[Show abstract][Hide abstract] 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; · 5.29 Impact Factor
[Show abstract][Hide abstract] 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; · 2.25 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: 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).
Clinical journal of the American Society of Nephrology : CJASN. 09/2014;
[Show abstract][Hide abstract] ABSTRACT: 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.
[Show abstract][Hide abstract] ABSTRACT: 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.
Journal of the American Heart Association. 09/2014; 3(5).
[Show abstract][Hide abstract] ABSTRACT: Background-Kidney transplant improves quality of life and survival compared with dialysis. Despite advances in immunosuppressant regimens and the prevention and treatment of acute rejection, graft survival rates have not improved significantly in the past decade. Although the clinical effectiveness of these regimens has been studied, the impact of changes over time on cost has not.Methods-Costs of kidney transplant were compared between 2 periods demarcated by a programmatic change from cyclosporine (early) to tacrolimus (late) and from nonroutine induction (early) to routine induction (late) therapy in adult patients receiving a first kidney-only transplant in Calgary, Alberta, Canada, in an 8-year period.Results-Complete costs for 3 years after transplant was available for 344 patients, including 161 adult recipients in the early period (April 1, 1998-December 31, 2001) and 183 adult recipients in the late period (January 1, 2002-March 31, 2006). The mean total 3-year cost of transplant for recipients was Can$100 034 in the early period and Can$144 712 in the late period largely attributed to increases in the cost of immunosuppressants (P< .001).Conclusions-Given that the cost of transplant has increased significantly over time, the cost-effectiveness of these and other immunosuppressive regimens should be evaluated carefully.
[Show abstract][Hide abstract] ABSTRACT: The prevalence of chronic kidney disease and end-stage renal disease requiring dialysis therapy continues to increase worldwide, and despite technological advances, treatment remains resource intensive. Thus, the increasing burden of dialysis therapy on finite health-care budgets is an important consideration. The principles of allocative efficiency and the concept of 'opportunity cost' can be used to assess whether dialysis is economically justified; if dialysis is to be provided, cost-minimization and cost-utility analyses can be used to identify the most efficient dialysis modality. Existing studies have examined the cost, and where relevant the effectiveness, of the various currently available peritoneal dialysis and haemodialysis modalities. In this Review, we discuss variations in the intrinsic costs of the available dialysis modalities as well as other factors, such as variation by country, available health-care infrastructures, the timing of dialysis initiation and renal transplantation. We draw on data from robust micro-costing studies of the various dialysis modalities in Canada to highlight key issues.
[Show abstract][Hide abstract] ABSTRACT: To improve quality of care and patient outcomes, health system decision-makers need to identify and implement effective interventions. An increasing number of systematic reviews document the effects of quality improvement programs to assist decision-makers in developing new initiatives. However, limitations in the reporting of primary studies and current meta-analysis methods (including approaches for exploring heterogeneity) reduce the utility of existing syntheses for health system decision-makers. This study will explore the role of innovative meta-analysis approaches and added value of enriched and updated data for increasing the utility of systematic reviews of complex interventions for health system decision-makers.
[Show abstract][Hide abstract] ABSTRACT: In a recent randomized trial, weekly recombinant tissue plasminogen activator (rt-PA), 1 mg per lumen, once per week, and twice-weekly heparin as a locking solution (rt-PA/heparin) resulted in lower risks of hemodialysis catheter malfunction and catheter-related bacteremia compared with thrice-weekly heparin (heparin alone). We collected detailed costs within this trial to determine how choice of locking solution would affect overall health care costs, including the cost of locking solutions and all other relevant medical costs over the course of the 6-month trial. Nonparametric bootstrap estimates were used to derive 95% confidence intervals (CIs) and mean cost differences between the treatment groups. The cost of the locking solution was higher in patients receiving rt-PA/heparin, but this was partially offset by lower costs for managing complications. Overall, the difference in unadjusted mean cost for managing patients with rt-PA/heparin versus heparin alone was Can$323 (95% CI, -$935 to $1581; P=0.62). When the costs were extrapolated over a 1-year time horizon using decision analysis, assuming ongoing rt-PA effectiveness, the overall costs of the strategies were similar. This finding was sensitive to plausible variation in the frequency and cost of managing patients with catheter-related bacteremia, and whether the benefit of rt-PA on catheter-related bacteremia was maintained in the long term. In summary, we noted no significant difference in the mean overall cost of an rt-PA/heparin strategy as a locking solution for catheters compared with thrice-weekly heparin. Cost savings due to a lower risk of hospitalization for catheter-related bacteremia partially offset the increased cost of rt-PA.
Journal of the American Society of Nephrology : JASN. 07/2014;
[Show abstract][Hide abstract] ABSTRACT: AimsTo determine the association between participation in a brief introductory didactic diabetes education programme and change in HbA1c among individuals with newly diagnosed diabetes.Methods
We identified a population-based cohort of adults newly diagnosed with diabetes between October 2005 and June 2008 in Calgary, Canada, and conducted a retrospective cohort study by linking administrative and laboratory data with programme attendance data. We matched individuals who attended the programme within the first 6 months after diagnosis with those who did not attend, based on their propensity scores. We measured the change in HbA1c between time of diagnosis and 6–18 months later to determine the association between programme participation and change in HbA1c.ResultsHbA1c was measured at baseline and follow-up for 7793 individuals, including 803 programme participants. After propensity score matching, programme participation was associated with a significantly greater adjusted mean reduction in HbA1c between baseline and follow-up of 3.3 mmol/mol (95% CI 2.2–4.3) or 0.30% (95% CI 0.20–0.39). There was a significant interaction between baseline HbA1c and programme participation—the difference in adjusted mean reduction in HbA1c associated with programme participation ranged from 2.7 mmol/mol (0.25%) at baseline HbA1c of 53 mmol/mol (7%) to 6.2 mmol/mol (0.56%) at baseline HbA1c of 97 mmol/mol (11%).Conclusion
Despite its brevity, participation in a diabetes education programme was associated with an additional reduction in HbA1c in newly diagnosed people that was comparable with that reported in trials of programmes targeted at those with prevalent diabetes.This article is protected by copyright. All rights reserved.
[Show abstract][Hide abstract] ABSTRACT: Value-based insurance design (V-BID) is an insurance cost-sharing model in which patients pay less for medications deemed to be of higher value. Our objective was to determine the association between V-BID and medication adherence, clinical outcomes, healthcare utilization, and spending in patients with or at risk for cardiovascular chronic diseases, compared with no differential lowering of drug co-payments.
The American journal of managed care. 06/2014; 20(6):e229-41.
[Show abstract][Hide abstract] ABSTRACT: People with chronic conditions who do not achieve therapeutic targets have a higher risk of adverse health outcomes. Failure to meet these targets may be due to a variety of barriers. This article examines self-reported financial barriers to health care among people with cardiovascular-related chronic conditions.
[Show abstract][Hide abstract] ABSTRACT: With increasing emphasis among health care providers and funders on patient-centered care, it follows that patients and their caregivers should be included when priorities for research are being established. This study sought to identify the most important unanswered questions about the management of kidney failure from the perspective of adult patients on or nearing dialysis, their caregivers, and the health care professionals who care for these patients. Research uncertainties were identified through a national Canadian survey of adult patients on or nearing dialysis, their caregivers, and health care professionals. Uncertainties were refined by a steering committee that included patients, caregivers, researchers, and clinicians to assemble a short-list of the top 30 uncertainties. Thirty-four people (11 patients; five caregivers; eight physicians; six nurses; and one social worker, pharmacist, physiotherapist, and dietitian each) from across Canada subsequently participated in a workshop to determine the top 10 research questions. In total, 1570 usable research uncertainties were received from 317 respondents to the survey. Among these, 259 unique uncertainties were identified; after ranking, these were reduced to a short-list of 30 uncertainties. During the in-person workshop, the top 10 research uncertainties were identified, which included questions about enhanced communication among patients and providers, dialysis modality options, itching, access to kidney transplantation, heart health, dietary restrictions, depression, and vascular access. These can be used alongside the results of other research priority-setting exercises to guide researchers in designing future studies and inform health care funders.
Clinical Journal of the American Society of Nephrology 05/2014; · 5.07 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: ABSTRACT BACKGROUND Malignant pleural effusion is associated with short life expectancy and significant morbidity. A recent randomized controlled trial comparing indwelling pleural catheters with talc pleurodesis found that indwelling pleural catheters reduced time in hospital and need for additional procedures but were associated with excess adverse events. METHODS Using data from the clinical trial, we compared costs associated with use of indwelling pleural catheters and with talc pleurodesis. Resource use and adverse events were captured through case report forms over the 1-year trial follow up. Costs for outpatient and inpatient visits, diagnostic imaging, nursing and doctor time were obtained from the NHS reference costs and University of Kent's Unit Costs of Health and Social Care 2011 and inflated to 2013 using the UK Consumer Price Index. Procedure supply costs were obtained from the manufacturer. Difference in mean costs was compared using non-parametric bootstrapping. All costs were converted to US dollars using the OECD Purchasing Power Parity Index. RESULTS Overall mean cost (SD) for managing patients with indwelling pleural catheters and talc pleurodesis was $4993 (5529) and $4581 (4359) respectively. The incremental mean cost difference was $401 with a 95% CI (-1387 to 2261). The mean cost related to ongoing drainage in the indwelling pleural catheter group was $1011 (732) versus $57 (213) in the talc pleurodesis group (p=0.001). This included the cost of drainage bottles, dressing changes in the first month and catheter removal. There was no significant difference in cost of the initial intervention or adverse events between the groups. For patients with survival less than 14 weeks, IPC is significantly less costly than talc pleurodesis with mean cost difference of -$1719(95% CI -3376 to -85). CONCLUSION There is no significant difference in mean cost of managing patients with indwelling pleural catheters compared with talc pleurodesis. For patients with limited survival, IPC appears less costly.
isrctn.org Identifier: ISRCTN87514420.
[Show abstract][Hide abstract] ABSTRACT: The optimal time at which to initiate chronic dialysis remains unknown. Using a contemporary knowledge translation approach (the knowledge-to-action framework), a pan-Canadian collaboration (CANN-NET) set out to study the scope of the problem, then develop and disseminate evidence-based guidelines addressing the timing of dialysis initiation. The purpose of this review is to summarize the key findings and describe the planned Canadian knowledge translation strategy for improving knowledge and practices pertaining to the timing dialysis initiation.
New research has provided considerable insights regarding the initiation of dialysis. A Canadian cohort study identified significant variation in the estimated glomerular filtration rate level at dialysis initiation, and a survey of providers identified related knowledge gaps that might be amenable to knowledge translation interventions. A recent knowledge synthesis/guideline concluded that early dialysis initiation is costly, and provides no measureable clinical benefits. A systematic knowledge translation intervention including a multifaceted approach may aid in reducing variation in practice and improving the quality of care.
Utilizing the knowledge-to-action framework, we identified practice variation and key barriers to the optimal timing for dialysis initiation that may be amenable to knowledge translation strategies.
Current Opinion in Nephrology and Hypertension 05/2014; 23(3):321-7. · 3.96 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Background: Physicians' perceptions and opinions may influence when to initiate dialysis. Objective: To examine providers' perspectives and opinions regarding the timing of dialysis initiation.
The Canadian Journal of Kidney Health and Disease. 05/2014;
[Show abstract][Hide abstract] ABSTRACT: Elucidation of the relationship between age, kidney function, and absolute coronary risk would facilitate efforts to promote chronic kidney disease (CKD) as a high-risk state for future vascular events and justify current recommendations for statin treatment in CKD.
1,268,538 people with data for estimated glomerular filtration rate and albuminuria who were treated in a single Canadian province.
CKD risk groups (G1, G2, G3a, G3b, and G4 had estimated glomerular filtration rate≥90, 60-89.9, 45-59.9, 30-44.9, and 15-29.9mL/min/1.73m(2), respectively; A1, A2, and A3 had albuminuria with albumin-creatinine ratio [ACR]<30mg/g or dipstick urinalysis negative, ACR of 30-300mg/g or dipstick trace or 1+, and ACR>300mg/g or dipstick ≥ 2+, respectively) and age (<40, 40-49, ≥50 years).
Rates of coronary death or nonfatal myocardial infarction (expressed per 1,000 person-years), stratified by age, sex, and CKD stage.
The first available serum creatinine value and the corresponding date were set as the index serum creatinine value and index date, respectively. ACR or dipstick urinalysis data were obtained from the periods defined by 6 months before and after the index creatinine value.
Absolute rates of coronary death or nonfatal myocardial infarction were consistently greater than 10 per 1,000 person-years for people with CKD and 50 years or older, regardless of CKD stage. However, absolute rates of the composite outcome were consistently less than 10 per 1,000 person-years for those younger than 50 years.
Single Canadian province, median follow-up only 4.0 years.
People with CKD who are 50 years or older should be considered at the highest risk of coronary events. In contrast, consideration of other risk factors will be required when assessing future risk among people with CKD who are younger than 50 years.
American Journal of Kidney Diseases 04/2014; · 5.29 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: This analysis explores barriers to the receipt of health care from a primary care physician for management of chronic conditions.
A population-based survey was administered to adults in Manitoba, Saskatchewan, Alberta and British Columbia who had hypertension, diabetes, heart disease or stroke (n=1,849). Associations between socio-demographic factors and barriers to receipt of primary care were identified.
Most respondents with chronic conditions required care from a primary care physician in the past year and had no difficulty receiving it; about 10% reported a barrier. Barriers were most commonly reported by respondents with diabetes (16%) and were related to initiation of care or waiting too long to get care.
A small percentage of adults with chronic conditions report barriers to receiving care from a primary care physician.
Health reports / Statistics Canada, Canadian Centre for Health Information = Rapports sur la santé / Statistique Canada, Centre canadien d'information sur la santé 04/2014; 25(4):3-10. · 4.28 Impact Factor