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1.
Am J Transplant ; 18(1): 43-52, 2018 01.
Artigo em Inglês | MEDLINE | ID: mdl-28898574

RESUMO

Healthcare reimbursement is increasingly tied to value instead of volume, with special attention paid to resource-intensive populations such as patients with renal disease. To this end, Medicare has sponsored pilot projects to encourage providers to develop care coordination and population health management strategies to provide quality care while reducing resource utilization. In this Personal Viewpoint essay, we argue in favor of expanding one such pilot project-the Comprehensive ESRD Care (CEC) initiative-to include patients with advanced chronic kidney disease and kidney transplant recipients. The implementation of the Medicare Access and CHIP Reauthorization Act (MACRA) offers a time-sensitive incentive for transplant centers in particular to align with extant CECs. An "expanded" CEC model proffers opportunity for robust cooperation between general nephrology practices, dialysis providers, and transplant centers to develop care coordination strategies for all patients with renal disease, realign incentives for all clinical stakeholders to increase kidney transplantation rates, and reduce total costs of care.


Assuntos
Prestação Integrada de Cuidados de Saúde/tendências , Medicare/tendências , Nefrologia/tendências , Qualidade da Assistência à Saúde , Insuficiência Renal Crônica/prevenção & controle , Redução de Custos , Prestação Integrada de Cuidados de Saúde/economia , Humanos , Medicare/economia , Nefrologia/economia , Prognóstico , Diálise Renal , Transplantados , Estados Unidos
2.
Clin Nephrol ; 88(8): 59-67, 2017 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-28587714

RESUMO

AIMS: Hyperphosphatemia has been associated with an increased risk of mortality in patients with end-stage renal disease. We sought to assess the real-world effectiveness of sucroferric oxyhydroxide (SO), an iron-based phosphate binder (PB), in control of serum phosphorus levels, and to determine the associated pill burden in hemodialysis patients. MATERIALS AND METHODS: Adult, in-center hemodialysis patients first prescribed SO through a renal pharmacy service as part of routine clinical care between April 1, 2014 and March 31, 2015 were included in the analysis. The proportion of patients with phosphorus levels ≤ 5.5 mg/dL and the mean prescribed PB pills/day were compared between baseline (3 months prior to SO) and SO follow-up at 3 (SO 1 - 3) and 6 months (SO 4 - 6). Mineral bone disease markers, hemoglobin, iron indices, and erythropoiesis-stimulating agents and intravenous iron use were assessed. RESULTS: At baseline, all patients (n = 1,029) were prescribed PB, and 13.9% had mean serum phosphorus ≤ 5.5 mg/dL. Comparing baseline to SO 1 - 3, the mean prescribed PB pills/day declined from 9.6 to 3.8 pills/day (p < 0.001), and the proportion of patients with serum phosphorus ≤ 5.5 mg/dL increased from 13.9 to 26.1% (+88%). Comparing baseline to SO 4 - 6 (n = 424), the mean prescribed PB pills/day declined from 9.7 to 4.0 pills/day (p < 0.001), and the proportion of patients with serum phosphorus ≤ 5.5 mg/dL increased from 15.6 to 30.4% (+95%). CONCLUSIONS: Prescription of SO was associated with an increase in the proportion of patients achieving serum phosphorus levels ≤ 5.5 mg/dL along with fewer prescribed PB pills/day.
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Assuntos
Compostos Férricos/uso terapêutico , Hiperfosfatemia/tratamento farmacológico , Diálise Renal , Sacarose/uso terapêutico , Adulto , Idoso , Combinação de Medicamentos , Feminino , Humanos , Falência Renal Crônica/terapia , Masculino , Pessoa de Meia-Idade , Fósforo/sangue , Diálise Renal/efeitos adversos , Estudos Retrospectivos
3.
Am J Kidney Dis ; 70(1): 132-138, 2017 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-28416322

RESUMO

As the costs of caring for patients with end-stage renal disease have grown, so has the pressure to provide high-quality care at a lower cost. Prompted in large part by regulatory and legislative changes, reimbursement is shifting from a fee-for-service environment to one of value-based payment models. Nephrologists in this new environment are increasingly responsible not only for direct patient care, but also for population management and the associated clinical outcomes for this vulnerable population. This Perspective article aims to recognize the key role and skills needed in order to successfully practice within these new value-based care models. The new paradigm of delivering and financing care also presents opportunities for nephrologists to shape how care is delivered, define meaningful quality metrics, and share in the financial outcomes of these approaches. Though it will take time, the training and mind-set of nephrologists must evolve to accommodate these expanded practice expectations required by a system that demands measurement, reporting, accountability, and improvement, not only for individuals but also for populations of patients.


Assuntos
Prestação Integrada de Cuidados de Saúde , Nefropatias/terapia , Nefrologia , Previsões , Custos de Cuidados de Saúde , Humanos , Nefropatias/economia , Modelos Teóricos , Papel do Médico
4.
Circulation ; 131(11): 972-9, 2015 Mar 17.
Artigo em Inglês | MEDLINE | ID: mdl-25595139

RESUMO

BACKGROUND: Dabigatran and rivaroxaban are new oral anticoagulants that are eliminated through the kidneys. Their use in dialysis patients is discouraged because these drugs can bioaccumulate to precipitate inadvertent bleeding. We wanted to determine whether prescription of dabigatran or rivaroxaban was occurring in the dialysis population and whether these practices were safe. METHODS AND RESULTS: Prevalence plots were used to describe the point prevalence (monthly) of dabigatran and rivaroxaban use among 29977 hemodialysis patients with atrial fibrillation. Poisson regression compared the rate of bleeding, stroke, and arterial embolism in patients who started dabigatran, rivaroxaban, or warfarin. The first record of dabigatran prescription among hemodialysis patients occurred 45 days after the drug became available in the United States. Since then, dabigatran and rivaroxaban use in the atrial fibrillation-end-stage renal disease population has steadily risen where 5.9% of anticoagulated dialysis patients are started on dabigatrian or rivaroxaban. In covariate adjusted Poisson regression, dabigatran (rate ratio, 1.48; 95% confidence interval, 1.21-1.81; P=0.0001) and rivaroxaban (rate ratio, 1.38; 95% confidence interval, 1.03-1.83; P=0.04) associated with a higher risk of hospitalization or death from bleeding when compared with warfarin. The risk of hemorrhagic death was even larger with dabigatran (rate ratio, 1.78; 95% confidence interval, 1.18-2.68; P=0.006) and rivaroxaban (rate ratio, 1.71; 95% confidence interval, 0.94-3.12; P=0.07) relative to warfarin. There were too few events in the study to detect meaningful differences in stroke and arterial embolism between the drug groups. CONCLUSIONS: More dialysis patients are being started on dabigatran and rivaroxaban, even when their use is contraindicated and there are no studies to support that the benefits outweigh the risks of these drugs in end-stage renal disease.


Assuntos
Anticoagulantes/uso terapêutico , Fibrilação Atrial/tratamento farmacológico , Benzimidazóis/uso terapêutico , Falência Renal Crônica/complicações , Morfolinas/uso terapêutico , Padrões de Prática Médica/estatística & dados numéricos , Diálise Renal , Tiofenos/uso terapêutico , beta-Alanina/análogos & derivados , Idoso , Idoso de 80 Anos ou mais , Anticoagulantes/efeitos adversos , Anticoagulantes/farmacocinética , Fibrilação Atrial/complicações , Fibrilação Atrial/metabolismo , Benzimidazóis/efeitos adversos , Benzimidazóis/farmacocinética , Dabigatrana , Bases de Dados Factuais , Relação Dose-Resposta a Droga , Uso de Medicamentos , Feminino , Hemorragia/induzido quimicamente , Hemorragia/epidemiologia , Hospitalização/estatística & dados numéricos , Humanos , Rim/efeitos dos fármacos , Rim/metabolismo , Falência Renal Crônica/metabolismo , Masculino , Análise por Pareamento , Pessoa de Meia-Idade , Morfolinas/efeitos adversos , Morfolinas/farmacocinética , Distribuição de Poisson , Padrões de Prática Médica/tendências , Estudos Retrospectivos , Risco , Rivaroxabana , Acidente Vascular Cerebral/etiologia , Tiofenos/efeitos adversos , Tiofenos/farmacocinética , Varfarina/efeitos adversos , Varfarina/farmacocinética , Varfarina/uso terapêutico , beta-Alanina/efeitos adversos , beta-Alanina/farmacocinética , beta-Alanina/uso terapêutico
5.
Clin J Am Soc Nephrol ; 10(2): 326-30, 2015 Feb 06.
Artigo em Inglês | MEDLINE | ID: mdl-25278550

RESUMO

The medical director has been a part of the fabric of Medicare's ESRD program since entitlement was extended under Section 299I of Public Law 92-603, passed on October 30, 1972, and implemented with the Conditions for Coverage that set out rules for administration and oversight of the care provided in the dialysis facility. The role of the medical director has progressively increased over time to effectively extend to the physicians serving in this role both the responsibility and accountability for the performance and reliability related to the care provided in the dialysis facility. This commentary provides context to the nature and expected competencies and behaviors of these medical director roles that remain central to the delivery of high-quality, safe, and efficient delivery of RRT, which has become much more intensive as the dialysis industry has matured.


Assuntos
Prestação Integrada de Cuidados de Saúde/tendências , Falência Renal Crônica/terapia , Nefrologia/tendências , Diretores Médicos/tendências , Papel do Médico , Qualidade da Assistência à Saúde/tendências , Competência Clínica , Prestação Integrada de Cuidados de Saúde/história , Prestação Integrada de Cuidados de Saúde/normas , História do Século XX , História do Século XXI , Humanos , Falência Renal Crônica/diagnóstico , Falência Renal Crônica/história , Liderança , Medicare , Nefrologia/história , Nefrologia/normas , Diretores Médicos/história , Diretores Médicos/normas , Papel do Médico/história , Qualidade da Assistência à Saúde/história , Qualidade da Assistência à Saúde/normas , Estados Unidos , Recursos Humanos
6.
Clin J Am Soc Nephrol ; 8(4): 694-700, 2013 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-23539229

RESUMO

Under the Patient Protection and Affordable Care Act of 2010, accountable care organizations (ACOs) will be the primary mechanism for achieving the dual goals of high-quality patient care at managed per capita costs. To achieve these goals in the newly emerging health care environment, the nephrology community must plan for and direct integrated delivery and coordination of renal care, focusing on population management. Even though the ESRD patient population is a complex group with comorbid conditions that may confound integration of care, the nephrology community has unique experience providing integrated care through ACO-like programs. Specifically, the recent ESRD Management Demonstration Project sponsored by the Centers for Medicare & Medicaid Services and the current ESRD Prospective Payment System with it Quality Incentive Program have demonstrated that integrated delivery of renal care can be accomplished in a manner that provides improved clinical outcomes with some financial margin of savings. Moving forward, integrated renal care will probably be linked to provider performance and quality outcomes measures, and clinical integration initiatives will share several common elements, namely performance-based payment models, coordination of communication via health care information technology, and development of best practices for care coordination and resource utilization. Integration initiatives must be designed to be measured and evaluated, and, consistent with principles of continuous quality improvement, each initiative will provide for iterative improvements of the initiative.


Assuntos
Prestação Integrada de Cuidados de Saúde/tendências , Falência Renal Crônica/terapia , Nefrologia/tendências , Sistema de Pagamento Prospectivo/tendências , Redução de Custos , Prestação Integrada de Cuidados de Saúde/economia , Humanos , Falência Renal Crônica/economia , Medicare/economia , Medicare/tendências , Nefrologia/economia , Patient Protection and Affordable Care Act , Sistema de Pagamento Prospectivo/economia , Garantia da Qualidade dos Cuidados de Saúde/economia , Garantia da Qualidade dos Cuidados de Saúde/tendências , Reembolso de Incentivo/economia , Reembolso de Incentivo/tendências , Diálise Renal/economia , Estados Unidos
7.
Blood Purif ; 36(3-4): 152-9, 2013.
Artigo em Inglês | MEDLINE | ID: mdl-24496184

RESUMO

Under the Patient Protection and Affordable Care Act of 2010, accountable care organizations (ACOs) will be the primary mechanism for achieving the dual goals of high-quality patient care at managed per capita costs. To achieve these goals in the newly emerging health care environment, the nephrology community must plan for and direct integrated delivery and coordination of renal care, focusing on population management. Even though the ESRD patient population is a complex group with comorbid conditions that may confound integration of care, the nephrology community has unique experience providing integrated care through ACO-like programs. Specifically, the recent ESRD Management Demonstration Project sponsored by the Centers for Medicare & Medicaid Services and the current ESRD Prospective Payment System with it Quality Incentive Program have demonstrated that integrated delivery of renal care can be accomplished in a manner that provides improved clinical outcomes with some financial margin of savings. Moving forward, integrated renal care will probably be linked to provider performance and quality outcomes measures, and clinical integration initiatives will share several common elements, namely performance-based payment models, coordination of communication via health care information technology, and development of best practices for care coordination and resource utilization. Integration initiatives must be designed to be measured and evaluated, and, consistent with principles of continuous quality improvement, each initiative will provide for iterative improvements of the initiative.


Assuntos
Prestação Integrada de Cuidados de Saúde , Gerenciamento Clínico , Falência Renal Crônica/terapia , Organizações de Assistência Responsáveis , Custos de Cuidados de Saúde , Humanos , Falência Renal Crônica/economia , Qualidade da Assistência à Saúde
8.
Semin Dial ; 21(1): 54-7, 2008.
Artigo em Inglês | MEDLINE | ID: mdl-18251959

RESUMO

The role of the dialysis unit Medical Director has evolved over time to an expanded set of roles from one that used to be strictly "medical" to one that is more "managerial." Physicians providing these Medical Director services are facing increasing demands for a leadership role regarding clinical quality improvement and measurement of performance in core areas of care within the dialysis program. The dialysis Medical Director is asked to lead in group decision-making, in analyzing core process and patient outcomes and in stimulating a team approach to Continuous Quality Improvement (CQI) and patient safety. For the end-stage renal disease program, national quality expectations in dialysis care have stimulated the dialysis providers to measure, report and respond consistently in an effort to provide a higher level of cost-efficient care. Medical Directors are usually contractually linked to the dialysis programs for which they provide oversight and their contracts are explicit about the relationship they maintain and the role they are expected to play within dialysis companies (often called "provider organizations"). The evolution of the Medical Director role has led to a close relationship between the company that provides the dialysis services and the physician providing the medical oversight.


Assuntos
Prestação Integrada de Cuidados de Saúde/normas , Unidades Hospitalares de Hemodiálise/organização & administração , Garantia da Qualidade dos Cuidados de Saúde , Diálise Renal/tendências , Humanos , Falência Renal Crônica/terapia , Equipe de Assistência ao Paciente , Satisfação do Paciente , Estados Unidos
9.
Adv Chronic Kidney Dis ; 15(1): 64-72, 2008 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-18155111

RESUMO

Clinical information technology (IT) systems that support nephrology-specific content can facilitate the coordinated, progressive, and comprehensive care of all patients with renal disease including those with each stage of chronic kidney disease (CKD). The ideal clinical IT system should have flexible features to meet the needs of individualized practice patterns, yet also have tools to enhance continuity, measure performance, and deliver decision support features that assist the nephrologist in providing optimal care for the CKD patient. This article provides insight into the complexities of engaging in the process of technology adoption, including selection, integration, and implementation while emphasizing the utility of using a continuous quality improvement paradigm to identify and achieve positive results from the adoption and integration of a clinical IT system into outpatient clinical practice of nephrology.


Assuntos
Tecnologia Biomédica , Atenção à Saúde , Nefropatias/terapia , Nefrologia , Automação de Escritório , Doença Crônica , Serviços Contratados , Técnicas de Apoio para a Decisão , Humanos , Sistemas Computadorizados de Registros Médicos , Administração da Prática Médica , Qualidade da Assistência à Saúde , Integração de Sistemas , Gestão da Qualidade Total
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