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2.
Nephrol Nurs J ; 47(2): 119-125, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32343085

RESUMO

The Northwest Kidney Center (NWC) in Seattle, Washington, has been a leader in nephrology care for almost 60 years, opening the first hemodialysis unit in the United States in 1962. In February 2020, one of their patients was the first reported death from COVID-19 in the United States. On April 6, 2020, as a part of NNJ Extra - the Nephrology Nursing Journal's podcast series, Beth Ulrich, EdD, RN, FACHE, FAONL, FAAN, Editor-in-Chief of the Nephrology Nursing Journal, talked with the leaders of the Northwest Kidney Centers - Suzanne Watnick, MD, the Chief Medical Officer, and Liz McNamara, MN, RN, Vice President of Patient Care Services and the Chief Nursing Officer, who discussed dealing with the onset of COVID-19 at NWC, how their team worked together to provide care for their patients and support for their staff members, and the lessons they learned that can benefit others.


Assuntos
Infecções por Coronavirus , Nefropatias , Cuidados de Enfermagem , Pandemias , Pneumonia Viral , Diálise Renal , Betacoronavirus , Infecções por Coronavirus/complicações , Infecções por Coronavirus/epidemiologia , Humanos , Nefropatias/terapia , Enfermeiras Administradoras , Pneumonia Viral/complicações , Pneumonia Viral/epidemiologia , Diálise Renal/enfermagem , Washington/epidemiologia
7.
Am J Kidney Dis ; 73(3): 385-390, 2019 03.
Artigo em Inglês | MEDLINE | ID: mdl-30611600

RESUMO

Since 2011, the Centers for Medicare & Medicaid Services has provided reimbursement for renal dialysis services furnished to Medicare beneficiaries through a bundled payment system known as the Prospective Payment System. Medications that have no injectable equivalent, known as "oral-only medications," are currently excluded from the bundle and are paid separately through Medicare Part D. Thus, before the development of etelcalcetide, the first injectable calcimimetic, calcimimetics were reimbursed outside the bundle. Etelcalcetide's introduction and approval for use in Medicare triggered a transition payment for a minimum of 2 years that will eventually result in the incorporation of calcimimetics into the dialysis bundle. Consequently, providers may face incentives to reduce calcimimetic use when the transition period has expired. The complexity of bone-mineral management in conjunction with the paucity of evidence-based recommendations in this area makes it difficult to predict the impact of this transition. Because these medications are expensive, a poor transition could have financial ramifications for dialysis organizations and potentially patient health. To ensure that patients are not adversely affected, it is critical that Medicare incorporate these medications into the bundle carefully, with close monitoring of outcomes.


Assuntos
Calcimiméticos/economia , Medicare , Peptídeos/economia , Sistema de Pagamento Prospectivo , Diálise Renal/economia , Humanos , Estados Unidos
9.
Circulation ; 137(2): 134-143, 2018 01 09.
Artigo em Inglês | MEDLINE | ID: mdl-29021322

RESUMO

BACKGROUND: In individuals with a low diastolic blood pressure (DBP), the potential benefits or risks of intensive systolic blood pressure (SBP) lowering are unclear. METHODS: SPRINT (Systolic Blood Pressure Intervention Trial) was a randomized controlled trial that compared the effects of intensive (target <120 mm Hg) and standard (target <140 mm Hg) SBP control in 9361 older adults with high blood pressure at increased risk of cardiovascular disease. The primary outcome was a composite of cardiovascular disease events. All-cause death and incident chronic kidney disease were secondary outcomes. This post hoc analysis examined whether the effects of the SBP intervention differed by baseline DBP. RESULTS: Mean baseline SBP and DBP were 139.7±15.6 and 78.1±11.9 mm Hg, respectively. Regardless of the randomized treatment, baseline DBP had a U-shaped association with the hazard of the primary cardiovascular disease outcome. However, the effects of the intensive SBP intervention on the primary outcome were not influenced by baseline DBP level (P for interaction=0.83). The primary outcome hazard ratio for intensive versus standard treatment was 0.78 (95% confidence interval, 0.57-1.07) in the lowest DBP quintile (mean baseline DBP, 61±5 mm Hg) and 0.74 (95% confidence interval, 0.61-0.90) in the upper 4 DBP quintiles (mean baseline DBP, 82±9 mm Hg), with an interaction P value of 0.78. Results were similar for all-cause death and kidney events. CONCLUSIONS: Low baseline DBP was associated with increased risk of cardiovascular disease events, but there was no evidence that the benefit of the intensive SBP lowering differed by baseline DBP. CLINICAL TRIAL REGISTRATION: URL: https://www.clinicaltrials.gov. Unique identifier: NCT01206062.


Assuntos
Anti-Hipertensivos/uso terapêutico , Pressão Sanguínea/efeitos dos fármacos , Hipertensão/tratamento farmacológico , Síndrome Coronariana Aguda/epidemiologia , Idoso , Idoso de 80 Anos ou mais , Anti-Hipertensivos/efeitos adversos , Diástole/efeitos dos fármacos , Feminino , Humanos , Hipertensão/diagnóstico , Hipertensão/mortalidade , Hipertensão/fisiopatologia , Incidência , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio/epidemiologia , Porto Rico , Insuficiência Renal Crônica/epidemiologia , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento , Estados Unidos
10.
J Am Soc Nephrol ; 28(6): 1697-1706, 2017 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-28298324

RESUMO

The ESRD Quality Incentive Program (QIP) is the first mandatory federal pay for performance program launched on January 1, 2012. The QIP is tied to the ESRD prospective payment system and mandated by the Medicare Improvements for Patients and Providers Act of 2008, which directed the Centers for Medicare and Medicaid Services to expand the payment bundle for renal dialysis services and legislated that payment be tied to quality measures. The QIP links 2% of the payment that a dialysis facility receives for Medicare patients on dialysis to the facility's performance on quality of care measures. Quality measures are evaluated annually for inclusion on the basis of importance, validity, and performance gap. Other quality assessment programs overlap with the QIP; all have substantial effects on provision of care as clinicians, patients, regulators, and dialysis organizations scramble to keep up with the frequent release of wide-ranging regulations. In this review, we provide an overview of quality assessment and quality measures, focusing on the ESRD QIP, its effect on care, and its potential future directions. We conclude that a patient-centered, individualized, and parsimonious approach to quality assessment needs to be maintained to allow the nephrology community to further bridge the quality chasm in dialysis care.


Assuntos
Falência Renal Crônica/terapia , Melhoria de Qualidade , Indicadores de Qualidade em Assistência à Saúde , Reembolso de Incentivo , Humanos , Diálise Renal , Estados Unidos
12.
Clin J Am Soc Nephrol ; 10(10): 1868-74, 2015 Oct 07.
Artigo em Inglês | MEDLINE | ID: mdl-26220818

RESUMO

The rate of AKI requiring dialysis has increased significantly over the past decade in the United States. At the same time, survival from AKI seems to be improving, and thus, more patients with AKI are surviving to discharge while still requiring dialysis. Currently, the options for providing outpatient dialysis in patients with AKI are limited, particularly after a 2012 revised interpretation of the Centers for Medicare and Medicaid Services guidelines, which prohibited Medicare reimbursement for acute dialysis at ESRD facilities. This article provides a historical perspective on outpatient dialysis management of patients with AKI, reviews the current clinical landscape of care for these patients, and highlights key areas of knowledge deficit. Lastly, policy changes that have the opportunity to significantly improve the care of this at-risk population are suggested.


Assuntos
Lesão Renal Aguda/terapia , Assistência Ambulatorial/organização & administração , Assistência à Saúde/organização & administração , Unidades Hospitalares de Hemodiálise/organização & administração , Diálise Renal , Assistência Ambulatorial/legislação & jurisprudência , Atitude do Pessoal de Saúde , Centers for Medicare and Medicaid Services, U.S. , Assistência à Saúde/legislação & jurisprudência , Política de Saúde , Unidades Hospitalares de Hemodiálise/legislação & jurisprudência , Humanos , Medicare , Aceitação pelo Paciente de Cuidados de Saúde , Melhoria de Qualidade , Mecanismo de Reembolso , Estados Unidos
13.
Clin J Am Soc Nephrol ; 9(4): 812-4, 2014 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-24458085

RESUMO

The National Institute of Diabetes, Digestive, and Kidney Diseases-supported Kidney Research National Dialogue asked the scientific community to formulate and prioritize research objectives that would improve our understanding of kidney function and disease. Kidney Research National Dialogue participants identified the need to improve outcomes in ESRD by decreasing mortality and morbidity and enhancing quality of life as high priority areas in kidney research. To reach these goals, we must identify retained toxins in kidney disease, accelerate technologic advances in dialysate composition and devices to remove these toxins, advance vascular access, and identify measures that decrease the burden of disease in maintenance dialysis patients. Together, these research objectives provide a path forward for improving patient-centered outcomes in ESRD.


Assuntos
Falência Renal Crônica/terapia , Diálise Renal , Humanos , Falência Renal Crônica/diagnóstico , Falência Renal Crônica/mortalidade , Seleção de Pacientes , Assistência Centrada no Paciente , Melhoria de Qualidade , Indicadores de Qualidade em Assistência à Saúde , Qualidade de Vida , Diálise Renal/efeitos adversos , Diálise Renal/métodos , Diálise Renal/mortalidade , Diálise Renal/normas , Fatores de Risco , Resultado do Tratamento
14.
Am J Kidney Dis ; 63(3): 521-9, 2014 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-24331978

RESUMO

The first governmental agency to provide maintenance hemodialysis to patients with end-stage renal disease (ESRD) was the Veterans Administration (VA; now the US Department of Veterans Affairs). Many historical VA policies and programs set the stage for the later care of both veteran and civilian patients with ESRD. More recent VA initiatives that target restructuring of care models based on quality management, system-wide payment policies to promote cost-effective dialysis, and innovation grants aim to improve contemporary care. The VA currently supports an expanded and diversified nationwide treatment program for patients with ESRD using an integrated patient-centered care paradigm. This narrative review of ESRD care by the VA explores not only the medical advances, but also the historical, socioeconomic, ethical, and political forces related to the care of veterans with ESRD.


Assuntos
Hospitais de Veteranos/organização & administração , Falência Renal Crônica/terapia , Assistência Centrada no Paciente/métodos , Diálise Renal/métodos , United States Department of Veterans Affairs , Veteranos , Humanos , Estados Unidos
15.
N Engl J Med ; 369(20): 1892-903, 2013 Nov 14.
Artigo em Inglês | MEDLINE | ID: mdl-24206457

RESUMO

BACKGROUND: Combination therapy with angiotensin-converting-enzyme (ACE) inhibitors and angiotensin-receptor blockers (ARBs) decreases proteinuria; however, its safety and effect on the progression of kidney disease are uncertain. Methods We provided losartan (at a dose of 100 mg per day) to patients with type 2 diabetes, a urinary albumin-to-creatinine ratio (with albumin measured in milligrams and creatinine measured in grams) of at least 300, and an estimated glomerular filtration rate (GFR) of 30.0 to 89.9 ml per minute per 1.73 m(2) of body-surface area and then randomly assigned them to receive lisinopril (at a dose of 10 to 40 mg per day) or placebo. The primary end point was the first occurrence of a change in the estimated GFR (a decline of ≥ 30 ml per minute per 1.73 m(2) if the initial estimated GFR was ≥ 60 ml per minute per 1.73 m(2) or a decline of ≥ 50% if the initial estimated GFR was <60 ml per minute per 1.73 m(2)), end-stage renal disease (ESRD), or death. The secondary renal end point was the first occurrence of a decline in the estimated GFR or ESRD. Safety outcomes included mortality, hyperkalemia, and acute kidney injury. Results The study was stopped early owing to safety concerns. Among 1448 randomly assigned patients with a median follow-up of 2.2 years, there were 152 primary end-point events in the monotherapy group and 132 in the combination-therapy group (hazard ratio with combination therapy, 0.88; 95% confidence interval [CI], 0.70 to 1.12; P=0.30). A trend toward a benefit from combination therapy with respect to the secondary end point (hazard ratio, 0.78; 95% CI, 0.58 to 1.05; P=0.10) decreased with time (P=0.02 for nonproportionality). There was no benefit with respect to mortality (hazard ratio for death, 1.04; 95% CI, 0.73 to 1.49; P=0.75) or cardiovascular events. Combination therapy increased the risk of hyperkalemia (6.3 events per 100 person-years, vs. 2.6 events per 100 person-years with monotherapy; P<0.001) and acute kidney injury (12.2 vs. 6.7 events per 100 person-years, P<0.001). Conclusions Combination therapy with an ACE inhibitor and an ARB was associated with an increased risk of adverse events among patients with diabetic nephropathy. (Funded by the Cooperative Studies Program of the Department of Veterans Affairs Office of Research and Development; VA NEPHRON-D ClinicalTrials.gov number, NCT00555217.).


Assuntos
Bloqueadores do Receptor Tipo 1 de Angiotensina II/uso terapêutico , Inibidores da Enzima Conversora de Angiotensina/uso terapêutico , Nefropatias Diabéticas/tratamento farmacológico , Lisinopril/uso terapêutico , Losartan/uso terapêutico , Adulto , Bloqueadores do Receptor Tipo 1 de Angiotensina II/efeitos adversos , Inibidores da Enzima Conversora de Angiotensina/efeitos adversos , Nefropatias Diabéticas/complicações , Nefropatias Diabéticas/mortalidade , Método Duplo-Cego , Quimioterapia Combinada , Feminino , Taxa de Filtração Glomerular , Humanos , Estimativa de Kaplan-Meier , Falência Renal Crônica/etiologia , Lisinopril/efeitos adversos , Losartan/efeitos adversos , Masculino , Pessoa de Meia-Idade
16.
Semin Dial ; 26(6): 702-5, 2013.
Artigo em Inglês | MEDLINE | ID: mdl-24118409

RESUMO

In the United States, multiple stakeholders have impacted the timing of dialysis initiation for patients with end-stage renal disease. The optimal policy to start dialysis for this vulnerable population remains unknown. Historically, patients initiated dialysis weeks after the appearance of uremic symptoms. This changed not only due to an evolution in medical providers' practice but also due to changes in the care delivery system, the political imperatives, and the economic driving forces surrounding the care of these patients. One large randomized control trial looked at patient outcomes with strategies of early versus late start. The trial included an economic analysis. Depending on the specific comparison, cost was either lower in the late-start group or was equivalent between groups. This result would tend to favor a late-start strategy, where patients had an additional 6 months of dialysis-free time. However, the generalizability of this analysis has been questioned. Future care models that would include patients before and after dialysis initiation would be ideal to study cost and quality at the time of this transition of care. The recently implemented CMS Quality Incentive Program is one mechanism that could use such findings to implement a high-value strategy for patients starting chronic dialysis therapies.


Assuntos
Política de Saúde/economia , Política de Saúde/legislação & jurisprudência , Falência Renal Crônica/terapia , Diálise Renal/economia , Austrália , Humanos , Falência Renal Crônica/diagnóstico , Falência Renal Crônica/economia , Nova Zelândia , Seleção de Pacientes , Qualidade de Vida , Fatores de Tempo , Tempo para o Tratamento , Resultado do Tratamento , Estados Unidos
17.
Clin J Am Soc Nephrol ; 7(9): 1535-43, 2012 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-22626961

RESUMO

In addition to extending health insurance coverage, the Affordable Care Act of 2010 aims to improve quality of care and contain costs. To this end, the act allowed introduction of bundled payments for a range of services, proposed the creation of accountable care organizations (ACOs), and established the Centers for Medicare and Medicaid Innovation to test new care delivery and payment models. The ACO program began April 1, 2012, along with demonstration projects for bundled payments for episodes of care in Medicaid. Yet even before many components of the Affordable Care Act are fully in place, the Medicare ESRD Program has instituted legislatively mandated changes for dialysis services that resemble many of these care delivery reform proposals. The ESRD program now operates under a fully bundled, case-mix adjusted prospective payment system and has implemented Medicare's first-ever mandatory pay-for-performance program: the ESRD Quality Incentive Program. As ACOs are developed, they may benefit from the nephrology community's experience with these relatively novel models of health care payment and delivery reform. Nephrologists are in a position to assure that the ACO development will benefit from the ESRD experience. This article reviews the new ESRD payment system and the Quality Incentive Program, comparing and contrasting them with ACOs. Better understanding of similarities and differences between the ESRD program and the ACO program will allow the nephrology community to have a more influential voice in shaping the future of health care delivery in the United States.


Assuntos
Organizações de Assistência Responsáveis/legislação & jurisprudência , Regulamentação Governamental , Reforma dos Serviços de Saúde/legislação & jurisprudência , Cobertura do Seguro/legislação & jurisprudência , Falência Renal Crônica/terapia , Medicare/legislação & jurisprudência , Patient Protection and Affordable Care Act/legislação & jurisprudência , Diálise Renal , Organizações de Assistência Responsáveis/economia , Organizações de Assistência Responsáveis/organização & administração , Redução de Custos , Custos de Cuidados de Saúde/legislação & jurisprudência , Reforma dos Serviços de Saúde/economia , Reforma dos Serviços de Saúde/organização & administração , Acesso aos Serviços de Saúde/legislação & jurisprudência , Humanos , Cobertura do Seguro/economia , Cobertura do Seguro/organização & administração , Falência Renal Crônica/economia , Medicare/economia , Medicare/organização & administração , Modelos Organizacionais , Patient Protection and Affordable Care Act/economia , Patient Protection and Affordable Care Act/organização & administração , Qualidade da Assistência à Saúde/legislação & jurisprudência , Reembolso de Incentivo/legislação & jurisprudência , Diálise Renal/economia , Estados Unidos
18.
Am J Kidney Dis ; 59(5): 645-52, 2012 May.
Artigo em Inglês | MEDLINE | ID: mdl-22285224

RESUMO

BACKGROUND: Oral calcitriol decreases parathyroid hormone (PTH) concentrations in patients who have chronic kidney disease (CKD); however, treatment response is highly variable. We evaluated whether patient characteristics affect the PTH response to oral calcitriol in nondialysis patients with CKD in a clinic-based setting. STUDY DESIGN: Cohort study. SETTING & PARTICIPANTS: This study included 379 new oral calcitriol users in the Veterans' Affairs Northwest Health Network. All had stages 3-4 CKD, hyperparathyroidism, and a serum PTH measurement before and 1-6 months after initiating oral calcitriol therapy. PREDICTORS: Patient-level characteristics hypothesized to affect calcitriol response: race, body size, concurrent medications, and kidney function. OUTCOMES: Relative decrease in serum PTH concentration after starting oral calcitriol therapy. MEASUREMENTS: Data were abstracted from the Veterans' Affairs Northwest Health Network (VISN 20) Data Warehouse, which includes electronic pharmacy and laboratory records. RESULTS: Mean estimated glomerular filtration rate was 30 mL/min/1.73 m(2) and mean initial PTH concentration was 199 pg/mL. Regular- (0.25 µg/d) and low-dose (<0.25 µg/d) oral calcitriol were associated with on average 23% and 13% relative decreases in serum PTH concentrations, respectively. After adjustment for calcitriol dosage, initial PTH concentration, and time to follow-up measurement, African American race was associated with a blunted calcitriol response (geometric mean final PTH value, 26% higher; 95% CI, 8%-47%). Serum albumin concentration <3.5 g/dL also was associated with a diminished calcitriol response (geometric mean final PTH, 19% higher; 95% CI, 6%-35%). Although numbers were small, concurrent use of benzodiazepines and nonactivated vitamin D supplements was associated with a significantly greater PTH response. LIMITATIONS: Clinic-based study is limited by the availability of PTH measurements after starting calcitriol therapy. Study of a predominantly older male population. CONCLUSIONS: In patients with stages 3-4 CKD, African American race and low serum albumin level are associated with a diminished PTH response to oral calcitriol.


Assuntos
Calcitriol/farmacologia , Nefropatias/sangue , Nefropatias/etnologia , Hormônio Paratireóideo/sangue , Índice de Gravidade de Doença , Vitaminas/farmacologia , Administração Oral , Grupo com Ancestrais do Continente Africano/etnologia , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Calcitriol/administração & dosagem , Doença Crônica , Estudos de Coortes , Relação Dose-Resposta a Droga , Grupo com Ancestrais do Continente Europeu/etnologia , Feminino , Taxa de Filtração Glomerular/efeitos dos fármacos , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Albumina Sérica/metabolismo , Vitaminas/administração & dosagem
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