The Role of Big Data in the Development and Evaluation of US Dialysis Care.

Rapid growth in electronic communications and digitalization, combined with advances in data management, analysis, and storage, have led to an era of "Big Data." The Social Security Amendments of 1972 turned end-stage renal disease (ESRD) care into a single-payer system for most patients requiring dialysis in the United States. As a result, there are few areas of medicine that have been as influenced by Big Data as dialysis care, for which Medicare's large administrative data sets have had a central role in the evaluation and development of public policy for several decades. In the 1970/1980s, Medicare data helped identify concerning trends in costs, access to dialysis care, and quality of care delivered. As the research community and policymakers made Medicare's administrative data increasingly accessible for investigation, analyses of Medicare claims have had a large role in facilitating policy synthesis and refinement. Efforts to address the skyrocketing cost of injectable drugs in the 1990s and 2000s exemplify this expanded role of Big Data. Although there are opportunities for large government and nongovernmental administrative data sets to continue serving a critical role in the evaluation and development of ESRD policies, it is important to understand challenges and limitations associated with their use.

Health Insurance and the Use of Peritoneal Dialysis in the United States.

BACKGROUND: Many patients in the United States have limited or no health insurance at the time they develop end-stage renal disease (ESRD). We examined whether health insurance limitations affected the likelihood of peritoneal dialysis (PD) use. STUDY DESIGN: Retrospective cohort analysis of patients from the US Renal Data System initiating dialysis therapy in 2006 through 2012. SETTING & PARTICIPANTS: We identified socioeconomically similar groups of patients to examine the association between health insurance and PD use. Patients aged 60 to 64 years with "limited insurance" (defined as having Medicaid or no insurance) at ESRD onset were compared with patients aged 66 to 70 years who were dually eligible for Medicare and Medicaid at ESRD onset. PREDICTOR: Type of insurance coverage at ESRD onset. OUTCOMES: The likelihoods of receiving PD before dialysis month 4, when all patients qualified for Medicare due to ESRD, and of switching to PD therapy following receipt of Medicare. RESULTS: After adjusting for observable patient and geographic differences, patients with limited insurance had an absolute 2.4% (95% CI, 1.1%-3.7%) lower probability of PD use by dialysis month 4 compared with patients with Medicare at ESRD onset. The association between insurance and PD use reversed when patients became Medicare eligible; patients with limited insurance had a 3-fold higher rate of switching to PD therapy between months 4 and 12 of dialysis (HR, 2.9; 95% CI, 1.8-4.6) compared with patients with Medicare at ESRD onset. LIMITATIONS: Because this study was observational, there is a potential for bias from unmeasured patient-level factors. CONCLUSIONS: Despite Medicare's policy of covering patients in the month that they initiate PD therapy, insurance limitations remain a barrier to PD use for many patients. Educating providers about Medicare reimbursement policy and expanding access to pre-ESRD education and training may help overcome these barriers.

Blood Pressure Parameters and their Associations with Death in Patients with Chronic Kidney Disease.

PURPOSE OF REVIEW: Optimal blood pressure (BP) parameters among patients with chronic kidney disease (CKD) have been a matter of debate. This review critically evaluates recent literature to better define the associations of BP parameters and death among individuals with non-dialysis-dependent CKD. RECENT FINDINGS: Observational studies report a "U- or J-shaped" association between BP and all-cause mortality in CKD and caution-intensive BP lowering in the elderly. Causes of death have been evaluated in a recent report noting higher cardiovascular and non-cardiovascular/non-malignant-related mortality among CKD population with SBP < 110 and > 150 mmHg. Very few randomized control trials evaluated the impact of different BP targets on patient-centered outcomes in those with CKD. Recently published SPRINT trial results suggest that intensive SBP control (<120 mm Hg) reduces cardiovascular events and all-cause death among non-diabetic patients with and without CKD. Clinical trial evidence supports lower BP target in those with mild to moderate non-diabetic CKD. However, clinical trials are warranted to further determine the beneficial effects of intensive blood pressure control in diabetic CKD population. In elderly population with CKD, BP targets might need to be individualized based on their comorbidities, life expectancy, and other factors.