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Biomedical subjects

Ashwini R Sehgal

Publications and source records attributed to Ashwini R Sehgal.

At least 19 recordsLinked to original sources
PubMed2006

Improving albumin levels among hemodialysis patients: a community-based randomized controlled trial.

BACKGROUND: Low albumin level is a strong predictor of mortality and morbidity among hemodialysis patients, yet few interventions are available to improve albumin levels. Moreover, the relative importance of nutritional barriers versus inflammation in contributing to hypoalbuminemia is unclear. We sought to determine whether targeting specific nutritional barriers will improve albumin levels. METHODS: We conducted a randomized controlled trial involving 180 patients with baseline albumin levels less than 3.7 g/dL (<37 g/L) at 44 long-term hemodialysis facilities. Study coordinators identified and intervened on specific barriers present among intervention patients, whereas control patients continued to receive the usual care. Barriers targeted included poor nutritional knowledge, poor appetite, help needed with shopping or cooking, low fluid intake, inadequate dialysis dose, depression, difficulty chewing, difficulty swallowing, gastrointestinal symptoms, and acidosis. RESULTS: At baseline, intervention and control patients had similar albumin levels, dietary intakes, levels of inflammatory markers, and numbers of nutritional barriers. After 12 months, intervention patients had greater increases in albumin levels compared with control patients (+0.21 versus +0.06 g/dL [+2.1 versus +0.6 g/L]; P < 0.01), as well as greater increases in energy intake (+4.1 versus -0.6 Kcal/d/kg; P < 0.001) and protein intake (+0.13 versus -0.06 g/d/kg; P < 0.001). The intervention appeared most effective for barriers related to poor nutritional knowledge, help needed with shopping or cooking, and difficulty swallowing. About half the subjects had elevated levels of inflammatory markers, but there was no relationship between change in levels of albumin and inflammatory markers. CONCLUSION: A nutrition intervention tailored to patient-specific barriers resulted in modest improvements in albumin levels regardless of levels of inflammatory markers.

Appetite↗
PubMed2006

The impact of Super Bowl parties on nutritional parameters among hemodialysis patients.

BACKGROUND: Little is known about the impact of holiday and other special-event meals on patients with chronic medical conditions. It is possible that patients are less adherent with dietary restrictions during such meals. We sought to determine the impact of Super Bowl parties on nutritional parameters among hemodialysis patients. OBJECTIVE: To determine the relationship between attending a Super Bowl party and subsequent change in serum phosphorus level, serum potassium level, interdialytic weight gain, and blood pressure. DESIGN: Retrospective cohort study. SETTING: Outpatient dialysis unit. PATIENTS: One hundred twenty-two chronic hemodialysis patients. MAIN OUTCOME MEASURES: Patients were asked whether they had attended a Super Bowl party. Serum phosphorus level, serum potassium level, interdialytic weight gain, and predialysis blood pressure at the hemodialysis treatment after the Super Bowl and at the hemodialysis treatment 1 month previously were obtained by chart abstraction. RESULTS: The 15 patients who had attended a party had increased serum phosphorus levels (+0.5 mg/dL) and interdialytic weight gain (+1.1% of dry weight) from baseline. These increases were statistically significant (P values .005 and .02, respectively) compared with patients who did not attend a party. Attendees also had increased systolic blood pressure (+6 mm Hg) from baseline, but this was of marginal statistical significance compared with nonattendees (P = .14). Attending a party was not significantly associated with changes in serum potassium and diastolic blood pressure. CONCLUSIONS: Attending a Super Bowl party is associated with adverse changes in several nutritional parameters. Although patients should not be discouraged from attending holiday and special-event meals, management of hemodialysis patients should include increased dietary counseling before holidays and special events and increased monitoring afterward.

Adult↗
PubMed2006

Job satisfaction among renal dietitians.

OBJECTIVE: Little is known about job satisfaction among renal dietitians. We sought to determine overall job satisfaction and specific domains of job satisfaction among renal dietitians. DESIGN: Cross-sectional study. SETTING: A total of 46 outpatient hemodialysis facilities in northeast Ohio. PARTICIPANTS: A group of 40 renal dietitians. INTERVENTION: Structured questionnaire. MAIN OUTCOME MEASURE: Overall job satisfaction; specific domains of job satisfaction, workload, and suggestions for improving job satisfaction. RESULTS: Of all responding dietitians, 78% expressed overall satisfaction with their job. Dietitians were least satisfied with opportunities for advancement (13%), supervisors' handling of employees (50%), the chance to be somebody in the community (53%), praise received for doing a good job (55%), and amount of work assigned (58%). Dietitians were most satisfied with the chance to do things for others (98%). A higher patient-to-renal dietitian ratio was associated with lower overall job satisfaction and a reduced likelihood that renal dietitians would recommend their career to others. The most common suggestions for improving job satisfaction consisted of reducing paperwork (named by 28% of dietitians), spending more time with patients (23%), and increasing time for creative projects (18%). CONCLUSIONS: Although renal dietitians generally expressed overall satisfaction with their jobs, almost all were dissatisfied with opportunities for advancement, and nearly half were dissatisfied with other specific aspects of their work. We urge local and national associations of renal dietitians to collaborate with dialysis facilities, chains, and regulatory agencies to improve job satisfaction. Further research is needed to determine the impact of job satisfaction of renal dietitians on patient outcomes.

Adult↗
PubMed2006

Universal health care and reform of the health care system: views of medical students in the United States.

PURPOSE: Nearly 46 million Americans did not have health insurance in 2004. Recent studies have documented physicians' support for various remedies, including universal health care. The authors undertook this study to assess medical students' views on these topics. METHOD: In 2002, the authors surveyed a national random sample of first-year and fourth-year medical students (from the American Medical Association Masterfile) to determine their views about health care reform options, including universal health care. Response data were weighted and compared using chi-squared tests; statistical significance was set at p < or = .05. RESULTS: Of 1,363 medical students, 770 completed the questionnaire (response rate = 56.5%). In rating the importance of several health care issues, more than 80% of both first-year and fourth-year students rated the expansion of health care coverage as important. Nearly all first-year (90%) and fourth-year (88%) students agreed with the statement, "Everyone is entitled to adequate medical care regardless of ability to pay." Most students favored health care reform that would achieve universal health care, with first-year students (70%) somewhat more likely than fourth-year students (61%) to support universal health care (p = .012). Students were less likely to believe that physicians support universal health care, and more likely to believe that the public does. CONCLUSIONS: Both groups of students generally support the expansion of health coverage to the uninsured and some form of universal health care. This may be relevant both to policymakers in their considerations of health care reform and to medical educators concerned with teaching students about health policy issues.

Attitude of Health Personnel↗
PubMed2006

Determinants of metabolic acidosis among hemodialysis patients.

Metabolic acidosis is frequently present, poorly controlled, and associated with adverse effects among hemodialysis patients. Potential determinants of metabolic acidosis include endogenous acid production, administration of alkali, neutralization of acid by buffers, dilution of serum bicarbonate by interdialytic fluid gain, and loss of bicarbonate in stool. Understanding the relative importance of these determinants may help guide efforts to manage metabolic acidosis. We used chart abstraction, patient interviews, and laboratory testing to assess variables related to acid production (protein breakdown), alkali administration (dialysis dose, missed treatments, dialysate bicarbonate concentration, oral bicarbonate supplements), acid buffering (phosphorus binders), dilution of bicarbonate (interdialytic weight gain), and loss of bicarbonate in stool (diarrhea) for 190 randomly selected patients from 44 hemodialysis facilities. We used multivariate analyses to determine which potential determinants were independently associated with predialysis serum bicarbonate levels. Of all patients, 30% had metabolic acidosis (serum bicarbonate level <22 mEq/L). On multivariate analysis, metabolic acidosis was more likely with increased protein nitrogen appearance (odds ratio [OR] 1.60 per 0.2 g/kg/day, p=0.001) and less likely with increased Kt/V (OR 0.61 per 0.20 increase in Kt/V, p<0.001) and with increased calcium carbonate use (OR 0.38 per 2 g/day, p=0.003). Key determinants of metabolic acidosis among hemodialysis patients are protein breakdown, dialysis dose, and specific phosphorus binders. Further work is needed to develop interventions to address these determinants.

Acidosis↗
PubMed2005

A dipstick protein and specific gravity algorithm accurately predicts pathological proteinuria.

BACKGROUND: The proper strategy to screen for early chronic kidney disease is debatable, but protein-creatinine ratio from a random urine sample (UPC) commonly is used. The purpose is to determine whether dipstick data effectively identify patients with increased UPC ratios. Because urine concentration affects proteinuria interpretation, we hypothesized that dipstick protein (DSP) and specific gravity (SG) are sufficient for screening. METHODS: A hospital laboratory database was searched for urine samples simultaneously assayed for UPC ratio, DSP, and SG (n = 2,098). A random 70% of the cohort was used to generate a development model, which was validated in the remaining 30%. Samples were stratified according to DSP and SG values. A DSP versus SG matrix was created, and each sample was allocated to a discrete DSP-SG category. Proportions of samples with overt (UPC ratio > or = 500 mg/g) and nephrotic-range proteinuria (UPC ratio > or = 3,000 mg/g) were calculated for all 40 cells. RESULTS: Optimum correlations between DSP-SG cells and UPC ratios were determined for the development model, yielding 97.0% negative predictive value (NPV) for a UPC ratio of 500 mg/g or less and 97.5% positive predictive value (PPV) for a UPC ratio of 500 mg/g or greater. NPV for a UPC ratio of 3,000 mg/g or less was 99.7%. Application of the model to the validation sample showed a 96.5% NPV for a UPC ratio of 500 mg/g or less, 99.4% PPV for a UPC ratio of 500 mg/g or greater, and 99.0% NPV for a UPC ratio of 3,000 mg/g or less. CONCLUSION: DSP and SG values effectively identify patients requiring proteinuria quantification by means of UPC ratio. A Web-based tool was developed that allows DSP and SG value entry and provides a recommendation regarding the need for proteinuria quantification.

Biomarkers↗
PubMed2005

Changes in Medicare reimbursement and patient-nephrologist visits, quality of care, and health-related quality of life.

BACKGROUND: Medicare's reimbursement system was changed in January 2004 to encourage more frequent visits between dialysis patients and nephrologists. We sought to determine the impact of this policy change on patient-nephrologist visits, quality of care, and health-related quality of life. METHODS: We examined visits and outcomes for 2,043 patients at 12 hemodialysis facilities in northeast Ohio for 12 months before and 7 months after the reimbursement change. For comparison of outcomes, we used linear, logistic, or negative binomial regression models (for continuous, binary, and rate outcomes, respectively) to assess the significance of changes across the 2 periods. RESULTS: For patients seen before and after the reimbursement change for at least 6 months, the number of visits per patient-month increased from 1.52 before to 3.14 after (P < 0.001). The percentage of patients with no nephrologist visits per patient-month decreased from 16.6% before to 4.6% after (P < 0.001). However, there were no clinically important changes in Kt/V, albumin level, hemoglobin level, phosphorus level, calcium level, hemodialysis catheter use, ultrafiltration volume, shortened or skipped treatments, hospital admissions, hospitalization days, or health-related quality of life, including patient satisfaction. CONCLUSION: Despite a marked increase in visits between patients and nephrologists, there was no clinically important impact on parameters related to quality of care or health-related quality of life. Additional work is needed to determine effective payment strategies to improve dialysis patient outcomes.

Cohort Studies↗
PubMed2005

Medical students' knowledge of the U.S. health care system and their preferences for curricular change: a national survey.

PURPOSE: To measure medical students' knowledge of central issues in the U.S. health care system and to understand their perception of the importance and quality of health policy curricula at their medical schools. METHOD: A questionnaire was developed using facts from recent national and international health reports to test students' knowledge of health policy. The instrument, containing 14 questions about health policy and four questions about school curriculum on health policy, was mailed to a national probability sample of 516 first-year and 847 fourth-year students in the United States. Chi-square and t tests were used to compare the responses of first- and fourth-year students. RESULTS: A total of 295 first-year (57%) and 475 fourth-year students (56%) responded. Nearly all respondents were aware of the adverse health consequences for the uninsured, but 40% of first- and fourth-year students underestimated the numbers of uninsured in the United States. Thirty-two percent of respondents incorrectly answered that the United States had the highest life expectancy of any nation, and 27% were not aware that the United States has the highest health cost per-person of any nation. First- and fourth-year students performed similarly on knowledge questions. Ninety-six percent of respondents felt that knowledge of health policy is important to their career, and 54% expressed dissatisfaction with the health policy curriculum in medical school. CONCLUSION: Medical students have significant gaps in knowledge concerning the U.S. health care system. Most students perceive that these deficiencies are not adequately addressed in the medical school curriculum.

Adult↗
PubMed2005

The morbidity and cost implications of hemodialysis clinical performance measures.

Clinical performance measures, including dialysis dose, hemoglobin, albumin, and vascular access, are the focus of monitoring and quality improvement activities. However, little is known about the implications of clinical performance measures for hospital utilization and health care costs. We obtained clinical performance measures and hospitalization records for a national random sample of 10,650 hemodialysis patients and analyzed the relationship between changes in clinical performance measures and hospital utilization after adjustment for patient demographic and medical characteristics. Higher hemoglobin, higher albumin, and fistula or graft use were independently associated with fewer hospitalizations, fewer hospital days, and decreased Medicare inpatient reimbursement. For example, a 0.5 g/dL higher hemoglobin, a 0.25 g/dL higher albumin, fistula use, and graft use were associated with hospitalization rate ratios of 0.90 (95% confidence interval 0.85, 0.96), 0.64 (0.53, 0.77), 0.60 (0.52, 0.69), and 0.79 (0.71, 0.89), respectively. Moreover, there was a 2-3-fold variation in hospital utilization across end-stage renal disease networks that was still evident after adjustment for patient characteristics and clinical performance measures. Clinical performance measures, especially albumin and vascular access, are strongly associated with hospital utilization and health care costs. These results highlight the importance of targeting nutrition and vascular access in quality improvement efforts. The marked variation in hospital utilization across networks deserves further examination.

Costs and Cost Analysis↗
PubMed2004

The net transfer of transplant organs across race, sex, age, and income.

PURPOSE: To determine how sociodemographic characteristics influence both access to transplantation and organ donation. METHODS: For all transplants in the United States from 1996 to 2001, donor-recipient pairs were categorized as white-white, white-black, black-white, or black-black. The difference in the percentage of white-black versus black-white pairs was calculated as a measure of the net transfer of organs from one racial group to another. A similar approach was used to examine the net transfer of organs across other sociodemographic categories. RESULTS: Among cadaveric renal transplants, 66% of donor-recipient pairs were white-white, 23% were white-black, 5% were black-white, and 6% were black-black. Thus, there was an 18% net transfer of organs from white donors to black recipients (23% minus 5%). Among living donor transplants involving spouses, there was a 36% net transfer from wives to husbands. Among all cadaveric transplants, there was a 36% to 68% net transfer from younger donors to older recipients. Among cadaveric nonrenal transplants, there was a 7% to 18% net transfer from lower-income donors to higher-income recipients. CONCLUSION: The sociodemographic characteristics of persons who donate organs and those who benefit from organ transplantation differ markedly. Efforts to improve access and increase donation should address these differences.

Adult↗
PubMed2004

Health care lobbying in the United States.

PURPOSE: To assess the relative political influence of different organizations, we examined the efforts of health care organizations to influence policy decisions by lobbying lawmakers. METHODS: We reviewed reports filed by lobbyists from 1997 to 2000, as required by the Lobbying Disclosure Act, to characterize health care lobbying at the federal level in the United States. RESULTS: Health care lobbying expenditures totaled 237 million dollars in 2000. These expenditures accounted for 15% of all federal lobbying and were larger than the lobbying expenditures of every other sector, including agriculture, communications, and defense. A total of 1192 organizations were involved in health care lobbying. Pharmaceutical and health product companies spent the most (96 million dollars), followed by physicians and other health professionals (46 million dollars). Disease advocacy and public health organizations spent 12 million dollars. From 1997 to 2000, lobbying expenditures by physicians and other health professionals grew more slowly than lobbying by other organizations (10% vs. 26%). CONCLUSION: Although policy decisions are influenced by many factors, our findings may indicate a limited political influence of disease advocacy and public health organizations and a declining political influence of physicians and other health professionals.

Drug Industry↗
PubMed2004

Overlap between whites and blacks in response to antihypertensive drugs.

On average, whites and blacks differ in their response to specific antihypertensive drugs. These differences are often highlighted in reviews and practice guidelines. However, there is wide variation in drug-associated changes in blood pressure within each race. The goal of this meta-analysis is to quantitate how often whites and blacks have similar responses to specific antihypertensive drugs. Computerized searches of MEDLINE (1983 to March 2003) and manual searches of references listed in identified articles were performed. Studies were included if they provided race-specific changes in blood pressure. Fifteen studies with a total of 9307 white subjects and 2902 black subjects were analyzed. For drug-associated changes in diastolic blood pressure, the mean difference between whites and blacks ranged from 0.6 to 3.0 mm Hg while the standard deviation within each race ranged from 5.0 to 10.1 mm Hg. The percentage of whites and blacks with similar drug-associated changes in diastolic blood pressure was 90% (95% confidence interval: 81 to 99) for diuretics, 90% (95% CI: 83 to 97) for beta-blockers, 95% (95% CI: 92 to 98) for calcium channel blockers, and 81% (95% CI: 76 to 86) for angiotensin converting enzyme inhibitors. The percentage of whites and blacks with similar drug-associated changes in systolic blood pressure ranged from 83% to 93%. In conclusion, the majority of whites and blacks have similar responses to commonly used antihypertensive drugs. Clinical decisions to use a specific drug should be based on other considerations such as efficacy in individual patients, compelling indications, and cost.

Antihypertensive Agents↗
PubMed2004

Decreased bone resorption with soy isoflavone supplementation in postmenopausal women.

OBJECTIVE: To investigate the effect of soy isoflavone supplementation on bone mineral density (BMD) and markers of bone turnover in postmenopausal women. METHODS: In this randomized, placebo-controlled clinical trial, we used a crossover design to test the effect of soy isoflavone (110 mg/day) (1.3:1.0:0.22 ratio of genistein/daidzein/ glycitein) on bone formation, bone resorption, bone mineral content (BMC), and BMD for 6 months. RESULTS: Postmenopausal women (n = 19), mean age 70.6 +/- 6.3 years and mean time since menopause 19.1 +/- 5.5 years, were given isoflavone supplements for 6 months. There was a 37% decrease in urinary concentrations of type 1 collagen alpha1-chain helical peptide (HP), a marker of bone resorption, during the isoflavone supplementation compared with baseline (p < 0.05) and a significant difference in mean (SE) HP excretion levels when isoflavone was compared with placebo (43.4 +/- 5.2 vs. 56.3 +/- 7.2 microg/mmol creatinine [cr], p < 0.05). With isoflavone supplementation, mean spine BMD at L2 and L3 was significantly greater when treatment was compared with control, with a difference between means of 0.03 +/- 0.04 g and 0.03 +/- 0.04 g (p < 0.05), respectively. There were nonsignificant increases from baseline for total spine BMC (3.5%), total spine BMD (1%), total hip BMC (3.6%), and total hip BMD (1.3%) with the isoflavone treatment. CONCLUSIONS: Soy isoflavone, in isolated form, was effective in this study to significantly decrease bone resorption in postmenopausal women. Further investigation needs to be done to evaluate the long-term effects of soy isoflavone on bone mass and fracture risk.

Aged↗
PubMed2003

Impact of quality improvement efforts on race and sex disparities in hemodialysis.

CONTEXT: By improving the process of care, quality improvement efforts have the potential to reduce race and sex disparities. However, little is known about whether reductions actually occur. National quality improvement activities targeting hemodialysis patients provide an opportunity to examine this issue. OBJECTIVE: To determine the effect of quality improvement efforts on race and sex disparities among hemodialysis patients. DESIGN, SETTING, AND SUBJECTS: Longitudinal study of 58 700 randomly selected hemodialysis patients from throughout the United States in 1993 through 2000. INTERVENTION: Medicare-funded quality improvement project involving monitoring of patient outcomes, feedback of performance data, and education of clinicians at dialysis centers. MAIN OUTCOME MEASURES: Changes in hemodialysis dose (Kt/V), anemia management (hemoglobin level), and nutritional status (albumin level). RESULTS: The proportion of all patients with an adequate hemodialysis dose increased 2-fold. In 1993, 46% of white patients and 36% of black patients received an adequate hemodialysis dose compared with 2000 when the proportions were 87% and 84%, respectively. Thus, the gap between white and black patients decreased from 10% to 3% (P<.001). The gap between female and male patients decreased from 23% to 9% over the same period (P =.008). The proportion of all patients with adequate hemoglobin levels increased 3-fold. The proportion of all patients with adequate albumin levels remained unchanged. Race and sex disparities in anemia management and nutritional status did not change significantly. CONCLUSIONS: Quality improvement efforts have a variable impact on race and sex disparities in health outcomes. Further work is needed to determine how quality improvement methods can be targeted to reduce health disparities.

Adult↗
PubMed2003

The provision and outcomes of diabetic care of hemodialysis patients.

BACKGROUND: Approximately 40% of hemodialysis patients have diabetes, yet little is known about their diabetic care. We sought to examine the provision and outcomes of diabetic care of hemodialysis patients. METHODS: We randomly selected 188 hemodialysis patients with diabetes from nine facilities and identified the physicians providing their diabetic care. Patients and physicians reported on the care provided for six domains (diet, diabetes medications, hypertension, cholesterol, feet, and eyes). Chart abstraction was used to determine four outcomes (glucose control, blood pressure, albumin level, and cholesterol level). RESULTS: Most patients had a nephrologist, primary care physician, eye specialist, and podiatrist. Each domain of care generally was addressed on a regular basis. Nephrologists and primary care physicians differed on who should provide care for specific domains. For example, only 12% of nephrologists believed primary care physicians should manage hypertension, whereas 74% of primary care physicians believed they should manage hypertension (P < 0.001). Patient outcomes often were suboptimal, with one fourth to one half of patients having elevated glucose, blood pressure, or lipid levels. Many patients were not administered insulin, appropriate antihypertensives, or lipid-lowering medications. Primary care physicians felt frustrated by a lack of communication from nephrologists about laboratory results, medication changes, and procedures. CONCLUSION: Although hemodialysis patients with diabetes appear to receive timely care from a variety of physicians, patient outcomes often are poor. Medication use is suboptimal, nephrologists and primary care physicians disagree on their roles, and communication among physicians is limited. Interventions to improve outcomes of hemodialysis patients with diabetes should address these impediments.

Adult↗
PubMed2003

Diet monotony as a correlate of poor nutritional intake among hemodialysis patients.

OBJECTIVE: Nutritional guidelines recommend eating a variety of foods, yet the renal diet restricts the intake of many foods. Poor appetite, present in 10% to 30% of hemodialysis patients, further narrows the range of foods consumed. We sought to determine the relationship between diet monotony and nutritional intake in patients on chronic hemodialysis. DESIGN: Cross-sectional study. SETTING: Eight freestanding hemodialysis units in northeast Ohio. SUBJECTS: Forty-eight randomly selected hemodialysis patients. INTERVENTION: We used the Block-National Cancer Institute questionnaire to obtain a detailed food frequency and also asked patients to rate their appetite for 10 specific high-protein foods. OUTCOME MEASURE: We adapted the Herfindahl index (a measure of hospital market concentration) to calculate a diet monotony index and then examined the relationship between monotony index and energy and protein intake. RESULTS: When stratified into tertiles by monotony index, patients with the most varied diets had the highest energy (33 kcal/kg/d) and protein (1.35 g/kg/d) intake, whereas patients with the most monotonous diets had the lowest energy (21 kcal/kg/d) and protein (0.83 g/kg/d) intake. A 5-point increase in monotony index was independently associated with a 10 kcal/kg/d decrease in energy intake (P = .004) and a 0.43 g/kg/d decrease in protein intake (P = .006) after adjustment for patient demographic and medical characteristics. Patients with the most monotonous diets reported a good appetite for an average of 3.1 high-protein foods that they were eating less than once per week. CONCLUSION: Diet monotony strongly correlates with nutritional intake. However, patients with monotonous diets have a good appetite for several high-protein foods that they are not eating. Helping patients to identify and increase the intake of these foods may both enhance diet variety and improve nutritional status.

Aged↗