Subject(s)
Kidney Failure, Chronic/therapy , Nephrology/organization & administration , Quality of Health Care/organization & administration , Reimbursement, Incentive/organization & administration , Renal Dialysis/standards , Humans , Kidney Failure, Chronic/economics , Nephrology/economics , Nephrology/standards , Organizational Case Studies , Quality of Health Care/economics , Quality of Health Care/trends , Reimbursement, Incentive/trends , Renal Dialysis/economicsABSTRACT
Monitoring the quality of dialysis care has long been a component of the Medicare ESRD program. As part of the 2008 Medicare Improvements for Patients and Providers Act (MIPPA), Congress mandated the Quality Incentive Program (QIP), which linked measures of care quality to payments. The legislation embraced the idea that this linkage of federal money to performance would encourage the purchase of greater 'value.' The first 2 program years for the QIP use a simple scoring methodology and a limited scope of quality metrics. For payment year 2014 (performance period calendar year 2012), the program changes substantially, with an expanded number of quality measures and a more complex scoring methodology. In this article, we describe the program structure, quality measures, scoring system, and financial impact.
Subject(s)
Centers for Medicare and Medicaid Services, U.S./economics , Delivery of Health Care/economics , Kidney Failure, Chronic/therapy , Outcome and Process Assessment, Health Care/economics , Quality Improvement/economics , Quality Indicators, Health Care/economics , Reimbursement, Incentive , Renal Dialysis/economics , Benchmarking/economics , Centers for Medicare and Medicaid Services, U.S./legislation & jurisprudence , Centers for Medicare and Medicaid Services, U.S./standards , Delivery of Health Care/legislation & jurisprudence , Delivery of Health Care/standards , Financing, Government , Government Regulation , Health Care Costs , Health Policy/economics , Humans , Kidney Failure, Chronic/diagnosis , Kidney Failure, Chronic/economics , Outcome and Process Assessment, Health Care/legislation & jurisprudence , Outcome and Process Assessment, Health Care/standards , Practice Guidelines as Topic , Program Development , Quality Improvement/legislation & jurisprudence , Quality Improvement/standards , Quality Indicators, Health Care/legislation & jurisprudence , Quality Indicators, Health Care/standards , Reimbursement, Incentive/legislation & jurisprudence , Reimbursement, Incentive/standards , Renal Dialysis/standards , Treatment Outcome , United StatesABSTRACT
BACKGROUND AND OBJECTIVES: Only rare cases of concurrent membranous glomerulonephritis (MGN) and antineutrophil cytoplasmic antibody (ANCA)-associated necrotizing and crescentic glomerulonephritis (NCGN) have been reported. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: The authors report the clinical and pathologic findings in 14 patients with MGN and ANCA-associated NCGN. RESULTS: The cohort consisted of eight men and six women with a mean age of 58.7 yr. ANCA positivity was documented by indirect immunofluorescence or ELISA in all patients. Indirect immunofluorescence was positive in 13 patients (seven P-ANCA, five C-ANCA, one atypical ANCA). ELISA was positive in nine of 10 patients (five MPO-ANCA, three PR3-ANCA, one MPO- and PR3-ANCA). Clinical presentation included heavy proteinuria (mean 24-hr urine protein 6.5 g/d), hematuria, and acute renal failure (mean creatinine 4.4 mg/dl). Pathologic evaluation revealed MGN and NCGN, with crescents involving a mean of 32% of glomeruli. On ultrastructural evaluation, the majority of cases showed stage I or II membranous changes. Follow-up was available for 13 patients, 12 of whom were treated with steroids and cyclophosphamide. At a mean follow-up of 24.3 mo, five patients progressed to ESRD, seven had stabilization or improvement in renal function, and one had worsening renal function. Five patients, including three with ESRD, died during the follow-up period. The only independent predictor of progression to ESRD was serum creatinine at biopsy. CONCLUSIONS: MGN with ANCA-associated NCGN is a rare dual glomerulopathy seen in patients with heavy proteinuria, acute renal failure, and active urine sediment. Prognosis is variable, with 50% of patients reaching endpoints of ESRD or death.
Subject(s)
Antibodies, Antineutrophil Cytoplasmic/analysis , Glomerulonephritis, Membranous/complications , Glomerulonephritis/complications , Kidney Glomerulus/pathology , Acute Kidney Injury/etiology , Acute Kidney Injury/immunology , Acute Kidney Injury/pathology , Adult , Aged , Biopsy , Creatinine/blood , Cyclophosphamide/therapeutic use , Disease Progression , Female , Glomerulonephritis/drug therapy , Glomerulonephritis/immunology , Glomerulonephritis/pathology , Glomerulonephritis, Membranous/drug therapy , Glomerulonephritis, Membranous/immunology , Glomerulonephritis, Membranous/pathology , Hematuria/etiology , Hematuria/immunology , Hematuria/pathology , Humans , Immunosuppressive Agents/therapeutic use , Kidney Failure, Chronic/etiology , Kidney Failure, Chronic/immunology , Kidney Failure, Chronic/pathology , Kidney Function Tests , Kidney Glomerulus/physiopathology , Male , Middle Aged , Necrosis , Proteinuria/etiology , Proteinuria/immunology , Proteinuria/pathology , Steroids/therapeutic use , Treatment OutcomeABSTRACT
Hemodialysis is associated with various complications, the most common being intradialytic hypotension (IDH). In the majority of cases, IDH is easily corrected and does not represent a life-threatening condition. We present a patient in whom IDH was unresponsive to various corrective strategies. A new mitral valve regurgitant lesion was diagnosed that eventually led to the patient's demise. Unusual etiologies of IDH need to be considered, particularly in instances where routine therapeutic measures are ineffective.
