Rationale and design of a multicenter Chronic Kidney Disease (CKD) and at-risk for CKD electronic health records-based registry: CURE-CKD.

BACKGROUND: Chronic kidney disease (CKD) is a global public health problem, exhibiting sharp increases in incidence, prevalence, and attributable morbidity and mortality. There is a critical need to better understand the demographics, clinical characteristics, and key risk factors for CKD; and to develop platforms for testing novel interventions to improve modifiable risk factors, particularly for the CKD patients with a rapid decline in kidney function. METHODS: We describe a novel collaboration between two large healthcare systems (Providence St. Joseph Health and University of California, Los Angeles Health) supported by leadership from both institutions, which was created to develop harmonized cohorts of patients with CKD or those at increased risk for CKD (hypertension/HTN, diabetes/DM, pre-diabetes) from electronic health record data. RESULTS: The combined repository of candidate records included more than 3.3 million patients with at least a single qualifying measure for CKD and/or at-risk for CKD. The CURE-CKD registry includes over 2.6 million patients with and/or at-risk for CKD identified by stricter guide-line based criteria using a combination of administrative encounter codes, physical examinations, laboratory values and medication use. Notably, data based on race/ethnicity and geography in part, will enable robust analyses to study traditionally disadvantaged or marginalized patients not typically included in clinical trials. DISCUSSION: CURE-CKD project is a unique multidisciplinary collaboration between nephrologists, endocrinologists, primary care physicians with health services research skills, health economists, and those with expertise in statistics, bio-informatics and machine learning. The CURE-CKD registry uses curated observations from real-world settings across two large healthcare systems and has great potential to provide important contributions for healthcare and for improving clinical outcomes in patients with and at-risk for CKD.

Catalyzing Implementation of Evidence-Based Interventions in Safety Net Settings: A Clinical-Community Partnership in South Los Angeles.

This study is a process evaluation of a clinical-community partnership that implemented evidence-based interventions in clinical safety net settings. Adoption and implementation of evidence-based interventions in these settings can help reduce health disparities by improving the quality of clinical preventive services in health care settings with underserved populations. A clinical-community partnership model is a possible avenue to catalyze adoption and implementation of interventions amid organizational barriers to change. Three Federally Qualified Health Centers in South Los Angeles participated in a partnership led by a local community-based organization (CBO) to implement hypertension interventions. Qualitative research methods were used to evaluate intervention selection and implementation processes between January 2014 and June 2015. Data collection tools included a key participant interview guide, health care provider interview guide, and protocol for taking meeting minutes. This case study demonstrates how a CBO acted as an external facilitator and employed a collaborative partnership model to catalyze implementation of evidence-based interventions in safety net settings. The study phases observed included initiation, planning, and implementation. Three emergent categories of organizational facilitators and barriers were identified (personnel capacity, professional development capacity, and technological capacity). Key participants and health care providers expressed a high level of satisfaction with the collaborative and the interventions, respectively. The CBO's role as a facilitator and catalyst is a replicable model to promote intervention adoption and implementation in safety net settings. Key lessons learned are provided for researchers and practitioners interested in partnering with Federally Qualified Health Centers to implement health promotion interventions.

Predictors of hospital readmissions in adult patients with sickle cell disease.

BACKGROUND: Sickle cell disease (SCD) is the most common inherited blood disorder, affecting primarily Black and Hispanic individuals. In 2016, 30-day readmissions incurred 95,445 extra days of hospitalization, $152 million in total hospitalization costs, and $609 million in total hospitalization charges. OBJECTIVES: 1) To estimate hospital readmissions within 30 days among patients with SCD in the State of California. 2) Identify the factors associated with readmission within 30 days for SCD patients in California. METHODS: We conducted a retrospective observational study of adult SCD patients hospitalized in California between 2005 and 2014. Descriptive statistics and logistic regression models were used to examine significant differences in patient characteristics and their association with hospital readmissions. RESULTS: From 2,728 individual index admissions, 70% presented with single admission, 10% experienced one readmission, and 20% experienced ≥ two readmissions within 30 days. Significant predictors associated with zero vs. one readmission were male gender (OR=1.37, CI: 1.06-1.77), Black ethnicity (OR=3.27, CI: 1.71-6.27) and having Medicare coverage (OR=1.89, CI: 1.30-2.75). Lower likelihood of readmission was found in those with a Charlson Comorbidity index of three or more (OR=0.53, CI: 0.29-0.97). For zero vs. ≥ two readmissions, significant predictors were male gender (OR=1.43, CI: 1.17-1.74), Black ethnicity (OR=6.90, CI: 3.41-13.97), Hispanic ethnicity (OR=2.33, CI: 1.05-5.17), Medicare coverage (OR=3.58, CI: 2.68-4.81) and Medi-Cal coverage (OR=1.70, CI: 1.31-2.20). Lower likelihood for having two or more readmissions were associated with individuals aged 65+ (OR=0.97, CI: 0.96-0.98) and those with self-payment status (OR=0.32, CI: 0.12-0.54). CONCLUSIONS: In California, male, Black, and Hispanic patients, as well as those covered by Medicare or Medi-Cal, were found to have an increased risk of hospital readmissions. Redirecting outpatient goals to address these patient populations and risk factors is crucial for reducing readmission rates.

Patient education integrated with acupuncture for relief of cancer-related fatigue randomized controlled feasibility study.

BACKGROUND: Cancer-related fatigue (CRF) is a prominent clinical problem. There are calls for multi-modal interventions. METHODS: We assessed the feasibility of delivering patient education integrated with acupuncture for relief of CRF in a pilot randomized controlled trial (RCT) with breast cancer survivors using usual care as control. Social cognitive and integrative medicine theories guided integration of patient education with acupuncture into a coherent treatment protocol. The intervention consisted of two parts. First, patients were taught to improve self-care by optimizing exercise routines, improving nutrition, implementing some additional evidence-based cognitive behavioral techniques such as stress management in four weekly 50-minute sessions. Second, patients received eight weekly 50-minute acupuncture sessions. The pre-specified primary outcome, CRF, was assessed with the Brief Fatigue Inventory (BFI). Secondary outcomes included three dimensions of cognitive impairment assessed with the FACT-COGv2. RESULTS: Due to difficulties in recruitment, we tried several methods that led to the development of a tailored recruitment strategy: we enlisted oncologists into the core research team and recruited patients completing treatment from oncology waiting rooms. Compared to usual care control, the intervention was associated with a 2.38-point decline in fatigue as measured by the BFI (90% Confidence Interval from 0.586 to 5.014; p <0.10). Outcomes associated with cognitive dysfunction were not statistically significant. CONCLUSIONS: Patient education integrated with acupuncture had a very promising effect that warrants conducting a larger RCT to confirm findings. An effective recruitment strategy will be essential for the successful execution of a larger-scale trial. TRIAL REGISTRATION: NCT00646633.

High prevalence of stage 3 chronic kidney disease in older adults despite normal serum creatinine.

BACKGROUND: Serum creatinine is commonly used to diagnose chronic kidney disease (CKD), but may underestimate CKD in older adults when compared with using glomerular filtration rates (eGFR). The magnitude of this underestimation is not clearly defined. OBJECTIVE: Using the Modification of Diet in Renal Disease (MDRD) equation, to describe both the prevalence and the magnitude of underestimation of stage 3 CKD (GFR 30-59 ml/min/1.73 m(2)), as well as ideal serum creatinine cutoff values to diagnose stage 3 CKD among Americans > or =65 years of age. DESIGN: Cross-sectional. PARTICIPANTS: A total of 3,406 participants > or =65 years of age from the 1999-2004 National Health and Nutrition Examination Surveys (NHANES). MEASUREMENTS: Serum creatinine levels were used to determine eGFR from the MDRD equation. Information on clinical conditions was self-reported. RESULTS: Overall, 36.1% of older adults in the US have stage 3 or greater CKD as defined by eGFR values. Among older adults with stage 3 CKD, 80.6% had creatinine values < or =1.5 mg/dl, and 38.6% had creatinine values < or =1.2 mg/dl. Optimal cutoff values for serum creatinine in the diagnosis of stage 3 CKD in older adults were > or =1.3 mg/dl for men and > or =1.0 mg/dl for women, regardless of the presence or absence of hypertension, diabetes, or congestive heart failure. CONCLUSION: Use of serum creatinine underestimates the presence of advanced (stage 3 or greater) CKD among older adults in the US. Automated eGFR reporting may improve the accuracy of risk stratification for older adults with CKD.

The neighborhood food resource environment and the health of residents with chronic conditions: the food resource environment and the health of residents.

BACKGROUND: Residence in disadvantaged neighborhoods is associated with poorer access to healthy foods. OBJECTIVE: To understand associations between the neighborhood food resource environment and residents' health status and body mass index (BMI) for adults with and without chronic conditions. DESIGN: Cross-sectional multilevel analysis. PARTICIPANTS: 2,536 adults from the 2000-2001 Los Angeles Family and Neighborhood Survey. MEASUREMENTS: The food resource environment was defined as the number of chain supermarkets, independent supermarkets, small markets, or convenience stores per roadway miles in the census tract. The main dependent variables were self-rated health, dichotomized as excellent or fair/poor, and body mass index (BMI). Multilevel regression models examined the association between the food resource environment and both BMI and the odds of reporting excellent health after adjustment for neighborhood SES and individual characteristics. RESULTS: More chain supermarkets per roadway mile in a census tract was associated with higher adjusted rates of reporting excellent health (33%, 38%, and 43% for those in the lowest, middle, and highest tertiles of chain supermarkets) and lower adjusted mean BMI (27, 26, and 25 kg/m(2)) for residents without a chronic condition, but not those with a chronic condition. In contrast, having more convenience stores per roadway mile was associated with lower health ratings only among adults with a chronic condition (39%, 32%, and 27% for the lowest to highest tertile of convenience stores). CONCLUSION: Health status and BMI are associated with the local food environment, but the associations differ by type of market and presence of a chronic condition.

Can a chronic care model collaborative reduce heart disease risk in patients with diabetes?

BACKGROUND: There is a need to identify effective practical interventions to decrease cardiovascular disease risk in patients with diabetes. OBJECTIVE: We examine the impact of participation in a collaborative implementing the chronic care model (CCM) on the reduction of cardiovascular disease risk in patients with diabetes. DESIGN: Controlled pre- and postintervention study. PATIENTS/PARTICIPANTS: Persons with diabetes receiving care at 13 health care organizations exposed to the CCM collaborative and controls receiving care in nonexposed sites. MEASUREMENTS AND MAIN RESULTS: Ten-year risk of cardiovascular disease; determined using a modified United Kingdom Prospective Diabetes Study risk engine score. A total number of 613 patients from CCM intervention sites and 557 patients from usual care control sites met the inclusion criteria. The baseline mean 10-year risk of cardiovascular disease was 31% for both the intervention group and the control group. Participants in both groups had improved blood pressure, lipid levels, and HbA1c levels during the observation period. Random intercept hierarchical regression models showed that the intervention group had a 2.1% (95% CI -3.7%, -0.5%) greater reduction in predicted risk for future cardiovascular events when compared to the control group. This would result in a reduced risk of one cardiovascular disease event for every 48 patients exposed to the intervention. CONCLUSIONS: Over a 1-year interval, this collaborative intervention using the CCM lowered the cardiovascular disease risk factors of patients with diabetes who were cared for in the participating organization's settings. Further work could enhance the impact of this promising multifactorial intervention on cardiovascular disease risk reduction.

Health insurance status and hypertension monitoring and control in the United States.

BACKGROUND: In this study, we examined whether insurance status (private, Medicare, Medicaid, no insurance) was associated with the odds of blood pressure (BP) monitoring and control. METHODS: We used data from the National Health and Nutrition Examination Surveys (NHANES) conducted in 1999 through 2002, defining hypertension as either self-report of elevated BP or an elevated BP value on examination. We conducted multivariate analyses adjusting for age, income, race/ethnicity, body mass index, and medical comorbidities. RESULTS: Among all hypertensive participants, only 58% of the uninsured had a BP check within 6 months, compared to 82% of the privately insured. Overall, uninsured individuals (adjusted odds ratio 0.63, 95% CI 0.44-0.92) were at lower odds of adequate BP control than the privately insured. Among treated participants, the uninsured were at lower odds of adequate control (adjusted OR 0.42, 95% CI 0.23-0.73) than the privately insured. Among participants who self-reported hypertension but were not taking antihypertensive medications, the odds of elevated BP did not differ by insurance status. No differences in BP control were observed for participants with Medicare or Medicaid compared to those with private insurance, in any comparisons. CONCLUSIONS: Lack of insurance is associated with lower rates of BP control among treated hypertensives, whereas the odds of elevated BP are similar among untreated hypertensives with different insurance status. Variation in BP control between the uninsured and privately insured with hypertension is likely related to differences in appropriate treatment intensification or adherence, rather than differences in rates of treatment initiation.

Racial and ethnic differences in utilization of health services in patients with diabetes enrolled in medicaid.

We evaluated racial and ethnic differences in use of medical care between patients with diabetes enrolled in Medicaid and explored whether differences varied by state Medicaid program. Using data from 137,006 patients we created a multivariable Poisson regression model to examine the effect of race on ambulatory care visits, emergency ward visits, and hospitalization rates for patients with diabetes mellitus enrolled in three state Medicaid programs. We found significant differences in service use between groups, which varied depending on state. For example, black patients compared with whites had significantly fewer outpatient visits but more hospitalizations in New Jersey; by contrast, blacks had higher outpatient visit rates and lower hospitalization rates in Georgia. Racial and ethnic differences in health service use among Medicaid enrollees were not consistent across states, suggesting that local factors, including varied Medicaid policies, may affect racial and ethnic differences in use of health care services.

Chronic Kidney Disease-A Quiet Revolution in Nephrology: Six Case Studies.

This article describes a study that examines changes in nephrology as it evolves from a focus on end-stage renal disease (ESRD) to the treatment of earlier stages of chronic kidney disease (CKD). Once patients reach ESRD, treatments are limited to kidney transplantation and dialysis. However, the progression of earlier stages of CKD can be slowed, halted, or reversed when treated. Data from 15 clinics focusing on CKD were examined, with the focus on six case studies. Clinics are still establishing best-practice models, and reimbursement remains a challenge. Recommendations also include widespread education for primary care physicians on how to interpret levels of kidney function and on referral of patients with decreased kidney function to nephrologists before ESRD is reached.

Characteristics of the original patient navigation programs to reduce disparities in the diagnosis and treatment of breast cancer.

BACKGROUND: Patient navigation is an intervention developed to reduce disparities in cancer care that is being widely replicated and receiving considerable support for demonstration projects and research to test its effectiveness. In the current study, the authors present an in-depth descriptive analysis of the original patient navigation programs to inform current and future program development. METHODS: A qualitative multistakeholder case study using interviews and site visits of the first patient navigation site and 2 sites subsequently developed by the leadership of the original site were evaluated. RESULTS: At these sites, patient navigation is a system, as opposed to a person, comprised primarily of navigators and directors that work together to remove barriers and facilitate access in a well-defined course of care; navigators were from the community or were culturally similar to the patient population served but were also paid employees of the clinical care site with detailed knowledge of the clinical course patients must traverse to complete care plans. Directors had administrative authority over the clinical facility and social capital across institutions, and communicated regularly and openly with navigators to implement system level changes to remove barriers to care. Contextual factors such as policies supporting breast cancer care also influenced the implementation of these programs. CONCLUSIONS: The first patient navigation programs combined community and culturally sensitive care-coordination with aspects of disease management programs to reduce racial, ethnic, and poverty-driven disparities in care. Future efforts to replicate and evaluate patient navigation should take into account these unique aspects of the original patient navigation programs.

Community-partnered approaches to enhance chronic kidney disease awareness, prevention, and early intervention.

There is a need to increase community involvement in addressing the growing burden of chronic kidney disease (CKD). Community-partnered participatory research (CPPR) is a collaborative approach that equitably involves academic, community, and professional partners in research, and the development of shared goals and of interventional programs to attain these goals. We present a case study of the processes, strategies, and activities concerning the interface of World Kidney Day goals and community-academic partnerships using a CPPR model focused on CKD. We show that CPPR methods can be used to (1) bring together community and academic leaders around goal sharing and research agenda development, (2) convene a community/professional conference aimed at knowledge transfer and data collection among partners, and (3) develop workgroups from a diverse group of participants to collaborate in community partnered strategies to reduce the burden of CKD. Participants included health care professionals, patients, faith-based professionals, government employees and officials, academics, caregivers, and community members. Follow-up workgroups developed action plans to address shared concerns. Using CPPR practices and principles, we were able to incorporate World Kidney Day objectives with community-derived goals to develop a community-partnered infrastructure, shared objectives, and workgroups to reduce the burden of chronic kidney disease.

Evolving trends in medical care-coordination for patients with HIV and AIDS.

HIV/AIDS is a condition characterized by a variety of medical and social needs that affect individuals over time. System-level problems of access, rising costs of care, and varying quality of HIV/AIDS care in addition to the individual barriers to care such as stigma, perceived discrimination, competing needs, and co-morbid conditions have highlighted the importance of using comprehensive approaches to care delivery. Several types of services have been proposed to improve care coordination for various diseases, including case management, community health workers, promotoras, and patient navigators. In this paper, we will review the characteristics of care coordination interventions for persons with HIV and the findings in the literature about their association with HIV health outcomes. We will conclude with a discussion of the implications and important areas for further investigations on this topic.