Robert Peter Pauly

Background: Fistulas are the preferred form of vascular access and historically, have been recommended by guidelines because they were associated with improved clinical outcomes and costs. However, there has never been a randomized comparison of catheters to fistulas and the evidence on which recommendations were based is observational with potential for bias. Methods: A pilot randomized controlled trial was conducted in 12 hemodialysis centers in Canada and Australia. Individuals aged 55 years and older who started hemodialysis using a tunneled or non-tunneled central venous catheter for vascular access were randomized to an attempt at fistula creation or continued use of a tunneled, central venous hemodialysis catheter. The primary outcome was feasibility, as measured by the proportion of eligible patients who consented to randomization and the proportion of patients randomized to the fistula group who underwent fistula placement within 90 days. Secondary outcomes included invasive access-related procedures, hospitalizations, access-related infections, tissue plasminogen activator usage, and death. Results: A total of 1287 patients were screened and 67 patients underwent randomization. A total of 25% of eligible patients agreed to randomization and 71% randomized to the fistula arm underwent fistula placement within 90 days. The most common reason patients declined to participate in the trial was that they preferred to continue to dialyze with their catheter. Patients randomized to fistulas had nominally more access-related interventions, hospitalizations, and bacteremia (the majority of which were catheter-related), while the catheter group experienced greater reliance on thrombolytic therapy. Conclusions: Findings from this trial suggest that conducting a definitive randomized trial of fistulas versus catheters is not feasible in the current climate. There was no signal of harm associated with randomization to the catheter strategy and most outcomes favored the catheter group. Patients exhibited strong preferences regarding choice of vascular access.

Background: Studies suggest that the introduction of electronic health records (EHRs) has decreased the efficiency of clinical practice and increased clinician workload for US-based physicians. Most studies involve clinicians in primary care settings. Less is known about other health care settings, subspecialist clinicians, or whether markers of efficiency and workload change over time. Objective: This study aimed to describe 2 common metrics of after-hours use of the EHR (pajama time and time outside scheduled hours [TOSH]) among diverse specialists and track these parameters longitudinally in a Canadian setting. Methods: In this longitudinal descriptive study, medical and surgical specialists were observed starting from the introduction of a system-wide EHR in 2019 to 2022 at a large quaternary teaching hospital in Edmonton, Alberta. Pajama time and TOSH were extracted from the EHR on an Epic system platform and monitored over time. Clinicians were stratified according to clinical group (medical and surgical) and workload (clinical full-time equivalent). Results: A total of 71 medical and surgical specialists participated in this study, spending approximately 24 to 40 minutes per day on pajama time and 32 to 55 minutes per day on TOSH depending on clinician grouping. Both metrics increased over the observation period, as reflected in the longitudinal plots and the higher values observed at the end vs the beginning of follow-up. Conclusions: After-hours EHR use in this Canadian cohort of medical and surgical specialists was similar to what is reported in the US literature, although the drivers may be different. Perhaps surprisingly, these markers increased over time despite presumed improved familiarity with the EHR. The extent to which this affects clinician well-being and work-life integration cannot be determined from these results, although there may be cause for concern.

BACKGROUND Studies suggest the introduction of electronic health records (EHRs) has decreased efficiency of clinical practice and increased clinician workload for United States (US)-based physicians. Less is known about other healthcare settings, nor whether markers of efficiency and workload change over time. OBJECTIVE This study reports on afterhours EHR use [pajama time and time outside scheduled hours (TOSH)] among diverse specialists and tracks these parameters longitudinally. METHODS A longitudinal descriptive study of medical and surgical specialists followed from the introduction of a system-wide EHR in 2019 to 2022 at a large quaternary teaching hospital in Edmonton, Canada. Pajama Time and TOSH were extracted from the EHR on an Epic System platform, and monitored over time. Clinicians were stratified according to clinical group (medical and surgical) and workload (clinical full-time equivalent). RESULTS Seventy-one medical and surgical specialists participated in this study, spending anywhere from 24 to 40 minutes per day on pajama time and 32 to 55 minutes per day on TOSH depending on clinician grouping. Both pajama time and TOSH increased significantly over the 22- and 33-month observation periods for both variables, respectively. CONCLUSIONS Afterhours EHR use in this Canadian cohort of medical and surgical specialists is similar to what is reported in US literature, though the drivers are likely to be different. Perhaps surprisingly, these markers increased over time despite presumed improved familiarity with the EHR. The extent to which this affects clinician wellbeing and work-life integration cannot be determined from these results though there may be cause for concern.

Objectives: Ramadan fasting is an Islamic religious practice involving abstinence from food and drink from dawn to sunset. Its consequences on kidney-relevant outcomes in patients with chronic kidney disease (CKD) and kidney transplant recipients remain unclear. Design: Systematic review and meta-analysis. Data sources: MEDLINE, Embase, Global Health, CINAHL (EBSCOhost), Scopus, Web of Science and Google Scholar were searched up to 18 September 2023. Eligibility criteria: We included observational studies among non-dialysis CKD and kidney transplant recipients who fasted during Ramadan and examined changes in kidney function. Data extraction and synthesis: Standardised methods were used by two independent reviewers to screen, select and extract data. Outcomes included changes in serum creatinine (SCr), estimated glomerular filtration rate (eGFR), proteinuria, blood pressure, electrolytes and adverse events—all pre- and post-Ramadan. Results were pooled using random effects modelling. Results: We included 32 observational studies with a total of 2592 participants. 21 studies reported on participants with CKD and 11 studies reported on kidney transplant recipients (studies variably including non-fasting control arms). Meta-analysis of 25 studies revealed that Ramadan fasting was not associated with changes to SCr for the following groups according to study design: CKD with a non-fasting arm (mean difference (MD)=0.82 µmol/L; 95% CI −7.22, 8.86; I ² =38%); transplant with a non-fasting arm (MD=−0.17 µmol/L; 95% CI −2.50, 2.15; I ² =0%) and CKD without a non-fasting arm (post–pre MD=13.84 µmol/L; 95% CI −3.78, 31.47; I ² =88%). For transplant studies without a non-fasting arm, lower SCr was associated with the post-Ramadan period (post–pre MD=−5.40 µmol/L; 95% CI –10.78, –0.02; I ² =0%). In the 18 studies that reported on eGFR, fasting during Ramadan was not associated with an effect on eGFR for any of the groups. Conclusion: We report inconsistent effects of Ramadan fasting on kidney function in CKD or kidney transplantation. Results should be interpreted with caution due to the significant limitations of the underlying studies.

Background: Peritoneal dialysis (PD) is actively promoted, but increasing PD utilisation is difficult. The objective of this study was to determine if the Starting dialysis on Time, At Home, on the Right Therapy (START) project was associated with an increase in the proportion of dialysis patients receiving PD within 6 months of starting therapy. Methods: Consecutive patients over age 18, with end-stage kidney failure, who started dialysis between 1 April 2015 and 31 March 2018 in the province of Alberta, Canada. Programmes were provided with high-quality data about the individual steps in the process of care that drive PD utilisation that were used to identify problem areas, design and implement interventions to address them, and then evaluate whether those interventions had impact. The primary outcome was the proportion of patients receiving PD within 6 months of starting dialysis. Secondary outcomes included hospitalisation, death or probability of transfer to haemodialysis (HD). Interrupted time series methodology was used to evaluate the impact of the quality improvement initiative on the primary and secondary outcomes. Results: A total of 1962 patients started dialysis during the study period. Twenty-seven per cent of incident patients received PD at baseline, and there was a 5.4% (95% confidence interval: 1.5–9.2) increase in the use of PD in the province immediately after implementation. There were no changes in the rates of hospitalisation, death or probability of transfer to HD after the introduction of START. Conclusions: The approach used in the START project was associated with an increase in the use of PD in a setting with high baseline utilisation.

The success of a home hemodialysis program depends largely on a patient safety framework and the risk tolerance of a home dialysis program. Dialysis treatments require operators to perform dozens of steps repeatedly and reliably in a complex procedure. For home hemodialysis, those operators are patients themselves or their care partners, so attention to safety and risk mitigation is front of mind. While newer, smaller, and more user-friendly dialysis machines designed explicitly for home use are slowly entering the marketplace, teaching patients to perform their own treatments in an unsupervised setting hundreds of times remains a foundational programmatic obligation regardless of machine. Just how safe is home hemodialysis? How does patient training affect this safety? There is a surprising lack of literature surrounding these questions. No consensus exists among home hemodialysis programs regarding optimized training schedules or methods, with each program adopting its own approach on the basis of local experience. Furthermore, there are little available data on the safety of home hemodialysis as compared with conventional in-center hemodialysis. This review will outline considerations for training patients on home hemodialysis, discuss the safety of home hemodialysis with an emphasis on the risk of serious and life-threatening adverse effects, and address the methods by which adverse events are monitored and prevented.

Background: This study investigated the association of intra-abdominal adhesions with the risk of peritoneal dialysis (PD) catheter complications. Methods: Individuals undergoing laparoscopic PD catheter insertion were prospectively enrolled from eight centers in Canada and the United States. Patients were grouped based on the presence of adhesions observed during catheter insertion. The primary outcome was the composite of PD never starting, termination of PD, or the need for an invasive procedure caused by flow restriction or abdominal pain. Results: Seven hundred and fifty-eight individuals were enrolled, of whom 201 (27%) had adhesions during laparoscopic PD catheter insertion. The risk of the primary outcome occurred in 35 (17%) in the adhesion group compared with 58 (10%) in the no adhesion group (adjusted HR, 1.64; 95% confidence interval [CI], 1.05 to 2.55) within 6 months of insertion. Lower abdominal or pelvic adhesions had an adjusted HR of 1.80 (95% CI, 1.09 to 2.98) compared with the no adhesion group. Invasive procedures were required in 26 (13%) and 47 (8%) of the adhesion and no adhesion groups, respectively (unadjusted HR, 1.60: 95% CI, 1.04 to 2.47) within 6 months of insertion. The adjusted odds ratio for adhesions for women was 1.65 (95% CI, 1.12 to 2.41), for body mass index per 5 kg/m ² was 1.16 (95% CI, 1.003 to 1.34), and for prior abdominal surgery was 8.34 (95% CI, 5.5 to 12.34). Common abnormalities found during invasive procedures included PD catheter tip migration, occlusion of the lumen with fibrin, omental wrapping, adherence to the bowel, and the development of new adhesions. Conclusions: People with intra-abdominal adhesions undergoing PD catheter insertion were at higher risk for abdominal pain or flow restriction preventing PD from starting, PD termination, or requiring an invasive procedure. However, most patients, with or without adhesions, did not experience complications, and most complications did not lead to the termination of PD therapy. Podcast: This article contains a podcast at https://www.asn-online.org/media/podcast/CJASN/2024_11_15_CJASN2024Trainee2nd.mp3

Journal of Medical Internet Research - International Scientific Journal for Medical Research, Information and Communication on the Internet #Preprint #PeerReviewMe: Warning: This is a unreviewed preprint. Readers are warned that the document has not been peer-reviewed by expert/patient reviewers or an academic editor, may contain misleading claims, and is likely to undergo changes before final publication, if accepted, or may have been rejected/withdrawn. Readers with interest and expertise are encouraged to sign up as peer-reviewer, if the paper is within an open peer-review period. Please cite this preprint only for review purposes or for grant applications and CVs (if you are the author). Background: Health care organizations implement electronic health record (EHR) systems with the expectation of improved patient care and enhanced provider performance. However, while these technologies hold the potential to create improved care and system efficiencies, they can also lead to unintended negative consequences, such as patient safety issues, communication problems, and provider burnout. Objective: The current study document In Basket metrics (Time in In Basket per Day; Time in In Basket per Appointment; In Basket Messages Received per Day; and Turnaround Time) of the EHR implemented by Alberta Health Services (AHS), the province-wide health delivery system, called Connect Care. The objective was to identify how a newly implemented EHR was utilized, the timing of its use, and the duration of use specifically related to in-basket activities. Methods: A descriptive study was conducted. Due to the diversity of specialties, the providers were grouped into Medical and Surgery based on previous similar studies. The participants were then further sub-grouped based on their self-reported clinical Full Time Equivalent (FTE). This resulted in 3 sub-groups for analysis: medical FTE < 0.5, medical FTE > 0.5, and surgical (all of whom reported FTE > 0.5). The analysis was limited to outpatient clinical interactions and explicitly excludes inpatient activities. Results: Seventy-two participants from 19 different specialties enrolled in this study. The providers had on average 8.31 appointments per day during the reporting periods. The providers received on average 21.93 messages per day and spent 7.61 minutes on average in Time in In Basket per Day and 1.84 minutes on average in Time in In Basket per Appointment. The time for the providers to mark messages as done (Turnaround Time), was on average 11.45 days during the reporting period. Although the surgical group had, on average, about twice as many appointments per scheduled day, they spent considerably less “connected time” (based on almost all of the time metrics) than the medical group. However, the surgical group took much longer to mark message as done (Turnaround time). Conclusions: We observed a range of patterns with no consistent direction. There does not seem to be evidence of a ‘learning curve’ which would have shown consistent reduction in time spent on the system over time due to familiarity and experience. While this study does not show how the included metrics could be used as predictors of providers’ satisfaction or feeling of burnout, the usage trends could be used to start discussions about future Canadian studies needed in this area.

BACKGROUND Health care organizations implement electronic health record (EHR) systems with the expectation of improved patient care and enhanced provider performance. However, while these technologies hold the potential to create improved care and system efficiencies, they can also lead to unintended negative consequences, such as patient safety issues, communication problems, and provider burnout. OBJECTIVE This study aims to document metrics related to the In Basket communication hub (time in In Basket per day, time in In Basket per appointment, In Basket messages received per day, and turnaround time) of the EHR system implemented by Alberta Health Services, the province-wide health delivery system called Connect Care (Epic Systems). The objective was to identify how a newly implemented EHR system was used, the timing of its use, and the duration of use specifically related to In Basket activities. METHODS A descriptive study was conducted. Due to the diversity of specialties, the providers were grouped into medical and surgical based on previous similar studies. The participants were further subgrouped based on their self-reported clinical full-time equivalent (FTE ) measure. This resulted in 3 subgroups for analysis: medical FTE 0.5, and surgical (all of whom reported FTE >0.5). The analysis was limited to outpatient clinical interactions and explicitly excluded inpatient activities. RESULTS A total of 72 participants from 19 different specialties enrolled in this study. The providers had, on average, 8.31 appointments per day during the reporting periods. The providers received, on average, 21.93 messages per day, and they spent 7.61 minutes on average in the time in In Basket per day metric and 1.84 minutes on average in the time in In Basket per appointment metric. The time for the providers to mark messages as done (turnaround time) was on average 11.45 days during the reporting period. Although the surgical group had, on average, approximately twice as many appointments per scheduled day, they spent considerably less connected time (based on almost all time metrics) than the medical group. However, the surgical group took much longer than the medical group to mark messages as done (turnaround time). CONCLUSIONS We observed a range of patterns with no consistent direction. There does not seem to be evidence of a “learning curve,” which would have shown a consistent reduction in time spent on the system over time due to familiarity and experience. While this study does not show how the included metrics could be used as predictors of providers’ satisfaction or feelings of burnout, the use trends could be used to start discussions about future Canadian studies needed in this area.

Long, frequent hemodialysis (HD) was thought to be a sound treatment because of improved clearance of uremic toxins and control of extracellular fluid volume. After all, no solute or volume control is tantamount to no dialysis, and whatever its shortcomings, dialysis does keep people alive. The question really is how much solute and volume control keeps people “more alive” (i.e., living longer and better).