The 50th Anniversary of the Implementation of PL 92-603: A Major Change in the Care of Patients with End Stage Kidney Disease.

Fifty years ago, in July 1973, providing care to patients with end stage kidney disease changed dramatically with the implementation of legislation (PL 92-603) that deemed chronic renal disease to be a disability and provided coverage under Medicare for the treatment of the disease. In this article, we discuss the impact of the implementation of PL 92-603.

Certification 101: the pathway to excellence.

Certification in a nursing specialty validates that patient care providers have attained the knowledge and skills necessary for competent practice in the particular specialty, achieving a higher degree of professional competence than the minimal requirement for licensure. Certification yields benefits to the individual nurse, the profession, and the public, including improved patient safety and a commitment to lifelong learning.

Does poly-N-acetyl glucosamine patch use reduce arteriovenous fistula and graft failure rates in hemodialysis patients with end-stage renal disease?

BACKGROUND: Maintenance of functional vascular access is crucial for the delivery of hemodialysis. The SyvekPatch is a topical marine microalgal poly-N-acetyl glucosamine hemostat approved by the Food and Drug Administration for use in the local management of bleeding wounds, such as vascular site, percutaneous catheters or tubes, and surgical debridement. METHODS: The Preservation of Vascular Access Study was designed to investigate the effectiveness of patch use in reducing failure rates of arteriovenous fistulas or grafts. Data from medical records of patients who received hemodialysis from January 2001 to December 2005 at local ambulatory outpatient hemodialysis units in Charleston, South Carolina were analyzed. To explore whether greater use of the poly-N-acetyl glucosamine patch resulted in more favorable outcomes, patients were categorized into no patch use (n = 183) or 2 groups involving patch use, <70% of hemodialysis sessions (n = 88) or >or=70% of hemodialysis sessions (n = 64). The outcome measure was failure of access site estimated using Poisson regression models. RESULTS: Three hundred thirty-five patients (54% women) with 178 fistulas (44%) and 227 grafts (56%) were included. The study population was predominantly African American (84%), with a median age of 58 years. The adjusted relative rate of access failure involving patch use in <70% of hemodialysis sessions versus no patch use was 0.84 (95% CI, 0.37-1.94), and for patch use in >or=70% of hemodialysis sessions versus no patch use was 0.40 (95% CI, 0.16-1.02; trend P = 0.045). CONCLUSIONS: The Preservation of Vascular Access Study results are consistent with improved access survival with frequent patch use. The application of patch in this population is a simple, well-accepted intervention and warrants further investigation.

Prospective analysis of global costs for maintenance of patients with ESRD.

BACKGROUND: The prevalence of end-stage renal disease (ESRD) has doubled in the past decade, with total costs projected to exceed 16.5 billion dollars by the end of 2002. METHODS: The purpose of this prospective study is to determine all costs related to inpatient and outpatient health care utilization incurred by 76 patients with ESRD in an outpatient hemodialysis setting for 1 year. Costs were derived from a computer-based cost-allocation process that distributed cost components and overhead to designated revenue-producing departments. RESULTS: During the 1-year study period, these patients had 1,459 total inpatient and outpatient hospital visits (mean, 19.2 visits/patient; range, 0 to 84 visits/patient). There were 149 general inpatient hospital admissions. Of 238 total emergency room visits, 89 visits resulted in admission to the hospital (37%). CONCLUSION: Total hospital costs for all patients for the year were 1,831,880 dollars (actual charges, 2,929,147 dollars). As expected, the greatest hospital cost expenditures were attributed to inpatient hospital admissions (1,419,022 dollars; 77.5% of total). Of total hospital costs, inpatient bed costs were the single highest expenditure. The cost for outpatient hemodialysis therapy was 33,784 dollars/patient-year, consisting of facility costs of 17,200 dollars, outpatient pharmacy costs of 14,100 dollars, and outpatient professional costs of 2,500 dollars/patient-year. Average costs for hospital facility and/or professional fees were 42,730 dollars/patient-year, whereas average costs for outpatient dialysis facility and/or professional fees were 33,784 dollars, for an estimated global cost of 76,515 dollars/patient-year. Our cost estimate for care of this unique inner-city population substantially exceeds those reported earlier by others.