Assessing the Level of Patient-Specific Treatment Recommendations in Clinical Practice Guidelines for Hemodialysis Vascular Access in the United States.

BACKGROUND: Hemodialysis is a procedure that requires efficient removal and return of blood to a patient's body. Despite being a life-sustaining process, hemodialysis is associated with morbidity, mortality, and high societal costs. A significant part of the financial costs to patients and society at large can be attributed to vascular access dysfunction. The cornerstone to efficient hemodialysis is a well-functioning vascular access that simultaneously allows efficient blood flow for dialysis and easy cannulation. It is hypothesized that the poor health outcomes associated with vascular access dysfunction can be improved by paying closer attention to patient-specific factors in clinical guidelines for hemodialysis vascular access. This may require a shift to a more patient-centered approach to vascular access management. OBJECTIVE: To assess the presence of patient-specific treatment recommendations in the current clinical practice guidelines for hemodialysis vascular access. METHODS: We conducted a systematic search of PubMed and professional nephrology organization websites for full-text clinical practice guidelines with treatment recommendations regarding hemodialysis vascular access. We developed a coding sheet to document the number of patient-specific treatment recommendations and other quality attributes found in the extracted clinical practice guidelines. RESULTS: Our search resulted in the extraction of 5 clinical practice guidelines for final review. Only 1 of the 5 extracted guidelines was found to contain patient-specific treatment recommendations, but the treatment recommendations were limited to juvenile patients. Of the 5 clinical practice guidelines, 4 were published within the past decade (ie, after 2006). CONCLUSION: Our findings show that current clinical practice guidelines for hemodialysis vascular access lack patient-specific recommendations. Future clinical guidelines must consider patient-specific treatment recommendations with the goal of improving hemodialysis vascular access outcomes for patients, a goal that is supported in the recommendations of the National Kidney Foundation.

Comparing Treatment Modalities for End-Stage Renal Disease: A Meta-Analysis.

BACKGROUND: End-stage renal disease (ESRD) imposes significant economic and social burdens on patients and healthcare systems. In the United States alone, more than 600,000 Americans have ESRD, with an estimated annual cost of treatment of more than $30 billion. Peritoneal dialysis and hemodialysis are competing renal replacement therapies in ESRD; however, data comparing quality-of-life outcomes between these 2 modalities are limited. OBJECTIVES: To compare the effectiveness of peritoneal dialysis with the more common treatment modality of hemodialysis on the health-related quality of life (HRQoL) of patients with ESRD in the general, physical, and psychological domains; and to determine whether the time of publication and the origin of each study influenced its findings regarding the effectiveness of the 2 modalities. METHODS: This meta-analysis followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines to collect the data. PubMed, MEDLINE, and PsycINFO were the primary databases searched. Only articles published in English were included in this meta-analysis. The measure of effect size was Cohen's standardized mean difference. A random-effects model was used to test the hypothesis of equality in the mean HRQoL. RESULTS: A total of 15 studies with a combined sample size of 4318 patients met the study criteria and were included in the analysis. The pooled effect sizes based on the random-effects model were 0.24 (95% confidence interval [CI], -0.17-0.66) in the general domain; 0.10 (95% CI, -0.09-0.29) in the physical-functioning domain; and 0.29 (95% CI, -0.13-0.71) in the psychological-functioning domain. None of the summary effect sizes was statistically significant. Subgroup analyses favored peritoneal dialysis regarding the time and country of publication. CONCLUSION: The majority of the studies included in this analysis favored peritoneal dialysis over hemodialysis in all 3 domains. However, the pooled effect sizes were not significant, resulting in the inability to conclude that peritoneal dialysis is the more effective of these 2 treatment modalities.

Regional variations in cancer screening rates found in women with diabetes.

BACKGROUND: A review of the literature gives conflicting findings regarding gender-specific cancer screening rates found in women with chronic illness. OBJECTIVES: The purpose of this study was to determine if women with diabetes have different patterns of cancer screening than women of the general population, and if so, to identify the determinants of these screening patterns guided by the Predisposing, Reinforcing, and Enabling Constructs in Educational Diagnosis and Evaluation (PRECEDE) model. METHODS: The 12 states using the optional women's health module for the 2003 Behavioral Risk Factor Surveillance System were downloaded into the STATA software. Contingency tables were used to identify the prevalence of cancer screening in women who self-report that they have diabetes in comparison with women who report being nondiabetic. Logistic regression was used to examine the association between the PRECEDE model determinants and the screening behaviors. RESULTS: No significant association was found between having a diagnosis of diabetes and having mammography screening rates (F = 1.5, p =.22). However, cervical cancer screening rates were statistically significantly different between the two groups of women (F = 39.01, p <.01). A gap in cervical cancer screening rates was identified among women with diabetes as compared with women without diabetes (78% versus 86%, respectively). Regional exceptions were noted between the 12 states. Ten of the 11 PRECEDE variables demonstrated a significant association with Papanicolaou test screening rates. The states demonstrating inadequate screening rates were the states with the most negative PRECEDE factors. DISCUSSION: Research has shown that the primary reason women seek cancer screening is when they are encouraged by a healthcare provider. If other care providers are focused on disease management, nurses who provide holistic care can build on the advocacy role inherent in nursing and encourage screening in underserved areas of the country.

Personal factors affecting African-American men's prostate cancer screening behavior.

PURPOSE: Although there are significant controversies about prostate cancer screening, it is the only method recognized to combat prostate cancer through early detection and appropriate treatment. The primary goal of this study was to identify personal factors influencing African-American men's participation in prostate cancer screening. METHODS: Two cross-sectional mail surveys were conducted over one year to test the validity of the Attitude-Social Influence-Efficacy model in predicting prostate cancer screening. Data were collected from African-American men age > or =40. The study hypotheses were tested using multiple linear regression and logistic regression analyses RESULTS: One-hundred-ninety-one African-American men participated in the first cross-sectional survey, and 65 African-American men responded to the follow-up survey a year later. The participants were mostly African-American men who were born and grew up in America, were 50-59 years of age, had some college training, were married, were urban residents, had full-time employment status and had a household income of $20,000-$39,000. The key determinants of intention to undergo prostate cancer screening were attitude, perceived behavioral control, past behavior and perceived susceptibility. Attitude was the primary determinant of screening behavior. CONCLUSION: To foster appropriate prostate cancer detection activities, the modifiable factors identified in this study should be considered.

Economic burden of dehydration among hospitalized elderly patients.

PURPOSE: The cost of unnecessary hospitalizations associated with dehydration in elderly patients was studied. METHODS: The study involved a retrospective examination of 1999 data on hospital discharges from the Healthcare Cost and Utilization Project Nationwide Inpatient Sample. The procedure code for volume depletion was used to extract hospitalization episodes for patients > or = 65 years of age who had a principal diagnosis of dehydration and were discharged alive. Hospitalizations with procedure codes unrelated to dehydration were omitted. RESULTS: The descriptive findings indicated that hospitalized older patients with a principal diagnosis of dehydration averaged 80.4 years of age, were primarily white (82.5%), and were more likely to live in the community than in a nursing home. Hospitalizations for dehydration were more common in the South and less common in the West. The average length of stay (LOS) was 4.6 days. The average total hospital charge was dollars 7,442, and the average per diem charge was dollars 1,628. Regression analysis explained nearly half of the variation in charges for dehydration (R2 = 0.457). Average LOS and number of diagnoses were directly related to hospital charges, and age was inversely related. Higher charges were associated with being nonwhite, entering the hospital via the emergency room, having private insurance, having no insurance, having comorbidities, and being hospitalized in the West or in teaching or urban hospitals. In 1999, the potential national saving from avoidable hospitalizations in these patients could have been as much as dollars 1.14 billion. CONCLUSION: The economic burden associated with avoidable hospitalizations due to dehydration in elderly patients was substantial.

Types of hysterectomy. Comparison of characteristics, hospital costs, utilization and outcomes.

OBJECTIVE: To compare hospital costs, patient characteristics and outcomes of 3 hysterectomy techniques--abdominal, vaginal and laparoscopically assisted vaginal (LAVH). STUDY DESIGN: A cross-sectional analysis was performed using patients discharged from Florida hospitals in 2000 with hysterectomy as the primary procedure. To avoid differences due to unrelated complications, records indicating cancer or other major non-hysterectomy-related procedure were excluded from the analysis. A total of 23,191 records were used to compare the 3 techniques on hospital costs and length of stay, controlling for patient differences in complicating diagnoses and related procedures. RESULTS: Consistent with previous studies, patients undergoing LAVH had higher hospital costs, shorter lengths of stay and no difference in surgical complications from either vaginal or total abdominal hysterectomy, even after controlling for patient comorbidities. Other factors affecting hospital costs and length of stay were patient race, type of insurance, hospital ownership and location. CONCLUSION: LAVH is still more expensive than vaginal and total abdominal hysterectomy but offers a speedier recovery, with no measurable difference in the rate of complications. Further research is warranted to ascertain differences in readmission rates across the techniques and to investigate the process used to select which hysterectomy technique is used for a given patient.

A trend analysis of organ transplantation among ethnic groups.

PURPOSE: This research provides public policy implications regarding organ resource allocation and increases public awareness of the current status of transplant use in various ethnic populations. PROCEDURES: Healthcare Cost and Utilization Project (HCUP), National Inpatient Sample (NIS) data were used to obtain a yearly estimate of the number of organ transplants by organ and by ethnic origin for 1988-1997. ICD-9-CM codes identified lung, heart, liver, and kidney organ-transplantation procedures. Each record in the sample was weighted by its respective discharge weight in order to extrapolate a national estimate. To assess whether there are significant differences among ethnic groups in organ transplantation rates over time, regression models were estimated for heart, liver, and kidney transplants. Transplantation rates were modeled as a function of time, ethnic origin, and interaction variables. FINDINGS: Examination of time trend graphs and regression analyses indicates that transplantation rates have not varied substantially across ethnic groups between 1988 and 1997. Rates for all groups, with the exception of Asians, exhibited similar time trends with little systematic variation. CONCLUSIONS: Further research is needed to determine whether variations exist due to organ availability versus prevalence of the disease.