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Contribution, preservation and uptake within a multicentre pre-exposure prophylaxis cohort utilizing on-line, smartphone-compatible information series.
This installment of the Core Curriculum in Nephrology outlines several practical applications of kidney supportive care, with a focus on the nephrologist's approach to symptom management, active medical management of kidney failure without dialysis (also known as comprehensive conservative care), acute kidney injury in seriously ill patients, and withdrawal from dialysis. RATIONALE & OBJECTIVES Dialysis patients frequently experience medication-related problems. We studied the association of a multidisciplinary medication therapy management (MTM) with 30-day readmission rates. STUDY DESIGN Retrospective cohort study. SETTING & PARTICIPANTS Maintenance dialysis patients discharged home from acute-care hospitals between May 2016 and April 2017 who returned to End-Stage Renal Disease Seamless Care Organization dialysis clinics after discharge were eligible. Patients who were readmitted within 3 days, died, or entered hospice within 30 days were excluded. EXPOSURE MTM consisting of nurse medication reconciliation, pharmacist medication review, and nephrologist oversight was categorized into 3 levels of intensity no MTM, partial MTM (defined as an incomplete MTM process), or full MTM (defined as a complete MTM process). OUTCOME The primary outcome was 30-day readmission. ANALYTICAL APPROACH Time-varying Prentice, Williams, and Peterson total time hazards models explored associationM was associated with lower 30-day readmission risk (HR, 0.20; 95% CI, 0.06-0.69). LIMITATIONS Reliance on observational data. Residual bias and confounding. CONCLUSIONS MTM services following hospital discharge were associated with fewer 30-day readmissions in dialysis patients. Randomized controlled studies evaluating different MTM delivery models and cost-effectiveness in dialysis populations are warranted. BACKGROUND The Center for Medicaid and Medicare Services penalizes hospitals with high readmission rates after coronary artery bypass grafting (CABG). Home health care (HHC) is a proven discharge support tool. We performed a propensity-matched analysis to determine impact of HHC on readmissions after CABG. METHODS We queried the National Readmissions Database (January 2012-December 2014) for patients undergoing isolated CABG discharged home with and without HHC. Primary end point was 30-day readmission. A well-balanced subset of patients with and without HHC was created with propensity matching. Weight-adjusted logistic regression was performed to determine impact of HHC on readmissions after CABG. RESULTS In our study, 204,184 patients (mean age. 64 years; 22% female) were discharged home after CABG; 86,206 (42%) received HHC. Old age (66 vs 63 years; P less then .01), diabetes (46% vs 41%; P less then .001), COPD (21% vs 18%; P less then .01), peripheral arterial disease (14% vs 11%; P less then .001), and chronic kidney disease (2% vs 1.5%; P = .01) were factors associated with HHC. With nearest-neighbor 11 matching without replacement, we identified 66,610 patient pairs (unweighted) for further analysis. Readmission occurred in 11.1% and 12.5% of patients with and without HHC, respectively. After adjustment for 21 clinical covariates, use of HHC (odds ratio, 0.816; 95% confidence interval, 0.808-0.823) led to significantly lower readmission rates (P less then .001). CONCLUSIONS HHC after coronary artery bypass surgery is more often provided to women, older patients, and those with diabetes mellitus, peripheral arterial disease, and chronic lung or kidney dysfunction. HHC appears to be associated with reduced rates of early readmission. Published by Elsevier Inc.BACKGROUND Long-term outcomes of aortic valve replacement (AVR) are worse in patients with tricuspid regurgitation (TR), but the impact of concomitant tricuspid valve intervention remains unclear. The purpose of this study was to determine the effect of tricuspid intervention in patients with TR undergoing AVR. METHODS Patients undergoing AVR in a regional Society of Thoracic Surgeons database (2001-2017) were stratified by severity of TR and whether or not they underwent concomitant tricuspid intervention. Operative morbidity and mortality were compared between the 2 groups. Further analysis was performed using propensity score-matched pairs. RESULTS Among 17,483 patients undergoing AVR, 8984 (51%) had no TR, 7252 (41%) had mild TR, 1060 (6%) had moderate TR, and 187 (1%) had severe TR. Overall, more severe TR was associated with higher morbidity and mortality. Tricuspid intervention was performed in 104 patients (0.6%), including 0.2% of patients with mild TR, 2% of those with moderate TR, and 31% of those with severe TR. In the propensity score-matched analysis, there was not a statistically significant difference in operative mortality between the 2 groups (18% vs 9%; P = .16), but there was significantly higher composite major morbidity (51% vs 26%; P = .006) in the tricuspid intervention group compared with those without surgical TR correction. CONCLUSIONS Increasing severity of TR is associated with higher rates of morbidity and mortality after AVR. Correction of TR at the time of surgical AVR is not associated with increased operative mortality and has been shown to improve long-term outcomes. OBJECTIVE We performed a post hoc analysis of the Arterial Revascularization Trial to compare 10-year outcomes after off-pump versus on-pump surgery. METHODS Among 3102 patients enrolled, 1252 (40% of total) and 1699 patients received off-pump and on-pump surgery (151 patients were excluded because of other reasons); 2792 patients (95%) completed 10-year follow-up. Propensity matching and mixed-effect Cox model were used to compare long-term outcomes. selleck chemical Interaction term analysis was used to determine whether bilateral internal thoracic artery grafting was a significant effect modifier. RESULTS One thousand seventy-eight matched pairs were selected for comparison. A total of 27 patients (2.5%) in the off-pump group required conversion to on-pump surgery. The off-pump and on-pump groups received a similar number of grafts (3.2 ± 0.89 vs 3.1 ± 0.8; P = .88). At 10 years, when compared with on-pump, there was no significant difference in death (adjusted hazard ratio for off-pump, 1.1; 95% confidence interval, 0.84-1.
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