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Background: Failure of a previously transplanted kidney is a common cause of end-stage renal disease (ESRD) and represents 5% of incident dialysis patients in the United States. Patients with native kidney failure ESRD (Nat-ESRD) who receive predialysis care from a nephrologist have better outcomes in the first 12 months on dialysis than those who don't. Because many patients with a failed kidney transplant ESRD (Tx-ESRD) receive care from nephrologists, they would also be expected to have good dialysis outcomes. We sought to compare the quality metrics of Tx-ESRD patients and Nat-ESRD patients during the first 12 months of hemodialysis.Methods: We used data from the United States Renal Data System to identify hemodialysis patients who began treatment between May 2012 and December 2013 and who received nephrology care prior to starting hemodialysis. Quality metrics by quarter for the first 12 months of treatment were dichotomized according to practice guidelines to determine the percentage of patients in each quarter who met quality of care goals.Results: Compared to Nat-ESRD (n = 96,063) patients, Tx-ESRD (n = 5,528) patients had 10-19% lower rates of at goal hemoglobin levels, 6-12% lower rates of at goal serum phosphorus, and 3-11% lower rates of at goal albumin levels. Compared to Nat-ESRD patients, -Tx-ESRD patients had a 6% higher rate of fistula use in the first quarter but a 3-7% lower rate in subsequent quarters.Conclusions: Tx-ESRD patients have worse quality metrics related to anemia, phosphorus, albumin, and vascular access compared to Nat-ESRD patients. Nephrology care for patients with Tx-ESRD should be improved to address these quality metrics gaps. [ABSTRACT FROM AUTHOR]

Neighborhoods affect health. In 3 adjoining inner-city Cleveland, Ohio, neighborhoods, residents have an average life expectancy 15 years less than that of a nearby suburb. To address this disparity, a local health funder created the 2010 to 2013 Francis H. Beam Community Health Fellowship to develop a strategic community engagement process to establish a Healthy Eating & Active Living (HEAL) culture and lifestyle in the neighborhoods. The fellow developed and advanced a model, engaging the community in establishing HEAL options and culture. Residents used the model to identify a shared vision for HEAL and collaborated with community partners to create and sustain innovative HEAL opportunities. This community-led, collaborative model produced high engagement levels (15% of targeted 12000 residents) and tangible improvements in the neighborhood's physical, resource, and social environments. [ABSTRACT FROM AUTHOR]

Objectives To determine the association between cognition and levels of cystatin C in persons with chronic kidney disease ( CKD). Design Prospective observational study. Setting Chronic Renal Insufficiency Cohort Cognitive Study. Participants Individuals with a baseline cognitive assessment completed at the same visit as serum cystatin C measurement (N = 821; mean age 64.9, 50.6% male, 48.6% white). Measurements Levels of serum cystatin C were categorized into tertiles; cognitive function was assessed using six neuropsychological tests. Scores on these tests were compared across tertiles of cystatin C using linear regression and logistic regression to examine the association between cystatin C level and cognitive performance (1 standard deviation difference from the mean). Results After multivariable adjustment for age, race, education, and medical comorbidities in linear models, higher levels of cystatin C were associated with worse cognition on the modified Mini-Mental State Examination, Buschke Delayed Recall, Trail-Making Test Part (Trails) A and Part B, and Boston Naming ( P < .05 for all). This association remained statistically significant for Buschke Delayed Recall ( P = .01) and Trails A ( P = .03) after additional adjustment for estimated glomerular filtration rate (e GFR). The highest tertile of cystatin C was associated with greater likelihood of poor performance on Trails A (odds ratio ( OR) = 2.17, 95% confidence interval ( CI) = 1.16-4.06), Trails B ( OR = 1.89, 95% CI = 1.09-3.27), and Boston Naming ( OR = 1.85, 95% CI = 1.07-3.19) than the lowest tertile after multivariate adjustment in logistic models. Conclusion In individuals with CKD, higher serum cystatin C levels were associated with worse cognition and greater likelihood of poor cognitive performance on attention, executive function, and naming. Cystatin C is a marker of cognitive impairment and may be associated with cognition independent of e GFR. [ABSTRACT FROM AUTHOR]

Background: U.S. News & World Report's annual rankings of the top 50 American hospitals in 12 specialties are based on a combination of subjective and objective measures of quality. Although the rankings have been criticized for emphasizing the subjective reputation of hospitals too strongly, the role of reputation in determining the relative standings of the top 50 hospitals has not been quantified. Objective: To quantify the role of reputation in determining the relative standings of the top 50 hospitals in the 2009 edition of U.S. News & World Report's rankings. Design: Cross-sectional study. Setting: The top 50 hospitals in each of 12 specialties. Measurements: Rankings based on the total U.S. News score and on a subjective reputation score. Results: On average, rankings based on reputation score alone agreed with U.S. News & World Report's overall rankings 100% of the time for the top hospital in each specialty, 97% for the top 5 hospitals, 91% for the top 10 hospitals, and 89% for the top 20 hospitals. Hospital reputation was minimally associated with objective quality measures (mean Spearman ρ2 = 0.03). Limitation: The findings apply primarily to interpretations about the relative standings of the 50 top-ranked hospitals in each specialty and not necessarily to the hundreds of unranked hospitals. Conclusion: The relative standings of the top 50 hospitals largely reflect the subjective reputations of those hospitals. Moreover, little relationship exists between subjective reputation and objective measures of hospital quality among the top 50 hospitals. [ABSTRACT FROM AUTHOR]

: PurposeTo assess the relative political influence of different organizations, we examined the efforts of health care organizations to influence policy decisions by lobbying lawmakers.: MethodsWe reviewed reports filed by lobbyists from 1997 to 2000, as required by the Lobbying Disclosure Act, to characterize health care lobbying at the federal level in the United States.: ResultsHealth care lobbying expenditures totaled $237 million in 2000. These expenditures accounted for 15% of all federal lobbying and were larger than the lobbying expenditures of every other sector, including agriculture, communications, and defense. A total of 1192 organizations were involved in health care lobbying. Pharmaceutical and health product companies spent the most ($96 million), followed by physicians and other health professionals ($46 million). Disease advocacy and public health organizations spent $12 million. From 1997 to 2000, lobbying expenditures by physicians and other health professionals grew more slowly than lobbying by other organizations (10% vs. 26%).: ConclusionAlthough policy decisions are influenced by many factors, our findings may indicate a limited political influence of disease advocacy and public health organizations and a declining political influence of physicians and other health professionals. [Copyright &y& Elsevier]

Investigates how physicians in the United States lobby members of Congress. Frequency of meetings between legislative assistants and physicians; Receptiveness of policymakers to physician input on a broad range of health care issues; Common issues discussed; Suggestion for the improvement of physician lobbying.

We evaluate the suggestion that high-sensitivity C-reactive protein testing be used for risk assessment in the primary prevention of cardiovascular disease, using the criteria proposed by the Guide to Clinical Preventive Services developed by the US Preventive Services Task Force. We conclude that at present, none of the 3 major criteria—accuracy, reliability, and likelihood of beneficial intervention— are satisfied. [ABSTRACT FROM AUTHOR]

The study by Cervantes and colleagues is the first to provide empirical evidence about the effects of EOHD on professionalism. The editorialist discusses the findings, draws parallels between providing standard dialysis to undocumented immigrants and providing universal health coverage to U.S. citizens, and proposes an approach to address the problem of EOHD. [ABSTRACT FROM AUTHOR]

The author reflects on the needs for a comprehensive universal health care in intervening health disparities in the U.S. He cited a study published within the issue which provided evidence that universal health insurance coverage sharply reduce disparities. He contends that eliminating disparities require interventions that specifically target the needs of minorities, the poor, the uninsured and other disadvantaged groups.

Focuses on a study which analyzed the shortening and postponement of hemodialysis treatments in the U.S. attributed to inadequate dialysis and increased mortality. Methods; Results; Discussion; Implications for patient care.

Objectives: Access to care at Veterans Affairs facilities may be limited by long wait times; however, additional barriers may prevent US military veterans from seeking help at all. We sought to understand the health needs of veterans in the community to identify possible barriers to health-seeking behavior. Methods: Focus groups were conducted with veteran students at a community college until thematic saturation was reached. Qualitative data analysis involved both an inductive content analysis approach and deductive elements. Results: A total of 17 veteran students participated in 6 separate focus groups. Health needs affecting health-seeking behavior were identified. Themes included lack of motivation to improve health, concern about social exclusion and stigma, social interactions and behavior, limited access to affordable and convenient health care, unmet basic needs for self and family, and academics competing with health needs. Conclusions: Veterans face a range of personal, societal, and logistical barriers to accessing care. In addition to decreasing wait times for appointments, efforts to improve the transition to civilian life; reduce stigma; and offer assistance related to work, housing, and convenient access to health care may improve health in veteran students. [ABSTRACT FROM AUTHOR]

Child trafficking is a pervasive public health problem in the United States, with significant health consequences for survivors. Previous studies demonstrated that survivors face barriers to healthcare, though much of the literature has not solely focused on domestic child trafficking. To identify barriers to healthcare faced by survivors of child trafficking in the United States, and to characterize the landscape of available trauma-informed medical services. 62 adult survivors of child trafficking (83% female, 10% male, 7% transgender; 90% sex trafficking, 25% labor trafficking; median age of entry 16) and 37 community agency professionals who work with trafficked children. The United States of America. The Barriers to Care Questionnaire (BCQ) was adapted, piloted with a focus group, and disseminated to participants. A statistically significant increase in survivors seeking healthcare after compared to before trafficking was demonstrated (p < 0.05). Eighteen consequential barriers to healthcare were identified. The marginalization domain, representing the individual's perception of negative experiences with the healthcare system, had the highest number of consequential barriers. The majority of survivor and agency participants felt the physical and mental health needs of survivors are not being met, but would seek out trauma-informed healthcare if it were available in their community. Survivors of child trafficking in the U.S. experience a wide range of barriers to healthcare, and a lack of available trauma-informed healthcare. This study identified barriers to healthcare that can be considered by providers hoping to provide accessible and truama-informed services to trafficked children. • Survivors of child trafficking experience barriers to obtaining healthcare. • Survivors in this study frequently sought healthcare before and after trafficking. • 18 consequential patient-centered barriers to healthcare were identified by this study. • Prominent barriers included perceptions of negative healthcare experiences. • Majority of survivor participants felt health needs were not being met. [ABSTRACT FROM AUTHOR]

Background: Whether and how much past slavery affects contemporary social and economic conditions in the United States is an area of active debate. Newly available data on which members of the United States Congress are descendants of slaveholders provides an opportunity to examine this topic. This study sought to determine the relationship between slaveholder ancestry and net worth among members of Congress., Methods: Total assets and liabilities were collected from financial declarations of all members of Congress as of April 15, 2021. Net worth was estimated as the difference between total assets and liabilities. Information on slaveholder ancestry was obtained from a Reuters investigative series based on an extensive review of historical documents and verification by board-certified genealogists. Quantile regression was used to determine the association between net worth and slaveholder ancestry after adjustment for demographic factors., Results: The median net worth of the 535 members of Congress was $1.28 million (interquartile range $0.11-5.87 million). On univariate analysis, net worth was associated with increased age, White race, increased education, and number of individuals enslaved by ancestors. On multivariate analysis, net worth was independently associated with age, White race, and number enslaved. Legislators whose ancestors enslaved 16 or more individuals had a $3.93 million (95% confidence interval 2.39-5.46) higher net worth compared to legislators whose ancestors were not slave owners after adjustment for age, sex, race, ethnicity, and education., Conclusions: Past slaveholding practices are independently associated with current wealth among members of Congress. Because members of Congress are a highly selected group, further work is needed to understand how slaveholder ancestry affects current wealth in the general population to inform efforts to reduce social and economic disparities., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2024 Sehgal, Sehgal. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Background: Greenhouse gas emissions from hemodialysis treatment in the United States have not been quantified. In addition, no previous studies have examined how much emissions vary across facilities, treatments, and emission contributors., Methods: To estimate the magnitude and sources of variation in the carbon footprint of hemodialysis treatment, we estimated life-cycle greenhouse gas emissions in carbon dioxide equivalents (CO 2 -eq) associated with 209,481 hemodialysis treatments in 2020 at 15 Ohio hemodialysis facilities belonging to the same organization. We considered emissions from electricity, natural gas, water, and supply use; patient and staff travel distance; and biohazard and landfill waste., Results: Annual emissions per facility averaged 769,374 kg CO 2 -eq (95% CI, 709,388 to 848,180 kg CO 2 -eq). The three largest contributors to total emissions were patient and staff transportation (28.3%), electricity (27.4%), and natural gas (15.2%). Emissions per treatment were 58.9 kg CO 2 -eq, with a three-fold variation across facilities. The contributors with the largest variation in emissions per treatment were transportation, natural gas, and water (coefficients of variation, 62.5%, 42.4%, and 37.7%, respectively). The annual emissions per hemodialysis facility are equivalent to emissions from the annual energy use in 93 homes; emissions per treatment are equivalent to driving an average automobile for 238 km (149 miles)., Conclusions: Similar medical treatments provided in a single geographic region by facilities that are part of the same organization may be expected to have small variations in the determinants of greenhouse gas emissions. However, we found substantial variation in carbon footprints across facilities, treatments, and emission contributors. Understanding the magnitude and variation in greenhouse gas emissions may help identify measures to reduce the environmental effect of hemodialysis treatment., (Copyright © 2022 by the American Society of Nephrology.)

Objective: This study described the job responsibilities and modalities of care among dialysis dietitians in the United States and their observations regarding the nutrition needs of their patients, during the COVID-19 pandemic., Design and Methods: Cross-sectional online survey captures dietitian characteristics and responsibilities, dialysis facility characteristics, and patient needs. We recruited US dialysis dietitians. We used chi-square tests to compare respondent stress and facility-level policies regarding eating/drinking and oral nutrition supplements based on facility ownership type., Results: We received 191 complete or partial survey responses. Sixty-three percent of respondents stated that their center banned eating/drinking during dialysis due to COVID-19 masking policies. DaVita and non-profit facilities were significantly more likely to still allow eating/drinking during dialysis (31% and 29%, respectively) compared to Fresenius facilities (7%). A common theme in open-ended responses regarding nutrition care for COVID-19-positive patients was providing less care to these patients. A majority of respondents admitted to stress from working in healthcare during COVID-19. The majority of respondents indicated that patients were taking precautions such as having a family member or friend grocery shop for them (69%) or going to the store less often (60%). Just over a quarter of respondents indicated that affordability of food was a concern among patients. Seventy-two percent reported that patients were cooking at home more often, 60% had observed an increase in serum phosphorus, and 72% an increase in interdialytic weight gain., Conclusions: Due to the increased risk of malnutrition and symptoms that can affect dietary intake in COVID-positive patients, and the economic conditions leading to increased rates of food insecurity, dietitians must be proactive in preventing and/or treating malnutrition through adequate protein and energy intake. Eating/drinking bans should not become permanent and dialysis centers should take precautions to allow intradialytic meals and oral nutrition supplement protocols to continue during the pandemic., (Copyright © 2021 National Kidney Foundation, Inc. Published by Elsevier Inc. All rights reserved.)

BACKGROUND: This study examined interview data from the National Health and Nutrition Examination Survey from 2005 to 2016. AIM: To determine national trends in self-reported depressive symptoms. METHOD: Depressive symptoms were assessed using self-reported data on the nine-item Patient Health Questionnaire (PHQ-9), with a total score ≥10 and an individual item score of 2 or 3, indicating greater severity. RESULTS: A total of 31,191 individuals contributed PHQ-9 data from 2005 to 2016. The absolute proportion of individuals with total PHQ-9 score ≥10 increased from 6.2% to 8.1%. After adjustment for participant demographic characteristics and comorbid conditions, the odds ratio for high PHQ-9 score at the end versus the beginning of the study interval was 1.27 (95% confidence interval [CI: 1.07, 1.50]). Anhedonia, guilt/worthlessness, appetite, and hypoactivity/hyperactivity had the largest increases in individual item risk after adjusting for demographic and comorbid characteristics. CONCLUSIONS: There were sizeable increases in the prevalence of self-reported depressive symptoms in the United States over an 11-year period. Further work is needed to understand the reasons for and implications of this increase. However, the results suggest greater efforts should be made by health care providers to screen for depressive symptoms that may warrant further assessment, treatment, or referral to mental health services as needed.

Background: News media and policy makers frequently discuss deaths from firearms, drug overdoses, and motor vehicle accidents. However, this information is generally presented as absolute numbers or annual rates. Cumulative lifetime risk may be an additional useful metric for understanding the impact of these causes of death., Methods: Data on all-cause firearm, drug overdose, and motor vehicle accident deaths were obtained from the US Centers for Disease Control and Prevention (CDC) for the year 2018. Age-specific death rates were used to estimate the cumulative risk of firearm, drug overdose, and motor vehicle accident deaths from birth to age 85 after accounting for other causes of death., Results: The lifetime risk of death from firearms, drug overdoses, and motor vehicle accidents was 0.93% (95% confidence interval [CI], 0.92%-0.94%), 1.52% (95% CI, 1.51%-1.53%), and 0.92% (95% CI, 0.91%-0.93%), respectively. Black males had a 2.61% (95% CI, 2.55%-2.66%) lifetime risk of firearm death, indicating that 1 out of 38 black males will die from firearms if current death rates persist. Residents of West Virginia had a 3.54% lifetime risk of drug overdose death, equivalent to 1 out of every 28 residents dying from overdoses., Conclusions: The lifetime risk of death from firearms, drug overdoses, and motor vehicle accidents is substantial and varies greatly across demographic subgroups and states., (Copyright © 2020 The Authors. Published by Elsevier Inc. All rights reserved.)

Objective: Patient to staff ratios vary based on facility characteristics, and therefore have been proposed as an explanatory factor for the variation in dialysis facility outcomes. This analysis tested that hypothesis., Design and Methods: Observational study using Dialysis Facility Report data. Reported staff numbers from the Annual Facility Survey were converted to full time equivalents (FTE). Subsequently, ratios were created for patients per FTE registered dietitian (RD), social worker, nurse, and patient care technician. Bivariate associations and structural equation modeling (SEM) were used to explore relationships between these ratios and patient outcomes: standardized mortality ratio and standardized hospitalization rate, when also considering the impact of non-modifiable facility characteristics (region, chain, profit status). Our focus was on RD staffing; therefore we also included serum phosphorus and normalized protein catabolic ratio in the model, and also conducted a sub-analysis of the 198 facilities that exceeded the KDOQI maximum of 150 patients:FTE RD., Subjects: Dialysis centers in the US with at least 30 adult patients and no pediatric patients. 4035 facilities had complete data for the proposed variables., Main Outcome Measure: Standardized mortality ratio and standardized hospitalization rate were the primary outcomes., Results: The mean and standard deviation for patients per FTE staff were 90.0 ± 34.0, 88.7 ± 32.8, 17.1 ± 20.5 and 11.9 ± 7.0 for RDs, social workers, nurses, and technicians, respectively. Facility characteristics impacted staffing in bivariate analyses and SEM. The only significant paths from staffing ratio to outcomes were for patient:FTE social worker to SMR (standardized beta = -0.09, 95% CI -0.13, -0.04) and Patients:FTE RD to SHR Days (standardized beta = 0.04, 95% CI 0.001, 0.09). In the sub-analysis, there were no significant paths from staffing to outcomes., Conclusions: This study did not provide evidence that patient per staff ratios explain variation in dialysis facility outcomes. While there are some important bivariate relationships, these disappear in more complex models. Future research should investigate the impacts of staffing ratios on individual patients, to overcome the possible ecological fallacy., (Copyright © 2018 National Kidney Foundation, Inc. Published by Elsevier Inc. All rights reserved.)

Background and Objectives: Despite the benefits of kidney transplantation, the total number of transplants performed in the United States has stagnated since 2006. Transplant center quality metrics have been associated with a decline in transplant volume among low-performing centers. There are concerns that regulatory oversight may lead to risk aversion and lack of transplantation growth., Design, Setting, Participants, & Measurements: A retrospective cohort study of adults (age≥18 years) wait-listed for kidney transplantation in the United States from 2003 to 2010 using the Scientific Registry of Transplant Recipients was conducted. The primary aim was to investigate whether measured center performance modifies the survival benefit of transplantation versus dialysis. Center performance was on the basis of the most recent Scientific Registry of Transplant Recipients evaluation at the time that patients were placed on the waiting list. The primary outcome was the time-dependent adjusted hazard ratio of death compared with remaining on the transplant waiting list., Results: Among 223,808 waitlisted patients, 59,199 and 32,764 patients received a deceased or living donor transplant, respectively. Median follow-up from listing was 43 months (25th percentile=25 months, 75th percentile=67 months), and there were 43,951 total patient deaths. Deceased donor transplantation was independently associated with lower mortality at each center performance level compared with remaining on the waiting list; adjusted hazard ratio was 0.24 (95% confidence interval, 0.21 to 0.27) among 11,972 patients listed at high-performing centers, adjusted hazard ratio was 0.32 (95% confidence interval, 0.31 to 0.33) among 203,797 patients listed at centers performing as expected, and adjusted hazard ratio was 0.40 (95% confidence interval, 0.35 to 0.45) among 8039 patients listed at low-performing centers. The survival benefit was significantly different by center performance (P value for interaction <0.001)., Conclusions: Findings indicate that measured center performance modifies the survival benefit of kidney transplantation, but the benefit of transplantation remains highly significant even at centers with low measured quality. Policies that concurrently emphasize improved center performance with access to transplantation should be prioritized to improve ESRD population outcomes., (Copyright © 2014 by the American Society of Nephrology.)

Objective: To evaluate the association of community health indicators with outcomes for kidney transplant recipients., Design: Retrospective observational cohort study using multivariable Cox proportional hazards models., Setting: Transplant recipients in the United States from the Scientific Registry of Transplant Recipients merged with health indicators compiled from several national databases and the Centers for Disease Control and Prevention, including the National Center for Health Statistics, the Behavioral Risk Factor Surveillance System, and the National Center for Chronic Disease Prevention and Health Promotion., Patients: A total of 100 164 living and deceased donor adult (aged 18 years) kidney transplant recipients who underwent a transplant between January 1, 2004, and December 31, 2010., Main Outcome Measures: Risk-adjusted time to posttransplant mortality and graft loss., Results: Multiple health indicators from recipients' residence were independently associated with outcomes, including low birth weight, preventable hospitalizations, inactivity rate, and smoking and obesity prevalence. Recipients in the highest-risk counties were more likely to be African American (adjusted odds ratio, 1.59, 95% CI, 1.51-1.68), to be younger (aged 18-39 years; 1.46; 1.32-1.60), to have lower educational attainment (

Background and Objectives: Cognitive impairment is common among persons with chronic kidney disease, but the extent to which nontraditional vascular risk factors mediate this association is unclear., Design, Setting, Participants, & Measurements: We conducted cross-sectional analyses of baseline data collected from adults with chronic kidney disease participating in the Chronic Renal Insufficiency Cohort study. Cognitive impairment was defined as a Modified Mini-Mental State Exam score>1 SD below the mean score., Results: Among 3591 participants, the mean age was 58.2±11.0 years, and the mean estimated GFR (eGFR) was 43.4±13.5 ml/min per 1.73 m2. Cognitive impairment was present in 13%. After adjustment for demographic characteristics, prevalent vascular disease (stroke, coronary artery disease, and peripheral arterial disease) and traditional vascular risk factors (diabetes, hypertension, smoking, and elevated cholesterol), an eGFR<30 ml/min per 1.73 m2 was associated with a 47% increased odds of cognitive impairment (odds ratio 1.47, 95% confidence interval 1.05, 2.05) relative to those with an eGFR 45 to 59 ml/min per 1.73 m2. This association was attenuated and no longer significant after adjustment for hemoglobin concentration. While other nontraditional vascular risk factors including C-reactive protein, homocysteine, serum albumin, and albuminuria were correlated with cognitive impairment in unadjusted analyses, they were not significantly associated with cognitive impairment after adjustment for eGFR and other confounders., Conclusions: The prevalence of cognitive impairment was higher among those with lower eGFR, independent of traditional vascular risk factors. This association may be explained in part by anemia.

Objectives: To investigate cognitive impairment in older, ethnically diverse individuals with a broad range of kidney function, to evaluate a spectrum of cognitive domains, and to determine whether the relationship between chronic kidney disease (CKD) and cognitive function is independent of demographic and clinical factors., Design: Cross-sectional., Setting: Chronic Renal Insufficiency Cohort Study., Participants: Eight hundred twenty-five adults aged 55 and older with CKD., Measurements: Estimated glomerular filtration rate (eGFR, mL/min per 1.73 m(2)) was estimated using the four-variable Modification of Diet in Renal Disease equation. Cognitive scores on six cognitive tests were compared across eGFR strata using linear regression; multivariable logistic regression was used to examine level of CKD and clinically significant cognitive impairment (score < or =1 standard deviations from the mean)., Results: Mean age of the participants was 64.9, 50.4% were male, and 44.5% were black. After multivariable adjustment, participants with lower eGFR had lower cognitive scores on most cognitive domains (P<.05). In addition, participants with advanced CKD (eGFR<30) were more likely to have clinically significant cognitive impairment on global cognition (adjusted odds ratio (AOR) 2.0, 95% CI=1.1-3.9), naming (AOR=1.9, 95% CI=1.0-3.3), attention (AOR=2.4, 95% CI=1.3-4.5), executive function (AOR=2.5, 95% CI=1.9-4.4), and delayed memory (AOR=1.5, 95% CI=0.9-2.6) but not on category fluency (AOR=1.1, 95% CI=0.6-2.0) than those with mild to moderate CKD (eGFR 45-59)., Conclusion: In older adults with CKD, lower level of kidney function was associated with lower cognitive function on most domains. These results suggest that older patients with advanced CKD should be screened for cognitive impairment.

Background: This study aimed to examine kidney transplant recipients' ability to afford transplant-related out-of-pocket expenses and the financial impact of these expenses on their lives., Patients and Methods: This cross-sectional study involved 77 kidney recipients. Variables analyzed were: ability to afford daily necessities; impact of immunosuppressant expenses on patients' lives; awareness of Medicare support terminating three yr post-transplant; and strategies used to pay for out-of-pocket transplant expenses. The Economic Strain Scale measured financial strain., Results: Twenty-nine percent of kidney recipients experienced financial strain. Poor, less educated, and younger patients were more likely to report financial strain. Out-of-pocket expenses relating to kidney transplantation adversely affected patients' ability to afford leisure activities (35%), a house (27%), and a car (26%). Thirty-one percent reported that immunosuppressant expenses have had somewhat to great (adverse) impact on their lives. Of those on Medicare and not disabled (n = 41), 51% were unaware Medicare coverage will terminate and 71% did not know how long coverage lasts., Conclusions: Financial strain presents a considerable risk to kidney recipients' ability to purchase immunosuppression. Socioeconomic disparities in recipients' financial strain may be a source of disparities in graft survival. Transplant professionals should better inform transplant candidates about financial consequences of transplantation.

Background: Medicare's reimbursement system was changed in January 2004 to encourage more frequent visits between dialysis patients and nephrologists. We sought to determine the impact of this policy change on patient-nephrologist visits, quality of care, and health-related quality of life., Methods: We examined visits and outcomes for 2,043 patients at 12 hemodialysis facilities in northeast Ohio for 12 months before and 7 months after the reimbursement change. For comparison of outcomes, we used linear, logistic, or negative binomial regression models (for continuous, binary, and rate outcomes, respectively) to assess the significance of changes across the 2 periods., Results: For patients seen before and after the reimbursement change for at least 6 months, the number of visits per patient-month increased from 1.52 before to 3.14 after (P < 0.001). The percentage of patients with no nephrologist visits per patient-month decreased from 16.6% before to 4.6% after (P < 0.001). However, there were no clinically important changes in Kt/V, albumin level, hemoglobin level, phosphorus level, calcium level, hemodialysis catheter use, ultrafiltration volume, shortened or skipped treatments, hospital admissions, hospitalization days, or health-related quality of life, including patient satisfaction., Conclusion: Despite a marked increase in visits between patients and nephrologists, there was no clinically important impact on parameters related to quality of care or health-related quality of life. Additional work is needed to determine effective payment strategies to improve dialysis patient outcomes.

Clinical performance measures, including dialysis dose, hemoglobin, albumin, and vascular access, are the focus of monitoring and quality improvement activities. However, little is known about the implications of clinical performance measures for hospital utilization and health care costs. We obtained clinical performance measures and hospitalization records for a national random sample of 10,650 hemodialysis patients and analyzed the relationship between changes in clinical performance measures and hospital utilization after adjustment for patient demographic and medical characteristics. Higher hemoglobin, higher albumin, and fistula or graft use were independently associated with fewer hospitalizations, fewer hospital days, and decreased Medicare inpatient reimbursement. For example, a 0.5 g/dL higher hemoglobin, a 0.25 g/dL higher albumin, fistula use, and graft use were associated with hospitalization rate ratios of 0.90 (95% confidence interval 0.85, 0.96), 0.64 (0.53, 0.77), 0.60 (0.52, 0.69), and 0.79 (0.71, 0.89), respectively. Moreover, there was a 2-3-fold variation in hospital utilization across end-stage renal disease networks that was still evident after adjustment for patient characteristics and clinical performance measures. Clinical performance measures, especially albumin and vascular access, are strongly associated with hospital utilization and health care costs. These results highlight the importance of targeting nutrition and vascular access in quality improvement efforts. The marked variation in hospital utilization across networks deserves further examination.

Purpose: To measure medical students' knowledge of central issues in the U.S. health care system and to understand their perception of the importance and quality of health policy curricula at their medical schools., Method: A questionnaire was developed using facts from recent national and international health reports to test students' knowledge of health policy. The instrument, containing 14 questions about health policy and four questions about school curriculum on health policy, was mailed to a national probability sample of 516 first-year and 847 fourth-year students in the United States. Chi-square and t tests were used to compare the responses of first- and fourth-year students., Results: A total of 295 first-year (57%) and 475 fourth-year students (56%) responded. Nearly all respondents were aware of the adverse health consequences for the uninsured, but 40% of first- and fourth-year students underestimated the numbers of uninsured in the United States. Thirty-two percent of respondents incorrectly answered that the United States had the highest life expectancy of any nation, and 27% were not aware that the United States has the highest health cost per-person of any nation. First- and fourth-year students performed similarly on knowledge questions. Ninety-six percent of respondents felt that knowledge of health policy is important to their career, and 54% expressed dissatisfaction with the health policy curriculum in medical school., Conclusion: Medical students have significant gaps in knowledge concerning the U.S. health care system. Most students perceive that these deficiencies are not adequately addressed in the medical school curriculum.

Purpose: To determine how sociodemographic characteristics influence both access to transplantation and organ donation., Methods: For all transplants in the United States from 1996 to 2001, donor-recipient pairs were categorized as white-white, white-black, black-white, or black-black. The difference in the percentage of white-black versus black-white pairs was calculated as a measure of the net transfer of organs from one racial group to another. A similar approach was used to examine the net transfer of organs across other sociodemographic categories., Results: Among cadaveric renal transplants, 66% of donor-recipient pairs were white-white, 23% were white-black, 5% were black-white, and 6% were black-black. Thus, there was an 18% net transfer of organs from white donors to black recipients (23% minus 5%). Among living donor transplants involving spouses, there was a 36% net transfer from wives to husbands. Among all cadaveric transplants, there was a 36% to 68% net transfer from younger donors to older recipients. Among cadaveric nonrenal transplants, there was a 7% to 18% net transfer from lower-income donors to higher-income recipients., Conclusion: The sociodemographic characteristics of persons who donate organs and those who benefit from organ transplantation differ markedly. Efforts to improve access and increase donation should address these differences.

Context: By improving the process of care, quality improvement efforts have the potential to reduce race and sex disparities. However, little is known about whether reductions actually occur. National quality improvement activities targeting hemodialysis patients provide an opportunity to examine this issue., Objective: To determine the effect of quality improvement efforts on race and sex disparities among hemodialysis patients., Design, Setting, and Subjects: Longitudinal study of 58 700 randomly selected hemodialysis patients from throughout the United States in 1993 through 2000., Intervention: Medicare-funded quality improvement project involving monitoring of patient outcomes, feedback of performance data, and education of clinicians at dialysis centers., Main Outcome Measures: Changes in hemodialysis dose (Kt/V), anemia management (hemoglobin level), and nutritional status (albumin level)., Results: The proportion of all patients with an adequate hemodialysis dose increased 2-fold. In 1993, 46% of white patients and 36% of black patients received an adequate hemodialysis dose compared with 2000 when the proportions were 87% and 84%, respectively. Thus, the gap between white and black patients decreased from 10% to 3% (P<.001). The gap between female and male patients decreased from 23% to 9% over the same period (P =.008). The proportion of all patients with adequate hemoglobin levels increased 3-fold. The proportion of all patients with adequate albumin levels remained unchanged. Race and sex disparities in anemia management and nutritional status did not change significantly., Conclusions: Quality improvement efforts have a variable impact on race and sex disparities in health outcomes. Further work is needed to determine how quality improvement methods can be targeted to reduce health disparities.