A unified framework for assessing interaction effects among environmental exposures in epidemiologic studies: A case study on temperature, air pollution, and kidney-related conditions in New York state.

BACKGROUND: There are various methods to assess interaction effects. However, current methods have limitations, and quantification of interaction effects is rarely performed. This study aimed to develop a unified quantitative framework for assessing interaction effects. METHODS: We proposed a novel framework using log-linear models with a product term(s) across the exposures that generates parametric bi-variate association and interaction effect surfaces and allows flexible functional forms for exposures in the interaction term(s). In a case study, we assessed the interaction effects between temperature and air pollution (i.e., PM2.5, NO2, and O3) on risk for kidney-related conditions in New York State (2007-2016) using a case-crossover design with conditional logistic models. Our measures of exposure were the moving averages at lag 0-5 days for air pollution (linear) and daytime mean outdoor wet-bulb globe temperature (WBGT; using a natural cubic spline). RESULTS: We derived closed-form expressions for the magnitude of multiplicative interaction effects (the joint relative risk divided by the product of the two conditional relative risks) and their uncertainties. In the case study, we found a Bonferroni-corrected significant multiplicative interaction effect (IE) between outdoor WBGT at the 99th percentile (median as the reference) and (1) PM2.5 (per 5 µg/m3 increase, IE = 1.052; 95 % confidence interval [CI]: 1.019, 1.087) for acute kidney failure and (2) O3 (per 5 ppb increase; IE = 1.022; 95 % CI: 1.008, 1.036) for urolithiasis (the latter being inconclusive based on the sensitivity analysis). CONCLUSIONS: Our framework allows different functional forms of exposure variables in the interaction term, quantifies the magnitudes of entire-exposure-range (in addition to discrete exposure level) multiplicative interaction effects and their uncertainties in a categorical or continuous (linear or non-linear) manner, and harmonizes the two-way evaluation of effect modification. The case study underscores co-consideration of heat and air pollution when estimating health burden and designing heat/pollution alert systems.

The design and baseline characteristics for the HOPE Consortium Trial to reduce pain and opioid use in hemodialysis.

The HOPE Consortium Trial to Reduce Pain and Opioid Use in Hemodialysis (HOPE Trial) is a multicenter randomized trial addressing chronic pain among patients receiving maintenance hemodialysis for end-stage kidney disease. The trial uses a sequential, multiple assignment design with a randomized component for all participants (Phase 1) and a non-randomized component for a subset of participants (Phase 2). During Phase 1, participants are randomized to Pain Coping Skills Training (PCST), an intervention designed to increase self-efficacy for managing pain, or Usual Care. PCST consists of weekly, live, coach-led cognitive behavioral therapy sessions delivered by video- or tele-conferencing for 12 weeks followed by daily interactive voice response sessions delivered by telephone for an additional 12 weeks. At 24 weeks (Phase 2), participants in both the PCST and Usual Care groups taking prescription opioid medications at an average dose of ≥20 morphine milligram equivalents per day are offered buprenorphine, a partial opioid agonist with a more favorable safety profile than full-agonist opioids. All participants are followed for 36 weeks. The primary outcome is pain interference ascertained, for the primary analysis, at 12 weeks. Secondary outcomes include additional patient-reported measures and clinical outcomes including falls, hospitalizations, and death. Exploratory outcomes include acceptability, tolerability, and efficacy of buprenorphine. The enrollment target of 640 participants was met 27 months after trial initiation. The findings of the trial will inform the management of chronic pain, a common and challenging issue for patients treated with maintenance hemodialysis. NCT04571619.

Eliminating Algorithmic Racial Bias in Clinical Decision Support Algorithms: Use Cases from the Veterans Health Administration.

The Veterans Health Administration uses equity- and evidence-based principles to examine, correct, and eliminate use of potentially biased clinical equations and predictive models. We discuss the processes, successes, challenges, and next steps in four examples. We detail elimination of the race modifier for estimated kidney function and discuss steps to achieve more equitable pulmonary function testing measurement. We detail the use of equity lenses in two predictive clinical modeling tools: Stratification Tool for Opioid Risk Mitigation (STORM) and Care Assessment Need (CAN) predictive models. We conclude with consideration of ways to advance racial health equity in clinical decision support algorithms.

Using RE-AIM to examine implementation of a tele-nephrology program for veterans living in rural areas.

Introduction: Chronic kidney disease (CKD) and refractory hypertension (rHTN) are common, chronic conditions that affect 10%-16% of Veterans. Several small studies have suggested that tele-nephrology can deliver nephrology care effectively to rural Veterans. The purpose of this evaluation was to examine perceptions and experiences with this tele-nephrology program among spoke site staff and clinicians using the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework to guide our understanding of tele-nephrology implementation. Methods: We conducted semi-structured interviews with fourteen clinicians at five tele-nephrology spoke sites. We used content analysis to analyze the results using our RE-AIM framework. Results: Five major themes arose: (1) Active engagement of a centralized clinical champion was a key factor in early success of tele-nephrology program; (2) Transition from community-based nephrology to VA tele-nephrology was heralded as the most meaningful indicator of the effectiveness of the intervention; (3) Effective adoption strategies included bi-weekly training with Hub nephrology staff and engagement of a local renal champion; (4) Meeting the needs of Veterans through proper staffing during tele-nephrology examinations was a key priority in facility program implementation; and (5) Growing reliance on Hub nephrologists may give rise to insufficient availability of nephrology appointments in some Spoke sites. Discussion: This evaluation represents an important step forward as VA considers how to provide care to Veterans at facilities without VA specialty providers. The COVID-19 pandemic has drastically shifted options for Veterans, and increasingly, the VA is moving to shift care from community to VA via virtual care. Further research should examine how the VA manages potential problems related to access to virtual providers and examine Veteran perspectives on community in-person vs. virtual VA care.

Needs and Considerations for Standardization of Kidney Disease Education in Patients with Advanced CKD.

Kidney health advocacy organizations and leaders in the nephrology community have repeatedly emphasized the need to increase home dialysis utilization in the United States. Limited awareness and understanding of options for the management of kidney failure among patients living with advanced CKD is a significant barrier to increasing the selection and use of home dialysis. Studies have shown that providing targeted comprehensive patient education before the onset of kidney failure can improve patients' awareness of kidney disease and substantially increase the informed utilization of home dialysis. Unfortunately, in the absence of validated evidence-based education protocols, outcomes associated with home dialysis use vary widely among published studies, potentially affecting the routine implementation and reporting of these services among patients with advanced CKD. This review provides pragmatic guidance on establishing effective patient-centered education programs to empower patients to make informed decisions about their KRT and, in turn, increase home dialysis use.

VA-Based Peritoneal Dialysis Program Feasibility Considerations and Process Outline.

Background: Home dialysis utilization is lower among veterans than in the general US population. Several sociodemographic factors and comorbidities contribute to peritoneal dialysis (PD) underutilization. In 2019, the Veterans Health Administration (VHA) Kidney Disease Program Office convened a PD workgroup to address this concern. Observations: The PD workgroup was explicitly concerned by the limited availability of PD within the VHA, which frequently requires veterans to transition kidney disease care from US Department of Veterans Affairs medical centers (VAMCs) to non-VHA facilities when they progress from chronic kidney disease to end-stage kidney disease, causing fragmentation of care. Since the administrative requirements and infrastructure of VAMCs vary, the workgroup focused its deliberations on synthesizing a standard process for evaluating the feasibility and establishing a new PD program within any individual VAMC. A 3-phased approach was envisioned, beginning with ascertainment of prerequisites, leading to an examination of the clinical and financial feasibility through the process of data gathering and synthesis, culminating in a business plan that translates the previous 2 steps into an administrative document necessary for obtaining VHA approvals. Conclusions: VAMCs can use the guide presented here to improve therapeutic options for veterans with kidney failure by establishing a new or restructured PD program.

Associations between short-term exposure to PM2.5, NO2 and O3 pollution and kidney-related conditions and the role of temperature-adjustment specification: A case-crossover study in New York state.

Epidemiologic evidence on the relationship between air pollution and kidney disease remains inconclusive. We evaluated associations between short-term exposure to PM2.5, NO2 and O3 and unplanned hospital visits for seven kidney-related conditions (acute kidney failure [AKF], urolithiasis, glomerular diseases [GD], renal tubulo-interstitial diseases, chronic kidney disease, dysnatremia, and volume depletion; n = 1,209,934) in New York State (2007-2016). We applied a case-crossover design with conditional logistic regression, controlling for temperature, dew point temperature, wind speed, and solar radiation. We used a three-pollutant model at lag 0-5 days of exposure as our main model. We also assessed the influence of model adjustment using different specifications of temperature by comparing seven temperature metrics (e.g., dry-bulb temperature, heat index) and five intraday temperature measures (e.g., daily mean, daily minimum, nighttime mean), according to model performance and association magnitudes between air pollutants and kidney-related conditions. In our main models, we adjusted for daytime mean outdoor wet-bulb globe temperature, which showed good model performance across all kidney-related conditions. We observed the odds ratios (ORs) for 5 µg/m3 increase in daily mean PM2.5 to be 1.013 (95% confidence interval [CI]: 1.001, 1.025) for AKF, 1.107 (95% CI: 1.018, 1.203) for GD, and 1.027 (95% CI: 1.015, 1.038) for volume depletion; and the OR for 5 ppb increase in daily 1-hour maximum NO2 to be 1.014 (95% CI; 1.008, 1.021) for AKF. We observed no associations with daily 8-hour maximum O3 exposure. Association estimates varied by adjustment for different intraday temperature measures: estimates adjusted for measures with poorer model performance resulted in the greatest deviation from estimates adjusted for daytime mean, especially for AKF and volume depletion. Our findings indicate that short-term exposure to PM2.5 and NO2 is a risk factor for specific kidney-related conditions and underscore the need for careful adjustment of temperature in air pollution epidemiologic studies.

Associations between short-term temperature exposure and kidney-related conditions in New York State: The influence of temperature metrics across four dimensions.

BACKGROUND: Evidence describing the relationship between short-term temperature exposure and kidney-related conditions is insufficient. It remains unclear how temperature specification affects estimation of these associations. This study aimed to assess associations between short-term temperature exposure and seven kidney-related conditions and to evaluate the influence of temperature specification. METHODS: We obtained data on hospital encounters in New York State (2007-2016). We assessed associations with a case-crossover design using conditional logistic regression with distributed lag non-linear models. We compared model performance (i.e., AIC) and association curves using 1) five temperature spatial resolutions; 2) temperature on an absolute versus relative scale; 3) seven temperature metrics incorporating humidity, wind speed, and/or solar radiation; and 4) five intraday temperature measures (e.g., daily minimum and daytime mean). RESULTS: We included 1,209,934 unplanned adult encounters. Temperature metric and intraday measure had considerably greater influence than spatial resolution and temperature scale. For outcomes not associated with temperature exposure, almost all metrics or intraday measures showed good model performance; for outcomes associated with temperature, there were meaningful differences in performance across metrics or intraday measures. For parsimony, we modelled daytime mean outdoor wet-bulb globe temperature, which showed good performance for all outcomes. At lag 0-6 days, we observed increased risk at the 95th percentile of temperature versus the minimum morbidity temperature for acute kidney failure (odds ratio [OR] = 1.36, 95% confidence interval [CI]: 1.09, 1.69), urolithiasis (OR = 1.41, 95% CI: 1.16, 1.70), dysnatremia (OR = 1.26, 95% CI: 1.01, 1.59), and volume depletion (OR = 1.88, 95% CI: 1.41, 2.51), but not for glomerular diseases, renal tubulo-interstitial diseases, and chronic kidney disease. CONCLUSIONS: High-temperature exposure over one week is a risk factor for acute kidney failure, urolithiasis, dysnatremia, and volume depletion. The differential model performance across temperature metrics and intraday measures indicates the importance of careful selection of exposure metrics when estimating temperature-related health burden.

Serum Creatinine-to-Cystatin-C Ratio as a Potential Muscle Mass Surrogate and Racial Differences in Mortality.

OBJECTIVES: Serum creatinine-based estimated glomerular filtration rate equations and muscle mass are powerful markers of health and mortality risk. However, the serum creatinine-to-cystatin-C ratio may be a better indicator of health status. The objective of this study was to describe the relationship between creatinine-to-cystatin-C ratio and all-cause mortality when stratifying patients as per race and as per chronic kidney disease status. METHODS: This was a retrospective cohort study examining black and nonblack US veterans between October 2004 and September 2019, with baseline cystatin C and creatinine data from those not on dialysis during the study period. Veterans were divided into four creatinine-to-cystatin-C ratio groups: <0.75, 0.75-<1.00, 1.0-<1.25, and ≥1.25. The primary outcome of interest was all-cause mortality subsequent to the cystatin C laboratory measure. RESULTS: Among 22,316 US veterans, the mean (± standard deviation) age of the cohort was 67 ± 14 years, 5% were female, 82% were nonblack, and 18% were black. The proportion of black veterans increased across creatinine-to-cystatin-C ratio groups. In the fully adjusted model, compared with the reference (creatinine-to-cystatin-C ratio: 1.00-<1.25), a creatinine-to-cystatin-C ratio <0.75 had the highest mortality risk among both black and nonblack veterans (nonblack: hazard ratio [HR] [95% confidence interval {CI}]: 3.01 [2.78-3.26] and black: 4.17 [3.31-5.24]). A creatinine-to-cystatin-ratio ≥1.25 was associated with lower death risk than the referent in both groups (nonblack: HR [95% CI]: 0.89 [0.80-0.99] and black: HR [95% CI]: 0.55 [0.45-0.69]). However, there was a significant difference in the effect by race (Wald's P-value: <0.01). CONCLUSIONS: Higher creatinine-to-cystatin-C ratios indicate better health status and are strongly associated with lower mortality risk regardless of the kidney function level, and the relation was similar for both black and nonblack veterans, but with different strengths of effect across racial groups. Thereby, use of a fixed race coefficient in estimating kidney function may be biased.

Usability Testing of the Kidney Score Platform to Enhance Communication About Kidney Disease in Primary Care Settings: Qualitative Think-Aloud Study.

BACKGROUND: Patient awareness of chronic kidney disease (CKD) is low in part due to suboptimal testing for CKD among those at risk and lack of discussions about kidney disease between patients and clinicians. To bridge these gaps, the National Kidney Foundation developed the Kidney Score Platform, which is a web-based series of tools that includes resources for health care professionals as well as an interactive, dynamic patient-facing component that includes a brief questionnaire about risk factors for kidney disease, individualized assessment of risk for developing CKD, and self-management tools to manage one's kidney disease. OBJECTIVE: The aim of this study is to perform usability testing of the patient component of the Kidney Score platform among veterans with and at risk for kidney disease and among clinicians working as primary care providers in Veterans Affairs administration. METHODS: Think-aloud exercises were conducted, during which participants (veterans and clinicians) engaged with the platform while verbalizing their thoughts and making their perceptions, reasonings, and decision points explicit. A usability facilitator observed participants' behaviors and probed selectively to clarify their comprehension of the tool's instructions, content, and overall functionality. Thematic analysis on the audio-recording transcripts was performed, focusing on positive attributes, negative comments, and areas that required facilitator involvement. RESULTS: Veterans (N=18) were 78% (14/18) male with a mean age of 58.1 years. Two-thirds (12/18) were of non-White race/ethnicity, 28% (5/18) had laboratory evidence of CKD without a formal diagnosis, and 50% (9/18) carried a diagnosis of hypertension or diabetes. Clinicians (N=19) were 29% (5/17) male, 30% (5/17) of non-White race/ethnicity, and had a mean of 17 (range 4-32) years of experience. Veterans and clinicians easily navigated the online tool and appreciated the personalized results page as well as the inclusion of infographics to deliver key educational messages. Three major themes related to content and communication about risk for CKD emerged from the think-aloud exercises: (1) tension between lay and medical terminology when discussing kidney disease and diagnostic tests, (2) importance of linking general information to concrete self-management actions, and (3) usefulness of the tool as an adjunct to the office visit to prepare for patient-clinician communication. Importantly, these themes were consistent among interviews involving both veterans and clinicians. CONCLUSIONS: Veterans and clinicians both thought that the Kidney Score Platform would successfully promote communication and discussion about kidney disease in primary care settings. Tension between using medical terminology that is used regularly by clinicians versus lay terminology to promote CKD awareness was a key challenge, and knowledge of this can inform the development of future CKD educational materials.

Implications of Cross-System Use Among US Veterans With Advanced Kidney Disease in the Era of the MISSION Act: A Qualitative Study of Health Care Records.

Importance: Since 2014, when Congress passed the Veterans Access Choice and Accountability (Choice) Act (replaced in 2018 with the more comprehensive Maintaining Internal Systems and Strengthening Integrated Outside Networks [MISSION] Act), the Department of Veterans Affairs (VA) has been paying for US veterans to receive increasing amounts of care in the private sector (non-VA care or VA community care). However, little is known about the implications of these legislative changes for the VA system. Objective: To describe the implications for the VA system of recent increases in VA-financed non-VA care. Design, Setting, and Participants: This qualitative study was a thematic analysis of documentation in the electronic health records (EHRs) of a random sample of US veterans with advanced kidney disease between June 6, 2019, and February 5, 2021. Exposures: Mentions of community care in participant EHRs. Main Outcomes and Measures: Dominant themes pertaining to VA-financed non-VA care. Results: Among 1000 study participants, the mean (SD) age was 73.8 (11.4) years, and 957 participants (95.7%) were male. Three interrelated themes pertaining to VA-financed non-VA care emerged from qualitative analysis of documentation in cohort member EHRs: (1) VA as mothership, which describes extensive care coordination by VA staff members and clinicians to facilitate care outside the VA and the tendency of veterans and their non-VA clinicians to rely on the VA to fill gaps in this care; (2) hidden work of veterans, which describes the efforts of veterans and their family members to navigate the referral process, and to serve as intermediaries between VA and non-VA clinicians; and (3) strain on the VA system, which describes a challenging referral process and the ways in which cross-system care has stretched the traditional roles of VA staff and clinicians and interfered with VA care processes. Conclusions and Relevance: The findings of this qualitative study describing VA-financed non-VA care for veterans with advanced kidney disease spotlight the substantial challenges of cross-system use and the strain placed on the VA system, VA staff and clinicians, and veterans and their families in recent years. These difficult-to-measure consequences of cross-system care should be considered when budgeting, evaluating, and planning the provision of VA-financed non-VA care in the private sector.

Relationships between short-term ambient temperature exposure and kidney disease hospitalizations in the warm season in Vietnam: A case-crossover study.

BACKGROUND: Under a warming climate, adverse health effects of heat are an increasing concern. We evaluated associations between short-term ambient temperature exposure and hospital admission for kidney disease in Vietnam. METHODS: We linked province-level meteorologic data with admission data from 14 province-level hospitals (2003-2015). We used a case-crossover design to evaluate associations between daily ambient temperature metrics (mean, maximum, and minimum temperature and mean heat index) and risk of hospitalization for four kidney disease subtypes: glomerular diseases, renal tubulo-interstitial diseases, chronic kidney disease, and urolithiasis, including lagged (≤lag 14 days) and cumulative (≤lag 0-6 days) associations, during the warm season. We also evaluated independent associations with extreme heat days (defined as days with daily maximum temperature >95th percentile of the provincial daily maximum temperature distribution). Akaike's information criterion and patterns of risk estimates across cumulative exposure time windows and single-day lags informed our selection of final models. RESULTS: We included 58,330 hospital admissions during the warm season. Daily mean temperature averaged over the same day and the previous six days (lag 0-6 days) was associated with risk of hospitalization for each kidney disease outcome with odds ratios (per 1 °C increase in daily mean temperature) of 1.07 (95% confidence interval [CI]: 0.99, 1.16) for glomerular diseases, 1.06 (95% CI: 0.96, 1.17) for renal tubulo-interstitial diseases, 1.12 (95% CI: 1.00, 1.24) for chronic kidney disease, and 1.09 (95% CI: 1.02, 1.16) for urolithiasis. We found no additional independent associations with extreme heat. Results for the four temperature metrics were similar. CONCLUSIONS: High ambient temperature was associated with increased risk of hospitalization for each kidney disease subtype, with the most convincing associations for chronic kidney disease and urolithiasis. Further laboratory and epidemiologic research is needed to confirm the findings and disentangle the underlying mechanisms.

Generalizability of an acute kidney injury prediction model across health systems.

Delays in the identification of acute kidney injury (AKI) in hospitalized patients are a major barrier to the development of effective interventions to treat AKI. A recent study by Tomasev and colleagues at DeepMind described a model that achieved a state-of-the-art performance in predicting AKI up to 48 hours in advance.1 Because this model was trained in a population of US Veterans that was 94% male, questions have arisen about its reproducibility and generalizability. In this study, we aimed to reproduce key aspects of this model, trained and evaluated it in a similar population of US Veterans, and evaluated its generalizability in a large academic hospital setting. We found that the model performed worse in predicting AKI in females in both populations, with miscalibration in lower stages of AKI and worse discrimination (a lower area under the curve) in higher stages of AKI. We demonstrate that while this discrepancy in performance can be largely corrected in non-Veterans by updating the original model using data from a sex-balanced academic hospital cohort, the worse model performance persists in Veterans. Our study sheds light on the importance of reproducing artificial intelligence studies, and on the complexity of discrepancies in model performance in subgroups that cannot be explained simply on the basis of sample size.

Depression screening and clinical outcomes among adults initiating maintenance hemodialysis.

BACKGROUND: Transitioning to maintenance hemodialysis (HD) is a vulnerable period for persons with end-stage renal disease (ESRD), punctuated by high rates of depression, hospitalizations and death. Screening for depression during this time may help to improve patient outcomes but formal inquiry has yet to be conducted. Among a national Veteran cohort, we examined whether depression screening in the year prior to HD initiation led to improved outcomes in the year thereafter. METHODS: Associations between pre-ESRD depression screening and post-ESRD outcomes were examined with Cox proportional hazards models (mortality) and Poisson regression models (hospitalization). Hierarchal adjustment models accounted for sociodemographic, clinical, pre-ESRD care and dialysis characteristics. RESULTS: The final analytic cohort of the study was 30 013 Veterans of whom 64% underwent pre-ESRD depression screening. During the 12 months post-transition, the crude all-cause mortality rate was 0.32 person-year for those screened and 0.35 person-year for those not screened, while the median (interquartile range) hospitalizations were 2 (2, 2) per year for both groups. In fully adjusted models, pre-ESRD depression screening was associated with a lower risk of mortality [hazard ratio (95% confidence interval): 0.94 (0.90-0.99)] and hospitalization [incidence rate ratio (95% confidence interval): 0.97 (0.9-0.99)]. CONCLUSION: Depression screening among adults prior to maintenance HD transition may be associated with better outcomes during the following year.

The landscape of renal replacement therapy in Veterans Affairs Medical Center intensive care units.

BACKGROUND: Outpatient dialysis is standardized with several evidence-based measures of adequacy and quality that providers aim to meet while providing treatment. By contrast, in the intensive care unit (ICU) there are different types of prolonged and continuous renal replacement therapies (PIRRT and CRRT, respectively) with varied strategies for addressing patient care and a dearth of nationally accepted quality parameters. To eventually describe appropriate quality measures for ICU-related renal replacement therapy (RRT), we first aimed to capture the variety and prevalence of basic strategies and equipment utilized in the ICUs of Veteran Affairs (VA) medical facilities with inpatient hemodialysis capabilities. METHODS: Via email to the dialysis directors of all VA facilities that provided inpatient hemodialysis during 2018, we requested survey participation regarding aspects of RRT in VA ICUs. Questions centered around the mode of therapy, equipment, solutions, prescription authority, nursing, anticoagulation, antimicrobial dosing, and access. RESULTS: Seventy-six centers completed the questionnaire, achieving a response rate of 87.4%. Fifty-five centers reported using PIRRT or CRRT in addition to intermittent hemodialysis. Of these centers, 42 reported being specifically CRRT-capable. Over half of respondents had the capabilities to perform PIRRT. Twelve centers (21.8%) were equipped to use slow low efficient dialysis (SLED) alone. Therapy was largely prescribed by nephrologists (94.4% of centers). CONCLUSIONS: Within the VA system, ICU-related RRT practice is quite varied. Variation in processes of care, prescription authority, nursing care coordination, medication management, and safety practices present opportunities for developing cross-cutting measures of quality of intensive care RRT that are agnostic of modality choice.

Burden and Cost of Caring for US Veterans With CKD: Initial Findings From the VA Renal Information System (VA-REINS).

Kidney disease is a common, complex, costly, and life-limiting condition. Most kidney disease registries or information systems have been limited to single institutions or regions. A national US Department of Veterans Affairs (VA) Renal Information System (VA-REINS) was recently developed. We describe its creation and present key initial findings related to chronic kidney disease (CKD) without kidney replacement therapy (KRT). Data from the VA's Corporate Data Warehouse were processed and linked with national Medicare data for patients with CKD receiving KRT. Operational definitions for VA user, CKD, acute kidney injury, and kidney failure were developed. Among 7 million VA users in fiscal year 2014, CKD was identified using either a strict or liberal operational definition in 1.1 million (16.4%) and 2.5 million (36.3%) veterans, respectively. Most were identified using an estimated glomerular filtration rate laboratory phenotype, some through proteinuria assessment, and very few through International Classification of Diseases, Ninth Revision coding. The VA spent ∼$18 billion for the care of patients with CKD without KRT, most of which was for CKD stage 3, with higher per-patient costs by CKD stage. VA-REINS can be leveraged for disease surveillance, population health management, and improving the quality and value of care, thereby enhancing VA's capacity as a patient-centered learning health system for US veterans.

Predictors of improvement in a family-based partial hospitalization/intensive outpatient program for eating disorders.

The efficacy of family-based treatment (FBT) in outpatient settings has led to efforts to incorporate FBT principles into higher levels of care. The present study examined predictors of improvement in an FBT-based partial hospitalization program/intensive outpatient program (PHP/IOP) as measured by the Eating Disorder Examination-Questionnaire. Participants were 113 patients with anorexia nervosa (AN) or eating disorder not otherwise specified (EDNOS) consecutively participating in an FBT-based PHP/IOP. Multilevel modeling was used to investigate predictors for adolescents and young adults separately. Predictors considered included illness duration, previous hospitalization, hospitalization immediately prior to treatment, previous outpatient therapy, hospitalization during treatment, diagnosis, gaining 4 pounds in 4 weeks, and family status as time-invariant variables. Time-varying variables considered included depression symptoms and mothers'/fathers' ratings of parental self-efficacy and expressed emotion. For adolescents, depression by time and diagnosis by time interactions were statistically significant. At all levels of depression, adolescent patients with AN demonstrated greater reductions in eating disorder symptoms compared to patients with EDNOS. For young adults, depression and gaining 4 pounds in 4 weeks were significant predictors. The relationships for young adults were curvilinear such that, while lower eating disorder symptoms were found during treatment, these gains were not maintained at follow up.