scholarly journals Facility-Level Variations in Kidney Disease Care among Veterans with Diabetes and CKD

2018 ◽  
Vol 13 (12) ◽  
pp. 1842-1850 ◽  
Author(s):  
Sankar D. Navaneethan ◽  
Julia M. Akeroyd ◽  
David Ramsey ◽  
Sarah T. Ahmed ◽  
Shiva Raj Mishra ◽  
...  
Keyword(s):  
Veterans Affairs ◽  
Creatinine Ratio ◽  
Angiotensin Receptor ◽  
Urine Protein ◽  
Urine Albumin ◽  
Patients With Diabetes ◽  
Facility Level ◽  
Rate Ratios ◽  
Core Measures ◽  
Median Rate

Background and objectivesFacility-level variation has been reported among veterans receiving care for various diseases. We studied the frequency and facility-level variations of guideline-recommended practices in patients with diabetes and CKD.Design, setting, participants, & measurementsPatients with diabetes and concomitant CKD (eGFR 15–59 ml/min per 1.73 m2, measured twice, 90 days apart) receiving care in 130 facilities across the Veterans Affairs Health Care System were included (n=281,223). We studied the proportions of patients (facility-level) receiving recommended core measures and facility-level variations of these study outcomes using median rate ratios, adjusting for various patient and provider-level factors. Median rate ratio quantifies the degree to which care may vary for similar patients receiving care at two randomly chosen facilities, with <1 being no variation and >1.2 as substantial variation between the facilities. Study outcomes included measurement of urine albumin-to-creatinine ratio/urine protein-to-creatinine ratio and blood hemoglobin concentration, prescription of statins and angiotensin-converting enzyme inhibitors/angiotensin receptor blockers, BP<140/90 mm Hg, and referral to a Veterans Affairs nephrologist (only for those with eGFR<30 ml/min per 1.73 m2).ResultsAmong those with eGFR 30–59 ml/min per 1.73 m2, proportion of patients receiving recommended core measures (median and interquartile range across facilities) were 37% (22%–47%) for urine albumin-to-creatinine ratio/urine protein-to-creatinine ratio, 74% (72%–79%) for hemoglobin measurement, 66% (62%–69%) for angiotensin-converting enzyme inhibitor/angiotensin receptor blocker prescription, 85% (74%–87%) for statin prescription, 47% (42%–53%) for achieving BP<140/90 mm Hg, and 13% (7%–16%) for meeting all outcome measures. Adjusted median rate ratios (95% confidence intervals) were 5.2 (4.1 to 6.4), 2.4 (2.1 to 2.6), 1.3 (1.2 to 1.3), 1.2 (1.2 to 1.3), 1.4 (1.3 to 1.4), and 4.1 (3.3 to 5.0), respectively. Median rate ratios were qualitatively similar in an analysis restricted to those with eGFR 15–29 ml/min per 1.73 m2.ConclusionsAmong patients with diabetes and CKD, at facility-level, ordering of laboratory tests, and scheduling of nephrology referrals in eligible patients remains suboptimal, with substantial variations across facilities.

scholarly journals Relationship between serum thyrotropin and urine albumin excretion in euthyroid subjects with diabetes

2018 ◽  
Vol 56 (1) ◽  
pp. 155-162 ◽  
Author(s):  
Gautam Das ◽  
Peter N Taylor ◽  
Hussam Abusahmin ◽  
Amer Ali ◽  
Brian P Tennant ◽  
...  
Keyword(s):  
Linear Regression Analysis ◽  
Creatinine Ratio ◽  
Albumin Creatinine Ratio ◽  
Urine Albumin Excretion ◽  
Albumin Excretion ◽  
Urine Albumin ◽  
The Metabolic Syndrome ◽  
Patients With Diabetes ◽  
Urine Albumin Creatinine Ratio ◽  
Serum Tsh

Background Microalbuminuria represents vascular and endothelial dysfunction. Thyroid hormones can influence urine albumin excretion as it exerts crucial effects on the kidney and on the vascular system. This study explores the relationship between serum thyrotropin and urine albumin excretion in euthyroid patients with diabetes. Methods A total of 433 patients with type 1 or 2 diabetes were included in this retrospective cross-sectional study. Data included anthropometric measurements and biochemical parameters from diabetes clinic. Males with urine albumin creatinine ratio >2.5 and female’s >3.5 mg/mmoL were considered to have microalbuminuria. Results 34.9% of the patients had microalbuminuria. Prevalence of microalbuminuria increased according to TSH quartiles (26.9, 34.6, 38.5 and 44.9%, P for trend = 0.02). In a fully adjusted logistic regression model, higher TSH concentrations were associated with high prevalence of microalbuminuria (adjusted odds ratio 2.06 [95% CI: 1.14–3.72]; P = 0.02), while comparing the highest with the lowest quartile of TSH. Multiple linear regression analysis showed an independent association between serum TSH and urine albumin creatinine ratio (β = 0.007, t = 2.03 and P = 0.04). The risk of having microalbuminuria was higher with rise in TSH concentration in patients with younger age (<65 years), raised body mass index (≥25 kg/m2), hypertension, type 2 diabetes and hyperlipidaemia and age was the most important determinant ( P for interaction = 0.02). Conclusion Serum TSH even in the euthyroid range was positively associated with microalbuminuria in euthyroid patients with diabetes independent of traditional risk factors. This relationship was strongest in patients with components of the metabolic syndrome.

scholarly journals Incident Chronic Kidney Disease Risk among Hispanics/Latinos in the United States: The Hispanic Community Health Study/Study of Latinos (HCHS/SOL)

2020 ◽  
Vol 31 (6) ◽  
pp. 1315-1324
Author(s):  
Ana C. Ricardo ◽  
Matthew Shane Loop ◽  
Franklyn Gonzalez ◽  
Claudia M. Lora ◽  
Jinsong Chen ◽  
...  
Keyword(s):  
United States ◽  
Risk Factors ◽  
The United States ◽  
Health Study ◽  
Creatinine Ratio ◽  
Albumin Creatinine Ratio ◽  
Urine Albumin ◽  
Hispanic Community ◽  
Urine Albumin Creatinine Ratio ◽  
Rate Ratios

BackgroundAlthough Hispanics/Latinos in the United States are often considered a single ethnic group, they represent a heterogenous mixture of ancestries who can self-identify as any race defined by the U.S. Census. They have higher ESKD incidence compared with non-Hispanics, but little is known about the CKD incidence in this population.MethodsWe examined rates and risk factors of new-onset CKD using data from 8774 adults in the Hispanic Community Health Study/Study of Latinos. Incident CKD was defined as eGFR <60 ml/min per 1.73 m2 with eGFR decline ≥1 ml/min per 1.73 m2 per year, or urine albumin/creatinine ratio ≥30 mg/g. Rates and incidence rate ratios were estimated using Poisson regression with robust variance while accounting for the study’s complex design.ResultsMean age was 40.3 years at baseline and 51.6% were women. In 5.9 years of follow-up, 648 participants developed CKD (10.6 per 1000 person-years). The age- and sex-adjusted incidence rates ranged from 6.6 (other Hispanic/mixed background) to 15.0 (Puerto Ricans) per 1000 person-years. Compared with Mexican background, Puerto Rican background was associated with 79% increased risk for incident CKD (incidence rate ratios, 1.79; 95% confidence interval, 1.33 to 2.40), which was accounted for by differences in sociodemographics, acculturation, and clinical characteristics. In multivariable regression analysis, predictors of incident CKD included BP >140/90 mm Hg, higher glycated hemoglobin, lower baseline eGFR, and higher baseline urine albumin/creatinine ratio.ConclusionsCKD incidence varies by Hispanic/Latino heritage and this disparity may be in part attributed to differences in sociodemographic characteristics. Culturally tailored public heath interventions focusing on the prevention and control of risk factors might ameliorate the CKD burden in this population.

scholarly journals Utilization Rates of SGLT2 Inhibitors and GLP-1 Receptor Agonists and Their Facility-Level Variation Among Patients With Atherosclerotic Cardiovascular Disease and Type 2 Diabetes: Insights From the Department of Veterans Affairs

2022 ◽  
Author(s):  
Dhruv Mahtta ◽  
David J. Ramsey ◽  
Michelle T. Lee ◽  
Liang Chen ◽  
Mahmoud Al Rifai ◽  
...  
Keyword(s):  
Type 2 Diabetes ◽  
Cardiovascular Disease ◽  
Veterans Affairs ◽  
Atherosclerotic Cardiovascular Disease ◽  
Level Variation ◽  
Receptor Agonists ◽  
Drug Classes ◽  
Facility Level ◽  
Rate Ratios

<i>Objective:</i> There is mounting evidence regarding the cardiovascular (CV) benefits of sodium-glucose cotransporter-2 inhibitors (SGLT2-Is) and glucagon like peptide-1 receptor agonists (GLP-1RAs) among patients with atherosclerotic cardiovascular disease (ASCVD) and type 2 diabetes (T2DM). There is paucity of data assessing real-world practice patterns for these drug classes. We aimed to assess utilization rates of these drug classes and facility-level variation in their utilization. <p> </p> <p><i>Research Design and Methods:</i> We used the nationwide Veterans Affairs (VA) healthcare system dataset from January 1, 2020 to December 31, 2020 and included patients with established ASCVD and T2DM. Among these patients, we assessed the use of SGLT2i and GLP-1RA and the facility-level variation in their utilization. Facility-level variation was computed using median rate ratios (MRR), a measure of likelihood that two random facilities differ in use of SGLT2i and GLP-1RA in patients with ASCVD and T2DM. </p> <p> </p> <p><i>Results:</i> Among 537,980 patients with ASCVD and T2DM across 130 VA facilities, 11.2% of patients received SGLT2i while 8.0% of patients received GLP-1RA. Patients receiving these cardioprotective glucose-lowering drug classes were on average younger and had a higher proportion of non-Hispanic Whites. Overall, median (10<sup>th</sup>-90<sup>th</sup> percentile) facility-level rates were 14.92% (9.31%-22.50%) for SGLT2i and 10.88% (4.44%-17.07%) for GLP-1RA. There was significant facility level variation among SGLT2-Is utilization - MRR<sub>unadjusted</sub> (95% CI):1.41 (1.35-1.47) and MRR<sub>adjusted</sub> (95% CI): 1.55 (1.46 – 1.63). Similar facility level variation was observed for utilization of GLP-1 RA – MRR<sub>unadjusted</sub> (95% CI):1.34 (1.29-1.38) and MRR<sub>adjusted </sub>(95% CI): 1.78 (1.65 – 1.90).</p> <p> </p> <p><i>Conclusions:</i> Overall utilization rates of SGLT2i and GLP-1RA among eligible patients are low with significantly higher residual facility-level variation in utilization of these drug classes. Our results suggest opportunities to optimize their use to prevent future adverse cardiovascular events among these patients. </p>

scholarly journals Facility-Level Variation in Cardiac Stress Test Use Among Patients With Diabetes: Findings From the Veterans Affairs National Database

Diabetes Care ◽  
2020 ◽  
Vol 43 (5) ◽  
pp. e58-e60
Author(s):  
Dhruv Mahtta ◽  
Sarah T. Ahmed ◽  
Nishant R. Shah ◽  
David J. Ramsey ◽  
Julia M. Akeroyd ◽  
...  
Keyword(s):  
Stress Test ◽  
Veterans Affairs ◽  
National Database ◽  
Level Variation ◽  
Cardiac Stress ◽  
Patients With Diabetes ◽  
Facility Level ◽  
Test Use ◽  
Cardiac Stress Test

Effects of alpha-lipoic acid supplementation on human diabetic nephropathy: A systematic review and meta-analysis

2021 ◽  
Vol 17 ◽  
Author(s):  
Elena Vakali ◽  
Dimitrios Rigopoulos ◽  
Andres E. Carrillo ◽  
Andreas D. Flouris ◽  
Petros C. Dinas
Keyword(s):  
Systematic Review ◽  
Diabetic Nephropathy ◽  
Lipoic Acid ◽  
Excretion Rate ◽  
Meta Analysis ◽  
Alpha Lipoic Acid ◽  
Creatinine Ratio ◽  
Biological Indices ◽  
Urine Albumin ◽  
Patients With Diabetes

Background: Diabetic nephropathy (DN) is a kidney dysfunction, which occurs due to elevated urine albumin excretion rate and reduced glomerular filtration rate. Studies in animals have shown that alpha-lipoic acid (ALA) supplementation can reduce the development of DN. Objectives: We performed a systematic review and meta-analysis to examine the effects of ALA supplementation on biological indices (albumin, creatinine etc.) indicative of human DN. Methods: The searching procedure included the databases PubMed Central, Embase, Cochrane Library (trials) and Web of Science, (protocol registration: INPLASY 202060095). Results: We found that ALA supplementation decreased urine albumin 24h excretion rate in patients with diabetes [standardized mean difference=-2.27; confidence interval (CI)=(-4.09)–(-0.45); I2=98%; Z=2.44; p=0.01]. A subgroup analysis revealed that the studies examining only ALA, did not differ from those examined ALA in combination with additional medicines (Chi-squared=0.19; p=0.66; I2=0%), while neither ALA nor ALA plus medication had an effect on urine albumin 24h excretion rate (p>0.05). Also, ALA supplementation decreased urine albumin mg/l [mean difference (MD)=-12.95; CI=(-23.88)–(-2.02); I2=44%; Z=2.32; p=0.02] and urine albumin to creatinine ratio [MD=-26.96; CI=(-35.25)–(-18.67); I2=0%; Z=6.37; p<0.01] in patients with diabetes. When the studies that examined ALA plus medication were removed, ALA supplementation had no effect on urine albumin mg/l (p>0.05), but did significantly decrease urine albumin to creatinine ratio [MD=-25.88, CI=(34.40–(-17.36), I2=0%, Z=5.95, p<0.00001]. Conclusion: The available evidence suggests that ALA supplementation does not improve biological indices that reflect DN in humans. Overall, we identified limited evidence and therefore, the outcomes should be considered with caution.

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