Diabetes is the strongest risk factor for lower-extremity amputation in new hemodialysis patients.

OBJECTIVE: End-stage renal disease (ESRD) patients, especially those with diabetes, have an increased risk of nontraumatic lower-extremity amputation (LEA). The present study aims to examine the association of demographic and clinical variables with the risk of hospitalization for LEA among incident hemodialysis patients. RESEARCH DESIGN AND METHODS: The study population consisted of incident hemodialysis patients from the study years 1996-1999 of the ESRD Core Indicator/Clinical Performance Measures (CPM) Project. Cox proportional hazard modeling was used to identify factors associated with LEA. RESULTS: Four percent (116 of 3,272) of noncensored incident patients had an LEA during the 12-month follow-up period. Factors associated with LEA included diabetes as the cause of ESRD or preexisting comorbidity (hazard ratio 6.4, 95% CI 3.4-12.0), cardiovascular comorbidity (1.8, 1.2-2.8), hemodialysis inadequacy (urea reduction ratio [URR] <58.5% (1.9, 1.1-3.3), and lower serum albumin level (1.6, 1.1-2.3). Among patients with diabetes, hemodialysis inadequacy and cardiovascular comorbidity were risk factors for LEA (2.6, 1.4-4.8, and 1.7, 1.1-2.6, respectively). CONCLUSIONS: These data suggest that diabetes is a potent risk factor for LEA in new hemodialysis patients. In ESRD patients with diabetes, a multipronged approach may reduce the rate of LEA. Potentially beneficial strategies include adherence to hemodialysis adequacy guidelines, aggressive treatment of cardiovascular comorbidities, and the utilization of LEA prevention strategies recommended for the general population of patients with diabetes.

Disparity in outcomes for adult Native American hemodialysis patients? Findings from the ESRD Clinical Performance Measures Project, 1996 to 1999.

BACKGROUND: There is a paucity of information regarding the quality of care for Native American hemodialysis patients. Outcomes, including 1-year hospitalization and mortality, for adult Native American in-center hemodialysis patients selected for the Centers for Medicare and Medicaid (CMS) end-stage renal disease (ESRD) Clinical Performance Measures (CPM) Project were compared to those for white and black patients to determine if disparity in care existed for this group. METHODS: Clinical data were abstracted from medical records for the last quarters of 1995 to 1998 and linked to United States Renal Data System (USRDS) data files for data on comorbidities and 1-year hospitalization and mortality. Associations of race were tested by bivariate analyses and multivariate logistic regression and Cox proportional hazard modeling. RESULTS: Two percent (467 of 27876) of patients were Native American, 37% black, and 51% white. Native American, compared to black and white patients, were more likely to have diabetes mellitus as the cause of ESRD (72%, 37%, and 38%, respectively, P < 0.01). In multivariate analyses, Native American patients were more likely to achieve a mean urea reduction ratio (URR) > or = 65% compared to whites (referent) [hazards ratio (HR) (95% CI) 1.7 (1.3, 2.2)] and be dialyzed with an arteriovenous fistula [HR (95% CI) 1.7 (1.2, 2.5)]. They were as likely as Whites to achieve a mean hematocrit > or =33% and a mean serum albumin > or =4.0/3.7 g/dL. In multivariate analyses, Native Americans were no more likely to be hospitalized or die during the follow-up period than whites. CONCLUSION: These data suggest that adult Native American hemodialysis patients experience equivalent or better dialytic care and are no more likely to experience 1-year hospitalization or mortality compared to whites.

National and state trends in quality of care for acute myocardial infarction between 1994-1995 and 1998-1999: the medicare health care quality improvement program.

BACKGROUND: National efforts have focused attention on quality of care, but relatively little is known about whether, and to what extent, improvement has occurred during this recent period. Furthermore, the variability of the recent change over time is not known. METHODS: We sought to determine national and state trends in quality of care for Medicare patients hospitalized with acute myocardial infarction (AMI) between 1994-1995 (n = 234754 discharges) and 1998-1999 (n = 35713 discharges) as part of the Centers for Medicare & Medicaid Services (CMS) National AMI Project. We assessed change in evidence-based, guideline-recommended processes of care. RESULTS: Nationally, among patients without contraindications to therapy, discharge beta-blocker prescription increased by 20.5 percentage points (50.3% to 70.7%); early administration of beta-blocker increased by 17.4 percentage points (51.1% to 68.4%); discharge angiotensin-converting enzyme inhibitor prescription for systolic dysfunction increased by 8.0 percentage points (62.8% to 70.8%); early administration of aspirin increased by 6.6 percentage points (76.4% to 82.9%); and aspirin prescribed at discharge increased by 5.6 percentage points (77.3% to 82.9%) (P<.001 for all categories). Smoking cessation counseling decreased by 3.6 percentage points (40.8% to 37.2%; P<.001). Rates of acute reperfusion therapy did not significantly change (59.2% to 60.6%; P =.35). The median time from hospital arrival to initiation of thrombolytic therapy decreased by 7 minutes (P<.001); and the median time from hospital arrival to initiation of primary percutaneous transluminal coronary angioplasty decreased by 12 minutes (P =.09). CONCLUSIONS: During this 4-year period, quality of care for AMI improved, but substantial variation was observed at both time points. While meaningful population-based improvement has been achieved, ample opportunities for improvement exist. Further work is required to elucidate the strategies associated with improvements in quality of care.

Comparison of urea reduction ratio and hematocrit data reported in different data systems: results from the Centers for Medicare & Medicaid Services and the Renal Network Inc.

BACKGROUND: Urea reduction ratio (URR) and hematocrit values reported on the Centers for Medicare & Medicaid Services (CMS) claims were compared with data from two different databases. METHODS: URRs and hematocrits from two different CMS databases (National Claims History and End-Stage Renal Disease Clinical Performance Measures [CPM] Project) and one Network database (The Renal Network Data System [TRNDS]) were compared for October through December 1998 and December 1998, respectively. A sample of records from the regional database was validated by independent chart review. RESULTS: Nationally, the percentage of agreement for patients with URRs of 65% or greater and less than 65% was 94% (kappa, 0.81; 95% confidence interval [CI], 0.80 to 0.83); regionally, the percentage of agreement was 95% (kappa, 0.85; 95% CI, 0.84 to 0.86). Nationally, linear regression of hematocrit values from both data sources yielded r(2) congruent with 0.61 each month and r(2) = 0.70 for average values during the 3-month study period. Nationally, the percentage of agreement for patients with hematocrits of 33% or greater and less than 33% was 84% (kappa approximately 0.66) each month. Regionally, linear regression of monthly hematocrit values from both data sources yielded r(2) = 0.66, and percentage of agreement for patients with hematocrits of 33% or greater and less than 33% was 87% (kappa, 0.71; 95% CI, 0.70 to 0.73). Validation of a sample of records in the TRNDS database resulted in 98% agreement for patients with URRs of 65% or greater and less than 65% and 96% agreement for patients with hematocrits of 33% or greater and less than 33%. CONCLUSION: Although there is general agreement between clinical variables submitted on the claims and in the CPM Project, some variation exists. Data from either source yield the same information when classifying patients as above or below threshold values.