Showing papers by "Paul W. Eggers published in 2004"

Chronic Kidney Disease Awareness, Prevalence, and Trends among U.S. Adults, 1999 to 2000

Abstract: The incidence of kidney failure treatment in the United States increased 57% from 1991 to 2000. Chronic kidney disease (CKD) prevalence was 11% among U.S. adults surveyed in 1988 to 1994. The objective of this study was to estimate awareness of CKD in the U.S. population during 1999 to 2000 and to determine whether the prevalence of CKD in the United States increased compared with 1988 to 1994. Analysis was conducted of nationally representative samples of noninstitutionalized adults, aged 20 yr and older, in two National Health and Nutrition Examination Surveys conducted in 1988 to 1994 (n = 15,488) and 1999 to 2000 (n = 4101) for prevalence +/- SE. Awareness of CKD is self-reported. Kidney function (GFR), kidney damage (microalbuminuria or greater), and stages of CKD (GFR and albuminuria) were estimated from calibrated serum creatinine, spot urine albumin to creatinine ratio (ACR), age, gender, and race. GFR was estimated using the simplified Modification of Diet in Renal Disease Study equation. Self-reported awareness of weak or failing kidneys in 1999 to 2000 was strongly associated with decreased kidney function and albuminuria but was low even in the presence of both conditions. Only 24.3 +/- 6.4% of patients at GFR 15 to 59 ml/min per 1.73 m(2) and albuminuria were aware of CKD compared with 1.1 +/- 0.3% at GFR of 90 ml/min per 1.73 m(2) or greater and no microalbuminuria. At moderately decreased kidney function (GFR 30 to 59 ml/min per 1.73 m(2)), awareness was much lower among women than men (2.9 +/- 1.6 versus 17.9 +/- 5.9%; P = 0.008). The prevalence of moderately or severely decreased kidney function (GFR 15 to 59 ml/min per 1.73 m(2)) remained stable over the past decade (4.4 +/- 0.3% in 1988 to 1994 and 3.8 +/- 0.4% in 1999 to 2000; P = 0.23). At the same time, the prevalence of albuminuria (ACR >/= 30 mg/g) in single spot urine increased from 8.2 +/- 0.4% to 10.1 +/- 0.7% (P = 0.01). Overall CKD prevalence was similar in both surveys (9% using ACR > 30 mg/g for persistent microalbuminuria; 11% in 1988 to 1994 and 12% in 1999 to 2000 using gender-specific ACR cutoffs). Despite a high prevalence, CKD awareness in the U.S. population is low. In contrast to the dramatic increase in treated kidney failure, overall CKD prevalence in the U.S. population has been relatively stable.

Associations of race, education, and patterns of preventive service use with stage of cancer at time of diagnosis.

Abstract: The passage of Medicare in 1965 was accompanied by a confident expectation that covering most of the costs of physicians' and inpatient hospital services would remove the major barriers to health care for the elderly. A lingering concern was the lack of coverage for prevention and early detection of disease. Over time, Medicare was amended to cover pap smears (1990), routine screening mammography (1991), influenza immunizations (1993), colorectal cancer screening (1998), and prostate cancer screening, including the prostate specific antigen (PSA) test (2000). During the past decade new concerns have been raised by a succession of studies indicating that race and socioeconomic status (SES) continue to influence the use of health care services by the elderly enrolled in Medicare; these studies show three distinct patterns: black beneficiaries and persons less economically and socially advantaged use (1) fewer preventive and cancer screening services, (2) fewer common surgical procedures to improve health and functioning, but (3) more procedures associated with poor outcomes of chronic diseases than white beneficiaries and beneficiaries in higher socioeconomic status (Ayanian et al. 1993; Gornick 2000; Health Care Financing Administration 1995a; Gornick et al. 1996). Disparities in the use of preventive, cancer screening, and other services to maintain health are especially troubling because blacks and disadvantaged persons experience higher rates of morbidity and mortality (National Center for Health Statistics 2002). Why substantial disparities persist in the use of preventive and cancer screening services, especially among the elderly covered by Medicare, remains a fundamental question. Although it is true that barriers relating to coinsurance requirements for services such as mammography may explain some of the disparities by race and SES, the greatest disparities are found in the use of flu shots, which are “free.” Moreover, about 90 percent of the elderly when surveyed respond that they have a usual source of care (Health and Health Care of the Medicare Population 2001). The Institute of Medicine convened two committees to consider ways of promoting health, particularly among vulnerable subgroups; committee reports were in accord that no single factor can explain disparities in health—given the multitude of complex social and behavioral factors that can influence health outcomes (Smedley and Syme 2000; Committee on Health and Behavior 2001). Smedley and Syme (2000) noted that “behavioral and social interventions … offer great promise to reduce disease morbidity and mortality, but as yet their potential to improve the public's health has been relatively poorly tapped.” The Committee on Health and Behavior (2001) recommended research that “integrates biological, psychological, behavioral, and social variables.” This study integrates into health services research some of the theories and findings from health psychology and the behavioral and social sciences. In this study we concentrate on a health behavior exemplified by a beneficiary's use of an array of covered preventive and cancer screening services (hereafter, described simply as “preventive services”). Health behaviors have been a subject of interest to health psychologists for a long time. Rosenstock (1969, p. 169) defined health behavior as “the activity undertaken by persons who believe themselves to be healthy, for the purpose of preventing or detecting disease in an asymptomatic stage.” It is generally believed that health behaviors reflect various beliefs and attitudes, such as an individual's conviction that illness is preventable or controllable—which may translate into behaviors relating to preventive service use. Studies, going as far back as the 1930's, have found a consistency in an individual's health behaviors, although the correlations were often only small or modest (Rosenstock 1969; Norris 1997). For this study we analyzed health behavior to see if there was some consistency in the use of an array of services that included flu shots, pneumonia immunizations, mammography, pap smears, and prostate and colon cancer screening. It is important to emphasize that use is driven not only by the behavior of beneficiaries themselves, who can initiative services such as flu shots, but also—and very significantly—by the behavior of providers, who may (or may not) recommend patients for services such as mammograms (O'Malley et al. 2001), colonoscopy, and PSA tests. The consistency of an individual's use of preventive services was illustrated by a study in Massachusetts reporting that women who had a mammogram and men who had a prostate specific antigen test (PSA) were more likely to have colorectal screening than their counterparts without a mammogram or a PSA test (Lemon et al. 2001). Further insight into the consistency of behaviors regarding preventive services was provided by a Medicare study that found women who had a mammogram were six times as likely to have a pap smear as women who did not have a mammogram, and men who had a flu shot were more likely to have a prostate screening test than men who did not have a flu shot; these patterns held across races and income groups (Gornick, Eggers, and Riley 2001). Additional insight into health behaviors comes from studies showing correlations across a variety of health behaviors, such as the use of preventive services and use of seatbelts, smoking cessation, regular exercise, alcohol consumption, and dietary fat intake (Hofer and Katz 1996; Costakis, Dunnagan, and Haynes 1999; Boutelle et al. 2000; Gornick, Eggers, and Riley 2001). Further insight comes from studies showing a consistency between health behaviors and behaviors that are not exclusively related to health, such as precautionary behaviors regarding crime prevention and hazard preparedness (e.g., having batteries ready for potential hurricanes), albeit, again, some of the correlations were only small or modest (Norris 1997; Weinstein 1993). We were interested in determining if health behaviors regarding preventive service use were associated with health outcomes—specifically, stage of cancer when first diagnosed. We hypothesized that Medicare beneficiaries who used more of an array of preventive services covered by Medicare would have a lower probability of late stage of cancer at time of diagnosis than others who used fewer of these services. Our rationale was: If the use of preventive services (a) is correlated—as the health psychology literature indicates—with other healthy behaviors (such as exercising, not smoking, controlling weight) and the belief that illness is preventable or controllable and (b) promotes opportunities to discuss signs and symptoms of illness with health care providers—then a greater use of preventive services will be associated with a lower probability of late stage cancer at the time a beneficiary is first diagnosed with cancer. In essence, our hypothesis was that the use of preventive services is consistent with a range of healthy behaviors that promote health and early detection of disease. We studied eight frequently diagnosed cancers in 1995—breast, colorectal, uterine, and ovarian cancer in women and prostate, colorectal, bladder, and stomach cancer in men, and an array of preventive services: influenza and pneumonia immunization, colonoscopy, sigmoidoscopy, barium enema, mammography, pap smear, and the PSA test. The time period selected for studying the use of preventive services prior to the diagnosis of cancer was set at two years. However, as described in the Methods section, we used the 24 months ending in the third month prior to diagnosis as our two-year observation period. The health outcome was stage of cancer when first diagnosed. Four of the eight types of cancers studied have a specific screening procedure associated with it. It is important to stress, however, that the objective of this research was not to analyze whether the use of any particular screening service, such as the PSA test or mammography, was related to stage of prostate or breast cancer when first diagnosed. Such studies require substantially different methods, data, and design than used in this study (Friedman et al. 1995). Rather, the objective was to determine if the health behavior characterized by using available preventive services was associated with stage of cancer at time of diagnosis. That finding would be of particular importance because data from the National Cancer Institute (Ries et al. 1997) show that elderly blacks are more likely to have late stage cancer when first diagnosed—and more likely to have lower five-year survival rates—than their white counterparts. Two specific questions were studied: Are beneficiaries with a stronger history of use of preventive services less likely to have late stage cancer when first diagnosed? Is this true for blacks and whites and for groups with different educational attainment?

Diabetes Is the Strongest Risk Factor for Lower-Extremity Amputation in New Hemodialysis Patients

Abstract: OBJECTIVE —End-stage renal disease (ESRD) patients, especially those with diabetes, have an increased risk of nontraumatic lower-extremity amputation (LEA). The present study aims to examine the association of demographic and clinical variables with the risk of hospitalization for LEA among incident hemodialysis patients. RESEARCH DESIGN AND METHODS —The study population consisted of incident hemodialysis patients from the study years 1996–1999 of the ESRD Core Indicator/Clinical Performance Measures (CPM) Project. Cox proportional hazard modeling was used to identify factors associated with LEA. RESULTS —Four percent (116 of 3,272) of noncensored incident patients had an LEA during the 12-month follow-up period. Factors associated with LEA included diabetes as the cause of ESRD or preexisting comorbidity (hazard ratio 6.4, 95% CI 3.4–12.0), cardiovascular comorbidity (1.8, 1.2–2.8), hemodialysis inadequacy (urea reduction ratio [URR] <58.5% (1.9, 1.1–3.3), and lower serum albumin level (1.6, 1.1–2.3). Among patients with diabetes, hemodialysis inadequacy and cardiovascular comorbidity were risk factors for LEA (2.6, 1.4–4.8, and 1.7, 1.1–2.6, respectively). CONCLUSIONS —These data suggest that diabetes is a potent risk factor for LEA in new hemodialysis patients. In ESRD patients with diabetes, a multipronged approach may reduce the rate of LEA. Potentially beneficial strategies include adherence to hemodialysis adequacy guidelines, aggressive treatment of cardiovascular comorbidities, and the utilization of LEA prevention strategies recommended for the general population of patients with diabetes.