Determining the Association Between Continuity of Primary Care and Acute Care Use in Chronic Kidney Disease: A Retrospective Cohort Study.

PURPOSE: Acute care use is high among individuals with chronic kidney disease (CKD). It is unclear how relational continuity of primary care influences downstream acute care use. We aimed to determine if poor continuity of care is associated with greater rates of acute care use and decreased prescriptions for guideline-recommended drugs. METHODS: We conducted a population-based retrospective cohort study of adults with stage 3-4 CKD and ≥3 visits to a primary care clinician during the period April 1, 2011 to March 31, 2014 in Alberta, Canada. Continuity was calculated using the Usual Provider Continuity index. Descriptive statistics were used to summarize patient and acute care encounter characteristics. Adjusted rates and incidence rate ratios for all-cause and CKD-related ambulatory care-sensitive condition (ACSC) hospitalizations and emergency department (ED) visits were estimated using negative binomial regression. Adjusted odds ratios for prescription use were estimated by multivariable logistic regression. RESULTS: Among 86,475 patients with CKD, 51.3%, 30.0%, and 18.7% had high, moderate, and poor continuity of care, respectively. There were 77,988 all-cause hospitalizations, 6,489 ACSC-related hospitalizations, 204,615 all-cause ED visits, and 8,461 ACSC-related ED visits during a median follow-up of 2.3 years. Rates of all-cause and ACSC hospitalization and ED use increased with poorer continuity of care in a stepwise fashion across CKD stages. Patients with poor continuity were less likely to be prescribed a statin. CONCLUSIONS: Poor continuity of care is associated with increased acute care use among patients with CKD. Targeted strategies that strengthen patient-physician relationships and guide physicians regarding guideline-recommended prescribing are needed.

A Qualitative Content Analysis of Comments on Press Articles on Deemed Consent for Organ Donation in Canada.

BACKGROUND AND OBJECTIVES: In 2019, two Canadian provinces became the first jurisdictions in North America to pass deemed consent legislation to increase deceased organ donation and transplantation rates. We sought to explore the perspectives of the deemed consent legislation for organ donation in Canada from the viewpoint of individuals commenting on press articles. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: In this qualitative descriptive study, we extracted public comments regarding deemed consent from online articles published by four major Canadian news outlets between January 2019 and July 2020. A total of 4357 comments were extracted from 35 eligible news articles. Comments were independently analyzed by two research team members using a conventional content analysis approach. RESULTS: Commenters' perceptions of the deemed consent legislation for organ donation in Canada predominantly fit within three organizational groups: perceived positive implications of the bills, perceived negative implications of the bills, and key considerations. Three themes emerged within each group that summarized perspectives of the proposed legislation. Themes regarding the perceived positive implications of the bills included majority rules, societal effect, and prioritizing donation. Themes regarding the perceived negative implications of the bills were a right to choose, the potential for abuse and errors, and a possible slippery slope. Improving government transparency and communication, clarifying questions and addressing concerns, and providing evidence for the bills were identified as key considerations. CONCLUSIONS: If deemed consent legislation is meant to increase organ donation and transplantation, addressing public concerns will be important to ensure successful implementation.

Use of Google Analytics to Explore Dissemination Activities for an Online CKD Clinical Pathway: A Retrospective Study.

Background: Data on dissemination strategies that generate awareness of clinical pathways for kidney care are limited. Objective: This study reports the application of Google Analytics to describe the reach and use of the Chronic Kidney Disease Pathway (CKD-P) using a multi-faceted dissemination strategy. Design: The design of this study is a retrospective descriptive study. Setting: This study was conducted in Alberta, Canada. Patients: Individuals who accessed the CKD-P Web site between November 5, 2014, and May 31, 2019. Measurements: Dissemination activities included print, electronic, in-person meetings, and a laboratory prompt. We used Google Analytics over a 5-year period to evaluate the following CKD-P Web site user metrics: number of sessions, pageviews, visit duration, user path, and bounce rate (when an individual visits a single page of the Web site and leaves the Web site without interacting with additional pages). Methods: We plotted dissemination activities alongside Web site metrics using control charts and described the data using means and percentages. We performed chi-square test for trends to evaluate year-over-year usage. Results: There were 83 294 users, 90 805 sessions, and 231 684 pageviews. The overall bounce rate was 45.7%. Each user had an average of 1.5 sessions and a session duration of 2 minutes and 8 seconds. There was a significant positive trend for total annual users (P = .008), new users (P = .009), number of sessions (P = .006), and pageviews per day (P = .016). Limitations: We were unable to confirm if users were primary care providers and if word-of-mouth dissemination among providers/researchers drove people to use the CKD-P. Conclusions: Google Analytics was a useful and accessible tool for evaluating CKD-P reach and use trends. It was challenging to identify how individual dissemination activities contributed to CKD-P reach; however, repeated dissemination appeared to play a role in increasing CKD-P use. Trial registration: Not applicable-observational study design.

Contexte: Il existe peu de données sur les stratégies de diffusion pour sensibiliser les différents intervenants aux plans d'intervention en santé rénale. Objectif: Cette étude rend compte de l'utilization de Google Analytics pour décrire la portée et l'utilization d'un plan d'intervention en ligne pour l'insuffisance rénale chronique (CKD-P ­ Chronic Kidney Disease Pathway) à l'aide d'une stratégie de diffusion à plusieurs facettes. Conception de l'étude: Étude descriptive rétrospective. Cadre: Alberta, Canada. Sujets: Les individus ayant accédé au site Web CKD-P entre le 5 novembre 2014 et le 31 mai 2019. Mesures: Les activités de diffusion comprenaient des documents imprimés, des documents électroniques, des réunions en personne et un lien internet vers le site web de CKD-P lors de la transmission d'un résultat anormal de laboratoire. Nous avons utilisé Google Analytics pendant cinq ans pour évaluer les mesures suivantes pour les utilisateurs du site Web CKD-P: nombre de sessions, vues de page, durée des visites, chemin d'accès utilisateur et taux de rebond (lorsqu'une personne visite une seule page du site Web et le quitte sans interagir avec d'autres pages). Méthodologie: Les activités de diffusion et les paramètres du site Web sont présentés à l'aide de tableaux de contrôle, et les données à l'aide de moyennes et de pourcentages. Un test de Chi-Deux a servi à déterminer les tendances et évaluer l'utilization d'une année sur l'autre. Résultats: Nous avons répertorié 83 294 utilisateurs, 90 805 sessions et 231 684 pages consultées. Le taux de rebond global était de 45,7 %. En moyenne, chaque utilisateur comptait 1,5 session dont la durée moyenne était de 2 minutes 8 secondes. On a observé une tendance positive significative pour le nombre total annuel d'utilisateurs (P = 0,008), les nouveaux utilisateurs (P = 0,009), le nombre de sessions (P = 0,006) et les vues de pages par jour (P = 0,016). Limites: Il n'a pas été possible de confirmer si les utilisateurs étaient des fournisseurs de soins primaires et si la diffusion de bouche-à-oreille entre les fournisseurs/chercheurs avait amené les gens à utiliser CKD-P. Conclusion: Google Analytics s'est avéré un outil utile et accessible pour évaluer les tendances de portée et d'utilization de CKD-P. Il est difficile d'établir comment les activités de diffusion individuelles contribuent à la portée de CKD-P; la diffusion répétée semble néanmoins jouer un rôle dans l'augmentation de l'utilization de CKD-P. Enregistrement de l'essai: Sans objet ­ étude observationnelle.

Cost of Potentially Preventable Hospitalizations Among Adults With Chronic Kidney Disease: A Population-Based Cohort Study.

BACKGROUND: Prior studies report high hospitalization rates among patients with chronic kidney disease (CKD) and approximately 10% to 20.9% of hospitalizations are potentially preventable. OBJECTIVE: To determine the rate, proportion, and cost of potentially preventable hospitalizations and whether this varied by CKD category. DESIGN: Retrospective cohort study using population-based data. SETTING: Alberta, Canada. PATIENTS: All adults with an outpatient serum creatinine measurement between January 1 and December 31, 2017 in the Alberta Kidney Disease Network data repository. MEASUREMENTS: CKD risk categories were based on measures of proteinuria (where available), eGFR, and use of dialysis. Patients were linked to administrative data to capture frequency and cost of hospital encounters and followed until death or end of study (December 31, 2018). The outcomes of interest were the rate and cost of potentially preventable hospitalizations, as identified using the Canadian Institute for Health Information (CIHI)-defined ambulatory care sensitive condition (ACSC) algorithm and a CKD-related ACSC algorithm. METHODS: Unadjusted and adjusted rates per 1000-patient years, proportions, and cost attributable to preventable hospitalizations were identified for the cohort as a whole and for patients within each CKD risk category. RESULTS: Of the 1,110,895 adults with eGFR and proteinuria measurements, 181,422 had CKD. During a median follow-up of 1 year, there were 62,023 hospitalizations among patients with CKD resulting in a total cost of $946 million CAD; 6907 (11.1%) of these hospitalizations were for CIHI-defined ACSCs while 4323 (7.0%) were for CKD-related ACSCs. Adjusted rates of hospitalization for ACSCs increased with CKD risk category and were highest among patients treated with dialysis. Among CKD patients, the total cost of potentially preventable hospitalizations was $79 million and $58 million CAD for CIHI-defined and CKD-related ACSCs (8.4% and 6.2% of total hospitalization cost, respectively). LIMITATIONS: Based on the ACSC construct, we were unable to determine if these hospitalizations were truly preventable. CONCLUSIONS: Potentially preventable hospitalizations have a substantial cost and burden on the health care system among people with CKD. Effective strategies that reduce preventable admissions among CKD patients may lead to significant cost savings. TRIAL REGISTRATION: Not applicable-observational study design.

CONTEXTE: Des études antérieures font état de taux élevés d'hospitalization chez les patients atteints d'insuffisance rénale chronique (IRC). Environ 10% à 20,9 % de ces hospitalisations seraient évitables. OBJECTIFS: Établir l'incidence et la proportion des hospitalisations potentiellement évitables, de même que les coûts qui y sont attribuables, et vérifier si cela varie en fonction de la catégorie d'IRC. TYPE D'ÉTUDE: Étude de cohorte rétrospective menée à partir de données basées sur une population. CADRE: Alberta, Canada. SUJETS: Tous les adultes pour qui le référentiel de données du Alberta Kidney Disease Network disposait d'une mesure de créatinine sérique en consultation externe entre le 1er janvier et le 31 décembre 2017. MESURES: La mesure de protéinurie (lorsque disponible), le DFGe et la dialyze ont servi à établir les catégories de risque d'IRC. Les patients ont été couplés aux données administratives afin de saisir la fréquence des consultations à l'hôpital et le coût associé à celles-ci. Le suivi s'est poursuivi jusqu'au décès du patient ou jusqu'au 31 décembre 2018 (fin de l'étude). Les critères d'intérêt étaient l'incidence des hospitalisations évitables, de même que les coûts qui y sont attribuables; hospitalisations définies par l'algorithme de l'Institut canadien d'information sur la santé (ICIS) pour les conditions propices aux soins ambulatoires (CPSA) et par un algorithme des CPSA liées à l'IRC. MÉTHODOLOGIE: Les taux corrigés ou non pour 1000 années-patients et les proportions des hospitalisations évitables, de même que les coûts qui y sont attribuables, ont été déterminés pour l'ensemble de la cohorte et pour les patients de chaque catégorie de risque d'IRC. RÉSULTATS: Parmi les 1 110 895 adultes disposant de mesures de protéinurie et de DFGe, 181 422 étaient atteints d'IRC. Au cours d'un suivi médian d'un an, on a répertorié 62 023 hospitalisations de patients atteints d'IRC, ce qui représente un coût total de 946 millions de dollars canadiens. De ces hospitalisations, 6 907 (11,1 %) concernaient des CPSA définies par l'ICIS et 4 323 (7,0 %) concernaient des CPSA liées à l'IRC. Les taux corrigés d'hospitalization pour les CPSA augmentaient selon la catégorie de risque d'IRC et étaient plus élevés chez les patients dialysés. Chez les patients atteints d'IRC, le coût total des hospitalisations évitables s'établissait à 79 millions de dollars pour les CPSA définies par l'ICIS et à 58 millions de dollars canadiens pour les CPSA liées à l'IRC (respectivement 8,4 % et 6,2 % du coût total attribuable aux hospitalisations). LIMITES: La structure des CPSA ne nous a pas permis de déterminer si ces hospitalisations étaient effectivement évitables. CONCLUSION: Les hospitalisations évitables chez les patients atteints d'IRC représentent un fardeau et des coûts considérables pour le système de santé. Des stratégies efficaces qui permettraient de les réduire chez les patients atteints d'IRC entraîneraient des économies substantielles.

Optimizing Physician Payment Models to Address Health System Priorities: Perspectives from Specialist Physicians.

OBJECTIVE: Despite well-documented data on the mixed impact of physician payment models, there is limited evidence on how to enhance existing payment model designs. This study examines the approaches to optimizing payment models from the perspective of specialist physicians to better support patient and physician experience and other health system objectives. METHOD: Semi-structured interviews were conducted with 32 specialist physicians across Alberta, Canada. Data from the interviews were analyzed using a framework approach. RESULTS: Respondents emphasized the need to incentivize physicians with the right blend of financial and non-financial incentives, including physician wellness. Respondents also highlighted the need for physician involvement and accountability to optimize the value of physician payment models. CONCLUSION: To optimize physician payment models, it may be useful to include a blend of financial and non-financial incentives with clear accountability measures as this may better align physician practice with health system priorities.

Factors that influence specialist physician preferences for fee-for-service and salary-based payment models: A qualitative study.

Most physicians across the world are paid through fee-for-service. However, there is increased interest in alternative payment models such as salary, capitation, episode-based payment, pay-for-performance, and strategic blends of these models. Such models may be more aligned with broad health policy goals such as fiscal sustainability, delivery of high-quality care, and physician and patient well-being. Despite this, there is limited research on physicians' preferences for different models and a disproportionate focus on differences in income over other issues such as physician autonomy and purpose. Using qualitative interviews with 32 specialist physicians in Alberta, Canada, we examined factors that influence preferences for fee-for-service (FFS) and salary-based payment models. Our findings suggest that a series of factors relating to (1) physician characteristics, (2) payment model characteristics, and (3) professional interests influence preferences. Within these themes, flexibility, autonomy, and compatibility with academic roles were highlighted. To encourage physicians to select a specific payment model, the model must appeal to them in terms of income potential as well as non-monetary values. These findings can support constructive discussions about the merits of different payment models and can assist policy makers in considering the impact of payment reform.

Identifying Mobile Applications Aimed at Self-Management in People With Chronic Kidney Disease.

BACKGROUND: A growing number of mobile applications (apps) target people with chronic illness as the primary user. There is increasing evidence that digital technology can improve health outcomes for users but the sheer number of apps available is likely to overwhelm many potential users. OBJECTIVE: The purpose of this study was to systematically search for apps aimed at people with chronic kidney disease. An important secondary objective was to develop a search strategy that could be used to identify similar apps in the future. DESIGN: A systematic review of the scientific and gray literature including app stores, clearinghouses, and Google. SETTING/PATIENTS: The focus of this research was the identification of apps that may be of use to people interested in self-management of chronic kidney disease. METHODS: Three reviewers independently searched app stores, websites, and databases to identify apps of potential interest and any information related to the function and efficacy of these. Apps that met the inclusion criteria were short-listed, reviewed in more detail, and cross-referenced with other sources such as clearinghouses, Google, and kidney care organizations. A population, intervention, comparison, outcome, and design framework was used to search selected databases. RESULTS: Of the 1464 apps purporting to be for chronic kidney disease, only 15 were eligible for inclusion. Searching the 2 major app stores (iOS and Android) appeared to be the most productive way of identifying apps of potential interest. An increasing number of public and private clearinghouses have been established to assist users with finding apps. Privacy and security of user information is a particular and valid concern of health care professionals and organizations. LIMITATIONS: The breadth and depth of information relating to each app varied and made it difficult to systematize the evaluation of apps. Due to the large number of health care apps and the challenges to searching app stores and websites, it is possible that some apps were missed during our searches. Similarly, while there are many kidney care-related websites that contain useful information, these were not captured by our study. CONCLUSION: There are very few available apps aimed specifically at people with chronic kidney disease; those that are available are best identified by manually searching the 2 major app stores. Privacy and confidentiality of user information when using the apps is a concern among health care providers in particular.

CONTEXTE: Un nombre croissant d'applications (apps) mobiles cible les personnes atteintes d'une maladie chronique comme utilisateur principal. Il apparait de plus en plus évident que la technologie numérique peut améliorer l'état de santé des utilisateurs, mais ceux-ci pourraient être dépassés par la quantité effarante d'applications disponibles. OBJECTIFS: Cette étude visait à rechercher systématiquement les applications s'adressant aux personnes atteintes de néphropathie chronique. On souhaitait également élaborer une stratégie de recherche qui pourrait être employée ultérieurement pour repérer les applications similaires. TYPE D'ÉTUDE: Une revue systématique de la littérature scientifique et de la littérature grise, y compris des boutiques d'applications (app stores), des centres d'échange d'information en ligne et de Google. SUJET: On cherchait plus précisément à répertorier les applications susceptibles d'être utiles aux personnes intéressées par l'autogestion de leur insuffisance rénale. MÉTHODOLOGIE: Trois réviseurs ont scruté, de façon indépendante, les boutiques d'applications, les sites Web et les bases de données afin de repérer les applications présentant un intérêt potentiel et les renseignements relatifs à leur fonction et à leur efficacité. Les applications satisfaisant les critères d'inclusion ont été retenues, revues en détail et comparées avec celles provenant d'autres sources telles que les centres d'échange d'information, Google et les organismes de santé rénale. Un cadre de population, d'intervention, de comparaison, de résultats et de conception a été employé pour chercher dans les bases de données choisies. RÉSULTATS: Des 1 464 applications recensées qui prétendaient traiter de néphropathie chronique, seules quinze étaient admissibles à l'inclusion. Il appert que consulter les deux principales boutiques d'applications (iOS et Android) est la façon la plus efficace de repérer les applications présentant un intérêt potentiel. Un nombre grandissant de centres d'échange d'informations publics et privés ont été créés pour aider les utilisateurs à trouver des applications. L'utilisation de ces dernières soulève des préoccupations chez les professionnels de la santé et certains organismes en santé rénale qui s'inquiètent du respect de la vie privée des utilisateurs et de la confidentialité de leurs renseignements personnels. LIMITES: L'ampleur et la profondeur de l'information relative à chaque application variaient beaucoup et ont rendu difficile la systématisation de l'évaluation. Vu le très grand nombre d'applications en santé et de la difficulté de chercher dans les boutiques d'applications et sur les différents sites Web, il est possible que nos recherches n'aient pas recensé toutes les applications disponibles. Aussi, bien qu'il existe plusieurs sites Web traitant de santé rénale et contenant des renseignements utiles, ceux-ci n'ont pas été retenus par notre étude. CONCLUSION: Il existe très peu d'applications mobiles ciblant spécifiquement les personnes atteintes d'insuffisance rénale chronique. La meilleure façon de les repérer est encore de chercher manuellement dans les deux principales boutiques d'applications. L'utilisation de ces applications soulève des préoccupations de la part des fournisseurs de soins quant au respect de la vie privée et à la confidentialité des renseignements personnels des utilisateurs.

A Population-Based Analysis of Quality Indicators in CKD.

BACKGROUND AND OBJECTIVES: Awareness of CKD remains low in comparison with other chronic diseases, such as diabetes, leading to low use of preventive medications and appropriate testing. The objective of this study was to evaluate the quality of care provided to people with and at risk of CKD. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: We conducted a population-based analysis of all Albertans with eGFR=15-59 ml/min per 1.73 m2 between April 1, 2011 and March 31, 2012 as well as patients with diabetes (as of March 31, 2012). We assessed multiple quality indicators in people with eGFR=15-59 ml/min per 1.73 m2, including appropriate risk stratification with albuminuria testing and preventive medication use and screened people with diabetes using urine albumin-to-creatinine ratio and serum creatinine measurements. RESULTS: Among 96,480 adults with eGFR=15-59 ml/min per 1.73 m2, we found that 17.0% of those without diabetes were appropriately risk stratified with a measure of albuminuria compared with 64.2% of those with diabetes (P<0.001). Of those with eGFR=15-59 ml/min per 1.73 m2 and moderate or severe albuminuria, 63.2% of those without diabetes received an angiotensin-converting enzyme inhibitor or an angiotensin receptor blocker compared with 82.1% in those with diabetes (P<0.001). Statin use was also significantly lower in patients with eGFR=15-59 ml/min per 1.73 m2 without diabetes (39.2%) compared with those with diabetes (64.6%; P<0.001). Among 235,649 adults with diabetes, only 41.8% received a urine albumin-to-creatinine ratio and 73.2% received a serum creatinine measurement over 1 year. CONCLUSIONS: We identified large gaps in care, especially in those with CKD but no diabetes. The largest gap was in the prescription of guideline-concordant medication in those with CKD as well as appropriate screening for albuminuria in those with diabetes. Our work illustrates the importance of measuring health system performance as the first step in a quality improvement process to improve care and outcomes in CKD.

Trends in the Management of Patients With Kidney Failure in Alberta, Canada (2004-2013).

BACKGROUND: Based on clinical practice guidelines, specific quality indicators are examined to assess the performance of a health care system for patients with end-stage renal disease (ESRD). We examined trends in the proportion of patients with ESRD referred late to nephrology, timing of dialysis initiation in those with chronic kidney disease, and proportion of patients with ESRD treated with pre-emptive kidney transplantation or peritoneal dialysis (PD). Design:: This was a retrospective cohort study. Setting:: The study was conducted in Alberta, Canada. Patients:: Alberta residents aged 18 years or older with incident ESRD requiring renal replacement therapy between 2004 and 2013 were included. Measurements:: Descriptive statistics, and log binomial and linear regression models were used for analysis. Methods:: We determined the proportion of patients with ESRD who did not see a nephrologist within 90 days prior to starting dialysis (late referrals) and those who were receiving PD 90 days after dialysis initiation. Among those who had been seen by a nephrologist for at least 90 days, we also assessed the proportion who initiated dialysis with estimated glomerular filtration rate (eGFR) higher than or equal to 10.5 mL/min/1.73 m2, and underwent a pre-emptive transplant. Results:: Our cohort included 5343 patients (mean age 61.8 years, 61.2% male). Over a 10-year period, there was a decrease in the proportion of late referrals (26.4% to 21.1%, P = .001). We also noted a decrease in the proportion of dialysis initiation with eGFR higher than or equal to 10.5 mL/min/1.73 m2 (21.2% to 14.7%, P < .001), with a significant increase in the proportion of patients initiating dialysis as an inpatient (38.8% to 45.2%, P = .001). There was a non-significant decrease in both the proportion of patients treated with a pre-emptive transplant and PD at 90 days over the 10-year period. Limitations:: The use of administrative data restricted the availability of clinical data regarding underlying circumstances of each quality indicator, including patient symptoms, indications for dialysis initiation, and PD eligibility. CONCLUSIONS: We noted improvement in late referrals and early dialysis initiation over time. However, we also noted low and stable use of pre-emptive kidney transplantation and PD at 90 days, which warrants further exploration. These findings support the need for quality improvement initiatives designed to address these gaps in care and improve outcomes for patients with kidney failure.

MISE EN CONTEXTE: Les indicateurs de la qualité, lorsqu'ils s'appuient sur des preuves solides, permettent d'évaluer efficacement la performance d'un système de soins de santé, y compris les soins dispensés aux patients atteints d'insuffisance rénale terminale (IRT). Nous avons examiné les tendances en matière d'indicateurs de la qualité, y compris la proportion de patients orientés tardivement en néphrologie, ainsi que la proportion de patients traités par dialyse péritonéale (DP) ou au moyen d'une greffe de rein comme modalité initiale de remplacement de la fonction rénale. TYPE D'ÉTUDE: Il s'agit d'une étude de cohorte rétrospective. CADRE: L'étude a été menée en Alberta, au Canada. PATIENTS: Il s'agit de patients albertains adultes nouvellement atteints d'IRT et nécessitant une thérapie continue de remplacement rénal. MESURES: Nous avons mesuré la proportion de patients qui n'avait pas vu un néphrologue dans les 90 jours précédant l'amorce de la dialyse (orientation tardive) ; la proportion de patients chez qui on avait amorcé la dialyse à la suite d'une mesure du DFGe ≥ 10.5 mL/min/1.73 m2 et la proportion de patients qui avaient subi une greffe comme modalité initiale de thérapie de remplacement de la fonction rénale et la proportion de ceux qui étaient traités par DP à 90 jours. MÉTHODOLOGIE: Nous avons utilisé des statistiques descriptives, un modèle logarithmique binomial ainsi que des modèles de régression linéaire pour évaluer les tendances des indicateurs de la qualité mentionnés ci-dessus. RÉSULTATS: Notre cohorte était formée de 5343 patients (61,2 % d'hommes) dont l'âge moyen se situait à 61.8 ans. Sur une période de 10 ans, nous avons observé que la proportion d'orientations tardives est passée de 26.4% à 21.1% (P = .001). Nous avons aussi noté une diminution de la proportion de patients chez qui on avait amorcé la dialyse avec une mesure du DFGe ≥ 10.5 mL/min/1.73 m2 (21.2% à 14.7%, P < .001). Toutefois, nous avons constaté une augmentation significative de la proportion de patients chez qui la dialyse avait été amorcée lors d'une hospitalisation (38.8% à 45.2%, P = .001). Enfin, nous avons noté une diminution non significative dans la proportion de patients traités par une greffe comme modalité initiale de remplacement de la fonction rénale ainsi que dans la proportion des patients traités par DP à 90 jours au cours de la même période. LIMITES DE L'ÉTUDE: L'utilisation de données administratives a limité la disponibilité des données cliniques en ce qui concerne les circonstances sous-jacentes à chaque indicateur de la qualité, incluant les symptômes du patient, les indications pour l'initiation de la dialyse et l'admissibilité à la dialyse péritonéale. CONCLUSIONS: Nous avons constaté une amélioration en ce qui concerne les orientations tardives et l'initiation d'une dialyse précoce au fil du temps. Cependant, nous avons remarqué, de façon constante dans le temps, un faible recours à la transplantation rénale comme modalité initiale et à la DP à 90 jours, ce qui devrait faire l'objet d'une étude plus poussée. Ces constatations constituent la première étape d'une proposition pour l'amélioration de la qualité conçue pour réduire les écarts observés au niveau des soins, et visant à améliorer les résultats pour les patients atteints d'insuffisance rénale.

Atomic layer deposition of a MoS2 film.

A mono- to multilayer thick MoS2 film has been grown by using the atomic layer deposition (ALD) technique at 300 °C on a sapphire wafer. ALD provides precise control of the MoS2 film thickness due to pulsed introduction of the reactants and self-limiting reactions of MoCl5 and H2S. A post-deposition annealing of the ALD-deposited monolayer film improves the crystallinity of the film, which is evident from the presence of triangle-shaped crystals that exhibit strong photoluminescence in the visible range.