Dialysis Initiation and Mortality Among Older Veterans With Kidney Failure Treated in Medicare vs the Department of Veterans Affairs

Tamura, Manjula Kurella; Thomas, I‐Chun; Montez‐Rath, Maria E.; Kapphahn, Kristopher; Desai, Manisha; Gale, Rena; Asch, Steven M.

doi:10.1001/jamainternmed.2018.0411

Cited by 29 publications

(30 citation statements)

References 31 publications

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“…Financial incentives and the pressure to meet productivity goals drive overutilisation of unnecessary testing and treatment, limit time with the patient and move the focus towards technical testing. This phenomenon is not limited to cardiology; evidence for variation in care attributable to differences in reimbursement mechanisms and supplier-induced demand exist for many specialties within healthcare including surgery,26 nephrology,27 neonatology28 and obstetrics 29. Published studies in diverse health settings in countries aside from the USA28 30 suggest that financial incentives lead to similar practice patterns by physicians in diverse settings and have a central role in efforts to change practice.…”

Section: Discussionmentioning

confidence: 99%

Qualitative study of cardiologists’ perceptions of factors influencing clinical practice decisions

Manja

Guyatt

You

et al. 2019

Heart

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BackgroundHealthcare costs are increasing in the USA and Canada and a substantial portion of health spending is devoted to services that do not improve health outcomes. Efforts to reduce waste by adopting evidence-based clinical practice guideline recommendations have had limited success. We sought insight into improving health system efficiency through understanding cardiologists’ perceptions of factors that influence clinical decision-making.MethodsIn this descriptive qualitative study, we conducted in-depth interviews with 18 American and 3 Canadian cardiologists. We used conventional content analysis including inductive and deductive approaches for data analysis and mapped findings to the ecological systems framework.ResultsPhysicians reported that major determinants of practice included interpersonal interactions with peers, patients and administrators; financial incentives and system factors. Patients’ insurance status represented an important consideration for some cardiologists. Other major influences included time constraints, fear of litigation (less prominent in Canada), a sense that their obligation was never to miss any underlying pathology, and patient demands. The need to bring income into their health system influenced American cardiologists’ practice; personal income implications influenced Canadian cardiologists’ practice. Cardiologists reported that knowledge limitations and logistical challenges limit their ability to assist patients with cost considerations. All these considerations were more influential than guidelines; some cardiologists expressed a high level of scepticism regarding guidelines.ConclusionsClinical decision-making by cardiologists is shaped by individual, interpersonal, organisational, environmental, financial and sociopolitical influences and only to a limited extent by guideline recommendations. Successful strategies to achieve efficient, evidence-based care will require addressing socioecological influences on decision-making.

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Section: Discussionmentioning

confidence: 99%

Qualitative study of cardiologists’ perceptions of factors influencing clinical practice decisions

Manja

Guyatt

You

et al. 2019

Heart

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“…When nephroangiosclerosis and diabetes-rather than pyelonephritis and glomerulonephritiscame to be seen as the causes of end-stage renal disease (ESRD), this was not without consequences for dialysis tolerance, and the first caveats on eating during dialysis date to this phase. The progressive shortening of dialysis time, made possible by increased dialysis efficiency, occurred at the same time as the dialysis population started to become progressively older, a process that is continuing, at least in many European settings [57][58][59][60][61][62].…”

Section: Intradialytic Nutrition: a Bit Of Historymentioning

confidence: 99%

Intradialytic Nutrition and Hemodialysis Prescriptions: A Personalized Stepwise Approach

et al. 2020

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Dialysis and nutrition are two sides of the same coin—dialysis depurates metabolic waste that is typically produced by food intake. Hence, dietetic restrictions are commonly imposed in order to limit potassium and phosphate and avoid fluid overload. Conversely, malnutrition is a major challenge and, albeit to differing degrees, all nutritional markers are associated with survival. Dialysis-related malnutrition has a multifactorial origin related to uremic syndrome and comorbidities but also to dialysis treatment. Both an insufficient dialysis dose and excessive removal are contributing factors. It is thus not surprising that dialysis alone, without proper nutritional management, often fails to be effective in combatting malnutrition. While composite indexes can be used to identify patients with poor prognosis, none is fully satisfactory, and the definitions of malnutrition and protein energy wasting are still controversial. Furthermore, most nutritional markers and interventions were assessed in hemodialysis patients, while hemodiafiltration and peritoneal dialysis have been less extensively studied. The significant loss of albumin in these two dialysis modalities makes it extremely difficult to interpret common markers and scores. Despite these problems, hemodialysis sessions represent a valuable opportunity to monitor nutritional status and prescribe nutritional interventions, and several approaches have been tried. In this concept paper, we review the current evidence on intradialytic nutrition and propose an algorithm for adapting nutritional interventions to individual patients.

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“…But despite being less likely to start dialysis, the VA patients’ mortality rate was 9% lower. 26 Another recent study found that patient satisfaction was markedly lower in investor-owned clinics than in nonprofit facilities. 27…”

Section: Corporate Medicine and For-profit Carementioning

confidence: 99%

U.S. Health Care in the Trump Era: A Data Update

2019

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We present a summary of recent studies and data regarding the state of health and health care in the United States. Health care remains unaffordable to many Americans, including many with insurance. Health outcomes are stagnating or deteriorating. Police killings disproportionately target minority men. The search for profits from prescription drug companies, medical device firms, and for-profit medical providers places patients at risk. The public Medicare and Medicaid insurance programs, which increasingly subcontract with private managed care insurers, now account for the majority of private insurers’ total business. Insurance firms continue to avoid unprofitable enrollees and impose a mounting bureaucratic burden on medical providers. Meanwhile, recent polls show mounting public support for single-payer national health insurance.

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Dialysis Initiation and Mortality Among Older Veterans With Kidney Failure Treated in Medicare vs the Department of Veterans Affairs

Cited by 29 publications

References 31 publications

Qualitative study of cardiologists’ perceptions of factors influencing clinical practice decisions

Qualitative study of cardiologists’ perceptions of factors influencing clinical practice decisions

Intradialytic Nutrition and Hemodialysis Prescriptions: A Personalized Stepwise Approach

U.S. Health Care in the Trump Era: A Data Update

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