Recommendations for Public Policy Changes to Improve Supportive Care for Seriously Ill Patients With Kidney Disease.

National and international nephrology organizations have identified substantial unmet supportive care needs of patients with kidney disease and issued recommendations. In the United States, the most recent comprehensive effort to change kidney care, the Advancing American Kidney Health Initiative, does not explicitly address supportive care needs, although it attempts to implement more patient-centered care. This Perspective from the leaders of the Coalition for Supportive Care of Kidney Patients advocates for urgent policy changes to improve patient-centered care and the quality of life of seriously ill patients with kidney disease. It argues for the provision of supportive care by an interdisciplinary team led by nephrology clinicians to improve shared decision-making, advance care planning, pain and symptom management, the explicit offering of active medical management without dialysis as an option for patients who may not benefit from dialysis, and the removal by the Centers for Medicare & Medicaid Services and all other payors of financial and regulatory disincentives to quality supportive care, including hospice, for patients with or approaching kidney failure. It also emphasizes that all educational and accreditation programs for nephrology clinicians include kidney supportive care and its essential role in the care of patients with kidney disease.

Improving end-of-life care for ESRD patients: an initiative for professionals.

The Coalition for Supportive Care of Kidney Patients convened subject matter experts (SMEs) to assess the current state of palliative care for pre-dialysis (chronic kidney disease) and end-stage renal disease patients (stages 3-5). The SMEs noted that in the final month of life, dialysis patients have the higher percentage of hospitalizations, longer length of stay, greater intensive care admissions, and higher number of deaths in hospitals than cancer or heart failure patients, but use hospice only half as much as these two groups. The group identified a strategic approach and framework for achieving specific aims to improve palliative care education of health care providers, raise awareness of supportive care resources, define palliative care skills for nephrologists, and continue the implementation of shared decision-making for individualized patient-centered care.

Prevalence of arteriovenous fistulas in incident hemodialysis patients: correlation with patient factors that may be associated with maturation failure.

BACKGROUND: Lok et al previously reported a risk equation for arteriovenous fistula (AVF) maturation failure. It is unclear whether this model or a more comprehensive model correlates with incident AVF use in the US hemodialysis population. STUDY DESIGN: Cross-sectional study. SETTING & PARTICIPANTS: 195,756 adult patients initiating outpatient hemodialysis therapy in the United States between July 1, 2005, and December 31, 2009, with 6 months or more prior nephrology care. PREDICTOR: Patient characteristics (age, peripheral vascular disease, coronary artery disease, and race) populating the AVF maturation failure risk equation and other demographic and clinical variables from the Centers for Medicare & Medicaid Services (CMS) Medical Evidence Report (CMS 2728). OUTCOMES & MEASUREMENTS: AVF use at first outpatient dialysis treatment as recorded on the CMS 2728. RESULTS: Using the risk categories defined by Lok et al, AVF use varied from 19.0% (very high risk) to 25.6% (low risk). In a model using only these risk categories, logistic regression showed lower ORs for moderate-, 0.90 (95% CI, 0.88-0.93); high-, 0.80 (95% CI, 0.78-0.83); and very high-risk patients, 0.68 (95% CI, 0.63-0.73) compared with low risk. In the expanded model, odds were lower for women, blacks, Hispanics, age older than 85 years, diabetes, peripheral vascular disease, congestive heart failure, other cardiac disease, and underweight. Odds were higher for hypertension, overweight, obesity, 12 months or more nephrologist care, most insurance types, and each successive year after 2005. Despite associations, the C statistic for the expanded model was 0.64. LIMITATIONS: This analysis is limited by lack of access creation history before dialysis therapy initiation and minimal external validation of CMS 2728 data. CONCLUSIONS: Clinical risk factors identified by Lok and expanded in this analysis have limited ability to predict incident AVF use. Even patients judged at highest risk can have successful AVF construction and initiate dialysis therapy through a functioning AVF.

Achieving the goal of the Fistula First breakthrough initiative for prevalent maintenance hemodialysis patients.

BACKGROUND: The Centers for Medicare & Medicaid Services (CMS) established a national goal of 66% arteriovenous fistula (AVF) use in prevalent hemodialysis (HD) patients for the current Fistula First Breakthrough Initiative. The feasibility of achieving the goal has been debated. We examined contemporary patterns of AVF use in prevalent patients to assess the potential for attaining the goal by dialysis facilities and their associated End-Stage Renal Disease Networks in the United States. STUDY DESIGN: Observational study. SETTING & PARTICIPANTS: US dialysis facilities with a mean HD patient census of 10 or more during the 40-month study period, January 2007-April 2010. OUTCOMES & MEASUREMENTS: Mean changes in facility-level AVF use and percentage of facilities achieving the 66% prevalent AVF goal within the United States and each network. RESULTS: Mean prevalent AVF use within dialysis facilities increased from 45.3% to 55.5% (P < 0.001) in the United States, but varied substantially across regions. The percentage of facilities achieving the 66% AVF use goal increased from 6.4% to 19.0% (P < 0.001). During the 40 months, 35.9% of facilities achieved the CMS goal for at least 1 month. On average, these facilities sustained mean use ≥66% for 12.9 ± 11.7 (SD) months. Case-mix and other facility characteristics explained 20% of the variation in proportion of facility patients using an AVF in the last measured month, leaving substantial unexplained variability. LIMITATIONS: This analysis is limited by the absence of facility case-mix data over time, and the national scope of the initiative precludes use of a comparison group. CONCLUSIONS: Achieving the CMS goal of 66% prevalent AVF use is feasible for individual dialysis facilities. There is a need to decrease regional variation before the CMS goal can be fully realized for US HD facilities.