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Jeffrey J Sands

Publications and source records attributed to Jeffrey J Sands.

13 recordsLinked to original sources
PubMed2006

Increasing AV fistulae and decreasing dialysis catheters: two aspects of improving patient outcomes.

Maximizing arteriovenous (AV) fistula prevalence and minimizing catheter use have become the dominant issues in hemodialysis vascular access management and offer the promise of improved patient outcomes with decreased overall expenditures. Recent efforts have increased AV fistula prevalence in the US to 42.9% with regional rates as high as 59.5% and with complementary declines in AV grafts. This should decrease access procedures but may not fully realize the potential reductions in mortality and cost possible if combined with catheter reduction. Successful catheter reduction requires similar approaches to those utilized in the Fistula First Program. Educating patients, the use of clearly defined protocols and updating payment systems to include chronic kidney disease care are crucial to continued progress. Expansion of the Fistula First Program to include a focus on decreasing catheter prevalence and complications should be considered as a requirement in the push toward the breakthrough targets of 66% AV fistula prevalence.

Arteriovenous Shunt, Surgical↗
PubMed2006

Disease management improves end-stage renal disease outcomes.

BACKGROUND/AIMS: Renal disease management organizations have reported achieving significant decreases in mortality and hospitalization in conjunction with cost savings, improved patient satisfaction and quality of life. Disease management organizations strive to fill existing gaps in care delivery through the standardized use of risk assessment, predictive modeling, evidence-based guidelines, and process and outcomes measurement. Patient self-management education and the provision of individual nurse care managers are also key program components. METHODS: As we more fully measure clinical outcomes and total healthcare costs, including payments from all insurance and government entities, pharmacy costs and out of pocket expenditures, the full implications of disease management can be better defined. RESULTS: The results of this analysis will have a profound influence on United States healthcare policy. CONCLUSION: At present current data suggest that the promise of disease management, improved care at reduced cost, can and is being realized in end-stage renal disease.

Centers for Medicare and Medicaid Services, U.S.↗
PubMed2006

Predicting hospitalization and mortality in end-stage renal disease (ESRD) patients using an Index of Coexisting Disease (ICED)-based risk stratification model.

We evaluated the use of an additive Index of Coexisting Diseases (ICED)-based stratification schema to determine subsequent hospitalization and mortality in a hemodialysis population. Patients from five commercial health plans were stratified into low-, medium-, and high-risk groups and followed for up to 1 year. Patients were reassessed and restratified at 90-day intervals and censored when disease management ceased. Outcome measures collected through selfreports and health plan records were captured in an active database. Survival to first hospitalization/ mortality was compared by Kaplan Meier curves, survivor function differences by the Wilcoxon test, and group comparisons by ANOVA and chi square. Population characteristics included mean age of 63.0, 57.7% male, and 58.8% diabetic. Mortality was 13.0% per patient year (standardized mortality ratio 0.43) and the hospitalization rate was 0.59 per patient year (standardized hospitalization ratio 0.24). Survival curves demonstrated differences in mortality and hospitalization between the patients in different initial risk categories (p < 0.01). Mean hospitalizations were 0.81 +/- 1.53 per patient year (high risk), 0.45 +/- 0.99 (medium risk), and 0.15 +/- 0.51 for the low-risk group (p < 0.001). Stratification was dynamic; 47.3% decreased and 4.7% increased risk level between the first and second assessment. These changes were associated with survival differences for initial low (p = 0.06) or medium patients (p < 0.01), and hospital-free survival for initial medium (p = 0.08) or high patients (p < 0.05). In conclusion, this ICED-based stratification schema predicted mortality and hospitalization for hemodialysis patients participating in our disease management program.

Analysis of Variance↗
PubMed2005

Vascular access monitoring improves outcomes.

Vascular access monitoring can identify patients at increased risk of future access thrombosis. When coupled with a program of elective stenosis correction, access thrombosis rates decline approximately 50-75%. This results in arteriovenous (AV) fistula thrombosis rates of 0.1-0.2/patient year (vs. 0.2-0.4 at baseline) and AV graft thrombosis rates <0.5/patient year (vs. 0.8-1.2 thromboses/patient year at baseline). Evaluating the long-term impact on access survival remains problematic. There are no large-scale randomized trials and existing studies exhibit marked differences in target populations, clinical protocols and outcome definitions. Differences in payment systems also significantly influence the efficacy of monitoring and intervention programs. Despite these challenges, the current data support the K/DOQI recommendations that all patients undergo a program of regular access monitoring preferably by access flow measurement coupled with prompt imaging and elective stenosis correction for low flow accesses.

Arteriovenous Shunt, Surgical↗
PubMed2003

Improving vascular access outcomes: a systems approach to eliminating structural barriers.

Maximizing AV fistula creation, regular access monitoring, prompt outpatient interventions and minimizing catheter use are well-accepted approaches for vascular access management. Systemic barriers impede the application of these strategies. A misaligned reimbursement system coupled with educational deficits and a lack of accountability has contributed to the institutionalization of substandard vascular access care. The hallmark of performance management is to create systems in which incentives are aligned to produce desired behaviors. Realigning reimbursement through a combination of pre-ESRD funding, enhancements to the composite rate to reward outcomes and cover vascular access monitoring and updated reimbursement for outpatient vascular access procedures would improve care and decrease unnecessary hospitalizations. This should be coupled with clearly defined outcome standards and accountability incorporated into hospital accreditation and credentialing. Capitation may provide alternative solutions. A two-phased approach including reimbursement reform while exploring capitation represents a prudent course with the best likelihood of success.

Arteriovenous Shunt, Surgical↗
PubMed2002

Frequency of anti-heparin-platelet factor 4 antibodies in hemodialysis patients and correlation with recurrent vascular access thrombosis.

Heparin-induced thrombocytopenia (HIT), characterized by the formation of antibodies to a complex of platelet factor 4 (PF4) and heparin, is a well-recognized risk factor for thromboembolic complications. The frequency of antibody development varies among patient populations. Hemodialysis patients have repeated heparin exposure and should be at risk of developing HIT. This might, contribute to the development of vascular access thrombosis. We prospectively evaluated 88 hemodialysis patients for the presence of anti-PF4/heparin antibodies. Eighteen patients (20%) had a prior history of 1 or more prior access thrombosis. One patient (1.14%), without a history of graft thrombosis, tested positive for anti-PF4/heparin antibodies. In our study, the presence of anti-PF4/heparin antibodies was rare and was not increased in patients with a history of vascular access thrombosis.

Antibodies↗
PubMed2002

Systemic barriers to improving vascular access outcomes.

Vascular access dysfunction is the most frequent cause of hospitalization for end-stage renal disease (ESRD) patients. Our system of vascular access care and industry standards developed for historic reasons have resulted in a haphazard approach to access management. The Dialysis Outcome Quality Initiative has provided a road map for improving vascular access management. However, despite widespread acceptance, these recommendations are not routinely followed. This is largely the result of inertia coupled with systemic barriers to improving access outcomes. These barriers include lack of funded pre-ESRD care and preoperative imaging, lack of reimbursement for access monitoring, unavailable surgical and interventional suites, erosion of the real value of the composite rate, bundling of additional new services without rate adjustment, poor accountability of surgeons and hospitals, and a reimbursement system that rewards procedures and, in particular, graft and catheter placement. Currently, Center for Medicare and Medicaid Services is reevaluating the composite rate and its included bundle of services. To provide the best access care with the fewest complications while insuring multidisciplinary involvement and accountability, a realistic appraisal and realignment of incentives must be developed to insure improvement of access care in the United States.

Arteriovenous Shunt, Surgical↗
PubMed2002

The role of color flow Doppler ultrasound in dialysis access.

Color flow Doppler provides accurate imaging and access flow volume measurement of the hemodialysis vascular access. It can readily identify subsets of patients at high risk for future thrombosis. It is noninvasive, mobile, and allows convenient clinical evaluation at the dialysis facility. In Europe, Doppler ultrasound has become the standard of care for evaluation of arteriovenous (AV) fistula dysfunction and is essential in the preoperative evaluation for access placement. It also can diagnose the arterial inflow disease that has become more prevalent in our aging, diabetic, end-stage renal disease (ESRD) population. Access management programs based on Doppler ultrasound have been highly successful and have produced outcome data as good or better than provided with other techniques. In light of its proven clinical efficacy, reimbursement and regulatory agencies should allow its appropriate inclusion into integrated access management programs. In conclusion, Doppler ultrasound should be included as a part of an integrated vascular access management program. This is supported by clinical outcome data and direct comparisons with other modalities.

Arteriovenous Shunt, Surgical↗