Lower Extremity Amputation and Health Care Utilization in the Last Year of Life among Medicare Beneficiaries with ESRD.

BACKGROUND: Lower extremity amputation is common among patients with ESRD, and often portends a poor prognosis. However, little is known about end-of-life care among patients with ESRD who undergo amputation. METHODS: We conducted a mortality follow-back study of Medicare beneficiaries with ESRD who died in 2002 through 2014 to analyze patterns of lower extremity amputation in the last year of life compared with a parallel cohort of beneficiaries without ESRD. We also examined the relationship between amputation and end-of-life care among the patients with ESRD. RESULTS: Overall, 8% of 754,777 beneficiaries with ESRD underwent at least one lower extremity amputation in their last year of life compared with 1% of 958,412 beneficiaries without ESRD. Adjusted analyses of patients with ESRD showed that those who had undergone lower extremity amputation were substantially more likely than those who had not to have been admitted to-and to have had prolonged stays in-acute and subacute care settings during their final year of life. Amputation was also associated with a greater likelihood of dying in the hospital, dialysis discontinuation before death, and less time receiving hospice services. CONCLUSIONS: Nearly one in ten patients with ESRD undergoes lower extremity amputation in their last year of life. These patients have prolonged stays in acute and subacute health care settings and appear to have limited access to hospice services. These findings likely signal unmet palliative care needs among seriously ill patients with ESRD who undergo amputation as well as opportunities to improve their care.

Hospice Use And End-Of-Life Spending Trajectories In Medicare Beneficiaries On Hemodialysis.

Infrequent and late referral to hospice among patients on dialysis likely reflects the impact of a Medicare payment policy that discourages the concurrent receipt of these services, but it may also reflect these patients' less predictable illness trajectories. Among a national cohort of patients on hemodialysis, we identified four distinct spending trajectories during the last year of life that represented markedly different intensities of care. Within the cohort, 9 percent had escalating spending and 13 percent had persistently high spending throughout the last year of life, while 41 percent had relatively low spending with late escalation, and 37 percent had moderate spending with late escalation. Across the four groups, the percentages of patients enrolled in hospice at the time of death were uniformly low ranging from only 19 percent of those with persistently high costs to 21 percent of those with moderate costs and the median number of days spent in hospice during the last year of life was virtually the same (either five or six days). These findings signal the need for greater flexibility in the provision of end-of-life care in this population.

Association Between Hospice Length of Stay, Health Care Utilization, and Medicare Costs at the End of Life Among Patients Who Received Maintenance Hemodialysis.

Importance: Patients with end-stage renal disease are less likely to use hospice services than other patients with advanced chronic illness. Little is known about the timing of hospice referral in this population and its association with health care utilization and costs. Objective: To examine the association between hospice length of stay and health care utilization and costs at the end of life among Medicare beneficiaries who had received maintenance hemodialysis. Design, Setting, and Participants: This cross-sectional observational study was conducted via the United States Renal Data System registry. Participants were all 770 191 hemodialysis patients in the registry who were enrolled in fee-for-service Medicare and died between January 1, 2000, and December 31, 2014. The dates of analysis were April 2016 to December 2017. Main Outcomes and Measures: Hospital admission, intensive care unit (ICU) admission, and receipt of an intensive procedure during the last month of life; death in the hospital; and costs to the Medicare program in the last week of life. Results: Among 770 191 patients, the mean (SD) age was 74.8 (11.0) years, and 53.7% were male. Twenty percent of cohort members were receiving hospice services when they died. Of these, 41.5% received hospice for 3 days or fewer. In adjusted analyses, compared with patients who did not receive hospice, those enrolled in hospice for 3 days or fewer were less likely to die in the hospital (13.5% vs 55.1%; P < .001) or to undergo an intensive procedure in the last month of life (17.7% vs 31.6%; P < .001) but had higher rates of hospitalization (83.6% vs 74.4%; P < .001) and ICU admission (54.0% vs 51.0%; P < .001) and similar Medicare costs in the last week of life ($10 756 vs $10 871; P = .08). Longer lengths of stay in hospice beyond 3 days were associated with progressively lower rates of utilization and costs, especially for those referred more than 15 days before death (35.1% hospitalized and 16.7% admitted to an ICU in the last month of life; the mean Medicare costs in the last week of life were $3221). Conclusions and Relevance: Overall, 41.5% of hospice enrollees who had been treated with hemodialysis for their end-stage renal disease entered hospice within 3 days of death. Although less likely to die in the hospital and to receive an intensive procedure, these patients were more likely than those not enrolled in hospice to be hospitalized and admitted to the ICU, and they had similar Medicare costs. Without addressing barriers to more timely referral, greater use of hospice may not translate into meaningful changes in patterns of health care utilization, costs, and quality of care at the end of life in this population.

Outcomes Associated With Left Ventricular Assist Devices Among Recipients With and Without End-stage Renal Disease.

Importance: Left ventricular assist devices (LVADs) are widely used both as a bridge to heart transplant and as destination therapy in advanced heart failure. Although heart failure is common in patients with end-stage renal disease (ESRD), little is known about outcomes after LVAD implantation in this population. Objective: To determine the utilization of and outcomes associated with LVADs in nationally representative cohorts of patients with and without ESRD. Design, Setting and Participants: We described LVAD utilization and outcomes among Medicare beneficiaries after ESRD onset (defined as having received maintenance dialysis or a kidney transplant) from 2003 to 2013 based on Medicare claims linked to data from the United States Renal Data System (USRDS), a national registry for ESRD. We compared Medicare beneficiaries with ESRD to a 5% sample of Medicare beneficiaries without ESRD. Exposures: ESRD (vs no ESRD) among patients who underwent LVAD placement. Main Outcomes and Measures: The primary outcome was survival after LVAD placement. Results: Among the patients with ESRD, the mean age was 58.4 (12.1) years and 62.0% (96) were male. Among those without ESRD, the mean age was 62.2 (12.6) years and 75.1% (196) were male. From 2003 to 2013, 155 Medicare beneficiaries with ESRD (median and interquartile range [IQR] days from ESRD onset to LVAD placement were 1655 days [453-3050 days]) and 261 beneficiaries without ESRD in the Medicare 5% sample received an LVAD. During a median follow-up of 762 days (IQR, 92-3850 days), 127 patients (81.9%) with and 95 (36.4%) without ESRD died. more than half of patients with ESRD (80 [51.6%]) compared with 11 (4%) of those without ESRD died during the index hospitalization. The median time to death was 16 days (IQR 2-447 days) for patients with ESRD compared with 2125 days (IQR, 565-3850 days) for those without ESRD. With adjustment for demographics, comorbidity and time period, patients with ESRD had a markedly increased adjusted risk of death (hazard ratio, 36.3; 95% CI, 15.6-84.5), especially in the first 60 days after LVAD placement. Conclusions and Relevance: Patients with ESRD at the time of LVAD placement had an extremely poor prognosis, with most surviving for less than 3 weeks. This information may be crucial in supporting shared decision-making around treatments for advanced heart failure for patients with ESRD.

Trends in Receipt of Intensive Procedures at the End of Life Among Patients Treated With Maintenance Dialysis.

BACKGROUND: Many dialysis patients receive intensive procedures intended to prolong life at the very end of life. However, little is known about trends over time in the use of these procedures. We describe temporal trends in receipt of inpatient intensive procedures during the last 6 months of life among patients treated with maintenance dialysis. STUDY DESIGN: Mortality follow-back study. SETTING & PARTICIPANTS: 649,607 adult Medicare beneficiaries on maintenance dialysis therapy who died in 2000 to 2012. PREDICTORS: Period of death (2000-2003, 2004-2008, or 2009-2012), age at time of death (18-59, 60-64, 65-69, 70-74, 75-79, 80-84, and ≥85 years), and race/ethnicity (Hispanic, non-Hispanic black, or non-Hispanic white). OUTCOME: Receipt of an inpatient intensive procedure (defined as invasive mechanical ventilation/intubation, tracheostomy, gastrostomy/jejunostomy tube insertion, enteral or parenteral nutrition, or cardiopulmonary resuscitation) during the last 6 months of life. RESULTS: Overall, 34% of cohort patients received an intensive procedure in the last 6 months of life, increasing from 29% in 2000 to 36% in 2012 (with 2000-2003 as the referent category; adjusted risk ratios [RRs] were 1.06 [95% CI, 1.05-1.07] and 1.10 [95% CI, 1.09-1.12] for 2004-2008 and 2009-2012, respectively). Use of intensive procedures increased more markedly over time in younger versus older patients (comparing 2009-2012 to 2000-2003, adjusted RR was 1.18 [95% CI, 1.15-1.20] for the youngest age group as opposed to 1.00 [95% CI, 0.96-1.04] for the oldest group). Comparing 2009 to 2012 to 2000 to 2003, the use of intensive procedures increased more dramatically for Hispanic patients than for non-Hispanic black or non-Hispanic white patients (adjusted RRs of 1.18 [95% CI, 1.14-1.22], 1.09 [95% CI, 1.07-1.11], and 1.10 [95% CI, 1.08-1.12], respectively). LIMITATIONS: Data sources do not provide insight into reasons for observed trends in the use of intensive procedures. CONCLUSIONS: Among patients treated with maintenance dialysis, there is a trend toward more frequent use of intensive procedures at the end of life, especially in younger patients and those of Hispanic ethnicity.

Changes in Urine Microalbumin-to-Creatinine Ratio in Children with Sickle Cell Disease over Time.

BACKGROUND: Approximately 20% of children with sickle cell disease (SCD) have microalbuminuria (MA). Very little is known about the progression of MA in children and young adults with SCD. METHODS: In this study, we analyzed 5-year EMR data of 373 children [with ≥2 microalbumin-to-creatinine (MA/Cr) ratio measurements] followed at the Medical University of South Carolina to determine the rate, direction, magnitude, and predictors of MA/Cr change over time. RESULTS: Age range was 1-22 years; mean 10.2 ± 5.2 years, 49.5% were males. Median follow-up duration was 3.12 ± 1.16 years. At baseline, 328 children had normal (<20 mg/L) MA level. Forty-five (12.1%) of children had MA (≥20 mg/L), of which 91% were ≥8 years and 21 (47%) continued to have MA at the end of the study period. On the other hand, during the study period, 24 new patients developed MA and 24 normalized their MA to levels <20 mg/L. In multivariate logistic regression model, age and bilirubin levels were predictive of MA/Cr increase in patients who received at least one blood transfusion during the study period. Baseline MA level was not predictive of the change in MA/Cr. CONCLUSION: In children and young adults, microalbuminuria is considered a marker of early renal injury. Over time, MA/Cr levels may increase or decrease. Further studies are needed to confirm our findings, assess the reliability of MA as marker of long-term renal injury, and identify high risk patients with SCD likely to have worsening of MA over time.

Blood Pressure, Heart Rate, and CNS Stimulant Medication Use in Children with and without ADHD: Analysis of NHANES Data.

It is estimated that 2-3% of children in the US have hypertension (HTN) and 8% of children ages 4-17 carry the diagnosis of attention-deficit hyperactivity disorder (ADHD). The prevalence of HTN and cardiovascular (CV) risk factors in children with ADHD on CNS stimulant treatment (stimulants) compared to no treatment and compared to their healthy counterparts is not well described. Using National Health and Nutrition Survey data, we examined demographic, blood pressure (BP) and CV risk factors of 4,907 children aged 12-18 years with and without the diagnosis of ADHD, and further examined the CV risk in a subgroup of ADHD patients on stimulants. Three hundred eighty-three (10.7%) children were reported to have ADHD, of whom 111 (3.4%) were on stimulants. Children with ADHD on stimulants were significantly younger, male, and white compared to those with ADHD not on medication and those without ADHD. Body mass index (BMI), eGFR, cholesterol, the prevalence of albuminuria, and poverty were not significantly different between the three groups. One hundred sixty (2.7%) had BP in the hypertensive and 637 (12.4%) in the pre-hypertensive range. The prevalence of elevated BP (HTN and/or pre-HTN range) was not different between children with ADHD on stimulants compared to ADHD without medication and those without ADHD. Heart rate (HR) was significantly higher in the ADHD group on stimulants vs. the groups ADHD on no stimulants and without ADHD. When the relationship between stimulants and the risk of abnormal BP was examined, there was a significant interaction between having BP in the HTN range and sex. After adjusting for BMI, race, and age, females with ADHD on stimulants tended to be older and had significantly more BP in the hypertensive range. On the other hand, males were more likely to be of a white race and older, but not hypertensive. Children with ADHD on stimulants have significantly higher HR than children with ADHD on no stimulants and children without ADHD. On the other hand, the prevalence of abnormal BP classification is comparable between the three groups.

The efficacy and safety of intravenous hydralazine for the treatment of hypertension in the hospitalized child.

BACKGROUND: Intravenous (IV) hydralazine is frequently used for the treatment of elevated blood pressure (BP) in hospitalized children. Its safety and efficacy have not been examined. METHODS: This is a retrospective chart review of IV hydralazine use in hospitalized children (birth to 17 years) over a 3-year period. Demographic data and data on adverse effects (AE), BP, and heart rate (HR) prior to and after each first dose were collected. RESULTS: The patient cohort comprised 110 children admitted to the hospital during the study period, of whom 77 received the recommended dose. Mean age of the children was 8.5 ± 5.4 years; 33 % were male, and 32.5 % were white. Pre-dose systolic and diastolic BP indexes were 1.3 and 1.2, respectively. The median reduction in systolic and diastolic BP was 8.5 and 11.5 %, respectively. Sixteen (21 %) children achieved a 25 % reduction in systolic or diastolic BP, and BP increased in 30 % of patients; 10 % of children had a BP of <95th percentile for age, sex, and height after one dose. Seven (9 %) children had a documented AE. HR increased by a median of 3.5 %. In the multivariable models examining percentage change in systolic and diastolic BP, male gender was significantly associated with a change in systolic BP. CONCLUSIONS: In hospitalized children, IV hydralazine was well tolerated, BP response was variable, and 21 % of the patients achieved a ≥25 % reduction of systolic or diastolic BP. Further studies are needed to compare the safety and efficacy of IV hydralazine to other short-acting antihypertensive agents.

Blood pressure reclassification in adolescents based on repeat clinic blood pressure measurements.

The common assumption is that blood pressure (BP) will decrease on subsequent readings. The objective of this study is to examine the prevalence and direction of BP classification change with repeat measurements and compare common clinical characteristics of groups of patients who do and do not have a change in BP classification. A nationally representative subsample of 1725 adolescents aged 13 to 18 years from the National Health and Nutrition Survey were analyzed. Three BP measurements were obtained. Patients were classified based on the first and the average of 3 BP measurements as having normal BP, hypertension, and/or prehypertension. Of the 1725 adolescents, 1569 (90.9%) maintained BP classification, 107 (6.2%) had a reduction in their classification, and 49 (2.9%) had an increase in their classification. Comparing the two groups that changed BP classification to the group without change, C-reactive protein and body mass index (BMI) z score were significantly higher in the groups that had a change in BP classification (P=.02 and <.001, respectively). After adjusting for other variables, higher BMI value was significantly associated with change in BP classification. With repeat measurements, the majority (~91%) did not have a change in classification. Obesity was a significant predictor of the 9% that had a change in classification. Repeat BP measurements in obese adolescents may lead to more accurate classification of BP status.

Serum uric acid in U.S. adolescents: distribution and relationship to demographic characteristics and cardiovascular risk factors.

BACKGROUND: Despite being associated with multiple disease processes and cardiovascular outcomes, uric acid (UA) reference ranges for adolescents are lacking. We sought to describe the distribution of UA and its relationship to demographic, clinical, socioeconomic, and dietary factors among U.S. adolescents. METHODS: A nationally representative subsample of 1,912 adolescents aged 13-18 years in NHANES 2005-2008 representing 19,888,299 adolescents was used for this study. Percentiles of the distribution of UA were estimated using quantile regression. Linear regression models examined the association of UA and demographic, socioeconomic, and dietary factors. RESULTS: Mean UA level was 5.14 ± 1.45 mg/dl. Mean UA increased with increasing age and was higher in non-Hispanic white race, male sex, higher body mass index (BMI) Z-score, and with higher systolic blood pressure. In fully adjusted linear regression models, sex, age, race, and BMI were independent determinants of higher UA. CONCLUSIONS: This study defines serum UA reference ranges for adolescents. Also, it reveals some intriguing relationships between UA and demographic and clinical characteristics that warrant further studies to examine the pathophysiological role of UA in different disease processes.

Association of ethnicity with involuntary childlessness and perceived reasons for infertility: baseline data from the Study of Women's Health Across the Nation (SWAN).

OBJECTIVE: To evaluate whether ethnicity is associated with involuntary childlessness and perceived reasons for difficulties in becoming pregnant. DESIGN: Cross-sectional analysis of baseline data from a longitudinal cohort. SETTING: Multiethnic, community-based observational study of US women. PATIENT(S): Women in midlife (3,149), aged 42-52 years. INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): Involuntary childlessness and perceived etiology of infertility. RESULT(S): One hundred thirty-three subjects (4.2%) were involuntarily childless, defined by a reported history of infertility and nulliparity. Ethnicity was significantly associated with self-reported involuntary childlessness. After controlling for economic and other risk factors, African American (odds ratio [OR] 0.30; 95% confidence interval [CI] 0.15-0.59) and Chinese women (OR 0.36; 95% CI 0.14-0.90) were less likely to suffer from involuntary childlessness compared with non-Hispanic white women. In addition, 302 subjects reported a perceived etiology of infertility. An unexpectedly large proportion of these women (24.5%, 74 of 302) reported etiologies not known to cause infertility (i.e., tipped uterus, ligaments for tubes were stretched), with African American women having been most likely to report these etiologies (OR 2.81; 95% CI 1.26-6.28) as the reason for not becoming pregnant. CONCLUSION(S): Ethnicity is significantly associated with involuntary childlessness and perceived etiology of infertility. Misattribution of causes of infertility is common and merits further consideration with respect to language or cultural barriers, as well as possible physician misattribution.