zaidi
- Medicine, University of Alberta, Edmonton, Alberta, Canada
| | | | - Aminu K Bello
- Medicine, University of Alberta, Edmonton, Alberta, Canada
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11
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Bele S, Chisolm C, Lategan C, Yakubets K, Lorenzetti D, Uwamahoro MC, Popeski N, Turin TC, Lang E, Rabi D. Medical complexity in emergency and urgent care settings: a scoping review protocol. BMJ Open 2025; 15:e086984. [PMID: 39832999 PMCID: PMC11751845 DOI: 10.1136/bmjopen-2024-086984] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2024] [Accepted: 12/12/2024] [Indexed: 01/22/2025] Open
Abstract
INTRODUCTION Considering the impact of non-medical factors (personal and social) on patients with multiple chronic conditions, the term 'medical complexity' is gaining traction as it encompasses both medical and non-medical aspects of patients' medical needs. When primary care is not able to provide timely care for chronic challenges or acute concerns, complex patients require care in emergency or urgent care settings. The concept of medical complexity is continually evolving, although without a universally accepted or standardised definition that determines if an adult patient is considered complex. Therefore, this scoping review aims to understand how medical complexity is defined, identify its defining attributes and examine its use in clinical care research. We also aim to consolidate and evaluate the evidence to suggest a more comprehensive and standardised definition of medical complexity and/or highlight key components required to define medical complexity in urgent care and emergency department settings. METHODS AND ANALYSIS This protocol is developed according to the approach described by Arksey and O'Malley (2005) and expanded by Levac and colleagues. We will use Walker and Avant's method of concept analysis (2005) to gain a comprehensive understanding of the concept of medical complexity. We will systematically search MEDLINE, CINAHL Plus, EMBASE, APA PsycINFO and Cochrane Library. A grey literature search will be conducted in Google and Google Scholar to identify additional information. Two reviewers will independently screen titles and abstracts for inclusion, followed by a screening of the full text of potentially relevant articles. Relevant data will be extracted from these studies. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews checklist will be used to report the selection of studies at different stages. ETHICS AND DISSEMINATION Scoping review methodology uses and reviews publicly available studies and data, so ethics approval is not required. We will disseminate the results of this scoping review through peer-reviewed publications and presentations at academic conferences and scientific meetings. We will also share these results with key stakeholders, including healthcare providers, community organisations and healthcare system leaders.
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Affiliation(s)
- Sumedh Bele
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Cassandra Chisolm
- University of Alberta College of Health Sciences, Edmonton, Alberta, Canada
| | - Conne Lategan
- University of Alberta College of Health Sciences, Edmonton, Alberta, Canada
| | - Kate Yakubets
- University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
| | - Diane Lorenzetti
- Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | | | - Naomi Popeski
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Tanvir C Turin
- Family Medicine, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
| | - Eddy Lang
- Emergency Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Doreen Rabi
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
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12
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Logan B, Pascoe EM, Viecelli AK, Johnson DW, Comans T, Hawley CM, Hickey LE, Janda M, Jaure A, Kalaw E, Kiriwandeniya C, Matsuyama M, Mihala G, Nguyen KH, Pole JD, Polkinghorne KR, Pond D, Raj R, Reidlinger DM, Scholes-Robertson N, Valks A, Wong G, Hubbard RE. Baseline Characteristics of Frailty and Disease Stage in Older People Living With CKD. Kidney Int Rep 2025; 10:120-133. [PMID: 39810773 PMCID: PMC11725818 DOI: 10.1016/j.ekir.2024.10.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2024] [Revised: 10/02/2024] [Accepted: 10/07/2024] [Indexed: 01/16/2025] Open
Abstract
Introduction The GOAL trial, a cluster randomized controlled trial, investigated the effect of comprehensive geriatric assessment (CGA) on frail older people with chronic kidney disease (CKD). This paper describes the following: (i) participant baseline characteristics, and (ii) their relationship with CKD stage and frailty severity. Methods Sixteen kidney outpatient clinics (clusters) were randomly allocated 1:1 to CGA or usual care. Enrolled frail older people with CKD (Frailty Index [FI] > 0.25; aged ≥65 years or ≥55 if First Nations people) received the intervention allocated to their cluster. CKD was defined as moderate (stages 3 or 4) or severe (stage 5 or 5D), and frailty categorized as moderate (>0.25-<0.36), severe (0.36-<0.45) or very severe (≥0.45). Participant characteristics were analyzed using descriptive statistics. Statistical methods appropriate for type of outcome were used to describe the association of frailty and CKD categories with participant characteristics. Results Over a 27-month period, 240 people were recruited (55.7% male, 82.9% White/European). Mean age was 76.9 (SD: 6.6) years and median FI was 0.39 (interquartile range [IQR]: 0.32-0.47). The median EQ-5D-5L quality-of-life index score was worse in those with very severe frailty (0.57, IQR: 0.28-0.83) compared to severe frailty (0.85, IQR: 0.67-0.92) and moderate frailty (0.90, IQR: 0.82-0.93) (overall P < 0.001). Median EQ-5D-5L was also worse in those with severe CKD (0.79, IQR: 0.40-0.89), compared to moderate CKD (median 0.87, IQR: 0.73-0.92; P = 0.001). Conclusion This cohort demonstrated poorer quality-of-life scores in those with more severe frailty and more advanced CKD.
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Affiliation(s)
- Benignus Logan
- Australian Frailty Network, The University of Queensland, Brisbane, Australia
- Centre for Health Services Research, The University of Queensland, Brisbane, Australia
| | - Elaine M. Pascoe
- Centre for Health Services Research, The University of Queensland, Brisbane, Australia
| | - Andrea K. Viecelli
- Australasian Kidney Trials Network, The University of Queensland, Brisbane, Australia
- Department of Kidney and Transplant Services, Princess Alexandra Hospital, Brisbane, Australia
| | - David W. Johnson
- Australasian Kidney Trials Network, The University of Queensland, Brisbane, Australia
- Department of Kidney and Transplant Services, Princess Alexandra Hospital, Brisbane, Australia
- Centre for Kidney Disease Research, Translational Research Institute, Brisbane, Australia
| | - Tracy Comans
- Australian Frailty Network, The University of Queensland, Brisbane, Australia
- Centre for Health Services Research, The University of Queensland, Brisbane, Australia
- National Ageing Research Institute, Melbourne, Australia
| | - Carmel M. Hawley
- Australasian Kidney Trials Network, The University of Queensland, Brisbane, Australia
- Department of Kidney and Transplant Services, Princess Alexandra Hospital, Brisbane, Australia
| | - Laura E. Hickey
- Australasian Kidney Trials Network, The University of Queensland, Brisbane, Australia
| | - Monika Janda
- Centre for Health Services Research, The University of Queensland, Brisbane, Australia
| | - Allison Jaure
- Sydney School of Public Health, The University of Sydney, Sydney, Australia
| | - Emarene Kalaw
- Australasian Kidney Trials Network, The University of Queensland, Brisbane, Australia
| | - Charani Kiriwandeniya
- Australasian Kidney Trials Network, The University of Queensland, Brisbane, Australia
| | - Misa Matsuyama
- Australasian Kidney Trials Network, The University of Queensland, Brisbane, Australia
| | - Gabor Mihala
- Centre for Health Services Research, The University of Queensland, Brisbane, Australia
- Australasian Kidney Trials Network, The University of Queensland, Brisbane, Australia
| | - Kim-Huong Nguyen
- Centre for Health Services Research, The University of Queensland, Brisbane, Australia
- School of Public Health, The University of Queensland, Brisbane, Australia
- Global Brain Health Institute, Trinity College Dublin, Dublin, Ireland and University of California, San Francisco, California, USA
| | - Jason D. Pole
- Centre for Health Services Research, The University of Queensland, Brisbane, Australia
- Dalla Lana School of Public Health, The University of Toronto, Toronto, Ontario, Canada
| | - Kevan R. Polkinghorne
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
- Department of Medicine, Monash University, Melbourne, Australia
- Department of Nephrology, Monash Health, Melbourne, Australia
| | - Dimity Pond
- Wicking Dementia Research and Education Centre, University of Tasmania, Hobart, Australia
- University of New England, Armidale, Australia
| | - Rajesh Raj
- School of Medicine, University of Tasmania, Hobart, Australia
- Department of Nephrology, Launceston General Hospital, Launceston, Australia
| | - Donna M. Reidlinger
- Australian Frailty Network, The University of Queensland, Brisbane, Australia
- Centre for Health Services Research, The University of Queensland, Brisbane, Australia
| | - Nicole Scholes-Robertson
- Sydney School of Public Health, The University of Sydney, Sydney, Australia
- Centre for Kidney Research, The Children’s Hospital at Westmead, Sydney, Australia
| | - Andrea Valks
- Australasian Kidney Trials Network, The University of Queensland, Brisbane, Australia
| | - Germaine Wong
- Sydney School of Public Health, The University of Sydney, Sydney, Australia
- Centre for Kidney Research, The Children’s Hospital at Westmead, Sydney, Australia
- Centre for Transplant and Renal Research, Westmead Hospital, Sydney, Australia
| | - Ruth E. Hubbard
- Australian Frailty Network, The University of Queensland, Brisbane, Australia
- Centre for Health Services Research, The University of Queensland, Brisbane, Australia
- Department of General and Geriatric Medicine, Princess Alexandra Hospital, Brisbane, Australia
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Serna MK, Yoon C, Fiskio J, Lakin JR, Schnipper JL, Dalal AK. A Mixed Methods Analysis of Standardized Documentation of Serious Illness Conversations Within an Electronic Health Record Module During Hospitalization. Am J Hosp Palliat Care 2025; 42:14-19. [PMID: 38334010 PMCID: PMC11566069 DOI: 10.1177/10499091241228269] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/10/2024] Open
Abstract
BACKGROUND Analysis of documented Serious Illness Conversations (SICs) in the inpatient setting can help clinicians align management to address patient and caregiver needs. METHODS We conducted a mixed methods analysis of the first instance of standardized documentation of a SIC within a structured module among hospitalized general medicine patients from 2018 to 2019. Percentage of documentations that included a description of patient or family understanding of the patient's medical condition and use of radio buttons to answer the "prognostic information shared," "hopes," and "worries" modules are reported. Using grounded theory approach, physicians analyzed free text entries to: "What is important to the patient/family?" and "Recommendations or next steps planned." RESULTS Out of 5142 patients, 59 patients had a documented SIC. Patient or family understanding of the medical condition(s) was reported in 56 (95%). For "prognostic information shared," the most frequently selected radio buttons were: 49 (83%) incurable disease and 28 (48%) prognosis of weeks to months while those for "hopes" were: 52 (88%) be comfortable and 27 (46%) be at home and for "worries" were: 49 (83%) other physical suffering and 36 (61%) pain. Themes generated from entries to "What's important to patient/family?" included being with loved ones; comfort; mentally and physically present; and reliable care while those for "Recommendations" were coordinating support services; symptom management; and support and communication. CONCLUSIONS SIC content indicated concern about pain and reliable care suggesting the complex, intensive nature of caring for seriously ill patients and the need to consider SICs earlier in the life course of patients.
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Affiliation(s)
- Myrna Katalina Serna
- Division of General Medicine, University of Texas Medical Branch, Galveston, TX, USA
| | - Catherine Yoon
- Hospital Medicine Unit, Division of General Internal Medicine and Primary Care, Brigham and Women’s Hospital, Boston, MA, USA
| | - Julie Fiskio
- Hospital Medicine Unit, Division of General Internal Medicine and Primary Care, Brigham and Women’s Hospital, Boston, MA, USA
| | - Joshua R. Lakin
- Harvard Medical School, Boston, MA, USA
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Jeffrey L. Schnipper
- Hospital Medicine Unit, Division of General Internal Medicine and Primary Care, Brigham and Women’s Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Anuj K. Dalal
- Hospital Medicine Unit, Division of General Internal Medicine and Primary Care, Brigham and Women’s Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
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14
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Russell O, Lester S, Black RJ, Lassere M, Barrett C, March L, Lynch T, Buchbinder R, Hill CL. Area-Level Socioeconomic Status Impacts Health Care Visit Frequency by Australian Patients With Inflammatory Arthritis: Results From the Australian Rheumatology Association Database. Arthritis Care Res (Hoboken) 2025; 77:127-135. [PMID: 39467045 DOI: 10.1002/acr.25456] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2024] [Revised: 10/11/2024] [Accepted: 10/16/2024] [Indexed: 10/30/2024]
Abstract
OBJECTIVE Individuals with inflammatory arthritis require long-term rheumatologist care for optimal outcomes. We sought to determine if socioeconomic status (SES) influences general practitioner (GP) and specialist physician visit frequency and out-of-pocket (OOP) visit costs. METHODS We linked data from Australian Rheumatology Association Database (ARAD) participants with rheumatoid arthritis or psoriatic arthritis to the Pharmaceutical Benefits (PBS) and Medicare Benefits Schedule from 2011 to 2018. Small-area SES was approximated as quintiles of the Index of Relative Socioeconomic Advantage and Disadvantage. A comorbidity index (Rx-Risk) was determined from PBS data. Analysis was performed using panel regression methods. RESULTS We included 1,916 ARAD participants (76.3% rheumatoid arthritis, 71.1% women, mean ± SD age 54 ± 12 years and disease duration 6 ± 4 years). Participants averaged 9.0 (95% confidence interval [CI] 8.6-9.4) annual GP visits and 3.9 (95% CI 3.8-4.1) annual specialist physician visits. After adjustment for sex, age, education, remoteness, and comorbidity, there was an inverse relationship between annual GP visit frequency and higher SES quintile (-0.6, 95% CI -0.9 to -0.3 visits per quintile) and a direct relationship between more frequent specialist visits and higher SES (linear slope 0.3, 95% CI 0.2-0.5 visits per quintile). Average OOP costs/visit were higher for specialist physician (AUD$38.43; 95% CI 37.34-39.53) versus GP visits (AUD$7.86; 95% CI 7.42-8.31), and higher SES was associated with greater OOP cost. CONCLUSION Patients with higher SES have relatively fewer GP visits and more specialist physician visits compared with patients with lower SES, suggesting individuals with lower SES may receive suboptimal specialist physician care. OOP costs may be a contributing factor.
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Affiliation(s)
- Oscar Russell
- The Queen Elizabeth Hospital, Woodville, South Australia, Australia, and The University of Adelaide, Adelaide, South Australia, Australia
| | - Susan Lester
- The Queen Elizabeth Hospital, Woodville, South Australia, Australia, and The University of Adelaide, Adelaide, South Australia, Australia
| | - Rachel J Black
- The Queen Elizabeth Hospital, Woodville, South Australia, Australia, and The University of Adelaide and Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Marissa Lassere
- St George Hospital, Kogarah, New South Wales, Australia, and University of New South Wales, Sydney, New South Wales, Australia
| | - Claire Barrett
- University of Queensland, Brisbane, Queensland, Australia
| | - Lyn March
- The University of Sydney, the Northern Sydney Local Health District, and Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - Tom Lynch
- The University of Sydney, the Northern Sydney Local Health District, and Royal North Shore Hospital, Sydney, New South Wales, Australia
| | | | - Catherine L Hill
- The Queen Elizabeth Hospital, Woodville, South Australia, Australia, and The University of Adelaide and Royal Adelaide Hospital, Adelaide, South Australia, Australia
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15
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Loewenthal JV, Beltran CP, Atalay A, Schwartz AW, Ramani S. "What's Going to Happen?": Internal Medicine Resident Experiences of Uncertainty in the Care of Older Adults. J Gen Intern Med 2025; 40:226-233. [PMID: 38485878 PMCID: PMC11780066 DOI: 10.1007/s11606-024-08720-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Accepted: 03/01/2024] [Indexed: 01/31/2025]
Abstract
PURPOSE Internal medicine residents care for clinically complex older adults and may experience increased moral distress due to knowledge gaps, time constraints, and institutional barriers. We conducted a phenomenological study to explore residents' experiences and challenges through the lens of uncertainty. METHODS Between January and March 2022, six focus groups were conducted comprising a total of 13 internal medicine residents in postgraduate years 2 and 3, who had completed a required 2-week geriatrics rotation. Applying the Beresford taxonomy of uncertainty as a conceptual model, data were analyzed using the framework method. RESULTS All challenging experiences described by residents caring for older adults were linked to uncertainty. Sources of uncertainty were categorized and mapped to the Beresford taxonomy: (1) lack of geriatrics knowledge or clinical guidelines (technical); (2) difficulty applying knowledge to complex older adults (conceptual); and (3) lack of longitudinal relationship with the older patient (personal). Residents identified capacity evaluation and discharge planning as two major geriatric knowledge areas linked with uncertainty. While the majority of residents reacted to uncertainty with some degree of distress, several reported positive coping strategies. CONCLUSIONS Internal medicine residents face uncertainty when caring for older adults, particularly related to technical and conceptual factors. Strategies for mitigating uncertainty in the care of older adults are needed given links with moral distress and trainee well-being.
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Affiliation(s)
- Julia V Loewenthal
- Division of Aging, Brigham and Women's Hospital, Boston, USA.
- Harvard Medical School, Boston, USA.
| | - Christine P Beltran
- Division of General Internal Medicine and Clinical Innovation, Department of Medicine, New York University Grossman School of Medicine, New York, USA
| | - Alev Atalay
- Harvard Medical School, Boston, USA
- Division of General Internal Medicine, Brigham and Women's Hospital, Boston, USA
| | - Andrea Wershof Schwartz
- Division of Aging, Brigham and Women's Hospital, Boston, USA
- Harvard Medical School, Boston, USA
- New England Geriatrics Research Education and Clinical Center, Veterans Boston Healthcare System, Boston, USA
- Harvard T.H. Chan School of Public Health, Boston, USA
| | - Subha Ramani
- Harvard Medical School, Boston, USA
- Division of General Internal Medicine, Brigham and Women's Hospital, Boston, USA
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16
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Costes-Albrespic M, Liabeuf S, Laville S, Jacquelinet C, Combe C, Fouque D, Laville M, Frimat L, Pecoits-Filho R, Lambert O, Massy ZA, Sautenet B, Alencar de Pinho N. Antihypertensive Treatment Patterns in CKD Stages 3 and 4: The CKD-REIN Cohort Study. Kidney Med 2024; 6:100912. [PMID: 39574792 PMCID: PMC11577237 DOI: 10.1016/j.xkme.2024.100912] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2024] Open
Abstract
Rationale & Objective Blood pressure (BP) control is essential for preventing cardiorenal complications in chronic kidney disease (CKD), but most patients fail to reach BP target. We assessed longitudinal patterns of antihypertensive drug prescription and systolic BP. Study Design Prospective observational cohort study. Setting & Population In total, 2,755 hypertensive patients with CKD stages 3-4, receiving care from a nephrologist, from the French CKD-Renal Epidemiology and Information Network (CKD-REIN cohort study). Exposure Patient factors, including sociodemographic characteristics, medical history, and laboratory data, and provider factors, including number of primary care physician and specialist encounters. Outcomes Changes in antihypertensive drug-class prescription during follow-up: add-on or withdrawal. Analytical Approach Hierarchical shared-frailty models to estimate hazard ratios (HR) to deal with clustering at the nephrologist level and linear mixed models to describe systolic BP trajectory. Results At baseline, median age was 69 years, and mean estimated glomerular filtration rate was 33 mL/min/1.73 m². In total, 66% of patients were men, 81% had BP ≥ 130/80 mm Hg, and 75% were prescribed ≥2 antihypertensive drugs. During a median 5-year follow-up, the rate of changes of antihypertensive prescription was 50 per 100 person-years, 23 per 100 for add-ons, and 25 per 100 for withdrawals. After adjusting for risk factors, systolic BP, and the number of antihypertensive drugs, poor medication adherence was associated with increased HR for add-on (1.35, 95% confidence interval [CI], 1.01-1.80), whereas a lower education level was associated with increased HR for withdrawal (1.23, 95% CI, 1.02-1.49) for 9-11 years versus ≥12 years. More frequent nephrologist visits (≥4 vs none) were associated with higher HRs of add-on and withdrawal (1.52, 95% CI, 1.06-2.18; 1.57, 95% CI, 1.12-2.19, respectively), whereas associations with visit frequency to other physicians varied with their specialty. Mean systolic BP decreased by 4 mm Hg following drug add-on but tended to increase thereafter. Limitations Lack of information on prescriber and drug dosing. Conclusions In patients with CKD and poor BP control, changes in antihypertensive drug prescriptions are common and relate to clinician preferences and patients' tolerability. Sustainable reduction in systolic BP after add-on of a drug class is infrequently achieved.
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Affiliation(s)
- Margaux Costes-Albrespic
- Centre for Research in Epidemiology and Population Health, Paris-Saclay University, Inserm U1018, Versailles Saint-Quentin University, Clinical Epidemiology Team, Villejuif, France
| | - Sophie Liabeuf
- Pharmaco-epidemiology Unit, Department of Clinical Pharmacology, Amiens-Picardie University Medical Center, Amiens, France
- MP3CV Laboratory, Jules Verne University of Picardie, Amiens, France
| | - Solène Laville
- Pharmaco-epidemiology Unit, Department of Clinical Pharmacology, Amiens-Picardie University Medical Center, Amiens, France
- MP3CV Laboratory, Jules Verne University of Picardie, Amiens, France
| | - Christian Jacquelinet
- Centre for Research in Epidemiology and Population Health, Paris-Saclay University, Inserm U1018, Versailles Saint-Quentin University, Clinical Epidemiology Team, Villejuif, France
- Biomedicine Agency, La Plaine Saint-Denis, France
| | - Christian Combe
- Nephrology, Transplantation, Dialysis, and Apheresis Department, University Hospital of Bordeaux, Bordeaux University, Bordeaux, France
- Inserm U1026, Bordeaux University, Bordeaux, France
| | - Denis Fouque
- Nephrology Department, Lyon-Sud University Hospital, Claude Bernard University Lyon 1, Pierre-Bénite, France
- Carmen INSERM U1060, Claude Bernard University Lyon 1, Pierre-Bénite, France
| | - Maurice Laville
- Carmen INSERM U1060, Claude Bernard University Lyon 1, Pierre-Bénite, France
| | - Luc Frimat
- Nephrology Department, University Regional Hospital of Nancy, Vandoeuvre-lès-Nancy, France
- APEMAC, Lorraine University, Nancy, France
| | | | - Oriane Lambert
- Centre for Research in Epidemiology and Population Health, Paris-Saclay University, Inserm U1018, Versailles Saint-Quentin University, Clinical Epidemiology Team, Villejuif, France
| | - Ziad A. Massy
- Centre for Research in Epidemiology and Population Health, Paris-Saclay University, Inserm U1018, Versailles Saint-Quentin University, Clinical Epidemiology Team, Villejuif, France
- Nephrology Department, Ambroise Paré University Hospital, APHP, Boulogne-Billancourt, Paris, France
| | - Bénédicte Sautenet
- Nephrology, Arterial Hypertension, Dialysis, and Renal Transplantation Department, INSERM U1246 SPHERE, Nantes, France
| | - Natalia Alencar de Pinho
- Centre for Research in Epidemiology and Population Health, Paris-Saclay University, Inserm U1018, Versailles Saint-Quentin University, Clinical Epidemiology Team, Villejuif, France
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17
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Schreiber MJ. PET Testing Has Utility in the Prescription of Peritoneal Dialysis: PRO. KIDNEY360 2024; 5:1791-1793. [PMID: 38573808 PMCID: PMC11687983 DOI: 10.34067/kid.0000000000000434] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/01/2023] [Accepted: 03/28/2024] [Indexed: 04/06/2024]
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18
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Tonelli M, Wiebe N, Boulton T, Donald M, Evans J, Hemmelgarn B, Howarth T, Lunney M, Nicholas D, Makaroff KS, So H, Thompson S, Klarenbach SW, Manns B. Associations Between Hearing Loss and Health-Related Costs: A Retrospective Population-Based Cohort Study. Am J Audiol 2024:1-10. [PMID: 39535959 DOI: 10.1044/2024_aja-24-00130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2024] Open
Abstract
PURPOSE Hearing loss (HL) is a leading cause of disability worldwide, but its health-related costs have been incompletely studied. Our objective was to examine the association between HL and direct health care costs and identify subgroups in which costs associated with HL are especially high. METHOD This was a retrospective population-based cohort study of adults treated in a universal health care system between April 2008 and March 2019. HL was identified using administrative health data. We estimate health care costs in 2023 Canadian dollars, including costs for hospitalization, provider claims, ambulatory care visits, prescription medications, and long-term care (LTC). RESULTS Of 4,424,632 participants, 146,644 (3.3%) had HL. Participants with HL were older (Mdn = 55 years [interquartile range: 43-68] vs. 35 years [24-50]) and had more comorbidities (1 [0-2] vs. 0 [0-1]) at baseline than participants without, whereas the likelihood of female sex, rural residence, and material deprivation were similar between groups with and without HL. Over median follow-up of 11.0 years, total age-sex adjusted annual health costs and each of its component costs were significantly higher in participants with HL compared to those without (annual total costs: $6,871, 95% confidence interval [CI] [$6,778, $6,962] vs. $4,716, 95% CI [$4,729, $4,763]). After full adjustment (a maximum of 29 comorbidities), annual costs remained significantly higher in participants with HL overall and for certain subcomponents (provider claims, ambulatory visits, and medications), whereas adjusted costs of hospitalization and LTC were lower among people with HL. The magnitude of the incremental costs among participants with HL was most pronounced for younger participants, men, or those with less comorbidity. Total projected annual direct health costs for Alberta residents with HL were $1.01 billion in 2023, of which $125 million (95% CI [$116, $135 million]) was attributable to HL specifically. CONCLUSIONS Compared to those without HL, health costs were markedly higher among participants with HL, partially due to a higher burden of comorbidity. The relatively high population attributable costs of HL suggest that better prevention, recognition, and management of this condition could yield substantial economic benefits. SUPPLEMENTAL MATERIAL https://doi.org/10.23641/asha.27353439.
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Affiliation(s)
| | - Natasha Wiebe
- Department of Medicine, University of Alberta, Edmonton, Canada
| | - Tiffany Boulton
- Department of Community Health Sciences, University of Calgary, Alberta, Canada
| | - Maoliosa Donald
- Department of Medicine, University of Calgary, Alberta, Canada
| | | | | | | | - Meg Lunney
- Department of Medicine, University of Calgary, Alberta, Canada
| | - David Nicholas
- Faculty of Social Work, University of Calgary, Alberta, Canada
| | | | - Helen So
- Department of Medicine, University of Alberta, Edmonton, Canada
| | | | | | - Braden Manns
- Department of Medicine, University of Calgary, Alberta, Canada
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19
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Klinkhammer BM, Ay I, Caravan P, Caroli A, Boor P. Advances in Molecular Imaging of Kidney Diseases. Nephron Clin Pract 2024; 149:149-159. [PMID: 39496240 DOI: 10.1159/000542412] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2024] [Accepted: 10/20/2024] [Indexed: 11/06/2024] Open
Abstract
BACKGROUND Diagnosing and monitoring kidney diseases traditionally rely on blood and urine analyses and invasive procedures such as kidney biopsies, the latter offering limited possibilities for longitudinal monitoring and a comprehensive understanding of disease dynamics. Current noninvasive methods lack specificity in capturing intrarenal molecular processes, hindering patient stratification and patient monitoring in clinical practice and clinical trials. SUMMARY Molecular imaging enables noninvasive and quantitative assessment of physiological and pathological molecular processes. By using specific molecular probes and imaging technologies, e.g., magnetic resonance imaging, positron emission tomography, single-photon emission computed tomography, or ultrasound, molecular imaging allows the detection and longitudinal monitoring of disease activity with spatial and temporal resolution of different kidney diseases and disease-specific pathways. Several approaches have already shown promising results in kidneys and exploratory clinical studies, and validation is needed before implementation in clinical practice. KEY MESSAGES Molecular imaging offers a noninvasive assessment of intrarenal molecular processes, overcoming the limitations of current diagnostic methods. It has the potential to serve as companion diagnostics, not only in clinical trials, aiding in patient stratification and treatment response assessment. By guiding therapeutic interventions, molecular imaging might contribute to the development of targeted therapies for kidney diseases.
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Affiliation(s)
| | - Ilknur Ay
- Athinoula A. Martinos Center for Biomedical Imaging, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Peter Caravan
- Institute for Innovation in Imaging, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Anna Caroli
- Bioengineering Department, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Milan, Italy
| | - Peter Boor
- Institute for Pathology, RWTH Aachen University, Aachen, Germany
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20
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Chesnaye NC, Ortiz A, Zoccali C, Stel VS, Jager KJ. The impact of population ageing on the burden of chronic kidney disease. Nat Rev Nephrol 2024; 20:569-585. [PMID: 39025992 DOI: 10.1038/s41581-024-00863-9] [Citation(s) in RCA: 29] [Impact Index Per Article: 29.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/13/2024] [Indexed: 07/20/2024]
Abstract
The burden of chronic kidney disease (CKD) and its risk factors are projected to rise in parallel with the rapidly ageing global population. By 2050, the prevalence of CKD category G3-G5 may exceed 10% in some regions, resulting in substantial health and economic burdens that will disproportionately affect lower-income countries. The extent to which the CKD epidemic can be mitigated depends largely on the uptake of prevention efforts to address modifiable risk factors, the implementation of cost-effective screening programmes for early detection of CKD in high-risk individuals and widespread access and affordability of new-generation kidney-protective drugs to prevent the development and delay the progression of CKD. Older patients require a multidisciplinary integrated approach to manage their multimorbidity, polypharmacy, high rates of adverse outcomes, mental health, fatigue and other age-related symptoms. In those who progress to kidney failure, comprehensive conservative management should be offered as a viable option during the shared decision-making process to collaboratively determine a treatment approach that respects the values and wishes of the patient. Interventions that maintain or improve quality of life, including pain management and palliative care services when appropriate, should also be made available.
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Affiliation(s)
- Nicholas C Chesnaye
- ERA Registry, Amsterdam UMC location University of Amsterdam, Medical Informatics, Amsterdam, Netherlands
- Amsterdam Public Health Research Institute, Quality of Care, Amsterdam, the Netherlands
| | - Alberto Ortiz
- Department of Nephrology and Hypertension, IIS-Fundacion Jimenez Diaz UAM, Madrid, Spain
- RICORS2040, Madrid, Spain
| | - Carmine Zoccali
- Associazione Ipertensione Nefrologia Trapianto Renale (IPNET), c/o Nefrologia, Grande Ospedale Metropolitano, Reggio Calabria, Italy
- Institute of Molecular Biology and Genetics (Biogem), Ariano Irpino, Italy
- Renal Research Institute, New York, NY, USA
| | - Vianda S Stel
- ERA Registry, Amsterdam UMC location University of Amsterdam, Medical Informatics, Amsterdam, Netherlands
- Amsterdam Public Health Research Institute, Quality of Care, Amsterdam, the Netherlands
| | - Kitty J Jager
- ERA Registry, Amsterdam UMC location University of Amsterdam, Medical Informatics, Amsterdam, Netherlands.
- Amsterdam Public Health Research Institute, Quality of Care, Amsterdam, the Netherlands.
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21
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Górriz JL, Alcázar Arroyo R, Arribas P, Artola S, Cinza-Sanjurjo S, la Espriella RD, Escalada J, García-Matarín L, Martínez L, Julián JC, Miramontes-González JP, Rubial F, Salgueira M, Soler MJ, Trillo JL. Multidisciplinary Delphi consensus on challenges and key factors for an optimal care model in chronic kidney disease. Nefrologia 2024; 44:678-688. [PMID: 39505678 DOI: 10.1016/j.nefroe.2024.09.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2023] [Accepted: 01/31/2024] [Indexed: 11/08/2024] Open
Abstract
BACKGROUND AND PURPOSE Chronic kidney disease (CKD) is associated with high morbidity, burden, and resource utilization, and represents a major challenge for healthcare systems. The purpose of this study was to analyse the care patterns for these patients and to reach a consensus on the key factors that should be implemented for an optimal care model in CKD, through a multidisciplinary and integrative vision. MATERIALS AND METHODS A multidisciplinary panel of professionals with experience in the field of CKD was formed, composed of an advisory committee of 15 experts and an additional panel of 44 experts. Challenges and areas for improvement across the continuum of care were identified through review of scientific evidence and individual interviews with the advisory committee. Key factors for an optimal model of care in CKD were agreed and assessed using the Rand/UCLA consensus methodology (adapted Delphi), evaluating their appropriateness and necessity. RESULTS 38 key factors were identified for an optimal CKD patient care model, organised into four challenges: (1) Development of CKD management models and increased visibility of the disease, (2) Prevention, optimisation of screening, early diagnosis and registration of CKD at all levels of care, (3) Comprehensive, multidisciplinary and coordinated monitoring, ensuring therapeutic optimisation and continuity of care, and (4) Reinforcement of CKD training for health care professionals and patients. 35 key factors were assessed by the panel as adequate and clearly necessary, and of these, 14 were considered highly imperative. CONCLUSIONS There is consensus on the need to prioritise CKD care at both institutional and societal levels, moving towards optimal models of CKD care based on prevention and early detection of the disease, as well as comprehensive and coordinated patient monitoring and training and awareness-raising at all levels. The key factors identified constitute a roadmap that can be implemented in the different Autonomous Communities and contribute to a significant improvement in the patient's care.
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Affiliation(s)
- José Luis Górriz
- Servicio de Nefrología, Hospital Clínico Universitario, INCLIVA, Universidad de Valencia, Valencia, Spain.
| | | | - Patricia Arribas
- Servicio de Nefrología, Hospital Universitario Infanta Leonor, Madrid, Spain.
| | | | - Sergio Cinza-Sanjurjo
- Centro de Salud Milladoiro, Área de Salud de Santiago de Compostela, A Coruña, Spain; Instituto de Investigación en Salud de Santiago de Compostela (IDIS), Santiago de Compostela, Spain; Centro de Investigación Biomédica en Red-Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain.
| | - Rafael de la Espriella
- Servicio de Cardiología, Hospital Clínico Universitario de Valencia, INCLIVA, Valencia, Spain; Grupo de Trabajo Cardiorrenal, Asociación de Insuficiencia Cardiaca, Sociedad Española de Cardiología, Madrid, Spain.
| | - Javier Escalada
- Departamento de Endocrinología y Nutrición, Clínica Universidad de Navarra, Pamplona, Spain; CIBER Fisiopatología de la Obesidad y Nutrición (CIBEROBN), Instituto de Salud Carlos III, Madrid, Spain.
| | | | - Luis Martínez
- Dirección General de Asistencia Sanitaria y Resultados en Salud, Consejería de Salud y Consumo, Servicio Andaluz de Salud, Sevilla, Spain.
| | - Juan Carlos Julián
- Federación Nacional de Asociaciones para la lucha contra las enfermedades del riñón (ALCER) España, Madrid, Spain.
| | - José Pablo Miramontes-González
- Servicio de Medicina Interna, Hospital Universitario Río Hortega, Valladolid, Spain; Departamento de Medicina, Facultad de Medicina, Universidad de Valladolid, Valladolid, Spain.
| | - Félix Rubial
- Gerencia del Área Sanitaria de Ourense, Verín e O Barco de Valdeorras, Servizo Galego de Saúde, Ourense, Spain.
| | - Mercedes Salgueira
- Servicio de Nefrología, Hospital Universitario Virgen Macarena, Sevilla, Spain; Departamento de Medicina, Grupo de Ingeniería Biomédica, Centro de Investigación Biomédica en Red en Bioingeniería de Biomateriales y Nanomedicina (CIBER- BBN), Universidad de Sevilla, Sevilla, Spain.
| | - María José Soler
- Servicio de Nefrología, Hospital Universitario Vall d'Hebron, Barcelona, Spain.
| | - José Luis Trillo
- Servicio de Farmacia del Área de Salud del Departamento Clínico Malvarrosa, Valencia, Spain.
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22
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Nakhoul GN, Taliercio JJ, Bassil EH, Arrigain S, Schold JD, Wardrop R, O'Toole J, Nally JV, Bierer SB, Sedor JR, Mehdi A. Virtual Nephron: Evaluation of a Novel Virtual Reality Educational Tool. Kidney Int Rep 2024; 9:2619-2626. [PMID: 39291202 PMCID: PMC11403093 DOI: 10.1016/j.ekir.2024.06.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2024] [Revised: 06/03/2024] [Accepted: 06/03/2024] [Indexed: 09/19/2024] Open
Abstract
Introduction Recent technological advancements allowed the development of engaging technological tools. Using ASN funding from the ASN, we developed a 3D Virtual Reality (VR) physiology course entitled DiAL-Neph (Diuretic Action and eLectrolyte transport in the Nephron). We hereby present its evaluation. Methods The study consisted of 2 parts: evaluation of knowledge gain, and qualitative evaluation of platform reception. Internal medicine PGY1 residents were randomly assigned into 2 groups: a VR group and a conventional group. Knowledge acquisition was assessed with a post-test administered at the end of the course and repeated within 6 to 12 weeks. Independent t-tests were used to compare the number of correct answers between the groups. A survey and focus groups composed of medicine residents evaluated the platform. Sessions were recorded and transcribed verbatim. Data was analyzed through the content analysis approach by two independent reviewers. Results Of 117 PGY1 resident participants, 64 were randomized to the VR group and 53 were randomized to the traditional group. Initial test results showed higher scores among VR compared to the traditional group (76.5% correct vs. 68.8%). Seventy-eight PGY1s participated in the follow up testing (46 VR group vs. 32 traditional group) and results showed no significant difference in test results. Greater than 90% of the residents rated the platform positively and 77% preferred it as a teaching method. Conclusion The DiAL-Neph VR platform appeared to improve short-term learning but not long-term retention. Further studies are needed to investigate the impact of such teaching platforms on overall interest in nephrology.
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Affiliation(s)
- Georges N Nakhoul
- Department of Kidney Medicine, Medical Subspecialty Institute, Cleveland Clinic, Cleveland, Ohio, USA
- Cleveland Clinic, Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio, USA
| | - Jonathan J Taliercio
- Department of Kidney Medicine, Medical Subspecialty Institute, Cleveland Clinic, Cleveland, Ohio, USA
- Cleveland Clinic, Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio, USA
| | - Elias H Bassil
- Department of Kidney Medicine, Medical Subspecialty Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Susana Arrigain
- Department of Surgery, University of Colorado - Anschutz Medical Campus, Aurora, Colorado, USA
- Colorado Center for Transplantation Care, Research, and Education, University of Colorado, Anschutz Medical Campus, Aurora, Colorado, USA
| | - Jesse D Schold
- Department of Surgery, University of Colorado - Anschutz Medical Campus, Aurora, Colorado, USA
- Department of Epidemiology, School of Public Health, University of Colorado - Anschutz Medical Campus, Aurora, Colorado, USA
- Colorado Center for Transplantation Care, Research, and Education, University of Colorado, Anschutz Medical Campus, Aurora, Colorado, USA
| | - Richard Wardrop
- Department of Hospital Medicine, Integrated Hospital Care Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - John O'Toole
- Department of Kidney Medicine, Medical Subspecialty Institute, Cleveland Clinic, Cleveland, Ohio, USA
- Cleveland Clinic, Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio, USA
| | - Joseph V Nally
- Department of Kidney Medicine, Medical Subspecialty Institute, Cleveland Clinic, Cleveland, Ohio, USA
- Cleveland Clinic, Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio, USA
| | - S Beth Bierer
- Cleveland Clinic, Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio, USA
| | - John R Sedor
- Department of Kidney Medicine, Medical Subspecialty Institute, Cleveland Clinic, Cleveland, Ohio, USA
- Cleveland Clinic, Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio, USA
| | - Ali Mehdi
- Department of Kidney Medicine, Medical Subspecialty Institute, Cleveland Clinic, Cleveland, Ohio, USA
- Cleveland Clinic, Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio, USA
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23
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Nicikowski J, Szczepański M, Miedziaszczyk M, Kudliński B. The potential of ChatGPT in medicine: an example analysis of nephrology specialty exams in Poland. Clin Kidney J 2024; 17:sfae193. [PMID: 39099569 PMCID: PMC11295106 DOI: 10.1093/ckj/sfae193] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2023] [Indexed: 08/06/2024] Open
Abstract
Background In November 2022, OpenAI released a chatbot named ChatGPT, a product capable of processing natural language to create human-like conversational dialogue. It has generated a lot of interest, including from the scientific community and the medical science community. Recent publications have shown that ChatGPT can correctly answer questions from medical exams such as the United States Medical Licensing Examination and other specialty exams. To date, there have been no studies in which ChatGPT has been tested on specialty questions in the field of nephrology anywhere in the world. Methods Using the ChatGPT-3.5 and -4.0 algorithms in this comparative cross-sectional study, we analysed 1560 single-answer questions from the national specialty exam in nephrology from 2017 to 2023 that were available in the Polish Medical Examination Center's question database along with answer keys. Results Of the 1556 questions posed to ChatGPT-4.0, correct answers were obtained with an accuracy of 69.84%, compared with ChatGPT-3.5 (45.70%, P = .0001) and with the top results of medical doctors (85.73%, P = .0001). Of the 13 tests, ChatGPT-4.0 exceeded the required ≥60% pass rate in 11 tests passed, and scored higher than the average of the human exam results. Conclusion ChatGPT-3.5 was not spectacularly successful in nephrology exams. The ChatGPT-4.0 algorithm was able to pass most of the analysed nephrology specialty exams. New generations of ChatGPT achieve similar results to humans. The best results of humans are better than those of ChatGPT-4.0.
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Affiliation(s)
- Jan Nicikowski
- University of Zielona Gora, Faculty of Medicine and Health Sciences, Student Scientific Section of Clinical Nutrition, Zielona Góra, Poland
- University of Zielona Góra, Faculty of Medicine and Health Sciences, Department of Anaesthesiology, Intensive Care and Emergency Medicine, Zielona Góra, Poland
| | - Mikołaj Szczepański
- University of Zielona Gora, Faculty of Medicine and Health Sciences, Student Scientific Section of Clinical Nutrition, Zielona Góra, Poland
- University of Zielona Góra, Faculty of Medicine and Health Sciences, Department of Anaesthesiology, Intensive Care and Emergency Medicine, Zielona Góra, Poland
| | - Miłosz Miedziaszczyk
- Poznan University of Medical Sciences, Department of General and Transplant Surgery, Poznan, Poland
| | - Bartosz Kudliński
- University of Zielona Góra, Faculty of Medicine and Health Sciences, Department of Anaesthesiology, Intensive Care and Emergency Medicine, Zielona Góra, Poland
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24
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Zoccali C, Mallamaci F, Lightstone L, Jha V, Pollock C, Tuttle K, Kotanko P, Wiecek A, Anders HJ, Remuzzi G, Kalantar-Zadeh K, Levin A, Vanholder R. A new era in the science and care of kidney diseases. Nat Rev Nephrol 2024; 20:460-472. [PMID: 38575770 DOI: 10.1038/s41581-024-00828-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/06/2024] [Indexed: 04/06/2024]
Abstract
Notable progress in basic, translational and clinical nephrology research has been made over the past five decades. Nonetheless, many challenges remain, including obstacles to the early detection of kidney disease, disparities in access to care and variability in responses to existing and emerging therapies. Innovations in drug development, research technologies, tissue engineering and regenerative medicine have the potential to improve patient outcomes. Exciting prospects include the availability of new drugs to slow or halt the progression of chronic kidney disease, the development of bioartificial kidneys that mimic healthy kidney functions, and tissue engineering techniques that could enable transplantable kidneys to be created from the cells of the recipient, removing the risk of rejection. Cell and gene therapies have the potential to be applied for kidney tissue regeneration and repair. In addition, about 30% of kidney disease cases are monogenic and could potentially be treated using these genetic medicine approaches. Systemic diseases that involve the kidney, such as diabetes mellitus and hypertension, might also be amenable to these treatments. Continued investment, communication, collaboration and translation of innovations are crucial to realize their full potential. In addition, increasing sophistication in exploring large datasets, implementation science, and qualitative methodologies will improve the ability to deliver transformational kidney health strategies.
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Affiliation(s)
- Carmine Zoccali
- Kidney Research Institute, New York City, NY, USA.
- Institute of Molecular Biology and Genetics (Biogem), Ariano Irpino, Italy.
- Associazione Ipertensione Nefrologia Trapianto Kidney (IPNET), c/o Nefrologia, Grande Ospedale Metropolitano, Reggio Calabria, Italy.
| | - Francesca Mallamaci
- Nephrology, Dialysis and Transplantation Unit Azienda Ospedaliera "Bianchi-Melacrino-Morelli", Reggio Calabria, Italy
- CNR-IFC, Institute of Clinical Physiology, Research Unit of Clinical Epidemiology and Physiopathology of Kidney Diseases and Hypertension of Reggio Calabria, Reggio Calabria, Italy
| | - Liz Lightstone
- Department of Immunology and Inflammation, Imperial College London, London, UK
- Imperial College Healthcare NHS Trust, Hammersmith Hospital, London, UK
| | - Vivek Jha
- George Institute for Global Health, UNSW, New Delhi, India
- School of Public Health, Imperial College, London, UK
- Prasanna School of Public Health, Manipal Academy of Medical Education, Manipal, India
| | - Carol Pollock
- Kolling Institute, Royal North Shore Hospital University of Sydney, Sydney, NSW, Australia
| | - Katherine Tuttle
- Providence Medical Research Center, Providence Inland Northwest, Spokane, Washington, USA
- Department of Medicine, University of Washington, Seattle, Spokane, Washington, USA
- Kidney Research Institute, Institute of Translational Health Sciences, University of Washington, Seattle, Washington, USA
| | - Peter Kotanko
- Kidney Research Institute, New York, NY, USA
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Andrzej Wiecek
- Department of Nephrology, Transplantation and Internal Medicine, Medical University of Silesia, 40-027, Katowice, Poland
| | - Hans Joachim Anders
- Division of Nephrology, Department of Medicine IV, Hospital of the Ludwig Maximilians University Munich, Munich, Germany
| | - Giuseppe Remuzzi
- Istituto di Ricerche Farmacologiche Mario Negri IRCSS, Bergamo, Italy
| | - Kamyar Kalantar-Zadeh
- Harold Simmons Center for Kidney Disease Research and Epidemiology, California, USA
- Division of Nephrology and Hypertension, University of California Irvine, School of Medicine, Orange, Irvine, USA
- Veterans Affairs Healthcare System, Division of Nephrology, Long Beach, California, USA
| | - Adeera Levin
- University of British Columbia, Vancouver General Hospital, Division of Nephrology, Vancouver, British Columbia, Canada
- British Columbia, Provincial Kidney Agency, Vancouver, British Columbia, Canada
| | - Raymond Vanholder
- European Kidney Health Alliance, Brussels, Belgium
- Nephrology Section, Department of Internal Medicine and Paediatrics, University Hospital Ghent, Ghent, Belgium
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25
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Francis A, Harhay MN, Ong ACM, Tummalapalli SL, Ortiz A, Fogo AB, Fliser D, Roy-Chaudhury P, Fontana M, Nangaku M, Wanner C, Malik C, Hradsky A, Adu D, Bavanandan S, Cusumano A, Sola L, Ulasi I, Jha V. Chronic kidney disease and the global public health agenda: an international consensus. Nat Rev Nephrol 2024; 20:473-485. [PMID: 38570631 DOI: 10.1038/s41581-024-00820-6] [Citation(s) in RCA: 133] [Impact Index Per Article: 133.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/19/2024] [Indexed: 04/05/2024]
Abstract
Early detection is a key strategy to prevent kidney disease, its progression and related complications, but numerous studies show that awareness of kidney disease at the population level is low. Therefore, increasing knowledge and implementing sustainable solutions for early detection of kidney disease are public health priorities. Economic and epidemiological data underscore why kidney disease should be placed on the global public health agenda - kidney disease prevalence is increasing globally and it is now the seventh leading risk factor for mortality worldwide. Moreover, demographic trends, the obesity epidemic and the sequelae of climate change are all likely to increase kidney disease prevalence further, with serious implications for survival, quality of life and health care spending worldwide. Importantly, the burden of kidney disease is highest among historically disadvantaged populations that often have limited access to optimal kidney disease therapies, which greatly contributes to current socioeconomic disparities in health outcomes. This joint statement from the International Society of Nephrology, European Renal Association and American Society of Nephrology, supported by three other regional nephrology societies, advocates for the inclusion of kidney disease in the current WHO statement on major non-communicable disease drivers of premature mortality.
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Affiliation(s)
- Anna Francis
- Department of Nephrology, Queensland Children's Hospital, Brisbane, Queensland, Australia
| | - Meera N Harhay
- Department of Medicine, Drexel University College of Medicine, Philadelphia, PA, USA
- Department of Epidemiology and Biostatistics, Drexel University Dornsife School of Public Health, Philadelphia, PA, USA
| | - Albert C M Ong
- Academic Nephrology Unit, Division of Clinical Medicine, School of Medicine and Population Health, University of Sheffield, Sheffield, UK
| | - Sri Lekha Tummalapalli
- Division of Healthcare Delivery Science & Innovation, Department of Population Health Sciences, Weill Cornell Medicine, New York, NY, USA
- Division of Nephrology & Hypertension, Department of Medicine, Weill Cornell Medicine, New York, NY, USA
| | - Alberto Ortiz
- IIS-Fundacion Jimenez Diaz UAM, RICORS2040, Madrid, Spain
| | - Agnes B Fogo
- Vanderbilt University Medical Center, Nashville, TN, USA
| | - Danilo Fliser
- Department of Internal Medicine IV, Renal and Hypertensive Disease & Transplant Centre, Saarland University Medical Centre, Homburg, Germany
| | - Prabir Roy-Chaudhury
- Department of Medicine, Division of Nephrology and Hypertension, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | | | - Masaomi Nangaku
- Division of Nephrology and Endocrinology, Department of Hemodialysis and Apheresis, The University of Tokyo Hospital, Tokyo, Japan
| | - Christoph Wanner
- Department of Clinical Research and Epidemiology, Renal Research Unit, University Hospital of Würzburg, Würzburg, Germany
| | - Charu Malik
- International Society of Nephrology, Brussels, Belgium
| | - Anne Hradsky
- International Society of Nephrology, Brussels, Belgium
| | - Dwomoa Adu
- Department of Medicine and Therapeutics, University of Ghana Medical School, Accra, Ghana
| | - Sunita Bavanandan
- Department of Nephrology, Kuala Lumpur Hospital, Kuala Lumpur, Malaysia
| | - Ana Cusumano
- Instituto de Nefrologia Pergamino, Pergamino City, Argentina
| | - Laura Sola
- Centro de Hemodiálisis Crónica CASMU-IAMPP, Montevideo, Uruguay
| | - Ifeoma Ulasi
- Renal Unit, Department of Medicine, University of Nigeria Teaching Hospital, Ituku-Ozalla, Enugu, Enugu State, Nigeria
| | - Vivekanand Jha
- George Institute for Global Health, University of New South Wales, New Delhi, India.
- School of Public Health, Imperial College, London, UK.
- Prasanna School of Public Health, Manipal Academy of Higher Education, Manipal, India.
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Gregoriano C, Hauser S, Schuetz P, Mueller B, Segerer S, Kutz A. Evaluation of health care utilisation and mortality in medical hospitalisations with multimorbidity and kidney disease, according to frailty: a nationwide cohort study. Swiss Med Wkly 2024; 154:3400. [PMID: 38980660 DOI: 10.57187/s.3400] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Accepted: 04/10/2024] [Indexed: 07/10/2024] Open
Abstract
INTRODUCTION The impact of impaired kidney function on healthcare use among medical hospitalisations with multimorbidity and frailty is incompletely understood. In this study, we assessed the prevalence of acute kidney injury (AKI) and chronic kidney disease (CKD) among multimorbid medical hospitalisations in Switzerland and explored the associations of kidney disease with in-hospital outcomes across different frailty strata. METHODS This observational study analysed nationwide hospitalisation records from 1 January 2012 to 31 December 2020. We included adults (age ≥18 years) with underlying multimorbidity hospitalised in a medical ward. The study population consisted of hospitalisations with AKI, CKD or no kidney disease (reference group), and was stratified by three frailty levels (non-frail, pre-frail, frail). Main outcomes were in-hospital mortality, intensive care unit (ICU) treatment, length of stay (LOS) and all-cause 30-day readmission. We estimated multivariable adjusted odds ratios (OR) and changes in percentage of log-transformed continuous outcomes with 95% confidence intervals (CI). RESULTS Among 2,651,501 medical hospitalisations with multimorbidity, 198,870 had a diagnosis of AKI (7.5%), 452,990 a diagnosis of CKD (17.1%) and 1,999,641 (75.4%) no kidney disease. For the reference group, the risk of in-hospital mortality was 4.4%, for the AKI group 14.4% (adjusted odds ratio [aOR] 2.56 [95% CI 2.52-2.61]) and for the CKD group 5.9% (aOR 0.98 [95% CI 0.96-0.99]), while prevalence of ICU treatment was, respectively, 10.5%, 21.8% (aOR 2.39 [95% CI 2.36-2.43]) and 9.3% (aOR 1.01 [95% CI 1.00-1.02]). Median LOS was 5 days (interquartile range [IQR] 2.0-9.0) in hospitalisations without kidney disease, 9 days (IQR 5.0-15.0) (adjusted change [%] 67.13% [95% CI 66.18-68.08%]) in those with AKI and 7 days (IQR 4.0-12.0) (adjusted change [%] 18.94% [95% CI 18.52-19.36%]) in those with CKD. The prevalence of 30-day readmission was, respectively, 13.3%, 13.7% (aOR 1.21 [95% CI 1.19-1.23]) and 14.8% (aOR 1.26 [95% CI 1.25-1.28]). In general, the frequency of adverse outcomes increased with the severity of frailty. CONCLUSION In medical hospitalisations with multimorbidity, the presence of AKI or CKD was associated with substantial additional hospitalisations and healthcare utilisation across all frailty strata. This information is of major importance for cost estimates and should stimulate discussion on reimbursement.
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Burkhalter DA, Cartellá A, Cozzo D, Ogna A, Forni Ogna V. Obstructive sleep apnea in the hemodialysis population: are clinicians putting existing scientific evidence into practice? FRONTIERS IN NEPHROLOGY 2024; 4:1394990. [PMID: 38915821 PMCID: PMC11194459 DOI: 10.3389/fneph.2024.1394990] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/02/2024] [Accepted: 05/28/2024] [Indexed: 06/26/2024]
Abstract
Introduction Hemodialysis (HD) populations have a high prevalence of Obstructive Sleep Apnea (OSA), which was specifically linked with fluid overload. HD fluid management targeting a low dry weight was shown to reduce OSA severity, opening to novel therapeutic options. We assessed nephrologists' awareness of OSA diagnosis in HD patients and whether they integrate the current knowledge into their fluid management strategy. Material and methods We performed a multicenter, cross-sectional study between July 2022 and July 2023, screening all HD patients of four HD units, and included those with confirmed OSA. We collected anthropometric parameters and fluid status from electronic dossiers. Predialysis fluid overload was measured by multifrequency bioelectrical impedance (BCM®). Nephrologists were asked to identify patients with known OSA, without consulting medical dossiers. The fluid management of patients identified as "OSA positive" was compared to that of patients misclassified as "OSA negative". Results Among 193 HD patients, 23.0% (n=45) had confirmed OSA. The mean age was 76.0 ± 7.5 years, 82.2% were men. Only 60% were correctly identified as "OSA positive" by nephrologists; 14.7% of patients on CPAP were identified. BMI was the only factor associated with correct OSA identification. The predialysis fluid overload tended to be greater in "OSA positive" patients than in the "OSA negative" patients (2.2 ± 1.4 kg vs 1.5 ± 1.3 kg; p=0.08), but there was no difference in postdialysis achievement of dry weight between the groups (residual overweight 0.2 ± 1.0 kg and 0.1 ± 0.7 kg; p= 0.672). Conclusions Our study suggests that the application of scientific evidence to the management of OSA in dialysis patients is not systematic. However, nephrologists have attempted to strictly achieve dry weight in all patients, regardless of OSA status. Sensibilization of nephrologists on the clinical and diagnostic peculiarities of OSA in HD patients may improve OSA diagnosis and therapeutic care.
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Affiliation(s)
| | - Antonio Cartellá
- Service of Pulmonology, Ente Ospedaliero Cantonale, Locarno, Switzerland
| | - Domenico Cozzo
- Service of Nephrology, Ente Ospedaliero Cantonale, Locarno, Switzerland
| | - Adam Ogna
- Faculty of Biomedical Sciences, Università della Svizzera Italiana, Lugano, Switzerland
- Service of Pulmonology, Ente Ospedaliero Cantonale, Locarno, Switzerland
| | - Valentina Forni Ogna
- Faculty of Biomedical Sciences, Università della Svizzera Italiana, Lugano, Switzerland
- Service of Nephrology, Ente Ospedaliero Cantonale, Locarno, Switzerland
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Klarenbach SW, Collister D, Wiebe N, Bello A, Thompson S, Pannu N. Association of Glomerular Filtration Rate Decline With Clinical Outcomes in a Population With Type 2 Diabetes. Can J Kidney Health Dis 2024; 11:20543581241255781. [PMID: 38860190 PMCID: PMC11163929 DOI: 10.1177/20543581241255781] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2023] [Accepted: 04/15/2024] [Indexed: 06/12/2024] Open
Abstract
Background While historical rate of decline in kidney function is informally used by clinicians to estimate risk of future adverse clinical outcomes especially kidney failure, in people with type 2 diabetes the epidemiology and independent association of historical eGFR slope on risk is not well described. Objective Determine the association of eGFR slope and risk of clinically important outcomes. Design Setting and Patients Observational population-based cohort with type 2 diabetes in Alberta. Measurement and Methods An Alberta population-based cohort with type 2 diabetes was assembled, characterized, and observed over 1 year (2018) for clinical outcomes of ESKD, first myocardial infarction, first stroke, heart failure, and disease-specific and all-cause hospitalization and mortality. Kidney function was defined using KDIGO criteria using the most recent eGFR and albuminuria measured in the preceding 18 months; annual eGFR slope utilized measurements in the 3 years prior and was parameterized using three methods (percentiles, and linear term with and without missingness indicator). Demographics, laboratory results, medications, and comorbid conditions using validated definitions were described. In addition to descriptive analysis, odds ratios from fully adjusted logistic models regressing outcomes on eGFR slope are reported; the marginal risk of clinical outcomes was also determined. Results Among 336 376 participants with type 2 diabetes, the median annual eGFR slope was -0.41 mL/min/1.73 m2 (IQR -1.67, 0.62). In fully adjusted models, eGFR slope was independently associated with many adverse clinical outcomes; among those with ≤10th percentile of slope (median -4.71 mL/min/1.73 m2) the OR of kidney failure was 2.22 (95% CI 1.75, 2.82), new stroke 1.23 (1.08, 1.40), heart failure 1.42 (1.27, 1.59), MI 0.98 (0.77, 1.23) all-cause hospitalization 1.31 (1.26, 1.36) and all-cause mortality 1.56 (1.44, 1.68). For every -1 mL/min/1.73 m2 in eGFR slope, the OR of outcomes ranged from 1.01 (0.98, 1.05 for new MI) to 1.09 (1.08, 1.10 for all-cause mortality); findings were significant for 10 of the 13 outcomes considered. Limitations Causality cannot be established with this study design. Conclusions These findings support consideration of the rate of eGFR decline in risk stratification and may inform clinicians and policymakers to optimize treatment and inform health care system planning.
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Affiliation(s)
| | - David Collister
- Department of Medicine, University of Alberta, Edmonton, Canada
| | - Natasha Wiebe
- Department of Medicine, University of Alberta, Edmonton, Canada
| | - Aminu Bello
- Department of Medicine, University of Alberta, Edmonton, Canada
| | | | - Neesh Pannu
- Department of Medicine, University of Alberta, Edmonton, Canada
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Wiebe N, Tonelli M. Long-term clinical outcomes of bariatric surgery in adults with severe obesity: A population-based retrospective cohort study. PLoS One 2024; 19:e0298402. [PMID: 38843138 PMCID: PMC11156280 DOI: 10.1371/journal.pone.0298402] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Accepted: 01/25/2024] [Indexed: 06/09/2024] Open
Abstract
BACKGROUND Bariatric surgery leads to sustained weight loss in a majority of recipients, and also reduces fasting insulin levels and markers of inflammation. We described the long-term associations between bariatric surgery and clinical outcomes including 30 morbidities. METHODS We did a retrospective population-based cohort study of 304,157 adults with severe obesity, living in Alberta, Canada; 6,212 of whom had bariatric surgery. We modelled adjusted time to mortality, hospitalization, surgery and the adjusted incidence/prevalence of 30 new or ongoing morbidities after 5 years of follow-up. RESULTS Over a median follow-up of 4.4 years (range 1 day-22.0 years), bariatric surgery was associated with increased risk of hospitalization (HR 1.46, 95% CI 1.41,1.51) and additional surgery (HR 1.42, 95% CI 1.32,1.52) but with a decreased risk of mortality (HR 0.76, 95% CI 0.64,0.91). After 5 years (median of 9.9 years), bariatric surgery was associated with a lower risk of severe chronic kidney disease (HR 0.45, 95% CI 0.27,0.75), coronary disease (HR 0.49, 95% CI 0.33,0.72), diabetes (HR 0.51, 95% CI 0.47,0.56), inflammatory bowel disease (HR 0.55, 95% CI 0.37,0.83), hypertension (HR 0.70, 95% CI 0.66,0.75), chronic pulmonary disease (HR 0.75, 95% CI 0.66,0.86), asthma (HR 0.79, 95% 0.65,0.96), cancer (HR 0.79, 95% CI 0.65,0.96), and chronic heart failure (HR 0.79, 95% CI 0.64,0.96). In contrast, after 5 years, bariatric surgery was associated with an increased risk of peptic ulcer (HR 1.99, 95% CI 1.32,3.01), alcohol misuse (HR 1.55, 95% CI 1.25,1.94), frailty (HR 1.28, 95% 1.11,1.46), severe constipation (HR 1.26, 95% CI 1.07,1.49), sleep disturbance (HR 1.21, 95% CI 1.08,1.35), depression (HR 1.18, 95% CI 1.10,1.27), and chronic pain (HR 1.12, 95% CI 1.04,1.20). INTERPRETATION Bariatric surgery was associated with lower risks of death and certain morbidities. However, bariatric surgery was also associated with increased risk of hospitalization and additional surgery, as well as certain other morbidities. Since values and preferences for these various benefits and harms may differ between individuals, this suggests that comprehensive counselling should be offered to patients considering bariatric surgery.
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Affiliation(s)
- Natasha Wiebe
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Marcello Tonelli
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
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Oosting IJ, Colombijn JM, Kaasenbrood L, Liabeuf S, Laville SM, Hooft L, Bots ML, Verhaar MC, Vernooij RW. Polypharmacy in Patients with CKD: A Systematic Review and Meta-Analysis. KIDNEY360 2024; 5:841-850. [PMID: 38661553 PMCID: PMC11219116 DOI: 10.34067/kid.0000000000000447] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Accepted: 04/12/2024] [Indexed: 04/26/2024]
Abstract
Key Points The prevalence of polypharmacy in patients with CKD was over 80%. Polypharmacy was highest in patients with a kidney transplant and those receiving dialysis. Polypharmacy is associated with worse clinical outcomes, lower quality of life, and medication-related problems in patients with CKD. Background Despite the high prevalence of polypharmacy in patients with CKD, the extent of polypharmacy across patients with (different stages of) CKD, as well as the association with clinical outcomes remains unknown. This systematic review aimed to evaluate the prevalence of polypharmacy in (different subgroups of) patients with CKD and assess the association between polypharmacy and patient-important outcomes. Methods MEDLINE, Embase, and the Cochrane Library were searched from inception until July 2022. Studies that reported the prevalence of polypharmacy, medication use, or pill burden in patients with CKD (including patients receiving dialysis and kidney transplant recipients) and their association with patient-important outcomes (i.e ., mortality, kidney failure, quality of life [QoL], and medication nonadherence) were included. Two reviewers independently screened title and abstract and full texts, extracted data, and assessed risk of bias. Data were pooled in a random-effects single-arm meta-analysis. Results In total, 127 studies were included (CKD 3–5 n =39, dialysis: n =38, kidney transplant n =13, different CKD stages n =37). The pooled prevalence of polypharmacy, based on 63 studies with 484,915 patients, across all patients with CKD was 82% (95% confidence interval, 76% to 86%), and the pooled mean number of prescribed medications was 9.7 (95% confidence interval, 8.4 to 11.0). The prevalence of polypharmacy was higher in patients who received dialysis or a kidney transplant compared with patients with CKD 3–5 but did not differ between studies with regards to region or patients' mean age or sex. In patients with CKD, polypharmacy was associated with a higher risk of all-cause mortality, kidney failure, faster eGFR decline, lower QoL, and higher medication nonadherence, adverse drug reactions, and potentially inappropriate medications. Conclusions The prevalence of polypharmacy in patients with CKD was over 80%, and highest in patients with a kidney transplant and those receiving dialysis. No causes of heterogeneity were identified, indicating that polypharmacy is an issue for all patients with CKD. Polypharmacy is associated with worse clinical outcomes, lower QoL, and medication-related problems in patients with CKD. Clinical Trial registry name and registration number: PROSPERO (CRD42022331941).
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Affiliation(s)
- Ilse J. Oosting
- Department of Nephrology and Hypertension, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Julia M.T. Colombijn
- Department of Nephrology and Hypertension, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Lotte Kaasenbrood
- Department of Nephrology and Hypertension, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Sophie Liabeuf
- MP3CV Laboratory, EA7517, Jules Verne University of Picardie, Amiens, France
- Pharmacoepidemiology Unit, Department of Clinical Pharmacology, Amiens University Medical Center, Amiens, France
| | - Solène M. Laville
- MP3CV Laboratory, EA7517, Jules Verne University of Picardie, Amiens, France
- Pharmacoepidemiology Unit, Department of Clinical Pharmacology, Amiens University Medical Center, Amiens, France
| | - Lotty Hooft
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
- Cochrane Netherlands, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Michiel L. Bots
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Marianne C. Verhaar
- Department of Nephrology and Hypertension, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Robin W.M. Vernooij
- Department of Nephrology and Hypertension, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
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Ronksley PE, Scory TD, McRae AD, MacRae JM, Manns BJ, Lang E, Donald M, Hemmelgarn BR, Elliott MJ. Emergency Department Use Among Adults Receiving Dialysis. JAMA Netw Open 2024; 7:e2413754. [PMID: 38809552 PMCID: PMC11137633 DOI: 10.1001/jamanetworkopen.2024.13754] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Accepted: 03/27/2024] [Indexed: 05/30/2024] Open
Abstract
Importance People with kidney failure receiving maintenance dialysis visit the emergency department (ED) 3 times per year on average, which is 3- to 8-fold more often than the general population. Little is known about the factors that contribute to potentially preventable ED use in this population. Objective To identify the clinical and sociodemographic factors associated with potentially preventable ED use among patients receiving maintenance dialysis. Design, Setting, and Participants This cohort study used linked administrative health data within the Alberta Kidney Disease Network to identify adults aged 18 years or older receiving maintenance dialysis (ie, hemodialysis or peritoneal dialysis) between April 1, 2010, and March 31, 2019. Patients who had been receiving dialysis for more than 90 days were followed up from cohort entry (defined as dialysis start date plus 90 days) until death, outmigration from the province, receipt of a kidney transplant, or end of study follow-up. The Andersen behavioral model of health services was used as a conceptual framework to identify variables related to health care need, predisposing factors, and enabling factors. Data were analyzed in March 2024. Main Outcomes and Measures Rates of all-cause ED encounters and potentially preventable ED use associated with 4 kidney disease-specific ambulatory care-sensitive conditions (hyperkalemia, heart failure, volume overload, and malignant hypertension) were calculated. Multivariable negative binomial regression models were used to examine the association between clinical and sociodemographic factors and rates of potentially preventable ED use. Results The cohort included 4925 adults (mean [SD] age, 60.8 [15.5] years; 3071 males [62.4%]) with kidney failure receiving maintenance hemodialysis (3183 patients) or peritoneal dialysis (1742 patients) who were followed up for a mean (SD) of 2.5 (2.0) years. In all, 3877 patients had 34 029 all-cause ED encounters (3100 [95% CI, 2996-3206] encounters per 1000 person-years). Of these, 755 patients (19.5%) had 1351 potentially preventable ED encounters (114 [95% CI, 105-124] encounters per 1000 person-years). Compared with patients with a nonpreventable ED encounter, patients with a potentially preventable ED encounter were more likely to be in the lowest income quintile (38.8% vs 30.9%; P < .001); to experience heart failure (46.8% vs 39.9%; P = .001), depression (36.6% vs 32.5%; P = .03), and chronic pain (60.1% vs 54.9%; P = .01); and to have a longer duration of dialysis (3.6 vs 2.6 years; P < .001). In multivariable regression analyses, potentially preventable ED use was higher for younger adults (incidence rate ratio [IRR], 1.69 [95% CI, 1.33-2.15] for those aged 18 to 44 years) and patients with chronic pain (IRR, 1.35 [95% CI, 1.14-1.61]), greater material deprivation (IRR, 1.57 [95% CI, 1.16-2.12]), a history of hyperkalemia (IRR, 1.31 [95% CI, 1.09-1.58]), and historically high ED use (ie, ≥3 ED encounters in the prior year; IRR, 1.46 [95% CI, 1.23-1.73). Conclusions and Relevance In this study of adults receiving maintenance dialysis in Alberta, Canada, among those with ED use, 1 in 5 had a potentially preventable ED encounter; reasons for such encounters were associated with both psychosocial and medical factors. The findings underscore the need for strategies that address social determinants of health to avert potentially preventable ED use in this population.
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Affiliation(s)
- Paul E. Ronksley
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Tayler D. Scory
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Andrew D. McRae
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
- Department of Emergency Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Jennifer M. MacRae
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
- Department of Cardiac Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Braden J. Manns
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Eddy Lang
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
- Department of Emergency Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Maoliosa Donald
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Brenda R. Hemmelgarn
- Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Meghan J. Elliott
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
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Serna MK, Yoon C, Fiskio J, Lakin JR, Schnipper JL, Dalal AK. The Association of Standardized Documentation of Serious Illness Conversations With Healthcare Utilization in Hospitalized Patients: A Propensity Score Matched Cohort Analysis. Am J Hosp Palliat Care 2024; 41:479-485. [PMID: 37385609 PMCID: PMC10983774 DOI: 10.1177/10499091231186818] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/01/2023] Open
Abstract
Background: Serious Illness Conversations (SICs) conducted during hospitalization can lead to meaningful patient participation in the decision-making process affecting medical management. The aim of this study is to determine if standardized documentation of a SIC within an institutionally approved EHR module during hospitalization is associated with palliative care consultation, change in code status, hospice enrollment prior to discharge, and 90-day readmissions. Methods: We conducted retrospective analyses of hospital encounters of general medicine patients at a community teaching hospital affiliated with an academic medical center from October 2018 to August 2019. Encounters with standardized documentation of a SIC were identified and matched by propensity score to control encounters without a SIC in a ratio of 1:3. We used multivariable, paired logistic regression and Cox proportional-hazards modeling to assess key outcomes. Results: Of 6853 encounters (5143 patients), 59 (.86%) encounters (59 patients) had standardized documentation of a SIC, and 58 (.85%) were matched to 167 control encounters (167 patients). Encounters with standardized documentation of a SIC had greater odds of palliative care consultation (odds ratio [OR] 60.10, 95% confidence interval [CI] 12.45-290.08, P < .01), a documented code status change (OR 8.04, 95% CI 1.54-42.05, P = .01), and discharge with hospice services (OR 35.07, 95% CI 5.80-212.08, P < .01) compared to matched controls. There was no significant association with 90-day readmissions (adjusted hazard ratio [HR] .88, standard error [SE] .37, P = .73). Conclusions: Standardized documentation of a SIC during hospitalization is associated with palliative care consultation, change in code status, and hospice enrollment.
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Affiliation(s)
- Myrna K. Serna
- Division of General Medicine, University of Texas Medical Branch, Galveston, TX, USA
| | - Catherine Yoon
- Hospital Medicine Unit, Division of General Internal Medicine and Primary Care, Brigham and Women’s Hospital, Boston, MA, USA
| | - Julie Fiskio
- Hospital Medicine Unit, Division of General Internal Medicine and Primary Care, Brigham and Women’s Hospital, Boston, MA, USA
| | - Joshua R. Lakin
- Harvard Medical School, Boston, MA, USA
- Department of Psychosocial Oncology and Palliative Care, Dana Farber Cancer Institute, Boston, MA, USA
| | - Jeffrey L. Schnipper
- Hospital Medicine Unit, Division of General Internal Medicine and Primary Care, Brigham and Women’s Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Anuj K. Dalal
- Hospital Medicine Unit, Division of General Internal Medicine and Primary Care, Brigham and Women’s Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
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Wang V, Wang CH(L, Assimon MM, Pun PH, Winkelmayer WC, Flythe JE. Prescription and Dispensation of QT-Prolonging Medications in Individuals Receiving Hemodialysis. JAMA Netw Open 2024; 7:e248732. [PMID: 38687480 PMCID: PMC11061769 DOI: 10.1001/jamanetworkopen.2024.8732] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Accepted: 02/27/2024] [Indexed: 05/02/2024] Open
Abstract
Importance Individuals with dialysis-dependent kidney failure have numerous risk factors for medication-related adverse events, including receipt of care by multiple clinicians and initiation of some QT-prolonging medications with known risk of torsades de pointes (TdP), which is associated with higher risk of sudden cardiac death. Little is known about the prescription and dispensation patterns of QT-prolonging medications among people receiving dialysis, hindering efforts to reduce drug-related harm from these and other medications in this high-risk population. Objective To examine prescription and dispensation patterns of QT-prolonging medications with known TdP risk and selected interacting medications prescribed to individuals receiving hemodialysis. Design, Setting, and Participants This cross-sectional study included patients 60 years or older who were enrolled in Medicare Parts A, B, and D receiving in-center hemodialysis from January 1 to December 31, 2019. Analyses were conducted from October 20, 2022, to June 16, 2023. Exposures New-user prescriptions for the 7 most frequently filled QT-prolonging medications characterized by the timing of the new prescription relative to acute care encounters, the type of prescribing clinician and pharmacy that dispensed the medication, and concomitant use of selected medications known to interact with the 7 most frequently filled QT-prolonging medications with known TdP risk. Main Outcomes and Measures The main outcomes were the frequencies of the most commonly filled and new-use episodes of QT-prolonging medications; the timing of medication fills relative to acute care events; prescribers and dispensing pharmacy characteristics for new use of medications; and the frequency and types of new-use episodes with concurrent use of potentially interacting medications. Results Of 20 761 individuals receiving hemodialysis in 2019 (mean [SD] age, 74 [7] years; 51.1% male), 10 992 (52.9%) filled a study drug prescription. Approximately 80% (from 78.6% for odansetron to 93.9% for escitalopram) of study drug new-use prescriptions occurred outside of an acute care event. Between 36.8% and 61.0% of individual prescriptions originated from general medicine clinicians. Between 16.4% and 26.2% of these prescriptions occurred with the use of another QT-prolonging medication. Most potentially interacting drugs were prescribed by different clinicians (46.3%-65.5%). Conclusions and Relevance In this cross-sectional study, QT-prolonging medications for individuals with dialysis-dependent kidney failure were commonly prescribed by nonnephrology clinicians and from nonacute settings. Prescriptions for potentially interacting medications often originated from different prescribers. Strategies aimed at minimizing high-risk medication-prescribing practices in the population undergoing dialysis are needed.
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Affiliation(s)
- Virginia Wang
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Medical Center, Durham, North Carolina
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina
| | - Chin-Hua (Lily) Wang
- The Cecil G. Sheps Center for Health Services Research, The University of North Carolina at Chapel Hill, Chapel Hill
| | | | - Patrick H. Pun
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina
- Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina
| | - Wolfgang C. Winkelmayer
- Selzman Institute for Kidney Health, Section of Nephrology, Baylor College of Medicine, Houston, Texas
| | - Jennifer E. Flythe
- The Cecil G. Sheps Center for Health Services Research, The University of North Carolina at Chapel Hill, Chapel Hill
- University of North Carolina Kidney Center, Division of Nephrology and Hypertension, Department of Medicine, The University of North Carolina School of Medicine, Chapel Hill
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Meyer-Schwickerath C, Weber C, Hornuss D, Rieg S, Hitzenbichler F, Hagel S, Ankert J, Hennigs A, Glossmann J, Jung N. Complexity of patients with or without infectious disease consultation in tertiary-care hospitals in Germany. Infection 2024; 52:577-582. [PMID: 38277092 PMCID: PMC10955003 DOI: 10.1007/s15010-023-02166-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Accepted: 12/21/2023] [Indexed: 01/27/2024]
Abstract
PURPOSE Patients seen by infectious disease (ID) specialists are more complex compared to patients treated by other subspecialities according to Tonelli et al. (2018). However, larger studies on the complexity of patients related to the involvement of ID consultation services are missing. METHODS Data of patients being treated in 2015 and 2019 in four different German university hospitals was retrospectively collected. Data were collected from the hospitals' software system and included whether the patients received an ID consultation as well as patient clinical complexity level (PCCL), case mix index (CMI) and length of stay (LOS) as a measurement for the patients' complexity. Furthermore, a comparison of patients with distinct infectious diseases treated with or without an ID consultation was initiated. RESULTS In total, 215.915 patients were included in the study, 3% (n = 6311) of those were seen by an ID consultant. Patients receiving ID consultations had a significantly (p < 0.05) higher PCCL (median 4 vs. 0), CMI (median 3,8 vs. 1,1) and deviation of the expected mean LOS (median 7 days vs. 0 days) than patients in the control group. No differences among hospitals or between years were observed. Comparing patients with distinct infectious diseases treated with or without an ID consultation, the differences were confirmed throughout the groups. CONCLUSION Patients receiving ID consultations are highly complex, frequently need further treatment after discharge and have a high economic impact. Thus, ID specialists should be clinically trained in a broad spectrum of diseases and treating these complex patients should be sufficiently remunerated.
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Affiliation(s)
- C Meyer-Schwickerath
- Department I of Internal Medicine, Division of Infectious Diseases, University of Cologne, Cologne, Germany
| | - C Weber
- Department of Cardiothoracic Surgery, University of Cologne, Cologne, Germany
| | - D Hornuss
- Faculty of Medicine, Department of Medicine II, Division of Infectious Diseases, Medical Center - University of Freiburg, Freiburg, Germany
| | - S Rieg
- Faculty of Medicine, Department of Medicine II, Division of Infectious Diseases, Medical Center - University of Freiburg, Freiburg, Germany
| | - F Hitzenbichler
- Department of Infection Prevention and Infectious Diseases, University Hospital of Regensburg, Regensburg, Germany
| | - S Hagel
- Institute for Infectious Diseases and Infection Control, Jena University Hospital, Friedrich Schiller University Jena, Jena, Germany
| | - J Ankert
- Institute for Infectious Diseases and Infection Control, Jena University Hospital, Friedrich Schiller University Jena, Jena, Germany
| | - A Hennigs
- I. Department of Medicine, Division of Infectious Diseases, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - J Glossmann
- Center of Integrated Oncology Aachen Bonn Cologne Düsseldorf, University of Cologne, Cologne, Germany
| | - N Jung
- Department I of Internal Medicine, Division of Infectious Diseases, University of Cologne, Cologne, Germany.
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Kennard AL, Glasgow NJ, Rainsford SE, Talaulikar GS. Narrative Review: Clinical Implications and Assessment of Frailty in Patients With Advanced CKD. Kidney Int Rep 2024; 9:791-806. [PMID: 38765572 PMCID: PMC11101734 DOI: 10.1016/j.ekir.2023.12.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Revised: 12/12/2023] [Accepted: 12/21/2023] [Indexed: 05/22/2024] Open
Abstract
Frailty is a multidimensional clinical syndrome characterized by low physical activity, reduced strength, accumulation of multiorgan deficits, decreased physiological reserve, and vulnerability to stressors. Frailty has key social, psychological, and cognitive implications. Frailty is accelerated by uremia, leading to a high prevalence of frailty in patients with advanced chronic kidney disease (CKD) and end-stage kidney disease (ESKD) as well as contributing to adverse outcomes in this patient population. Frailty assessment is not routine in patients with CKD; however, a number of validated clinical assessment tools can assist in prognostication. Frailty assessment in nephrology populations supports shared decision-making and advanced communication and should inform key medical transitions. Frailty screening and interventions in CKD or ESKD are a developing research priority with a rapidly expanding literature base.
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Affiliation(s)
- Alice L. Kennard
- Department of Renal Medicine, Canberra Health Services, Australian Capital Territory, Australia
- Australian National University, Canberra, Australian Capital Territory, Australia
| | - Nicholas J. Glasgow
- Australian National University, Canberra, Australian Capital Territory, Australia
| | - Suzanne E. Rainsford
- Australian National University, Canberra, Australian Capital Territory, Australia
| | - Girish S. Talaulikar
- Department of Renal Medicine, Canberra Health Services, Australian Capital Territory, Australia
- Australian National University, Canberra, Australian Capital Territory, Australia
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Comendeiro-Maaløe M, Ridao-Lopez M, Bernal-Delgado E, Sansó-Rosselló A. Delving into public-expenditure elasticity: Evidence from a National Health Service acute-care hospital network. PLoS One 2024; 19:e0291991. [PMID: 38437234 PMCID: PMC10911587 DOI: 10.1371/journal.pone.0291991] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Accepted: 09/03/2023] [Indexed: 03/06/2024] Open
Abstract
INTRODUCTION The sustainability of public hospital financing in Spain is a recurring issue, given its representativeness in annual public healthcare budgets which must adapt to the macroeconomic challenges that influence the evolution of spending. Knowing whether the responsiveness of hospital expenditure to its determinants (need, utilisation, and quasi-prices) varies according to the type of hospital could help better design strategies aimed at optimising performance. METHODS Using SARIMAX models, we dynamically assess unique nationwide monthly activity data over a 14-year period from 274 acute-care hospitals in the Spanish National Health Service network, clustering these providers according to the average severity of the episodes treated. RESULTS All groups showed seasonal patterns and increasing trends in the evolution of expenditure. The fourth quartile of hospitals, treating the most severe episodes and accounting for more than 50% of expenditure, is the most sensitive to quasi-price factors, particularly the number of beds per hospital. Meanwhile, the first quartile of hospitals, which treat the least severe episodes and account for 10% of expenditure, is most sensitive to quantity factors, for which expenditure showed an elasticity above one, while factors of production were not affected. CONCLUSIONS Belonging to one or another cluster of hospitals means that the determinants of expenditure have a different impact and intensity. The system should focus on these differences in order to optimally modulate expenditure not only according to the needs of the population, but also according to the macroeconomic situation, while leaving hospitals room for manoeuvre in case of unforeseen events. The findings suggest strengthening a network of smaller hospitals (Group 1)-closer to their reference population, focused on managing and responding to chronicity and stabilising acute events-prior to transfer to tertiary hospitals (Group 4)-larger but appropriately sized, specialising in solving acute and complex health problems-when needed.
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Affiliation(s)
- Micaela Comendeiro-Maaløe
- Data Science for Health Services and Policy Research, Instituto Aragonés de Ciencias de la Salud (IACS), Zaragoza, Spain
- Network for Research on Chronicity, Primary Care, and Health Promotion (RICAPPS), Instituto de Salud Carlos III, Madrid, Spain
- Department of Applied Economics, University of the Balearic Islands, Palma, Spain
| | - Manuel Ridao-Lopez
- Network for Research on Chronicity, Primary Care, and Health Promotion (RICAPPS), Instituto de Salud Carlos III, Madrid, Spain
- Aragon Health Research Institute (IISA), Zaragoza, Spain
| | - Enrique Bernal-Delgado
- Data Science for Health Services and Policy Research, Instituto Aragonés de Ciencias de la Salud (IACS), Zaragoza, Spain
- Network for Research on Chronicity, Primary Care, and Health Promotion (RICAPPS), Instituto de Salud Carlos III, Madrid, Spain
| | - Andreu Sansó-Rosselló
- Department of Applied Economics, University of the Balearic Islands, Palma, Spain
- Models for Information Processing and Fuzzy Information (MOTIBO) Research Group, Balearic Islands Health Research Institute, Idisba, Mallorca, Spain
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Oude Engberink A, Tessier G, Kamil I, Bourrel G, Moranne O. General practitioners' representation of early-stage CKD is a barrier to adequate management and patient empowerment: a phenomenological study. J Nephrol 2024; 37:379-390. [PMID: 38227278 DOI: 10.1007/s40620-023-01838-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Accepted: 11/18/2023] [Indexed: 01/17/2024]
Abstract
BACKGROUND In high-income countries, chronic kidney disease (CKD) affects over 10% of the population. Identifying these patients early is a priority, especially as new treatments are available to reduce the risk of cardiovascular and renal morbidity. We aimed at understanding the management and care pathway of patients with early-to-moderate CKD defined as an estimated glomerular filtration rate (eGFR) ≥ 45 mL/min/1.73 m2 (CKD-EPI), by analyzing the experience of general practitioners in a region in France. METHODS This qualitative semiopragmatic phenomenological study analyzed in-depth interviews held with a purposive sample (age, gender, training, type of practice, rural/urban context) of 24 general practitioners, with triangulation of research until data saturation. RESULTS From diagnostic, etiological and prognostic viewpoints, the general practitioners enrolled in our study perceived CKD as a complex, poorly-defined clinical entity in asymptomatic and multimorbid patients. They distinguished it from a rare condition they considered as 'mainly renal'. The fact that they did not perceive early-stage CKD as a disease was a hindrance to patient care, which should protect the kidneys with a preventive approach. Indeed, general practitioners perceived CKD patient management as a pathway requiring a personalized, integrative model, common to all chronic diseases, without necessarily involving a nephrologist, at least in the early stages. CONCLUSIONS This study shows how the general practitioners' representations influence their attitudes and interventions. Clarifying the concept of early-stage CKD by taking factors like age and etiology into account would facilitate personalized management of this heterogeneous, often multimorbid, population. Finally, organizational models to support patient empowerment in an integrative care pathway must be established and validated.
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Affiliation(s)
- Agnès Oude Engberink
- Desbrest Institute of Epidemiology and Public Health (IDESP), UMR UA11 INSERM-University of Montpellier, Montpellier, France
- Department of Primary Care, School of Medicine, University of Montpellier, Montpellier, France
| | - Guillaume Tessier
- Department of Primary Care, School of Medicine, University of Montpellier, Montpellier, France
| | - Ilham Kamil
- Department of Primary Care, School of Medicine, University of Montpellier, Montpellier, France
| | - Gérard Bourrel
- Desbrest Institute of Epidemiology and Public Health (IDESP), UMR UA11 INSERM-University of Montpellier, Montpellier, France
- Department of Primary Care, School of Medicine, University of Montpellier, Montpellier, France
| | - Olivier Moranne
- Desbrest Institute of Epidemiology and Public Health (IDESP), UMR UA11 INSERM-University of Montpellier, Montpellier, France.
- Nephrology-Dialysis-Apheresis Department, University Hospital of Nîmes, Place Pr Debré, Nîmes, France.
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Logan B, Viecelli AK, Pascoe EM, Pimm B, Hickey LE, Johnson DW, Hubbard RE. Training healthcare professionals to administer Goal Attainment Scaling as an outcome measure. J Patient Rep Outcomes 2024; 8:22. [PMID: 38407666 PMCID: PMC10897066 DOI: 10.1186/s41687-024-00704-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Accepted: 02/18/2024] [Indexed: 02/27/2024] Open
Abstract
BACKGROUND Goals generated by Goal Attainment Scaling (GAS) can be used as an outcome measure to promote person-centred research and care. There are no training packages which support its use outside of the rehabilitation discipline. This paper describes the development and evaluation of a training package to support the implementation of GAS as an outcome measure in healthcare research. The training package consisted of classroom teaching, a training manual for self-directed learning, one-on-one simulation and hot reviews. It was developed for the GOAL Trial, a randomised controlled trial assessing a Comprehensive Geriatric Assessment's effectiveness in enabling frail older people living with chronic kidney disease to attain their goals. Training participants were invited to complete pre- and post-training online evaluation surveys. RESULTS Forty-two healthcare professionals attended an initial online classroom teaching, with 27 proceeding to administer GAS to GOAL Trial patients. Response rates for the online pre- and post-training surveys were 95% and 72%, respectively. Prior to training, only 15% of participants reported being able to appropriately scale and troubleshoot GAS goals. Post-training this was 92%. There was 100% participant satisfaction for the training manual, one-on-one simulation, and hot reviews. CONCLUSIONS This training package helps ensure healthcare professionals administering GAS have adequate knowledge and skills. It has the potential for adoption as a guide to support the implementation of GAS by other researchers seeking to embrace persont-centred principles in their work.
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Affiliation(s)
- Benignus Logan
- Centre for Health Services Research, University of Queensland, 34 Cornwall St, Woolloongabba, Brisbane, QLD, 4102, Australia.
| | - Andrea K Viecelli
- Australasian Kidney Trials Network, University of Queensland, Brisbane, Australia
- Department of Kidney and Transplant Services, Princess Alexandra Hospital, Ipswich Rd, Woolloongabba, Brisbane, QLD, 4102, Australia
| | - Elaine M Pascoe
- Centre for Health Services Research, University of Queensland, 34 Cornwall St, Woolloongabba, Brisbane, QLD, 4102, Australia
| | - Bonnie Pimm
- Centre for Health Services Research, University of Queensland, 34 Cornwall St, Woolloongabba, Brisbane, QLD, 4102, Australia
| | - Laura E Hickey
- Australasian Kidney Trials Network, University of Queensland, Brisbane, Australia
| | - David W Johnson
- Australasian Kidney Trials Network, University of Queensland, Brisbane, Australia
- Department of Kidney and Transplant Services, Princess Alexandra Hospital, Ipswich Rd, Woolloongabba, Brisbane, QLD, 4102, Australia
- Centre for Kidney Disease Research, Translational Research Institute, Brisbane, Australia
| | - Ruth E Hubbard
- Centre for Health Services Research, University of Queensland, 34 Cornwall St, Woolloongabba, Brisbane, QLD, 4102, Australia
- Department of Geriatric Medicine, Princess Alexandra Hospital, Brisbane, Australia
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Siaton BC, Hogans BB, Frey-Law LA, Brown LM, Herndon CM, Buenaver LF. Pain, comorbidities, and clinical decision-making: conceptualization, development, and pilot testing of the Pain in Aging, Educational Assessment of Need instrument. FRONTIERS IN PAIN RESEARCH 2024; 5:1254792. [PMID: 38455875 PMCID: PMC10918012 DOI: 10.3389/fpain.2024.1254792] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Accepted: 01/26/2024] [Indexed: 03/09/2024] Open
Abstract
Introduction Pain is highly prevalent in older adults and often contextualized by multiple clinical conditions (pain comorbidities). Pain comorbidities increase with age and this makes clinical decisions more complex. To address gaps in clinical training and geriatric pain management, we established the Pain in Aging-Educational Assessment of Need (PAEAN) project to appraise the impacts of medical and mental health conditions on clinical decision-making regarding older adults with pain. We here report development and pilot testing of the PAEAN survey instrument to assess clinician perspectives. Methods Mixed-methods approaches were used. Scoping review methodology was applied to appraise both research literature and selected Medicare-based data. A geographically and professionally diverse interprofessional advisory panel of experts in pain research, medical education, and geriatrics was formed to advise development of the list of pain comorbidities potentially impacting healthcare professional clinical decision-making. A survey instrument was developed, and pilot tested by diverse licensed healthcare practitioners from 2 institutions. Respondents were asked to rate agreement regarding clinical decision-making impact using a 5-point Likert scale. Items were scored for percent agreement. Results Scoping reviews indicated that pain conditions and comorbidities are prevalent in older adults but not universally recognized. We found no research literature directly guiding pain educators in designing pain education modules that mirror older adult clinical complexity. The interprofessional advisory panel identified 26 common clinical conditions for inclusion in the pilot PAEAN instrument. Conditions fell into three main categories: "major medical", i.e., cardio-vascular-pulmonary; metabolic; and neuropsychiatric/age-related. The instrument was pilot tested by surveying clinically active healthcare providers, e.g., physicians, nurse practitioners, who all responded completely. Median survey completion time was less than 3 min. Conclusion This study, developing and pilot testing our "Pain in Aging-Educational Assessment of Need" (PAEAN) instrument, suggests that 1) many clinical conditions impact pain clinical decision-making, and 2) surveying healthcare practitioners about the impact of pain comorbidities on clinical decision-making for older adults is highly feasible. Given the challenges intrinsic to safe and effective clinical care of older adults with pain, and attendant risks, together with the paucity of existing relevant work, much more education and research are needed.
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Affiliation(s)
- Bernadette C. Siaton
- Division of Rheumatology and Clinical Immunology, Department of Medicine, University of Maryland School of Medicine, Baltimore, MD, United States
- Geriatric Research Education and Clinical Center, VA Maryland Health Care System, Baltimore, MD, United States
| | - Beth B. Hogans
- Geriatric Research Education and Clinical Center, VA Maryland Health Care System, Baltimore, MD, United States
- Department of Neurology, Johns Hopkins School of Medicine, Baltimore, MD, United States
| | - Laura A. Frey-Law
- Department of Physical Therapy and Rehabilitative Science, University of Iowa Carver College of Medicine, Iowa City, IA, United States
| | - Lana M. Brown
- Geriatric Research Education and Clinical Center, Central Arkansas Veterans Healthcare System, Little Rock, AR, United States
| | - Christopher M. Herndon
- Department of Pharmacy Practice, Southern Illinois University Edwardsville School of Pharmacy, Edwardsville, IL, United States
- Department of Family and Community Medicine, St. Louis University School of Medicine, St. Louis, MO, United States
| | - Luis F. Buenaver
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins School of Medicine, Baltimore, MD, United States
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Faye M, Manneville F, Faye A, Frimat L, Guillemin F. Quality-of-life measures and their psychometric properties used in African chronic kidney disease populations: a systematic review using COSMIN methodology. BMC Nephrol 2024; 25:50. [PMID: 38331827 PMCID: PMC10854046 DOI: 10.1186/s12882-024-03482-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Accepted: 01/25/2024] [Indexed: 02/10/2024] Open
Abstract
BACKGROUND If any benefit is to be derived from the use of the health-related quality of life (HRQoL) questionnaires in chronic kidney disease (CKD) patients, they should be validated and culturally adapted to the target population. We aimed to critically appraise the psychometric properties of HRQoL questionnaires used in African populations with CKD. METHODS Web of Science, Embase, PubMed and PsycINFO databases were searched. Psychometric validation studies of HRQoL questionnaires reporting at least one psychometric property of the COSMIN checklist in CKD African population, published up to October 16, 2023 were included and independently assessed for methodological quality and level of measurement properties by using the COSMIN methodology. RESULTS From 1163 articles, 5 full-text were included. Only the Kidney Disease Quality-of-Life questionnaire was translated and cross-culturally adapted for studies of patients with CKD. Internal consistency was of doubtful quality in 4 studies and very good in 1. Its measurement was sufficient in 1 study and insufficient in 4. Test-retest reliability was of doubtful quality in 4 studies. Its measurement was sufficient in 3 studies and insufficient in 1. Structural validity was of inadequate quality in 1 study and very good quality in 1. Its measurement was sufficient in both. Construct validity was of inadequate quality in all studies. Their measurement was insufficient in 4 studies and sufficient in 1. CONCLUSIONS This review highlighted that only one HRQoL questionnaire used in studies of African populations with CKD underwent a small number of cultural adaptations and psychometric validations, generally of poor methodological quality. HRQoL validation studies in African CKD populations are needed to better take advantage of the benefits in patient care, population health management, and research.
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Affiliation(s)
- Moustapha Faye
- Service de Néphrologie, CHU Aristide Le Dantec, Université Cheikh Anta Diop, Dakar, Sénégal.
- Université de Lorraine, APEMAC, Nancy, France.
| | - Florian Manneville
- Université de Lorraine, APEMAC, Nancy, France
- CHRU-Nancy, INSERM, Université de Lorraine, CIC Epidémiologie Clinique, Nancy, 54000, France
| | - Adama Faye
- Institut Santé Et Développement (ISED), Université Cheikh Anta Diop de Dakar, Dakar, Senegal
| | - Luc Frimat
- Université de Lorraine, APEMAC, Nancy, France
- Service de Néphrologie, CHRU-Nancy Brabois Santé, Vandœuvre-lès-Nancy, France
| | - Francis Guillemin
- Université de Lorraine, APEMAC, Nancy, France
- CHRU-Nancy, INSERM, Université de Lorraine, CIC Epidémiologie Clinique, Nancy, 54000, France
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Naik H, Murray TM, Khan M, Daly-Grafstein D, Liu G, Kassen BO, Onrot J, Sutherland JM, Staples JA. Population-Based Trends in Complexity of Hospital Inpatients. JAMA Intern Med 2024; 184:183-192. [PMID: 38190179 PMCID: PMC10775081 DOI: 10.1001/jamainternmed.2023.7410] [Citation(s) in RCA: 44] [Impact Index Per Article: 44.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Accepted: 11/11/2023] [Indexed: 01/09/2024]
Abstract
Importance Clinical experience suggests that hospital inpatients have become more complex over time, but few studies have evaluated this impression. Objective To assess whether there has been an increase in measures of hospital inpatient complexity over a 15-year period. Design, Setting and Participants This cohort study used population-based administrative health data from nonelective hospitalizations from April 1, 2002, to January 31, 2017, to describe trends in the complexity of inpatients in British Columbia, Canada. Hospitalizations were included for individuals 18 years and older and for which the most responsible diagnosis did not correspond to pregnancy, childbirth, the puerperal period, or the perinatal period. Data analysis was performed from July to November 2023. Exposure The passage of time (15-year study interval). Main Outcomes and Measures Measures of complexity included patient characteristics at the time of admission (eg, advanced age, multimorbidity, polypharmacy, recent hospitalization), features of the index hospitalization (eg, admission via the emergency department, multiple acute medical problems, use of intensive care, prolonged length of stay, in-hospital adverse events, in-hospital death), and 30-day outcomes after hospital discharge (eg, unplanned readmission, all-cause mortality). Logistic regression was used to estimate the relative change in each measure of complexity over the entire 15-year study interval. Results The final study cohort included 3 367 463 nonelective acute care hospital admissions occurring among 1 272 444 unique individuals (median [IQR] age, 66 [48-79] years; 49.1% female and 50.8% male individuals). Relative to the beginning of the study interval, inpatients at the end of the study interval were more likely to have been admitted via the emergency department (odds ratio [OR], 2.74; 95% CI, 2.71-2.77), to have multimorbidity (OR, 1.50; 95% CI, 1.47-1.53) and polypharmacy (OR, 1.82; 95% CI, 1.78-1.85) at presentation, to receive treatment for 5 or more acute medical issues (OR, 2.06; 95% CI, 2.02-2.09), and to experience an in-hospital adverse event (OR, 1.20; 95% CI, 1.19-1.22). The likelihood of an intensive care unit stay and of in-hospital death declined over the study interval (OR, 0.96; 95% CI, 0.95-0.97, and OR, 0.81; 95% CI, 0.80-0.83, respectively), but the risks of unplanned readmission and death in the 30 days after discharge increased (OR, 1.14; 95% CI, 1.12-1.16, and OR, 1.28; 95% CI, 1.25-1.31, respectively). Conclusions and Relevance By most measures, hospital inpatients have become more complex over time. Health system planning should account for these trends.
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Affiliation(s)
- Hiten Naik
- Department of Medicine, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Tyler M. Murray
- Department of Medicine, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Mayesha Khan
- Department of Medicine, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Daniel Daly-Grafstein
- Department of Medicine, The University of British Columbia, Vancouver, British Columbia, Canada
- Department of Statistics, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Guiping Liu
- Center for Health Services and Policy Research (CHSPR), School of Population and Public Health, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Barry O. Kassen
- Department of Medicine, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Jake Onrot
- Department of Medicine, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Jason M. Sutherland
- Center for Health Services and Policy Research (CHSPR), School of Population and Public Health, The University of British Columbia, Vancouver, British Columbia, Canada
- Centre for Advancing Health Outcomes, Vancouver, British Columbia, Canada
| | - John A. Staples
- Department of Medicine, The University of British Columbia, Vancouver, British Columbia, Canada
- Centre for Clinical Epidemiology & Evaluation (C2E2), Vancouver, British Columbia, Canada
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Coumoundouros C, Farrand P, Sanderman R, von Essen L, Woodford J. "Systems seem to get in the way": a qualitative study exploring experiences of accessing and receiving support among informal caregivers of people living with chronic kidney disease. BMC Nephrol 2024; 25:7. [PMID: 38172754 PMCID: PMC10765659 DOI: 10.1186/s12882-023-03444-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2023] [Accepted: 12/19/2023] [Indexed: 01/05/2024] Open
Abstract
BACKGROUND The well-being of informal caregivers of people living with chronic kidney disease is influenced by their experiences with support, however, few studies have focused on exploring these experiences. This study aimed to explore informal caregivers' experiences accessing and receiving support while caring for someone living with chronic kidney disease. METHODS Informal caregivers of people living with chronic kidney disease (n = 13) in the United Kingdom were primarily recruited via community organisations and social media adverts to participate in semi-structured interviews. Interviews explored support needs, experiences of receiving support from different groups (e.g. healthcare professionals, family/friends), and barriers and facilitators to accessing support. Support was understood as including emotional, practical, and informational support. Data were analysed using reflexive thematic analysis. RESULTS Three themes were generated: (1) "Systems seem to get in the way" - challenges within support systems, illustrating the challenges informal caregivers encountered when navigating complex support systems; (2) Relying on yourself, describing how informal caregivers leveraged their existing skills and networks to access support independently, while recognising the limitations of having to rely on yourself to find support; and (3) Support systems can "take the pressure off", showing how support systems were able to help informal caregivers cope with the challenges they experienced if certain conditions were met. CONCLUSIONS In response to the challenges informal caregivers experienced when seeking support, improvements are needed to better consider informal caregiver needs within healthcare systems, and to develop interventions tailored to informal caregiver needs and context. Within the healthcare system, informal caregivers may benefit from system navigation support and better integration within healthcare teams to ensure their informational support needs are met. New interventions developed to support informal caregivers should fit within their existing support systems and incorporate the qualities of support, such as empathy, that were valued. Additionally, use of an equity framework and user-centered design approaches during intervention development could help ensure interventions are accessible and acceptable.
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Affiliation(s)
- Chelsea Coumoundouros
- Healthcare Sciences and e-Health, Department of Women's and Children's Health, Uppsala University, Dag Hammarskjölds väg 14B, Uppsala, 751 05, Sweden
- Clinical Education, Development and Research (CEDAR); Psychology, University of Exeter, Exeter, UK
| | - Paul Farrand
- Clinical Education, Development and Research (CEDAR); Psychology, University of Exeter, Exeter, UK
| | - Robbert Sanderman
- Department of Health Psychology, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Louise von Essen
- Healthcare Sciences and e-Health, Department of Women's and Children's Health, Uppsala University, Dag Hammarskjölds väg 14B, Uppsala, 751 05, Sweden
| | - Joanne Woodford
- Healthcare Sciences and e-Health, Department of Women's and Children's Health, Uppsala University, Dag Hammarskjölds väg 14B, Uppsala, 751 05, Sweden.
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Pisano A, Zoccali C, Bolignano D, D'Arrigo G, Mallamaci F. Sleep apnoea syndrome prevalence in chronic kidney disease and end-stage kidney disease patients: a systematic review and meta-analysis. Clin Kidney J 2024; 17:sfad179. [PMID: 38186876 PMCID: PMC10768783 DOI: 10.1093/ckj/sfad179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Indexed: 01/09/2024] Open
Abstract
Background Several studies have examined the frequency of sleep apnoea (SA) in patients with chronic kidney disease (CKD), reporting different prevalence rates. Our systematic review and meta-analysis aimed to define the clinical penetrance of SA in CKD and end-stage kidney disease (ESKD) patients. Methods Ovid-MEDLINE and PubMed databases were explored up to 5 June 2023 to identify studies providing SA prevalence in CKD and ESKD patients assessed by different diagnostic methods, either sleep questionnaires or respiration monitoring equipment [such as polysomnography (PSG), type III portable monitors or other diagnostic tools]. Single-study data were pooled using the random-effects model. The Chi2 and Cochrane-I2 tests were used to assess the presence of heterogeneity, which was explored performing sensitivity and/or subgroup analyses. Results A cumulative analysis from 32 single-study data revealed a prevalence of SA of 57% [95% confidence interval (CI) 42%-71%] in the CKD population, whereas a prevalence of 49% (95% CI 47%-52%) was found pooling data from 91 studies in ESKD individuals. The prevalence of SA using instrumental sleep monitoring devices, including classical PSG and type III portable sleep monitors, was 62% (95% CI 52%-72%) and 56% (95% CI 42%-69%) in CKD and ESKD populations, respectively. Sleep questionnaires revealed a prevalence of 33% (95% CI 16%-49%) and 39% (95% CI 30%-49%). Conclusions SA is commonly seen in both non-dialysis CKD and ESKD patients. Sleep-related questionnaires underestimated the presence of SA in this population. This emphasizes the need to use objective diagnostic tools to identify such a syndrome in kidney disease.
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Affiliation(s)
- Anna Pisano
- CNR-Institute of Clinical Physiology; Clinical Epidemiology and Physiopathology of Renal Diseases and Hypertension, Reggio Calabria, Italy
| | - Carmine Zoccali
- Renal Research Institute, NY, USA
- Institute of Molecular Biology and Genetics (BIOGEM), Ariano Irpino, Italy
- Associazione Ipertensione Nefrologia e Trapianto Renale (IPNET), Reggio Calabria, Italy
| | - Davide Bolignano
- Department of Surgical and Medical Sciences-Magna Graecia, University of Catanzaro, Catanzaro, Italy
| | - Graziella D'Arrigo
- CNR-Institute of Clinical Physiology; Clinical Epidemiology and Physiopathology of Renal Diseases and Hypertension, Reggio Calabria, Italy
| | - Francesca Mallamaci
- CNR-Institute of Clinical Physiology; Clinical Epidemiology and Physiopathology of Renal Diseases and Hypertension, Reggio Calabria, Italy
- Nephology and Transplantation Unit, Grande Ospedale Metropolitano, Reggio Calabria, Italy
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Boyle SM, Martindale J, Parsons AS, Sozio SM, Hilburg R, Bahrainwala J, Chan L, Stern LD, Warburton KM. Development and Validation of a Formative Assessment Tool for Nephrology Fellows' Clinical Reasoning. Clin J Am Soc Nephrol 2024; 19:26-34. [PMID: 37851423 PMCID: PMC10843222 DOI: 10.2215/cjn.0000000000000315] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Accepted: 10/02/2023] [Indexed: 10/19/2023]
Abstract
BACKGROUND Diagnostic errors are commonly driven by failures in clinical reasoning. Deficits in clinical reasoning are common among graduate medical learners, including nephrology fellows. We created and validated an instrument to assess clinical reasoning in a national cohort of nephrology fellows and established performance thresholds for remedial coaching. METHODS Experts in nephrology education and clinical reasoning remediation designed an instrument to measure clinical reasoning through a written patient encounter note from a web-based, simulated AKI consult. The instrument measured clinical reasoning in three domains: problem representation, differential diagnosis with justification, and diagnostic plan with justification. Inter-rater reliability was established in a pilot cohort ( n =7 raters) of first-year nephrology fellows using a two-way random effects agreement intraclass correlation coefficient model. The instrument was then administered to a larger cohort of first-year fellows to establish performance standards for coaching using the Hofstee method ( n =6 raters). RESULTS In the pilot cohort, there were 15 fellows from four training program, and in the study cohort, there were 61 fellows from 20 training programs. The intraclass correlation coefficients for problem representation, differential diagnosis, and diagnostic plan were 0.90, 0.70, and 0.50, respectively. Passing thresholds (% total points) in problem representation, differential diagnosis, and diagnostic plan were 59%, 57%, and 62%, respectively. Fifty-nine percent ( n =36) met the threshold for remedial coaching in at least one domain. CONCLUSIONS We provide validity evidence for a simulated AKI consult for formative assessment of clinical reasoning in nephrology fellows. Most fellows met criteria for coaching in at least one of three reasoning domains, demonstrating a need for learner assessment and instruction in clinical reasoning.
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Affiliation(s)
- Suzanne M. Boyle
- Section of Nephrology, Hypertension, and Kidney Transplantation, Lewis Katz School of Medicine at Temple University, Philadelphia, Pennsylvania
| | - James Martindale
- Office of Medical Education, University of Virginia School of Medicine, Charlottesville, Virginia
| | - Andrew S. Parsons
- Division of General, Geriatric, Palliative, and Hospital Medicine, University of Virginia School of Medicine, Charlottesville, Virginia
| | - Stephen M. Sozio
- Division of Nephrology, Department of Medicine, Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Rachel Hilburg
- Renal, Electrolyte, and Hypertension Division, Perelman School of Medicine, The University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jehan Bahrainwala
- Division of Nephrology, Stanford University School of Medicine, Palo Alto, California
| | - Lili Chan
- Barbara T. Murphy Division of Nephrology, Mt. Sinai School of Medicine, New York, New York
| | - Lauren D. Stern
- Renal Section, Boston University Chobanian and Avedisian School of Medicine, Boston, Massachusetts
| | - Karen M. Warburton
- Division of Nephrology, University of Virginia School of Medicine, Charlottsville, Virginia
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Colombijn JM, Colombijn F, van Berkom L, van Dijk LA, Senders D, Tierolf C, Abrahams AC, van Jaarsveld BC. Polypharmacy and Quality of Life Among Dialysis Patients: A Qualitative Study. Kidney Med 2024; 6:100749. [PMID: 38205432 PMCID: PMC10777060 DOI: 10.1016/j.xkme.2023.100749] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2024] Open
Abstract
Rationale & Objective Almost all patients who receive dialysis experience polypharmacy, but little is known about their experiences with medication or perceptions toward it. In this qualitative study, we aimed to gain insight into dialysis patients' experiences with polypharmacy, the ways they integrate their medication into their daily lives, and the ways it affects their quality of life. Study Design Qualitative study using semistructured interviews. Setting & Participants Patients who received dialysis from 2 Dutch university hospitals. Analytical Approach Interviews were transcribed verbatim and analyzed independently by 2 researchers through thematic content analysis. Results Overall, 28 individuals were interviewed (29% women, mean age 63 ± 16 years, median dialysis vintage 25.5 [interquartile range, 15-48] months, mean daily number of medications 10 ± 3). Important themes were as follows: (1) their own definition of what constitutes "medication," (2) their perception of medication, (3) medication routines and their impact on daily (quality of) life, and (4) interactions with health care professionals and others regarding medication. Participants generally perceived medication as burdensome but less so than dialysis. Medication was accepted as an essential precondition for their health, although participants did not always notice these health benefits directly. Medication routines and other coping mechanisms helped participants reduce the perceived negative effects of medication. In fact, medication increased freedom for some participants. Participants generally had constructive relationships with their physicians when discussing their medication. Limitations Results are context dependent and might therefore not apply directly to other contexts. Conclusions Polypharmacy negatively affected dialysis patients' quality of life, but these effects were overshadowed by the burden of dialysis. The patients' realization that medication is important to their health and effective coping strategies mitigated the negative impact of polypharmacy on their quality of life. Physicians and patients should work together continuously to evaluate the impact of treatments on health and other aspects of patients' daily lives. Plain-Language Summary People receiving dialysis treatment are prescribed a large number of medications (polypharmacy). Polypharmacy is associated with a number of issues, including a lower health-related quality of life. In this study we interviewed patients who received dialysis treatment to understand how they experience polypharmacy in the context of their daily lives. Participants generally perceived medication as burdensome but less so than dialysis and accepted medication as an essential precondition for their health. Medication routines and other coping mechanisms helped participants mitigate the perceived negative effects of medication. In fact, medication led to increased freedom for some participants. Participants had generally constructive relationships with their physicians when discussing their medication but felt that physicians sometimes do not understand them.
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Affiliation(s)
- Julia M.T. Colombijn
- Department of Nephrology and Hypertension, University Medical Center Utrecht, Utrecht, the Netherlands
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
- Department of Nephrology, Amsterdam UMC, Vrije Universiteit Amsterdam, Research Institute Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands
| | - Freek Colombijn
- Department of Social and Cultural Anthropology, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Lideweij van Berkom
- Department of Social and Cultural Anthropology, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Lia A. van Dijk
- Department of Social and Cultural Anthropology, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Dionne Senders
- Department of Social and Cultural Anthropology, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Charlotte Tierolf
- Department of Social and Cultural Anthropology, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Alferso C. Abrahams
- Department of Nephrology and Hypertension, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Brigit C. van Jaarsveld
- Department of Nephrology, Amsterdam UMC, Vrije Universiteit Amsterdam, Research Institute Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands
- Diapriva Dialysis Center, Amsterdam, the Netherlands
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Maisons V, Vinchon F, Frajerman A, Gouy E, Rolland F, Truong LN, Hadouiri N, Florens N. Breaking the stereotypes: how do medical professionals really view nephrologists? A cross-national survey among medical students, residents, and physicians. J Nephrol 2024; 37:241-244. [PMID: 37294402 DOI: 10.1007/s40620-023-01682-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Accepted: 05/08/2023] [Indexed: 06/10/2023]
Affiliation(s)
- Valentin Maisons
- Université de Tours, CHU de Tours, Service de Néphrologie, Hôpital Bretonneau, Tours, France
- INSERM U1246-SPHERE (Methods in Patient-Centered Outcomes and Health Research), Université de Tours, Université de Nantes, Tours, France
- Club des Jeunes Néphrologues, Paris, France
| | - Florent Vinchon
- Université de Paris Cité et Université Gustave Eiffel, LaPEA, Boulogne-Billancourt, France
| | - Ariel Frajerman
- Université de Paris-Saclay, AP-HP, Service Hospitalo-Universitaire de Psychiatrie, Hôpital de Bicêtre, Paris, France
- Equipe MOODS, INSERM U1178, CESP (Centre de Recherche en Epidémiologie et Santé des Populations), Le Kremlin-Bicêtre, Paris, France
| | - Evan Gouy
- Equipe MOODS, INSERM U1178, CESP (Centre de Recherche en Epidémiologie et Santé des Populations), Le Kremlin-Bicêtre, Paris, France
| | - Franck Rolland
- Université de Paris-Saclay, AP-HP, Service Hospitalo-Universitaire de Psychiatrie, Hôpital de Bicêtre, Paris, France
| | - Linh Nam Truong
- Faculté de Médecine, Université de Bourgogne-Franche-Comté, Dijon, France
| | - Nawale Hadouiri
- Université de Dijon, CHU de Dijon, Pôle Rééducation-Réadaptation, Dijon, France
| | - Nans Florens
- Club des Jeunes Néphrologues, Paris, France.
- Université de Strasbourg, CHU de Strasbourg, Service de Néphrologie, CHU de Strasbourg, Strasbourg, France.
- Team 3072 "Mitochondria, Oxidative Stress and Muscle Protection", Translational Medicine Federation of Strasbourg (FMTS), Faculty of Medicine, University of Strasbourg, Strasbourg, France.
- INI-CRCT (Cardiovascular and Renal Trialists), F-CRIN Network, Vandoeuvre-les-Nancy, France.
- Service de Néphrologie, Dialyse, Transplantation, Nouvel Hôpital Civil, Hôpitaux Universitaires de Strasbourg, 1 Place de l'hôpital, 67000, Strasbourg, France.
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Liabeuf S, Pešić V, Spasovski G, Maciulaitis R, Bobot M, Farinha A, Wagner CA, Unwin RJ, Capasso G, Bumblyte IA, Hafez G. Drugs with a negative impact on cognitive function (Part 1): chronic kidney disease as a risk factor. Clin Kidney J 2023; 16:2365-2377. [PMID: 38045996 PMCID: PMC10689135 DOI: 10.1093/ckj/sfad241] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Indexed: 12/05/2023] Open
Abstract
People living with chronic kidney disease (CKD) frequently suffer from mild cognitive impairment and/or other neurocognitive disorders. This review in two parts will focus on adverse drug reactions resulting in cognitive impairment as a potentially modifiable risk factor in CKD patients. Many patients with CKD have a substantial burden of comorbidities leading to polypharmacy. A recent study found that patients seen by nephrologists were the most complex to treat because of their high number of comorbidities and medications. Due to polypharmacy, these patients may experience a wide range of adverse drug reactions. Along with CKD progression, the accumulation of uremic toxins may lead to blood-brain barrier (BBB) disruption and pharmacokinetic alterations, increasing the risk of adverse reactions affecting the central nervous system (CNS). In patients on dialysis, the excretion of drugs that depend on kidney function is severely reduced such that adverse and toxic levels of a drug or its metabolites may be reached at relatively low doses, unless dosing is adjusted. This first review will discuss how CKD represents a risk factor for adverse drug reactions affecting the CNS via (i) BBB disruption associated with CKD and (ii) the impact of reduced kidney function and dialysis itself on drug pharmacokinetics.
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Affiliation(s)
- Sophie Liabeuf
- Pharmacoepidemiology Unit, Department of Clinical Pharmacology, Amiens University Medical Center, Amiens, France
- MP3CV Laboratory, EA7517, Jules Verne University of Picardie, Amiens, France
| | - Vesna Pešić
- Faculty of Pharmacy, University of Belgrade, Belgrade, Serbia
| | - Goce Spasovski
- Department of Nephrology, Clinical Centre “Mother Theresa”, Saints Cyril and Methodius University, Skopje, North Macedonia
| | - Romaldas Maciulaitis
- Department of Nephrology, Lithuanian University of Health Sciences, Kaunas, Lithuania
- Institute of Physiology and Pharmacology, Faculty of Medicines, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Mickaël Bobot
- Aix-Marseille University, Department of Nephrology, AP-HM, La Conception Hospital, Marseille, France; C2VN Laboratory, Inserm 1263, INRAE 1260, Aix-Marseille University, Marseille, France
| | - Ana Farinha
- Department of Nephrology, Hospital de Vila Franca de Xira, Lisbon, Portugal
| | - Carsten A Wagner
- Institute of Physiology, University of Zürich, Zurich, Switzerland
| | - Robert J Unwin
- Department of Renal Medicine, Royal Free Hospital, University College London, London, UK
| | - Giovambattista Capasso
- Department of Translantional Medical Sciences, University of Campania Luigi Vanvitelli , Naples, Italy
- Biogem Research Institute , Ariano Irpino, Italy
| | - Inga Arune Bumblyte
- Department of Nephrology, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Gaye Hafez
- Department of Pharmacology, Faculty of Pharmacy, Altinbas University, Istanbul, Turkey
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Baragar BH, Schorr M, Verdin N, Woodlock T, Clark DA, Hundemer GL, Mathew A, Mustafa RA, Ryz KS, Harrison TG. Identification and Prioritization of Canadian Society of Nephrology Clinical Practice Guideline Topics With Multidisciplinary Stakeholders and People Living With Kidney Disease: A Clinical Research Protocol. Can J Kidney Health Dis 2023; 10:20543581231207142. [PMID: 38020482 PMCID: PMC10676059 DOI: 10.1177/20543581231207142] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Accepted: 09/03/2023] [Indexed: 12/01/2023] Open
Abstract
Background Despite efforts to provide evidence-based care for people living with kidney disease, health care provider goals and priorities are often misaligned with those of individuals with lived experience of disease. Coupled with competing interests of time, resources, and an abundance of suitable guideline topics, identifying and prioritizing areas of focus for the Canadian nephrology community with a patient-oriented perspective is necessary and important. Similar priority-setting exercises have been undertaken to establish research priorities for kidney disease and to standardize outcomes for kidney disease research and clinical care; however, research priorities are distinct from priorities for guideline development. Inclusion of people living with health conditions in the selection and prioritization of guideline topics is suggested by patient engagement frameworks, though the process to operationalizing this is variable. We propose that the Canadian Society of Nephrology Clinical Practice Guideline Committee (CSN CPGC) takes the opportunity at this juncture to incorporate evidence-based prioritization exercises with involvement of people living with kidney disease and their caregivers to inform future guideline activities. In this protocol, we describe our planned research methods to address this. Objective To establish consensus-based guideline topic priorities for the CSN CPGC using a modified Delphi survey with involvement of multidisciplinary stakeholders, including people living with kidney disease and their caregivers. Study design Protocol for a Modified Delphi Survey. Setting Pilot-tested surveys will be distributed via email and conducted using the online platform SurveyMonkey, in both French and English. Participants We will establish a group of multidisciplinary clinical and research stakeholders (both within and outside CSN membership) from Canada, in addition to people living with kidney disease and/or their caregivers. Methods A comprehensive literature search will be conducted to generate an initial list of guideline topics, which will be organized into three main categories: (1) International nephrology-focused guidelines that may require Canadian commentary, (2) Non-nephrology specific guidelines from Canada that may require CSN commentary, and (3) Novel topics for guideline development. Participants will engage in a multi-round Modified Delphi Survey to prioritize a set of "important guideline topics." Measures Consensus will be reached for an item based on both median score on the Likert-type scale (≥ 7) and the percentage agreement (≥ 75%); the Delphi process will be complete when consensus is reached on each item. Guideline topics will then be given a priority score calculated from the total Likert ratings across participants, adjusted for the number of participants. Limitations Potential limitations include participant response rates and compliance to survey completion. Conclusions We propose to incorporate evidence-based prioritization exercises with the engagement of people living with kidney disease and their caregivers to establish consensus-based guideline topics and inform future guidelines activities of the CSN CPGC.
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Affiliation(s)
| | - Melissa Schorr
- Department of Medicine, Western University, London, ON, Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Nancy Verdin
- Patient and Community Engagement Research Unit, O’Brien Institute for Public Health, University of Calgary, AB, Canada
| | | | - David A. Clark
- Division of Nephrology, Department of Medicine, Dalhousie University, Halifax, NS, Canada
- Kidney Research Institute Nova Scotia, Queen Elizabeth II Health Sciences Centre, Halifax, NS, Canada
| | - Gregory L. Hundemer
- Ottawa Hospital Research Institute, University of Ottawa, ON, Canada
- Division of Nephrology, Department of Medicine, University of Ottawa, ON, Canada
| | - Anna Mathew
- Division of Nephrology, Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Reem A. Mustafa
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
- Departments of Internal Medicine and Population Health, The University of Kansas Health System, Kansas City, USA
| | - Krista S. Ryz
- Department of Medicine, University of Manitoba, Winnipeg, Canada
| | - Tyrone G. Harrison
- Department of Medicine, University of Calgary, AB, Canada
- Department of Community Health Sciences, University of Calgary, AB, Canada
- O’Brien Institute for Public Health, Cumming School of Medicine, University of Calgary, AB, Canada
- Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary, AB, Canada
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Hartman VC, Bapat SS, Weiner MG, Navi BB, Sholle ET, Campion TR. A method to automate the discharge summary hospital course for neurology patients. J Am Med Inform Assoc 2023; 30:1995-2003. [PMID: 37639624 PMCID: PMC10654848 DOI: 10.1093/jamia/ocad177] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Revised: 07/17/2023] [Accepted: 08/16/2023] [Indexed: 08/31/2023] Open
Abstract
OBJECTIVE Generation of automated clinical notes has been posited as a strategy to mitigate physician burnout. In particular, an automated narrative summary of a patient's hospital stay could supplement the hospital course section of the discharge summary that inpatient physicians document in electronic health record (EHR) systems. In the current study, we developed and evaluated an automated method for summarizing the hospital course section using encoder-decoder sequence-to-sequence transformer models. MATERIALS AND METHODS We fine-tuned BERT and BART models and optimized for factuality through constraining beam search, which we trained and tested using EHR data from patients admitted to the neurology unit of an academic medical center. RESULTS The approach demonstrated good ROUGE scores with an R-2 of 13.76. In a blind evaluation, 2 board-certified physicians rated 62% of the automated summaries as meeting the standard of care, which suggests the method may be useful clinically. DISCUSSION AND CONCLUSION To our knowledge, this study is among the first to demonstrate an automated method for generating a discharge summary hospital course that approaches a quality level of what a physician would write.
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Affiliation(s)
- Vince C Hartman
- Cornell Tech, New York, NY 10044, United States
- Abstractive Health, New York, NY 10022, United States
| | - Sanika S Bapat
- Cornell Tech, New York, NY 10044, United States
- Abstractive Health, New York, NY 10022, United States
| | - Mark G Weiner
- Department of Medicine, Weill Cornell Medicine, New York, NY 10065, United States
- Department of Population Health, Weill Cornell Medicine, New York, NY 10065, United States
| | - Babak B Navi
- Department of Neurology and Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, New York, NY 10065, United States
| | - Evan T Sholle
- Department of Population Health, Weill Cornell Medicine, New York, NY 10065, United States
| | - Thomas R Campion
- Department of Population Health, Weill Cornell Medicine, New York, NY 10065, United States
- Clinical & Translational Science Center, Weill Cornell Medicine, New York, NY 10065, United States
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Cooke-Hubley SM, Senior P, Bello AK, Wiebe N, Klarenbach S. Degree of Albuminuria is Associated With Increased Risk of Fragility Fractures Independent of Estimated GFR. Kidney Int Rep 2023; 8:2315-2325. [PMID: 38025225 PMCID: PMC10658242 DOI: 10.1016/j.ekir.2023.08.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Accepted: 08/14/2023] [Indexed: 12/01/2023] Open
Abstract
Introduction Fragility fractures are common in persons with chronic kidney disease (CKD); however, the association between fragility fractures and albuminuria is not well-studied. The primary objective of this study is to determine the association of albuminuria with incident risk of fragility fractures. The secondary objective is to examine the risk of fragility fracture by estimated glomerular filtration rate (eGFR) and Kidney Disease Improving Global Outcomes (KDIGO) risk categories. Methods Community dwelling adults residing in Alberta, Canada who had at least 1 creatinine and albuminuria measurement between April 1, 2008 and March 31, 2019 participated in the study (N = 2.72 million). Incident fragility fractures were identified using Canadian Chronic Disease Surveillance Systems Osteoporosis Working Group algorithms. Albuminuria was categorized as none/mild (albumin-to-creatinine ratio [ACR] <30 mg/g, protein-to-creatinine ratio [PCR] <150 mg/g, trace/negative dipstick); moderate (ACR 30-300 mg/g, PCR 150-500 mg/g, 1+ dipstick) or severe (ACR >300 mg/g, PCR >500 mg/g, ≥2+ dipstick). Multivariable analysis controlled for 42 variables. Results Patients with severe albuminuria had an increased risk of hip fracture (odds ratio [OR] = 1.37; 95% confidence interval [CI] 1.28, 1.47]), vertebral fracture (OR = 1.31; 95% CI 1.21, 1.41) and any-type fracture (OR = 1.22; 95% CI 1.17, 1.28) compared with patients with none/mild albuminuria. Patients in the most severe KDIGO risk category had an increased risk of hip fracture (OR = 1.22; 95% CI 1.16, 1.29), vertebral fracture (OR = 1.18; 95% CI 1.09, 1.26) and any type of fracture (OR = 1.25; 95% CI 1.21, 1.30). Conclusion This study demonstrates the important role of albuminuria as a risk factor for fragility fractures in CKD and may help inform risk stratification and prevention strategies in this high-risk population category.
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Affiliation(s)
- Sandra M. Cooke-Hubley
- Division of Endocrinology and Metabolism, Department of Medicine, Memorial University. St. John’s, Newfoundland and Labrador, Canada
| | - Peter Senior
- Division of Endocrinology and Metabolism, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Aminu K. Bello
- Division of Nephrology, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Natasha Wiebe
- Kidney Health Research Chair, Division of Nephrology, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Scott Klarenbach
- Division of Nephrology, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
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