RESUMEN
OBJECTIVES: To assess the association between optimal end-stage renal disease (ESRD) starts and clinical and utilization outcomes in an integrated healthcare delivery system. STUDY DESIGN: Retrospective observational cohort study in 6 regions of an integrated healthcare delivery system, 2011-2013. METHODS: Propensity score techniques were used to match 1826 patients who experienced an optimal start of renal replacement therapy (initial therapy of hemodialysis via an arteriovenous fistula or graft, peritoneal dialysis, or pre-emptive transplant) to 1826 patients who experienced a nonoptimal start (hemodialysis via a central venous catheter). Outcomes included 12-month rates of sepsis, mortality, and utilization (inpatient stays, total inpatient days, emergency department visits, and outpatient visits to primary care and specialty care). RESULTS: Optimal starts were associated with a 65% reduction in sepsis (odds ratio, 0.35; 95% CI, 0.29-0.42) and a 56% reduction in 12-month mortality (hazard ratio, 0.44; 95% CI, 0.36-0.53). Optimal starts were also associated with lower utilization, except for nephrology visits. Large utilization differences were observed for total inpatient days (9.4 for optimal starts vs 27.5 for nonoptimal starts; relative rate [RR], 0.45; 95% CI, 0.38-0.52) and outpatient visits for specialty care other than nephrology or vascular surgery (12.5 vs 18.3, respectively; RR, 0.62; 95% CI, 0.53-0.74). CONCLUSIONS: Compared with patients with nonoptimal starts, patients with optimal ESRD starts have lower morbidity and mortality and less use of inpatient and outpatient care. Late-stage chronic kidney disease and ESRD care in an integrated system may be associated with greater benefits than those previously reported in the literature.
Asunto(s)
Fallo Renal Crónico/mortalidad , Fallo Renal Crónico/terapia , Aceptación de la Atención de Salud/estadística & datos numéricos , Terapia de Reemplazo Renal/métodos , Terapia de Reemplazo Renal/estadística & datos numéricos , Factores de Edad , Anciano , Prestación Integrada de Atención de Salud/organización & administración , Prestación Integrada de Atención de Salud/estadística & datos numéricos , Femenino , Gastos en Salud/estadística & datos numéricos , Recursos en Salud/estadística & datos numéricos , Humanos , Fallo Renal Crónico/economía , Fallo Renal Crónico/fisiopatología , Masculino , Persona de Mediana Edad , Evaluación de Resultado en la Atención de Salud , Evaluación de Procesos y Resultados en Atención de Salud , Guías de Práctica Clínica como Asunto , Puntaje de Propensión , Modelos de Riesgos Proporcionales , Grupos Raciales , Terapia de Reemplazo Renal/economía , Características de la Residencia , Estudios Retrospectivos , Factores de Riesgo , Sepsis/epidemiología , Factores Sexuales , Factores Socioeconómicos , Factores de TiempoRESUMEN
OBJECTIVE: To estimate the incidence of occult uterine sarcoma and leiomyosarcoma in hysterectomies for leiomyomas and the risk associated with their morcellation. METHODS: We conducted a population-based cohort study. All uterine sarcomas from 2006-2013 in an integrated health care system were identified. Age- and race-specific incidences of occult uterine sarcoma were calculated. Kaplan-Meier survival analysis was performed. Crude and adjusted risk ratios of recurrence and death associated with morcellation at 1, 2, and 3 years were estimated using Poisson regression with inverse probability weighting. RESULTS: There were 125 hysterectomies with occult uterine sarcomas identified among 34,728 hysterectomies performed for leiomyomas. The incidence of occult uterine sarcoma and leiomyosarcoma was 1 of 278 or 3.60 (95% confidence interval [CI] 2.97-4.23) and 1 of 429 or 2.33 (95% CI 1.83-2.84) per 1,000 hysterectomies. For stage I leiomyosarcoma (n=111), eight (7.2%) were power and 27 (24.3%) nonpower-morcellated. The unadjusted 3-year probability of disease-free survival for no morcellation, power and nonpower morcellation was 0.54, 0.19, and 0.51, respectively (P=.15); overall survival was 0.64, 0.75, and 0.68, respectively (P=.97). None of the adjusted risk ratios for recurrence or death were significant except for death at 1 year for power and nonpower morcellation groups combined (6/33) compared with no morcellation (4/76) (5.12, 95% CI 1.33-19.76, P=.02). We had inadequate power to infer differences for all other comparisons including 3-year survival and power morcellation. CONCLUSION: Morcellation is associated with decreased early survival of women with occult leiomyosarcomas. We could not accurately assess associations between power morcellation and 3-year survival as a result of small numbers.