Reducing the Frequency of Surveillance Blood Work in Patients Treated With Maintenance Hemodialysis: A Local Quality Improvement Initiative.

Introduction: There is little evidence on the ideal frequency of routine blood work in maintenance dialysis patients to manage complications, including anemia, mineral bone disease (MBD), and hyperkalemia. Recent quality improvement studies from Ontario showed no negative impacts when decreasing the frequency from monthly to every 6 weeks in conventional in-center hemodialysis (ICHD) patients. In December 2020, Alberta Kidney Care-South (AKC-S) reduced the frequency of routine blood work from every 6 weeks to every 8 weeks for ICHD patients. Objective: We aimed to assess the impact of reducing blood work frequency on patient outcomes. Methods: We compared prevalent AKC-S ICHD patients in 2 cohorts: (1) retrospective control (October 31, 2019-October 31, 2020) and (2) prospective intervention (December 1, 2020-December 1, 2021). Primary outcomes were true frequency of routine blood work, odds of patients being within target for anemia and MBD, and proportion of lab values of hyperkalemia. Furthermore, we compared hospitalizations and mortality. Results: A total of 972 patients in Calgary's ICHD program were included, 787 in each period (with 602 patients overlapping both cohorts). The frequency of routine blood work decreased from every 39.5 days in the control period to every 54.2 days in the intervention period (P < .01). There was a reduction in the odds of phosphate values in targets (P = .02), and an increase in the odds of labs with hyperkalemia (>6.0 mmol/L) during the intervention period (P = .01). There was no significant change in the odds of being within the accepted targets during the intervention period compared with the control period for hemoglobin, Tsat, calcium, or parathyroid hormone (PTH). Fewer patients were hospitalized during the intervention period and the risk of death decreased as well, although additional factors such as the COVID-19 pandemic may have affected this. A cost-savings of $32 962 occurred from the reduced anemia and MBD blood work during the intervention period. Conclusions: When ICHD units in Calgary reduced routine blood work frequency from every 6 weeks to 8 weeks, there were no negative impacts on hospitalizations or deaths. A slightly lower proportion of phosphate values were within target, and a 0.7% increase in potassium values greater than 6 mmol/L was demonstrated. Our study suggests that blood work frequency in ICHD dialysis patients may be further reduced to every 8 weeks safely. Ultimately, additional pragmatic trials are needed to identify the optimal frequency of routine blood work.

Introduction: Il existe peu de données quant à la fréquence idéale des analyses sanguines chez les patients sous dialyse d'entretien pour gérer les complications comme l'anémie, les troubles liés à la densité osseuse (TDO) et l'hyperkaliémie. De récentes études d'amélioration de la qualité menées en Ontario n'ont montré aucune conséquence négative lorsque la fréquence des analyses des patients traités de façon traditionnelle par hémodialyse en centre (HDC) est passée d'une fois par mois à une fois toutes les 6 semaines. L'Alberta Kidney Care-South (AKC-S) a réduit la fréquence des analyses sanguines de routine; depuis décembre 2020, les analyses des patients traités par HDC sont effectuées toutes les 8 semaines plutôt qu'aux 6 semaines. Objectif: Évaluer les effets d'une réduction de la fréquence des analyses sanguines sur les résultats des patients. Méthodologie: Nous avons comparé des patients de l'AKC-S prévalents pour l'HDC dans deux cohortes: a) période témoin ­ rétrospective (31 octobre 2019 au 31 octobre 2020); b) période d'intervention ­ prospective (1er décembre 2020 au 1er décembre 2021). Les principaux critères d'évaluation étaient la fréquence réelle des analyses sanguines de routine, la probabilité que les patients soient dans la cible pour l'anémie et les TDO, et dans la fourchette cible des valeurs de laboratoire pour l'hyperkaliémie. Les hospitalisations et la mortalité ont également été comparées entre les deux cohortes. Résultats: Au total, 972 patients du programme d'HDC de Calgary ont été inclus, soit deux cohortes de 787 patients (602 patients ont chevauché les deux cohortes). Les analyses sanguines étaient effectuées tous les 39,5 jours pendant la période témoin; cette fréquence est passée aux 54,2 jours pendant la période d'intervention (p<0,01). On a observé une réduction des probabilités que le taux de phosphate soit dans les cibles (p=0,02) et une augmentation des valeurs de laboratoire montrant une hyperkaliémie (>6,0 mmol/L) pendant la période d'intervention (p=0,01). Aucun changement significatif n'a été observé entre les deux périodes en ce qui concerne la probabilité que les valeurs de laboratoire soient dans les cibles acceptées pour l'hémoglobine, le TSAT, le calcium ou la PTH. Pendant la période d'intervention, moins de patients ont été hospitalisés et le risque de décès a diminué, mais d'autres facteurs, notamment la pandémie de COVID-19, ont pu influer sur ce résultat. Enfin, le fait de réduire la fréquence des analyses de suivi pour l'anémie et les TDO a entraîné des économies de 32 962 $. Conclusion: Aucune conséquence négative n'a été observée lorsque la fréquence des analyses sanguines des patients des unités d'hémodialyse en centre de Calgary est passée de 6 à 8 semaines. Une proportion légèrement plus faible des valeurs de phosphate se situait dans la fourchette cible et une augmentation de 0,7 % des valeurs de potassium supérieures à 6 mmol/L a été constatée. Notre étude suggère qu'il est sécuritaire d'effectuer les analyses sanguines des patients hémodialysés en centre toutes les 8 semaines. Des essais pragmatiques sont nécessaires pour déterminer la fréquence optimale de ces analyses.

Splice site and de novo mutations can cause mixed dominant negative/gain of function PLCG2-associated immune dysregulation with cold urticaria (CU-PLAID).

Background: Phospholipase Cγ2 (PLCγ2) is an important signaling molecule that receives and transmits signals from various cell surface receptors in most hematopoietic lineages. Variants of PLCG2 cause PLCγ2-associated immune dysregulation (PLAID), a family of conditions that are classified by mutational effect. PLAID with cold urticaria (CU-PLAID) is caused by in-frame deletions of PLCG2 that are dominant negative at physiologic temperatures but become spontaneously active at sub-physiologic temperatures. Objective: To identify genetic lesions that cause PLAID by combining RNA sequencing of full-length PLCG2 with whole genome sequencing. Methods: We studied nine probands with antibody deficiency and a positive evaporative cooling test, together with two known CU-PLAID patients and three healthy subjects. Illumina sequencing was performed on full-length PLCG2 cDNA synthesized from peripheral blood mononuclear cell RNA and whole genome sequencing was used to identify genetic lesions. Novel alternate transcripts were overexpressed in the Plcg2-deficient DT40 cell overexpression system. ERK phosphorylation was quantified by flow cytometry with and without BCR crosslinking. Results: Two probands expressed novel alternative transcripts of PLCG2 with in-frame deletions. The first, expressing PLCG2 without exons 18-19, carried a splice site mutation in intron 19. The second, expressing PLCG2 without exons 19-22, carried a 14kb de novo deletion of PLCG2. DT40 cells overexpressing the exon 18-19 or exon 19-22 deletions failed to phosphorylate ERK in response to BCR crosslinking. Conclusion: In addition to autosomal dominant genomic deletions, de novo deletions and splice site mutations of PLCG2 can also cause CU-PLAID. All of these can be identified by cDNA-based sequencing.

Impact of quality improvement initiatives to improve CKD referral patterns: a systematic review protocol.

INTRODUCTION: Chronic kidney disease (CKD) is a global-health problem. A significant proportion of referrals to nephrologists for CKD management are early and guideline-discordant, which may lead to an excess number of referrals and increased wait-times. Various initiatives have been tested to increase the proportion of guideline-concordant referrals and decrease wait times. This paper describes the protocol for a systematic review to study the impacts of quality improvement initiatives aimed at decreasing the number of non-guideline concordant referrals, increasing the number of guideline-concordant referrals and decreasing wait times for patients to access a nephrologist. METHODS AND ANALYSIS: We developed this protocol by using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses for Protocols (2015). We will search the following empirical electronic databases: MEDLINE, Embase, Cochrane Library, CINAHL, Web of Science, PsycINFO and grey literature for studies designed to improve guideline-concordant referrals or to reduce unnecessary referrals of patients with CKD from primary care to nephrology. Our search will include all studies published from database inception to April 2021 with no language restrictions. The studies will be limited to referrals for adult patients to nephrologists. Referrals of patients with CKD from non-nephrology specialists (eg, general internal medicine) will be excluded. ETHICS AND DISSEMINATION: Ethics approval will not be required, as we will analyse data from studies that have already been published and are publicly accessible. We will share our findings using traditional approaches, including scientific presentations, open access peer-reviewed platforms, and appropriate government and public health agencies. PROSPERO REGISTRATION NUMBER: CRD42021247756.

Electronic Advice Request System for Nephrology in Alberta: Pilot Results and Implementation.

BACKGROUND: Residents of rural areas of Alberta face significant barriers regarding access to specialist care, resulting in delays in provision of optimal care. Electronic referral and consultation systems are promising tools for facilitating timely access to specialist care, especially for people living in rural locations. OBJECTIVE: To report our initial experience with the launch of an electronic advice request system for ambulatory kidney care in Alberta, Canada. METHODS: We analyzed electronic advice requests for nephrology services in Alberta after the system's pilot launch, from October 2016 to December 2017. Data for province-wide advice request utility by primary care providers (PCPs) were extracted from Alberta Netcare for analysis. RESULTS: The total number of electronic advice requests directed to nephrology was 118 (mean number of requests: 2 per week). Only 31 (26.3%) of the cases required a face-to-face clinic visit with a nephrologist. Most (87; 73.7%) cases were managed by PCPs with ongoing nephrologist support via the advice request tool. Typical nephrologist response time was 5.7 ± 0.6 (mean ± SEM) days. CONCLUSION: These preliminary data suggest that the electronic advice request program has potential to enhance timely access to specialist kidney care and minimize unnecessary nephrologist visits while reducing response time. Broad implementation of this system may have a substantial positive impact on health outcomes and improve cost-effectiveness for nephrology care in the long term, particularly in rural communities of Alberta.

CONTEXTE: Les résidents des zones rurales de l'Alberta se heurtent à des obstacles importants en ce qui concerne l'accès aux soins spécialisés, ce qui entraîne des retards dans la fourniture de soins adéquats. Les systèmes électroniques de référence et de consultation sont des outils prometteurs qui peuvent faciliter un accès rapide à des soins spécialisés, en particulier pour les personnes résidant en milieu rural. OBJECTIF: Présenter notre première expérience avec le lancement d'un système de demande de consultation électronique en soins rénaux ambulatoires en Alberta, Canada. MÉTHODOLOGIE: Nous avons analysé les demandes de consultation électroniques pour des services de néphrologie en Alberta, entre octobre 2016 et décembre 2017, après le lancement pilote du système. Les données sur la pertinence des demandes de consultation à l'échelle provinciale, et selon les fournisseurs de soins primaires, ont été extraites du registre Alberta Netcare pour fins d'analyze. RÉSULTATS: Le nombre total de consultations électroniques adressées en néphrologie était de 118 (moyenne de 2 demandes/semaine), et 31 cas seulement (26,3%) ont nécessité une visite en clinique avec un néphrologue. La majorité des cas (87), soit 73,7%, a été prise en charge par des fournisseurs de soins primaires qui bénéficiaient du soutien permanent d'un néphrologue par l'entremise de l'outil électronique. Le temps de réponse moyen des néphrologues était de 5,7 ± 0,6 jour (moyenne ± SEM). CONCLUSION: Ces données préliminaires suggèrent que le program de demande de consultation électronique pourrait faciliter l'accès rapide à des soins par un néphrologue et minimiser les visites inutiles en clinique, tout en réduisant le temps de réponse. La mise en œuvre à grande échelle de ce système pourrait avoir une incidence très positive sur les résultats de santé et améliorer la rentabilité des soins en néphrologie à long terme, en particulier dans les communautés rurales de l'Alberta.

Assessing postgraduate trainees in Canada: are we achieving diversity in methods?

BACKGROUND: Resident evaluation is a complex and challenging task, and little is known about what assessment methods, predominate within or across specialties. AIMS: To determine the methods program directors in Canada use to assess residents and their perceptions of how evaluation could be improved. METHODS: We conducted a web-based survey of program directors from The Royal College of Physicians and Surgeons of Canada (RCPSC)-accredited training programs, to examine the use of the In-Training Evaluation Report (ITER), the use of non-ITER tools and program directors' perceived needs for improvement in evaluation methods. RESULTS: One hundred forty-nine of the eligible 280 program directors participated in the survey. ITERs were used by all but one program. Of the non-ITER tools, multiple choice questions (71.8%) and oral examinations (85.9%) were most utilized, whereas essays (11.4%) and simulations (28.2%) were least used across all specialties. Surgical specialties had significantly higher multiple choice questions and logbook utilization, whereas medical specialties were significantly more likely to include Objective Stuctured Clinical Examinations (OSCEs). Program directors expressed a strong need for national collaboration between programs within a specialty to improve the resident evaluation processes. CONCLUSIONS: Program directors use a variety of methods to assess trainees. They continue to rely heavily on the ITER, but are using other tools.

CanMEDS evaluation in Canadian postgraduate training programmes: tools used and programme director satisfaction.

CONTEXT: The Royal College of Physicians and Surgeons of Canada (RCPSC) CanMEDS framework is being incorporated into specialty education worldwide. However, the literature on how to evaluate trainees in the CanMEDS competencies remains sparse. OBJECTIVES: The goals of this study were to examine the assessment tools used and programme directors' perceptions of how well they evaluate performance of the CanMEDS roles in Canadian postgraduate training programmes. METHODS: We conducted a web-based survey of programme directors of RCPSC-accredited training programmes. The survey consisted of two questions. Question 1 was designed to establish which assessment tools were used to assess each of the CanMEDS roles. Question 2 was intended to assess programme directors' perceived satisfaction with CanMEDS evaluation in their programmes. RESULTS: A total of 149 of the eligible 280 programme directors participated in the survey. Programme directors used a variety of assessment tools to evaluate trainees in CanMEDS competencies. Programmes used more tools to evaluate the Medical Expert (mean = 4.03, standard deviation [SD] = 1.59) and Communicator (mean = 2.36, SD = 1.02) roles. Programme directors used the fewest tools for the Collaborator (mean = 1.75, SD = 1.10) and Manager (mean = 1.75, SD = 1.18) roles. More than 92% of the programmes used in-training evaluation reports to evaluate all the CanMEDS roles. Programme directors were satisfied with their evaluation of the Medical Expert role, but less so with assessment of the other CanMEDS competencies. CONCLUSIONS: This study demonstrates that Canadian postgraduate training programmes use a variety of assessment tools to evaluate the CanMEDS competencies. Programme directors are neutral or concerned about how the CanMEDS roles other than that of Medical Expert are evaluated in their programmes. Further efforts are required to establish best practice in CanMEDS evaluation.

The effect of question format and task difficulty on reasoning strategies and diagnostic performance in Internal Medicine residents.

BACKGROUND: Previous studies have suggested an association between reasoning strategies and diagnostic success, but the influence on this relationship of variables such as question format and task difficulty, has not been studied. Our objective was to study the association between question format, task difficulty, reasoning strategies and diagnostic success. METHODS: Study participants were 13 Internal Medicine residents at the University of Calgary. Each was given eight problem-solving questions in four clinical presentations and were randomized to groups that differed only in the question format, such that a question presented as short answer (SA) to the first group was presented as extended matching (EM) to the second group. There were equal numbers of SA/EM questions and straightforward/difficult tasks. Participants performed think-aloud during diagnostic reasoning. Data were analyzed using multiple logistic regression. RESULTS: Question format was associated with reasoning strategies; hypothetico-deductive reasoning being used more frequently on EM questions and scheme-inductive reasoning on SA questions. For SA question, non-analytic reasoning alone was used more frequently to answer straightforward cases than difficult cases, whereas for EM questions no such association was observed. EM format and straightforward task increased the odds of diagnostic success, whereas hypothetico-deductive reasoning was associated with reduced odds of success. CONCLUSIONS: Question format and task difficulty both influence diagnostic reasoning strategies and studies that examine the effect of reasoning strategies on diagnostic success should control for these effects. Further studies are needed to investigate the effect of reasoning strategies on performance of different groups of learners.

Differences in use of peritoneal dialysis and survival among East Asian, Indo Asian, and white ESRD patients in Canada.

BACKGROUND: Racial differences in health outcomes in general are well documented; however, few studies examined the impact of East Asian and Indo Asian race on choice of dialytic modality and survival among patients with end-stage renal disease (ESRD). METHODS: We compared the use of peritoneal dialysis (PD) and survival among East Asian, Indo Asian, and white patients with ESRD initiating dialysis therapy in Canada between January 1, 1990, and December 31, 2000. RESULTS: Of 10,338 patients, 5.7% were East Asian, 3.2% were Indo Asian, and 91% were white. After controlling for sociodemographics and comorbidities, East Asian and Indo Asian patients were significantly more likely to initiate dialysis therapy on PD compared with white patients (odds ratio, 1.63; 95% confidence interval [CI], 1.36 to 1.96; odds ratio, 1.52; 95% CI, 1.21 to 1.93, respectively), with no difference in likelihood of technique failure. East Asian and Indo Asian patients had a lower risk for death after the initiation of dialysis therapy (irrespective of modality) compared with white patients, with adjusted hazard ratios of 0.66 (95% CI, 0.58 to 0.76) for East Asian patients and 0.63 (95% CI, 0.53 to 0.75) for Indo Asian patients. The survival benefit for East Asian and Indo Asian patients was similar in the subgroup that initiated dialysis therapy with PD. CONCLUSION: We found that Asian patients with ESRD were more likely to initiate dialysis therapy using PD, with improved survival after the initiation of dialysis therapy, compared with white patients. Elucidation of factors in East Asian and Indo Asian ESRD populations that result in improved outcomes may have implications for ESRD treatment for other racial groups.

Quality of care among Aboriginal hemodialysis patients.

Registry data report racial differences in hemodialysis (HD) care, with ethnic minorities at a disadvantage. However, little information is available regarding Aboriginal HD patients specifically. This study sought to compare the quality of HD care between Aboriginal and non-Aboriginal patients in Canada. All adults who were established on HD for > or = 6 mo in a single Canadian province were included. Clinical information was obtained by patient interview and chart review, with race determined by self-report. Quality of HD care was assessed by small solute clearance, BP control, mineral metabolism, and anemia management. Of the 835 patients, 95 (11.4%) were Aboriginal. Aboriginal patients were significantly younger, were more likely to have diabetes as the cause of ESRD, and had a higher degree of comorbidity than non-Aboriginal patients. There were no differences between Aboriginal and non-Aboriginal patients for small solute clearance, anemia management, or use of permanent vascular access. Aboriginal patients, however, were less likely to achieve a target predialysis systolic BP of < 140 mmHg (29.5 versus 44.9%; P = 0.004), a target phosphate level of < 1.8 mmol/L (40.0 versus 67.3%; P < 0.0001), and a calcium-phosphate product < 4.4 mmol2/L2 (52.6 versus 72.7%; P < 0.001). Quality of care was found to be similar for Aboriginal compared with non-Aboriginal HD patients except for differences in predialysis systolic BP and mineral metabolism, which may be influenced by individual and cultural factors. Explanations for these differences and their impact on morbidity and mortality warrant further investigation.

Wait-listing for kidney transplantation among Aboriginal hemodialysis patients.

BACKGROUND: Although there has been rapid growth in the global prevalence of Aboriginal patients with end-stage renal disease (ESRD), these individuals have markedly lower rates of kidney transplantation for reasons that are unclear. We investigated barriers to kidney transplantation for Aboriginal patients treated with hemodialysis for ESRD in Canada. METHODS: All consenting adults in the province of Alberta, Canada, who had been established on hemodialysis therapy for 6 months or longer were interviewed by a physician. Data for transplantation referral, waiting list status, and the assessment process were determined from the regional transplant programs, with race defined by patient self-report. For purposes of this analysis, race was dichotomized as either Aboriginal or non-Aboriginal. RESULTS: Of 835 subjects, 100 (12%) were Aboriginal. Aboriginal patients were significantly younger and more likely to have diabetes mellitus as the cause of ESRD than non-Aboriginal patients. Although a greater proportion of Aboriginal patients were referred for transplantation assessment (60.6% versus 46.0%; P < 0.01), after adjustment, the likelihood of referral was similar for both racial groups (hazard ratio associated with Aboriginal race, 0.80; 95% confidence interval, 0.59 to 1.08). Aboriginal patients also were significantly less likely to be active on the transplant wait list than non-Aboriginal patients (adjusted hazard ratio, 0.46; 95% confidence interval, 0.27 to 0.78). Aboriginal subjects who had been referred for assessment were significantly more likely than non-Aboriginals to be in the process of completing the transplantation workup (69.6% versus 26.9%; P < 0.01) as opposed to being temporarily or permanently unsuitable for transplantation (30.4% versus 73.3%; P < 0.01). Although not statistically significant, median duration of the workup in progress in referred, but nonlisted, participants appeared longer in Aboriginal participants (954 versus 596 days; P = 0.07). CONCLUSION: The likelihood of referral for transplantation was similar between Aboriginal and non-Aboriginal people. However, Aboriginal people were approximately half as likely to be successfully activated to the transplant waiting list compared with non-Aboriginal people. These data suggest that the major barrier to transplantation in Aboriginal patients occurs after referral, but early in the course of evaluation for eligibility.