To determine whether there is an increased odds of mortality among trauma patients treated at hospitals with higher proportions of minority patients (ie, black and Hispanic patients combined).
Hospitals were categorized on the basis of the percentage of minority patients admitted with trauma. The adjusted odds of in-hospital mortality were compared between hospitals with less than 25% of patients who were minorities (the reference group) and hospitals with 25% to 50% of patients who were minorities and hospitals with more than 50% of patients who were minorities. Multivariate logistic regression (with generalized linear modeling and a cluster-correlated robust estimate of variance) was used to control for multiple patient and injury severity characteristics.
A total of 434 hospitals in the National Trauma Data Bank.
Patients aged 18 to 64 years whose medical records were included in the National Trauma Data Bank for the years 2007 and 2008 with an Injury Severity Score of 9 or greater and who were white, black, or Hispanic.
Main Outcome Measures
Crude mortality and adjusted odds of in-hospital mortality.
A total of 311 568 patients were examined. Hospitals in which the percentage of minority patients was more than 50% also had younger patients, fewer female patients, more patients with penetrating trauma, and the highest crude mortality. After adjustment for potential confounders, patients treated at hospitals in which the percentage of minority patients was 25% to 50% and at hospitals in which the percentage of minority patients was more than 50% demonstrated increased odds of death (adjusted odds ratio, 1.16 [95% confidence interval, 1.01–1.34] and adjusted odds ratio, 1.37 [95% confidence interval, 1.16–1.61], respectively), compared with the reference group. This disparity increased further on subset analysis of patients with a blunt injury. Uninsured patients had significantly increased odds of mortality within all 3 hospital groups.
Patients treated at hospitals with higher proportions of minority trauma patients have increased odds of dying, even after adjusting for potential confounders. Differences in outcomes between trauma hospitals may partly explain racial disparities.
Lower physical and social functioning in pregnancy has been linked to an increased risk of preterm delivery and low birth weight infants, butt few studies have examined racial differences in pregnant women’s perception of their functioning. Even fewer studies have elucidated the demographic and clinical factors contributing to racial differences in functioning. Our objective was to determine whether there are racial differences in health-related quality of life (HRQoL) in early pregnancy; and if so, to identify the contributions of socio-demographic characteristics, depression symptoms, social support and clinical factors to these differences.
Cross-sectional study of 175 women in early pregnancy attending prenatal clinics in urban setting. In multivariate analysis, we assessed the independent relation of black race (compared to white) to HRQoL scores from the eight domains of the Medical Outcomes (SF-36) Survey: Physical Functioning, Role-Physical, Bodily Pain, Vitality, General Health, Social Functioning, Role-Emotional, and Mental Health. We compared socio-demographic and clinical factors and depression symptoms between black and white women and assessed the relative importance of these factors in explaining racial differences in physical and social functioning.
Black women comprised 59% of the sample; white women comprised 41%. Before adjustment, black women had scores that were 14 points lower in Physical Function and Bodily Pain, 8 points lower in General Health, 4 points lower in Vitality and 7 points lower in Social Functioning. After adjustment for depression symptoms, social support and clinical factors, black women still had HRQoL scores that were 4 to 10 points lower than white women, but the differences were no longer statistically significant. Level of social support and payment source accounted for most of the variation in Physical Functioning, Bodily Pain and General Health. Social support accounted for most of the differences in Vitality and Social Functioning.
Payment source and social support accounted for much of the racial differences in physical and social function scores. Efforts to reduce racial differences might focus on improving social support networks and Socio-economic barriers.
Depressive symptoms; Race; Pregnancy and health-related quality of life
Awareness of chronic kidney disease (CKD) is low. Efforts are underway to increase recognition of CKD among patients, assuming that such an increase will lead to better outcomes through greater adherence to proven therapies. Few studies have tested this assumption.
CKD awareness, defined by a ‘yes’ answer to ‘Have you ever been told by a healthcare provider you have weak or failing kidneys?’, was assessed among 2,404 adults with CKD stages 1–4, who participated in the 2003–2008 National Health and Nutrition Examination Surveys. Odds of blood pressure (BP) control, self-reported use of angiotensin-converting enzyme inhibitors (ACEI) or angiotensin receptor blockers (ARB), and glycemic control, were determined among those aware vs. unaware of their CKD.
Optimal BP control, ACEI/ARB use and glycemic control were low in the US adult population with CKD, although there was a recent increase in attainment of guideline-concordant BP control. Odds of BP control and ACEI/ARB use were not different among individuals aware of their CKD compared to those unaware (adjusted odds ratio (AOR) 0.91; 95% CI 0.52–1.58 and AOR 0.75; 0.44–1.30, respectively). CKD awareness among diabetic participants was not associated with glycemic control (AOR 0.41; 95% CI 0.14–1.18).
Awareness of CKD is not associated with more optimal BP control, ACEI/ARB use or glycemic control. Future efforts in this area should further explore the measurement of CKD awareness and behaviors associated with CKD awareness.
Chronic kidney disease; Awareness; National Health And Nutrition Examination Survey (NHANES); Guidelines
Social characteristics (e.g. race, gender, age, education) are associated with health care disparities. We introduce social concordance, a composite measure of shared social characteristics between patients and physicians.
To determine whether social concordance predicts differences in medical visit communication and patients’ perceptions of care.
Regression analyses were used to determine the association of patient-provider social concordance with medical visit communication and patients’ perceptions of care using data from two observational studies involving 64 primary care physicians and 489 of their patients from the Baltimore, MD /Washington, DC/Northern Virginia area.
Lower patient-physician social concordance was associated with less positive patient perceptions of care and lower positive patient affect. Patient-physician dyads with low vs. high social concordance reported lower ratings of global satisfaction with office visits (OR=0.64 vs. OR=1.37, p=0.036) and were less likely to recommend their physician to a friend (OR=0.61vs. OR=1.37, p=0.035). A graded-response was observed for social concordance with patient positive affect and patient perceptions of care.
Patient-physician concordance across multiple social characteristics may have cumulative effects on patient-physician communication and perceptions of care.
Research should move beyond one-dimensional measures of patient-physician concordance to understand how multiple social characteristics influence health care quality.
patient-provider communication; health care disparities; patient-provider concordance
Living related kidney transplantation (LRT) is underutilized, particularly among African Americans. The effectiveness of informational and financial interventions to enhance informed decision-making among African Americans with end stage renal disease (ESRD) and improve rates of LRT is unknown.
We report the protocol of the Providing Resources to Enhance African American Patients’ Readiness to Make Decisions about Kidney Disease (PREPARED) Study, a two-phase study utilizing qualitative and quantitative research methods to design and test the effectiveness of informational (focused on shared decision-making) and financial interventions to overcome barriers to pursuit of LRT among African American patients and their families. Study Phase I involved the evidence-based development of informational materials as well as a financial intervention to enhance African American patients’ and families’ proficiency in shared decision-making regarding LRT. In Study Phase 2, we are currently conducting a randomized controlled trial in which patients with new-onset ESRD receive 1) usual dialysis care by their nephrologists, 2) the informational intervention (educational video and handbook), or 3) the informational intervention in addition to the option of participating in a live kidney donor financial assistance program. The primary outcome of the randomized controlled trial will include patients’ self-reported rates of consideration of LRT (including family discussions of LRT, patient-physician discussions of LRT, and identification of a LRT donor).
Results from the PREPARED study will provide needed evidence on ways to enhance the decision to pursue LRT among African American patients with ESRD.
Shared decision-making; Live kidney transplantation; Live kidney donation; Chronic kidney disease; End stage renal disease
Little is known about racial/ethnic differences in preferred methods of disclosing deceased organ donation intentions among persons not previously designating their organ donation preferences publicly or the association of medical mistrust with preferences.
We surveyed 307 United States (US) adults who had not yet designated their donation intentions via drivers’ licenses or organ donor cards (non-designators) to identify their preferred disclosure methods (personal discussions with family, physicians, or religious representatives or public registration via mail/telephone/computer, workplace, place of religious worship, or grocery store/bank/post office) and to assess the association of mistrust with preferences. In multivariable models, we assessed racial/ethnic differences in preferences and the influence of medical mistrust on preferences.
Non-designators most preferred discussions with physicians (65%) or family members (63%). After adjustment, African Americans (AAs) were more likely than Whites to prefer discussion with religious representatives. In contrast, AAs and Hispanics were less likely than Whites to prefer registration at a workplace or through mail/telephone/computer. Medical mistrust was common and associated with less willingness to disclose via several methods.
Encouraging donation intention disclosure via discussions with physicians, family, and religious representatives and addressing medical mistrust could enhance strategies to improve non-designators’ donation rates.
deceased organ donation; donor designation; minority donation; organ transplantation; public attitudes; racial disparities
As several studies have shown an association between periodontal disease and chronic kidney disease (CKD), regular dental care may be an important strategy for reducing the burden of CKD. Access to dental care may be limited in the US public health system.
In this retrospective cohort study of 6,498 adult patients with (n = 2,235) and without (n = 4,263) CKD and at least 12 months of follow-up within the San Francisco Department of Public Health Community Health Network clinical databases, we examined the likelihood of having a dental visit within the observation period (2005-2010) using Cox proportional hazards models. To determine whether dental visits reflected a uniform approach to preventive service use in this setting, we similarly examined the likelihood of having an eye visit among those with diabetes, for whom regular retinopathy screening is recommended. We defined CKD status by average estimated glomerular filtration rate based on two or more creatinine measurements ≥ 3 months apart (no CKD, ≥ 60 ml/min/1.73 m2; CKD, < 60 ml/min/1.73 m2).
Only 11.0% and 17.4% of patients with and without CKD, respectively, had at least one dental visit. Those with CKD had a 25% lower likelihood of having a dental visit [HR = 0.75, 95% CI (0.64-0.88)] than those without CKD after adjustment for confounders. Among the subgroup of patients with diabetes, 11.8% vs. 17.2% of those with and without CKD had a dental visit, while 58.8% vs. 57.8% had an eye visit.
Dental visits, but not eye visits, in a US public healthcare setting are extremely low, particularly among patients with CKD. Given the emerging association between oral health and CKD, addressing factors that impede dental access may be important for reducing the disparate burden of CKD in this population.
P-selectin is released by activated platelets and endothelium contributing to inflammation and thrombosis. We evaluated the association between soluble P-selectin and atherosclerotic cardiovascular disease (ASCVD) in dialysis patients.
We measured soluble P-selectin in serum from 824 incident dialysis patients. Using Cox proportional hazards models, we modeled the association of P-selectin levels with ASCVD events, cardiovascular mortality and sudden cardiac death.
After adjustment for demographics, comorbidity and traditional cardiovascular risk factors, higher P-selectin levels were associated with increased risk of ASCVD and cardiovascular mortality among males (p = 0.02 and p = 0.01, respectively), but not females (p = 0.52 and p = 0.31, respectively; p interaction = 0.003), over a median of 38.2 months. Higher P-selectin was associated with a greater risk of sudden cardiac death among males (p = 0.05). The associations between increasing P-selectin and cardiovascular mortality as well as sudden cardiac death in males persisted after adjustment for C-reactive protein, interleukin-6, serum albumin and platelet count (p = 0.01 and p = 0.03, respectively). The risk for sudden cardiac death was more than 3 times greater for males in the highest tertile of soluble P-selectin compared with the lowest tertile after adjustment (HR: 3.19; 95% CI: 1.18 – 8.62; p = 0.02).
P-selectin is associated with ASCVD, cardiovascular mortality and sudden cardiac death among male dialysis patients.
Cardiovascular disease; Dialysis; End-stage renal disease; Inflammation; Sudden cardiac death; P-selectin
Little is known about disability in early-stage chronic kidney disease (CKD).
Cross-sectional national survey (National Health and Nutrition Examination Survey 1999–2006).
Setting and Participants
Community-based survey of 16,011 non-institutionalized U.S. civilian adults (≥20 years).
CKD, categorized as: no CKD, stages 1 and 2 [albuminuria and estimated glomerular filtration rate (eGFR) ≥60 ml/min/1.73 m2], and stages 3 and 4 (eGFR 15–59).
Self-reported disability, defined by limitations in working, walking, and cognition; and difficulties in activities of daily living (ADL), instrumental ADL, leisure and social activities, lower extremity mobility, and general physical activity.
Albuminuria and eGFR assessed from urine and blood samples; disability, demographics, access to care, and comorbid conditions assessed by standardized questionnaire.
Age-adjusted prevalence of reported limitations was generally significantly greater with CKD: e.g., difficulty with ADLs was reported by 17.6%, 24.7%, and 23.9% of older (≥65 years) and 6.8%, 11.9%, and 11.0% of younger (20–64 years) adults with no CKD, stages 1 and 2, and stages 3 and 4, respectively. CKD was also associated with greater reported limitations and difficulty in other activities after age adjustment, including instrumental ADL, leisure and social activities, lower extremity mobility, and general physical activity. Other demographics, socioeconomic status, and access to care generally only slightly attenuated the observed associations, particularly among older individuals; adjustment for cardiovascular disease, arthritis, and cancer attenuated most associations such that statistical significance was no longer achieved.
Inability to establish causality and possible unmeasured confounding.
CKD is associated with higher prevalence of disability in the United States. Age and other comorbid conditions account for most, but not all, of this association.
chronic kidney disease; disability; activities of daily living; limitations; employment; physical functioning; cognitive functioning
Accurate classification of individuals with kidney disease is vital to research and public health efforts aimed at improving health outcomes. Our objective was to identify and synthesize published literature evaluating the accuracy of existing data sources related to kidney disease.
A systematic review of studies seeking to validate the accuracy of the underlying data relevant to kidney disease.
Setting & Population
U.S.-based and international studies covering a wide range of both outpatient and inpatient study populations.
Selection Criteria for Studies
Any English-language study investigating the prevalence or etiology of kidney disease, the existence of co-morbid conditions, or the cause of death in those with CKD. All definitions and stages of CKD, including end-stage renal disease (ESRD), were accepted.
Presence of a kidney disease-related variable in existing datasets, including administrative datasets and disease registries.
Presence of a kidney disease-related variable defined by laboratory criteria or medical record review.
Thirty studies were identified. Most studies investigated the accuracy of kidney disease reporting, comparing coded renal disease to that defined by estimated glomerular filtration rate (eGFR). Sensitivity of coded renal disease varied widely (0.08–0.83). Specificity was higher, with all studies reporting values of ≥0.90. The studies evaluating the etiology of CKD, comorbidities, and the cause of death in CKD all used ESRD or transplant populations exclusively, and accuracy was highly variable when compared to ESRD registry data.
Only English-language studies were evaluated.
Given the heterogeneous results of validation studies, a variety of attributes of existing data sources, including the accuracy of individual data items within these sources, should be carefully considered prior to use in research, quality improvement and public health efforts.
Socioeconomic disparities are associated with the prevalence of disability in the general population; however, it is unknown whether a similar association exists between socioeconomic status and disability from chronic kidney disease (CKD, defined as albuminuria or an estimated glomerular filtration rate of 15-59 mL/min/1.73 m2).
A total of 4,257 US adults aged 20 years or older with CKD who participated in the National Health and Nutrition Examination Survey 1999-2008 completed standardized questionnaires assessing self-reported difficulties in activities of daily living (ADL), instrumental ADL (IADL), lower-extremity mobility (LEM), and leisure and social activities (LSA). We used multivariable logistic regression with population-based weighting to obtain adjusted prevalence estimates of disability by demographic, socioeconomic, health care access, and clinical characteristics.
Participants with less education had more disability (age- and sex-adjusted prevalence of disability by lowest vs highest level of education: ADL, 24.5% vs 16.9%; IADL, 34.0% vs 20.3%; LEM, 56.9% vs 44.6%; LSA, 26.2% vs 16.8%; P < .001 for all). We observed similar trends for income. After further adjustment for other sociodemographic factors, health care access, and comorbid conditions, education and income both remained significantly associated, by any measure, with lower prevalence of disability.
Among people with CKD in the United States, lower socioeconomic status is associated with greater risk of disability, independent of race/ethnicity, health care access, and comorbid conditions. Our findings suggest that people with CKD and limited education or lower income should be targeted for early intervention to limit disability and further loss of income, both of which could worsen outcomes in CKD.
Residual kidney function (RKF) is associated with improved survival in peritoneal dialysis patients but its role in hemodialysis patients is less well known. Urine output may provide an estimate of RKF. The aim of our study was to determine the association of urine output with mortality, quality of life (QOL) and inflammation in incident hemodialysis patients.
Nationally representative prospective cohort study
Setting & Participants
734 incident hemodialysis participants treated in 81 clinics; enrollment, 1995-1998, follow-up until December 2004.
Urine output, defined as producing at least 250 mL (1 cup) of urine daily, ascertained by questionnaires at baseline and year 1.
Outcomes & Measurements
Primary outcomes were all-cause and cardiovascular (CVD) mortality, analyzed using Cox regression adjusted for demographic, clinical and treatment characteristics. Secondary outcomes were QOL, inflammation (CRP and interleukin-6 [IL-6] levels) and erythropoietin (EPO) requirements.
617/734 (84%) participants reported urine output at baseline and 163/579 (28%) at year 1. Baseline urine output was not associated with survival. Urine output at year 1, indicating preserved RKF, was independently associated with lower all-cause mortality (Hazard Ratio [HR], 0.70; 95% Confidence Interval [CI], 0.52-0.93; p=0.02) and a trend towards lower CVD mortality (HR, 0.69; 95% CI, 0.45-1.05; p=0.09). Participants with urine output at baseline reported better QOL and had lower CRP (p=0.02) and IL-6 (p=0.03) levels. Importantly, EPO dose was 12,000 units/week lower in those with urine output at year 1 compared with those without (p=0.001).
Urine volume was measured in only a subset of patients (42%) but was in agreement with self-report (p<0.001).
RKF in hemodialysis patients is associated with better survival and QOL, lower inflammation and significantly less EPO use. RKF should be monitored routinely in hemodialysis patients. Development of methods to assess and preserve RKF is important and may improve dialysis care.
End-stage Renal Disease; Hemodialysis; Residual Kidney Function; Mortality; Quality of Life; Inflammation
We sought to synthesize the findings of studies evaluating interventions to improve the cultural competence of health professionals.
This was a systematic literature review and analysis.
We performed electronic and hand searches from 1980 through June 2003 to identify studies that evaluated interventions designed to improve the cultural competence of health professionals. We abstracted and synthesized data from studies that had both a before- and an after-intervention evaluation or had a control group for comparison and graded the strength of the evidence as excellent, good, fair, or poor using predetermined criteria.
Main Outcome Measures
We sought evidence of the effectiveness and costs of cultural competence training of health professionals.
Thirty-four studies were included in our review. There is excellent evidence that cultural competence training improves the knowledge of health professionals (17 of 19 studies demonstrated a beneficial effect), and good evidence that cultural competence training improves the attitudes and skills of health professionals (21 of 25 studies evaluating attitudes demonstrated a beneficial effect and 14 of 14 studies evaluating skills demonstrated a beneficial effect). There is good evidence that cultural competence training impacts patient satisfaction (3 of 3 studies demonstrated a beneficial effect), poor evidence that cultural competence training impacts patient adherence (although the one study designed to do this demonstrated a beneficial effect), and no studies that have evaluated patient health status outcomes. There is poor evidence to determine the costs of cultural competence training (5 studies included incomplete estimates of costs).
Cultural competence training shows promise as a strategy for improving the knowledge, attitudes, and skills of health professionals. However, evidence that it improves patient adherence to therapy, health outcomes, and equity of services across racial and ethnic groups is lacking. Future research should focus on these outcomes and should determine which teaching methods and content are most effective.
race/ethnicity; health disparities; cultural competence
Patients with sickle cell disease (SCD) often perceive negative provider attitudes, which may affect the quality of patient–provider communication and care during vaso-occlusive crises (VOCs). This study investigated the validity and reliability of a scale to measure provider attitudes toward patients with acute VOC.
Using a cohort of adults with VOC (September 2006 to June 2007), we administered a 10-item provider questionnaire within 72 h of patient encounters. After factor analysis, we created a 7-item Positive Provider Attitudes toward Sickle Cell Patients Scale (PASS); higher scores indicate more positive attitudes. We assessed internal consistency and evidence of construct validity, exploring bivariate relationships between provider or patient characteristics and the PASS score using multilevel modeling.
We collected 121 surveys from 84 health care providers for 47 patients. Patients averaged 30.3 years in age, and 60% were women. Among providers, 79% were nurses, and 70% worked in inpatient settings. PASS scores averaged 24.1 (S.D. 6.7), ranged 7–35, and had high internal consistency (Cronbach’s alpha = 0.91). As hypothesized, inpatient vs. emergency department providers (Δ = 4.65, p < 0.001) and nurses vs. other providers (Δ = 0.95, p < 0.001) had higher PASS scores. Higher patient educational attainment (Δ per year = 2.74, p < 0.001) and employment (Δ = 5.62, p = 0.001) were associated with higher PASS scores. More frequent hospitalizations (Δ per episode = −0.52, p < 0.001) and prior disputes with staff (Δ = −7.53, p = 0.002) were associated with lower PASS scores.
Our findings provide preliminary evidence for the reliability and construct validity of the PASS score in measuring provider attitudes toward patients with VOC.
Future studies should examine the validity of PASS in other cohorts of patients with SCD and their providers. With further evidence, PASS may prove useful for investigating the impact of provider attitudes on the quality of communication and care provided to these patients.
Validity and reliability; Instrument development; Patient–provider relationship; Pain management; Sickle cell disease
Adults with sickle cell disease often report poor interpersonal healthcare experiences, including poor communication with providers. However, the effect of these experiences on patient trust is unknown.
To determine the association between patient ratings of the previous quality of provider communication and current trust in the medical profession among adults with sickle cell disease.
A total of 95 adults with sickle cell disease.
The four-item Provider Communication Subscale from the Consumer Assessment of Healthcare Plans and Systems Survey; The five-item Wake Forest Trust in the Medical Profession Scale.
Better ratings of previous provider communication were significantly associated with higher levels of trust toward the medical profession. A 10% increase in provider communication rating was associated with a 3.76% increase in trust scores (p < 0.001, 95% CI [1.76%, 5.76%]), adjusting for patient-level demographic, clinical, and attitudinal characteristics.
Poorer patient ratings of provider communication are associated with lower trust toward the medical profession among adults with sickle cell disease. Future research should examine the impact of low trust in the medical profession on clinical outcomes in this population of patients.
sickle cell disease; trust; quality of healthcare
Low socioeconomic status (SES) and African American race are both independently associated with end-stage renal disease and progressive chronic kidney disease (CKD), however, despite their frequent co-occurrence, the effect of low SES independent of race has not been well-studied in CKD.
Setting & Participants
2,375 community-dwelling adults age 30-64 years residing within 12 neighborhoods selected for both socioeconomic and racial diversity in Baltimore City, Maryland.
Low SES [self-reported household income <125% of 2004 Department of Health and Human Services guideline], higher SES (≥125% of guideline); white and African American race.
Outcomes & Measurements
CKD defined as estimated glomerular filtration rate (eGFR) <60 mL/min/1.73 m2. Logistic regression used to calculate odds ratios (OR) for relationship between poverty and CKD, stratified by race.
Of 2,375 participants; 955 were white (347 low SES and 608 higher SES); 1,420 were African American (713 low SES and 707 higher SES). A total of 146 (6.2%) participants had CKD. Overall, race was not associated with CKD [OR, 1.05; 95% confidence interval (CI), 0.57-1.96]; however, African Americans had a much greater odds of advanced CKD (eGFR <30 mL/min/1.73 m2). Low SES was independently associated with 59% greater odds of CKD after adjustment for demographics, insurance status and comorbid disease (OR, 1.59; 95% CI, 1.27-1.99). However, when stratified by race, low SES was associated with CKD in African Americans (OR, 1.91; 95% CI, 1.54-2.38), but not in whites (OR, 0.95; 95% CI, 0.58-1.55; P for interaction, 0.003).
Cross-sectional design; findings may not be generalizable to non-urban populations.
Low SES has a profound relationship with CKD in African Americans but not in whites in an urban population of adults, and its role in the racial disparities seen in CKD is worthy of further investigation.
Socioeconomic status; health disparities; epidemiology; renal disease
Earlier recognition of chronic kidney disease (CKD) could slow progression, prevent complications, and reduce cardiovascular-related outcomes. However, current estimates of CKD awareness indicate that both patient- and provider-level awareness remain unacceptably low. Many of the factors that are possibly associated with CKD awareness, which could help guide implementation of awareness efforts, have yet to be fully examined. Also, little is known regarding whether increased patient or provider awareness improves clinical outcomes or whether there are possible negative consequences of awareness for CKD patients. Further research is necessary to continue to design and refine awareness campaigns aimed at both patients and providers, but there is an immediate need for dissemination of basic CKD information, given both the high prevalence of CKD and its risk factors and the low estimated awareness of CKD.
chronic kidney disease; awareness; knowledge; patient; provider; review
Hypertension is both a cause and consequence of chronic kidney disease, but the prevalence of chronic kidney disease throughout the diagnostic spectrum of blood pressure has not been established. We determined the prevalence of chronic kidney disease within blood pressure categories in 17,794 adults surveyed by the National Health and Nutrition Examination Survey during 1999–2006. Diagnosed hypertension was defined as self-reported provider diagnosis (n=5,832); undiagnosed hypertension was defined as systolic blood pressure ≥140 mmHg or diastolic blood pressure ≥90 mmHg, without report of provider diagnosis (n=3,046); pre-hypertension was defined as systolic blood pressure ≥120 and < 140 mmHg or diastolic blood pressure ≥80 and < 90 mmHg (n=3,719); and normal was defined as systolic blood pressure < 120 mmHg and diastolic blood pressure < 80 mmHg (n=5,197). Chronic kidney disease was defined as estimated glomerular filtration rate 15–60 ml/min/1.73m2 or urinary albumin-creatinine ratio > 30 mg/g. Prevalence of chronic kidney disease among those with pre- and undiagnosed hypertension was 17.3% and 22.0%, respectively, compared to 27.5% with diagnosed hypertension and 13.4% with normal blood pressure, after adjustment for age, gender and race in multivariable logistic regression. This pattern persisted with varying definitions of kidney disease; macro-albuminuria (urinary albumin-creatinine ratio > 300 mg/g) had the strongest association with increasing blood pressure category [odds ratio 2.37 (95% confidence interval, 2.00–2.81)]. Chronic kidney disease is prevalent in undiagnosed and pre-hypertension. Earlier identification and treatment of both these conditions may prevent or delay morbidity and mortality from chronic kidney disease.
epidemiology; albuminuria; renal; prevention; awareness; surveillance
Examine the influences of race, socioeconomic status, sex, and age on barriers to participation in a study of cross-sectional differences and longitudinal changes in health-related outcomes.
We designed a multidisciplinary, community-based, prospective longitudinal epidemiologic study among socioeconomically diverse African Americans and whites. The study protocol facilitated our ability to recruit 3722 participants from Baltimore, MD with mean age 47.7 (range 30–64) years, % males/female, 2200 African Americans (59%) and 1522 whites (41%); 41% reported household incomes below the 125% poverty delimiter.
There were no significant age differences associated with sex or race. Participants below the 125% poverty delimiter were slightly younger than those above the delimiter. Age, race, and sex, but not poverty status, were associated with the likelihood of an examination. Older participants, women, and whites were more likely to complete their examinations. Among those who completed their examinations, there were no age differences associated with sex and poverty status, but African Americans were negligibly younger than whites.
Although some literature suggests that minorities and low-income people are less willing to participate in clinical research, these baseline data suggest that African Americans individuals and individuals from households with incomes below 125% of the poverty level are at least as willing to participate in observational clinical studies as whites and higher income individuals of similar age and sex.
Healthcare disparities; socioeconomic status; Population groups; Epidemiologic research design; Health surveys; Longitudinal studies
Inpatient initiation of chronic hemodialysis is considered undesirable because of cost and possible harms of hospitalization. We examined the patient characteristics and outcomes associated with inpatient initiation.
In a prospective cohort study of incident dialysis patients, the independent association of inpatient hemodialysis initiation with patient outcomes was assessed in multivariable analyses with adjustment for patient characteristics and propensity for inpatient initiation.
A total of 410 of 652 (63%) hemodialysis patients began as inpatients; uremia and volume overload were the most commonly documented reasons. Compared to outpatients, inpatients were more likely to be unmarried, report less social support, have multiple comorbidities and be referred to a nephrologist 4 months or less prior to initiation. Inpatient initiation was protective for subsequent all-cause hospitalization (incidence rate ratio (IRR) = 0.92, confidence interval (CI) 0.89–0.94); this was most pronounced among those who had the highest propensity for inpatient initiation (IRR = 0.66, CI 0.56–0.78), including those referred late to nephrology. Similar results were found for infectious hospitalization. Mortality [hazard ratio = 1.03, CI 0.82–1.30] and cardiovascular events were not significantly different for inpatients versus outpatients.
Inpatient hemodialysis initiation has a protective association with hospitalization among those patients referred late to nephrology, with multiple comorbidities and/or little social support.
End-stage renal disease; Hospitalization; Late referral; Mortality; Social support
Primary care providers' suboptimal recognition of the severity of chronic kidney disease (CKD) may contribute to untimely referrals of patients with CKD to subspecialty care. It is unknown whether U.S. primary care physicians' use of estimated glomerular filtration rate (eGFR) rather than serum creatinine to estimate CKD severity could improve the timeliness of their subspecialty referral decisions.
We conducted a cross-sectional study of 154 United States primary care physicians to assess the effect of use of eGFR (versus creatinine) on the timing of their subspecialty referrals. Primary care physicians completed a questionnaire featuring questions regarding a hypothetical White or African American patient with progressing CKD. We asked primary care physicians to identify the serum creatinine and eGFR levels at which they would recommend patients like the hypothetical patient be referred for subspecialty evaluation. We assessed significant improvement in the timing [from eGFR < 30 to ≥ 30 mL/min/1.73m2) of their recommended referrals based on their use of creatinine versus eGFR.
Primary care physicians recommended subspecialty referrals later (CKD more advanced) when using creatinine versus eGFR to assess kidney function [median eGFR 32 versus 55 mL/min/1.73m2, p < 0.001]. Forty percent of primary care physicians significantly improved the timing of their referrals when basing their recommendations on eGFR. Improved timing occurred more frequently among primary care physicians practicing in academic (versus non-academic) practices or presented with White (versus African American) hypothetical patients [adjusted percentage(95% CI): 70% (45-87) versus 37% (reference) and 57% (39-73) versus 25% (reference), respectively, both p ≤ 0.01).
Primary care physicians recommended subspecialty referrals earlier when using eGFR (versus creatinine) to assess kidney function. Enhanced use of eGFR by primary care physicians' could lead to more timely subspecialty care and improved clinical outcomes for patients with CKD.
Patients’ views of their risk for the development or progression of chronic kidney disease (CKD) are poorly characterized.
To assess perceived risk and concern regarding CKD development or progression among high-risk patients seen in primary care, identify predictors of perceptions, and correlate perceptions with adherence to high blood pressure management.
DESIGN AND PARTICIPANTS
Cross-sectional study of 195 patients enrolled in a randomized controlled trial on hypertension management in 40 Maryland primary care practices.
We assessed independent predictors (sociodemographics, health literacy, clinical presence of CKD, co-morbid conditions, and health behaviors) of perceived susceptibility (assessed via questionnaire) and adherence (assessed via Hill-Bone blood pressure adherence scale) in multivariable analyses.
In this hypertensive majority African American (63%) population, many participants had uncontrolled blood pressure (44%) or diabetes (42%). Few (20%) felt “very likely” to develop CKD and one third (33%) were “very concerned” about developing CKD. Participants who were female and had low health literacy had lower perceived susceptibility to CKD compared to males and those with higher health literacy. Race and diabetes were also associated with perceived susceptibility. Greater perceived susceptibility was associated with poorer blood pressure management adherence scores.
Many high-risk patients have low perceived susceptibility to CKD. Poor blood pressure therapy adherence scores among those with greatest perceived susceptibility suggest fatalistic attitudes about CKD. If our findings are confirmed in larger studies, interventions targeting patient perceptions of CKD risk and other attitudes associated with these perceptions could impact adherence to therapies and health outcomes.
chronic kidney disease; attitudes; perceived susceptibility; adherence; primary care
Stroke is the third most common cause of cardiovascular disease death in patients on dialysis; however, characteristics of cerebrovascular disease, including clinical subtypes and subsequent consequences, have not been well described.
Prospective national cohort study, the Choices for Healthy Outcomes in Caring for ESRD (CHOICE) study.
Settings & Participants
1,041 incident dialysis patients treated in 81 clinics, enrolled from 10/95–7/98, followed until 12/31/2004.
Time from dialysis initiation.
Outcomes & Measurements
Cerebrovascular disease events were defined as non-fatal (hospitalized stroke, carotid endarterectomy) and fatal (stroke death) events after dialysis initiation. Stroke subtypes were classified using standardized criteria from the Trial of ORG 10172 in Acute Stroke Treatment (TOAST) system. Incidence of cerebrovascular event subtypes were analyzed using time-to-event analyses accounting for competing risk of death. Clinical outcomes after stroke were abstracted from medical records.
A total of 165 participants experienced a cerebrovascular event with an overall incidence of 4.9 per 100 person-years. Ischemic stroke was the most common (76% of all 200 events) with cardioembolism subtype accounting for 28% of the 95 abstracted ischemic events. The median time from onset of symptoms to first stroke evaluation was 8.5 hours (25th and 75th percentiles 1, 42 hours), with only 56% of patients successfully escaping death, nursing home, or a skilled nursing facility.
Relatively small sample size limits power to determine risk factors.
Cerebrovascular disease is common in dialysis patients, is identified late, and carries a significant risk of morbidity and mortality. Stroke etiologic subtypes on dialysis are multifactorial, suggesting risk factors may change the longer one has ESRD. Further studies are needed to address the poor prognosis through prevention, early identification, and treatment.
Cerebrovascular disease; Stroke; Dialysis; Prognosis; Epidemiology
Clinical practice guidelines were established to improve the diagnosis and management of chronic kidney disease (CKD), but the extent, determinants, and cost implications of guideline adherence and variation in adherence have not been evaluated.
Settings & Participants
Nationally representative sample of 301 U.S. primary care physicians and nephrologists
Provider and patient characteristics
Outcomes & Measurements
Guideline adherence was assessed as present if physicians recommended at least 5 of 6 clinical tests prescribed by the National Kidney Foundation-Kidney Disease Outcomes and Quality Initiative (KDOQI) guidelines for a hypothetical patient with newly identified CKD. We also assessed patterns and cost of additional non-recommended tests for the initial clinical evaluation of CKD.
Most of the 86 family medicine, 89 internal medicine, and 126 nephrology physicians practiced greater than 10 years (54%), were in non-academic practices (76%), spent greater than 80% of their time performing clinical duties (78%), and correctly estimated kidney function (73%). Overall, 35% of participants were guideline adherent. Compared to nephrologists, internal medicine and family physicians had lower odds of adherence for all recommended testing (Odds Ratio (OR) [95% CI]:0.6[0.3–1.1] and 0.3[0.1–0.6], respectively). Participants practicing greater than 10 years had lower odds of ordering all recommended testing compared to participants practicing less than 10 years (OR[95% CI]: 0.5[0.3–0.9]). Eighty-five percent of participants recommended additional tests, which resulted in a 23% increased total per patient cost of the clinical evaluation.
Recommendations for a hypothetical case scenario may differ from that of actual patients.
Adherence to the recommended clinical testing for the diagnosis and management of CKD was poor and additional testing was associated with substantially increased cost of the clinical evaluation. Improved clarity, dissemination, and uptake of existing guidelines are needed to improve quality and decrease costs of care for patients with CKD.
chronic kidney disease; primary care providers; guidelines; KDOQI; cost