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Substance use is associated with greater barriers and reduced access to care. Little research, however, has examined the relationship between cannabis use and receipt of preventive health services. Using data from the 2017 Behavioral Risk Factor Surveillance System, we examined the association between current cannabis use and receipt of 12 preventive health services, adjusting for sociodemographic characteristics and access to care. In analyses that adjusted for sociodemographic factors and access to care, participants with current cannabis use had lower odds of being vaccinated for influenza (AOR = 0.67, 95% CI = 0.54-0.83) and higher odds of ever receiving HPV vaccination (AOR = 1.77, 95% CI = 1.06-2.96) and HIV screening (AOR = 2.34, 95% CI = 1.88-2.92) compared with those without cannabis use. Among the 12 preventive services examined, we found three differences in receipt of preventive services by cannabis use status. Cannabis use does not appear to be associated with significant underuse of preventive services.

ImportanceNovel therapies for type 2 diabetes can reduce the risk of cardiovascular disease and chronic kidney disease progression. The equitability of these agents’ prescription across racial and ethnic groups has not been well-evaluated.ObjectiveTo investigate differences in the prescription of sodium-glucose cotransporter-2 inhibitors (SGLT2i) and glucagon-like peptide-1 receptor agonists (GLP-1 RA) among adult patients with type 2 diabetes by racial and ethnic groups.Design, Setting, and ParticipantsCross-sectional analysis of data from the US Veterans Health Administration’s Corporate Data Warehouse. The sample included adult patients with type 2 diabetes and at least 2 primary care clinic visits from January 1, 2019, to December 31, 2020.ExposuresSelf-identified race and self-identified ethnicity.Main Outcomes and MeasuresThe primary outcomes were prevalent SGLT2i or GLP-1 RA prescription, defined as any active prescription during the study period.ResultsAmong 1 197 914 patients (mean age, 68 years; 96% men; 1% American Indian or Alaska Native, 2% Asian, Native Hawaiian, or Other Pacific Islander, 20% Black or African American, 71% White, and 7% of Hispanic or Latino ethnicity), 10.7% and 7.7% were prescribed an SGLT2i or a GLP-1 RA, respectively. Prescription rates for SGLT2i and GLP-1 RA, respectively, were 11% and 8.4% among American Indian or Alaska Native patients; 11.8% and 8% among Asian, Native Hawaiian, or Other Pacific Islander patients; 8.8% and 6.1% among Black or African American patients; and 11.3% and 8.2% among White patients, respectively. Prescription rates for SGLT2i and GLP-1 RA, respectively, were 11% and 7.1% among Hispanic or Latino patients and 10.7% and 7.8% among non-Hispanic or Latino patients. After accounting for patient- and system-level factors, all racial groups had significantly lower odds of SGLT2i and GLP-1 RA prescription compared with White patients. Black patients had the lowest odds of prescription compared with White patients (adjusted odds ratio, 0.72 [95% CI, 0.71-0.74] for SGLT2i and 0.64 [95% CI, 0.63-0.66] for GLP-1 RA). Patients of Hispanic or Latino ethnicity had significantly lower odds of prescription (0.90 [95% CI, 0.88-0.93] for SGLT2i and 0.88 [95% CI, 0.85-0.91] for GLP-1 RA) compared with non-Hispanic or Latino patients.Conclusions and RelevanceAmong patients with type 2 diabetes in the Veterans Health Administration system during 2019 and 2020, prescription rates of SGLT2i and GLP-1 RA medications were low, and individuals of several different racial groups and those of Hispanic ethnicity had statistically significantly lower odds of receiving prescriptions for these medications compared with individuals of White race and non-Hispanic ethnicity. Further research is needed to understand the mechanisms underlying these differences in rates of prescribing and the potential relationship with differences in clinical outcomes.

Home dialysis rates for end-stage kidney disease (ESKD) treatment are substantially lower in the US than in other high-income countries, yet there is limited knowledge on how to increase these rates.To report results from the first year of a nationwide randomized clinical trial that provides financial incentives to ESKD facilities and managing clinicians to increase home dialysis rates.Results were analyzed from the first year of the End-Stage Renal Disease Treatment Choice (ETC) model, a multiyear, mandatory-participation randomized clinical trial designed and implemented by the US Center for MedicareMedicaid Innovation. Data were reported on Medicare patients with ESKD 66 years or older who initiated treatment with dialysis in 2021, with data collection through December 31, 2021; the study included all eligible ESKD facilities and managing clinicians. Eligible hospital referral regions (HRRs) were randomly assigned to the ETC (91 HRRs) or a control group (211 HRRs).The ESKD facilities and managing clinicians received financial incentives for home dialysis use.The primary outcome was the percentage of patients with ESKD who received any home dialysis during the first 90 days of treatment. Secondary outcomes included other measures of home dialysis and patient volume and characteristics.Among the 302 HRRs eligible for randomization, 18 621 eligible patients initiated dialysis treatment during the study period (mean [SD] age, 74.8 [1.05] years; 7856 women [42.1%]; 10 765 men [57.9%]; 859 Asian [5.2%], 3280 [17.7%] Black, 730 [4.3%] Hispanic, 239 North American Native, and 12 394 managing clinicians. The mean (SD) share of patients with any home dialysis during the first 90 days was 20.6% (7.8%) in the control group and was 0.12 percentage points higher (95% CI, -1.42 to 1.65 percentage points; P = .88) in the ETC group, a statistically nonsignificant difference. None of the secondary outcomes differed significantly between groups.The trial results found that in the first year of the US Center for MedicareMedicaid Innovation-designed ETC model, HRRs assigned to the model did not have statistically significantly different rates in home dialysis compared with control HRRs. This raises questions about the efficacy of the financial incentives provided, although further evaluation is needed, as the size of these incentives will increase in subsequent years.ClinicalTrials.gov Identifier: NCT05005572.

BACKGROUND: The coronavirus disease 2019 (COVID-19) pandemic has disproportionately affected socially disadvantaged populations. Whether disparities in COVID-19 incidence related to race/ethnicity and socioeconomic factors exist in the hemodialysis population is unknown. METHODS: Our study involved patients receiving in-center hemodialysis in New York City. We used a validated index of neighborhood social vulnerability, the Social Vulnerability Index (SVI), which comprises 15 census tract-level indicators organized into four themes: socioeconomic status, household composition and disability, minority status and language, and housing type and transportation. We examined the association of race/ethnicity and the SVI with symptomatic COVID-19 between March 1, 2020 and August 3, 2020. COVID-19 cases were ascertained using PCR testing. We performed multivariable logistic regression to adjust for demographics, individual-level social factors, dialysis-related medical history, and dialysis facility factors. RESULTS: Of the 1378 patients on hemodialysis in the study, 247 (17.9%) developed symptomatic COVID-19. In adjusted analyses, non-Hispanic Black and Hispanic patients had significantly increased odds of COVID-19 compared with non-Hispanic White patients. Census tract-level overall SVI, modeled continuously or in quintiles, was not associated with COVID-19 in unadjusted or adjusted analyses. Among non-Hispanic White patients, the socioeconomic status SVI theme, the minority status and language SVI theme, and housing crowding were significantly associated with COVID-19 in unadjusted analyses. CONCLUSIONS: Among patients on hemodialysis in New York City, there were substantial racial/ethnic disparities in COVID-19 incidence not explained by neighborhood-level social vulnerability. Neighborhood-level socioeconomic status, minority status and language, and housing crowding were positively associated with acquiring COVID-19 among non-Hispanic Whites. Our findings suggest that socially vulnerable patients on dialysis face disparate COVID-19-related exposures, requiring targeted risk-mitigation strategies.

Introduction The Veterans Choice Program expanded Veteran access to community care. The Veterans Choice Program may negatively impact the receipt of preventive care services owing to care fragmentation. This study assesses 10 measures of preventive care in Veterans with the Department of Veterans Affairs coverage before and after the Veterans Choice Program. Methods The study population included Veterans who responded to the National Health Interview Survey during the 2 time periods before and after Veterans Choice Program implementation: January 2011–October 2014 and November 2015–December 2018. Outcomes were preventive care services categorized as cardiovascular risk reduction (cholesterol monitoring, blood pressure monitoring, aspirin use), infectious disease prevention (influenza vaccination and HIV testing), and diabetes care (fasting blood glucose monitoring, podiatry visits, ophthalmology visits, influenza vaccination, and pneumonia vaccination). Two different analyses were conducted: (1) unadjusted and multivariable-adjusted pre–post analysis and (2) difference-in-differences analyses. Analyses were conducted in 2019. Results Measures of cardiovascular risk reduction and influenza vaccination were not statistically different before and after Veterans Choice Program implementation using the 2 different analytic approaches. In unadjusted pre–post analysis, after Veterans Choice Program implementation, Veterans with Veterans Affairs coverage had increased HIV testing (66.1%‒75.4%, p=0.008), podiatry visits (22.4%‒38.3%, p=0.01), and ophthalmology visits (62.2%‒77.2%, p=0.02). Using multivariable adjustment for participant sociodemographic factors, Veterans Choice Program implementation was associated with higher odds of podiatry visits (AOR=2.28, 95% CI=1.24, 4.20, p=0.009) and ophthalmology visits (AOR=2.11, 95% CI=1.13, 3.94, p=0.02) among Veterans with diabetes. In difference-in-differences analyses, Veterans Choice Program implementation was associated with increased podiatry visits (AOR=2.95, 95% CI=1.49, 5.83, p=0.002) among Veterans with diabetes and Veterans Affairs coverage compared with that among those with other coverage types, but no statistically significant effect was observed for ophthalmology visits. Conclusions Veterans with Veterans Affairs coverage and diabetes had an increase in podiatry visits after Veterans Choice Program implementation. There was no evidence that Veterans Choice Program implementation had a negative impact on the receipt of preventive care services among Veterans with Veterans Affairs coverage.

Objective To assess the prevalence and correlates of prescription of sodium-glucose co-transporter-2-inhibitors (SGLT2i) and/or glucagon-like peptide-1-receptor agonists (GLP1-RA) in persons with type 2 diabetes mellitus (T2DM) with and without chronic kidney disease (CKD). Methods Cross-sectional analyses of SGLT2i and GLP1-RA prescriptions from January 1st, 2019, to December 31st, 2020, in the Veterans Health Administration System. The likelihood of prescriptions was examined by presence or absence of CKD and by predicted risks of atherosclerotic cardiovascular disease (ASCVD) and end-stage kidney disease (ESKD). Results Of 1,197,880 adults with T2DM, SGLT2is and GLP1-RAs were prescribed to 11% and 8% of patients overall, and to 12% and 10% of those with concomitant CKD, respectively. In adjusted models, patients with severe albuminuria were less likely to be prescribed SGLT2i or GLP1-RA versus non-albuminuric patients with CKD: OR (95% CI) = 0.91 (0.89, 0.93) and 0.97 (0.94, 1.00), respectively. Patients with 10-year ASCVD risk >20% (versus 5%, compared with Conclusions Among a large cohort of patients with T2DM, prescription of SGLT2i and GLP1-RA was low in those with CKD. We observed a “risk-treatment paradox”, whereby patients with higher risk of adverse outcomes were less likely to receive these therapies.

On July 10, 2019, the Trump administration signed an Executive Order titled the “Advancing American Kidney Health” (AAKH) Initiative, which primarily aims to reduce the incidence of kidney failure by 25% by 2030 and shift kidney care from treating kidney failure to maximizing kidney health ([1][

BACKGROUND AND OBJECTIVES: Medicare plans to extend financial structures tested through the Comprehensive End-Stage Renal Disease Care (CEC) Initiative—an alternative payment model for maintenance dialysis providers—to promote high-value care for beneficiaries with kidney failure. The End-Stage Renal Disease Seamless Care Organizations (ESCOs) that formed under the CEC Initiative varied greatly in their ability to generate cost savings and improve patient health outcomes. This study examined whether organizational or community characteristics were associated with ESCOs’ performance. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: We used a retrospective pooled cross-sectional analysis of all 37 ESCOs participating in the CEC Initiative during 2015–2018 (n=87 ESCO-years). Key exposures included ESCO characteristics: number of dialysis facilities, number and types of physicians, and years of CEC Initiative experience. Outcomes of interest included were above versus below median gross financial savings (2.4%) and standardized mortality ratio (0.93). We analyzed unadjusted differences between high- and low-performing ESCOs and then used multivariable logistic regression to construct average marginal effect estimates for parameters of interest. RESULTS: Above-median gross savings were obtained by 23 (52%) ESCOs with no program experience, 14 (32%) organizations with 1 year of experience, and seven (16%) organizations with 2 years of experience. The adjusted likelihoods of achieving above-median gross savings were 23 (95% confidence interval, 8 to 37) and 48 (95% confidence interval, 24 to 68) percentage points higher for ESCOs with 1 or 2 years of program experience, respectively (versus none). The adjusted likelihood of achieving above-median gross savings was 1.7 (95% confidence interval, −3 to −1) percentage points lower with each additional affiliated dialysis facility. Adjusted mortality rates were lower for ESCOs located in areas with higher socioeconomic status. CONCLUSIONS: Smaller ESCOs, organizations with more experience in the CEC Initiative, and those located in more affluent areas performed better under the CEC Initiative.

Background: Recent guidelines recommend use of SGLT2i and/or GLP1-RA in persons with type 2 diabetes (T2D) and CVD or CKD, regardless of glycemic control. The degree of adoption of these recommendations thus far is unclear Methods: Among T2D patients receiving care within the VA Health Care System, we evaluated the prevalence and correlates of SGLT2i and GLP1-RA prescription during 20 and 2020. Logistic regression was used to examine associations of atherosclerotic CVD (ASCVD) , heart failure, and CKD (defined by lab values and/or administrative codes) as well as predicted risks of ASCVD and end-stage kidney disease (ESKD) , with prescription of SGLT2i and GLP1-RA Results: Of 1,319,500 adults with T2D, 10% and 7% were prescribed SGLT2is and GLP1-RAs, respectively. Prescription prevalence of SGLT2i and GLP1-RA were 13% and 9% in patients with established ASCVD; 14% and 11% in those with heart failure; and 11% and 10% in those with CKD. In adjusted models, patients with severe albuminuria were less likely to be prescribed an SGLT2i or a GLP1-RA versus non-albuminuric patients with CKD: aOR (95% CI) = 0.89 (0.87, 0.91) and 0.95 (0.93, 0.98) , respectively. In patients with 10-year ASCVD risk >20% versus those with risk 5% were less likely to be prescribed an SGLT2i: OR=0.61 (0.57, 0.66) , versus those with ESKD risk Conclusions: Among a national VA cohort of patients with T2D, prescription of SGLT2i and GLP1-RA was pervasively low across conditions for which they are currently indicated to lower the risk of CVD and CKD progression. Furthermore, we observed a “risk-treatment paradox”, where patients with higher risk of adverse outcomes were less likely to receive these therapies. Intensive implementation efforts are needed to prioritize prescription of these medications to patients who would derive the largest benefit. Disclosure J.A. Lamprea Montealegre: Research Support; Bayer AG. E. Madden: None. S. Tummalapalli: Consultant; Bayer AG. Research Support; Scanwell Health. C. Chu: Research Support; Bayer AG. Y. Du: Employee; Bayer AG. Stock/Shareholder; Bayer AG. R. Singh: None. S. Kong: Employee; Bayer AG. D.S. Tuot: None. C. Peralta: Employee; Cricket Health, Inc. Research Support; American Heart Association, National Institutes of Health. M.G. Shlipak: Advisory Panel; TAI Diagnostics. Consultant; Cricket Health, Intercept Pharmaceuticals, Inc. Research Support; Bayer AG. Other Relationship; AstraZeneca, Boehringer Ingelheim International GmbH. M. Estrella: Research Support; Bayer AG. Other Relationship; AstraZeneca, Boehringer Ingelheim International GmbH.

OBJECTIVE To assess the prevalence and correlates of prescription of sodium–glucose cotransporter 2 inhibitors (SGLT2i) and/or glucagon-like peptide 1 receptor agonists (GLP1-RA) in individuals with type 2 diabetes mellitus (T2DM) with and without chronic kidney disease (CKD). RESEARCH DESIGN AND METHODS This was a cross-sectional analyses of SGLT2i and GLP1-RA prescriptions from 1 January 2019 to 31 December 2020 in the Veterans Health Administration System. The likelihood of prescriptions was examined by the presence or absence of CKD and by predicted risks of atherosclerotic cardiovascular disease (ASCVD) and end-stage kidney disease (ESKD). RESULTS Of 1,197,880 adults with T2DM, SGLT2i and GLP1-RA were prescribed to 11% and 8% of patients overall, and to 12% and 10% of those with concomitant CKD, respectively. In adjusted models, patients with severe albuminuria were less likely to be prescribed SGLT2i or GLP1-RA versus nonalbuminuric patients with CKD, with odds ratios (ORs) of 0.91 (95% CI 0.89, 0.93) and 0.97 (0.94, 1.00), respectively. Patients with a 10-year ASCVD risk >20% (vs. 5%, compared with CONCLUSIONS Among a large cohort of patients with T2DM, prescription of SGLT2i and GLP1-RA was low in those with CKD. We observed a “risk-treatment paradox,” whereby patients with higher risk of adverse outcomes were less likely to receive these therapies.

The United States healthcare system has increasingly embraced value-based programs that reward improved outcomes and lower costs. Healthcare value, defined as quality per unit cost, was a major goal of the 2010 Patient Protection and Affordable Care Act amidst high and rising US healthcare expenditures. Many early value-based programs were specifically designed for patients with end-stage renal disease (ESRD) and targeted towards dialysis facilities, including the ESRD Prospective Payment System (PPS), ESRD Quality Incentive Program (QIP), and ESRD Seamless Care Organizations (ESCOs). While a great deal of attention has been paid to these ESRD-focused programs, other value-based programs targeted towards hospitals and health systems may also affect the quality and costs of care for a broader population of patients with kidney disease. Value-based care for kidney disease is increasingly relevant in light of the Advancing American Kidney Health (AAKH) initiative, which introduces new value-based payment models: the mandatory ESRD Treatment Choices (ETC) Model in 2021 and voluntary Kidney Care Choices (KCC) Model in 2022.(1) In this review article, we summarize the emergence and impact of value-based programs on the quality and costs of kidney care, with a focus on federal programs. Key opportunities in value-based kidney care include shifting the focus towards chronic kidney disease, enhancing population health management capabilities, improving quality measurement, and leveraging programs to advance health equity.

Background: The majority of people with chronic kidney disease (CKD) are unaware of their kidney disease. Assessing the clinical significance of increasing CKD awareness has critical public health and healthcare delivery implications. Whether CKD awareness among persons with CKD is associated with longitudinal health behaviors, disease management, and health outcomes is unknown. Methods: We analyzed data from participants with CKD in the REasons for Geographic And Racial Differences in Stroke study, a national, longitudinal, population-based cohort. Our predictor was participant CKD awareness. Outcomes were (1) health behaviors (smoking avoidance, exercise, and nonsteroidal anti-inflammatory drug use); (2) CKD management indicators (angiotensin-converting enzyme inhibitor or angiotensin receptor blocker use, statin use, systolic blood pressure, fasting blood glucose, and body mass index); (3) change in estimated glomerular filtration rate (eGFR) and urine albumin-to-creatinine ratio (UACR); and (4) health outcomes (incident end-stage kidney disease [ESKD], coronary heart disease [CHD], stroke, and death). Logistic and linear regressions were used to examine the association of baseline CKD awareness with outcomes of interest, adjusted for CKD stage and participant demographic and clinical factors. Results: Of 6,529 participants with baseline CKD, 285 (4.4%) were aware of their CKD. Among the 3,586 participants who survived until follow-up (median 9.5 years), baseline awareness was not associated with subsequent odds of health behaviors, CKD management indicators, or changes in eGFR and UACR in adjusted analyses. Baseline CKD awareness was associated with increased risk of ESKD (adjusted hazard ratio [aHR] 1.44; 95% CI 1.08–1.92) and death (aHR 1.18; 95% CI 1.00–1.39), but not with subsequent CHD or stroke, in adjusted models. Conclusions: Individuals aware of their CKD were more likely to experience ESKD and death, suggesting that CKD awareness reflects disease severity. Most persons with CKD, including those that are high-risk, remain unaware of their CKD. There was no evidence of associations between baseline CKD awareness and longitudinal health behaviors, CKD management indicators, or eGFR decline and albuminuria.

Background Patients discharged against medical advice (AMA) have disproportionately high health care costs and increased morbidity, mortality, and hospital readmissions. Although patient risk factors for discharge AMA are known, there are little data regarding physician discharge practices surrounding AMA discharges. Methods We performed a cross-sectional analysis of patients discharged AMA from a large, urban, academic medical center. Our study predictors included patient demographics and admission characteristics: primary service team, time of discharge, documentation of anticipated AMA discharge, and length of stay. The primary outcomes were physician discharge practices including a scheduled follow-up appointment, documentation of informed consent, documentation of a risk/benefit discussion, and notification of the attending physician. Our coprimary outcome was the incidence of 30-day hospital readmission. Results Among AMA discharges, 33% had follow-up appointments scheduled upon discharge. There was documentation of a risk/benefit discussion (69%), informed consent (63%), and notification of the attending physician (72%) in most discharges. Physician discharge practices were not associated with 30-day hospital readmission. Conclusions Adherence to discharge best practices in AMA discharges was inconsistent and suboptimal, particularly for scheduling follow-up appointments, but was not associated with hospital readmission. Our results highlight the difficulty in facilitating safe transitions of care for patients discharged AMA.

Background and objectives Improving the quality of CKD care has important public health implications to delay disease progression and prevent ESKD. National trends of the quality of CKD care are not well established. Furthermore, it is unknown whether gaps in quality of care are due to lack of physician awareness of CKD status of patients or other factors. Design, setting, participants, & measurements We performed a national, serial, cross-sectional study of visits to office-based ambulatory care practices for adults with diagnosed CKD from the years 2006 to 2014. We assessed the following quality indicators: (1) BP measurement, (2) uncontrolled hypertension, (3) uncontrolled diabetes, (4) angiotensin-converting enzyme inhibitor or angiotensin receptor blocker use among patients with hypertension, (5) statin use if age ≥50 years old, and (6) nonsteroidal anti-inflammatory drug use. Using multivariable linear regression and chi-squared analysis, we examined the change in quality performance over time. Results Between 2006 and 2014, there were 7099 unweighted visits for patients with CKD representing 186,961,565 weighted visits. There was no difference in the prevalence of uncontrolled hypertension (>130/80 mm Hg) over time (46% in 2006–2008 versus 48% in 2012–2014; P=0.50). There was a high prevalence of uncontrolled diabetes in 2012–2014 (40% for hemoglobin A1c >7%). The prevalence of ACEi/ARB use decreased from 45% in 2006–2008 to 36% in 2012–2014, which did not reach statistical significance (P=0.07). Statin use in patients with CKD who were 50 years or older was low and remained unchanged from 29% in 2006–2008 to 31% in 2012–2014 (P=0.92). Conclusions In a nationally representative dataset, we found that patients with CKD had a high prevalence of uncontrolled hypertension and diabetes and a low use of statins that did not improve over time and was not concordant with guidelines.

In the United States, dialysis provision is an example of a robust, single-payer dominant system with cost containment. When compared with the cost of dialysis in other countries, Medicare dialysis costs in the United States as a function of overall health care expenditures are approximately $60,000 per patient less than expected, likely due to substantial cost containment imposed by Medicare as the dominant payer.

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Chronic kidney disease (CKD) causes substantial global morbidity and increases cardiovascular and all-cause mortality. Unlike other chronic diseases with established strategies for screening, there has been no consensus on whether health systems and governments should prioritize early identification and intervention for CKD. Guidelines on evaluating and managing early CKD are available but have not been universally adopted in the absence of incentives or quality measures for prioritizing CKD care. The burden of CKD falls disproportionately upon persons with lower socioeconomic status, who have a higher prevalence of CKD, limited access to treatment, and poorer outcomes. Therefore, identifying and treating CKD at the earliest stages is an equity imperative. In 2019, Kidney Disease: Improving Global Outcomes (KDIGO) held a controversies conference entitled "Early Identification and Intervention in CKD." Participants identified strategies for screening, risk stratification, and treatment for early CKD and the key health system and economic factors for implementing these processes. A consensus emerged that CKD screening coupled with risk stratification and treatment should be implemented immediately for high-risk persons and that this should ideally occur in primary or community care settings with tailoring to the local context.

Background: Kidney disease is a major global public health problem, and laboratory testing of kidney health measures is essential for diagnosis and monitoring. The availability and affordability of kidney health laboratory tests across countries has not been systematically described. Methods: The International Society of Nephrology (ISN), in partnership with leaders of a Kidney Disease: Improving Global Outcomes (KDIGO) Controversies Conference, surveyed a representative subset of ISN-Global Kidney Health Atlas (ISN-GKHA) respondents from April to June 2020. We assessed the association between country gross national income (GNI) per capita and laboratory testing availability and affordability. Results: Of 33 regional expert nephrologists invited, 24 (73%) responded, representing all 10 ISN regions around the world. Availability of kidney health laboratory tests was as follows: serum Cr (100%), serum cystatin C (67%), urine albumin (96%), urine Cr (100%), and dipstick urinalysis (100%). Median (IQR) reimbursement values in international dollars were as follows: serum Cr Int$ 6.61 (3.42–8.84), serum cystatin C Int$ 31.51 (17.36–46.25), urine albumin Int$ 10.22 (5.90–15.42), urine Cr Int$ 7.50 (1.66–8.84), and dipstick urinalysis Int$ 6.26 (2.56–8.40). Reimbursement values did not differ significantly by World Bank income group or by GNI per capita. Conclusion: There was widespread availability of kidney health laboratory tests and substantial variation in reimbursement values. To achieve meaningful progress across nations in mitigating the growth of kidney disease, access to affordable diagnostic technology is essential. Our results are highly relevant to policymakers and researchers as countries increasingly consider national strategies for kidney disease detection and management.

Background: Renal ultrasounds (RUS) are commonly ordered in hospitalized patients with acute kidney injury (AKI). Clinical decision support tools could be used to inform which patients may benefit from RUS to rule out hydronephrosis, however current risk stratification frameworks are underutilized.Methods: We performed a cross-sectional study of hospitalized adults with AKI at a large, tertiary, academic medical center who had a RUS ordered. We validated an existing risk stratification framework to predict hydronephrosis based on 7 criteria. Outcomes were presence of unilateral or bilateral hydronephrosis and incidental findings on RUS. Results: Two hundred and eighty-one patients were included in the study cohort; 111 (40%), 76 (27%), and 94 (33%) patients were in the high-, medium-, and low-risk groups for hydronephrosis, respectively, based on the risk stratification framework. Thirty-five patients (12%) were found to have hydronephrosis, of whom 86% were captured in the high-risk group. A nephrology consult was involved in 168 (60%) patients and RUS was recommended by the nephrology service in 95 (57%) cases. Of the 95 patients recommended for a RUS, 9 patients (9%) had hydronephrosis. Among the patients with a nephrology consultation, 9 (56%) of the 16 total patients with hydronephrosis were recommended to obtain a RUS. Conclusions: We further validated a risk stratification framework for hydronephrosis and found that nephrology recommendations predicted hydronephrosis less well than the risk stratification framework. Decision support tools for hydronephrosis may be useful to supplement clinical judgement in the evaluation of AKI.

BACKGROUND Medicaid expansion substantially increased health insurance coverage, but its effect on the delivery of preventative health care is unclear. OBJECTIVE The objective of this study was to assess the impact of Medicaid expansion on the receipt of 15 different measures of preventive care including cancer screening, cardiovascular risk reduction, diabetes care, and other primary care measures. RESEARCH DESIGN We performed serial cross-sectional analysis of Behavioral Risk Factor Surveillance System (BRFSS) survey data from 2012 to 2017. We used a quasi-experimental design with difference-in-differences (DiD) analyses to examine changes in preventative health care delivery over 3 time periods in Medicaid expansion compared with nonexpansion states. SUBJECTS We included low-income (

On July 10, 2019, the Department of Health and Human Services announced the historic kidney care strategy Advancing American Kidney Health (AAKH), which has three tangible goals: ( 1 ) reducing incident ESKD by 25% by 2030, ( 2 ) having 80% of patients with incident ESKD receiving home dialysis or a

BACKGROUND AND OBJECTIVES: Glomerular hyperfiltration has been considered to be a contributing factor to the development of diabetic kidney disease (DKD). To address this issue, we analyzed GFR follow-up data on participants with type 1 diabetes undergoing (125)I-iothalamate clearance on entry into the Diabetes Control and Complications Trial (DCCT)/Epidemiology of Diabetes Interventions and Complications study. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: This was a cohort study of DCCT participants with type 1 diabetes who underwent an (125)I-iothalamate clearance (iGFR) at DCCT baseline. Presence of hyperfiltration was defined as iGFR levels ≥140 ml/min per 1.73 m(2), with secondary thresholds of 130 or 150 ml/min per 1.73 m(2). Cox proportional hazards models assessed the association between the baseline hyperfiltration status and the subsequent risk of reaching an eGFR

This cross-sectional study evaluates the stipulations of coverage under commercial, health insurance exchange, Veterans Affairs, Medicare, Medicaid, or other insurance for canagliflozin, dapagliflozin, empagliflozin, and ertugliflozin.

Introduction: The associations between marijuana use and various health-related behaviors, including receipt of preventive health services, have not been widely examined. Hypothesis: Given the known adverse cognitive effects of tetrahydrocannabinol (THC), we hypothesized that current marijuana users were less likely than non-users to receive recommended preventive health services. Methods: The Behavioral Risk Factor Surveillance System (BRFSS) is an ongoing telephone survey that collects data on health-related risk behaviors, chronic health conditions, and use of preventive services by non-institutionalized U.S. adults ≥18 years of age from the 50 U.S. states, the District of Columbia, Puerto Rico, the U.S. Virgin Islands, Guam, American Samoa, and Palau. In 2017, there were 10 U.S. states that administered the BRFSS Marijuana Module. We identified survey respondents that were eligible for receipt of each recommended preventive health service. Using chi square statistics, we examined the rates of receipt of recommended preventive services among eligible users compared to non-users in these 10 states. Results: In 2017, among 45,655,241 participants, 10.7% used marijuana in the past 30 days, and 69.3% of those used it daily. The predominant method of marijuana use was smoking (90.4%). Compared to non-users, marijuana users were more likely to be 18-29 years of age (39.7% vs 17.4%, p Conclusion: Marijuana users were less likely to receive an influenza vaccination and preventive services recommended for cardiovascular risk reduction. Users may need more targeted interventions to receive needed care.

BACKGROUND: Leveraging quality metrics can be a powerful approach to identify substantial performance gaps in kidney disease care that affect patient outcomes. However, metrics must be meaningful, evidence-based, attributable, and feasible to improve care delivery. As members of the American Society of Nephrology Quality Committee, we evaluated existing kidney quality metrics and provide a framework for quality measurement to guide clinicians and policy makers. METHODS: We compiled a comprehensive list of national kidney quality metrics from multiple established kidney and quality organizations. To assess the measures’ validity, we conducted two rounds of structured metric evaluation, on the basis of the American College of Physicians criteria: importance, appropriate care, clinical evidence base, clarity of measure specifications, and feasibility and applicability. RESULTS: We included 60 quality metrics, including seven for CKD prevention, two for slowing CKD progression, two for CKD management, one for advanced CKD and kidney replacement planning, 28 for dialysis management, 18 for broad measures, and two patient-reported outcome measures. We determined that on the basis of defined criteria, 29 (49%) of the metrics have high validity, 23 (38%) have medium validity, and eight (13%) have low validity. CONCLUSIONS: We rated less than half of kidney disease quality metrics as highly valid; the others fell short because of unclear attribution, inadequate definitions and risk adjustment, or discordance with recent evidence. Nearly half of the metrics were related to dialysis management, compared with only one metric related to kidney replacement planning and two related to patient-reported outcomes. We advocate refining existing measures and developing new metrics that better reflect the spectrum of kidney care delivery.

Poor identification of individuals with CKD is a major barrier to research and appropriate clinical management of the disease. We aimed to develop and validate a pragmatic electronic (e-) phenotype to identify patients likely to have CKD.The e-phenotype was developed by an expert working group and implemented among adults receiving in- or outpatient care at five healthcare organizations. To determine urine albumin (UA) dipstick cutoffs for CKD to enable use in the e-phenotype when lacking urine albumin-to-creatinine ratio (UACR), we compared same day UACR and UA results at four sites. A sample of patients, spanning no CKD to ESKD, was randomly selected at four sites for validation via blinded chart review.The CKD e-phenotype was defined as most recent eGFR60 ml/min per 1.73 mThe CKD e-phenotype provides a pragmatic and accurate method for EHR-based identification of patients likely to have CKD.

Abstract Background Renal ultrasounds (RUS) are commonly ordered in hospitalized patients with acute kidney injury (AKI), however clinical risk prediction could be used to inform which patients require imaging to rule out hydronephrosis. While risk stratification frameworks have been described, the role of nephrology consultation as an additional driver of RUS ordering has not been comprehensively studied. Methods We performed a cross-sectional study of hospitalized adults at a large, tertiary, academic medical center with AKI who had a RUS ordered. Predictors were high-risk, medium-risk, or low-risk category based on an existing risk stratification framework and RUS recommended by a consulting nephrology service. Outcomes were presence of unilateral or bilateral hydronephrosis and incidental findings on RUS. Results Two hundred and eighty-one patients were included in the study cohort; 111 (40%), 76 (27%), and 94 (33%) patients were in the high-, medium-, and low-risk groups for hydronephrosis, respectively, based on the risk stratification framework. Thirty-five patients (12%) were found to have hydronephrosis, of whom 86% were captured in the high-risk group. A nephrology consult was involved in 168 (60%) patients and RUS was recommended by the nephrology service in 95 (57%) cases. Of the 95 patients recommended for a RUS, 9 patients (9%) had hydronephrosis. Among the patients with a nephrology consultation, 9 (56%) of the 16 total patients with hydronephrosis were recommended to obtain a RUS. Conclusions We further validated a risk stratification framework for hydronephrosis and found that nephrology consultation was an additional driver of RUS ordering, but predicted hydronephrosis less well than the risk stratification framework. Our decision framework strengthens the argument for the use of risk stratification to improve upon consultant recommendations, reduce incidental findings, and decrease RUS overuse.

Patients with CKD have low awareness of their CKD status. In the National Kidney Foundation’s Kidney Early Evaluation Program (KEEP), only 8.1% of adults with hypertension, diabetes, or a relevant family history were aware of their CKD ([1][1]). This was concordant with estimates from the National