Trajectories of Physical Resilience Among Older Veterans With Stage 4 CKD.

RATIONALE & OBJECTIVE: Although functional impairment is common among older adults with chronic kidney disease (CKD), functional reserve before an acute health event and physical resilience after the event have not been characterized in this population. The purpose of this study was to identify distinct patterns of physical function before and after an acute health event among older veterans with stage 4 CKD. STUDY DESIGN: Prospective cohort study. SETTING & PARTICIPANTS: National sample of veterans≥70 years of age with an estimated glomerular filtration rate (eGFR) of<30mL/min/1.73m2 who had an acute care encounter (emergency department visit or hospitalization) during the follow-up period (n = 272). PREDICTORS: Demographic characteristics, eGFR, basic and instrumental activities of daily living (ADL/IADL) difficulty, symptom burden, cognition, depressive symptoms, social support. OUTCOME: Function measured using the life-space mobility assessment obtained by telephone survey before and after an acute care encounter. ANALYTICAL APPROACH: General growth mixture models to identify classes of functional trajectories. Calculation of percentages for demographic characteristics and means for eGFR, ADL/IADL difficulty, symptom burden, cognition, depressive symptoms, and social support by trajectory class. RESULTS: Four trajectory classes were identified and characterized by different levels of life-space mobility before (reserve) and change in life-space mobility after (resilience) an acute care encounter: (1) low reserve, low resilience (n=91), (2) high reserve, high resilience (n=23), (3) moderate reserve, moderate resilience (n=89), and (4) high reserve, low resilience (n=69). Mean levels of ADL/IADL difficulty, symptom burden, cognition, and depressive symptoms, but not demographic characteristics, eGFR, or social support, differed by trajectory class. LIMITATIONS: Veteran cohort was primarily male. CONCLUSIONS: Among older adults with stage 4 CKD, physical function trajectories before and after an acute health event vary. Integrating reserve and resilience into care for this population may be useful for anticipating changes in function and developing tailored treatment plans.

Effects of Implementation of a Supervised Walking Program in Veterans Affairs Hospitals : A Stepped-Wedge, Cluster Randomized Trial.

BACKGROUND: In trials, hospital walking programs have been shown to improve functional ability after discharge, but little evidence exists about their effectiveness under routine practice conditions. OBJECTIVE: To evaluate the effect of implementation of a supervised walking program known as STRIDE (AssiSTed EaRly MobIlity for HospitalizeD VEterans) on discharge to a skilled-nursing facility (SNF), length of stay (LOS), and inpatient falls. DESIGN: Stepped-wedge, cluster randomized trial. (ClinicalTrials.gov: NCT03300336). SETTING: 8 Veterans Affairs hospitals from 20 August 2017 to 19 August 2019. PATIENTS: Analyses included hospitalizations involving patients aged 60 years or older who were community dwelling and admitted for 2 or more days to a participating medicine ward. INTERVENTION: Hospitals were randomly assigned in 2 stratified blocks to a launch date for STRIDE. All hospitals received implementation support according to the Replicating Effective Programs framework. MEASUREMENTS: The prespecified primary outcomes were discharge to a SNF and hospital LOS, and having 1 or more inpatient falls was exploratory. Generalized linear mixed models were fit to account for clustering of patients within hospitals and included patient-level covariates. RESULTS: Patients in pre-STRIDE time periods (n = 6722) were similar to post-STRIDE time periods (n = 6141). The proportion of patients with any documented walk during a potentially eligible hospitalization ranged from 0.6% to 22.7% per hospital. The estimated rates of discharge to a SNF were 13% pre-STRIDE and 8% post-STRIDE. In adjusted models, odds of discharge to a SNF were lower among eligible patients hospitalized in post-STRIDE time periods (odds ratio [OR], 0.6 [95% CI, 0.5 to 0.8]) compared with pre-STRIDE. Findings were robust to sensitivity analyses. There were no differences in LOS (rate ratio, 1.0 [CI, 0.9 to 1.1]) or having an inpatient fall (OR, 0.8 [CI, 0.5 to 1.1]). LIMITATION: Direct program reach was low. CONCLUSION: Although the reach was limited and variable, hospitalizations occurring during the STRIDE hospital walking program implementation period had lower odds of discharge to a SNF, with no change in hospital LOS or inpatient falls. PRIMARY FUNDING SOURCE: U.S. Department of Veterans Affairs Quality Enhancement Research Initiative (Optimizing Function and Independence QUERI).

Epidemiology of Community-Acquired Acute Kidney Injury Among US Veterans.

RATIONALE & OBJECTIVE: Community-acquired acute kidney injury (CA-AKI) develops outside of the hospital and is the most common form of AKI globally. National estimates of CA-AKI in the United States are absent due to limited availability of laboratory data. This study leverages national data from the Veterans Health Administration (VA) to estimate incidence and risk factors of CA-AKI. STUDY DESIGN: Retrospective cohort study using national VA administrative and laboratory data to assess cumulative CA-AKI incidence. SETTING & PARTICIPANTS: VA primary care patients in 2013-2017 with recorded outpatient serum creatinine (Scr) and no history of chronic kidney disease≥stage 5. PREDICTOR: Sociodemographics, comorbidities, medication use, and health care utilization. OUTCOME: Annual incidence of CA-AKI defined as a≥1.5-fold relative increase in Scr on either a subsequent outpatient Scr or inpatient Scr obtained within ≤24 hours of admission. ANALYTICAL APPROACH: We calculated the relative change in Scr within 12 months of an outpatient Scr value. A Cox model was used to estimate the association between CA-AKI and baseline characteristics, accounting for repeated measurements. RESULTS: Of approximately 2.5 million eligible veterans each year, the cumulative incidence of CA-AKI was approximately 2% annually. Only 27% of CA-AKI was detected at hospital admission. In adjusted analyses, high health care utilization, chronic illness, cancer, rural location, female sex, and use of renin-angiotensin aldosterone system inhibitors or diuretics were associated with increased CA-AKI risk (all, HR>1.20). LIMITATIONS: Limited generalizability of results outside a veteran population, lack of a standardized definition for CA-AKI, and possibility of surveillance bias and misclassification. CONCLUSIONS: CA-AKI affects 1 of every 50 US veterans annually. With less than a third of CA-AKI observed in the inpatient hospital setting, reliance on inpatient evaluation of AKI suggests significant underrecognition and missed opportunities to prevent and manage the long-term consequences of AKI.

A Cluster Randomized Trial of a Family Health History Platform to Identify and Manage Patients at Increased Risk for Colorectal Cancer.

BACKGROUND: Obtaining comprehensive family health history (FHH) to inform colorectal cancer (CRC) risk management in primary care settings is challenging. OBJECTIVE: To examine the effectiveness of a patient-facing FHH platform to identify and manage patients at increased CRC risk. DESIGN: Two-site, two-arm, cluster-randomized, implementation-effectiveness trial with primary care providers (PCPs) randomized to immediate intervention versus wait-list control. PARTICIPANTS: PCPs treating patients at least one half-day per week; patients aged 40-64 with no medical conditions that increased CRC risk. INTERVENTIONS: Immediate-arm patients entered their FHH into a web-based platform that provided risk assessment and guideline-driven decision support; wait-list control patients did so 12 months later. MAIN MEASURES: McNemar's test examined differences between the platform and electronic medical record (EMR) in rates of increased risk documentation. General estimating equations using logistic regression models compared arms in risk-concordant provider actions and patient screening test completion. Referral for genetic consultation was analyzed descriptively. KEY RESULTS: Seventeen PCPs were randomized to each arm. Patients (n = 252 immediate, n = 253 control) averaged 51.4 (SD = 7.2) years, with 83% assigned male at birth, 58% White persons, and 33% Black persons. The percentage of patients identified as increased risk for CRC was greater with the platform (9.9%) versus EMR (5.2%), difference = 4.8% (95% CI: 2.6%, 6.9%), p < .0001. There was no difference in PCP risk-concordant action [odds ratio (OR) = 0.7, 95% CI (0.4, 1.2; p = 0.16)]. Among 177 patients with a risk-concordant screening test ordered, there was no difference in test completion, OR = 0.8 [0.5,1.3]; p = 0.36. Of 50 patients identified by the platform as increased risk, 78.6% immediate and 68.2% control patients received a recommendation for genetic consultation, of which only one in each arm had a referral placed. CONCLUSIONS: FHH tools could accurately assess and document the clinical needs of patients at increased risk for CRC. Barriers to acting on those recommendations warrant further exploration. TRIAL REGISTRATION NUMBER: ClinicalTrials.gov NCT02247336 https://clinicaltrials.gov/ct2/show/NCT02247336.

Impact of the COVID-19 Pandemic on the Provision of Dialysis Service and Mortality in Veterans Receiving Maintenance Hemodialysis in the VA: An Interrupted Time-Series Analysis.

INTRODUCTION: According to the US Renal Data System (USRDS), patients with end-stage kidney disease (ESKD) on maintenance dialysis had higher mortality during early COVID-19 pandemic. Less is known about the effect of the pandemic on the delivery of outpatient maintenance hemodialysis and its impact on death. We examined the effect of pandemic-related disruption on the delivery of dialysis treatment and mortality in patients with ESKD receiving maintenance hemodialysis in the Veterans Health Administration (VHA) facilities, the largest integrated national healthcare system in the USA. METHODS: Using national VHA electronic health records data, we identified 7,302 Veterans with ESKD who received outpatient maintenance hemodialysis in VHA healthcare facilities during the COVID-19 pandemic (February 1, 2020, to December 31, 2021). We estimated the average change in the number of hemodialysis treatments received and deaths per 1,000 patients per month during the pandemic by conducting interrupted time-series analyses. We used seasonal autoregressive moving average (SARMA) models, in which February 2020 was used as the conditional intercept and months thereafter as conditional slope. The models were adjusted for seasonal variations and trends in rates during the pre-pandemic period (January 1, 2007, to January 31, 2020). RESULTS: The number (95% CI) of hemodialysis treatments received per 1,000 patients per month during the pre-pandemic and pandemic periods were 12,670 (12,525-12,796) and 12,865 (12,729-13,002), respectively. Respective all-cause mortality rates (95% CI) were 17.1 (16.7-17.5) and 19.6 (18.5-20.7) per 1,000 patients per month. Findings from SARMA models demonstrate that there was no reduction in the dialysis treatments delivered during the pandemic (rate ratio: 0.999; 95% CI: 0.998-1.001), but there was a 2.3% (95% CI: 1.5-3.1%) increase in mortality. During the pandemic, the non-COVID hospitalization rate was 146 (95% CI: 143-149) per 1,000 patients per month, which was lower than the pre-pandemic rate of 175 (95% CI: 173-176). In contrast, there was evidence of higher use of telephone encounters during the pandemic (3,023; 95% CI: 2,957-3,089), compared with the pre-pandemic rate (1,282; 95% CI: 1,241-1,324). CONCLUSIONS: We found no evidence that there was a disruption in the delivery of outpatient maintenance hemodialysis treatment in VHA facilities during the COVID-19 pandemic and that the modest rise in deaths during the pandemic is unlikely to be due to missed dialysis.

Self-Organization of Interprofessional Staff to Improve Mobility of Hospitalized Patients with STRIDE: a Complexity Science-Informed Qualitative Study.

BACKGROUND: Inpatient mobility programs can help older adults maintain function during hospitalization. Changing hospital practice can be complex and require engagement of various staff levels and disciplines; however, we know little about how interprofessional teams organize around implementing such interventions. Complexity science can inform approaches to understanding and improving multidisciplinary collaboration to implement clinical programs. OBJECTIVE: To examine, through a complexity science lens, how clinical staff's understanding about roles in promoting inpatient mobility evolved during implementation of the STRIDE (assiSTed eaRly mobIlity for hospitalizeD older vEterans) hospital mobility program. DESIGN: Qualitative study using semi-structured interviews. PARTICIPANTS: Ninety-two clinical staff at eight Veterans Affairs hospitals. INTERVENTIONS: STRIDE is a supervised walking program for hospitalized older adults designed to maintain patients' mobility and function. APPROACH: We interviewed key staff involved in inpatient mobility efforts at each STRIDE site in pre- and post-implementation periods. Interviews elicited staff's perception of complexity-science aspects of inpatient mobility teams (e.g., roles over time, team composition). We analyzed data using complexity science-informed qualitative content analysis. KEY RESULTS: We identified three key themes related to patterns of self-organization: (1) individuals outside of the "core" STRIDE team voluntarily assumed roles as STRIDE advocates, (2) leader-champions adapted their engagement level to match local implementation team needs during implementation, and (3) continued leadership support and physical therapy involvement were key factors for sustainment. CONCLUSIONS: Staff self-organized around implementation of a new clinical program in ways that were responsive to changing program and contextual needs. These findings demonstrate the importance of effective self-organization for clinical program implementation. Researchers and practitioners implementing clinical programs should allow for, and encourage, flexibility in staff roles in planning for implementation of a new clinical program, encourage the development of advocates, and engage leaders in program planning and sustainment efforts.

Reserve and resilience in CKD: concept introduction and baseline results from the Physical REsilience Prediction in Advanced REnal Disease (PREPARED) study.

BACKGROUND: The purpose of this manuscript is to introduce reserve and resilience as novel concepts in chronic kidney disease (CKD) research and present baseline data from a unique prospective cohort study designed to characterize recovery from functional decline after a health event. METHODS: The Physical REsilience Prediction in Advanced REnal Disease (PREPARED) study recruited a national, prospective cohort of Veterans ≥70 years old with an estimated glomerular filtration rate (eGFR) < 30 ml/min/1.73 m2, prior nephrology care, and at high risk for hospitalization. Electronic health record data were paired with telephone surveys. Self-reported measures of reserve included physical, psychological, and cognitive capacity and environmental resources. We calculated counts (frequencies) and medians (25th, 75th percentiles) for baseline measures of reserve. The study's longitudinal follow-up of physical function every 8 weeks or following an acute care encounter, which will be used to define resilience, is ongoing. RESULTS: Participants had a median (25th, 75th percentile) age of 76.3 (72.8, 81.4) years and eGFR of 23.4 (18.2, 28.8) ml/min/1.73 m2; 23.3% were Black, and 97.4% were male, 91.6% had hypertension, 67.4% had diabetes mellitus, 46.0% had coronary heart disease, and 39.8% had heart failure. Baseline measures of physical, psychological, and cognitive domains showed low reserve on average, but with wide ranges. CONCLUSIONS: Despite similar levels of kidney function, older adults participating in PREPARED had a wide range of measures of reserve in other health domains. Non-renal measures of reserve may be important indicators of capacity of CKD patients to recover after acute care encounters.

Improving chronic kidney disease detection and treatment in the United States: the chronic kidney disease cascade of care (C3) study protocol.

BACKGROUND: There are major gaps in the implementation of guideline-concordant care for persons with chronic kidney disease (CKD). The CKD Cascade of Care (C3) initiative seeks to improve CKD care by improving detection and treatment of CKD in primary care. METHODS: C3 is a multi-modal initiative deployed in three major academic medical centers within the Department of Veterans Affairs (VA) Health Care System: San Francisco VA, San Diego VA, and Houston VA. The main objective of the first phase of C3 described in this protocol is to establish the infrastructure for universal CKD detection among primary care patients at high-risk for CKD with a triple-marker screen comprising cystatin C, creatinine, and albuminuria. Across the three sites, a comprehensive educational intervention and the integration of primary care-based clinical champions will be employed with the goal of improving CKD detection and treatment. The San Francisco VA will also implement a practice-facilitation intervention leveraging telehealth and health informatics tools and capabilities for enhanced CKD detection. Parallel formative evaluation across the three sites will assess the feasibility and acceptability of integrating cystatin C as part of routine CKD detection in primary care practice. The effectiveness of the interventions will be assessed using a pre-post observational design for change in the proportion of patients tested annually for CKD. Secondary outcomes will assess change in the initiation of cardio-kidney protective therapies and in nephrology referrals of high-risk patients. DISCUSSION: The first phase of C3 is a multi-facility multi-modal initiative that aims to improve CKD care by implementing a triple-marker screen for enhanced CKD detection in primary care.

Adapting to CONNECT: modifying a nursing home-based team-building intervention to improve hospital care team interactions, functioning, and implementation readiness.

BACKGROUND: Clinical interventions often need to be adapted from their original design when they are applied to new settings. There is a growing literature describing frameworks and approaches to deploying and documenting adaptations of evidence-based practices in healthcare. Still, intervention modifications are often limited in detail and justification, which may prevent rigorous evaluation of interventions and intervention adaptation effectiveness in new contexts. We describe our approach in a case study, combining two complementary intervention adaptation frameworks to modify CONNECT for Quality, a provider-facing team building and communication intervention designed to facilitate implementation of a new clinical program. METHODS: This process of intervention adaptation involved the use of the Planned Adaptation Framework and the Framework for Reporting Adaptations and Modifications, for systematically identifying key drivers, core and non-core components of interventions for documenting planned and unplanned changes to intervention design. RESULTS: The CONNECT intervention's original context and setting is first described and then compared with its new application. This lays the groundwork for the intentional modifications to intervention design, which are developed before intervention delivery to participating providers. The unpredictable nature of implementation in real-world practice required unplanned adaptations, which were also considered and documented. Attendance and participation rates were examined and qualitative assessment of reported participant experience supported the feasibility and acceptability of adaptations of the original CONNECT intervention in a new clinical context. CONCLUSION: This approach may serve as a useful guide for intervention implementation efforts applied in diverse clinical contexts and subsequent evaluations of intervention effectiveness. TRIAL REGISTRATION: The study was registered at ClinicalTrials.gov ( NCT03300336 ) on September 28, 2017.

Comparing Mortality of Peritoneal and Hemodialysis Patients in an Era of Medicare Payment Reform.

BACKGROUND: Prior studies have shown peritoneal dialysis (PD) patients to have lower or equivalent mortality to patients who receive in-center hemodialysis (HD). Medicare's 2011 bundled dialysis prospective payment system encouraged expansion of home-based PD with unclear impacts on patient outcomes. This paper revisits the comparative risk of mortality between HD and PD among patients with incident end-stage kidney disease initiating dialysis in 2006-2013. RESEARCH DESIGN: We conducted a retrospective cohort study comparing 2-year all-cause mortality among patients with incident end-stage kidney disease initiating dialysis via HD and PD in 2006-2013, using data from the US Renal Data System and Medicare. Analysis was conducted using Cox proportional hazards models fit with inverse probability of treatment weighting that adjusted for measured patient demographic and clinical characteristics and dialysis market characteristics. RESULTS: Of the 449,652 patients starting dialysis between 2006 and 2013, the rate of PD use in the first 90 days increased from 9.3% of incident patients in 2006 to 14.2% in 2013. Crude 2-year mortality was 27.6% for patients dialyzing via HD and 16.7% for patients on PD. In adjusted models, there was no evidence of mortality differences between PD and HD before and after bundled payment (hazard ratio, 0.96; 95% confidence interval, 0.89-1.04; P=0.33). CONCLUSIONS: Overall mortality for HD and PD use was similar and mortality differences between modalities did not change before versus after the 2011 Medicare dialysis bundled payment, suggesting that increased use of home-based PD did not adversely impact patient outcomes.

Disparities in Chronic Kidney Disease Progression by Medicare Advantage Enrollees.

INTRODUCTION: The prevalence of chronic kidney disease (CKD) in Medicare beneficiaries has quadrupled in the past 2 decades, but little is known about risk factors affecting the progression of CKD. This study aims to understand the progression in Medicare Advantage enrollees and whether it differs by provider recognition of CKD, race and ethnicity, or geographic location. In a large cohort of Medicare Advantage (MA) enrollees, we examined whether CKD progression, up to 5 years after study entry, differed by demographic and clinical factors and identified additional risk factors of CKD progression. METHODS: In a cohort of 1,002,388 MA enrollees with CKD stages 1-4 based on 2013-2018 labs, progression was estimated using a mixed-effects model that adjusted for demographics, geographic location, comorbidity, urine albumin-to-creatinine ratio, clinical recognition via diagnosed CKD, and time-fixed effects. Race and ethnicity, geographic location, and clinical recognition of CKD were interacted with time in 3 separate regression models. RESULTS: Mean (median) follow-up was 3.1 (3.0) years. Black and Hispanic MA enrollees had greater kidney function at study entry than other beneficiaries, but their kidney function declined faster. MA enrollees with clinically recognized CKD had estimated glomerular filtration rate levels that were 18.6 units (95% confidence interval [CI]: 18.5-18.7) lower than levels of unrecognized patients, but kidney function declined more slowly in enrollees with clinical recognition. There were no differences in CKD progression by geography. After removal of the race coefficient from the eGFR equation in a sensitivity analysis, kidney function was much lower in all years among Black MA enrollees, but patterns of progression remained the same. DISCUSSION/CONCLUSIONS: These results suggest that patients with clinically recognized CKD and racial and ethnic minorities merit closer surveillance and management to reduce their risk of faster progression.

Annual wellness visits and care management before and after dialysis initiation.

INTRODUCTION: Demands of dialysis regimens may pose challenges for primary care provider (PCP) engagement and timely preventive care. This is especially the case for patients initiating dialysis adjusting to new logistical challenges and management of symptoms and existing comorbid conditions. Since 2011, Medicare has provided coverage for annual wellness visits (AWV), which are primarily conducted by PCPs and may be useful for older adults undergoing dialysis. METHODS: We used the OptumLabs® Data Warehouse to identify a cohort of 1,794 Medicare Advantage (MA) enrollees initiating dialysis in 2014-2017 and examined whether MA enrollees (1) were seen by a PCP during an outpatient visit and (2) received an AWV in the year following dialysis initiation. RESULTS: In the year after initiating dialysis, 93 % of MA enrollees had an outpatient PCP visit but only 24 % received an annual wellness visit. MA enrollees were less likely to see a PCP if they had Charlson comorbidity scores between 0 and 5 than those with scores 6-9 (odds ratio (OR) = 0.59, 95 % CI: 0.37-0.95), but more likely if seen by a nephrologist (OR = 1.60, 95 % CI: 1.01-2.52) or a PCP (OR = 15.65, 95 % CI: 9.26-26.46) prior to initiation. Following dialysis initiation, 24 % of MA enrollees had an AWV. Hispanic MA enrollees were less likely (OR = 0.57, 95 % CI: 0.39-0.84) to have an AWV than White MA enrollees, but enrollees were more likely if they initiated peritoneal dialysis (OR = 1.54, 95 % CI: 1.07-2.23) or had an AWV in the year before dialysis initiation (OR = 4.96, 95 % CI: 3.88-6.34). CONCLUSIONS: AWVs are provided at low rates to MA enrollees initiating dialysis, particularly Hispanic enrollees, and represent a missed opportunity for better care management for patients with ESKD. Increasing patient awareness and provider provision of AWV use among dialysis patients may be needed, to realize better preventive care for dialysis patients.

Fragmentation of care as a barrier to optimal ESKD management.

Caring for patients with end-stage kidney disease (ESKD) in the United States is challenging, due in part to the complex epidemiology of the disease's progression as well as the ways in which care is delivered. As CKD progresses toward ESKD, the number of comorbidities increases and care involves multiple healthcare providers from multiple subspecialties. This occurs in the context of a fragmented US healthcare delivery system that is traditionally siloed by provider specialty, organization, as well as systems of payment and administration. This article describes the role of care fragmentation in the delivery of optimal ESKD care and identifies research gaps in the evidence across the continuum of care. We then consider the impact of care fragmentation on ESKD care from the patient and health system perspectives and explore opportunities for system-level interventions aimed at improving care for patients with ESKD.

Implementation of a group physical therapy program for Veterans with knee osteoarthritis.

BACKGROUND: A previous randomized clinical trial found that a Group Physical Therapy (PT) program for knee osteoarthritis yielded similar improvements in pain and function compared with traditional individual PT. Based on these findings the Group PT program was implemented in a Department of Veterans Affairs Health Care System. The objective of this study was to evaluate implementation metrics and changes in patient-level measures following implementation of the Group PT program. METHODS: This was a one-year prospective observational study. The Group PT program involved 6 weekly sessions. Implementation metrics included numbers of referrals and completed sessions. Patient-level measures were collected at the first and last PT sessions and included the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC; self-report of pain, stiffness and function (range 0-96)) and a 30-s chair rise test. RESULTS: During the evaluation period, 152 patients were referred, 80 had an initial session scheduled, 71 completed at least one session and 49 completed at least 5 sessions. The mean number of completed appointments per patient was 4.1. Among patients completing baseline and follow-up measures, WOMAC scores (n = 33) improved from 56.8 (SD = 15.8) to 46.9 (SD = 14.0); number of chair rises (n = 38) completed in 30 s increased from 10.4 (SD = 5.1) to 11.9 (SD = 5.0). CONCLUSIONS: Patients completing the Group PT program in this implementation phase showed clinically relevant improvements comparable to those observed in the previous clinical trial that compared group and individual PT for knee osteoarthritis. These results are important because Group PT can improve efficiency and access compared with individual PT. However, there were some limitations with respect to attendance and completion rates, and program adaptations may be needed to optimize these implementation metrics. Larger, longer-term studies are required to more fully evaluate the effectiveness of this program.

Survival among Veterans Obtaining Dialysis in VA and Non-VA Settings.

BACKGROUND: Outcomes of veterans with ESRD may differ depending on where they receive dialysis and who finances this care, but little is known about variation in outcomes across different dialysis settings and financial arrangements. METHODS: We examined survival among 27,241 Veterans Affairs (VA)-enrolled veterans who initiated chronic dialysis in 2008-2011 at (1) VA-based units, (2) community-based clinics through the Veterans Affairs Purchased Care program (VA-PC), (3) community-based clinics under Medicare, or (4) more than one of these settings ("dual" care). Using a Cox proportional hazards model, we compared all-cause mortality across dialysis settings during the 2-year period after dialysis initiation, adjusting for demographic and clinical characteristics. RESULTS: Overall, 4% of patients received dialysis in VA, 11% under VA-PC, 67% under Medicare, and 18% in dual settings (nearly half receiving dual VA and VA-PC dialysis). Crude 2-year mortality was 25% for veterans receiving dialysis in the VA, 30% under VA-PC, 42% under Medicare, and 23% in dual settings. After adjustment, dialysis patients in VA or in dual settings had significantly lower 2-year mortality than those under Medicare; mortality did not differ in VA-PC and Medicare dialysis settings. CONCLUSIONS: Mortality rates were highest for veterans receiving dialysis in Medicare or VA-PC settings and lowest for veterans receiving dialysis in the VA or dual settings. These findings inform institutional decisions about provision of dialysis for veterans. Further research identifying processes associated with improved survival for patients receiving VA-based dialysis may be useful in establishing best practices for outsourced veteran care.

Adaptation and Implementation of a Family Caregiver Skills Training Program: From Single Site RCT to Multisite Pragmatic Intervention.

PURPOSE: We describe an approach to rapidly adapt and implement an education and skills improvement intervention to address the needs of family caregivers of functionally impaired veterans-Helping Invested Families Improve Veterans' Experience Study (HI-FIVES). DESIGN: Prior to implementation in eight sites, a multidisciplinary study team made systematic adaptations to the curriculum content and delivery process using input from the original randomized controlled trial (RCT); a stakeholder advisory board comprised of national experts in caregiver education, nursing, and implementation; and a veteran/caregiver engagement panel. To address site-specific implementation barriers in diverse settings, we applied the Replicating Effective Programs implementation framework. FINDINGS: Adaptations to HI-FIVES content and delivery included identifying core/noncore curriculum components, reducing instruction time, and simplifying caregiver recruitment for clinical settings. To enhance curriculum flexibility and potential uptake, site personnel were able to choose which staff would deliver the intervention and whether to offer class sessions in person or remotely. Curriculum materials were standardized and packaged to reduce the time required for implementation and to promote fidelity to the intervention. CONCLUSIONS: The emphasis on flexible intervention delivery and standardized materials has been identified as strengths of the adaptation process. Two key challenges have been identifying feasible impact measures and reaching eligible caregivers for intervention recruitment. CLINICAL RELEVANCE: This systematic implementation process can be used to rapidly adapt an intervention to diverse clinical sites and contexts. Nursing professionals play a significant role in educating and supporting caregivers and care recipients and can take a leading role to implement interventions that address skills and unmet needs for caregivers.

Lab-based and diagnosis-based chronic kidney disease recognition and staging concordance.

BACKGROUND: Chronic kidney disease (CKD) is often under-recognized and poorly documented via diagnoses, but the extent of under-recognition is not well understood among Medicare beneficiaries. The current study used claims-based diagnosis and lab data to examine patient factors associated with clinically recognized CKD and CKD stage concordance between claims- and lab-based sources in a cohort of Medicare beneficiaries. METHODS: In a cohort of fee-for-service (FFS) beneficiaries with CKD based on 2011 labs, we examined the proportion with clinically recognized CKD via diagnoses and factors associated with clinical recognition in logistic regression. In the subset of beneficiaries with CKD stage identified from both labs and diagnoses, we examined concordance in CKD stage from both sources, and factors independently associated with CKD stage concordance in logistic regression. RESULTS: Among the subset of 206,036 beneficiaries with lab-based CKD, only 11.8% (n = 24,286) had clinically recognized CKD via diagnoses. Clinical recognition was more likely for beneficiaries who had higher CKD stages, were non-elderly, were Hispanic or non-Hispanic Black, lived in core metropolitan areas, had multiple chronic conditions or outpatient visits in 2010, or saw a nephrologist. In the subset of 18,749 beneficiaries with CKD stage identified from both labs and diagnoses, 70.0% had concordant CKD stage, which was more likely if beneficiaries were older adults, male, lived in micropolitan areas instead of non-core areas, or saw a nephrologist. CONCLUSIONS: There is significant under-diagnosis of CKD in Medicare FFS beneficiaries, which can be addressed with the availability of lab results.

Prescriber Continuity and Disease Control of Older Adults.

BACKGROUND: Medicare beneficiaries with multiple chronic conditions are typically seen by multiple providers, particularly specialists. Clinically appropriate referrals to multiple specialists may compromise the continuity of care for multiple chronic condition beneficiaries and create care plans that patients may find challenging to reconcile, which may impact patient outcomes. OBJECTIVE: The objective was to examine whether glycemic control or lipid control was associated with the number of prescribers of cardiometabolic medications. RESEARCH DESIGN, SUBJECTS, AND MEASURES: A retrospective cross-sectional cohort analysis of 51,879 elderly Medicare fee-for-service beneficiaries with diabetes and 129,762 beneficiaries with dyslipidemia living in 10 east coast states. Glycemic control was defined as having an HbA1c<7.5. Lipid control was defined as an low-density lipoprotein<100 for beneficiaries with heart disease or diabetes or an low-density lipoprotein<130 for all other beneficiaries. We examined the association between the number of prescribers of cardiometabolic medications and disease or lipid control in 2011 through logistic regression, controlling for age, sex, race, Medicaid enrollment, 17 chronic conditions and state-fixed effects. RESULTS: Among beneficiaries with diabetes, 76% with one prescriber had well-controlled diabetes in 2011, which decreased to 65% for beneficiaries with 5+ prescribers. In adjusted analyses, Medicare beneficiaries with 3 or more prescribers were less likely to have glycemic control than beneficiaries with a single prescriber. Among those with dyslipidemia, nearly all (91%-92%) beneficiaries had lipid control. After adjustment for demographics and comorbidity burden, beneficiaries with 3 prescribers were less likely to have lipid control than beneficiaries with a single prescriber. CONCLUSIONS: Multiple prescribers were associated with worse disease control, possibly because patients with more severe diabetes or dyslipidemia have multiple prescribers or because care fragmentation is associated with worse disease control.

Minding the gap and overlap: a literature review of fragmentation of primary care for chronic dialysis patients.

BACKGROUND: Care coordination is a challenge for patients with kidney disease, who often see multiple providers to manage their associated complex chronic conditions. Much of the focus has been on primary care physician (PCP) and nephrologist collaboration in the early stages of chronic kidney disease, but less is known about the co-management of the patients in the end-stage of renal disease. We conducted a systematic review and synthesis of empirical studies on primary care services for dialysis patients. METHODS: Systematic literature search of MEDLINE/PubMED, CINAHL, and EmBase databases for studies, published until August 2015. Inclusion criteria included publications in English, empirical studies involving human subjects (e.g., patients, physicians), conducted in US and Canadian study settings that evaluated primary care services in the dialysis patient population. RESULTS: Fourteen articles examined three major themes of primary care services for dialysis patients: perceived roles of providers, estimated time in providing primary care, and the extent of dialysis patients' use of primary care services. There was general agreement among providers that PCPs should be involved but time, appropriate roles, and miscommunication are potential barriers to good primary care for dialysis patients. Although many dialysis patients report having a PCP, the majority rely on primary care from their nephrologists. Studies using administrative data found lower rates of preventive care services than found in studies relying on provider or patient self-report. DISCUSSION: The extant literature revealed gaps and opportunities to optimize primary care services for dialysis patients, foreshadowing the challenges and promise of Accountable Care / End-Stage Seamless Care Organizations and care coordination programs currently underway in the United States to improve clinical and logistical complexities of care for this commonly overlooked population. Studies linking the relationship between providers and patients' receipt of primary care to outcomes will serve as important comparisons to the nascent care models for ESRD patients, whose value is yet to be determined.

Appropriate baseline laboratory testing following ACEI or ARB initiation by Medicare FFS beneficiaries.

BACKGROUND: Laboratory testing to identify contraindications and adverse drug reactions is important for safety of patients initiating angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs). Rates and predictors of appropriate testing among Medicare fee-for-service beneficiaries are unknown. PURPOSE: The study's purpose was to examine baseline laboratory testing rates, identify predictors of suboptimal testing, and assess the prevalence of abnormal creatinine and potassium among beneficiaries initiating ACE inhibitors or ARBs. DESIGN AND SUBJECTS: Retrospective cohort of 101 376 fee-for-service beneficiaries from 10 eastern US states in 1 July to 30 November 2011. MAIN MEASURES: Appropriate monitoring for serum creatinine or serum potassium was defined as evidence of an outpatient claim within 180 days before or 14 days after the index prescription fill date. KEY RESULTS: Thirty-eight percent of beneficiaries were men, 78% were White race, 26% had prevalent heart failure, and 89% had prevalent hypertension. Rates of appropriate baseline laboratory testing were 82.7% for potassium, 83.2% for creatinine, and 82.6% for both potassium and creatinine 180 days prior to initiation. In logistic regression, men (odds ratio [OR] = 1.15, 95% confidence interval [CI]: 1.11, 1.19), African-Americans (OR = 1.26, 95%CI: 1.20, 1.32), and beneficiaries with Alzheimer's disease and related disorders (OR = 1.22, 95%CI: 1.15, 1.28) or stroke (OR = 1.34, 95%CI: 1.26, 1.43) were more likely to experience suboptimal testing. At baseline, hyperkalemia was relatively uncommon (5.8%), and elevated creatinine values were rare (1.4%). CONCLUSIONS: Appropriate monitoring could be improved for African-American beneficiaries and beneficiaries with a history of stroke or Alzheimer's disease and related disorders initiating ACE inhibitors or ARBs. Copyright © 2016 John Wiley & Sons, Ltd.