Comparing Mortality of Peritoneal and Hemodialysis Patients in an Era of Medicare Payment Reform.

BACKGROUND: Prior studies have shown peritoneal dialysis (PD) patients to have lower or equivalent mortality to patients who receive in-center hemodialysis (HD). Medicare's 2011 bundled dialysis prospective payment system encouraged expansion of home-based PD with unclear impacts on patient outcomes. This paper revisits the comparative risk of mortality between HD and PD among patients with incident end-stage kidney disease initiating dialysis in 2006-2013. RESEARCH DESIGN: We conducted a retrospective cohort study comparing 2-year all-cause mortality among patients with incident end-stage kidney disease initiating dialysis via HD and PD in 2006-2013, using data from the US Renal Data System and Medicare. Analysis was conducted using Cox proportional hazards models fit with inverse probability of treatment weighting that adjusted for measured patient demographic and clinical characteristics and dialysis market characteristics. RESULTS: Of the 449,652 patients starting dialysis between 2006 and 2013, the rate of PD use in the first 90 days increased from 9.3% of incident patients in 2006 to 14.2% in 2013. Crude 2-year mortality was 27.6% for patients dialyzing via HD and 16.7% for patients on PD. In adjusted models, there was no evidence of mortality differences between PD and HD before and after bundled payment (hazard ratio, 0.96; 95% confidence interval, 0.89-1.04; P=0.33). CONCLUSIONS: Overall mortality for HD and PD use was similar and mortality differences between modalities did not change before versus after the 2011 Medicare dialysis bundled payment, suggesting that increased use of home-based PD did not adversely impact patient outcomes.

Greater mindfulness associated with lower pain, fatigue, and psychological distress in women with metastatic breast cancer.

OBJECTIVE: Women with metastatic breast cancer (MBC) report high levels of disease-related symptoms including pain, fatigue, psychological distress, and sleep disturbance. Mindfulness may be particularly relevant to women with MBC given the high symptom burden and psychological toll of this disease; however, the topic is understudied among this patient population. Therefore, we aimed to test the associations between mindfulness and patient-reported symptoms among a sample of women with MBC. METHODS: Sixty-four women with MBC completed baseline questionnaires of mindfulness (Five Facet Mindfulness Questionnaire-Short Form [FFMQ-SF]) and symptoms of pain severity and interference, fatigue, psychological distress, and sleep disturbance as part of a randomized controlled trial of a Mindful Yoga intervention. Correlational analyses of data collected at baseline tested associations between the five mindfulness facets (observing, describing, acting with awareness, nonjudging, and nonreactivity) and patient-reported measures of symptoms. RESULTS: Overall, higher mindfulness was associated with lower symptom levels including lower pain severity, pain interference, fatigue, anxiety, depression, and sleep disturbance. However, degree of association varied by mindfulness facet. Nonreactivity, nonjudging, and describing showed the most frequent associations and largest effect sizes across symptoms, while observing showed the least frequent associations and lowest effect sizes. CONCLUSIONS: Mindfulness-and in particular nonreactivity, nonjudging, and describing-may be a personal resource for women with MBC in coping with complex symptoms of this life-threatening illness. Findings are discussed relative to their implications for interventions aimed at increasing mindfulness in this vulnerable population.

Health Coaching Has Differential Effects on Veterans with Limited Health Literacy and Numeracy: a Secondary Analysis of ACTIVATE.

BACKGROUND: Health coaching is an effective behavior change strategy. Understanding if there is a differential impact of health coaching on patients with low health literacy has not been well investigated. OBJECTIVE: To determine whether a telephone coaching intervention would result in similar improvements in enrollment in prevention programs and patient activation among Veterans with low versus high health literacy (specifically, reading literacy and numeracy). DESIGN: Secondary analysis of a randomized controlled trial. PARTICIPANTS: Four hundred seventeen Veterans with at least one modifiable risk factor: current smoker, BMI ≥ 30, or < 150 min of moderate physical activity weekly. METHODS: A single-item assessment of health literacy and a subjective numeracy scale were assessed at baseline. A logistic regression and general linear longitudinal models were used to examine the differential impact of the intervention compared to control on enrollment in prevention programs and changes in patient activation measures (PAM) scores among patients with low versus high health literacy. RESULTS: The coaching intervention resulted in higher enrollment in prevention programs and improvements in PAM scores compared to usual care regardless of baseline health literacy. The coaching intervention had a greater effect on the probability of enrollment in prevention programs for patients with low numeracy (intervention vs control difference of 0.31, 95% CI 0.18, 0.45) as compared to those with high numeracy (0.13, 95% CI - 0.01, 0.27); the low compared to high differential effect was clinically, but not statistically significant (0.18, 95% CI - 0.01, 0.38; p = 0.07). Among patients with high numeracy, the intervention group had greater increases in PAM as compared to the control group at 6 months (mean difference in improvement 4.8; 95% CI 1.7, 7.9; p = 0.003). This led to a clinically and statistically significant differential intervention effect for low vs high numeracy (- 4.6; 95% CI - 9.1, - 0.15; p = 0.04). CONCLUSIONS: We suggest that health coaching may be particularly beneficial in behavior change strategies in populations with low numeracy when interpretation of health risk information is part of the intervention. CLINICALTRIALS. GOV IDENTIFIER: NCT01828567.

A Coaching by Telephone Intervention on Engaging Patients to Address Modifiable Cardiovascular Risk Factors: a Randomized Controlled Trial.

BACKGROUND: A large proportion of deaths and chronic illnesses can be attributed to three modifiable risk factors: tobacco use, overweight/obesity, and physical inactivity. OBJECTIVE: To test whether telephone-based health coaching after completion of a comprehensive health risk assessment (HRA) increases patient activation and enrollment in a prevention program compared to HRA completion alone. DESIGN: Two-arm randomized trial at three sites. SETTING: Primary care clinics at Veterans Affairs facilities. PARTICIPANTS: Four hundred seventeen veterans with at least one modifiable risk factor (BMI ≥ 30, < 150 min of at least moderate physically activity per week, or current smoker). INTERVENTION: Participants completed an online HRA. Intervention participants received two telephone-delivered health coaching calls at 1 and 4 weeks to collaboratively set goals to enroll in, and attend structured prevention programs designed to reduce modifiable risk factors. MEASUREMENTS: Primary outcome was enrollment in a structured prevention program by 6 months. Secondary outcomes were Patient Activation Measure (PAM) and Framingham Risk Score (FRS). RESULTS: Most participants were male (85%), white (50%), with a mean age of 56. Participants were eligible, because their BMI was ≥ 30 (80%), they were physically inactive (50%), and/or they were current smokers (39%). When compared to HLA only at 6 months, health coaching intervention participants reported higher rates of enrollment in a prevention program, 51 vs 29% (OR = 2.5; 95% CI: 1.7, 3.9; p < 0.0001), higher rates of program participation, 40 vs 23% (OR = 2.3; 95% CI: 1.5, 3.6; p = 0.0004), and greater improvement in PAM scores, mean difference 2.5 (95% CI: 0.2, 4.7; p = 0.03), but no change in FRS scores, mean difference 0.7 (95% CI - 0.7, 2.2; p = 0.33). CONCLUSIONS: Brief telephone health coaching after completing an online HRA increased patient activation and increased enrollment in structured prevention programs to improve health behaviors. CLINICALTRIALS. GOV IDENTIFIER: NCT01828567.

Practical Telemedicine for Veterans with Persistently Poor Diabetes Control: A Randomized Pilot Trial.

BACKGROUND: Telemedicine-based diabetes management improves outcomes versus clinic care but is seldom implemented by healthcare systems. In order to advance telemedicine-based management as a practical option for veterans with persistent poorly controlled diabetes mellitus (PPDM) despite clinic-based care, we evaluated a comprehensive telemedicine intervention that we specifically designed for delivery using existing Veterans Health Administration (VHA) clinical staffing and equipment. MATERIALS AND METHODS: We conducted a 6-month randomized trial among 50 veterans with PPDM; all maintained hemoglobin A1c (HbA1c) levels continuously >9.0% for >1 year despite clinic-based management. Participants received usual care or a telemedicine intervention combining telemonitoring, medication management, self-management support, and depression management; existing VHA clinical staff delivered the intervention. Using linear mixed models, we examined HbA1c, diabetes self-care (measured by the Self-Care Inventory-Revised questionnaire), depression, and blood pressure. RESULTS: At baseline, the model-estimated common HbA1c intercept was 10.5%. By 6 months, estimated HbA1c had improved by 1.3% for intervention participants and 0.3% for usual care (estimated difference, -1.0%, 95% confidence interval [CI], -2.0%, 0.0%; p = 0.050). Intervention participants' diabetes self-care (estimated difference, 7.0; 95% CI, 0.1, 14.0; p = 0.047), systolic blood pressure (-7.7 mm Hg; 95% CI, -14.8, -0.6; p = 0.035), and diastolic blood pressure (-5.6 mm Hg; 95% CI, -9.9, -1.2; p = 0.013) were improved versus usual care by 6 months. Depressive symptoms were similar between groups. CONCLUSIONS: A comprehensive telemedicine intervention improved outcomes among veterans with PPDM despite clinic-based care. Because we specifically designed this intervention with scalability in mind, it may represent a practical, real-world strategy to reduce the burden of poor diabetes control among veterans.

The feasibility and acceptability of a chaplain-led intervention for caregivers of seriously ill patients: A Caregiver Outlook pilot study.

OBJECTIVE: When caring for a loved one with a life-limiting illness, a caregiver's own physical, emotional, and spiritual suffering can be profound. While many interventions focus on physical and emotional well-being, few caregiver interventions address existential and spiritual needs and the meaning that caregivers ascribe to their role. To evaluate the feasibility and acceptability of the process and content of Caregiver Outlook, we employed a manualized chaplain-led intervention to improve well-being by exploring role-related meaning among caregivers of patients with a life-limiting illness. METHOD: We conducted a single-arm pre-post pilot evaluation among caregivers of patients with advanced cancer or amyotrophic lateral sclerosis (ALS). Caregivers completed three chaplain-led intervention sessions focusing on (1) a relationship review, (2) forgiveness, and (3) legacy. Outcomes administered at baseline and at 1 and 2 weeks after the intervention included quality of life, anxiety, depression, spiritual well-being, religious coping, caregiver burden, and grief. RESULTS: The sample (N = 31) included a range of socioeconomic status groups, and the average age was approximately 60 years. A third of them worked full-time. Some 74% of our participants cared for a spouse or partner, and the other quarter of the sample cared for a parent (13%), child (10%), or other close family member (3%). At baseline, participants did not demonstrate clinical threshold levels of anxiety, depression, or other indicators of distress. Outcomes were stable over time. The qualitative results showed the ways in which Caregiver Outlook was assistive: stepping back from day-to-day tasks, the opportunity to process emotions, reflecting on support received, provoking thoughts and emotions between sessions, discussing role changes, stimulating communication with others, and the anonymity of a phone conversation. Both religious and nonreligious participants were pleased with administration of the chaplain intervention. SIGNIFICANCE OF RESULTS: The acceptability and feasibility of Caregiver Outlook were demonstrated among caregivers of patients with an advanced illness. Our pilot findings suggest minor modifications to study participant screening, interventionist guidance, and the study measures.

Prescriber continuity and medication adherence for complex patients.

BACKGROUND: Medication adherence is a critical aspect of managing cardiometabolic conditions, including diabetes, hypertension, dyslipidemia, and heart failure. Patients who have multiple cardiometabolic conditions and multiple prescribers may be at increased risk for nonadherence. OBJECTIVE: The purpose of this study was to examine the relationship between number of prescribers, number of conditions, and refill adherence to oral medications to treat cardiometabolic conditions. METHODS: In this retrospective cohort study, 7933 veterans were identified with 1 to 4 cardiometabolic conditions. Refill adherence to oral medications for diabetes, hypertension, and dyslipidemia was measured using an administrative claims-based continuous multiple-interval gap (CMG) that estimates the percentage of days a patient did not possess medication. We dichotomized refill adherence for each condition as a CMG ≤20% for each year of analysis. Condition-specific logistic regression models estimated the relationship between refill adherence and number of cardiometabolic conditions and number of prescribers, controlling for demographic characteristics, other comorbidities, and a count of cardiometabolic drug classes used. RESULTS: Compared with patients with 1 prescriber, antihypertensive refill adherence was lower in patients seeing ≥4 prescribers (odds ratio [OR] = 0.69; 95% CI = 0.59-0.80), but the number of cardiometabolic conditions was not a significant predictor. Antidyslipidemia refill adherence was lower in patients seeing 3 prescribers (OR = 0.80; 95% CI = 0.70-0.92) or ≥4 prescribers (OR = 0.77; 95% CI = 0.64-0.91). Conversely, antidyslipidemia refill adherence improved with the number of cardiometabolic conditions, but differences were only statistically significant for ≥3 conditions (OR = 1.31; 95% CI = 1.09-1.57). In multivariate regression models, the number of conditions and number of prescribers were not significant predictors of refill adherence in the group of patients with diabetes. CONCLUSIONS: Effective management of care and medication regimens for complex patients remains an unresolved challenge, but these results suggest that medication refill adherence might be improved by minimizing the number of prescribers involved in a patient's care, at least for hypertension and dyslipidemia.

The intersection of patient complexity, prescriber continuity and acute care utilization.

BACKGROUND: Care continuity is considered a critical characteristic of high-performing health systems. Few studies have examined the continuity of medication management of complex patients, who often have multiple providers and complex medication regimens. PURPOSE: The purpose of this study was to characterize patient factors associated with having more prescribers and the association between number of prescribers and acute care utilization. DESIGN AND SUBJECTS: A retrospective cohort study was conducted of 7,933 Veterans with one to four cardiometabolic conditions (diabetes, hypertension, hyperlipidemia or congestive heart failure) and prescribed medications for these conditions in 2008. MAIN MEASURES: The association between number of cardiometabolic conditions and prescribers was modeled using Poisson regression. The number of cardiometabolic conditions and number of prescribers were modeled to predict probability of inpatient admission, probability of emergency room (ER) visits, and number of ER visits among ER users. Demographic characteristics, number of cardiometabolic medications and comorbidities were included as covariates in all models. KEY RESULTS: Patients had more prescribers if they had more cardiometabolic conditions (p < 0.001). The adjusted odds of an ER visit increased with the number of prescribers (two prescribers, Odds Ratio (OR) = 1.16; three prescribers, OR = 1.21; 4+ prescribers, OR = 1.39), but not with the number of conditions. Among ER users, the number of ER visits was neither associated with the number of prescribers nor the number of conditions. The adjusted odds of an inpatient admission increased with the number of prescribers (two prescribers, OR = 1.27; three prescribers, OR = 1.30; 4+ prescribers, OR = 1.34), but not with the number of conditions. CONCLUSIONS: Having more prescribers was associated with greater healthcare utilization for complex patients, despite adjustment for the number of conditions and medications. The number of prescribers may be an appropriate target for reducing acute care utilization by complex patients.

Health care utilization before and after an outpatient ED visit in older people.

BACKGROUND: Older adults in the United States receive a significant amount of care in the emergency department (ED), yet the associations between ED and other types of health care utilization have not been adequately studied in this population. OBJECTIVES: The goals of this study were to examine the relationships between health care use before and after an ED visit among older adults. METHODS: This retrospective cohort study examined health care use among 308 patients 65 years or older discharged from a university-affiliated ED. Proportional-hazards models were used to assess the relationship between pre-ED health care use (primary care physician [PCP], specialist, ED, and hospital) and risk of return ED visits. RESULTS: Older ED patients in this study had visited other types of providers frequently in the previous year (median number of PCP and specialist visits, 4). Patients who used the ED on 2 or more occasions in the previous year were found to have visited their PCP more often than those without frequent ED use (median number of visits, 7.0 vs 4.0; P < .001). Despite more PCP use in this population, frequent ED use was associated with increased risk of a repeat ED visit (hazard ratio, 2.20; 95% confidence interval, 1.15-4.21), in models adjusted for demographics and health status. CONCLUSION: Older adults who use the ED are also receiving significant amounts of care from other sources; simply providing additional access to care may not improve outcomes for these vulnerable individuals.

Racial and Ethnic Differences in Communication Quality During Family-Centered Rounds.

OBJECTIVES: To evaluate racial and ethnic differences in communication quality during family centered rounds. METHODS: We conducted an observational study of family-centered rounds on hospital day 1. All enrolled caregivers completed a survey following rounds and a subset consented to audio record their encounter with the medical team. We applied a priori defined codes to transcriptions of the audio-recorded encounters to assess objective communication quality, including medical team behaviors, caregiver participatory behaviors, and global communication scores. The surveys were designed to measure subjective communication quality. Incident Rate Ratios (IRR) were calculated with regression models to compare the relative mean number of behaviors per encounter time minute by race and ethnicity. RESULTS: Overall, 202 of 341 eligible caregivers completed the survey, and 59 had accompanying audio- recorded rounds. We found racial and ethnic differences in participatory behaviors: English-speaking Latinx (IRR 0.5; 95% confidence interval [CI] 0.3-0.8) Black (IRR 0.6; 95% CI 0.4-0.8), and Spanish-speaking Latinx caregivers (IRR 0.3; 95% CI 0.2-0.5) participated less than white caregivers. Coder-rated global ratings of medical team respect and partnership were lower for Black and Spanish-speaking Latinx caregivers than white caregivers (respect 3.1 and 2.9 vs 3.6, P values .03 and .04, respectively: partnership 2.4 and 2.3 vs 3.1, P values .03 and .04 respectively). In surveys, Spanish-speaking caregivers reported lower subjective communication quality in several domains. CONCLUSIONS: In this study, Black and Latinx caregivers were treated with less partnership and respect than white caregivers.

Caregiver Inclusivity and Empowerment During Family-Centered Rounds.

OBJECTIVE: Despite widespread adoption of family-centered rounds, few have investigated differences in the experience of family-centered rounds by family race and ethnicity. The purpose of this study was to explore racial and ethnic differences in caregiver perception of inclusion and empowerment during family-centered rounds. METHODS: We identified eligible caregivers of children admitted to the general pediatrics team through the electronic health record. Surveys were completed by 99 caregivers (47 non-Latinx White and 52 Black, Latinx, or other caregivers of color). To compare agreement with statements of inclusivity and empowerment, we used the Wilcoxon rank sum test in unadjusted analyses and linear regression for the adjusted analyses. RESULTS: Most (91%) caregivers were satisfied or extremely satisfied with family-centered rounds. We found no differences by race or ethnicity in statements of satisfaction or understanding family-centered rounds content. However, in both unadjusted and adjusted analyses, we found that White caregivers more strongly agreed with the statements "I felt comfortable participating in rounds," "I had adequate time to ask questions during rounds," and "I felt a valued member of the team during rounds" compared with Black, Latinx, and other caregivers of color. CONCLUSIONS: Congruent with studies of communication in other settings, caregivers of color may experience barriers to inclusion in family-centered rounds, such as medical team bias, less empathic communication, and shorter encounters. Future studies are needed to better understand family-centered rounds disparities and develop interventions that promote inclusive rounds.

Trends in Regional Supply of Peritoneal Dialysis in an Era of Health Reform, 2006 to 2013.

Peritoneal dialysis (PD), a home-based treatment for kidney failure, is associated with similar mortality, higher quality of life, and lower costs compared with hemodialysis. Yet <10% of patients receive PD. Access to this alternative treatment, vis-à-vis providers' supply of PD services, may be an important factor but has been sparsely studied in the current era of national payment reform for dialysis care. We describe temporal and regional variation in PD supply among Medicare-certified dialysis facilities from 2006 to 2013. The average proportion of facilities offering PD per hospital referral region increased from 40% (2006) to 43% (2013). PD supply was highest in hospital referral regions with higher percentage of facilities in urban areas (p = .004), prevalence of PD use (p < .0001), percentage of White end-stage renal disease patients (p = .02), and per capita income (p = .02). Disparities in PD access persist in rural, non-White, and low-income regions. Policy efforts to further increase regional PD supply should focus on these underserved communities.

Association of Provider Perspectives on Race and Racial Health Care Disparities with Patient Perceptions of Care and Health Outcomes.

Purpose: Research suggests that providers contribute to racial disparities in health outcomes. Identifying modifiable provider perspectives that are associated with decreased racial disparities will help in the design of effective educational interventions for providers. Methods: This cross-sectional study investigated the association between primary care provider (PCP) perspectives on race and racial disparities with patient outcomes. Results: Study participants included 40 PCPs (70% White, 30% racial minority) caring for 55 patients (45% White, 55% Black) with type 2 diabetes mellitus. Associations of provider perspectives on race and racial disparities with patient variables (Interpersonal Processes of Care [IPC] Survey, which measures patient's ratings of their provider's interpersonal skills; medication adherence; glycemic control) were measured using Spearman correlation coefficients. Results suggest that Black patients of providers who reported greater skill in caring for Black patients had more positive perceptions of care in three of four IPC subdomains (Spearman correlation coefficients of -0.43, 0.44, 0.46, all with p<0.05); however, Black patients of providers who believe that racial disparities are highly prevalent had more negative perceptions of care in three of four IPC subdomains (Spearman correlation coefficients of 0.38, -0.53, -0.51, all with p<0.05). These same provider characteristics had no correlation with outcomes of medication adherence and hemoglobin A1c (HbA1c) or among White patients. Conclusion: Findings suggest that Black patients of providers who felt better equipped to take care of Black patients had a better experience. Therefore, educational interventions for providers may be most effective if they focus on skill development rather than increasing awareness about racial disparities alone.

Trends in Peritoneal Dialysis Use in the United States after Medicare Payment Reform.

BACKGROUND AND OBJECTIVES: Peritoneal dialysis (PD) for ESKD is associated with similar mortality, higher quality of life, and lower costs compared with hemodialysis (HD), but has historically been underused. We assessed the effect of the 2011 Medicare prospective payment system (PPS) for dialysis on PD initiation, modality switches, and stable PD use. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: Using US Renal Data System and Medicare data, we identified all United States patients with ESKD initiating dialysis before (2006-2010) and after (2011-2013) PPS implementation, and observed their modality for up to 2 years after dialysis initiation. Using logistic regression models, we examined the associations between PPS and early PD experience (any PD 1-90 days after initiation), late PD use (any PD 91-730 days after initiation), and modality switches (PD-to-HD or HD-to-PD 91-730 days after initiation). We adjusted for patient, dialysis facility, and regional characteristics. RESULTS: Overall, 619,126 patients with incident ESKD received dialysis at Medicare-certified facilities, 2006-2013. Observed early PD experience increased from 9.4% before PPS to 12.6% after PPS. Observed late PD use increased from 12.1% to 16.1%. In adjusted analyses, PPS was associated with increased early PD experience (odds ratio [OR], 1.51; 95% confidence interval [95% CI], 1.47 to 1.55; P<0.001) and late PD use (OR, 1.47; 95% CI, 1.45 to 1.50; P<0.001). In subgroup analyses, late PD use increased in part due to an increase in HD-to-PD switches among those without early PD experience (OR, 1.59; 95% CI, 1.52 to 1.66; P<0.001) and a decrease in PD-to-HD switches among those with early PD experience (OR, 0.92; 95% CI, 0.87 to 0.98; P=0.004). CONCLUSIONS: More patients started, stayed on, and switched to PD after dialysis payment reform. This occurred without a substantial increase in transfers to HD.

Medicare's New Prospective Payment System on Facility Provision of Peritoneal Dialysis.

BACKGROUND AND OBJECTIVES: Peritoneal dialysis is a self-administered, home-based treatment for ESKD associated with equivalent mortality, higher quality of life, and lower costs compared with hemodialysis. In 2011, Medicare implemented a comprehensive prospective payment system that makes a single payment for all dialysis, medication, and ancillary services. We examined whether the prospective payment system increased dialysis facility provision of peritoneal dialysis services and whether changes in peritoneal dialysis provision were more common among dialysis facilities that are chain affiliated, located in nonurban areas, and in regions with high dialysis market competition. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: We conducted a longitudinal retrospective cohort study of n=6433 United States nonfederal dialysis facilities before (2006-2010) and after (2011-2013) the prospective payment system using data from the US Renal Data System, Medicare, and Area Health Resource Files. The outcomes of interest were a dichotomous indicator of peritoneal dialysis service availability and a discrete count variable of dialysis facility peritoneal dialysis program size defined as the annual number of patients on peritoneal dialysis in a facility. We used general estimating equation models to examine changes in peritoneal dialysis service offerings and peritoneal dialysis program size by a pre- versus post-prospective payment system effect and whether changes differed by chain affiliation, urban location, facility size, or market competition, adjusting for 1-year lagged facility-, patient with ESKD-, and region-level demographic characteristics. RESULTS: We found a modest increase in observed facility provision of peritoneal dialysis and peritoneal dialysis program size after the prospective payment system (36% and 5.7 patients in 2006 to 42% and 6.9 patients in 2013, respectively). There was a positive association of the prospective payment system with peritoneal dialysis provision (odds ratio, 1.20; 95% confidence interval, 1.13 to 1.18) and PD program size (incidence rate ratio, 1.27; 95% confidence interval, 1.22 to 1.33). Post-prospective payment system change in peritoneal dialysis provision was greater among nonurban (P<0.001), chain-affiliated (P=0.002), and larger-sized facilities (P<0.001), and there were higher rates of peritoneal dialysis program size growth in nonurban facilities (P<0.001). CONCLUSIONS: Medicare's 2011 prospective payment system was associated with more facilities' availability of peritoneal dialysis and modest growth in facility peritoneal dialysis program size. PODCAST: This article contains a podcast at https://www.asn-online.org/media/podcast/CJASN/2018_11_19_CJASNPodcast_18_12_.mp3.

Outcome by Gender in the Veterans Health Administration Motivating Overweight/Obese Veterans Everywhere Weight Management Program.

BACKGROUND: Few evaluations of the Veterans Health Administration Motivating Overweight/Obese Veterans Everywhere (MOVE!) weight management program have assessed 6-month weight change or factors associated with weight change by gender. MATERIALS AND METHODS: Analysis of administrative data from a national sample of veterans in the VA MOVE! RESULTS: A total of 62,882 participants were included, 14.6% were women. Compared with men, women were younger (49.6 years [standard deviation, SD, 10.8] vs. 59.3 years [SD, 9.8], p < 0.0001), less likely to be married (34.1% vs. 56.0%, p < 0.0001), and had higher rates of post-traumatic stress disorder (26.0% vs. 22.4%, p < 0.0001) and depression (49.3% vs. 32.9%, p < 0.001). The mean number of MOVE! visits attended by women was lower than men (5.6 [SD, 5.3] vs. 6.0 [SD, 5.9], p < 0.0001). Women, compared with men, reported lower rates of being able to rely on family or friends (35.7% vs. 40.8%, p < 0.0001). Observed mean percent change in weight for women was -1.5% (SD, 5.2) and for men was -1.9% (SD, 4.8, p < 0.0001). The odds of ≥5% weight loss were no different for women (body-mass index [BMI] >25 kg/m2) compared with men (BMI >25 kg/m2; odds ratio, 1.05 [95% confidence interval, 0.99-1.11; p = 0.13]). CONCLUSIONS: Women veterans lost less weight overall compared with men. There was no difference in the odds of achieving clinically significant weight loss by gender. The majority of women and men enrolled lost <5% weight despite being enrolled in a lifestyle intervention. Future studies should focus on identifying program- and participant-level barriers to weight loss.

Evaluation of a packaging approach to improve cholesterol medication adherence.

OBJECTIVES: Elevated low-density lipoprotein cholesterol (LDL-C) is a major modifiable risk factor for cardiovascular disease, a leading cause of death in the United States. Our goal was to evaluate a simple, scalable, and affordable medication packaging method for improving cholesterol medication adherence and subsequently lowering LDL-C levels. STUDY DESIGN: Mixed-method study. METHODS: This mixed-method study involved US military veterans with LDL-C levels greater than 130 mg/dL and/or less than 80% refill adherence of cholesterol-lowering medication in the last 12 months; they were randomized to an education-only (control) group or an adherence packaging intervention group. Adherence packaging group participants' statin medication was provided in special blister packaging labeled for daily use that included written reminder prompts. Outcomes included 12-month cholesterol medication possession ratio (MPR) for medication refills; baseline, 6-, and 12-month self-reported cholesterol medication use; LDL-C and high-density lipoprotein cholesterol (HDL-C) levels; and total cholesterol changes over 12 months. Qualitative evaluation of the intervention is presented as well. RESULTS: We enrolled 240 individuals (120 intervention, 120 control). Overall, 54.2% of the adherence packaging intervention group was adherent per MPR over 12 months compared with 46.6% of the education-only group (difference = 7.6%; 95% confidence interval, -5% to 20%; P ≤.24). Both arms reported improvements in self-reported cholesterol adherence at 12 months, and decreases in LDL-C, HDL-C, and total cholesterol were observed, but differences in change between arms were not statistically significant. Qualitatively, patients reported high levels of satisfaction with the blister package. CONCLUSIONS: In a sample of US veterans, prefilled calendared blister packaging provided an inexpensive method for improving cholesterol medication adherence.

Impacts of Geographic Distance on Peritoneal Dialysis Utilization: Refining Models of Treatment Selection.

OBJECTIVE: To examine the relationship between distance to dialysis provider and patient selection of dialysis modality, informed by the absolute distance from a patient's home and relative distance of alternative modalities. DATA SOURCES: U.S. Renal Data System. STUDY DESIGN: About 70,131 patients initiating chronic dialysis and 4,795 dialysis facilities in 2006. The primary outcome was patient utilization of peritoneal dialysis (PD). Independent variables included absolute distance between patients' home and the nearest hemodialysis (HD) facility, relative distance between patients' home and nearest PD versus nearest HD facilities, and their interaction. Logistic regression was used to model distance on PD use, controlling for patient and market characteristics. PRINCIPAL FINDINGS: Nine percent of incident dialysis patients used PD in 2006. There was a positive, nonlinear relationship between absolute distance to HD services and PD use (p < .0001), with the magnitude of the effect increasing at greater distances. In terms of relative distance, odds of PD use increased if a PD facility was closer or the same distance as the nearest HD facility (p = .006). Interaction of distance measures to dialysis facilities was not significant. CONCLUSIONS: Analyses of patient choice between alternative treatments should model distance to reflect all relevant dimensions of geographic access to treatment options.

Diabetes Quality of Care Before and After Implementation of a Resident Clinic Practice Partnership System.

Deficiencies in resident diabetes care quality may relate to continuity clinic design. This retrospective analysis compared diabetes care processes and outcomes within a traditional resident continuity clinic structure (2005) and after the implementation of a practice partnership system (PPS; 2009). Under PPS, patients were more likely to receive annual foot examinations (odds ratio [OR] = 11.6; 95% confidence interval [CI] = 7.2, 18.5), microalbumin screening (OR = 2.4; 95% CI = 1.6, 3.4), and aspirin use counseling (OR = 3.8; 95% CI = 2.5, 6.0) and were less likely to receive eye examinations (OR = 0.54; 95% CI = 0.36, 0.82). Hemoglobin A1c and lipid testing were similar between periods, and there was no difference in achievement of diabetes and blood pressure goals. Patients were less likely to achieve cholesterol goals under PPS (OR = 0.62; 95% CI = 0.39, 0.98). Resident practice partnerships may improve processes of diabetes care but may not affect intermediate outcomes.

Nonalcoholic steatohepatitis and nonalcoholic Fatty liver disease in young women with polycystic ovary syndrome.

CONTEXT: Nonalcoholic fatty liver disease and polycystic ovary syndrome (PCOS) are both associated with insulin resistance. Thus, women with PCOS may have an increased prevalence of nonalcoholic fatty liver disease, including nonalcoholic steatohepatitis (NASH). OBJECTIVE: The objective of the study was to determine the prevalence and characteristics of NASH and abnormal aminotransferase activity in women with PCOS. DESIGN: The study is a retrospective chart review. SETTING: The setting is an academic endocrinology clinic. PATIENTS: Patients were 200 women with PCOS, defined as irregular menses and hyperandrogenism. MAIN OUTCOME MEASURES: Biopsy-documented NASH and aminotransferase levels were the main outcome measures. RESULTS: Fifteen percent (29 of 200) had aspartate aminotransferase and/or alanine aminotransferase more than 60 U/liter. Women with aminotransferase elevations had lower high-density lipoprotein (HDL) (41 vs. 50 mg/dl, P = 0.006), higher triglycerides (174 vs. 129 mg/dl, P = 0.024), and higher fasting insulin (21 vs. 12 microIU/ml, P = 0.036) compared with women with normal aminotransferases. Six women (mean age 29 yr) with persistent aminotransferase elevations underwent liver biopsy. All six had NASH with fibrosis. Compared with the 194 of 200 PCOS women who did not undergo biopsy, women with biopsy-documented NASH had lower HDL (median 34 vs. 50 mg/dl, P < 0.001), and higher triglycerides (245 vs. 132 mg/dl, P = 0.025), fasting insulin (26 vs. 13 microIU/ml, P = 0.038), aspartate aminotransferase (144 vs. 22 U/liter, P < 0.001), and alanine aminotransferase (143 vs. 28 U/liter, P < 0.001). CONCLUSION: Abnormal aminotransferase activity is common in women with PCOS. Low HDL, high triglycerides, and high fasting insulin were associated with abnormal aminotransferase activity. Some women already had evidence of NASH with fibrosis. Further studies are needed to evaluate whether to screen PCOS women for liver disease at an earlier age than is currently recommended for the general population.