Integrating a Medical Home in an Outpatient Dialysis Setting: Effects on Health-Related Quality of Life.

BACKGROUND: Integrating primary care has been proposed to reduce fragmented care delivery for patients with complex medical needs. Because of their high rates of morbidity, healthcare use, and mortality, patients with end-stage kidney disease (ESKD) may benefit from increased access to a primary care medical home. OBJECTIVE: To evaluate the effect of integrating a primary care medical home on health-related quality of life (HRQOL) for patients with ESKD receiving chronic hemodialysis. DESIGN: Before-after intervention trial with repeated measures at two Chicago dialysis centers. PARTICIPANTS: Patients receiving hemodialysis at either of the two centers. INTERVENTION: To the standard hemodialysis team (nephrologist, nurse, social worker, dietitian), we added a primary care physician, a pharmacist, a nurse coordinator, and a community health worker. The intervention took place from January 2015 through August 2016. MAIN MEASURES: Health-related quality of life, using the Kidney Disease Quality of Life (KDQOL) measures. KEY RESULTS: Of 247 eligible patients, 175 (71%) consented and participated; mean age was 54 years; 55% were men and 97% were African American or Hispanic. In regression analysis adjusted for individual visits with the medical home providers and other factors, there were significant improvements in four of five KDQOL domains: at 12 and 18 months, the Mental Component Score improved from baseline (adjusted mean 49.0) by 2.64 (p = 0.01) and 2.96 (p = 0.007) points, respectively. At 6 and 12 months, the Symptoms domain improved from baseline (adjusted mean = 77.0) by 2.61 (p = 0.02) and 2.35 points (p = 0.05) respectively. The Kidney Disease Effects domain improved from baseline (adjusted mean = 72.7), to 6, 12, and 18 months by 4.36 (p = 0.003), 6.95 (p < 0.0001), and 4.14 (p = 0.02) points respectively. The Physical Component Score improved at 6 months only. CONCLUSIONS: Integrating primary care and enhancing care coordination in two dialysis facilities was associated with improvements in HRQOL among patients with ESKD who required chronic hemodialysis.

Utilizing Exploratory Spatial Data Analysis to Examine Health and Environmental Disparities in Disadvantaged Neighborhoods.

Health disparities research has focused primarily on racial and socioeconomic differences in health outcomes. Although neighborhood characteristics and the concept of built environment have been shown to affect individual health, measuring the effects of environmental risks on health has been a less developed area of disparities research. To examine spatial associations and the distribution of geographic patterns of sociodemographic characteristics, environmental cancer risk, and cancer rates, we utilized existing data from multiple sources. The findings from our initial analysis, which concerned with proximity to environmental hazards and at-risk communities, were consistent with results of previous studies, which often reported mixed relationships between health disparity indicators and environmental burden. However, further analysis with refined models showed that several key demographic and subdomains of cancer risk measures were shown to have spatial components. With the application of exploratory spatial data analysis, we were able to identify areas with both high rates of poverty and racial minorities to further examine for possible associations to environmental cancer risk. Global spatial autocorrelation found spatial clustering with percent black, percent poverty, point and non-point cancer risks requiring further spatial analysis to determine relationship of significance based on geography. This methodology was based upon particular assumptions associated with data and applications, which needed to be met. We conclude that careful assessment of the data and applications were required to properly interpret the findings in understanding the relationship between vulnerable populations and environmental burden.