Allan J. Collins

We aimed to assess demographic characteristics, comorbidity and hospitalization burdens, laboratory abnormalities, and patterns of chronic kidney disease (CKD)-related medication use in a large cohort of patients with CKD stage 4 - 5.In a retrospective cohort analysis, the Medicare 5% sample and Truven MarketScan employer group health plan databases were used to examine patients aged ≥ 65 and < 65 years, respectively. CKD was determined by ≥ 1 inpatient or ≥ 2 outpatient claims with relevant ICD-9-CM diagnosis codes during the 1-year baseline period. The follow-up period was 1 year from day 91 after the index date Results: In the Medicare data, 12,930 (1.1%) CKD stage 4 - 5 patients were identified. Mean age was 79.2 ± 7.4 years; 56.1% were women and 83.1% white; 46.8% had atherosclerotic heart disease, and 36.9% congestive heart failure; 37.9% were hospitalized within 1 year. In the MarketScan data, 6,010 (0.04%) patients were identified. Mean age was 55.2 ± 8.8 years; 48.0% were women; 21.4% were hospitalized within 1 year. Heart failure was the leading cause of hospitalization for both groups. Parathyroid hormone levels were > 300 pg/mL for 39.1% of MarketScan patients, but only 20.9% received activated vitamin D. ESAs were administered to 28.2% of MarketScan patients with iron saturation < 30% and to 7.7% with hemoglobin > 11.5% and saturation ≥ 30%.Comorbidity burdens and hospitalization rates were high for patients with advanced, non-dialysisrequiring CKD. While hyperparathyroidism and anemia were common, appropriate medication use was not optimal, suggesting opportunities for improved care.

111 Background: Increasing emphasis on assessing the quality of treatment (tx) for cancer patients highlights the need for real-world data sets that can address critical policy questions about cancer care in the US. This study examined treatment and mortality in women with incident early-stage breast cancer (BC) 2007-2009 using the Surveillance, Epidemiology, and End Results (SEER)-Medicare linked data. Methods: We identified women age ≥66 years at the diagnosis of AJCC stage II/III BC between 2007-2009, who received surgery and were enrolled with Medicare Parts A and B. Women were followed from definitive surgery until the end of 2010, death, or change in enrollment status. Risk (cumulative incidence proportion [CIP]) of all-cause death was calculated with 95% confidence intervals (CI) using the Kaplan-Meier method stratified by tumor characteristics and tx type. Results: The cohort included 10,048 women with stage II (78%) or III (22%); 58% were ≥75 years and 78% had hormone-receptor (HR) positive tumors (77% ER positive, 64% PR positive). After the definitive surgery, 1,271 deaths reflected a CIP of 5.7% (95% CI 5.3-6.2) at 1 year, 10.9% (10.2-11.5) at 2 years, and 16.9% (15.9-17.9) at 3 years. Unadjusted mortality (Table) was higher among those without chemotherapy (chemo), women with neo-adjuvant tx, and those identified as “triple negative” phenotype (HR negative, no trastuzumab). Conclusions: Linking SEER and Medicare allowed us to assess mortality according to tumor characteristics and cancer treatments, respectively, which are both related to prognosis. The use of administrative data from Medicare should be further enhanced with inclusion of test results from standard gene expression panels to ensure a better match of therapy for the patient and adequate assessment of resource utilization. [Table: see text]

The choice of vascular access type is an important aspect of care for incident hemodialysis patients. However, data from the Centers for Medicare & Medicaid Services (CMS) Medical Evidence Report (form CMS-2728) identifying the first access for incident patients have not previously been validated. Medicare began requiring that vascular access type be reported on claims in July 2010. We aimed to determine the agreement between the reported vascular access at initiation from form CMS-2728 and from Medicare claims.

Summary: This article summarizes the administrative structure underlying the Unites States Renal Data System (USRDS); summarizes incidence, prevalence, patient characteristics, and treatment modalities; and describes data regarding clinical indicators and preventive care, hospitalization, survival, and costs. The USRDS recently instituted a comprehensive assessment system to characterize the transition to the new Centers for Medicare & Medicaid Services Prospective Payment System, which bundles into a single payment several integral components of dialysis care. This challenging initiative will be an important component of future USRDS Annual Data Reports. The main strengths of the USRDS are its size and representativeness, nearly complete inclusion of the US end-stage renal disease population, and linkage to Medicare claims. Limitations include lack of continuous validation of its methods, lack of complete comorbidity and laboratory data at registration, an initial survival bias, and lack of accuracy of cause-of-death reporting.

Design principles for a chronic kidney disease (CKD) screening program start with the general population at increased risk of CKD. Simple risk factor analysis demonstrates diabetes, hypertension, cardiovascular disease and older age as significant associated conditions. More comprehensive risk factor analysis shows only diabetes and hypertension as risk factors in people aged less than 50–60 years, and that anyone aged older than 50–60 years is at risk. Assessment of the relationship between CKD stage and cardiovascular risk factors shows early stage CKD to be associated with poor blood pressure control, which should be addressed. Other risk factors should be more completely assessed to determine if participants and their physicians are adequately addressing factors amenable to treatment to reduce high adverse event rates, premature death and progression to end‐stage renal disease (ESRD). Such assessment is needed to reduce the high burden of ESRD on national health‐care systems, which can only be addressed by early screening and active treatment.

This review examines trends in the ESRD program, assessing progress in preventive care, hospitalizations, and mortality since 1989, the year of the Dallas Morbidity and Mortality Conference. The number of prevalent dialysis patients nearly tripled, to 366,000 in 2007 from 123,000 in 1989. Prevalent population mortality rates declined in the mid-1980s but did not change overall through the 1990s; rates declined for patients on dialysis for less than 5 yr but increased for patients on dialysis for longer than 5 yr. Death rates throughout the prevalent population have subsequently declined since 2000. In the incident dialysis population, death rates after the first year have declined, but first-year rates have remained flat since 1996; rates peak in months 2 and 3, then decline to the level of the first month by 12 mo. Infectious hospitalization rates in the prevalent population increased 40% in the last 10 yr. For incident patients, infectious hospitalizations increased almost 100% over 10 yr, vascular access hospitalizations by 200%, and cardiovascular hospitalizations by 30%. Use of dialysis catheters is high; 82% of patients start dialysis with a catheter. Poor planning for dialysis initiation may contribute to catheter use and the associated high infectious hospitalization rate, limiting potential for improved patient survival during the first year. Public health programs, including the new Medicare chronic kidney disease education benefit, are needed to promote better care of patients who may need dialysis to reduce the high morbidity and mortality in the first year.

Risk for ESRD among elderly patients with acute kidney injury (AKI) has not been studied in a large, representative sample. This study aimed to determine incidence rates and hazard ratios for developing ESRD in elderly individuals, with and without chronic kidney disease (CKD), who had AKI. In the 2000 5% random sample of Medicare beneficiaries, clinical conditions were identified using Medicare claims; ESRD treatment information was obtained from ESRD registration during 2 yr of follow-up. Our cohort of 233,803 patients were hospitalized in 2000, were aged ≥67 yr on discharge, did not have previous ESRD or AKI, and were Medicare-entitled for ≥2 yr before discharge. In this cohort, 3.1% survived to discharge with a diagnosis of AKI, and 5.3 per 1000 developed ESRD. Among patients who received treatment for ESRD, 25.2% had a previous history of AKI. After adjustment for age, gender, race, diabetes, and hypertension, the hazard ratio for developing ESRD was 41.2 (95% confidence interval [CI] 34.6 to 49.1) for patients with AKI and CKD relative to those without kidney disease, 13.0 (95% CI 10.6 to 16.0) for patients with AKI and without previous CKD, and 8.4 (95% CI 7.4 to 9.6) for patients with CKD and without AKI. In summary, elderly individuals with AKI, particularly those with previously diagnosed CKD, are at significantly increased risk for ESRD, suggesting that episodes of AKI may accelerate progression of renal disease.

Concern lingers that dialysis therapy at for-profit (versus not-for-profit) hemodialysis facilities in the United States may be associated with higher mortality, even though 4 of every 5 contemporary dialysis patients receive therapy in such a setting. Our primary objective was to compare the mortality hazards of patients initiating hemodialysis at for-profit and not-for-profit centers in the United States between 1998 and 2003. For-profit status of dialysis facilities was determined after subjects received 6 months of dialysis therapy, and mean follow-up was 1.7 years. Of the study population (N = 205,076), 79.9% were dialyzed in for-profit facilities after 6 months of dialysis therapy. Dialysis at for-profit facilities was associated with higher urea reduction ratios, hemoglobin levels (including levels above 12 and 13 g/dL [120 and 130 g/L]), epoetin doses, and use of intravenous iron, and less use of blood transfusions and lower proportions of patients on the transplant waiting-list (P < 0.05). Patients dialyzed at for-profit and at not-for-profit facilities had similar mortality risks (adjusted hazards ratio 1.02, 95% CI 0.99–1.06, P = 0.143). While hemodialysis treatment at for-profit and not-for-profit dialysis facilities is associated with different patterns of clinical benchmark achievement, mortality rates are similar.