Chattanooga, TN, United States
Chattanooga, TN, United States

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Plantinga L.C.,San Francisco General Hospital | Fink N.E.,Johns Hopkins University | Harrington-Levey R.,Edith Nourse Rogers Memorial Veterans Hospital | Finkelstein F.O.,Yale University | And 3 more authors.
Clinical Journal of the American Society of Nephrology | Year: 2010

Background and objectives: The association of social support with outcomes in ESRD, overall and by peritoneal dialysis (PD) versus hemodialysis (HD), remains understudied. Design, setting, participants, & measurements: In an incident cohort of 949 dialysis patients from 77 US clinics, we examined functional social support scores (scaled 0 to 100 and categorized by tertile) both overall and in emotional, tangible, affectionate, and social interaction subdomains. Outcomes included 1-year patient satisfaction and quality of life (QOL), dialysis modality switching, and hospitalizations and mortality (through December 2004). Associations were examined using overall and modality-stratified multivariable logistic, Poisson, and Cox proportional hazards models. Results: We found that mean social support scores in this population were higher in PD versus HD patients (overall 80.5 versus 76.1; P < 0.01). After adjustment, highest versus lowest overall support predicted greater 1-year satisfaction and QOL in all patients (odds ratio 2.47 [95% confidence interval (CI) 1.18 to 5.15] and 2.06 [95% CI 1.31 to 3.22] for recommendation of center and higher mental component summary score, respectively). In addition, patients were less likely to be hospitalized (incidence rate ratio 0.86; 95% CI 0.77 to 0.98). Results were similar with subdomain scores. Modality switching and mortality did not differ by social support in these patients, and associations of social support with outcomes did not generally differ by dialysis modality. Conclusions: Social support is important for both HD and PD patients in terms of greater satisfaction and QOL and fewer hospitalizations. Intervention studies to possibly improve these outcomes are warranted. Copyright © 2010 by the American Society of Nephrology.


Wise M.E.,Centers for Disease Control and Prevention | Lovell C.,Dialysis Clinic Inc.
Seminars in Dialysis | Year: 2013

The US Centers for Disease Control and Prevention has conducted public health surveillance for healthcare-associated infections (HAIs) in dialysis facilities since the 1970s, evolving from facility-level surveys to patient-level surveillance systems. The Centers for Medicare and Medicaid Services (CMS) recently implemented incentives for all end-stage renal disease (ESRD) facilities to monitor and report patient-level quality indicators to the Centers for Disease Control and Prevention's (CDC's) National Healthcare Safety Network (NHSN) in accordance with the NHSN Dialysis Event Protocol. These CMS incentives have led to a rapid increase in dialysis facility NHSN enrollment during 2012. Ongoing challenges to HAI surveillance in this setting include variability in the surveillance process, assurance of data quality, and staff time and resource requirements. Use of existing electronic health records (EHR), especially in conjunction with detection algorithms, has increasingly been shown to produce valid and reliable estimates of HAI frequency in acute care hospitals. Given the large number of dialysis facilities that are now beginning to conduct surveillance using NHSN, the typical lack of dedicated infection prevention personnel in those facilities, and the widespread use of EHR in large dialysis provider organizations, the use of EHR will probably become a cornerstone of surveillance in these settings. Implemented properly, the use of EHR to support public health surveillance has enormous potential to focus and strengthen infection prevention activities in dialysis facilities. Systematic, ongoing validation efforts will be vital to ensure that reported data are accurate, permit valid comparisons of facility performance, and effectively support improved outcomes for dialysis patients. © 2013 Wiley Periodicals, Inc.


Krishnan M.,DaVita HealthCare Partners Inc | Brunelli S.M.,DaVita HealthCare Partners Inc | Maddux F.W.,Clinical and Scientific Affairs | Parker T.F.,Renal Ventures Management | And 4 more authors.
Clinical Journal of the American Society of Nephrology | Year: 2014

The Centers for Medicare and Medicaid Services oversees the ESRD Quality Incentive Program to ensure that the highest quality of health care is provided by outpatient dialysis facilities that treat patientswith ESRD. To that end, Centers for Medicare and Medicaid Services uses clinical performance measures to evaluate quality of care under a pay-for-performance or value-based purchasing model. Now more than ever, the ESRD therapeutic area serves as the vanguard of health care delivery. By translating medical evidence into clinical performance measures, the ESRD Prospective Payment System became the first disease-specific sector using the payfor- performancemodel. Amajor challenge for the creation and implementation of clinical performancemeasures is the adjustments that are necessary to transition from taking care of individual patients to managing the care of patient populations. The National Quality Forum and others have developed effective and appropriate population-based clinical performancemeasures quality metrics that can be aggregated at the physician, hospital, dialysis facility, nursing home, or surgery center level. Clinical performance measures considered for endorsement by theNational Quality Forumare evaluated using five key criteria: evidence, performance gap, and priority (impact); reliability; validity; feasibility; and usability and use. We have developed a checklist of special considerations for clinical performance measure development according to these National Quality Forum criteria. Although the checklist is focused on ESRD, it could also have broad application to chronic disease states, where health care delivery organizations seek to enhance quality, safety, and efficiency of their services. Clinical performance measures are likely to become the norm for tracking performance for health care insurers. Thus, it is critical that the methodologies used to develop such metrics serve the payer and the provider and most importantly, reflect what represents the best care to improve patient outcomes. © 2014 by the American Society of Nephrology.


Weiner D.E.,Dialysis Clinic Inc | Brunelli S.M.,DaVita Clinical Research | Hunt A.,DaVita Clinical Research | Schiller B.,Satellite Healthcare Inc | And 5 more authors.
American Journal of Kidney Diseases | Year: 2014

Addressing fluid intake and volume control requires alignment and coordination of patients, providers, dialysis facilities, and payers, potentially necessitating a "Volume First" approach. This article reports the consensus opinions achieved at the March 2013 symposium of the Chief Medical Officers of 14 of the largest dialysis providers in the United States. These opinions are based on broad experience among participants, but often reinforced by only observational and frequently retrospective studies, highlighting the lack of high-quality clinical trials in nephrology. Given the high morbidity and mortality rates among dialysis patients and the absence of sufficient trial data to guide most aspects of hemodialysis therapy, participants believed that immediate attempts to improve care based on quality improvement initiatives, physiologic principles, and clinical experiences are warranted until such time as rigorous clinical trial data become available. The following overarching consensus opinions emerged. (1) Extracellular fluid status should be a component of sufficient dialysis, such that approaching normalization of extracellular fluid volume should be a primary goal of dialysis care. (2) Fluid removal should be gradual and dialysis treatment duration should not routinely be less than 4 hours without justification based on individual patient factors. (3) Intradialytic sodium loading should be avoided by incorporating dialysate sodium concentrations set routinely in the range of 134-138 mEq/L, avoidance of routine use of sodium modeling, and avoidance of hypertonic saline solution. (4) Dietary counseling should emphasize sodium avoidance. © 2014 National Kidney Foundation, Inc.


Weiner D.E.,Tufts Medical Center | Tighiouart H.,Biostatistics Research Center | Ladik V.,Dialysis Clinic Inc | Meyer K.B.,Tufts Medical Center | And 2 more authors.
American Journal of Kidney Diseases | Year: 2014

Background Hemodialysis patients have high mortality rates, potentially reflecting underlying comorbid conditions and ongoing catabolism. Intradialytic oral nutritional supplements may reduce this risk. Study Design Retrospective propensity-matched cohort. Setting & Participants Maintenance hemodialysis patients treated at Dialysis Clinic Inc facilities who were initiated on a nutritional supplement protocol in September to October 2010 were matched using a propensity score to patients at facilities at which the protocol was not used. Predictors Prescription of the protocol, whereby hemodialysis patients with serum albumin levels ≤3.5 g/dL would initiate oral protein supplementation during the dialysis procedure. Sensitivity analyses matched on actual supplement intake during the first 3 study months. Covariates included patient and facility characteristics, which were used to develop the propensity scores and adjust multivariable models. Outcomes All-cause mortality, ascertained though March 2012. Results Of 6,453 eligible patients in 101 eligible hemodialysis facilities, the protocol was prescribed to 2,700, and 1,278 of these were propensity matched to controls. Mean age was 61 ± 15 (SD) years and median dialysis vintage was 34 months. There were 258 deaths among protocol assignees versus 310 among matched controls during a mean follow-up of 14 months. In matched analyses, protocol prescription was associated with a 29% reduction in the hazard of all-cause mortality (HR, 0.71; 95% CI, 0.58-0.86); adjustment had minimal impact on models. In time-dependent models incorporating change in albumin level, protocol status remained significant but was attenuated in models incorporating a 30-day lag. Similar results were seen in sensitivity analyses of 439 patients receiving supplements who were propensity-matched to controls, with 116 deaths among supplement users versus 140 among controls (HR, 0.79; 95% CI, 0.60-1.05), achieving statistical significance in adjusted models. Limitations Observational design, potential residual confounding. Conclusions Prescription of an oral nutritional supplement protocol and use of oral protein nutritional supplements during hemodialysis are associated with reduced mortality among in-center maintenance hemodialysis patients, an effect likely not mediated by change in serum albumin levels. © 2014 by the National Kidney Foundation, Inc.


Obialo C.I.,Morehouse School of Medicine | Hunt W.C.,Dialysis Clinic Inc. | Bashir K.,Morehouse School of Medicine | Zager P.G.,Dialysis Clinic Inc.
CKJ: Clinical Kidney Journal | Year: 2012

BackgroundThe relationship of missed and shortened hemodialysis (HD) to clinical outcomes has not been well characterized in HD patients in the USA. Here we explored the frequency of missed and shortened treatments and their impact on mortality and hospitalization. MethodsA retrospective review of data from a cohort of 15 340 HD patients treated in facilities operated by Dialysis Clinics, Inc. We compared the frequency of missed and shortened treatments by gender, race, age and treatment schedules [Mondays, Wednesdays, Fridays (MWF) versus Tuesdays, Thursdays, Saturdays (TTS)]. ResultsOf the 15 340 patients, 48 were non-Hispanic whites (NHWs), 41 African Americans (AAs), 6 Hispanics, 2 Native American (NA), 2 Asians and 1 other races. The median number of years on HD was 1.8 years and the median follow-up was 12.4 months. The odds of missing at least one treatment in a month were higher in: patients aged <55 years, odds ratio (OR) 1.33 (P<0.0001); in AAs, OR 1.51 (P < 0.0001); in NAs, OR 1.50 (P 0.0003); and in Hispanics, OR 1.33 (P 0.0003) compared with NHWs and in patients who dialyzed on TTS compared with MWF, OR 1.33 (P < 0.0001). Similar findings were observed for treatments shortened by at least 10 min per month. Missed and shortened treatments were most prevalent on Saturdays and were also associated with progressive increases in hospitalization and mortality. ConclusionMissed and shortened HD treatments pose a challenge to providers. Improved adherence to prescribed dialysis may decrease the morbidity and mortality. © 2012 The Author.


Myers O.B.,University of New Mexico | Adams C.,University of New Mexico | Rohrscheib M.R.,University of New Mexico | Servilla K.S.,New Mexico Veterans Health Care System | And 4 more authors.
Journal of the American Society of Nephrology | Year: 2010

Observational studies involving hemodialysis patients suggest a U-shaped relationship between BP and mortality, but the majority of these studies followed large, heterogeneous cohorts. To examine whether age, race, and diabetes status affect the association between systolic BP (SBP; predialysis) and mortality, we studied a cohort of 16,283 incident hemodialysis patients. We constructed a series of multivariate proportional hazards models, adding age and BP to the analyses as cubic polynomial splines to model potential nonlinear relationships with mortality. Overall, low SBP associated with increased mortality, and the association was more pronounced among older patients and those with diabetes. Higher SBP associated with increased mortality among younger patients, regardless of race or diabetes status. We observed a survival advantage for black patients primarily among older patients. Diabetes associated with increased mortality mainly among older patients with low BP. In conclusion, the design of randomized clinical trials to identify optimal BP targets for patients with ESRD should take age and diabetes status into consideration. Copyright © 2010 by the American Society of Nephrology.


Wish D.,Centers for Dialysis Care Inc | Johnson D.,Dialysis Clinic Inc | Wish J.,Indiana University
Clinical Journal of the American Society of Nephrology | Year: 2014

After Medicare’s implementation of the bundled payment for dialysis in 2011, there has been a predictable decrease in the use of intravenous drugs included in the bundle. The change in use of erythropoiesis-stimulating agents,which decreased by 37%between 2007, when its allowance in the bundle was calculated, and 2012, was because of both changes in the Food and Drug Administration labeling for erythropoiesis-stimulating agents in 2011 and cost-containment efforts at the facility level. Legislation in 2012 required Medicare to decrease (rebase) the bundled payment for dialysis in 2014 to reflect this decrease in intravenous drug use, which amounted to a cut of 12%or $30 per treatment. Medicare subsequently decided to phase in this decrease in payment over several years to offset the increase in dialysis payment that would otherwise have occurred with inflation. A 3%reduction from the rebasing would offset an approximately 3% increase in themarket basket that determines a facility’s costs for 2014 and 2015. Legislation inMarch of 2014 provides that the rebasing will result in a 1.25% decrease in the market basket adjustment in 2016 and 2017 and a 1%decrease in the market basket adjustment in 2018 for an aggregate rebasing of 9.5% spread over 5 years. Adjusting to this payment decrease in inflation-adjusted dollarswill be challenging formany dialysis providers in an industry that operates at an average 3%–4% margin. Closure of facilities, decreases in services, and increased consolidation of the industry are possible scenarios.Newermodels of reimbursement, such as ESRDseamless care organizations, offer dialysis providers the opportunity to align incentives between themselves, nephrologists, hospitals, and other health care providers, potentially improving outcomes and saving money, which will be shared between Medicare and the participating providers. Copyright © 2014 by the American Society of Nephrology.


Sheridan S.,Dialysis Clinic Inc.
Nephrology nursing journal : journal of the American Nephrology Nurses' Association | Year: 2012

There is a prevalence of lower extremity amputations in patients with diabetes mellitus who are receiving hemodialysis; the frequency occurs because diabetes affects sensation, circulation, and the healing process, which predisposes patients with diabetes to skin damage and increases the risk for infections and foot ulcers. In a lifetime, about 15% of patients with diabetes will develop foot ulcers requiring an amputation. Previous research demonstrates that proper foot care and adequate footwear with frequent inspections of the feet will prevent foot ulcers. This article proposes the use of a comprehensive foot care model.


Trademark
Dialysis Clinic Inc. | Date: 2016-03-01

Biological tissue grafts; Biological organs, eye tissue, corneas, musculoskeletal tissue, skin, and other human tissue intended for subsequent implantation; Human allograft bone and tissue. Medical services in the field of organ and tissue donation, namely, obtaining consent, conducting donor screening and providing donor medical data; Organ and tissue bank services; Providing information in the field of organ and tissue donation.

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