Costs Associated With Progression of Mildly Reduced Kidney Function Among Medicare Advantage Enrollees.

Rationale & Objective: The prevalence of early chronic kidney disease (CKD) in older adults has increased in the past 2 decades, yet CKD disease progression, overall, is variable. It is unclear whether health care costs differ by progression trajectory. The purpose of this study was to estimate the trajectories of CKD progression and examine Medicare Advantage (MA) health care costs of each trajectory over a 3-year period in a large cohort of MA enrollees with mildly reduced kidney function. Study Design: Cohort study. Setting & Population: 421,187 MA enrollees with stage G2 CKD in 2014-2017. Outcomes: We identified 5 trajectories of kidney function over time. Model Perspective & Timeframe: Mean total health care costs for each of the trajectories were described in each of the following 3 years from a payer perspective: 1 year before and 2 years after the index date establishing stage G2 CKD (study entry). Results: The mean estimated glomerular filtration rate (eGFR) at study entry was 75.9 mL/min/1.73 m2 and the median (interquartile range) follow-up period was 2.6 (1.6, 3.7) years. The cohort had a mean age of 72.6 years and had predominantly female participants (57.2%), and White (71.2%). We identified the following 5 distinct trajectories of kidney function: a stable eGFR (22.3%); slow eGFR decline with a mean eGFR at study entry of 78.6 (30.2%); slow eGFR decline with an eGFR at study entry of 70.9 (28.4%); steep eGFR decline (16.3%); and accelerated eGFR decline (2.8%). Mean costs of enrollees with accelerated eGFR decline were double the MA enrollees' mean costs in each of the other 4 trajectories in every year ($27,738 vs $13,498 for a stable eGFR 1 year after study entry). Limitations: Results may not generalized beyond MA and a lack of albumin values. Conclusions: The small fraction of MA enrollees with accelerated eGFR decline has disproportionately higher costs than other enrollees with mildly reduced kidney function.

Have racial disparities in home dialysis utilization changed over time?

OBJECTIVES: The Medicare end-stage kidney disease (ESKD) prospective payment system (PPS) for maintenance dialysis, implemented in 2011, resulted in modestly increased access to both home-based peritoneal dialysis (PD) and home hemodialysis (HHD) treatment modalities, but it is unclear whether regional disparities in home dialysis (PD and HHD) were affected. We compared regional home dialysis use by White and non-White individuals over time. STUDY DESIGN: Retrospective cohort study of dialysis facilities offering home dialysis in 2006-2016 and of 1,098,579 patients with prevalent ESKD in 2006-2016. METHODS: We compared hospital referral region (HRR) utilization rates of home dialysis between White and non-White patients over time using a generalized estimating equation model with a negative binomial distribution adjusting for regional characteristics. RESULTS: The mean number of facilities offering home dialysis operating in each HRR increased from 15.6 in 2006 to 22.1 in 2016. Observed mean HRR home dialysis rates increased overall, but White patients maintained greater home dialysis use than non-White patients: 19.7% in 2006 and 26.2% in 2016 among White patients vs 13.0% in 2006 and 17.8% in 2016 among non-White patients. In adjusted analysis, there was no evidence of changes in White/non-White disparities in home dialysis use over time (P = .84) or after the Medicare ESKD PPS in 2011 (incidence rate ratio, 0.97; 95% CI, 0.92-1.02; P = .29). CONCLUSIONS: Even after modest increases in dialysis facility availability and patient utilization after the implementation of the Medicare ESKD PPS in 2011, significant racial disparities in home dialysis remain.

Association of Acute Kidney Injury and Cardiovascular Disease Following Percutaneous Coronary Intervention: Assessment of Interactions by Race, Diabetes, and Kidney Function.

RATIONALE & OBJECTIVE: Black patients and those with diabetes or reduced kidney function experience a disproportionate burden of acute kidney injury (AKI) and cardiovascular events. However, whether these factors modify the association between AKI and cardiovascular events after percutaneous coronary intervention (PCI) is unknown and was the focus of this study. STUDY DESIGN: Observational cohort. SETTING & PARTICIPANTS: Patients who underwent PCI at Duke between January 1, 2003, and December 31, 2013, with data available in the Duke Databank for Cardiovascular Disease. EXPOSURE: AKI, defined as ≥1.5-fold relative elevation in serum creatinine within 7 days from a reference value ascertained 30 days before PCI, or a 0.3 mg/dL increase from the reference value within 48 hours. OUTCOME: A composite of all-cause death, myocardial infarction, stroke, or revascularization during the first year after PCI. ANALYTICAL APPROACH: Cox regression models adjusted for potential confounders and with interaction terms between AKI and race, diabetes, or baseline estimated glomerular filtration rate (eGFR). RESULTS: Among 9,422 patients, 9% (n = 865) developed AKI, and the primary composite outcome occurred in 21% (n = 2,017). AKI was associated with a nearly 2-fold higher risk of the primary outcome (adjusted HR, 1.94 [95% CI, 1.71-2.20]). The association between AKI and cardiovascular risk did not significantly differ by race (P interaction, 0.4), diabetes, (P interaction, 0.06), or eGFR (P interaction, 0.2). However, Black race and severely reduced eGFR, but not diabetes, each had a cumulative impact with AKI on risk for the primary outcome. Compared with White patients with no AKI as the reference, the risk for the outcome was highest in Black patients with AKI (HR, 2.27 [95% CI, 1.83-2.82]), followed by White patients with AKI (HR, 1.87 [95% CI, 1.58-2.21]), and was least in patients of other races with AKI (HR, 1.48 [95% CI, 0.88-2.48]). LIMITATIONS: Residual confounding, including the impact of clinical care following PCI on cardiovascular outcomes of AKI. CONCLUSIONS: Neither race, diabetes, nor reduced eGFR potentiated the association of AKI with cardiovascular risk, but Black patients with AKI had a qualitatively greater risk than White patients with AKI or patients of other races with AKI. PLAIN-LANGUAGE SUMMARY: This study examined differences by race, diabetes, or kidney function in the well-known association of AKI with increased risk for cardiovascular outcomes among patients undergoing percutaneous coronary intervention. The authors found that AKI was associated with a greater risk for cardiovascular outcomes, but this risk did not differ by patients' race, diabetes status, or level of kidney function before the procedure. That said, the risk for cardiovascular outcomes was numerically highest among Black patients compared with White patients or those of other races. These study findings suggest that future efforts to prevent AKI among patients undergoing the procedure could reduce racial disparities in risk for unfavorable cardiovascular outcomes afterward.

Association between Gentrification and Health and Healthcare Utilization.

There is tremendous interest in understanding how neighborhoods impact health by linking extant social and environmental drivers of health (SDOH) data with electronic health record (EHR) data. Studies quantifying such associations often use static neighborhood measures. Little research examines the impact of gentrification-a measure of neighborhood change-on the health of long-term neighborhood residents using EHR data, which may have a more generalizable population than traditional approaches. We quantified associations between gentrification and health and healthcare utilization by linking longitudinal socioeconomic data from the American Community Survey with EHR data across two health systems accessed by long-term residents of Durham County, NC, from 2007 to 2017. Census block group-level neighborhoods were eligible to be gentrified if they had low socioeconomic status relative to the county average. Gentrification was defined using socioeconomic data from 2006 to 2010 and 2011-2015, with the Steinmetz-Wood definition. Multivariable logistic and Poisson regression models estimated associations between gentrification and development of health indicators (cardiovascular disease, hypertension, diabetes, obesity, asthma, depression) or healthcare encounters (emergency department [ED], inpatient, or outpatient). Sensitivity analyses examined two alternative gentrification measures. Of the 99 block groups within the city of Durham, 28 were eligible (N = 10,807; median age = 42; 83% Black; 55% female) and 5 gentrified. Individuals in gentrifying neighborhoods had lower odds of obesity (odds ratio [OR] = 0.89; 95% confidence interval [CI]: 0.81-0.99), higher odds of an ED encounter (OR = 1.10; 95% CI: 1.01-1.20), and lower risk for outpatient encounters (incidence rate ratio = 0.93; 95% CI: 0.87-1.00) compared with non-gentrifying neighborhoods. The association between gentrification and health and healthcare utilization was sensitive to gentrification definition.

Missing Care: the Initial Impact of the COVID-19 Pandemic on CKD Care Delivery.

BACKGROUND: Chronic kidney disease (CKD) is a common condition with adverse health outcomes addressable by early disease management. The impact of the COVID-19 pandemic on care utilization for the CKD population is unknown. OBJECTIVE: To examine pandemic CKD care and identify factors associated with a high care deficit. DESIGN: Retrospective observational study PARTICIPANTS: 248,898 insured individuals (95% Medicare Advantage, 5% commercial) with stage G3-G4 CKD in 2018 MAIN MEASURES: Predicted (based on the pre-pandemic period of January 1, 2019-February 28, 2020) to observed per-member monthly face-to-face and telehealth encounters, laboratory testing, and proportion of days covered (PDC) for medications, evaluated during the early (March 1, 2020-June 30, 2020), pre-vaccine (July 1, 2020-December 31, 2020), and late (January 2021-August 2021) periods and overall. KEY RESULTS: In-person encounters fell by 24.1% during the pandemic overall; this was mitigated by a 14.2% increase in telehealth encounters, resulting in a cumulative observed utilization deficit of 10% relative to predicted. These reductions were greatest in the early pandemic period, with a 19.8% cumulative deficit. PDC progressively decreased during the pandemic (range 9-20% overall reduction), with the greatest reductions in hypertension and diabetes medicines. CKD laboratory monitoring was also reduced (range 11.8-43.3%). Individuals of younger age (OR 1.63, 95% CI 1.16, 2.28), with commercial insurance (1.43, 95% CI 1.25, 1.63), residing in the Southern US (OR 1.17, 95% CI 1.14, 1.21), and with stage G4 CKD (OR 1.21, 95% CI 1.17, 1.26) had greater odds of a higher care deficit overall. CONCLUSIONS: The early COVID-19 pandemic resulted in a marked decline of healthcare services for individuals with CKD, with an incomplete recovery during the later pandemic. Increased telehealth use partially compensated for this deficit. The downstream impact of CKD care reduction on health outcomes requires further study, as does evaluation of effective care delivery models for this population.

Annual wellness visits and care management before and after dialysis initiation.

INTRODUCTION: Demands of dialysis regimens may pose challenges for primary care provider (PCP) engagement and timely preventive care. This is especially the case for patients initiating dialysis adjusting to new logistical challenges and management of symptoms and existing comorbid conditions. Since 2011, Medicare has provided coverage for annual wellness visits (AWV), which are primarily conducted by PCPs and may be useful for older adults undergoing dialysis. METHODS: We used the OptumLabs® Data Warehouse to identify a cohort of 1,794 Medicare Advantage (MA) enrollees initiating dialysis in 2014-2017 and examined whether MA enrollees (1) were seen by a PCP during an outpatient visit and (2) received an AWV in the year following dialysis initiation. RESULTS: In the year after initiating dialysis, 93 % of MA enrollees had an outpatient PCP visit but only 24 % received an annual wellness visit. MA enrollees were less likely to see a PCP if they had Charlson comorbidity scores between 0 and 5 than those with scores 6-9 (odds ratio (OR) = 0.59, 95 % CI: 0.37-0.95), but more likely if seen by a nephrologist (OR = 1.60, 95 % CI: 1.01-2.52) or a PCP (OR = 15.65, 95 % CI: 9.26-26.46) prior to initiation. Following dialysis initiation, 24 % of MA enrollees had an AWV. Hispanic MA enrollees were less likely (OR = 0.57, 95 % CI: 0.39-0.84) to have an AWV than White MA enrollees, but enrollees were more likely if they initiated peritoneal dialysis (OR = 1.54, 95 % CI: 1.07-2.23) or had an AWV in the year before dialysis initiation (OR = 4.96, 95 % CI: 3.88-6.34). CONCLUSIONS: AWVs are provided at low rates to MA enrollees initiating dialysis, particularly Hispanic enrollees, and represent a missed opportunity for better care management for patients with ESKD. Increasing patient awareness and provider provision of AWV use among dialysis patients may be needed, to realize better preventive care for dialysis patients.

Racism and Kidney Health: Turning Equity Into a Reality.

Kidney disease continues to manifest stark racial inequities in the United States, revealing the entrenchment of racism and bias within multiple facets of society, including in our institutions, practices, norms, and beliefs. In this perspective, we synthesize theory and evidence to describe why an understanding of race and racism is integral to kidney care, providing examples of how kidney health disparities manifest interpersonal and structural racism. We then describe racialized medicine and "colorblind" approaches as well as their pitfalls, offering in their place suggestions to embed antiracism and an "equity lens" into our practice. We propose examples of how we can enhance kidney health equity by enhancing our structural competency, using equity-focused race consciousness, and centering investigation and solutions around the needs of the most marginalized. To achieve equitable outcomes for all, our medical institutions must embed antiracism and equity into all aspects of advocacy, policy, patient/community engagement, educational efforts, and clinical care processes. Organizations engaged in kidney care should commit to promoting structural equity and eliminating potential sources of bias across referral practices, guidelines, research agendas, and clinical care. Kidney care providers should reaffirm our commitment to structurally competent patient care and educational endeavors in which empathy and continuous self-education about social drivers of health and inequity, racism, and bias are integral. We envision a future in which kidney health equity is a reality for all. Through bold collective and sustained investment, we can achieve this critical goal.

Transplant social worker and donor financial assistance to increase living donor kidney transplants among African Americans: The TALKS Study, a randomized comparative effectiveness trial.

Lack of donors hinders living donor kidney transplantation (LDKT) for African Americans. We studied the effectiveness of a transplant social worker intervention (TALK SWI) alone or paired with living donor financial assistance to activate African Americans' potential living kidney donors. African Americans (N = 300) on the transplant waiting list were randomly assigned to usual care; TALK SWI; or TALK SWI plus Living Donor Financial Assistance. We quantified differences in live kidney donor activation (composite rate of live donor inquiries, completed new live donor evaluations, or live kidney donation) after 12 months. Participants' mean age was 52 years, 56% were male, and 43% had annual household income less than $40,000. Most previously pursued LDKT. Participants were highly satisfied with TALK social workers, but they rarely utilized Financial Assistance. After 12 months, few (n = 39, 13%) participants had a new donor activation event (35 [12%] new donor inquiries; 17 [6%] new donor evaluations; 4 [1%] LDKT). There were no group differences in donor activation events (subdistribution hazard ratio [95% CI]: 1.09 [0.51-2.30] for TALK SWI and 0.92 [0.42-2.02] for TALK SWI plus Financial Assistance compared to Usual Care, p = 91). Alternative interventions to increase LDKT for African Americans on the waiting list may be needed. Trial registration: ClinicalTrials.gov (NCT02369354).

Mobile Health (mHealth) Technology: Assessment of Availability, Acceptability, and Use in CKD.

RATIONALE & OBJECTIVE: Digital and mobile health (mHealth) technologies improve patient-provider communication and increase information accessibility. We assessed the use of technology, attitudes toward using mHealth technologies, and proficiency in using mHealth technologies among individuals with chronic kidney disease (CKD). STUDY DESIGN: Cross-sectional survey with open text responses. SETTING & PARTICIPANTS: Chronic Renal Insufficiency Cohort (CRIC) Study participants who completed current use and interest in using mHealth technologies questionnaires and the eHealth literacy Survey (eHEALS). EXPOSURE: Participant characteristics. OUTCOMES: Use of technology (ie, internet, email, smartphone, and mHealth applications [apps]), interest in future mHealth use, and proficiency in using digital and mHealth technologies, or eHealth literacy, determined by eHEALS score. ANALYTICAL APPROACH: Poisson regression and a qualitative content analysis of open-ended responses. RESULTS: Study participants (n = 932) had a mean age of 68 years old and an estimated glomerular filtration rate (eGFR) of 54 mL/min/1.73 m2, and 59% were male. Approximately 70% reported current use of internet, email, and smartphones, and 35% used mHealth apps; only 27% had adequate eHealth literacy (eHEALS score ≥ 32). Participants <65 years of age (vs. ≥65), with more education, higher income, better cognition, and adequate health literacy reported more use of technology, and greater interest in using technologies. Participants of White (vs. non-White) race reported more use of internet and email but less interest in future use of mHealth. Younger age, higher annual income, and greater disease self-efficacy were associated with adequate eHealth literacy. Three themes regarding interest in using digital and mHealth technologies emerged: willingness, concerns, and barriers. LIMITATIONS: Residual confounding, ascertainment bias. CONCLUSIONS: Many individuals with CKD currently use the internet and smartphones and are interested in using mHealth in the future, but few use mHealth apps or have adequate eHealth literacy. mHealth technologies present an opportunity to engage individuals with CKD, especially members of racial or ethnic minority groups because those groups reported greater interest in using mHealth technology than the nonminority population. Further research is needed to identify strategies to overcome inadequate eHealth literacy.

Opioid Prescribing in the 2016 Medicare Fee-for-Service Population.

BACKGROUND AND OBJECTIVES: Opioid use and misuse are prevalent and remain a national crisis. This study identified beneficiary characteristics associated with filling opioid prescriptions, variation in opioid dosing, and opioid use with average daily doses (ADDs) equal to 120 morphine milligram equivalents (MMEs) or more in the 100% Medicare fee-for-service (FFS) population. DESIGN, SETTING, PARTICIPANTS, AND MEASUREMENTS: In a cohort of FFS beneficiaries with 12 months of Medicare Part D coverage in 2016, we examined patient factors associated with filling an opioid prescription (n = 20,880,490) and variation in ADDs (n = 7,325,031) in a two-part model. Among those filling opioids, we also examined the probability of ADD equal to 120 MMEs or more via logistic regression. RESULTS: About 35% of FFS beneficiaries had one or more opioid prescription fills in 2016 and 1.5% had ADDs equal to 120 MMEs or more. Disability-eligible beneficiaries and beneficiaries with multiple chronic conditions were more likely to fill opioids, to have higher ADDs or were more likely to have ADD equal to 120 MMEs or more. Beneficiaries with chronic obstructive pulmonary disease (COPD) were more likely to fill opioids (odds ratio (OR) = 1.47, 95% confidence interval (CI) = 1.46-1.47), have higher ADDs (rate ratio = 1.06, 95% CI = 1.06-1.06) when filled and were more likely to have ADD equal to 120 MMEs or more (OR = 1.23, 95% CI = 1.21-1.24). Finally, black and Hispanic beneficiaries were less likely to fill opioids, had lower overall doses and were less likely to have ADDs equal to 120 MMEs or more compared to white beneficiaries. CONCLUSION: Several beneficiary subgroups have underappreciated risk of adverse events associated with ADD equal to 120 MMEs or more that may benefit from opioid optimization interventions that balance pain management and adverse event risk, especially beneficiaries with COPD who are at risk for respiratory depression.

Primary Care Providers' Acceptance of Pharmacists' Recommendations to Support Optimal Medication Management for Patients with Diabetic Kidney Disease.

BACKGROUND: Patients with diabetic kidney disease (DKD) often struggle with blood pressure control. In team-based models of care, pharmacists and primary care providers (PCPs) play important roles in supporting patients' blood pressure management. OBJECTIVE: To describe whether PCPs' acceptance of pharmacists' recommendations impacts systolic blood pressure (SBP) at 36 months. DESIGN: An observational analysis of a subset of participants randomized to the intervention arm of the Simultaneous risk factor control using Telehealth to slOw Progression of Diabetic Kidney Disease (STOP-DKD) study. PARTICIPANTS: STOP-DKD participants for whom (1) the pharmacist made at least one recommendation to the PCP; (2) there were available data regarding the PCP's corresponding action; and (3) there were SBP measurements at baseline and 36 months. INTERVENTION: Participants received monthly telephone calls with a pharmacist addressing health behaviors and medication management. Pharmacists made medication-related recommendations to PCPs. MAIN MEASURES: We fit an unadjusted generalized linear mixed model to assess the association between the number of pharmacists' recommendations for DKD and blood pressure management and PCPs' acceptance of such recommendations. We used a linear regression model to evaluate the association between PCP acceptance and SBP at 36 months, adjusted for baseline SBP. KEY RESULTS: Pharmacists made 176 treatment recommendations (among 59 participants), of which 107 (61%) were accepted by PCPs. SBP significantly declined by an average of 10.5 mmHg (p < 0.01) among 47 of 59 participants who had valid measurements at baseline and 36 months. There was a significant association between the number of pharmacist recommendations and the odds of PCP acceptance (OR 1.19; 95%CI 1.00, 1.42; p < 0.05), but no association between the number of accepted recommendations and SBP. CONCLUSIONS: Pharmacists provided actionable medication-related recommendations. We identified a significant decline in SBP at 36 months, but this reduction was not associated with recommendation acceptance. TRIAL REGISTRATION: NCT01829256.

Lab-based and diagnosis-based chronic kidney disease recognition and staging concordance.

BACKGROUND: Chronic kidney disease (CKD) is often under-recognized and poorly documented via diagnoses, but the extent of under-recognition is not well understood among Medicare beneficiaries. The current study used claims-based diagnosis and lab data to examine patient factors associated with clinically recognized CKD and CKD stage concordance between claims- and lab-based sources in a cohort of Medicare beneficiaries. METHODS: In a cohort of fee-for-service (FFS) beneficiaries with CKD based on 2011 labs, we examined the proportion with clinically recognized CKD via diagnoses and factors associated with clinical recognition in logistic regression. In the subset of beneficiaries with CKD stage identified from both labs and diagnoses, we examined concordance in CKD stage from both sources, and factors independently associated with CKD stage concordance in logistic regression. RESULTS: Among the subset of 206,036 beneficiaries with lab-based CKD, only 11.8% (n = 24,286) had clinically recognized CKD via diagnoses. Clinical recognition was more likely for beneficiaries who had higher CKD stages, were non-elderly, were Hispanic or non-Hispanic Black, lived in core metropolitan areas, had multiple chronic conditions or outpatient visits in 2010, or saw a nephrologist. In the subset of 18,749 beneficiaries with CKD stage identified from both labs and diagnoses, 70.0% had concordant CKD stage, which was more likely if beneficiaries were older adults, male, lived in micropolitan areas instead of non-core areas, or saw a nephrologist. CONCLUSIONS: There is significant under-diagnosis of CKD in Medicare FFS beneficiaries, which can be addressed with the availability of lab results.

Long-term exposure to ambient air pollution and renal function in African Americans: the Jackson Heart Study.

Renal dysfunction is prevalent in the US among African Americans. Air pollution is associated with renal dysfunction in mostly white American populations, but has not been studied among African Americans. We evaluated cross-sectional associations between 1-year and 3-year fine particulate matter (PM2.5) and ozone (O3) concentrations, and renal function among 5090 African American participants in the Jackson Heart Study. We used mixed-effect linear regression to estimate associations between 1-year and 3-year PM2.5 and O3 and estimated glomerular filtration rate (eGFR), urine albumin/creatinine ratio (UACR), serum creatinine, and serum cystatin C, adjusting for: sociodemographic factors, health behaviors, and medical history and accounting for clustering by census tract. At baseline, JHS participants had mean age 55.4 years, and 63.8% were female; mean 1-year and 3-year PM2.5 concentrations were 12.2 and 12.4 µg/m3, and mean 1-year and 3-year O3 concentrations were 40.2 and 40.7 ppb, respectively. Approximately 6.5% of participants had reduced eGFR (< 60 mL/min/1.73m2) and 12.7% had elevated UACR (> 30 mg/g), both indicating impaired renal function. Annual and 3-year O3 concentrations were inversely associated with eGFR and positively associated with serum creatinine; annual and 3-year PM2.5 concentrations were inversely associated with UACR. We observed impaired renal function associated with increased O3 but not PM2.5 exposure among African Americans.

Consideration of ICD-9 code-derived disease-specific safety indicators in CKD.

BACKGROUND AND OBJECTIVES: The Agency for Healthcare and Research Quality patient safety indicators track adverse safety events in hospitalized patients but overlook safety incidents specific to CKD. This study considers candidate CKD-pertinent patient safety indicators and compares them with the Agency for Healthcare and Research Quality patient safety indicators. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: Using a national Veterans Health Administration database of hospitalized veterans from fiscal year 2005, 247,160 hospitalized veterans with prehospitalization measures of renal function were retrospectively examined for proposed CKD patient safety indicators versus Agency for Healthcare and Research Quality patient safety indicators using International Classification of Diseases, Ninth Revision diagnosis codes. Candidate CKD-pertinent patient safety indicators included in-hospital acute kidney failure; in-hospital congestive heart failure (and related diagnostic codes); electrolyte disturbances; and medication errors, poisoning, and intoxication. Patients with a prehospital estimated GFR<60 ml/min per 1.73 m(2) (CKD group) were compared with a non-CKD group. For CKD patient safety indicators, hospitalizations were excluded if the admitting condition was a potential cause of the secondary condition. Regression methods were used to present adjusted rates in study groups of interest. RESULTS: The CKD patient safety indicators were generally more common than the Agency for Healthcare and Research Quality patient safety indicators in all groups, tended to occur in different patients than those patients who experienced Agency for Healthcare and Research Quality patient safety indicators, and were more common in the CKD group than the non-CKD group, except for hypoglycemia, hypokalemia, and hyponatremia. The adjusted composite CKD patient safety indicators rate (per 1000 patient-hospitalizations) was 398.0 (95% confidence interval, 391.2 to 405.0) for patients in the CKD group and 250.0 (95% confidence interval, 247.4 to 252.7) for patients in the non-CKD group. The prevalence ratio of CKD patient safety indicators to Agency for Healthcare and Research Quality patient safety indicators was 23.4 (95% confidence interval, 21.9 to 25.0). CONCLUSION: The candidate CKD patient safety indicators that occur in hospitalized patients are distinct from the Agency for Healthcare and Research Quality patient safety indicators and tend to be more common in CKD than non-CKD patients. These measures have the potential to serve as sentinel tools for identifying patients with CKD who warrant examination for disease-pertinent safety events.