Braden J Manns

The University of Calgary, Calgary, Alberta, Canada

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Publications (300)1861.92 Total impact

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    ABSTRACT: Multimorbidity is common and associated with poor clinical outcomes and high health care costs. Administrative data are a promising tool for studying the epidemiology of multimorbidity. Our goal was to derive and apply a new scheme for using administrative data to identify the presence of chronic conditions and multimorbidity. We identified validated algorithms that use ICD-9 CM/ICD-10 data to ascertain the presence or absence of 40 morbidities. Algorithms with both positive predictive value and sensitivity ≥70% were graded as "high validity"; those with positive predictive value ≥70% and sensitivity <70% were graded as "moderate validity". To show proof of concept, we applied identified algorithms with high to moderate validity to inpatient and outpatient claims and utilization data from 574,409 people residing in Edmonton, Canada during the 2008/2009 fiscal year. Of the 40 morbidities, we identified 30 that could be identified with high to moderate validity. Approximately one quarter of participants had identified multimorbidity (2 or more conditions), one quarter had a single identified morbidity and the remaining participants were not identified as having any of the 30 morbidities. We identified a panel of 30 chronic conditions that can be identified from administrative data using validated algorithms, facilitating the study and surveillance of multimorbidity. We encourage other groups to use this scheme, to facilitate comparisons between settings and jurisdictions.
    BMC Medical Informatics and Decision Making 04/2015; 15(1):31. DOI:10.1186/s12911-015-0155-5 · 1.50 Impact Factor
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    ABSTRACT: People with kidney failure are often deficient in zinc and selenium, but little is known about the optimal way to correct such deficiency. We did a double-blind randomized trial evaluating the effects of zinc (Zn), selenium (Se) and vitamin E added to the standard oral renal vitamin supplement (B and C vitamins) among hemodialysis patients in Alberta, Canada. We evaluated the effect of two daily doses of the new supplement (medium dose: 50 mg Zn, 75 mcg Se, 250 IU vitamin E; low dose: 25 mg Zn, 50 mcg Se, 250 IU vitamin E) compared to the standard supplement on blood concentrations of Se and Zn at 90 days (primary outcome) and 180 days (secondary outcome) as well as safety outcomes. We enrolled 150 participants. The proportion of participants with low zinc status (blood level <815 ug/L) did not differ between the control group and the two intervention groups at 90 days (control 23.9% vs combined intervention groups 23.9%, P > 0.99) or 180 days (18.6% vs 28.2%, P = 0.24). The proportion with low selenium status (blood level <121 ug/L) was similar for controls and the combined intervention groups at 90 days (32.6 vs 19.6%, P = 0.09) and 180 days (34.9% vs 23.5%, P = 0.17). There were no significant differences in the risk of adverse events between the groups. Supplementation with low or medium doses of zinc and selenium did not correct low zinc or selenium status in hemodialysis patients. Future studies should consider higher doses of zinc (≥75 mg/d) and selenium (≥100 mcg/d) with the standard supplement. Registered with ClinicalTrials.gov ( NCT01473914 ).
    BMC Nephrology 04/2015; 16(1):52. DOI:10.1186/s12882-015-0042-4 · 1.52 Impact Factor
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    ABSTRACT: Information on common causes of death in people with CKD is limited. We hypothesized that, as eGFR declines, cardiovascular mortality and mortality from infection account for increasing proportions of deaths. We calculated eGFR using the CKD Epidemiology Collaboration equation for residents of Alberta, Canada who died between 2002 and 2009. We used multinomial logistic regression to estimate unadjusted and age- and sex-adjusted differences in the proportions of deaths from each cause according to the severity of CKD. Cause of death was classified as cardiovascular, infection, cancer, other, or not reported using International Classification of Diseases codes. Among 81,064 deaths, the most common cause was cancer (31.9%) followed by cardiovascular disease (30.2%). The most common cause of death for those with eGFR≥60 ml/min per 1.73 m(2) and no proteinuria was cancer (38.1%); the most common cause of death for those with eGFR<60 ml/min per 1.73 m(2) was cardiovascular disease. The unadjusted proportion of patients who died from cardiovascular disease increased as eGFR decreased (20.7%, 36.8%, 41.2%, and 43.7% of patients with eGFR≥60 [with proteinuria], 45-59.9, 30-44.9, and 15-29.9 ml/min per 1.73 m(2), respectively). The proportions of deaths from heart failure and valvular disease specifically increased with declining eGFR along with the proportions of deaths from infectious and other causes, whereas the proportion of deaths from cancer decreased. In conclusion, we found an inverse association between eGFR and specific causes of death, including specific types of cardiovascular disease, infection, and other causes, in this cohort. Copyright © 2015 by the American Society of Nephrology.
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    ABSTRACT: To determine rates of major bleeding by level of kidney function for older adults with atrial fibrillation starting warfarin. Retrospective cohort study. Community based, using province wide laboratory and administrative data in Alberta, Canada. 12 403 adults aged 66 years or more, with atrial fibrillation who started warfarin treatment between 1 May 2003 and 31 March 2010 and had a measure of kidney function at baseline. Kidney function was estimated using the Chronic Kidney Disease Epidemiology Collaboration equation and participants were categorised based on estimated glomerular filtration rate (eGFR): ≥90, 60-89, 45-59, 30-44, 15-29, <15 mL/min/1.73m(2). We excluded participants with end stage renal disease (dialysis or renal transplant) at baseline. Admission to hospital or visit to an emergency department for major bleeding (intracranial, upper and lower gastrointestinal, or other). Of 12 403 participants, 45% had an eGFR <60 mL/min/1.73m(2). Overall, 1443 (11.6%) experienced a major bleeding episode over a median follow-up of 2.1 (interquartile range: 1.0-3.8) years. During the first 30 days of warfarin treatment, unadjusted and adjusted rates of major bleeding were higher at lower eGFR (P for trend <0.001 and 0.001, respectively). Adjusted bleeding rates per 100 person years were 63.4 (95% confidence interval 24.9 to 161.6) in participants with eGFR <15 mL/min/1.73m(2) compared with 6.1 (1.9 to 19.4) among those with eGFR >90 mL/min/1.73m(2) (adjusted incidence rate ratio 10.3, 95% confidence interval 2.3 to 45.5). Similar associations were observed at more than 30 days after starting warfarin, although the magnitude of the increase in rates across eGFR categories was attenuated. Across all eGFR categories, adjusted rates of major bleeding were consistently higher during the first 30 days of warfarin treatment compared with the remainder of follow-up. Increases in major bleeding rates were largely due to gastrointestinal bleeding (3.5-fold greater in eGFR <15 mL/min/1.73m(2) compared with ≥90 mL/min/1.73m(2)). Intracranial bleeding was not increased with worsening kidney function. Reduced kidney function was associated with an increased risk of major bleeding among older adults with atrial fibrillation starting warfarin; excess risks from reduced eGFR were most pronounced during the first 30 days of treatment. Our results support the need for careful consideration of the bleeding risk relative to kidney function when assessing the risk-benefit ratio of warfarin treatment in people with chronic kidney disease and atrial fibrillation, particularly in the first 30 days of treatment. © Jun et al 2015.
    BMJ (online) 02/2015; 350(h246). DOI:10.1136/bmj.h246 · 16.38 Impact Factor
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    ABSTRACT: Resources for research are insufficient to cover all unanswered questions, and therefore difficult choices about allocation must be made. Recently there has been a move toward more patient-centered research. This study aims to evaluate approaches to research prioritization in kidney disease and describe research priorities of patients with kidney disease, their caregivers, the health care providers involved in their care, and policy makers. Systematic review. Studies that elicited patient, caregiver, health care provider, or policy maker priorities for research in kidney disease were included. MEDLINE, EMBASE, PsycINFO, and CINAHL were searched to May 2014. Descriptive synthesis. We identified 16 studies (n=2,365 participants) conducted in the United States, the Netherlands, Australia, Canada, and internationally. Only 4 (25%) studies explicitly involved patients. Various priority-setting methods were used, including the Delphi technique, expert panels, consensus conference, ranking or voting surveys, focus groups, and interviews, of which the process was described in detail by 11 (69%) studies. The priority areas for research most frequently identified across studies were prevention of acute kidney injury, prevention of chronic kidney disease progression, fluid and diet restrictions, improving vascular access, kidney transplant survival, access to transplantation, patient education, and psychosocial impact of chronic kidney disease. Most studies were conducted in high-income countries. The priorities identified by kidney disease research priority-setting exercises are broad ranging, but patient involvement is uncommon and the processes often are incompletely described. Establishing research priorities using a prespecified and transparent process that engages patients, caregivers, and health care providers is needed to ensure that resources are invested to answer questions that address the shared priorities in kidney disease. Copyright © 2015 National Kidney Foundation, Inc. Published by Elsevier Inc. All rights reserved.
    American Journal of Kidney Diseases 01/2015; DOI:10.1053/j.ajkd.2014.11.011 · 5.76 Impact Factor
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    ABSTRACT: Validation of current and promising surrogate outcomes for ESRD in randomized controlled trials (RCTs) has been limited. We conducted a systematic review and meta-analysis of RCTs to further inform the ability of surrogate outcomes for ESRD to predict the efficacy of various interventions on ESRD. MEDLINE, EMBASE, and CENTRAL (from inception through September 2013) were searched. All RCTs in adults with proteinuria, diabetes, or CKD stages 1–4 or renal transplant recipients reporting ≥10 ESRD events and a surrogate outcome (change in proteinuria or doubling of serum creatinine [DSCR]) for ESRD during a ≥1-year follow-up were included. Two reviewers abstracted trial characteristics and outcome data independently. To assess the correlation between the surrogate outcomes and ESRD, we determined the treatment effect ratio (TER), defined as the ratio of the treatment effects on ESRD and the effects on the change in surrogate outcomes. TERs close to 1 indicate greater agreement between ESRD and the surrogate, and these ratios were pooled across interventions. We identified 27 trials (97,458 participants; 4187 participants with ESRD). Seven trials reported the effects on change in proteinuria and showed consistent effects for proteinuria and ESRD (TER, 0.82; 95% confidence interval, 0.59 to 1.16), with minimal heterogeneity. Twenty trials reported on DSCR. Treatment effects on DSCR were consistent with the effects on ESRD (TER, 0.98; 95% confidence interval, 0.85 to 1.14), with moderate heterogeneity. In conclusion, DSCR is generally a good surrogate for ESRD, whereas data on proteinuria were limited. Further assessment of the surrogacy of proteinuria using prospective RCTs is warranted.
    Journal of the American Society of Nephrology 01/2015; DOI:10.1681/ASN.2014040396 · 9.47 Impact Factor
  • Braden J Manns
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    ABSTRACT: The pressure for health care systems to provide more resource intensive health care and newer, more costly, therapies is significant, despite limited health care budgets. As such, demonstration that a new therapy is effective is no longer sufficient to ensure that it is funded within publicly funded health care systems. The impact of a therapy on health care costs is also an important consideration for decision-makers who must allocate scarce resources. The clinical benefits and costs of a new therapy can be estimated simultaneously using economic evaluation, the strengths and limitations of which are discussed herein. In addition, this chapter includes discussion of the important economic outcomes that can be collected within a clinical trial (alongside the clinical outcome data) enabling consideration of the impact of the therapy on overall resource use, thus enabling performance of an economic evaluation, if the therapy is shown to be effective.
    Methods in molecular biology (Clifton, N.J.) 01/2015; 1281:315-30. DOI:10.1007/978-1-4939-2428-8_19 · 1.29 Impact Factor
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    ABSTRACT: Individuals with chronic diseases may have difficulty optimizing their health and getting the care they need due to a combination of patient, provider, and health system level barriers. Patient navigator programs, in which trained personnel assess and assist patients in overcoming barriers to care, may improve care and outcomes for patients with chronic disease by providing an alternative approach to conventional information and support resources. This systematic review will evaluate the evidence for patient navigator programs, compared to usual care, in patients with chronic disease. We will include RCTs, cluster RCTs, and quasi-randomized RCTs that study the effects of patient navigator programs on clinical outcomes, patient experience, and markers of adherence to care. Studies will be identified by searching MEDLINE, Embase, the Cochrane Central Register of Controlled Trials (CENTRAL), CINAHL, PsycINFO, Social Work Abstracts, and the references of included studies. Two authors will screen titles and abstracts independently. Full texts will be reviewed for relevance and data extraction will be done independently by two authors. Studies will be included if they assess patients of any age with one or more chronic diseases. Outcomes will be categorized into groups characterized by their proximity to mechanism of action of the intervention: patient-level outcomes, intermediate outcomes, and process outcomes. Descriptive data about the elements of the patient navigator intervention will also be collected for potential subgroup analyses. Risk of bias will be assessed using the Effective Practice and Organisation of Care Group (EPOC) risk of bias tool. Data will be analyzed using random effects meta-analysis (relative risk for dichotomous data and mean difference for continuous data), if appropriate. A comprehensive review of patient navigator programs, including a summary of the elements of programs that are associated with a successful intervention, does not yet exist. This systematic review will synthesize the evidence of the effect of patient navigator interventions on clinical and patient-oriented outcomes in populations across a comprehensive set of chronic diseases. PROSPERO CRD42013005857 .
    01/2015; 4(1):28. DOI:10.1186/s13643-015-0019-1
  • Braden J Manns
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    ABSTRACT: There is a significant gap between what is known and what is implemented by key stakeholders in practice (the evidence to practice gap). The primary purpose of knowledge translation is to address this gap, bridging evidence to clinical practice. The knowledge to action cycle is one framework for knowledge translation that integrates policy-makers throughout the research cycle. The knowledge to action cycle begins with the identification of a problem (usually a gap in care provision). After identification of the problem, knowledge creation is undertaken, depicted at the center of the cycle as a funnel. Knowledge inquiry is at the wide end of the funnel, and moving down the funnel, the primary data is synthesized into knowledge products in the form of educational materials, guidelines, decision aids, or clinical pathways. The remaining components of the knowledge to action cycle refer to the action of applying the knowledge that has been created. This includes adapting knowledge to local context, assessing barriers to knowledge use, selecting, tailoring implementing interventions, monitoring knowledge use, evaluating outcomes, and sustaining knowledge use. Each of these steps is connected by bidirectional arrows and ideally involves healthcare decision-makers and key stakeholders at each transition.
    Methods in molecular biology (Clifton, N.J.) 01/2015; 1281:485-500. DOI:10.1007/978-1-4939-2428-8_29 · 1.29 Impact Factor
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    ABSTRACT: Lower estimated glomerular filtration rate is associated with reduced life expectancy. Whether this association is modified by the presence or absence of albuminuria, another cardinal finding of chronic kidney disease, is unknown. Our objective was to estimate the life expectancy of middle-aged men and women with varying levels of eGFR and concomitant albuminuria. A retrospective cohort study. A large population-based cohort identified from the provincial laboratory registry in Alberta, Canada. Adults aged ≥30 years who had outpatient measures of serum creatinine and albuminuria between May 1, 2002 and March 31, 2008. Baseline levels of kidney function identified from serum creatinine and albuminuria measurements. all cause mortality during the follow-up. Patients were categorized based on their estimated glomerular filtration rate (eGFR) (≥60, 45-59, 30-44, and 15-29 mL/min/1 · 73 m(2)) as well as albuminuria (normal, mild, and heavy) measured by albumin-to-creatinine ratio or urine dipstick. The abridged life table method was applied to calculate the life expectancies of men and women from age 40 to 80 years across combined eGFR and albuminuria categories. We also categorized participants by severity of kidney disease (low risk, moderately increased risk, high risk, and very high risk) using the combination of eGFR and albuminuria levels. Among men aged 50 years and with eGFR ≥60 mL/min/1.73 m(2), estimated life expectancy was 24.8 (95% CI: 24.6-25.0), 17.5 (95% CI: 17.1-17.9), and 13.5 (95% CI: 12.6-14.3) years for participants with normal, mild and heavy albuminuria respectively. Life expectancy for men with mild and heavy albuminuria was 7.3 (95% CI: 6.9-7.8) and 11.3 (95% CI: 10.5-12.2) years shorter than men with normal proteinuria, respectively. A reduction in life expectancy was associated with an increasing severity of kidney disease; 24.8 years for low risk (95% CI: 24.6-25.0), 19.1 years for moderately increased risk (95% CI: 18.7-19.5), 14.2 years for high risk (95% CI: 13.5-15.0), and 9.6 years for very high risk (95% CI: 8.4-10.8). Among women of similar age and kidney function, estimated life expectancy was 28.9 (95% CI: 28.7-29.1), 19.8 (95% CI: 19.2-20.3), and 14.8 (95% CI: 13.5-16.0) years for participants with normal, mild and heavy albuminuria respectively. Life expectancy for women with mild and heavy albuminuria was 9.1 (95% CI: 8.5-9.7) and 14.2 (95% CI: 12.9-15.4) years shorter than the women with normal proteinuria, respectively. For women also a graded reduction in life expectancy was observed across the increasing severity of kidney disease; 28.9 years for low risk (95% CI: 28.7-29.1), 22.5 years for moderately increased risk (95% CI: 22.0-22.9), 16.5 years for high risk (95% CI: 15.4-17.5), and 9.2 years for very high risk (95% CI: 7.8-10.7). Possible misclassification of long-term kidney function categories cannot be eliminated. Possibility of confounding due to concomitant comorbidities cannot be ruled out. The presence and degree of albuminuria was associated with lower estimated life expectancy for both gender and was especially notable in those with eGFR ≥30 mL/min/1.73 m(2). Life expectancy associated with a given level of eGFR differs substantially based on the presence and severity of albuminuria.
    12/2014; 1:33. DOI:10.1186/s40697-014-0033-6
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    ABSTRACT: New technologies to identify diseased feedlot cattle in early stages of illness have been developed to reduce costs and welfare impacts associated with bovine respiratory disease (BRD). However, the economic value of early BRD detection has never been assessed. The objective was to simulate cost differences between two BRD detection methods during the first 61 d on feed (DOF) applied in moderate- to large-sized feedlots using an automated recording system (ARS) for feeding behavior and the current industry standard, pen-checking (visual appraisal confirmed by rectal temperature). Economic impact was assessed with a cost analysis in a simple decision model. Scenarios for Canadian and US feedlots with high- and low-risk cattle were modeled, and uncertainty was estimated using extensive sensitivity analyses. Input costs and probabilities were mainly extracted from publicly accessible market observations and a large-scale US feedlot study. In the baseline scenario, we modeled high-risk cattle with a treatment rate of 20% within the first 61 DOF in a feedlot of >8000 cattle in Canada. Early BRD detection was estimated to result in a relative risk of 0.60 in retreatment and 0.66 in mortality compared to pen-checking (based on previously published estimates). The additional cost of monitoring health with ARS in Canadian dollar (CAD) was 13.68 per steer. Scenario analysis for similar sized US feedlots and low-risk cattle with a treatment rate of 8% were included to account for variability in costs and probabilities in various cattle populations. Considering the cost of monitoring, all relevant treatment costs and sale price, ARS was more costly than visual appraisal during the first 61 DOF by CAD 9.61 and CAD 9.69 per steer in Canada and the US, respectively. This cost difference increased in low-risk cattle in Canada to CAD 12.45. Early BRD detection with ARS became less expensive if the costs for the system decreased to less than CAD 4.06/steer, or if the underlying true BRD incidence (not treatment rate) within the first 61 DOF exceeded 47%. The model was robust to variability in the remaining input variables. Some of the assumptions in the baseline analyses were conservative and may have underestimated the real value of early BRD detection. Systems such as ARS may reduce treatment costs in some scenarios, but the investment costs are currently too high to be cost-effective when used solely for BRD detection compared to pen-checking. Copyright © 2014 Elsevier B.V. All rights reserved.
    Preventive Veterinary Medicine 12/2014; 118(4). DOI:10.1016/j.prevetmed.2014.12.001 · 2.51 Impact Factor
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    ABSTRACT: Patients with proliferative lupus nephritis are at risk of frequent relapses. Whether low- dose prednisone prevents relapses is uncertain. We undertook a pilot RCT to determine the feasibility of a larger trial. Pilot randomized controlled trial. Single center Canadian outpatient nephrology clinic. Participants with systemic lupus erythematosus (SLE) and a history of class III or IV lupus nephritis that achieved at least partial remission and remained on prednisone were eligible. Feasibility: proportion of eligible patients randomized and adherence to tapering regimen. Clinical: occurrence of renal or major non-renal flare of SLE. We conducted a blinded, two-parallel-group randomized controlled trial of prednisone 7.5 mg/day (continuation) compared to a matching placebo (withdrawal). Of nineteen eligible patients screened, 15 (79%) were recruited and randomized; 8 to prednisone continuation and seven to withdrawal. All participants adhered to the tapering protocol to their assigned withdrawal or low-dose maintenance target. Over 36 months, the primary outcome occurred in four (50%) patients in the continuation group (three renal and one major non-renal flare), compared with one patient (14%) in the withdrawal group (one renal flare). Three participants (38%) in the continuation group had minor flares, while no patients in the withdrawal group did. This pilot RCT was small and not designed to assess the efficacy or safety of maintenance with low-dose prednisone. The high proportion of eligible patients recruited, and success of protocol adherence suggest a large trial of prednisone maintenance therapy compared to withdrawal is feasible. Current Controlled Trials ISRCTN31327267.
    11/2014; 1:30. DOI:10.1186/s40697-014-0030-9
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    ABSTRACT: We congratulate the KDIGO (Kidney Disease: Improving Global Outcomes) work group on their comprehensive work in a broad subject area, and agreed with many of the recommendations in their clinical practice guideline on the evaluation and management of chronic kidney disease. We concur with the KDIGO definitions and classification of kidney disease, and welcome the addition of albuminuria categories at all levels of glomerular filtration rate (GFR) , the terminology of G categories rather than stages to describe level of GFR, the division of former stage 3 into new G categories 3a and 3b, and the addition of the underlying diagnosis. We agree with the use of the heat map to illustrate the relative contributions of low GFR and albuminuria to cardiovascular and renal risk, though we felt that the highest risk category was too broad, including as it does people at quite disparate levels of risk. We add an albuminuria category A4 for nephrotic-range proteinuria, and D and T categories for patients on dialysis or with a functioning renal transplant.We recommend target blood pressure of 140/90 mm Hg regardless of diabetes or proteinuria, and against the combination of angiotensin-receptor blockers with angiotensin-converting enzyme inhibitors. We recommend against routine protein restriction. We concur on individualization of HbA1C targets. We do not agree with routine restriction of sodium to less than 2 g/d, instead suggesting reduction of sodium intake in those with high intake (> 3.3 g/d). We suggest screening for anemia only when GFR < 30 mL/min/1.73 m2. We recognize the absence of evidence on appropriate phosphate targets and methods of achieving them, and do not agree with suggestions in this area. In drug dosing, we agree with the recommendation of using absolute clearance (ie, mL/min), calculated from the patient’s estimated GFR (which is normalized to 1.73 m2) and the patient’s actual anthropomorphic body surface area. We agree with referral to a nephrologist when GFR < 30 mL/min/1.73 m2 (and for many other scenarios), but suggest urine albumin-creatinine ratio > 60 mg/mmol or proteinuria > 1 g/d as the referral threshold for proteinuria.
    American Journal of Kidney Diseases 11/2014; DOI:10.1053/j.ajkd.2014.10.013 · 5.76 Impact Factor
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    ABSTRACT: Chronic kidney disease (CKD) is an important global public health problem that is associated with adverse health outcomes and high health care costs. Effective and cost-effective treatments are available for slowing the progression of CKD and preventing its complications, including cardiovascular disease. Although wealthy nations have highly structured schemes in place to support the care of people with kidney failure, less consideration has been given to health systems and policy for the much larger population of people with non-dialysis-dependent CKD. Further, how to integrate such strategies with national and international initiatives for control of other chronic noncommunicable diseases (NCDs) merits attention. We synthesized the various approaches to CKD control across 17 European countries and present our findings according to the key domains suggested by the World Health Organization framework for NCD control. This report identifies opportunities to strengthen CKD-relevant health systems and explores potential mechanisms to capitalize on these opportunities. Across the 17 countries studied, we found a number of common barriers to the care of people with non-dialysis-dependent CKD: limited work force capacity, the nearly complete absence of mechanisms for disease surveillance, lack of a coordinated CKD care strategy, poor integration of CKD care with other NCD control initiatives, and low awareness of the significance of CKD. These common challenges faced by diverse health systems reflect the need for international cooperation to strengthen health systems and policies for CKD care. Copyright © 2014 National Kidney Foundation, Inc. Published by Elsevier Inc. All rights reserved.
    American Journal of Kidney Diseases 11/2014; 65(1). DOI:10.1053/j.ajkd.2014.07.033 · 5.76 Impact Factor
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    ABSTRACT: There is an increasing level of emphasis being placed on health care providers and funders to incorporate patient-centered care into research. Involving patients and caregivers in establishing research priorities ensures the relevance of the research produced. Priority setting is a process that can be used to produce a robust set of research questions that researchers can address over the coming years. One of the methods for determining research priorities that involves patients, caregivers and clinicians is the James Lind Alliance priority setting partnership model. This method is focused on being exclusive, transparent, and evidence-based. Using a recent example of patients on or nearing dialysis, we highlight the key steps to assess research priorities in patients, caregivers and clinicians: (i) formation of a steering committee to guide the overall process; (ii) form priority setting partnerships; (iii) identify and gather research uncertainties; (iv) process and collate submitted research uncertainties; and (v) final priority setting workshop to determine the top 10 research priorities.
    Seminars in Dialysis 11/2014; 28(2). DOI:10.1111/sdi.12325 · 2.07 Impact Factor
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    Lianne Barnieh, Cam Donaldson, Braden Manns
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    ABSTRACT: Publicly funded health care systems are increasingly confronted with fiscal and demographic challenges and face pressure to constrain resource use without impacting clinical outcomes. Clinicians routinely make decisions in the care of their patients that use finite health care resources. Aligning the goal of caring for their patients with ensuring that effective interventions are available for patients who are most likely to benefit is critical to sustaining the publicly funded health care system. Balancing the needs of patients with health care prioritization will require changes to be made across the health care system. Incorporating costs and value for money when caring for patients and making decisions will play an important role in efficiency and value in the health system.
    10/2014; 1:27. DOI:10.1186/s40697-014-0027-4
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    ABSTRACT: Management of chronic diseases requires patients to adhere to recommended health behavior change and complete tests for monitoring. While studies have shown an association between low income and lack of adherence, the reasons why people with low income may be less likely to adhere are unclear. We sought to determine the association between household income and receipt of health behavior change advice, adherence to advice, receipt of recommended monitoring tests, and self-reported reasons for non-adherence/non-receipt. We conducted a population-weighted survey, with 1849 respondents with cardiovascular-related chronic diseases (heart disease, hypertension, diabetes, stroke) from Western Canada (n = 1849). We used log-binomial regression to examine the association between household income and the outcome variables of interest: receipt of advice for and adherence to health behavior change (sodium reduction, dietary improvement, increased physical activity, smoking cessation, weight loss), reasons for non-adherence, receipt of recommended monitoring tests (cholesterol, blood glucose, blood pressure), and reasons for non-receipt of tests. Behavior change advice was received equally by both low and high income respondents. Low income respondents were more likely than those with high income to not adhere to recommendations regarding smoking cessation (adjusted prevalence rate ratio (PRR): 1.55, 95%CI: 1.09-2.20), and more likely to not receive measurements of blood cholesterol (PRR: 1.72, 95%CI 1.24-2.40) or glucose (PRR: 1.80, 95%CI: 1.26-2.58). Those with low income were less likely to state that non-adherence/non-receipt was due to personal choice, and more likely to state that it was due to an extrinsic factor, such as cost or lack of accessibility. There are important income-related differences in the patterns of health behavior change and disease monitoring, as well as reasons for non-adherence or non-receipt. Among those with low income, adherence to health behavior change and monitoring may be improved by addressing modifiable barriers such as cost and access.
    PLoS ONE 10/2014; 9(4):e94007. DOI:10.1371/journal.pone.0094007 · 3.53 Impact Factor
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    ABSTRACT: Background and objectives The relative influence of facilities and regions on the timing of dialysis initiation remains unknown. The purpose of the study is to determine the variation in eGFR at dialysis initiation across dialysis facilities and geographic regions in Canada after accounting for patient-level factors (case mix). Design, setting, participants, & measurements In total, 33,263 dialysis patients with an eGFR measure at dialysis initiation between January of 2001 and December of 2010 representing 63 dialysis facilities and 14 geographic regions were included in the study. Multilevel models and intraclass correlation coefficients were used to evaluate the variation in timing of dialysis initiation by eGFR at the patient, facility, and geographic levels. Results The proportion initiating dialysis with an eGFR >= 10.5 ml/min per 1.73 m(2) was 35.3%, varying from 20.1% to 57.2% across geographic regions and from 10% to 67% across facilities. In an unadjusted, intercept-only linear model, 90.7%, 6.6%, and 2.7% of the explained variability were attributable to patient, facility, and geography, respectively. After adjustment for patient and facility factors, 96.9% of the explained variability was attributable to patient case mix, 3.1% was attributable to the facility, and 0.0% was attributable to the geographic region. These findings were consistent when the eGFR was categorized as a binary variable (>= 10.5 ml/min per 1.73 m2) or in an analysis limited to patients with >3 months of predialysis care. Conclusions Patient characteristics accounted for the majority of the explained variation regarding the eGFR at the initiation of dialysis. There was a small amount of variation at the facility level and no variation among geographic regions that was independent of patient-and facility-level factors.
    Clinical Journal of the American Society of Nephrology 09/2014; 9(10). DOI:10.2215/CJN.12321213 · 5.25 Impact Factor
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    ABSTRACT: Background: The cost-effectiveness of annual colonoscopy for detection of colorectal neoplasia among patients with inflammatory bowel disease (IBD) and primary sclerosing cholangitis (PSC) is uncertain. The aim of this study was to determine whether annual colonoscopy among patients with IBD-PSC is cost-effective compared with less frequent intervals from the perspective of a publicly funded health care system. Methods: A cost-utility analysis using a Markov model was used to simulate a 35-year-old patient with a 10-year history of well-controlled IBD and a recent diagnosis of concomitant PSC. The following strategies were compared: no surveillance, colonoscopy every 5 years, biennial colonoscopy, and annual colonoscopy. Outcome measures included: costs, number of cases of dysplasia found, number of cancers found and missed, deaths, quality-adjusted life-years (QALYs) gained, and the incremental cost per QALY gained. Results: In the base-case analysis, no surveillance was the least expensive and least effective strategy. Compared with no surveillance, the cost per QALY of surveillance every 5 years was CAD $15,021. The cost per QALY of biennial surveillance compared with surveillance every 5 years was CAD $ 37,522. Annual surveillance was more effective than biennial surveillance, but at an incremental cost of CAD $ 174,650 per QALY gained compared with biennial surveillance. Conclusions: More frequent colonoscopy screening intervals improve effectiveness (i.e., detects more cancers and prevents additional deaths), but at higher cost. Health systems must consider the opportunity costs associated with different surveillance colonoscopy intervals when deciding which strategy to implement among patients with IBD-PSC.
    Inflammatory Bowel Diseases 09/2014; 20(11). DOI:10.1097/MIB.0000000000000181 · 5.48 Impact Factor
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    ABSTRACT: Background-Lower estimated glomerular filtration rate (eGFR) on a single occasion is associated with risk of cardiovascular events; whether the degree of change in eGFR during a 1-year period adds prognostic information is unknown. Methods and Results-We included adults who had >= 2 outpatient eGFR measurements (>= 6 months apart) during a 1-year accrual period in Alberta, Canada. According to recent guidelines, we used a change in eGFR category (>= 90, 60 to 89, 45 to 59, 30 to 44, 15 to 29, and <15 mL/min per 1.73 m(2)), and the presence/absence of a >= 25% change from baseline to classify participants into 5 groups: certain drop, uncertain drop, stable (no change), uncertain rise, and certain rise. We calculated adjusted rates of cardiovascular events (per 10 000 person-years) for each group. We estimated the adjusted risks of cardiovascular events associated with each category of change in eGFR, in reference to stable kidney function. Among the 526 388 participants, 76.1% (n=400 560) had stable, 2.6% (n=13 668) had a certain drop, and 3.3% (n=17 499) had a certain rise in eGFR. Compared with participants with stable kidney function, adjusted risks of myocardial infarction, heart failure, and stroke were 27%, 51%, and 20% higher, respectively, for those with a certain drop in kidney function. After adjusting for the last eGFR at the end of the accrual period, the observed association diminished. Conclusion-Clinically relevant changes in eGFR are associated with increased risk of cardiovascular events. However, most of the apparent increase in risk can be accounted for by assessing comorbidity and baseline kidney function.
    Journal of the American Heart Association 09/2014; 3(5). DOI:10.1161/JAHA.114.000997 · 2.88 Impact Factor

Publication Stats

8k Citations
1,861.92 Total Impact Points

Institutions

  • 1998–2015
    • The University of Calgary
      • • Department of Community Health Sciences
      • • Department of Medicine
      • • Faculty of Medicine
      Calgary, Alberta, Canada
  • 2003–2013
    • University of Alberta
      • • Department of Medicine
      • • Division of Nephrology
      Edmonton, Alberta, Canada
  • 2006–2009
    • Institute of Health Economics
      Edmonton, Alberta, Canada
  • 2007
    • Humber River Regional Hospital
      Toronto, Ontario, Canada
  • 2001–2005
    • McMaster University
      • • Department of Medicine
      • • Department of Clinical Epidemiology and Biostatistics
      Hamilton, Ontario, Canada
    • Dalhousie University
      • Department of Medicine
      Halifax, Nova Scotia, Canada
  • 2004
    • Duke University
      Durham, North Carolina, United States