Medicare Part D: challenges for dialysis patients. Part 1.

Dialysis patients require numerous medications and have high prescription drug costs compared with general Medicare patients, possibly making them more vulnerable to Medicare Part D policy-related issues. The purpose of this study was to identify problems that dialysis patients experience with Medicare Part D through a survey of dialysis social workers. The online survey was posted on www.kidneyhealthcarecoverage.org and results were collected from January 2010 through October 2010. It was completed by 184 social workers in 38 states, representing 14,200 patients. The greatest Part D plan restrictions were seen with the highest cost prescription medications--Lanthanum carbonate, sevelamer carbonate, and cinacalcet. Seventeen percent of social workers reported that dialysis patients were "very frequently" or "frequently" unaware of available Medicare Part D coverage and 54% reported that up to 20% of their patients continued to have no insurance coverage for prescription drugs. Social workers reported that patients affected by the coverage gap exhibited various changes in medication-taking behavior, such as skipping doses and decreasing dosing frequency. Higher out-of-pocket costs for some dialysis patients during the coverage gap led to reduced use of medications; such gaps in treatment could lead to increased use of medical services, but further data are needed. Currently, the government is slowly phasing out the coverage gap; this process should be completed by 2020. The anticipated shift of self-administered bone and mineral disorder medications from Part D into the dialysis bundle in 2014 has the potential to affect dialysis patients' access to these medications.

Factors affecting employment at initiation of dialysis.

BACKGROUND AND OBJECTIVES: Half the individuals who reach ESRD are working age (< 65 years old) and many are at risk for job loss. Factors that contribute to job retention among working-age patients with chronic kidney disease before ESRD are unknown. The purpose of the study is to understand factors associated with maintaining employment among working-age patients with advanced kidney failure. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: In this retrospective study we reviewed the United States Renal Data System database (1992 through 2003) and selected all patients (n = 102,104) who were working age and employed 6 months before dialysis initiation. Factors that were examined for an association with maintaining employment status included demographics, comorbid conditions, ESRD cause, insurance, predialysis erythropoietin use, and dialysis modality. RESULTS: Maintaining employment at the same level during the final 6 months before dialysis was more likely among (1) white men ages 30 to 49 years; (2) patients with either glomerulonephritis, cystic, or urologic causes of renal failure; (3) patients choosing peritoneal dialysis for their first treatment; (4) those with employer group or other health plans; and (5) erythropoietin usage before ESRD. Maintaining employment status was less likely among patients with congestive heart failure, cardiovascular disease, cancer, and other chronic illnesses. CONCLUSIONS: The rate of unemployment in working-age patients with chronic kidney disease and ESRD is high compared with that of the general population. Treating anemia with erythropoietin before kidney failure and educating patients about work-friendly home dialysis options might improve job retention.

Vocational rehabilitation: is your facility on track?

BACKGROUND: The Conditions for Coverage for End-Stage Renal Disease Facilities require that facilities evaluate each patient for referral to vocational rehabilitation (VR) services, assist the patient in achieving and sustaining an appropriate level of productive activity, and develop a plan that reflects individual patient preference. Though research shows that people on dialysis who keep working feel better, data collected in the 2008 USRDS Comprehensive Dialysis Study indicates that only half of dialysis patients continued to work after starting treatment. OBJECTIVES: A review of the data and the reasons dialysis patients do not work provides an opportunity to identify resources and strategies to address barriers. FMQAI: The Florida ESRD Network (Network 7) initiated a quality improvement project in June 2008 to increase the percentage of Florida ESRD patients, aged 18 through 54, who were receivingVR services, attending school, or employed. METHODS: Using the 2007 ESRD Facility Survey (CMS-2744A) data as a baseline, Network 7 employed a two-pronged approach using both statewide spread efforts and focus group interventions with a targeted group of providers. All facilities identified in the focus group began the project with a baseline of 0% of patients ages 18-54 either engaged in VR, working, or in school. Quality improvement plan (QIP) workshops, conference calls, tracking tools, individualized facility data reports, educational materials, and technical assistance were utilized to improve VR rates in Florida. RESULTS: As of December 31, 2008, Network 7 increased their statewide results (patients aged 18-54 either engaged in VR services, attending school or working) by 2.5% over the 2007 baseline. For the focus group, as of June 30, 2009, results indicate that 40% of patients are either engaged in VR, working, or in school. RECOMMENDATIONS: By including VR in facility quality assessment and performance improvement (QAPI) activities, facilities can demonstrate outcomes-driven practice and enhance the independence and quality of life for ESRD patients.

The Missouri Kidney Program's Patient Education Program: a 12-year retrospective analysis.

Unbiased patient education for individuals with chronic kidney disease can result in a multitude of positive benefits. The current study reviewed 1,844 participants in a six-topic patient education program over a 12-year period from June 1994 to July 2006, examining patients' level of knowledge about CKD, preferences for treatment, and feelings of hope and fear before and after the educational intervention. After the educational intervention, patients scored significantly higher on knowledge tests of all topics than they scored on the pre-test (p < .05). Overall, there were no significant differences from pre- to post-test on self-ratings of being "scared" or "hopeful," although on the post-test, females were significantly more hopeful than males (p < .01). More patients were interested in peritoneal dialysis as a treatment option after class attendance (p < .001). Multivariate logistic regressions indicated that patients who were older, black, or who had a high school education or less were more likely to prefer center hemodialysis (p < .007). Although overall interest in the transplant option did not change significantly from pre- to post-test, younger patients (52 vs. 67 mean years, p < .001) and males (59% vs. 54%, p = .02) were more interested in receiving a transplant.