Abstract
Introduction:Use of kidney replacement therapy (KRT) prediction models for guiding arteriovenous fistula (AVF) referrals in advanced chronic kidney disease (CKD) is unknown. We aimed to compare a hypothetical approach using a KRT prediction model developed in Kaiser Permanente Northwest to estimated glomerular filtration rate (eGFR) for AVF referrals.Methods:Our retrospective cohort consisted of patients with stage G4 CKD in Kaiser Permanente Northwest followed by nephrology. Two-year KRT risk was calculated at each nephrology visit up to 2 years from entrance into cohort based on a previously published model. We calculated sensitivity, specificity, and area under the receiver operating characteristic curve (AUC) based on several 2-year KRT risk and eGFR cutoffs for outcome of hemodialysis at 18 months. We compared an approach of AVF referral using 2-year KRT risk and eGFR cutoffs using decision curve analysis.Results:Two-year KRT risk better discriminated progression to hemodialysis compared to eGFR < 15 mL/min (AUC 0.60 vs 0.69 at 2-year KRT risk > 20% and 0.69 at 2-year KRT risk > 40%, p = 0.003 and 0.006, respectively) but not to eGFR of 20 mL/min (AUC 0.64, p = 0.16 and 0.19, respectively). Decision curve analysis showed that AVF referral guided by 2-year KRT risk score resulted in higher net benefit compared to eGFR at low thresholds for referral.Conclusion:In stage G4 CKD, a 2-year KRT risk model better predicted progression to KRT at 18 months compared to an eGFR of 15 mL/min but not to 20 mL/min and may improve timely referral for AVF placement in patients at lower thresholds for referral.
Highlights
The patient-centered medical home model stresses the importance of team-based care as a foundation to improving care, costs, and patient experience
Enhancing Medical assistants (MAs) training and competencies is widely recognized as an important part of advancing team-based care
New programs like the National Institute for Medical Assistant Advancement38 are creating partnerships between education and practice to enhance training and skills. It is largely incumbent on individual health care organizations to train MAs to have a more impactful role in the clinic if they want to deliver on the benefits of team-based care
Summary
The patient-centered medical home model stresses the importance of team-based care as a foundation to improving care, costs, and patient experience. Emerging evidence indicates that teams can bolster access to care and more effective engagement of practice members in continuous quality improvement (QI).17 Bringing these promising outcomes to fruition requires substantive work for practices that are not organized in this way.. Life expectancy has long been used as a population-based indicator of health as it reflects improvements and changes in public health, health care, economic conditions, and social factors.. The complexity of chronic non-cancer pain in the setting of regulatory efforts to curb opioid usage presents a novel challenge for the medical community Much of this burden falls on primary care clinics. Case presentation: We describe a 66-year-old woman with a significant past medical history of chronic obstructive pulmonary disease and asthma who presented with hypoxia after completing radiotherapy for breast cancer. Despite the mounting evidence on fasting, little is known on its physiological effects in humans as most of the studies on physiological effects are done in animals
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