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1.  Prevalence of pre-ESRD care and associated outcomes among urban, micropolitan, and rural dialysis patients 
American journal of nephrology  2013;37(3):274-280.
Background/aims
Pre-ESRD care associates with improved outcomes among patients receiving dialysis. It is unknown what proportion of US micropolitan and rural dialysis patients receive pre-ESRD care and benefit from such care when compared to urban.
Methods
A retrospective cohort study was performed using data from the US Renal Data System. Patients ≥18 years old who initiated dialysis in 2006 and 2007 were classified as rural, micropolitan, or urban and prevalence of pre-ESRD care (early nephrology care >6 months, permanent vascular access, dietary education) was determined using the medical evidence report. The association of pre-ESRD care with dialysis mortality and transplantation was assessed using Cox regression with stratification for geographic residence.
Results
Of 204,463 dialysis patients, 80% were urban, 10.2% were micropolitan, and 9.8% were rural. Overall attainment of pre-ESRD care was poor. After adjustment, there were no significant geographic differences in attainment of early nephrology care or permanent dialysis access. Receiving care reduced all-cause mortality and increased the likelihood of transplantation to a similar degree regardless of geographic residence. Both micropolitan and rural patients received less dietary education (RR 0.80 95% CI 0.76–0.84 and RR 0.85 95% CI 0.80–0.89, respectively).
Conclusion
Among patients who receive dialysis, the prevalence of early nephrology care and permanent dialysis access is poor and does not vary by geographic residence. Micropolitan and rural patients receive less dietary education despite an observed mortality benefit, suggesting that barriers may exist to quality dietary care in more remote locations.
doi:10.1159/000348377
PMCID: PMC3787839  PMID: 23548738
rural; disparity; chronic kidney disease
2.  Validation of the Diabetes Numeracy Test With Adolescents 
Journal of health communication  2013;18(7):10.1080/10810730.2012.757394.
There is currently a lack of valid instruments to measure adolescent diabetes numeracy. The Diabetes Numeracy Test (DNT) was adapted for type 1 diabetes and administered to two samples of adolescents. Sample 1 was administered the 39-item version of the DNT (DNT-39) with measures of self-management, responsibility, reading, and glycemic control (A1C). Sample 2 was administered the 14-item version of the DNT (DNT-14) with measures of self-management, responsibility, problem solving, and A1C. Both versions of the DNT showed adequate internal reliability. In sample 1, the DNT-39 and DNT-14 were related (r=.87, p=.001), and both DNT versions were related to parent education (DNT-14 r=.31, p=.02; DNT-39 r=.29, p=.03) and reading (DNT-14 r=.36, p=.005; DNT-39 r=.40, p=.001). In sample 2, the DNT-14 was related to A1C (r=−.29, p=.001), reading skills (r=.36, p=.005), diabetes problem solving (r=.27, p=.02), adolescent age (r=.19, p=.03), and parent education (r=.31, p=.02). In combined analyses, 75% of items were answered correctly on the DNT-14 (Range 7-100), and performance was associated with age (r=.19, p=.03), pump use (r=.33 p=.001), and A1C (r=−.29, p=.001). The DNT-14 is a feasible, reliable, and valid numeracy assessment that indicated adolescents with T1D have numeracy deficits that may impact their glycemic control.
doi:10.1080/10810730.2012.757394
PMCID: PMC3817720  PMID: 23577642
3.  Dietary Sodium in Chronic Kidney Disease: A Comprehensive Approach 
Seminars in dialysis  2010;23(4):415-421.
Despite existing guidelines, dietary sodium intake among people worldwide often exceeds recommended limits. Research evidence is growing in both animal and human studies showing indirect and direct adverse consequences of high dietary sodium on the kidney. In patients with kidney disease, dietary sodium may have important effects on proteinuria, efficacy of antiproteinuric pharmacologic therapy, hypertension control, maintaining an optimal volume status, and immunosuppressant therapy. Dietary sodium intake is an important consideration in patients with all stages of chronic kidney disease, including those receiving dialysis therapy or those who have received a kidney transplant. We review in detail the dietary sodium recommendations suggested by various organizations for patients with kidney disease. Potential barriers to successfully translating current sodium intake guidelines into practice include poor knowledge about the sodium content of food among both patients and providers, complex labeling information, patient preferences related to taste, and limited support for modifications in public policy. Finally, we offer existing and potential solutions that may assist providers in educating and empowering patients to effectively manage their dietary sodium intake.
doi:10.1111/j.1525-139X.2010.00752.x
PMCID: PMC2921029  PMID: 20557489
4.  Patient Knowledge of Blood Pressure Target is Associated with Improved Blood Pressure Control in Chronic Kidney Disease 
Patient education and counseling  2012;88(2):184-188.
Objective
To describe patient hypertension knowledge and associations with blood pressure measurements.
Methods
Patients with chronic kidney disease (CKD) were asked about the impact of high blood pressure on kidneys and their target blood pressure goal. Systolic blood pressure was measured using automated sphygmomanometers.
Results
In 338 adults with hypertension and pre-dialysis CKD, the median [IQR] age was 59 [47, 68] years, 45% [n=152] were women, and 18% [n=62] were non-white. Lower systolic blood pressure (SBP) was associated with female sex (SBP mmHg median [IQR] 132 [117,149] women vs. 137 [124,152] men; p=0.04), less advanced CKD (SBP 134 [122,147] stages 1–2 vs. 132 [118,148] stage 3 vs. 140 [125,156] stages 4–5; p=0.01), and patient ability to correctly identify SBP goal (SBP 134 [119,150] correct vs. 141 [125,154] incorrect; p=0.05). In adjusted analysis, knowledge of blood pressure goal remained independently associated with lower SBP (−9.96 mmHg [−19.97, −1.95] in correct respondents vs. incorrect; p<0.001).
Conclusion
Patient knowledge of goal blood pressure is independently associated with improved blood pressure control.
Practice Implications
Interventions to improve patient knowledge of specific blood pressure targets may have an important role in optimizing blood pressure management.
doi:10.1016/j.pec.2012.02.015
PMCID: PMC3404190  PMID: 22459637
5.  Associations among perceived and objective disease knowledge and satisfaction with physician communication in patients with chronic kidney disease 
Kidney international  2011;80(12):1344-1351.
It is likely that patients with chronic kidney disease (CKD) have a limited understanding of their illness. Here we studied the relationships between objective and perceived knowledge in CKD using the Kidney Disease Knowledge Survey and the Perceived Kidney Disease Knowledge Survey. We quantified perceived and objective knowledge in 399 patients at all stages of non-dialysis dependent CKD. Demographically, the patient median age was 58 years, 47% were women, 77% had stages 3-5 CKD, and 83% were Caucasians. The overall median score of the perceived knowledge survey was 2.56 (range: 1-4), and this new measure exhibited excellent reliability and construct validity. In unadjusted analysis, perceived knowledge was associated with patient characteristics defined a priori, including objective knowledge and patient satisfaction with physician communication. In adjusted analysis, older age, male gender, and limited health literacy were associated with lower perceived knowledge. Additional analysis revealed that perceived knowledge was associated with significantly higher odds (2.13), and objective knowledge with lower odds (0.91), of patient satisfaction with physician communication. Thus, our results present a mechanism to evaluate distinct forms of patient kidney knowledge, and identify specific opportunities for education tailored to patients with CKD.
doi:10.1038/ki.2011.240
PMCID: PMC3712792  PMID: 21832984
Patient knowledge; kidney disease; health literacy; perceived knowledge; objective knowledge
6.  Patient-Provider Communication in Patients with Diabetes and Depressive Symptoms 
Summary
The association between depressive symptoms and patient-provider communication was examined in adult primary care patients with diabetes. Most communication was not patient-centered, but did not differ by level of patient’s depressive symptoms.
doi:10.1016/j.diabres.2011.09.024
PMCID: PMC3246039  PMID: 21995868
7.  Incidence and Predictors of End Stage Renal Disease among Low-Income Blacks and Whites 
PLoS ONE  2012;7(10):e48407.
We evaluated whether black race is associated with higher incidence of End Stage Renal Disease (ESRD) among a cohort of blacks and whites of similar, generally low socioeconomic status, and whether risk factor patterns differ among blacks and whites and explain the poorly understood racial disparity in ESRD. Incident diagnoses of ESRD among 79,943 black and white participants in the Southern Community Cohort Study (SCCS) were ascertained by linkage with the United States Renal Data System (USRDS) from 2002 through 2009. Person-years of follow up were calculated from date of entry into the SCCS until date of ESRD diagnosis, date of death, or September 1, 2009, whichever occurred first. Cox proportional hazards models were used to estimate hazard ratios (HRs) and 95% confidence intervals (CI) for incident ESRD among black and white participants in relation to baseline characteristics. After 329,003 person-years of follow-up, 687 incident cases of ESRD were identified in the cohort. The age-adjusted ESRD incidence rate was 273 (per 100,000) among blacks, 3.5-fold higher than the rate of 78 among whites. Risk factors for ESRD included male sex (HR = 1.6; 95% CI 1.4–1.9), low income (HR = 1.5; 95% CI 1.2–1.8 for income below vs. above $15,000), smoking (HR = 1.2; 95% CI 1.02–1.4) and histories of diabetes (HRs increasing to 9.4 (95% CI 7.4–11.9) among those with ≥20 years diabetes duration) and hypertension (HR = 2.9; 95% CI 2.3–3.7). Patterns and magnitudes of association were virtually identical among blacks and whites. After adjustment for these risk factors, blacks continued to have a higher risk for ESRD (HR = 2.4; 95% CI = 1.9–3.0) relative to whites. The black-white disparity in risk of ESRD was attenuated but not eliminated after control for known risk factors in a closely socioeconomically matched cohort. Further research characterizing biomedical factors, including CKD progression, in ESRD occurrence in these two racial groups is needed.
doi:10.1371/journal.pone.0048407
PMCID: PMC3480508  PMID: 23110237
8.  Outpatient versus Inpatient Observation after Percutaneous Native Kidney Biopsy: A Cost Minimization Study 
American Journal of Nephrology  2011;34(1):64-70.
Background/Aims
Percutaneous kidney biopsy (PKB) is the primary diagnostic tool for kidney disease. Outpatient ‘day surgery’ (ODS) following PKB in low-risk patients has previously been described as a safe alternative to inpatient observation (IO). This study aims to determine if ODS is less costly compared to IO while accounting for all institutional costs (IC) associated with post-PKB complications, including death.
Methods
A cost minimization study was performed using decision analysis methodology which models relative costs in relation to outcome probabilities yielding an optimum decision. The potential outcomes included major complications (bleeding requiring blood transfusion or advanced intervention), minor complications (bleeding or pain requiring additional observation), and death. Probabilities were obtained from the published literature and a base case was selected. IC were obtained for all complications from institutional activity-based cost estimates. The base case assumed a complication rate of 10% with major bleeding occurring in 2.5% of patients (for both arms) and death in 0.1 and 0.15% of IO and ODS patients, respectively.
Results
ODS costs USD 1,394 per biopsy compared to USD 1,800 for IO inclusive of all complications. IC for ODS remain less when overall complications <20%, major complications <5.5%, and IC per death
Conclusion
Outpatient management after PKB for low-risk patients costs less from the institutional perspective compared to IO, inclusive of complications and death. ODS should be considered for low-risk patients undergoing native kidney biopsy.
doi:10.1159/000328901
PMCID: PMC3123742  PMID: 21677428
Kidney biopsy; Decision analysis; Institutional costs
Background
Little is known about disease specific knowledge in patients with chronic kidney disease (CKD). We developed and examined the results of a survey to characterize kidney disease knowledge.
Design
Survey about kidney disease knowledge, with questions developed by experts. Setting and Participants: 401 adult patients with CKD (Stages 1–5) attending a nephrology clinic from April to October 2009.
Outcomes & Measurements
We calculated survey reliability using the Kuder-Richardson-20 coefficient, and established construct validity by testing a priori hypotheses of associations between the survey and patient characteristics. We descriptively analyzed survey responses and applied linear regression analyses to evaluate associations with patient characteristics. Health literacy was measured using the Rapid Estimate of Adult Literacy in Medicine.
Results
Participants median age was 58 (25th-75th percentile, 46–68) years, 83% were White, 18% had limited literacy, and 77% had CKD Stages 3–5. The 28 question knowledge survey had good reliability (KR-20=0.72), and mean (SD) knowledge score was 66% (15%). In support of construct validity of our knowledge survey, bivariate analysis shows that scores are associated with age (β, −0.01 per ten years; 95% CI, −0.02–−0.005; p=0.003), formal education (β, 0.09; 95% CI, 0.03–0.15; p=0.004), health literacy (β, 0.06; 95% CI, 0.03–0.10; p=0.001), kidney education class participation (β, 0.05; 95% CI, 0.01–0.09; p=0.009), knowing someone else with CKD (β, 0.05; 95% CI, 0.02–0.08; p=0.001), and awareness of one’s own CKD diagnosis (β, 0.07; 95% CI, 0.04–0.10; p<0.001). Findings were similar in adjusted analyses.
Limitations
Recruitment from one clinic limits generalizabilty of findings.
Conclusions
For patients with CKD, this kidney disease knowledge survey (KiKS) is reliable and valid, and identifies areas of and risk factors for poor kidney knowledge. Further study is needed to determine the impact of CKD knowledge on self-care behaviors and clinical outcomes.
doi:10.1053/j.ajkd.2010.09.018
PMCID: PMC3053083  PMID: 21168943
SUMMARY
The exchange of complex health information among patients, providers, health organizations and the public is often described as health literacy. Low levels of health literacy is common and associated with processes of healthcare and important health outcomes. In diabetes, health literacy is related to diabetes knowledge, self-efficacy and self-care behaviors and glycemic control. Health literacy may also provide a better understanding of racial disparities observed in patients with diabetes. Strategies to address health literacy, based upon this understanding of its role, provide a means to improve diabetes care. This article describes the concept of health literacy and its assessment and the evidence of its impact on patients with diabetes, and offers suggested methods and tools that may be implemented to improve clinical care.
doi:10.2217/dmt.11.5
PMCID: PMC3158575  PMID: 21860659
Objective
To describe the perspectives and experiences of chronic hemodialysis (CHD) patients regarding self-care and adherence to fluid restrictions.
Design
Semi-structured focus groups.
Setting
Two outpatient hemodialysis centers.
Participants
19 patients on chronic hemodialysis.
Intervention
Patients were asked a series of open-ended questions to encourage discussion about the management of fluid restriction within the broad categories of general knowledge, knowledge sources or barriers, beliefs and attitudes, self-efficacy, emotion, and self-care skills.
Main outcome measure
We analyzed session transcripts using the theoretical framework of content analysis to identify themes generated by the patients.
Results
Patients discussed both facilitators and barriers to fluid restriction which we categorized into 6 themes: knowledge, self-assessment, psychological factors, social, physical, and environmental. Psychological factors were the most common barriers to fluid restriction adherence, predominantly involving lack of motivation. Knowledge was the most discussed facilitator with accurate self-assessment, positive psychological factors, and supportive social contacts also playing a role. Dialysis providers were most commonly described as the source of dialysis information (54%), but learning through personal experience was also frequently noted (28%).
Conclusion
Interventions to improve fluid restriction adherence of chronic hemodialysis patients should target motivational issues, assess and improve patient knowledge, augment social support, and facilitate accurate self-assessment of fluid status.
doi:10.1053/j.jrn.2009.09.001
PMCID: PMC2888683  PMID: 19913443
hemodialysis; interdialytic weight gain; focus group; quality of life; qualitative research
Objective
We examined the protein anabolic effects of Pro-Stat 64, a high nitrogen-containing, enzyme-hydrolyzed, tryptophan-fortified, collagen protein supplement administrated during hemodialysis, at two different dosing regimens.
Design
This was a randomized, controlled, prospective study with 3 different groups: control, single dose of supplementation, and double dose of supplementation.
Setting
This study was performed at a clinical research center.
Patients
Six prevalent chronic hemodialysis (HD) patients were enrolled: 5 males, 1 female, 4 African Americans, and 2 Caucasians. Their mean age was 45 ± 11 years. Two patients were diabetic.
Methods
Protein turnover studies were performed using amino-acid (AA) balance and primed constant infusion of L-(1-13C) leucine.
Main Outcome Measure
Whole-body protein balance was determined according to substrate kinetics.
Results
There were no statistically significant difference at any time point between protocols for blood chemistries and hormonal markers, except for minor variations in plasma glucose. All plasma AA groups displayed decreases during control. Compared with the control group, plasma nonessential AA and total AA concentrations were statistically significantly higher during HD after both single and double doses of supplementation. The forearm arteriovenous AA balance was statistically significantly better for essential, nonessential, and total AA uptake after both single-dose and double-dose supplementation compared with the control group, except for nonessential AA, which was significantly better only after a double dose. Whole-body protein breakdown and net protein balance were statistically significantly better during HD with a double-dose administration in a dose-dependent manner, compared with the control and single-dose groups.
Conclusions
Oral AA supplementation alone improves whole-body and skeletal muscle protein anabolism in a dose-dependent manner in chronic HD patients. These data should be taken into account during clinical decision-making or when designing clinical trials of nutritional supplementation.
doi:10.1053/j.jrn.2009.01.019
PMCID: PMC2758490  PMID: 19500999
Background
Portion-size estimation is an important component of weight management. Literacy and numeracy skills may be important for accurate portion-size estimation. It was hypothesized that low literacy and numeracy would be associated with decreased accuracy in portion estimation.
Methods
A cross-sectional study of primary care patients was performed from July 2006 to August 2007; analyses were performed from January 2008 to October 2008. Literacy and numeracy were assessed with validated measures (the Rapid Estimate of Adult Literacy in Medicine and the Wide Range Achievement Test, third edition). For three solid-food items and one liquid item, participants were asked to serve both a single serving and a specified weight or volume amount representing a single serving. Portion-size estimation was considered accurate if it fell within ±25% of a single standard serving.
Results
Of 164 participants, 71% were women, 64% were white, and mean (SD) BMI was 30.6 (8.3) kg/m2. While 91% reported completing high school, 24% had <9th-grade literacy skills and 67% had <9th-grade numeracy skills. When all items were combined, 65% of participants were accurate when asked to serve a single serving, and 62% were accurate when asked to serve a specified amount. In unadjusted analyses, both literacy and numeracy were associated with inaccurate estimation. In multivariate analyses, only lower literacy was associated with inaccuracy in serving a single serving (OR=2.54; 95% CI=1.11, 5.81).
Conclusions
In this study, many participants had poor portion-size estimation skills. Lower literacy skills were associated with less accuracy when participants were asked to serve a single serving. Opportunities may exist to improve portion-size estimation by addressing literacy.
doi:10.1016/j.amepre.2008.11.012
PMCID: PMC2692952  PMID: 19285197
Background
Patient awareness of chronic diseases is low. Unawareness may represent poor understanding of chronic illness and may be associated with poor outcomes in end-stage renal disease (ESRD) patients.
Study Design
Concurrent, prospective national cohort study.
Setting & Participants
Incident hemodialysis and peritoneal dialysis patients enrolled in the Choices for Healthy Outcomes In Caring for ESRD (CHOICE) Study and followed until 2004.
Predictor
Inaccurate patient self-report of eight comorbid diseases as compared to the medical record.
Outcomes & Measurements
All-cause mortality was the primary outcome. Cox proportional hazard models were used to assess the contribution of demographics and clinical measures in the relation of inaccurate self-report to mortality.
Results
In 965 patients, the proportion of inaccurate self-reporters ranged from 3% for diabetes mellitus to 35% for congestive heart failure. Generally, inaccurate self-reporters were older and had more chronic diseases. A higher risk of death was found for inaccurate self-reporters of ischemic heart disease (Hazard Ratio (HR) [95% CI] =1.34 [1.12 –1.59]; p=0.001), coronary intervention (HR=1.46 [1.08 – 1.97]; p=0.01), and chronic obstructive pulmonary disease (COPD) (HR=1.40 [1.14–1.70]; p=0.001). The higher risk of death remained significant for COPD (HR=1.36 [1.11 – 1.66]; p=0.003) after adjustment for age, sex, and race. In patients receiving peritoneal dialysis, a higher risk of death (HR=2.06 [1.34 – 3.15]; p=0.001) was found for inaccurate self-reporters of ischemic heart disease.
Limitations
Includes potential for residual confounding, medical record error, misclassification of patient accuracy of self-report, and low inaccurate self-report of some chronic diseases, reducing the power to measure associations.
Conclusions
Accuracy of self-report depends upon the specific comorbid disease. ESRD patients, especially those receiving peritoneal dialysis, who inaccurately report heart disease may be less aware of their chronic comorbid disease and may be at higher risk of mortality compared to those who accurately report their comorbid disease.
doi:10.1053/j.ajkd.2008.02.001
PMCID: PMC2587104  PMID: 18589216
End-stage renal disease (ESRD); mortality; self-report; awareness; comorbid disease; outcomes
Obesity (Silver Spring, Md.)  2008;16(8):1966-1968.
Low numeracy skills and obesity are both common. Numeracy skills are used in healthy weight management to monitor caloric intake. The relationship between obesity and numeracy skills in adult primary care patients is unknown. A cross-sectional study enrolled adult, English-speaking primary care patients. BMI was assessed by self-report; numeracy and literacy skills were measured with the Wide Range Achievement Test, 3rd Edition (WRAT-3) and the Rapid Estimate of Adult Literacy in Medicine (REALM), respectively. The relationship between numeracy and BMI was described with Spearman's rank correlation and linear regression analyses. In 160 patients, the mean (s.d.) age was 46 (16) years, 66% were white, 70% were female, and 91% completed high school. The mean BMI was 30.5 (8.3) kg/m2. Less than 9th grade numeracy skills were found in 66% of the participants. Participants with numeracy skills <9th grade had a mean BMI of 31.8 (9.0) whereas those with numeracy skills ≥9th grade had a mean BMI of 27.9 (6.0), P = 0.008. Numeracy was negatively and significantly correlated with BMI (ρ = −0.26, P = 0.001). This correlation persisted after adjusting for age, sex, race, income, years of education, and literacy (β coefficient = −0.14; P = 0.010). Literacy skills were not associated with BMI. We found a significant association between low numeracy skills and higher BMI in adult primary care patients. A causal relationship cannot be determined. However, numeracy may have important clinical implications in the design and implementation of healthy weight management interventions and should be further evaluated to determine the magnitude of its effect.
doi:10.1038/oby.2008.294
PMCID: PMC2694664  PMID: 18535541

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