Search

Background: Renal osteodystrophy leading to fractures in chronic kidney disease (CKD) is associated with significant hospitalization, morbidity, mortality and health care costs. There is a paucity of data on fractures in the CKD population in Australia. Aim: To describe the trends and impact of hospitalized fractures in an Australian population of non‐dialysis CKD patients. Methods: Retrospective observational data derived using data linkage. Fracture rates, trends in hospital admissions, comorbidity burden and mortality were analysed in a non‐dialysis CKD population between 2000 and 2010 in the Australian state of New South Wales. Hospitalized patients with CKD and fractures were compared with CKD patients without fracture. Results: A total of 149 839 hospitalized patients with CKD were included, of whom 9898 (6.6%) experienced one or more fractures. Patients with fracture were older, more likely to be female with a higher comorbidity burden than those without. Hospital admissions involving fracture were longer than non‐fracture admissions (14.3 vs 5.9 days, P <.0001) and patients were less likely to be discharged home (28.3% vs 80.9%, P <.0001). The 12‐month mortality rate was high at 41%. Conclusion: Australian non‐dialysis CKD patients with hospitalized fractures were older, had a greater burden of disease, and have similar rates of fracture and associated mortality compared to international CKD cohorts. Implications of fracture requiring hospitalization are considerable, with longer admissions, greater healthcare costs, lower likelihood of discharge home and significant mortality. As fracture prevention in the CKD population evolves, treatment algorithms should account for those at greatest risk. SUMMARY AT A GLANCE: Among 6.6% of 149 839 hospitalized patients with non‐dialysis chronic kidney disease (CKD), fracture risks expectedly included old age, female gender and a higher comorbidity burden. They have similar rates of fracture and associated mortality compared to international CKD cohorts. [ABSTRACT FROM AUTHOR]

Background: The influence of health insurance systems on the treatment of end‐stage kidney disease (ESKD) patients ispoorly understood. Aim: We investigated how supplemental private health insurance (PHI) coverage impacted ESKD treatment modalitiesand patient outcomes. The influence of health insurance systems on the treatment of end‐stage kidney disease (ESKD) patients is poorly understood. We investigated how supplemental private health insurance (PHI) coverage impacted ESKD treatment modalities and patient outcomes. Methods: All adult patients commencing ESKD treatment in New South Wales, Australia from 2000 to 2010 were identified using the Australia and New Zealand Dialysis and Transplant Registry. Data were linked to the state hospitalisation dataset to obtain insurance status, allowing the comparisons of mortality, ESKD treatment modality and health service utilisation between privately insured and public patients. Results: The cohort of 5737 patients included 38% (n = 2152) with PHI. At 1 year after ESKD treatment initiation, PHI patients had lower mortality (hazard ratio 0.84, 95% confidence interval (CI) 0.74–0.95, P = 0.01), were more likely to be receiving home haemodialysis (HD) (odds ratio (OR) 1.38, 95% CI 1.01–1.89, P = 0.04), to have been transplanted (OR 1.75, 95% CI 1.25–2.46, P = 0.001) and used fewer hospital days (incidence rate ratio 0.85, 95% CI 0.74–0.96, P = 0.01). After adjustment, PHI patients were more likely to initiate ESKD treatment with facility‐based HD (OR 1.22, 95% CI 1.01–1.46, P = 0.03) but were less likely to be started on peritoneal dialysis (OR 0.81, 95% CI 0.67–0.98, P = 0.03). Conclusion: Our findings suggest that supplemental PHI in Australia is associated with lower‐risk ESKD treatment attributes and improved health outcomes. A greater understanding of the treatment pathways that deliver these outcomes may inform treatment for the broader ESKD treatment population. [ABSTRACT FROM AUTHOR]

Objective: To determine the incidence of and factors associated with an estimated glomerular filtration rate (eGFR) <60 mL/min/1.73 m2 in people with diabetes.Research Design and Methods: We identified people with diabetes in the EXamining ouTcomEs in chroNic Disease in the 45 and Up Study (EXTEND45), a population-based cohort study (2006-2014) that linked the Sax Institute's 45 and Up Study cohort to community laboratory and administrative data in New South Wales, Australia. The study outcome was the first eGFR measurement <60 mL/min/1.73 m2 recorded during the follow-up period. Participants with eGFR < 60 mL/min/1.73 m2 at baseline were excluded. We used Poisson regression to estimate the incidence of eGFR <60 mL/min/1.73 m2 and multivariable Cox regression to examine factors associated with the study outcome.Results: Of 9,313 participants with diabetes, 2,106 (22.6%) developed incident eGFR <60 mL/min/1.73 m2 over a median follow-up time of 5.7 years (interquartile range, 3.0-5.9 years). The eGFR <60 mL/min/1.73 m2 incidence rate per 100 person-years was 6.0 (95% CI 5.7-6.3) overall, 1.5 (1.3-1.9) in participants aged 45-54 years, 3.7 (3.4-4.0) for 55-64 year olds, 7.6 (7.1-8.1) for 65-74 year olds, 15.0 (13.0-16.0) for 75-84 year olds, and 26.0 (22.0-32.0) for those aged 85 years and over. In a fully adjusted multivariable model incidence was independently associated with age (hazard ratio 1.23 per 5-year increase; 95% CI 1.19-1.26), geography (outer regional and remote versus major city: 1.36; 1.17-1.58), obesity (obese class III versus normal: 1.44; 1.16-1.80), and the presence of hypertension (1.52; 1.33-1.73), coronary heart disease (1.13; 1.02-1.24), cancer (1.30; 1.14-1.50), and depression/anxiety (1.14; 1.01-1.27).Conclusions: In participants with diabetes, the incidence of an eGFR <60 mL/min/1.73 m2 was high. Older age, remoteness of residence, and the presence of various comorbid conditions were associated with higher incidence. [ABSTRACT FROM AUTHOR]

The article focuses on the relationship between patients' cultural and linguistic backgrounds and their level of patient activation, particularly in individuals with diabetes and chronic kidney disease (CKD). It also discusses the impact of a co-designed integrated model of care for kidney and diabetes on patient activation in culturally and linguistically diverse patients.

Background: Kidney disease is a significant burden on health systems globally, with the rising prevalence of end stage kidney disease in Australia mirrored in many other countries. Approximately 25% of the Australian population lives in regional and rural areas and accessing complex tertiary services is challenging. Objective: We aim to compare the burden and outcomes of chronic kidney disease and end stage kidney disease in rural and urban regions of New South Wales (Australia's most populous state) using linked health data. Methods: This is a retrospective cohort study and we have defined two cohorts: one with end stage kidney disease and one with chronic kidney disease. The end stage kidney disease cohort was defined using the Australia and New Zealand Dialysis and Transplant Registry, identifying all patients living in NSW receiving renal replacement therapy at any time between 01/07/2000 and 31/07/2010. The chronic kidney disease cohort used the NSW Admitted Patient Data Collection (APDC) to identify patients with a diagnostic code relating to chronic renal failure during any admission between 01/07/2000 and 31/07/2010. Both cohorts were linked to the NSW APDC, the Registry of Births, Deaths and Marriages, and the Central Cancer Registry allowing derivation of outcomes by categories of geographical remoteness. Results: To date, we have identified 10,505 patients with 2,384,218 records in the end stage kidney disease cohort and 159,033 patients with 1,599,770 records in the chronic kidney disease cohort. Conclusions: This study will define the geographical distribution of end stage and chronic kidney disease and compare the health service utilization between rural and urban renal populations. [ABSTRACT FROM AUTHOR]

Background: The incidence of ischaemic heart disease (IHD) has fallen consistently in the general population; attributed to effective primary prevention strategies. Differences in incidence have been demonstrated by sex. Whether this fall in incidence and sex differences is mirrored in people with end-stage kidney disease (ESKD) is unclear. We aimed to establish the relative risk of IHD events in the ESKD population.Methods: We performed a retrospective cohort study from 2000 to 2010 in people with ESKD in New South Wales. We performed data linkage of the Australia and New Zealand Dialysis and Transplant Registry and state wide hospital admission and death registry data and compared this to general population data. The primary outcome was the incidence rate, incidence rate ratio (IRR), and time-trend for any IHD event. We calculated these using indirect standardisation by IHD event.Results: 10,766 participants, contributed 44,149 years of observation time. Incidence rates were substantially higher than the general population for all IHD events (any IHD event: IRR 1.8, 95% confidence interval [CI] 1.7-1.9 for men, IRR 3.4, 95% CI 3.1-3.6 for women). Excess risk was higher in younger people (age 30-49 IRR 4.8, 95% CI 4.2-5.4), and in women with a three-fold increase risk overall and nearly a 10-fold increase in risk in young women (female age 30-49 years: IRR 9.8 95% CI 7.7-12.3), results were similar for angina and acute myocardial infarction. Ischaemic heart disease rates showed some decline for men over time, (ratio of IRR 0.93, 95% CI 0.90-0.95) but were stable for women (ratio of IRR 0.97, 95% CI 0.94-1.01).Conclusions: People with ESKD have substantially higher rates of IHD than the general population, especially women, in whom no improvement appears evident over the past 10 years. [ABSTRACT FROM AUTHOR]

Background: Acute myocardial infarction (AMI) has poorer outcomes in disadvantaged populations such as those in regional and remote locations. We compared long-term outcomes associated with presentation to regional or remote hospitals among AMI patients.Methods and Results: Administrative claims data from New South Wales (27% regional and remote residents) was used to identify patients >18 years admitted to any NSW hospital with a principal diagnosis of AMI (ICD10 codes: I21·0-I21·4) between 01/07/2004 and 30/06/2008. Hospital of presentation location with a population of <250,000 was defined as regional and remote while hospitals with a population >250,000 were deemed urban. Receipt of revascularisation and mortality were analysed and adjusted for age, comorbidities and previous revascularisation. Patients were censored at death or end of the follow-up period (31 December 2009). 39,798 patients were identified with 9,393 (23.6%) regional and remote presenters. In multivariable models, regional and remote presentation was associated with reduced rates of revascularisation (OR 0.30 95%CI 0.28-0.32; p<0.001), no impact on overall mortality (HR 1.04 95%CI 0.99-1.02; p=0.11), but with increased mortality for patients presenting with STEMI (HR 1.14; 95% CI 1.06-1.23; p<0.001). The propensity analysis was consistent with these findings.Conclusions: Presentation to a regional and remote hospital was associated with lower revascularisation rates following AMI, but with a higher long-term mortality if presenting with ST segment elevation. [ABSTRACT FROM AUTHOR]

Background: Interhospital transfer of patients admitted with an acute myocardial infarction for specialised care is common and costly. However, the long-term mortality of transferred patients compared with patients solely treated at the presenting hospital has not been evaluated. Here, we assess the long-term mortality of patients who undergo interhospital transfer during their acute myocardial infarction admission., Methods: We evaluated 40 482 patients with a ICD10-AM diagnosis of acute myocardial infarction admitted to hospitals in New South Wales, Australia, from 2004 to 2008, of whom 10 107 (25%) were transferred. We compared in-hospital and mortality up to 5.5 years postdischarge among transferred and non-transferred patients. We created a 1:1 propensity score matched cohort (n=16 854; 8427 per group) to account for selection bias., Results: In the matched cohort, transferred patients were more likely to undergo revascularisation (55.6% vs 13.7%, RR 4.05; 95% CI 3.83 to 4.29) and had lower mortality at 30 days (3.5% vs 5.7%, HR 0.60; 95% CI 0.52 to 0.70), 1 year (7.5% vs 12.6%, HR 0.58; 95% CI 0.52 to 0.64) and at the end of follow-up (15.3% vs 22.5%, HR 0.65; 95% CI 0.61 to 0.70) than patients treated in presenting hospitals. With the exception of transfers originating from revascularisation capable hospitals, these findings were consistent across a range of subgroups, including patients of all ages, ST-elevation myocardial infarction and non ST-elevation myocardial infarction patients, and transfers originating from hospitals in regional and major city areas. Sensitivity analyses showed that these findings are unlikely to be due to survival bias or to confounding by unmeasured variables., Conclusions: Patients hospitalised for an acute myocardial infarction who are transferred to one or more hospitals for specialised care have higher rates of coronary revascularisation and experience lower long-term mortality., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.)

Aim: To evaluate the efficacy of a team-led anaemia management protocol based on current guidelines., Methods: The effect of a treatment protocol in implementing an anaemia guideline was evaluated in a large teaching hospital, encompassing three (two in-hospital and one satellite) dialysis facilities. Quarterly data were collected, over a 6-year period, on all patients dialysing in these facilities, before and after implementation of an anaemia management treatment protocol. This protocol was developed by a physician-led team and implemented by an anaemia coordinator assisted by the unit staff. The primary outcome measure was the proportion of patients receiving erythropoietin with ferritin levels within the national guidelines target range calculated using data on haemoglobin (Hb), iron studies, dry weight and erythropoietin dose., Results: Data was collected on >150 patients every quarter between 2005 and 2010 (inclusive). The proportion of patients within the primary outcome target range increased from a nadir of 17% to 51% with evidence of true systematic change. The proportion of patients with Hb values within the unit target range also increased from 46% to 56% (P = 0.25) between the first and last years of the project. These changes were also associated with reduced erythropoietin drug use down to 0.44 μg/kg per week., Conclusion: Implementation of a treatment protocol for anaemia management in haemodialysis patients was associated with greater consistency with guideline evidence and lower drug use. Achieving such guideline recommendations for ferritin targets in more than 50% of patients appears feasible., (© 2013 The Authors. Nephrology © 2013 Asian Pacific Society of Nephrology.)

Background and Objectives: Kidney disease-related loss is clinically significant in patients with ESRD and is related to depression and quality of life. The Kidney Disease Loss Scale (KDLS) was recently developed for long-term dialysis patients as a means of studying loss and applying it to clinical practice; however, its validity and usability in the other developmental stages of ESRD-predialysis and early dialysis-remain unknown. This study examined the validity and reliability of the KDLS in the long-term dialysis, early dialysis, and predialysis populations., Design, Setting, Participants, & Measurements: Four groups of participants were recruited from four large university teaching hospitals in the Sydney metropolitan area. Participants were long-term dialysis (n=151), early dialysis (n=163), and predialysis (n=111) patients. An additional independent group of dialysis (n=50) patients were recruited to measure the test-retest reliability. Multisample confirmatory factor analysis and correlational analysis were used., Results: Results demonstrated good internal consistency and test-retest reliability for KDLS. Multisample confirmatory factor analysis indicated that the factor structure of KDLS was invariant across samples and thus supported its construct validity. The convergent and discriminant validities of KDLS were supported by its correlations with scales that measure health-related quality of life, depression, and positive affect in the expected directions and magnitudes. The KDLS was sensitive to the developmental stages of ESRD., Conclusions: These findings demonstrated that the concept of loss exists in dialysis patients. The KDLS is a reliable measure of loss in ESRD and valid in the developmental stages of ESRD.