Changes in Medicare reimbursement and patient-nephrologist visits, quality of care, and health-related quality of life.

BACKGROUND: Medicare's reimbursement system was changed in January 2004 to encourage more frequent visits between dialysis patients and nephrologists. We sought to determine the impact of this policy change on patient-nephrologist visits, quality of care, and health-related quality of life. METHODS: We examined visits and outcomes for 2,043 patients at 12 hemodialysis facilities in northeast Ohio for 12 months before and 7 months after the reimbursement change. For comparison of outcomes, we used linear, logistic, or negative binomial regression models (for continuous, binary, and rate outcomes, respectively) to assess the significance of changes across the 2 periods. RESULTS: For patients seen before and after the reimbursement change for at least 6 months, the number of visits per patient-month increased from 1.52 before to 3.14 after (P < 0.001). The percentage of patients with no nephrologist visits per patient-month decreased from 16.6% before to 4.6% after (P < 0.001). However, there were no clinically important changes in Kt/V, albumin level, hemoglobin level, phosphorus level, calcium level, hemodialysis catheter use, ultrafiltration volume, shortened or skipped treatments, hospital admissions, hospitalization days, or health-related quality of life, including patient satisfaction. CONCLUSION: Despite a marked increase in visits between patients and nephrologists, there was no clinically important impact on parameters related to quality of care or health-related quality of life. Additional work is needed to determine effective payment strategies to improve dialysis patient outcomes.

Blood pressure and progression of chronic kidney disease: importance of systolic, diastolic, or diurnal variation.

Several studies show that systolic blood pressure is an important predictor of renal disease progression, just as it is linked with cardiovascular consequences in hypertension. In contrast, particularly in older patients, diastolic blood pressure was not independently associated with risk of kidney disease progression in the same studies. Pulse pressure has been shown to be equivalent in predicting renal outcomes, but might not have added value after adjusting for systolic blood pressure. Several cross- sectional studies present a strong correlation of ambulatory blood pressure monitoring values with microalbuminuria, compared with office-based blood pressure measurements. Small, prospective studies have shown an association between loss of nocturnal blood pressure decline and outcomes, including microalbuminuria, accelerated kidney disease progression, and mortality.

Highly active antiretroviral therapy and the incidence of HIV-1-associated nephropathy: a 12-year cohort study.

OBJECTIVE: to assess temporal changes in the incidence of human immunodeficiency virus-1-associated nephropathy (HIVAN), and the association with use of highly active antiretroviral therapy (HAART). METHODS: HIVAN incidence and risk factors were assessed in 3976 HIV-1-infected individuals followed in clinical cohort in Baltimore, Maryland, USA from 1989 to 2001. The incidence of HIVAN, defined by biopsy or a conservative uniformly applied clinical coding protocol, was expressed in terms of person-years, and Poisson regression was used for multivariate analysis. RESULTS: Ninety-four patients developed HIVAN over the course of the study for an incidence of 8.0 per 1000 person-years [95% confidence interval (CI), 6.5 to 9.8]. African American race and advanced immunosuppression were strongly associated with HIVAN risk. HIVAN incidence declined significantly in 1998-2001 compared with 1995-1997. Among patients with a prior diagnosis of AIDS, HIVAN incidence was 26.4, 14.4, and 6.8 per 1000 person-years in patients not receiving antiretroviral therapy, treated with nucleoside analogue therapy only, or treated with HAART, respectively (P < 0.001 for trend). In multivariate analysis, HIVAN risk was reduced 60% (95% CI, -30 to -80%) by use of HAART, and no patient developed HIVAN when HAART had been initiated prior to the development of AIDS. CONCLUSION: HAART was associated with a substantial reduction in HIVAN incidence. Additional follow-up will be needed to determine if renal damage in susceptible individuals is halted or merely slowed by HAART, particularly when control of viremia is incomplete or intermittent.