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Objective: To examine which factors are driving improvement in the Dialysis Facility Compare (DFC) star ratings and to test whether nonclinical facility characteristics are associated with observed longitudinal changes in the star ratings. Data Sources: Data were collected from eligible patients in over 6,000 Medicare-certified dialysis facilities from three annual star rating and individual measure updates, publicly released on DFC in October 2015, October 2016, and April 2018. Study Design: Changes in the star rating and individual quality measures were investigated across three public data releases. Year-to-year changes in the star ratings were linked to facility characteristics, adjusting for baseline differences in quality measure performance. Data Collection: Data from publicly reported quality measures, including standardized mortality, hospitalization, and transfusion ratios, dialysis adequacy, type of vascular access for dialysis, and management of mineral and bone disease, were extracted from annual DFC data releases. Principal Findings: The proportion of four- and five-star facilities increased from 30.0% to 53.4% between October 2015 and April 2018. Quality improvement was driven by the domain of care containing the dialysis adequacy and hypercalcemia measures. Additionally, independently owned facilities and facilities belonging to smaller dialysis organizations had significantly lower odds of year-to-year improvement than facilities belonging to either of the two large dialysis organizations (Odds Ratio [OR]: 0.736,95% Confidence Interval [CI]: 0.631-0.856 and OR: 0.797, 95% CI: 0.723-0.879, respectively). Conclusions: The percentage of four- and five-star facilities has increased markedly over a three-year time period. These changes were driven by improvement in the specific quality measures that may be most directly under the control of the dialysis facility. KEYWORDS public reporting, quality measures, star ratings, dialysis, medicare, 1 | INTRODUCTION In 2000, Dialysis Facility Compare (DFC) emerged as one of the earliest public reporting programs implemented by the Centers for Medicare & Medicaid Services (CMS) and has [...]

Objective. To analyze variation in medical care use attributable to Medicare's decentralized claims adjudication process as exemplified in home hemodialysis (HHD) therapy. Data Sources/Study Setting. Secondary data analysis using 2009-2012 paid Medicare claims for HHD and in-center hemodialysis (IHD). Study Design. We compared variation across Medicare administrative contractors (MACs) in predicted paid treatments per standardized patient-month for HHD and IHD patients. We used ordinary least-squares regression to determine whether higher paid HHD treatment counts expanded HHD programs' presence among dialysis facilities. Data Collection. We identified HHD and IHD treatments using procedure, revenue center, and claim condition codes on type 72x claims. Principal Findings. MACs varied persistently in predicted HHD treatments per patient-month, ranging from 14.3 to 21.9 treatments versus 10.9 to 12.4 IHD treatments. The presence of facilities' HHD programs was uncorrelated with average HHD payment counts. Conclusions. Medicare's claims adjudication process promotes variation in medical care use, as we observe among HHD patients. MACs' discretionary decision making, while potentially facilitating innovation, may admit inefficiency in care practice as well as inequitable access to health care services. Regulators should weigh the benefits of flexibility in local coverage decisions against those of national standards for medical necessity. Key Words. Variation, Medicare, dialysis, It is a basic assumption of much of the geographic variation literature that Medicare beneficiaries have coverage for the same set of services if they receive care in Alaska or [...]

Objective. To examine the relationship between distance to dialysis provider and patient selection of dialysis modality, informed by the absolute distance from a patient's home and relative distance of alternative [...]

Approximately 50% of the mortality in hemodialysis patients is due to cardiovascular disease. Antioxidant vitamins and carotenoids may be protective because oxidation of low-density lipoproteins appears to be a necessary prerequisite for the development of atherogenesis, and hemodialysis itself may stimulate the generation of oxygen reactive species. African Americans comprise a substantial proportion of dialysis patients because they have higher rates of hypertension, glomerulonephritis, and diabetic end-stage renal disease than do whites. The purpose of this cross-sectional study was to determine the plasma concentrations of antioxidant vitamins and carotenoids in hemodialysis patients and to investigate whether differences in these concentrations in the major racial or ethnic groups exist. Plasma concentrations of [Alpha]- and [Gamma]-tocopherol, carotenoids, and retinol were measured with HPLC and plasma vitamin C was measured with a spectrophotometric method in 109 white and African American hemodialysis patients. Dietary intakes of selected micronutrients were also compared by using data from a food-frequency questionnaire. Overall, plasma vitamin C and [Alpha]-tocopherol concentrations were comparable but plasma carotenoid concentrations were lower than those reported for other populations. African American patients had significantly higher mean plasma concentrations of retinol (P [is less than] 0.04), lutein (P [is less than] 0.02%, and total carotenoids minus lycopene (P [is less than] 0.04); whites had significantly higher mean plasma concentrations of [Alpha]-tocopherol (P [is less than] 0.02), independent of age and plasma lipid concentrations. Diabetes comorbidity had an independent negative association with plasma [Beta]-carotene concentration but was not associated with other measures.

The effects of cyclosporine on the immune system are discussed. This immunosuppressive drug is thought to work by inhibiting the proliferation of some types of T cells (a cell type of the immune system), while leaving the proliferation of other types unaffected. Conventional immunosuppressive drugs kill T cells that are proliferating, an action that can lead to permanent depletion of immunological memory. Cyclosporine, though, does not kill these cells (although it limits their rate of proliferation), and the patient's immunologic repertoire returns to normal if the drug is stopped. Immunosuppressive drugs are associated with an increased risk of cancer, perhaps because they activate latent oncogenic viruses (viruses that promote malignant change) or because they inhibit immunologic responses that arrest tumor growth. The experimental evidence for these hypotheses is reviewed. The effects of cyclosporine on cancer risk have been difficult to evaluate, since the drug has been most often given to transplant patients. Such patients receive so many immunosuppressive agents that the effects of any one drug cannot be determined. However, some studies implicate cyclosporine in elevating the risk for certain malignancies in these patients. When taken by patients with certain skin disorders (skin cancer, psoriasis), the drug appears to promote tumor development in cases of prior exposure to carcinogens. A discussion is presented of the effects on the immune system when cyclosporine is used to treat psoriasis, an increasingly common use of the drug. Whether cyclosporine will become the drug of choice for that disease depends on results from long-term studies that can assess the cancer risk. (Consumer Summary produced by Reliance Medical Information, Inc.)