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Abstract Background As several studies have shown an association between periodontal disease and chronic kidney disease (CKD), regular dental care may be an important strategy for reducing the burden of CKD. Access to dental care may be limited in the US public health system. Methods In this retrospective cohort study of 6,498 adult patients with (n = 2,235) and without (n = 4,263) CKD and at least 12 months of follow-up within the San Francisco Department of Public Health Community Health Network clinical databases, we examined the likelihood of having a dental visit within the observation period (2005-2010) using Cox proportional hazards models. To determine whether dental visits reflected a uniform approach to preventive service use in this setting, we similarly examined the likelihood of having an eye visit among those with diabetes, for whom regular retinopathy screening is recommended. We defined CKD status by average estimated glomerular filtration rate based on two or more creatinine measurements ≥ 3 months apart (no CKD, ≥ 60 ml/min/1.73 m2; CKD, < 60 ml/min/1.73 m2). Results Only 11.0% and 17.4% of patients with and without CKD, respectively, had at least one dental visit. Those with CKD had a 25% lower likelihood of having a dental visit [HR = 0.75, 95% CI (0.64-0.88)] than those without CKD after adjustment for confounders. Among the subgroup of patients with diabetes, 11.8% vs. 17.2% of those with and without CKD had a dental visit, while 58.8% vs. 57.8% had an eye visit. Conclusions Dental visits, but not eye visits, in a US public healthcare setting are extremely low, particularly among patients with CKD. Given the emerging association between oral health and CKD, addressing factors that impede dental access may be important for reducing the disparate burden of CKD in this population.

Objectives: Challenges in implementing telemedicine disproportionately affect patients served in safety-net settings. Few studies have elucidated pragmatic, team-based strategies for successful telemedicine implementation in primary care, especially with a safety-net population., Study Design: We conducted in-depth, semistructured qualitative interviews with primary care clinicians and staff in a large urban safety-net health care system on the facilitators, challenges, and impact of implementing team workflows for synchronous telemedicine video and audio-only visits., Methods: Interviews were analyzed using modified grounded theory with multistage coding. Common themes were identified and reviewed to describe within-group and between-group variations. We used the Practical, Robust Implementation Sustainability Model framework to organize the final themes with an implementation science lens., Results: Four themes emerged from 11 interviews: (1) having a dedicated individual preparing patients for video visits is a prerequisite for the successful introduction of video visits to patients with limited digital literacy; (2) health care maintenance during video and audio-only visits benefits from standardized workflows and communication; (3) the increased flexibility and accessibility of telemedicine visits were perceived benefits to patient care, despite barriers for subsets of patients; and (4) telemedicine visits generally have a positive impact on work experience for clinicians and staff due to increased efficiency, despite audio-only visits feeling less engaging., Conclusions: Understanding how to strategically use team-based workflows to expand video visit access while ensuring care quality of all telemedicine visits will allow primary care practices to maximize telemedicine's benefits to patients in the safety-net setting.

Background: Simultaneous urine testing for albumin (UAlb) and serum creatinine (SCr), that is, 'dual testing,' is an accepted quality measure in the management of diabetes. As chronic kidney disease (CKD) is defined by both UAlb and SCr testing, this approach could be more widely adopted in kidney care., Objective: We assessed time trends and facility-level variation in the performance of outpatient dual testing in the integrated Veterans Health Administration (VHA) system., Design, Subjects and Main Measures: This retrospective cohort study included patients with any inpatient or outpatient visit to the VHA system during the period 2009-2018. Dual testing was defined as UAlb and SCr testing in the outpatient setting within a calendar year. We assessed time trends in dual testing by demographics, comorbidities, high-risk (eg, diabetes) specialty care and facilities. A generalised linear mixed-effects model was applied to explore individual and facility-level predictors of receiving dual testing., Key Results: We analysed data from approximately 6.9 million veterans per year. Dual testing increased, on average, from 17.4% to 21.2%, but varied substantially among VHA centres (0.3%-43.7% in 2018). Dual testing was strongly associated with diabetes (OR 10.4, 95% CI 10.3 to 10.5, p<0.0001) and not associated with VHA centre complexity level. However, among patients with high-risk conditions including diabetes, <50% received dual testing in any given year. As compared with white veterans, black veterans were less likely to be tested after adjusting for other individual and facility characteristics (OR 0.93, 95% CI 0.92 to 0.93, p<0.0001)., Conclusions: Dual testing for CKD in high-risk specialties is increasing but remains low. This appears primarily due to low rates of testing for albuminuria. Promoting dual testing in high-risk patients will help to improve disease management and patient outcomes., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Introduction: To support the expansion of a successful regional electronic consultation (eConsult) service, we hosted a full-day national eConsult Policy Think Tank, connecting health-services researchers, clinicians, patients and policymakers to discuss policy considerations related to eConsult. In this paper, we assess the discussion arising from the Think Tank to identify and understand the policy enablers and barriers to the national spread and scale of eConsult services across Canada., Methods: We conducted a constant comparative thematic analysis of stakeholder discussions captured during the Think Tank held in Ottawa, Canada, on 5 December 2016. Forty-seven participants attended and debated the following topic areas: (a) delivery of services and standards; (b) payment considerations; and (c) equitable access. The meeting was recorded, and verbatim transcripts were analysed using qualitative approaches., Results: We identified four themes affecting spread and scale of eConsult innovation from a policy perspective: (a) patient-centredness; (b) value; (c) regulation; and (d) considerations for spread and scale. Patient-centredness was viewed as a foundational principle upon which policy shifts should be guided. Active participation of patient partners transitioned the discussions and resulting recommendations from provider-centred to patient-centred thinking around the relevant policy issues, explicitly demonstrating the importance of patient involvement in healthcare policy decision making., Discussion: eConsult was viewed as a high-value, disruptive innovation with great potential to transform access to specialists in Canada. A patient-centred approach to policy change (and not just healthcare delivery) was identified as a novel yet critical enabler to the scale and spread of eConsult across Canada.

Background: Polypharmacy, often defined as the concomitant use of ≥ 5 medications, has been identified as a significant global public health threat. Aging and multimorbidity are key drivers of polypharmacy and have been linked to a broad range of adverse health outcomes and mortality. Patients with chronic kidney disease (CKD) are particularly at high risk of polypharmacy and use of potentially inappropriate medications given the numerous risk factors and complications associated with CKD. The aim of this systematic review will be to assess the prevalence of polypharmacy among adult patients with CKD, and the potential association between polypharmacy and adverse health outcomes within this population., Methods/design: We will search empirical databases such as MEDLINE, Embase, Cochrane Library, CINAHL, Web of Science, and PsycINFO and grey literature from inception onwards (with no language restrictions) for observational studies (e.g., cross-sectional or cohort studies) reporting the prevalence of polypharmacy in adult patients with CKD (all stages including dialysis). Two reviewers will independently screen all citations, full-text articles, and extract data. Potential conflicts will be resolved through discussion. The study methodological quality will be appraised using an appropriate tool. The primary outcome will be the prevalence of polypharmacy. Secondary outcomes will include any adverse health outcomes (e.g., worsening kidney function) in association with polypharmacy. If appropriate, we will conduct random effects meta-analysis of observational data to summarize the pooled prevalence of polypharmacy and the associations between polypharmacy and adverse outcomes. Statistical heterogeneity will be estimated using Cochran's Q and I 2 index. Additional analyses will be conducted to explore the potential sources of heterogeneity (e.g., sex, kidney replacement therapy, multimorbidity)., Discussion: Given that polypharmacy is a major and a growing public health issue, our findings will highlight the prevalence of polypharmacy, hazards associated with it, and medication thresholds associated with adverse outcomes in patients with CKD. Our study will also draw attention to the prognostic importance of improving medication practices as a key priority area to help minimize the use of inappropriate medications in patients with CKD., Systematic Review Registration: PROSPERO registration number: [ CRD42020206514 ].

Background: Limited English proficiency (LEP) is an important driver of health disparities. Many successful patient-level interventions to prevent chronic disease progression and complications have used automated telephone self-management support, which relies on patient activation and communication to achieve improved health outcomes. It is not clear whether these interventions are similarly applicable to patients with LEP compared to patients with English proficiency., Objective: The objectives of this study were as follows: (1) To examine the impact of LEP on patient engagement (primary outcome) with a 12-month language-concordant self-management program that included automated telephone self-management support, designed for patients with chronic kidney disease (CKD). (2) To assess the impact of LEP on change in systolic blood pressure (SBP) and albuminuria (secondary outcomes) resulting from the self-management program., Methods: This was a secondary analysis of the Kidney Awareness Registry and Education (KARE) pilot trial (NCT01530958) which was funded by the National Institutes of Health in August 2011, approved by the University of California Institutional Review Board in October 2011 (No. 11-07399), and executed between 2013 and 2015. Multivariable logistic and linear models were used to examine various facets of patient engagement with the CKD self-management support program by LEP status. Patient engagement was defined by patient's use of educational materials, completion of a health coaching action plan, and degree of participation with automated telephone self-management support. Changes in SBP and albuminuria at 12 months by LEP status were determined using multivariable linear mixed models., Results: Of 137 study participants, 53 (38.7%) reported LEP, of which 45 (85%) were Spanish speaking and 8 (15%) Cantonese speaking. While patients with LEP and English proficiency similarly used the program's educational materials (85% [17/20] vs 88% [30/34], P=.69) and completed an action plan (81% [22/27] vs 74% [35/47], P=.49), those with LEP engaged more with the automated telephone self-management support component. Average call completion was 66% among patients with LEP compared with 57% among those with English proficiency; patients with LEP requested more health coach telephone calls (P=.08) and had a significantly longer average automated call duration (3.3 [SD 1.4] min vs 2.2 [1.1 min], P<.001), indicating higher patient engagement. Patients with LEP randomized to self-management support had a larger, though nonstatistically significant (P=.74), change in SBP (-4.5 mmHg; 95% CI -9.4 to 0.3) and albuminuria (-72.4 mg/dL; 95% CI -208.9 to 64.1) compared with patients with English proficiency randomized to self-management support (-2.1 mmHg; 95% CI -8.6 to 4.3 and -11.1 mg/dL; 95% CI -166.9 to 144.7)., Conclusions: Patients with LEP with CKD were equally or more engaged with a language-concordant, culturally appropriate telehealth intervention compared with their English-speaking counterparts. Augmented telehealth may be useful in mitigating communication barriers among patients with LEP., Trial Registration: ClinicalTrials.gov NCT01530958; https://clinicaltrials.gov/ct2/show/NCT01530958., (©Leah Machen, Margaret A Handley, Neil Powe, Delphine Tuot. Originally published in JMIR mHealth and uHealth (https://mhealth.jmir.org), 11.05.2021.)

Objective: The COVID-19 pandemic prompted unprecedented expansion of telemedicine services. We sought to describe clinician experiences providing telemedicine to publicly-insured, low-income patients during COVID-19., Methods: Online survey of ambulatory clinicians in an urban safety-net hospital system, conducted May 28 2020-July 14 2020., Results: Among 311 participants (response rate 48.3%), 34.7% (N=108/311) practiced in primary/urgent care, 37.0% (N=115/311) medical specialty and 7.7% (N=24/311) surgical clinics. 87.8% (273/311) had conducted telephone visits, 26% (81/311) video. Participants reported observing both technical and non-technical patient barriers. Clinicians reported concerns about the diagnostic safety of telephone (58.9%, 129/219) vs video (35.3%, 24/68). However, clinician comfort with telemedicine was high (89.3% (216/242) for telephone, 91.0% (61/67) for video), with many clinicians (220/239 or 92.1% telephone, 60/66 or 90.9% video) planning to continue telemedicine after COVID-19., Conclusions: Clinicians in a safety-net healthcare system report high comfort with and intention to continue telemedicine after the pandemic, despite patient challenges and safety concerns., Competing Interests: The authors have no other disclosures or conflicts of interest.

Background: To better understand the relation between sleep problems and CKD, we examined temporal trends in the prevalence of self-reported sleep problems in adults in the United States and their associations with CKD and all-cause mortality., Methods: Using data from 27,365 adult participants in five biannual National Health and Examination Surveys (2005-2006 through 2013-2014), we studied five self-reported sleep problems-trouble sleeping, sleep disorder, nocturia (urinating ≥2 times/night), inadequate sleep (<7 hours/night), and excessive sleep (>9 hours/night)-plus a composite index. We conducted three types of analysis: temporal trends in the prevalence of each sleep measure by CKD status, using model-based standardization; cross-sectional analysis of associations between four CKD measures and each sleep measure, using logistic regression; and survival analysis of the association between each sleep measure and mortality, using Cox regression., Results: The prevalence of trouble sleeping and sleep disorder increased over the five surveys by 4% and 3%, respectively, whereas the other sleep problems remained relatively stable. All sleep problems, except inadequate sleep, were more common during the study period among adults with CKD than without CKD (40% versus 21% for nocturia; 5% versus 2% for excessive sleep; 30% versus 25% for trouble sleeping; 12% versus 8% for sleep disorder). Both eGFR <30 ml/min per 1.73 m 2 and albuminuria were positively associated with nocturia and excessive sleep. Excessive sleep and nocturia were also associated with higher mortality (adjusted hazard ratio for >9 versus 7-9 hours/night=1.7; 95% CI, 1.3 to 2.1; and for nocturia=1.2; 95% CI, 1.1 to 1.4)., Conclusions: The high prevalence of sleep problems among persons with CKD and their associations with mortality suggest their potential importance to clinical practice. Future work could examine the health effects of identifying and treating sleep problems in patients with CKD., Competing Interests: H. Morgenstern has been a consultant at Arbor Research Collaborative for Health. All remaining authors have nothing to disclose., (Copyright © 2020 by the American Society of Nephrology.)

Background and Objectives: We conducted a pilot, pragmatic, cluster-randomized trial to evaluate feasibility and preliminary effectiveness of screening for CKD using a triple-marker approach (creatinine, cystatin C, and albumin/creatinine ratio), followed by education and guidance, to improve care of hypertensive veterans in primary care. We used the electronic health record for identification, enrollment, intervention delivery, and outcome ascertainment., Design, Setting, Participants, & Measurements: We randomized 1819 veterans without diabetes but with hypertension (41 clusters) into three arms: ( 1 ) CKD screening followed by patient and provider education; ( 2 ) screening, education, plus pharmacist comanagement; or ( 3 ) usual care. The primary clinical outcome was BP change over 1 year. Implementation and process measures included proportion screened; CKD detection rate; and total and new use of renin-angiotensin system inhibitors, nonsteroidal anti-inflammatory drugs, and diuretics., Results: Median age was 68 years, 55% were white, 1658 (91%) had a prior creatinine measure, but only 172 (9%) had prior urine albumin/creatinine ratio, and 83 (5%) had a prior cystatin C measure. Among those in the intervention, 527 of 1215 (43%) were identified with upcoming appointments to have CKD screening. Of these, 367 (69%) completed testing. Among those tested, 77 (21%) persons had newly diagnosed CKD. After 1 year, change in systolic BP was -1 mm Hg (interquartile range, -11 to 11) in usual care, -2 mm Hg (-11 to 11) in the screen-educate arm, and -2 mm Hg (-13 to 10) in the screen-educate plus pharmacist arm; P =0.49. There were no significant differences in secondary outcomes in intention-to-treat analyses. In as-treated analyses, higher proportions of participants in the intervention arms initiated a renin-angiotensin system inhibitor (15% and 12% versus 7% in usual care, P =0.01) or diuretic (9% and 12% versus 4%, P =0.03)., Conclusions: The pragmatic design made identification, enrollment, and intervention delivery highly efficient. The limited ability to identify appointments resulted in inadequate between-arm differences in CKD testing rates to determine whether screening improves clinical outcomes., (Copyright © 2020 by the American Society of Nephrology.)

Introduction: Electronic consultations (eConsults) provide asynchronous, store-and-forward communication between primary care clinicians (PCCs) and specialists using web-based platforms, electronic health records or mobile applications. eConsults have demonstrated benefits in many areas of the Quadruple Aim, including educational value for PCCs. In this study, we explored the connection between eConsults and the Quadruple Aim using a unique national dataset of PCC-reported eConsult outcomes., Methods: We conducted a retrospective study analysing registry data from the RubiconMD electronic consultation platform used by PCCs in 34 US states. We analysed PCC-reported outcomes from eConsults that took place between March 2017 and January 2018. PCCs were asked to select one or more of the following options after each eConsult: improved care plan, educational, avoided unnecessary diagnostics/procedures, avoided referral altogether or to wrong specialty, or no effect., Results: PCCs reported an outcome for 3872 eConsults. eConsults for dermatology, endocrinology, and haematology-oncology were most common. Over one in four PCCs reported that the eConsult avoided a referral altogether or to the wrong specialty (26.3%) and avoided unnecessary diagnostics/procedures (26.1%). In 75% of eConsults, PCCs reported an improved care plan. Fifty percent reported that the eConsult was educational., Discussion: PCCs in diverse practice settings reported substantial benefits from eConsults. In over half of eConsults, PCCs reported that the eConsult avoided unnecessary diagnostics/procedures, avoided a referral altogether or avoided a referral to the wrong specialty. Findings suggest that eConsults demonstrate important educational benefits, but may also influence PCC decision-making in a way that yields tremendous cost-saving potential and improved patient experience.

Objectives: Usable tools to support individual primary care clinicians in their diagnostic processes could help to reduce preventable harm from diagnostic errors. We conducted a formative study with primary care providers to identify key requisites to optimize the acceptability of 1 online collective intelligence platform (Human Diagnosis Project; Human Dx)., Materials and Methods: We conducted semistructured interviews with practicing primary care clinicians in a sample of the US community-based clinics to examine the acceptability and early usability of the collective intelligence online platform using standardized clinical cases and real-world clinical cases from the participants' own practice. We used an integrated inductive-deductive qualitative analysis approach to analyze the interview transcripts., Results and Discussion: Perceived usefulness, perceived accuracy, quality assurance, trust, and ease of use emerged as essential domains of acceptability required for providers to use a collective intelligence tool in clinical practice. Participants conveyed that the collective opinion should: (1) contribute to their clinical reasoning, (2) boost their confidence, (3) be generated in a timely manner, and (4) be relevant to their clinical settings and use cases. Trust in the technology platform and the clinical accuracy of its collective intelligence output emerged as an incontrovertible requirement for user acceptance and engagement., Conclusion: We documented key requisites to building a collective intelligence technology platform that is trustworthy, useful, and acceptable to target end users for assistance in the diagnostic process. These key lessons may be applicable to other provider-facing decision support platforms., (© The Author(s) 2019. Published by Oxford University Press on behalf of the American Medical Informatics Association.)

Objective: To understand patient, primary care clinician (PCC), and subspecialist perspectives on potential, unexplored roles for patients in electronic consultation and referral (eCR) systems., Data Sources: Primary focus group and survey data collected April-November 2015. Zuckerberg San Francisco General Hospital (ZSFG) is part of an integrated public health delivery system. Its mature eCR system was first implemented in 2005., Study Design: This mixed-methods study synthesizes patient, subspecialist, and PCC perspectives through two patient focus groups in English, Spanish, and Cantonese (n = 6); subspecialist focus groups (n = 2); and an electronic survey of all PCCs (n = 222/634, 35 percent response)., Data Collection/extraction Methods: Focus groups were audio-recorded and transcribed. Two researchers coded the transcripts to identify recurrent themes. Survey data were analyzed using summary and bivariate statistics., Principal Findings: Patients expressed minimal desire to directly engage in eCR, instead of emphasizing their PCC's role in advocating, informing, and finding health solutions. Subspecialists requested more consistent communication to patients about the electronic consultation process. Most PCCs (52 percent) supported patient engagement in the eCR process, particularly patient ability to track consult status and securely message with subspecialists., Conclusions: Results suggest a continuum of opportunities for patients and their caregivers to engage in eCR systems., (© Health Research and Educational Trust.)

Background: Considerable geographic variation exists in the prevalence of chronic kidney disease across the United States. While some of this variability can be explained by differences in patient-level risk factors, substantial variability still exists. We hypothesize this may be due to understudied environmental exposures such as air pollution., Methods: Using data on 1.1 million persons from the 2010 5% Medicare sample and Environmental Protection Agency air-quality measures, we examined the association between county-level particulate matter ≤2.5 μm (PM2.5) and the prevalence of diagnosed CKD, based on claims. Modified Poisson regression was used to estimate associations (prevalence ratios [PR]) between county PM2.5 concentration and individual-level diagnosis of CKD, adjusting for age, sex, race/ethnicity, hypertension, diabetes, and urban/rural status., Results: Prevalence of diagnosed CKD ranged from 0% to 60% by county (median = 16%). As a continuous variable, PM2.5 concentration shows adjusted PR of diagnosed CKD = 1.03 (95% CI: 1.02-1.05; p<0.001) for an increase of 4 μg/m3 in PM2.5. Investigation by quartiles shows an elevated prevalence of diagnosed CKD for mean PM2.5 levels ≥14 μg/m3 (highest quartile: PR = 1.05, 95% CI: 1.03-1.07), which is consistent with current ambient air quality standard of 12 μg/m3, but much lower than the level typically considered healthy for sensitive groups (~40 μg/m3)., Conclusion: A positive association was observed between county-level PM2.5 concentration and diagnosed CKD. The reliance on CKD diagnostic codes likely identified associations with the most severe CKD cases. These results can be strengthened by exploring laboratory-based diagnosis of CKD, individual measures of exposure to multiple pollutants, and more control of confounding., Competing Interests: The authors have declared that no competing interests exist.

Importance: Undocumented immigrants with end-stage renal disease have variable access to hemodialysis in the United States despite evidence-based standards for frequency of dialysis care., Objective: To determine whether mortality and health care use differs among undocumented immigrants who receive emergency-only hemodialysis vs standard hemodialysis (3 times weekly at a health care center)., Design, Setting, and Participants: A retrospective cohort study was conducted of undocumented immigrants with incident end-stage renal disease who initiated emergency-only hemodialysis (Denver Health, Denver, Colorado, and Harris Health, Houston, Texas) or standard (Zuckerberg San Francisco General Hospital, San Francisco, California) hemodialysis between January 1, 2007, and July 15, 2014., Exposures: Access to emergency-only hemodialysis vs standard hemodialysis., Main Outcomes and Measures: The primary outcome was mortality. Secondary outcomes were health care use (acute care days and ambulatory care visits) and rates of bacteremia. Outcomes were adjusted for propensity to undergo emergency hemodialysis vs standard hemodialysis., Results: A total of 211 undocumented patients (86 women and 125 men; mean [SD] age, 46.5 [14.6] years; 42 from the standard hemodialysis group and 169 from the emergency-only hemodialysis group) initiated hemodialysis during the study period. Patients receiving standard hemodialysis were more likely to initiate hemodialysis with an arteriovenous fistula or graft and had higher albumin and hemoglobin levels than patients receiving emergency-only hemodialysis. Adjusting for propensity score, the mean 3-year relative hazard of mortality among patients who received emergency-only hemodialysis was nearly 5-fold (hazard ratio, 4.96; 95% CI, 0.93-26.45; P = .06) greater compared with patients who received standard hemodialysis. Mean 5-year relative hazard of mortality for patients who received emergency-only hemodialysis was more than 14-fold (hazard ratio, 14.13; 95% CI, 1.24-161.00; P = .03) higher than for those who received standard hemodialysis after adjustment for propensity score. The number of acute care days for patients who received emergency-only hemodialysis was 9.81 times (95% CI, 6.27-15.35; P < .001) the expected number of days for patients who had standard hemodialysis after adjustment for propensity score. Ambulatory care visits for patients who received emergency-only hemodialysis were 0.31 (95% CI, 0.21-0.46; P < .001) times less than the expected number of days for patients who received standard hemodialysis., Conclusions and Relevance: Undocumented immigrants with end-stage renal disease treated with emergency-only hemodialysis have higher mortality and spend more days in the hospital than those receiving standard hemodialysis. States and cities should consider offering standard hemodialysis to undocumented immigrants.

San Francisco Health Initiative (SFHI) is an undergraduate student organization founded in 2017 that works to address community issues in health by increasing awareness of high school students to relevant topics; it is expected that their increased awareness of local issues in health, coupled with improved access to higher education in Science, Technology, Engineering, and Math (STEM), will expand the capacity of the free clinic workforce. SFHI has collaborated with local high schools in San Francisco to actualize this mission by conducting five workshops on the following topics: (1) environmental and racial health disparities, (2) racial disparities amongst people who suffer from chronic disease, (3) social pressure defined and assessed, (4) the basis of disease as a preventative health measure, and (5) effects of adiposity in the development of Type 2 diabetes mellitus (T2DM). SFHI aims to create an affirming and inclusive environment that spurs high schools to pursue a college degree in a STEM field and to consider a career serving in a free clinic.

Introduction: Effective chronic disease care is dependent on well-organised quality improvement (QI) strategies that monitor processes of care and outcomes for optimal care delivery. Although healthcare is provincially/territorially structured in Canada, there are national networks such as the Canadian Primary Care Sentinel Surveillance Network (CPCSSN) as important facilitators for national QI-based studies to improve chronic disease care. The goal of our study is to improve the understanding of how patients with chronic kidney disease (CKD) are managed in primary care and the variation across practices and provinces and territories to drive improvements in care delivery., Methods and Analysis: The CPCSSN database contains anonymised health information from the electronic medical records for patients of participating primary care practices (PCPs) across Canada (n=1200). The dataset includes information on patient sociodemographics, medications, laboratory results and comorbidities. Leveraging validated algorithms, case definitions and guidelines will help define CKD and the related processes of care, and these enable us to: (1) determine prevalent CKD burden; (2) ascertain the current practice pattern on risk identification and management of CKD and (3) study variation in care indicators (eg, achievement of blood pressure and proteinuria targets) and referral pattern for specialist kidney care. The process of care outcomes will be stratified across patients' demographics as well as provider and regional (provincial/territorial) characteristics. The prevalence of CKD stages 3-5 will be presented as age-sex standardised prevalence estimates stratified by province and as weighted averages for population rates with 95% CIs using census data. For each PCP, age-sex standardised prevalence will be calculated and compared with expected standardised prevalence estimates. The process-based outcomes will be defined using established methods., Ethics and Dissemination: The CPCSSN is committed to high ethical standards when dealing with individual data collected, and this work is reviewed and approved by the Network Scientific Committee. The results will be published in peer-reviewed journals and presented at relevant national and international scientific meetings., Competing Interests: Competing interests: None declared., (© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2017. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

Background: Whether screening for chronic kidney disease (CKD) can improve the care of persons at high risk for complications remains uncertain. We describe the design and early implementation experience of a pilot, cluster-randomized pragmatic trial to evaluate the feasibility, implementation, and effectiveness of a "triple marker" CKD screening program (creatinine, cystatin C and albumin to creatinine ratio) for improving care among hypertensive veterans seen in primary care at one Veterans Administration Hospital., Methods/design: Non-diabetic hypertensive veterans age 18-80 without known CKD were randomized in clusters determined by primary care provider (unit of randomization) into three arms. Usual care will be compared with two incrementally intensified treatment strategies: (1) screen for CKD followed by patient and provider education or (2) screen-educate plus a clinical pharmacist-led CKD and BP management program. The primary clinical outcome is systolic blood pressure (BP) change from baseline. Secondary clinical outcome is BP control. The primary process outcomes is triple marker screening (across three arms), and secondary process outcomes include use of inhibitors of the renin-angiotensin system (ACE/ARB) overall and in persons with albuminuria, CKD recognition by PCP, use of non-steroidal anti-inflammatory drugs (NSAIDs) and NSAID education by PCP. The design uses the Veterans Health Administration electronic health record (EHR) to identify participants, deliver the interventions and ascertain study outcomes. Assessment of the program implementation will use the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework. Study duration is 12 months., Results: A total of 1,819 patients have been randomized within 41 provider clusters. The median age (interquartile range) is 68 years (61-72), and 99% of participants are male. Approximately 16% are Black, and 5% Hispanic. In the first 6 months of the trial, 434 triple marker screening tests have been ordered, and 217(50%) have been tested. A total of 48 new CKD cases have been identified among those tested, for a preliminary yield of 22%., Conclusion: We have successfully implemented a pragmatic protocol that uses the EHR to identify and characterize eligible participants, deliver the intervention, and ascertain study outcomes with high rates of participation by providers and patients. Results from this study can guide design of pragmatic trials in the field of CKD., Trial Registration: NCT01978951 ; Date or Registration: 1/17/2014.

Pregnancy in chronic dialysis patients is unusual and associated with many complications. Infants are often born both prematurely and small for gestational age. We report a case of a 36-year-old diabetic hemodialysis patient G4P3 who had prolonged hyperemesis gravidarum, for whom intradialytic parenteral nutrition (IDPN) was started at week 14 and continued throughout her pregnancy. She delivered a 3.5-kg baby girl at the 36th week of gestation by cesarean section. We discuss the use of IDPN as adjunct therapy for pregnant dialysis patients.

The treatment of lover limb erysipelas rests on antibiotic therapy directed against streptococci, but the necessity of prescribing a concomitant anticoagulant treatment has not yet been established. The incidence of deep vein thrombosis in patients with erysipelas of the leg in unknown. In a prospective study of 40 patients presenting with this type of skin disease, we looked for deep vein thrombosis, using systematically pulsed Doppler vein exploration combined with ultrasonography and, if necessary, a second Doppler examination and a phlebography. Six cases of deep vein thrombosis were diagnosed. This complication was observed in 5 patients at high risk for deep venous thrombosis; it had never been foreseen at clinical examination.