Showing papers by "Mark Unruh published in 2022"

Strategic use of health information exchange and market share, payer mix, and operating margins.

Abstract: Background Health information exchange (HIE) capabilities are tied to health care organizations' strategic and business goals. As a technology that connects information from different organizations, HIE may be a source of competitive advantage and a path to improvements in performance. Purpose The aim of the study was to identify the impact of hospitals' use of HIE capabilities on outcomes that may be sensitive to changes in various contracting arrangements and referral patterns arising from improved connectivity. Methodology Using a panel of community hospitals in nine states, we examined the association between the number of different data types the hospital could exchange via HIE and changes in market share, payer mix, and operating margin (2010-2014). Regression models that controlled for the number of different data types shared intraorganizationally and other time-varying factors and included both hospital and time fixed effects were used for adjusted estimates of the relationships between changes in HIE capabilities and outcomes. Results Increasing HIE capability was associated with a 13 percentage point increase in a hospital's discharges that were covered by commercial insurers or Medicare (i.e., payer mix). Conversely, increasing intraorganizational information sharing was associated with a 9.6 percentage point decrease in the percentage of discharges covered by commercial insurers or Medicare. Increasing HIE capability or intraorganizational information sharing was not associated with increased market share nor with operating margin. Conclusions Improving information sharing with external organizations may be an approach to support strategic business goals. Practice implications Organizations may be served by identifying ways to leverage HIE instead of focusing on intraorganizational exchange capabilities.

Hypernatremia in Hospitalized Patients: A Large Population-Based Study

Abstract: Key Points Hypernatremia has been studied less than hyponatremia and may serve as an important predictor of outcomes among hospitalized patients. This work addresses a key gap regarding outcomes of hypernatremia by assessing the relationship of hypernatremia to outcomes by eGFR or age groups. Hypernatremia was significantly associated with in-hospital mortality and discharge to a hospice or nursing facility. Visual Abstract Background Hypernatremia is a frequently encountered electrolyte disorder in hospitalized patients. Controversies still exist over the relationship between hypernatremia and its outcomes in hospitalized patients. This study examines the relationship of hypernatremia to outcomes among hospitalized patients and the extent to which this relationship varies by kidney function and age. Methods We conducted an observational study to investigate the association between hypernatremia, eGFR, and age at hospital admission and in-hospital mortality, and discharge dispositions. We analyzed the data of 1.9 million patients extracted from the Cerner Health Facts databases (2000–2018). Adjusted multinomial regression models were used to estimate the relationship of hypernatremia to outcomes of hospitalized patients. Results Of all hospitalized patients, 3% had serum sodium (Na) >145 mEq/L at hospital admission. Incidence of in-hospital mortality was 12% and 2% in hyper- and normonatremic patients, respectively. The risk of all outcomes increased significantly for Na >155 mEq/L compared with the reference interval of Na=135–145 mEq/L. Odds ratios (95% confidence intervals) for in-hospital mortality and discharge to a hospice or nursing facility were 34.41 (30.59–38.71), 21.14 (17.53–25.5), and 12.21 (10.95–13.61), respectively (all P<0.001). In adjusted models, we found that the association between Na and disposition was modified by eGFR (P<0.001) and by age (P<0.001). Sensitivity analyses were performed using the eGFR equation without race as a covariate, and the inferences did not substantially change. In all hypernatremic groups, patients aged 76–89 and ≥90 had higher odds of in-hospital mortality compared with younger patients (all P<0.001). Conclusions Hypernatremia was significantly associated with in-hospital mortality and discharge to a hospice or nursing facility. The risk of in-hospital mortality and other outcomes was highest among those with Na >155 mEq/L. This work demonstrates that hypernatremia is an important factor related to discharge disposition and supports the need to study whether protocolized treatment of hypernatremia improves outcomes.

Edelman Revisited: Concepts, Achievements, and Challenges

Abstract: The key message from the 1958 Edelman study states that combinations of external gains or losses of sodium, potassium and water leading to an increase of the fraction (total body sodium plus total body potassium) over total body water will raise the serum sodium concentration ([Na]S), while external gains or losses leading to a decrease in this fraction will lower [Na]S. A variety of studies have supported this concept and current quantitative methods for correcting dysnatremias, including formulas calculating the volume of saline needed for a change in [Na]S are based on it. Not accounting for external losses of sodium, potassium and water during treatment and faulty values for body water inserted in the formulas predicting the change in [Na]S affect the accuracy of these formulas. Newly described factors potentially affecting the change in [Na]S during treatment of dysnatremias include the following: (a) exchanges during development or correction of dysnatremias between osmotically inactive sodium stored in tissues and osmotically active sodium in solution in body fluids; (b) chemical binding of part of body water to macromolecules which would decrease the amount of body water available for osmotic exchanges; and (c) genetic influences on the determination of sodium concentration in body fluids. The effects of these newer developments on the methods of treatment of dysnatremias are not well-established and will need extensive studying. Currently, monitoring of serum sodium concentration remains a critical step during treatment of dysnatremias.

Association Between Patient Diversity in Hospitals and Racial/Ethnic Differences in Patient Length of Stay

Abstract: Hospitals serving a disproportionate share of racial/ethnic minorities have been shown to have poorer quality outcomes. It is unknown whether efficiencies in inpatient care, measured by length of stay (LOS), differ based on the proportion patients served by a hospital who are minorities. To examine the association between the racial/ethnic diversity of a hospital’s patients and disparities in LOS. Retrospective cross-sectional study. One million five hundred forty-six thousand nine hundred fifty-five admissions using the 2017 New York State Inpatient Database from the Healthcare Cost and Utilization Project. Differences in mean adjusted LOS (ALOS) between White and Black, Hispanic, and Other (Asian, Pacific Islander, Native American, and Other) admissions by Racial/Ethnic Diversity Index (proportion of non-White patients admitted to total patients admitted to that same hospital) in quintiles (Q1 to Q5), stratified by discharge destination. Mean LOS was adjusted for patient demographic, clinical, and admission characteristics and for individual intercepts for each hospital. In both unadjusted and adjusted analysis, Black-White and Other-White mean LOS differences were smallest in the most diverse hospitals (Black-White: unadjusted, −0.07 days [−0.1 to −0.04], and adjusted, 0.16 days [95% CI: 0.16 to 0.16]; Other-White: unadjusted, −0.74 days [95% CI: −0.77 to −0.71], and adjusted, 0.01 days [95% CI: 0.01 to 0.02]). For Hispanic patients, in unadjusted analysis, the mean LOS difference was greatest in the most diverse hospitals (−0.92 days, 95% CI: −0.95 to −0.89) but after adjustment, this was no longer the case. Similar patterns across all racial/ethnic groups were observed after analyses were stratified by discharge destination. Mean adjusted LOS differences between White and Black patients, and White and patients of Other race was smallest in most diverse hospitals, but not differences between Hispanic and White patients. These findings may reflect specific structural factors which affect racial/ethnic differences in patient LOS.

Emergency Department/Urgent Care as Usual Source of Care and Clinical Outcomes in CKD: Findings From the Chronic Renal Insufficiency Cohort Study

Abstract: Having a usual source of care increases use of preventive services and is associated with improved survival in the general population. We evaluated this association in adults with chronic kidney disease (CKD).Prospective, observational cohort study.Adults with CKD enrolled in the Chronic Renal Insufficiency Cohort (CRIC) Study.Usual source of care was self-reported as: 1) clinic, 2) emergency department (ED)/urgent care, 3) other.Primary outcomes included incident end-stage kidney disease (ESKD), atherosclerotic events (myocardial infarction, stroke, or peripheral artery disease), incident heart failure, hospitalization events, and all-cause death.Multivariable regression analyses to evaluate the association between usual source of care (ED/urgent care vs clinic) and primary outcomes.Among 3,140 participants, mean age was 65 years, 44% female, 45% non-Hispanic White, 43% non-Hispanic Black, and 9% Hispanic, mean estimated glomerular filtration rate 50 mL/min/1.73 m2. Approximately 90% identified clinic as usual source of care, 9% ED/urgent care, and 1% other. ED/urgent care reflected a more vulnerable population given lower baseline socioeconomic status, higher comorbid condition burden, and poorer blood pressure and glycemic control. Over a median follow-up time of 3.6 years, there were 181 incident end-stage kidney disease events, 264 atherosclerotic events, 263 incident heart failure events, 288 deaths, and 7,957 hospitalizations. Compared to clinic as usual source of care, ED/urgent care was associated with higher risk for all-cause death (HR, 1.53; 95% CI, 1.05-2.23) and hospitalizations (RR, 1.41; 95% CI, 1.32-1.51).Cannot be generalized to all patients with CKD. Causal relationships cannot be established.In this large, diverse cohort of adults with moderate-to-severe CKD, those identifying ED/urgent care as usual source of care were at increased risk for death and hospitalizations. These findings highlight the need to develop strategies to improve health care access for this high-risk population.

Implementation of the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program and outcomes of bariatric surgery.

Abstract: This study evaluates the performance of bariatric surgery prior to and after the implementation of Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP).The eras prior to (2007-2015) and after (2016-2018) the transition to MBSAQIP were compared for patients, operations and outcomes using adjusted logistic regression estimates.Thirty-day surgical (6%vs.2.9%,p < 0.01) and medical (3.4%vs.1.7%,p < 0.01) complications rates were reduced over the period 2007 through 2018. Th use of sleeve gastrectomy has steadily increased from 2010 to 2018 (14%vs.66.6%,p < 0.01). The proportion of patients who were discharged early continued to rise (9.8%vs.46.9%,p < 0.01) from 2007 to 2018. The MBSAQIP period was associated with reduced odds for 30-day surgical (OR = 0.86,CI = [0.81-0.91]) and medical (OR = 0.81,CI = [0.75-0.88]) complications. Implementation of the MBSAQIP was also predictive of early discharge (OR = 1.93,CI = [1.90-2.00]).The type of bariatric procedure, in addition to trends in morbidity and hospital stays, gradually changed from 2007 to 2018. Our findings suggest that outcomes of bariatric operations have improved over the past decade. The MBSAQIP era is associated with lower rates of complications and greater likelihood of early discharge, independent of the procedure type.

Video Images about Decisions for Ethical Outcomes in Kidney Disease (VIDEO-KD): the study protocol for a multi-centre randomised controlled trial

Abstract: Introduction Older patients with advanced chronic kidney disease (CKD) often are inadequately prepared to make informed decisions about treatments including dialysis and cardiopulmonary resuscitation. Further, evidence shows that patients with advanced CKD do not commonly engage in advance care planning (ACP), may suffer from poor quality of life, and may be exposed to end-of-life care that is not concordant with their goals. We aim to study the effectiveness of a video intervention on ACP, treatment preferences and other patient-reported outcomes. Methods and analysis The Video Images about Decisions for Ethical Outcomes in Kidney Disease trial is a multi-centre randomised controlled trial that will test the effectiveness of an intervention that includes a CKD-related video decision aid followed by recording personal video declarations about goals of care and treatment preferences in older adults with advancing CKD. We aim to enrol 600 patients over 5 years at 10 sites. Ethics and dissemination Regulatory and ethical aspects of this trial include a single Institutional Review Board mechanism for approval, data use agreements among sites, and a Data Safety and Monitoring Board. We intend to disseminate findings at national meetings and publish our results. Trial registration number NCT04347629.

Elevated SARS-CoV-2 in peripheral blood and increased COVID-19 severity in American Indians/Alaska Natives

Abstract: Epidemiological data across the United States show health disparities in COVID-19 infection, hospitalization, and mortality by race/ethnicity. While the association between elevated SARS-CoV-2 viral loads (VLs) (i.e. upper respiratory tract (URT) and peripheral blood (PB)) and increased COVID-19 severity has been reported, data remain largely unavailable for some disproportionately impacted racial/ethnic groups, particularly for American Indian or Alaska Native (AI/AN) populations. As such, we determined the relationship between SARS-CoV-2 VL dynamics and disease severity in a diverse cohort of hospitalized patients. Results presented here are for study participants (n = 94, ages 21–88 years) enrolled in a prospective observational study between May and October 2020 who had SARS-CoV-2 viral clades 20A, C, and G. Based on self-reported race/ethnicity and sample size distribution, the cohort was stratified into two groups: (AI/AN, n = 43) and all other races/ethnicities combined (non-AI/AN, n = 51). SARS-CoV-2 VLs were quantified in the URT and PB on days 0–3, 6, 9, and 14. The strongest predictor of severe COVID-19 in the study population was the mean VL in PB (OR = 3.34; P = 2.00 × 10−4). The AI/AN group had the following: (1) comparable co-morbidities and admission laboratory values, yet more severe COVID-19 (OR = 4.81; P = 0.014); (2) a 2.1 longer duration of hospital stay (P = 0.023); and (3) higher initial and cumulative PB VLs during severe disease (P = 0.025). Moreover, self-reported race/ethnicity as AI/AN was the strongest predictor of elevated PB VLs (β = 1.08; P = 6.00 × 10−4) and detection of SARS-CoV-2 in PB (hazard ratio = 3.58; P = 0.004). The findings presented here suggest a strong relationship between PB VL (magnitude and frequency) and severe COVID-19, particularly for the AI/AN group.

Development of a Patient Preference Survey for Wearable Kidney Replacement Therapy Devices

Abstract: Key Points We included the risks of serious bleeding and serious infection based on patient concerns and regulator input about future trial end points. The survey will estimate maximal acceptable risks for serious bleeding and infection and willingness to wait for devices with lower risk. Visual Abstract Background Recent innovations have the potential to disrupt the current paradigm for kidney failure treatment. The US Food and Drug Administration is committed to incorporating valid scientific evidence about how patients weigh the benefits and risks of new devices into their decision making, but to date, premarket submission of patient preference information (PPI) has been limited for kidney devices. With input from stakeholders, we developed a survey intended to yield valid PPI, capturing how patients trade off the potential benefits and risks of wearable dialysis devices and in-center hemodialysis. Methods We conducted concept elicitation interviews with individuals receiving dialysis to inform instrument content. After instrument drafting, we conducted two rounds of pretest interviews to evaluate survey face validity, comprehensibility, and perceived relevance. We pilot tested the survey with in-center hemodialysis patients to assess comprehensibility and usability further. Throughout, we used participant input to guide survey refinements. Results Thirty-six individuals receiving in-center or home dialysis participated in concept elicitation (N=20) and pretest (N=16) interviews. Participants identified reduced fatigue, lower treatment burden, and enhanced freedom as important benefits of a wearable device, and many expressed concerns about risks related to device disconnection—specifically bleeding and infection. We drafted a survey that included descriptions of the risks of serious bleeding and serious infection and an assessment of respondent willingness to wait for a safer device. Input from pretest interviewees led to various instrument modifications, including treatment descriptions, item wording, and risk-level explanations. Pilot testing of the updated survey among 24 in-center hemodialysis patients demonstrated acceptable survey comprehensibility and usability, although 50% of patients required some assistance. Conclusions The final survey is a 54-item web-based instrument that will yield estimates of the maximal acceptable risk for the described wearable device and willingness to wait for wearable devices with lower risk.

Aspirin for Primary and Secondary Prevention of Mortality, Cardiovascular Disease, and Kidney Failure in the Chronic Renal Insufficiency Cohort (CRIC) Study

Abstract: Chronic kidney disease is a risk enhancing factor for cardiovascular disease (CVD) and mortality, and the role of aspirin use is unclear in this population. We investigated the risk and benefits of aspirin use in primary and secondary prevention of CVD in the Chronic Renal Insufficiency Cohort Study.Prospective observational cohort.3,664 Chronic Renal Insufficiency Cohort participants.Aspirin use in patients with and without preexisting CVD.Mortality, composite and individual CVD events (myocardial infarction, stroke, and peripheral arterial disease), kidney failure (dialysis and transplant), and major bleeding.Intention-to-treat analysis and multivariable Cox proportional hazards model to examine associations of time varying aspirin use.The primary prevention group was composed of 2,578 (70.3%) individuals. Mean age was 57 ± 11 years, 46% women, 42% Black, and 47% had diabetes. The mean estimated glomerular filtration rate was 45 mL/min/1.73 m2. Median follow-up was 11.5 (IQR, 7.4-13) years. Aspirin was not associated with all-cause mortality in those without preexisting cardiovascular disease (CVD) (HR, 0.84; 95% CI, 0.7-1.01; P = 0.06) or those with CVD (HR, 0.88; 95% CI, 0.77-1.02, P = 0.08). Aspirin was not associated with a reduction of the CVD composite in primary prevention (HR, 0.97; 95% CI, 0.77-1.23; P = 0.79) and in secondary prevention because the original study design was not meant to study the effects of aspirin.This is not a randomized controlled trial, and therefore, causality cannot be determined.Aspirin use in chronic kidney disease patients was not associated with reduction in primary or secondary CVD events, progression to kidney failure, or major bleeding.

Implementing Advance Care Planning for dialysis patients: HIGHway project

Abstract: Patients undergoing hemodialysis have a high mortality rate and yet underutilize palliative care and hospice resources. The Shared Decision Making-Renal Supportive Care (SDM-RSC) intervention focused on goals of care conversations between patients and family members with the nephrologist and social worker. The intervention targeted deficiencies in communication, estimating prognosis, and transition planning for seriously ill dialysis patients. The intervention showed capacity to increase substantially completion of advance care directives. The HIGHway Project, adapted from the previous SDM-RSC, scale up training social workers or nurses in dialysis center in advance care planning (ACP), and then support them for a subsequent 9-month action period, to engage in ACP conversations with patients at their dialysis center regarding their preferences for end-of-life care.We will train between 50-60 dialysis teams, led by social workers or nurses, to engage in ACP conversations with patients at their dialysis center regarding their preferences for end-of-life care. This implementation project uses the Knowledge to Action (KTA) Framework within the Consolidated Framework for Implementation Research (CFIR) to increase adoption and sustainability in the participating dialysis centers. This includes a curriculum about how to hold ACP conversation and coaching with monthly teleconferences through case discussion and mentoring. An application software will guide on the process and provide resources for holding ACP conversations. Our project will focus on implementation outcomes. Success will be determined by adoption and effective use of the ACP approach. Patient and provider outcomes will be measured by the number of ACP conversations held and documented; the quality and fidelity of ACP conversations to the HIGHway process as taught during education sessions; impact on knowledge and skills; content, relevance, and significance of ACP intervention for patients, and Supportive Kidney Care (SKC) App usage. Currently HIGHway is in the recruitment stage.Effective changes to advance care planning processes in dialysis centers can lead to institutional policy and protocol changes, providing a model for patients receiving dialysis treatment in the US. The result will be a widespread improvement in advance care planning, thereby remedying one of the current barriers to patient-centered, goal-concordant care for dialysis patients.The George Washington University Protocol Record NCR213481, Honoring Individual Goals and Hopes: Implementing Advance Care Planning for Persons with Kidney Disease on Dialysis, is registered in ClinicalTrials.gov Identifier: NCT05324878 on April 11th, 2022.

Physician prices and low-value services: evidence from general internal medicine.

Abstract: OBJECTIVES To assess the cross-sectional relationship between prices paid to physicians by commercial insurers and the provision of low-value services. STUDY DESIGN Observational study design using Health Care Cost Institute claims representing 3 large national commercial insurers. METHODS The main outcome was count of 19 potential low-value services in 2014. The secondary outcome was total spending on the low-value services. Independent variables of interest were price quintiles based on each physician's mean geographically adjusted price of a mid-level office visit, the most commonly billed service by general internal medicine (GIM) physicians. We estimated the association between physician price quintile and provision of low-value services via negative binomial or generalized linear models with adjustments for measure, region, and patient and physician characteristics. RESULTS This study included 750,452 commercially insured patients attributed to 28,951 GIM physicians. In 2014, the mean geographically adjusted price for physicians in the highest price quintile was $122.6 vs $54.7 for physicians in the lowest quintile ($67.9 difference; 95% CI, $67.5-$68.3). Relative to patients attributed to the lowest-priced physicians, those attributed to the highest-priced physicians received 3.6, or 22.9%, fewer low-value services per 100 patients (95% CI, 2.7-4.7 services per 100 patients). Spending on low-value services attributed to the highest-priced physicians was 10.9% higher ($520 difference per 100 patients; 95% CI, $167-$872). CONCLUSIONS Commercially insured patients of high-priced physicians received fewer low-value services, although spending on low-value services was higher. More research is needed to understand why high-priced providers deliver fewer low-value services and whether physician prices are correlated with other measures of quality.

Association of Vitamin K Status with Arterial Calcification and Stiffness in Chronic Kidney Disease: The Chronic Renal Insufficiency Cohort

Abstract: Arterial calcification and stiffness are common in people with chronic kidney disease (CKD). Higher vitamin K status has been associated with less arterial calcification and stiffness in CKD in cross-sectional studies.To determine the association of vitamin K status with coronary artery calcium (CAC) and arterial stiffness [pulse wave velocity (PWV)] at baseline and over 2-4 follow-up years in adults with mild-to-moderate CKD.Participants (n = 2722) were drawn from the well-characterized Chronic Renal Insufficiency Cohort. Two vitamin K status biomarkers, plasma phylloquinone and plasma dephospho-uncarboxylated matrix gla protein [(dp)ucMGP], were measured at baseline. CAC and PWV were measured at baseline and over 2-4 y of follow-up. Differences across vitamin K status categories in CAC prevalence, incidence, and progression (defined as ≥100 Agatston units/y increase) and PWV at baseline and over follow-up were evaluated using multivariable-adjusted generalized linear models.CAC prevalence, incidence, and progression did not differ across plasma phylloquinone categories. Moreover, CAC prevalence and incidence did not differ according to plasma (dp)ucMGP concentration. Compared with participants with the highest (dp)ucMGP (≥450 pmol/L), those in the middle category (300-449 pmol/L) had a 49% lower rate of CAC progression (incidence rate ratio: 0.51; 95% CI: 0.33, 0.78). However, CAC progression did not differ between those with the lowest (<300 pmol/L) and those with the highest plasma (dp)ucMGP concentration (incidence rate ratio: 0.82; 95% CI: 0.56, 1.19). Neither vitamin K status biomarker was associated with PWV at baseline or longitudinally.Vitamin K status was not consistently associated with CAC or PWV in adults with mild-to-moderate CKD.

Heart failure-type symptom scores in chronic kidney disease: The importance of body mass index

Abstract: This analysis sought to determine factors (including adiposity-related factors) most associated with HF-type symptoms (fatigue, shortness of breath, and edema) in adults with chronic kidney disease (CKD). Symptom burden impairs quality of life in CKD, especially symptoms that overlap with HF. These symptoms are common regardless of clinical HF diagnosis, and may be affected by subtle cardiac dysfunction, kidney dysfunction, and other factors. We used machine learning to investigate cross-sectional relationships of clinical variables with symptom scores in a CKD cohort. Participants in the Chronic Renal Insufficiency Cohort (CRIC) with a baseline modified Kansas City Cardiomyopathy Questionnaire (KCCQ) score were included, regardless of prior HF diagnosis. The primary outcome was Overall Summary Score as a continuous measure. Predictors were 99 clinical variables representing demographic, cardiac, kidney and other health dimensions. A correlation filter was applied. Random forest regression models were fitted. Variable importance scores and adjusted predicted outcomes are presented. The cohort included 3426 individuals, 10.3% with prior HF diagnosis. BMI was the most important factor, with BMI 24.3 kg/m2 associated with the least symptoms. Symptoms worsened with higher or lower BMIs, with a potentially clinically relevant 5 point score decline at 35.7 kg/m2 and a 1-point decline at the threshold for low BMI, 18.5 kg/m2. The most important cardiac and kidney factors were heart rate and eGFR, the 4th and 5th most important variables, respectively. Results were similar for secondary analyses. In a CKD cohort, BMI was the most important feature for explaining HF-type symptoms regardless of clinical HF diagnosis, identifying an important focus for symptom directed investigations.

CPAP Therapy for CKD in Patients with OSA: The Jury Is Still Out.

Abstract: "CPAP Therapy for CKD in Patients with OSA: The Jury Is Still Out." American Journal of Respiratory and Critical Care Medicine, 0(ja), pp. –

Protocol for the AKT-MP trial: Access to Kidney Transplantation in Minority Populations

Abstract: Kidney transplant (KT) is the optimal treatment for kidney failure (KF), and although completion of KT evaluation is an essential step in gaining access to transplantation, the process is lengthy, time consuming, and burdensome. Furthermore, despite similar referral rates to non-Hispanic Whites, both Hispanic/Latinos and American Indians are less likely to be wait-listed or to undergo KT.The Access to Kidney Transplantation in Minority Populations (AKT-MP) Trial compares two patient-centered methods to facilitate KT evaluation: kidney transplant fast track (KTFT), a streamlined KT evaluation process; and peer navigators (PN), a peer-assisted evaluation program that incorporates motivational interviewing. This pragmatic randomized trial will use a comparative effectiveness approach to assess whether KTFT or PN can help patients overcome barriers to transplant listing. We will randomly assign patients to the two conditions. We will track participants' medical records and conduct surveys prior to their initial evaluation clinic visit and again after they complete or discontinue evaluation.Our aims are to (1) compare KTFT and PN to assess improvements in kidney transplant (KT) related outcomes and cost effectiveness; (2) examine how each approach effects changes in cultural/contextual factors, KT concerns, KT knowledge, and KT ambivalence; and (3) develop a framework for widespread implementation of either approach. The results of this trial will provide key information for facilitating the evaluation process, improving patient care, and decreasing disparities in KT.

US Generalist Physicians and Groups That Focused Practice in a Single Care Setting

Abstract: Background: Some generalist physicians whose training prepared them for primary care practice increasingly practice in a facility (eg, hospitals, nursing homes); however, whether this trend was accompanied by a complimentary rise in generalist physicians who focused their practice on office-based care is unknown. Objectives: Our objective in this study was to examine trends in the prevalence of generalist physicians and physician groups that practice in a single setting. Research Design: This was a retrospective cross-sectional study of generalist physicians trained in family medicine, internal medicine, or geriatrics. We used 2014–2017 billing data for Medicare fee-for-service beneficiaries to measure the proportion of all patient visits made by physicians in the following care settings: office, outpatient hospital department, inpatient hospital, and other sites. Results: From 2014 to 2017, the proportion of generalist physicians who narrowed their practice to a single setting increased by 6.69% (from 62.80% to 67.00%, pfor trend<0.001). In 2017, 4.63% of physician groups included more than 1 type of setting-based physicians. Conclusions: Generalist physicians treating older adults increasingly narrowed their practice focus to a single type of health care setting. This trend was not accompanied by growth among physician groups that included different types of setting-based physicians. Further evaluation of the consequences of these trends on the fragmentation of primary care delivery across different health care settings and primary care outcomes is needed.

Abstract 14871: Ambulatory Cardiac Rhythm Monitoring in Individuals With Chronic Kidney Disease

Abstract: Introduction: Chronic kidney disease (CKD) is associated with arrhythmias such as atrial fibrillation (AF) and sudden cardiac death, but limited rigorous data exist on the prevalence of AF, ventricular tachycardia (VT), nonsustained VT (NSVT), and high-degree atrioventricular (AV) block in a CKD cohort. Hypothesis: In participants with CKD, worse kidney function is associated with a higher burden of atrial and ventricular arrhythmias. Methods: We evaluated the prevalence of AF, VT, NSVT, and high degree AV block in participants in the Chronic Renal Insufficiency Cohort (CRIC) Study who underwent monitoring using the ZIO XT patch, a noninvasive, 14-day continuous single-lead electrocardiogram monitor. We evaluated patient characteristics and the association between kidney function and each arrhythmia. Results: Among 1182 participants (mean age 69±9 years; 48% women), mean patch wear time was 11.9±3.8 days, and mean analyzable time was 95±11%. AF was detected in 82 (7.4%) participants, with AF burden (% time spent in AF) ranging from 0.1% to 100%, and the majority had long-standing, persistent AF. Participants with AF were older (74 vs 69 years, p<0.001), had a higher prevalence of cardiovascular disease including prior MI and heart failure (48% versus 34%, p<0.05); and had a higher body mass index (34 vs 32 kg/m 2 ; p<0.05) than those without AF. NSVT occurred in 31% of participants, while no participant experienced sustained VT. High-degree AV block was present 2 participants (<1%). Overall, pre-monitoring mean estimated glomerular filtration rate was 51±18 ml/min/1.73m2, and median urine albumin-to-creatinine ratio was 9.2 [4.4 - 44.6] mg/g. Kidney function or proteinturia were not independently associated with any of the arrhythmias. Conclusions: In adults with CKD undergoing 14-day continuous monitoring, AF was present in 1 in 14 indivduals, and nearly one-third had evidence of NSVT. Worsening kidney function was not independently associated with the prevalence of arrhythmias in this cohort. Future studies will need to assess the signficance of NSVT on cardiovascular events across the spectrum of CKD severity.

Are cultural or psychosocial factors associated with patient‐reported outcomes at the conclusion of kidney transplant evaluation?

Abstract: Kidney transplant evaluation (KTE) is a period marked by many stressors for patients, which may lead to poorer patient‐reported outcomes (PROs). Research on the association of cultural and psychosocial factors with PROs during KTE is lacking, even though cultural and psychosocial variables may mitigate the relationship between acceptance status and PROs.