Racial/Ethnic Disparities in Atrial Fibrillation Treatment and Outcomes among Dialysis Patients in the United States.

BACKGROUND: Because stroke prevention is a major goal in the management of ESKD hemodialysis patients with atrial fibrillation, investigating racial/ethnic disparities in stroke among such patients is important to those who could benefit from strategies to maximize preventive measures. METHODS: We used the United States Renal Data System to identify ESKD patients who initiated hemodialysis from 2006 to 2013 and then identified those with a subsequent atrial fibrillation diagnosis and Medicare Part A/B/D. Patients were followed for 1 year for all-cause stroke, mortality, prescription medications, and cardiovascular disease procedures. The survival mediational g-formula quantified the percentage of excess strokes attributable to lower use of atrial fibrillation treatments by race/ethnicity. RESULTS: The study included 56,587 ESKD hemodialysis patients with atrial fibrillation. Black, white, Hispanic, and Asian patients accounted for 19%, 69%, 8%, and 3% of the population, respectively. Compared with white patients, black, Hispanic, or Asian patients were more likely to experience stroke (13%, 15%, and 16%, respectively) but less likely to fill a warfarin prescription (10%, 17%, and 28%, respectively). Warfarin prescription was associated with decreased stroke rates. Analyses suggested that equalizing the warfarin distribution to that in the white population would prevent 7%, 10%, and 12% of excess strokes among black, Hispanic, and Asian patients, respectively. We found no racial/ethnic disparities in all-cause mortality or use of cardiovascular disease procedures. CONCLUSIONS: Racial/ethnic disparities in all-cause stroke among hemodialysis patients with atrial fibrillation are partially mediated by lower use of anticoagulants among black, Hispanic, and Asian patients. The reasons for these disparities are unknown, but strategies to maximize stroke prevention in minority hemodialysis populations should be further investigated.

Opioid Prescription, Morbidity, and Mortality in US Transplant Recipients.

BACKGROUND: Centers for Disease Control and Prevention guidelines recommend caution in prescribing opioids for chronic pain. The characteristics of opioid prescription (OpRx) among kidney transplant (KTx) recipients have not been described in a national population. METHODS: We assessed OpRx prevalence among prevalent KTx recipients, and associated duration (long-term, defined as ≥90 days in a year) and dosing (in morphine milligram equivalents per day of <50, 50-89, and ≥90) with outcomes, death and graft loss, among incident KTx recipients using 2006-2010 US Renal Data System files, including Medicare Part D for medication ascertainment. Cox models controlled for recipient factors. RESULTS: Of 36,486 KTx recipients in the 2010 prevalent cohort, approximately 14.6% had long-term OpRx. The strongest association with long-term OpRx after KTx was long-term OpRx before KTx (64%; adjusted odds ratio, 95% confidence interval, 95.2, 74.2-122.1). Incident KTx recipients with long-term OpRx had increased risk of mortality and graft loss compared with those without OpRx or short-term OpRx after KTx. This risk was highest among recipients with long-term OpRx doses of ≥90 morphine milligram equivalents or higher per day (adjusted hazard ratio, 95% confidence interval, 1.61, 1.24-2.10 for death, and 1.33, 1.05-1.67 for graft loss, respectively). CONCLUSIONS: In contrast to either no or short-term OpRx, long-term, and especially long-term high-dose OpRx, is associated with increased risk of death and graft loss in US KTx recipients. Causal relationships cannot be inferred, and OpRx may be an illness marker. Nevertheless, efforts to treat pain effectively in KTx recipients with less toxic interventions and decrease OpRx deserve consideration.

Opioid Prescription, Morbidity, and Mortality in United States Dialysis Patients.

Aggressive pain treatment was advocated for ESRD patients, but new Centers for Disease Control and Prevention guidelines recommend cautious opioid prescription. Little is known regarding outcomes associated with ESRD opioid prescription. We assessed opioid prescriptions and associations between opioid prescription and dose and patient outcomes using 2006-2010 US Renal Data System information in patients on maintenance dialysis with Medicare Part A, B, and D coverage in each study year (n=671,281, of whom 271,285 were unique patients). Opioid prescription was confirmed from Part D prescription claims. In the 2010 prevalent cohort (n=153,758), we examined associations of opioid prescription with subsequent all-cause death, dialysis discontinuation, and hospitalization controlled for demographics, comorbidity, modality, and residence. Overall, >60% of dialysis patients had at least one opioid prescription every year. Approximately 20% of patients had a chronic (≥90-day supply) opioid prescription each year, in 2010 usually for hydrocodone, oxycodone, or tramadol. In the 2010 cohort, compared with patients without an opioid prescription, patients with short-term (1-89 days) and chronic opioid prescriptions had increased mortality, dialysis discontinuation, and hospitalization. All opioid drugs associated with mortality; most associated with worsened morbidity. Higher opioid doses correlated with death in a monotonically increasing fashion. We conclude that opioid drug prescription is associated with increased risk of death, dialysis discontinuation, and hospitalization in dialysis patients. Causal relationships cannot be inferred, and opioid prescription may be an illness marker. Efforts to treat pain effectively in patients on dialysis yet decrease opioid prescriptions and dose deserve consideration.

Social Determinants of Racial Disparities in CKD.

Significant disparities in CKD rates and outcomes exist between black and white Americans. Health disparities are defined as health differences that adversely affect disadvantaged populations, on the basis of one or more health outcomes. CKD is the complex result of genetic and environmental factors, reflecting the balance of nature and nurture. Social determinants of health have an important role as environmental components, especially for black populations, who are disproportionately disadvantaged. Understanding the social determinants of health and appreciating the underlying differences associated with meaningful clinical outcomes may help nephrologists treat all their patients with CKD in an optimal manner. Altering the social determinants of health, although difficult, may embody important policy and research efforts, with the ultimate goal of improving outcomes for patients with kidney diseases, and minimizing the disparities between groups.

Racial Disparities in Poverty Account for Mortality Differences in US Medicare Beneficiaries.

Higher mortality in Blacks than Whites has been consistently reported in the US, but previous investigations have not accounted for poverty at the individual level. The health of its population is an important part of the capital of a nation. We examined the association between individual level poverty and disability and racial mortality differences in a 5% Medicare beneficiary random sample from 2004 to 2010. Cox regression models examined associations of race with all-cause mortality, adjusted for demographics, comorbidities, disability, neighborhood income, and Medicare "Buy-in" status (a proxy for individual level poverty) in 1,190,510 Black and White beneficiaries between 65 and 99 years old as of January 1, 2014, who had full and primary Medicare Part A and B coverage in 2004, and lived in one of the 50 states or Washington DC. Overall, black beneficiaries had higher sex-and-age adjusted mortality than Whites (hazard ratio [HR] 1.18). Controlling for health-related measures and disability reduced the HR for Black beneficiaries to 1.03. Adding "Buy-in" as an individual level covariate lowered the HR for Black beneficiaries to 0.92. Neither of the residential measures added to the predictive model. We conclude that poorer health status, excess disability, and most importantly, greater poverty among Black beneficiaries accounts for racial mortality differences in the aged US Medicare population. Poverty fosters social and health inequalities, including mortality disparities, notwithstanding national health insurance for the US elderly. Controlling for individual level poverty, in contrast to the common use of area level poverty in previous analyses, accounts for the White survival advantage in Medicare beneficiaries, and should be a covariate in analyses of administrative databases.

Has the incidence of end-stage renal disease in the USA and other countries stabilized?

PURPOSE OF REVIEW: Recent trends in incident rates of end-stage renal disease (ESRD) in the USA suggest that ESRD incidence may be leveling off after decades of increases. This article examines recent worldwide ESRD incidence trends as well as population dynamics for their implications on ESRD treatment. RECENT FINDINGS: There is some evidence that ESRD rates have stabilized in countries with relatively high gross domestic product and where renal replacement therapy has been widely available for many years. However, population dynamics, particularly the aging of populations, as well as increases in diabetes prevalence will exert pressure to increase the absolute numbers of people on renal replacement therapy (RRT). In developing countries, the population dynamics are similar, if not more dramatic. Heretofore, access to RRT in developing countries has been limited due to economic limitations. To the extent that these nations approach the economic prosperity of Westernized countries, access to RRT will also increase and the total ESRD population will continue to increase. SUMMARY: It is likely that the absolute numbers of incident ESRD patients will continue to increase in westernized countries due to the aging of those populations. In developing countries, ESRD incidence will increase to the extent that economic development allows.

Recruitment and training for home hemodialysis: experience and lessons from the Nocturnal Dialysis Trial.

BACKGROUND AND OBJECTIVES: We assessed perceived barriers and incentives to home hemodialysis and evaluated potential correlates with the duration of home hemodialysis training. DESIGN, SETTINGS, PARTICIPANTS, & MEASUREMENTS: Surveys were sent to the principal investigator and study coordinator for each clinical center in the Frequent Hemodialysis Network Nocturnal Trial. Baseline data were obtained on medical comorbidities, cognitive and physical functioning, sessions required for home hemodialysis training, and costs of home renovations. RESULTS: The most commonly perceived barriers included lack of patient motivation, unwillingness to change from in-center modality, and fear of self-cannulation. The most common incentives were greater scheduling flexibility and reduced travel time. The median costs for home renovations varied between $1191 and $4018. The mean number of home hemodialysis training sessions was 27.7 +/- 10.4 (11-59 days). Average training time was less for patients with experience in either self-care or both self-care and cannulation. The number of training sessions was unrelated to the score on the Modified Mini Mental Status or Trailmaking B tests or patient's education level. Training time also did not correlate with the SF-36 Physical Function subscale but did with the modified Charlson comorbidity score and older patient age. CONCLUSIONS: Lack of patient or family motivation and fear of the dialysis process are surmountable barriers for accepting home hemodialysis as a modality for renal replacement therapy. Formal education and scores on cognitive function tests are not predictors of training time.

Racial disparities in access to transplantation: a tough nut to crack.

Racial disparities in access to kidney transplantation continue to exist despite determined efforts to improve minority access. Subtle barriers to transplant access will be difficult to overcome. However, the gap between the number of persons needing transplant and the available organs is the greatest impediment to transplantation equality.

Prevalence and psychosocial correlates of symptoms suggestive of painful bladder syndrome: results from the Boston area community health survey.

PURPOSE: We estimated the prevalence of symptoms suggestive of painful bladder syndrome defined as pain increasing as the bladder fills and/or pain relieved by urination for at least 3 months, and its association with sociodemographics (gender, age, race/ethnicity and socioeconomic status), lifestyle (smoking, alcohol consumption, physical activity) and psychosocial variables (sexual, physical, emotional abuse experienced as a child or as an adult, worry, trouble paying for basics, depression). MATERIALS AND METHODS: The data used come from the Boston Area Community Health Survey, an epidemiological study of 5,506 randomly selected adults 30 to 79 years old of 3 race/ethnic groups (black, Hispanic, white). RESULTS: The overall prevalence of symptoms suggestive of painful bladder syndrome was 2% (1.3% in men and 2.6% in women) with increased prevalence in middle-aged adults and those of lower socioeconomic status. Symptoms suggestive of painful bladder syndrome were more common in those who experienced abuse, in those who were worried about someone close to them and in those who were having trouble paying for basics. This pattern held even after adjusting for depression. CONCLUSIONS: Painful bladder syndrome is associated with a number of lifestyle and psychosocial correlates. This suggests that the treatment of patients with painful bladder syndrome (physical symptoms) may benefit from a multifaceted approach of combining medical, psychological and cognitive treatment.

The contribution of common medical conditions and drug exposures to erectile dysfunction in adult males.

PURPOSE: We examined the association of prevalent erectile dysfunction and coexisting medical conditions in United States men taking into account age and drug exposures. MATERIALS AND METHODS: Men older than 40 years who participated in the 2001 to 2002 National Health and Nutrition Examination Survey were asked to report on erectile function. Men who were never able to achieve an erection sufficient for intercourse were defined as having complete erectile dysfunction. Adjusted odds ratios for complete erectile dysfunction prevalence in men with a coexisting condition compared to those without the condition were calculated. Age, race/ethnicity, urinary symptoms, cardiovascular disease, diabetes, hypertension with and without selected antihypertensive therapy (mainly beta blockers and thiazide diuretics), selected antidepressant therapy (mainly, tricyclics and selective serotonin reuptake inhibitors), smoking and alcohol were included in all statistical models. RESULTS: Of United States men 8% (95% CI 6.0-10.2) reported complete erectile dysfunction. In multivariate analyses, obstructive urinary symptoms (OR 2.0, 95% CI 1.2-3.4), diabetes (OR 2.6, 95% CI 1.3-5.2), hypertension with selected antihypertensive therapy (OR 3.0, 95% CI 1.6-5.9), and selected antidepressant therapy (OR 5.2, 95% CI 1.7-15.9), increased the odds of complete erectile dysfunction prevalence, whereas presence of cardiovascular disease, urinary incontinence and hypertension without selected antihypertensive therapy did not. CONCLUSIONS: Obstructive urinary symptoms, diabetes, hypertension treated with selected medications, and selected antidepressant drug use are independently associated with increased erectile dysfunction risk in United States men. Physicians should carefully consider the potential impact of these medications and comorbid conditions when discussing sexual function with their male patients.

Longitudinal study of racial and ethnic differences in developing end-stage renal disease among aged medicare beneficiaries.

Diabetes and hypertension are the leading causes of renal failure. This study investigated racial differences in developing ESRD by participants' diabetes and hypertension status. This longitudinal study included 1,306,825 Medicare beneficiaries who were aged > or =66 yr at the study start and followed up to 10 yr from January 1, 1993, for the development of ESRD or death. During the 10 yr, 0.93 patients per 100 received ESRD treatment. After adjustment for age and gender, among patients with diabetes, black patients were 2.4 to 2.7 times and other races/ethnicities 1.6 to 1.7 times more likely than white patients to develop ESRD. Among hypertensive patients, black patients were 2.5 to 2.9 and others 1.7 to 1.8 times more likely than white patients to develop ESRD. Among patients with neither diabetes nor hypertension, black patients were 3.5 and others 2.0 times more likely. Black men with diabetes were 1.9 to 2.1 and women 2.5 to 3.4 times more likely than their white counterparts to develop ESRD. Hypertensive black men were 2.1 to 2.2 and women 2.8 to 3.6 times more likely to develop ESRD. The same findings were noted in women of other races/ethnicities. Compared with white counterparts, mortality was higher for black patients in all cohorts but lower among patients with ESRD. Although they are leading causes for renal failure, diabetes and hypertension do not cause racial differences in developing ESRD. Minority women especially are at greater risk for ESRD than white women. Further studies are needed to determine whether earlier initiation of dialysis is a factor in higher ESRD incidence among minorities.

Incidence and mortality of acute renal failure in Medicare beneficiaries, 1992 to 2001.

This study's objective was to determine the incidence and mortality of acute renal failure (ARF) in Medicare beneficiaries. Data were from hospitalized Medicare beneficiaries (5,403,015 discharges) between 1992 and 2001 from the 5% sample of Medicare claims. For 1992 to 2001, the overall incidence rate of ARF was 23.8 cases per 1000 discharges, with rates increasing by approximately 11% per year. Older age, male gender, and black race were strongly associated (P < 0.0001) with ARF. The overall in-hospital death rate was 4.6% in discharges without ARF, 15.2% in discharges with ARF coded as the principal diagnosis, and 32.6% in discharges with ARF as a secondary diagnosis. In-hospital death rates were 32.9% in discharges with ARF that required renal dialysis and 27.5% in those with ARF that did not require dialysis. Death within 90 d after hospital admission was 13.1% in discharges without ARF, 34.5% in discharges with ARF coded as the principal diagnosis, and 48.6% in discharges with ARF as a secondary diagnosis. Discharges with ARF were more (P < 0.0001) likely to have intensive care and other acute organ dysfunction than those without ARF. For discharges both with and without ARF, rates for death within 90 d after hospital admission showed a declining trend. In conclusion, the incidence rate of ARF in Medicare beneficiaries has been increasing. Those of older age, male gender, and black race are more likely to have ARF. These data show ARF to be a major contributor to morbidity and mortality in hospitalized patients.

Chronic kidney disease and the risk for cardiovascular disease, renal replacement, and death in the United States Medicare population, 1998 to 1999.

Knowledge of the excess risk posed by specific cardiovascular syndromes could help in the development of strategies to reduce premature mortality among patients with chronic kidney disease (CKD). The rates of atherosclerotic vascular disease, congestive heart failure, renal replacement therapy, and death were compared in a 5% sample of the United States Medicare population in 1998 and 1999 (n = 1,091,201). Patients were divided into the following groups: 1, no diabetes, no CKD (79.7%); 2, diabetes, no CKD (16.5%); 3, CKD, no diabetes (2.2%); and 4, both CKD and diabetes (1.6%). During the 2 yr of follow-up, the rates (per 100 patient-years) in the four groups were as follows: atherosclerotic vascular disease, 14.1, 25.3, 35.7, and 49.1; congestive heart failure, 8.6, 18.5, 30.7, and 52.3; renal replacement therapy, 0.04, 0.2, 1.6, and 3.4; and death, 5.5, 8.1, 17.7, and 19.9, respectively (P < 0.0001). With use of Cox regression, the corresponding adjusted hazards ratios were as follows: atherosclerotic vascular disease, 1, 1.30, 1.16, and 1.41 (P < 0.0001); congestive heart failure, 1, 1.44, 1.28, and 1.79 (P < 0.0001); renal replacement therapy, 1, 2.52, 23.1, and 38.9 (P < 0.0001); and death, 1, 1.21, 1.38, and 1.56 (P < 0.0001). On a relative basis, patients with CKD were at a much greater risk for the least frequent study outcome, renal replacement therapy. On an absolute basis, however, the high death rates of patients with CKD may reflect accelerated rates of atherosclerotic vascular disease and congestive heart failure.

Associations of race, education, and patterns of preventive service use with stage of cancer at time of diagnosis.

OBJECTIVE: To go beyond the documentation of disparities by race and SES by analyzing health behaviors regarding preventive and cancer screening services and determining if these behaviors are associated with stage of cancer when first diagnosed. DATA: Stage of cancer for Medicare patients diagnosed in 1995 with breast, colorectal, uterine, ovarian, prostate, bladder, or stomach cancer; and use of influenza and pneumonia immunization, mammography, pap smear, colon cancer screening, and the prostate specific antigen test during the two years preceding diagnosis of cancer. STUDY DESIGN: Hypothesis tested: health behaviors regarding use of preventive and cancer screening services are associated with stage of cancer when first diagnosed. DATA COLLECTION/EXTRACTION METHODS: Information was extracted from the database formed by the linkage of Surveillance, Epidemiology, and End Results (SEER) cancer registries with Medicare files. PRINCIPAL FINDINGS: Black and white patients (of higher and lower SES) who used more of the preventive and cancer screening services were at a lower risk of having late stage cancer for six cancers studied (breast, colorectal [male and female], prostate, uterine, and male bladder cancer) than their counterparts who used fewer of these services. CONCLUSIONS: The use of preventive and cancer screening services is a health behavior associated with better health outcomes for the elderly diagnosed with cancer. The lack of preventive service use can serve as a marker for identifying persons at risk of late stage cancer when first diagnosed. Strategies that encourage the use of preventive services by low users of these services are likely to reinforce a range of healthy behaviors that help to ameliorate disparities in health outcomes.

Comparison of mortality and intermediate outcomes between medicare dialysis patients in HMO and fee for service.

End-stage renal disease (ESRD) is the only disease entitlement for Medicare; therefore, most patients with ESRD have Medicare coverage. Patients with ESRD are prohibited by law from enrolling in health maintenance organizations (HMOs), the only group prohibited within Medicare. However, they may remain in an HMO if they enrolled in such a plan before their kidneys failed. Thus, it is possible to compare patients with ESRD in HMOs with those in fee-for-service (FFS) plans. To determine whether mortality, transplantation rates, and intermediate outcomes differed between Medicare ESRD beneficiaries enrolled in HMO versus FFS providers, a retrospective cohort analysis was performed of patients with ESRD from three Health Care Financing Administration data sets containing administrative and outcome information for Medicare ESRD beneficiaries from 1990 to 1998. On December 31, 1998, a total of 278,510 prevalent patients with ESRD were in FFS plans, and 18,332 patients were in HMOs. HMO patients were older and more likely to be white and male and have diabetes mellitus and comorbid cardiovascular conditions than FFS patients. Unadjusted 2-year survival rates were 48.4% and 49.3% for FFS and HMO patients, respectively. In a multivariate model, HMO status had no significant effect on mortality, which was greater with older age, male sex, and white race. In 1998, unadjusted renal transplantation rates were 23.5% and 15.5% for FFS and HMO patients, respectively; age adjustment abrogated the apparent difference. For FFS and HMO patients, adequate hemodialysis was delivered to 72% and 82%, and 56% and 62% had hematocrits greater than the benchmark, respectively. There was no statistical difference in these outcomes in multivariate comparison. In conclusion, care by HMO for patients with an expensive chronic illness can achieve outcomes similar to those for FFS patients. Claims of poorer care and worse outcomes for patients with ESRD enrolled onto an HMO, an argument used to justify continued prohibition against widespread participation by patients with ESRD, are not supported.

Medicare's End Stage Renal Disease Program.

Perhaps no other Federal Government program can lay claim to have saved as many lives as the Medicare end stage renal disease (ESRD) program. Since its inception in 1973, as a result of the Social Security Amendments of 1972 (Public Law 92-603, section 299I), over 1 million persons have received life-saving renal replacement therapy under this program. Prior to the enactment of this legislation, treatment was limited to a very few patients due to its extremely high cost and the limited number of dialysis machines. In the 1960s, it was not uncommon for hospitals that had dialysis machines to appoint special committees to review applicants for dialysis and decide who should receive treatment, the others were left to die of renal failure. Public Law 92-603 removed this odious task from the nephrology community. A person with ESRD is entitled to Medicare if he/she is fully or currently insured for benefits under Social Security, or is a spouse or dependent of an insured person. Consequently, entitlement is less than universal, with 92 percent of all persons with ESRD qualifying for Medicare coverage.