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Day: 03/27/2022
Increased fatty liver disease awareness needed to mitigate burden among young adults
Increased awareness is needed to mitigate burden fatty liver disease and modifiable risk factors among adolescents and young adults, according to research presented at The Liver Meeting Digital Experience.
“The prevalence of fatty liver disease is potentially increasing in adolescents and young adults, what we call the AYA population, and this is due to increased rates of alcohol consumption in recent years leading to an increase in alcohol-associated fatty liver disease, or ALD, and the obesity pandemic leading to an increase in the prevalence of nonalcoholic fatty liver disease, or NAFLD,” Naim Alkhouri, MD, vice president of academic affairs and director of the Fatty Liver Program at Arizona Liver Health, said. “Previous studies that estimated the prevalence of fatty liver disease in the AYA population relied on liver enzymes or liver ultrasound with known issues in terms of sensitivity and specificity.”
To assess the prevalence and burden of alcohol-associated fatty liver disease (ALD) and nonalcoholic fatty liver disease, researchers analyzed data from the National Health and Nutrition Examination Survey database for adolescents and young adults aged 15 years to 39 years with valid FibroScan measurements. They further divided the study population by excessive alcohol consumption (males: > 2 drinks/day; females: > 1 drink/day) and generated controlled attenuation parameter scores ([CAP] 248 dB/m) to identify subjects with suspected ALD and NAFLD.
According to study results, subjects who consumed alcohol excessively were older (28.1 years vs. 26.2 years), had a higher BMI (29.2 kg/m2 vs. 27.6 kg/m2), were current smokers (51% vs. 17.9%) and were more likely to be male (63.4% vs. 51.1%).
Suspected ALD was present in 42.4% of subjects (95% CI, 36.5-48.4) with suspected significant and advanced fibrosis present in 17.7% (95% CI, 13-23.6) and 9.4% (95% CI, 6.5-12.3), respectively. Among subjects without excessive alcohol consumption, 39% (95% CI, 35.6-42.4) had suspected NAFLD with suspected significant and advanced fibrosis present in 25.1% (95% CI, 21.3-29.5) and 14.4% (95% CI, 9.7-20).
“A significant percentage of adolescents and young adults in the United States are at risk for alcohol associated liver disease and nonalcoholic fatty liver disease and a subset of these subjects are at risk of significant liver fibrosis and even advanced liver fibrosis,” Alkhouri concluded. “Therefore, efforts should focus on increasing awareness of the burden of ALD and NAFLD in this population and to mitigate modifiable risk factors to prevent disease development and disease progression to potentially advanced fibrosis and cirrhosis.”
Providers should ‘think TB’ as data show possibility of underdiagnosis
There was a 20% decline in reported cases of tuberculosis in the United States in 2020 compared with previous years, which was not a result of underreporting but did raise concerns that TB was underdiagnosed, researchers said.
Kathryn Winglee
“This drop was dramatically different from the average yearly decrease of 2% to 3% observed over the past 10 years,” Kathryn Winglee, PhD, a statistician in the CDC’s Division of Tuberculosis Elimination, told Healio. “CDC explored whether this decrease could have been caused by underreporting due to strains on the public health system from the COVID-19 pandemic.”
Winglee and colleagues compared trends of prescriptions for TB medications with reported TB cases to determine if the number of patients who were likely treated for TB differed from the number of cases reported by public health departments.
Overall, the data showed large declines in 2020 “strongly correlating” with national TB surveillance case counts, which researchers said helped rule out underreporting as a cause. According to the study, NTSS case counts decreased every year except 2007 and 2014, with 2009 seeing the largest decrease before 2020. They said the 2020 decrease is larger than previously reported because the treatment start date is missing for 2.8% of cases counted in 2019 and 5.2% of cases counted in 2020.
Similarly, the researchers found that the isoniazid IQVIA projected patient counts generally decreased each year, with 2020 seeing the largest decrease (28.6%). However, the pyrazinamide IQVIA patient counts revealed 4 years during which more cases occurred than the previous year 2014, 2015, 2017 and 2019. Azithromycin IQVIA data also showed multiple years with more projected patients than the previous year but a large drop in 2020 of 25.9%.
Researchers then analyzed whether the large declines in 2020 were within the error of what was expected based on previous trends. Overall, they found that most of the data within the 95% prediction interval with the April to December 2020 NTSS monthly case counts and IQVIA isoniazid projected patient counts were all below the lower bound of the 95% prediction interval. In contrast, however, the IQVIA projected patient counts for pyrazinamide, were only lower than the 95% prediction interval in April.
“This analysis has helped to rule out underreporting of TB cases as a cause of the 2020 decline, since the trends in TB prescriptions are similar to the trends in reported TB cases,” Winglee said. “However, concerns remain about missed or delayed diagnoses of TB disease.”
Because of this, she sais health care providers “should think TB,” especially for patients with risk factors and symptoms of TB disease.
“Timely diagnoses of TB disease save lives and prevent further spread in our communities,” she said.
Addition of P2Y12 inhibitor fails to benefit noncritically ill patients with COVID-19
In a cohort of noncritically ill patients with COVID-19, the addition of a P2Y12 inhibitor to anticoagulation did not extend survival or lessen disease severity, according to results of the ACTIV-4a trial.
Thrombosis and inflammation contribute to the risk for death and complications in patients with COVID-19.
Jeffrey S. Berger
“Data from the [multiplatform randomized controlled trial] demonstrated that therapeutic-dose heparin increased days alive and free of organ support in noncritically ill (moderate) patients with COVID-19,” Jeffrey S. Berger, MD, MS, associate professor of medicine and surgery with appointments in cardiology, hematology and vascular surgery at NYU Grossman School of Medicine and director of the Center for the Prevention of Cardiovascular Disease at NYU Langone Health, said during a presentation at the American Heart Association Scientific Sessions. “Nonetheless, nearly one out of four patients receiving therapeutic-dose heparin still died or received intensive care level support, highlighting the need for additional therapies in this cohort.”
This led Berger and colleagues to conduct the open-label ACTIV-4a trial, in which they randomly assigned patients 1:1 to a P2Y12 inhibitor plus standard care anticoagulation of therapeutic-dose heparin or standard care anticoagulation and no P2Y12 inhibitor (usual care).
The preferred recommended P2Y12 inhibitor was ticagrelor (60 mg twice daily without a loading dose; Brilinta, AstraZeneca). Clopidogrel (300 mg loading dose followed by 75 mg daily) and prasugrel (30 mg loading dose and 10 mg daily; Effient, Daiichi Sankyo/Eli Lilly) were also allowed. Patients received P2Y12 inhibitor treatment for 14 days or until hospital discharge, whichever came first.
The researchers defined the primary endpoint as 21-day organ support-free days; key secondary endpoint as the composite of major thrombotic events or death; and primary safety endpoint as major bleeding according to the International Society on Thrombosis and Haemostasis definition.
The study continued until a conclusion of superiority (> 99% posterior probability proportional OR > 1) or futility (> 95% posterior probability proportional OR < 1.2) with P2Y12 inhibitor treatment was reached.
In all, researchers enrolled 562 noncritically ill patients with laboratory-confirmed SARS-CoV-2 infection at the time of enrollment discontinuation. Among them, 293 patients received a P2Y12 inhibitor and 269 received usual care.
Primary endpoint data indicated an adjusted OR of 0.83 (95% credible interval, 0.55-1.25), with a futility probability of 96.2%.
In addition, there was no benefit with P2Y12 inhibition on the composite of death or organ support (aHR = 1.19; 95% CI, 0.84-1.68; P = .34); the key secondary outcome (aOR = 1.42; 95% CI, 0.64-3.13); or the primary safety endpoint (aOR = 3.31; 95% CI, 0.64-17.2).
“In noncritically ill hospitalized patients with COVID-19, use of P2Y12 inhibitors did not result in a greater number of days alive and free of cardiovascular or respiratory organ support,” Berger concluded, noting the low rate of major bleeding with the therapy, which increased the absolute risk by approximately 1%. “Testing P2Y12 inhibitors in critically ill patients is ongoing.”
Antiplatelet agents fail to benefit critically ill adults with COVID-19
Compared with no antiplatelet therapy, aspirin and P2Y12 inhibitors did not improve the number of organ support-free days in critically ill patients with COVID-19, according to results of the REMAP-CAP trial published in JAMA.
The researchers enrolled 1,557 critically ill patients with COVID-19 (median age, 57 years; 34% women) in the REMAP-CAP ongoing adaptive platform trial. Patients were randomly assigned aspirin, a P2Y12 inhibitor or no antiplatelet therapy for a maximum of 14 days on top of anticoagulation thromboprophylaxis.
The primary endpoint was number of organ support-free days, defined as being alive and free from ICU-based CV or respiratory organ support, at 21 days.
The aspirin group and the P2Y12 inhibitor group met the prespecified criteria for equivalence and were pooled for comparison to the control group, the researchers wrote.
No net benefit
Charlotte A. Bradbury
The median number of organ support-free days for both the antiplatelet and control groups was 7 (interquartile range, –1 to 16; median-adjusted OR = 1.02; 95% credible interval [CrI], 0.86-1.23; posterior probability of futility, 95.7%), Charlotte A. Bradbury, MD, PhD, from the Bristol Haematology and Oncology Centre, Bristol, U.K., and colleagues wrote.
Among the antiplatelet cohort, 71.5% survived to hospital discharge compared with 67.9% of the control group (median-adjusted OR = 1.27; 95% CrI, 0.99-1.62; adjusted absolute difference, 5%; 95% CrI, –0.2 to 9.5; posterior probability of efficacy, 97%), the researchers wrote.
In both groups, among patients who survived, the median number of organ support-free days was 14.
“The reduction in mortality was counterbalanced by an increase in the number of patients receiving short durations of organ support (< 6 days), resulting in an overall net neutral effect on the outcome of organ support–free days,” the researchers wrote.
Major bleeding occurred in 2.1% of the antiplatelet group and 0.4% of the control group (adjusted OR = 2.97; 95% CrI, 1.23-8.28; adjusted absolute risk increase, 0.8%; 95% CrI, 0.1-2.7; probability of harm, 99.4%), Bradbury and colleagues wrote.
“It is possible that antiplatelet therapy may reduce fatal complications of COVID-19 in critically ill patients while potentially increasing the need for organ support, possibly through bleeding that may or may not be clinically evident, such as alveolar hemorrhage,” the researchers wrote. “Major bleeding occurred more frequently in patients randomized to antiplatelet therapy. It is also possible that the net neutral effect of antiplatelet therapy on organ support–free days may have been influenced by a harmful interaction between antiplatelet therapy and therapeutic-dose anticoagulation, whereby patients receiving the combination appeared to have worse outcomes.”
‘No proven efficacy’
Paul M. Ridker
In a related editorial, Jean M. Connors, MD, hematologist at Brigham and Women’s Hospital and associate professor of medicine at Harvard Medical School, and Paul M. Ridker, MD, MPH, director of the Center for Cardiovascular Disease Prevention at Brigham and Women’s Hospital and Eugene Braunwald Professor of Medicine at Harvard Medical School, wrote that REMAP-CAP is the latest of several trials to demonstrate that a net hazard is produced when antiplatelets are added to anticoagulation alone in patients with COVID-19.
“The accumulated data should provide physicians with the rare confidence to do less rather than more, a finding that also has become apparent with anticoagulation therapy,” Connors and Ridker wrote.
“At this juncture in the global pandemic, all hospitalized patients with COVID-19 and low risk of bleeding should receive at least prophylactic-dose anticoagulation with a heparin anticoagulant, with consideration of therapeutic-dose heparin in some cases, but there is no proven efficacy supporting the addition of traditional antiplatelet therapies to prevent progressive thromboinflammatory complications of COVID-19,” they wrote. “The clinical goal, however, should be to avoid thromboinflammation and hospitalization in the first place, an objective largely achievable through aggressive vaccination.”
Reference:
Mediterranean diet may preserve kidney function better than low-fat for adults with CHD
Adults with coronary heart disease who followed a Mediterranean diet preserved their kidney function better than those who followed a low-fat diet for 5 years, according to study data published in Clinical Nutrition.
“In persons suffering from coronary heart disease and, in combination with type 2 diabetes, the long-term consumption of a Mediterranean diet would be recommended to preserve kidney function,” Jose Lopez Miranda, MD, PhD, professor of internal medicine at the University of Cordoba and director of the internal medicine unit at Reina Sofia University Hospital in Spain, and Elena M. Yubero-Serrano, PhD, emerging researcher at the Maimonides Biomedical Research Institute of Cordoba, told Healio. “Besides the pharmacological treatment for these diseases, recommendation to follow this dietary model could reduce and delay kidney complications.”
Lopez Miranda, Yubero-Serrano and colleagues conducted a prospective, randomized, single-blind, controlled trial based on an intention-to-treat analysis with 1,002 adults aged 20 to 75 years with established CHD, no clinical events in the 6 months before enrollment, no other serious illness and a life expectancy of at least 5 years. Participants were recruited from Reina Sofia University Hospital and other centers in Spain from November 2009 to February 2012. In addition to conventional treatment for CHD, participants were randomly assigned to follow a Mediterranean diet with at least 35% of total calories from fat and no more than 50% of calories coming from carbohydrates; or a low-fat diet with at least 55% of calories coming from carbohydrates and less than 30% from fat. Participants were followed for 5 years. Kidney function was measure by determining the serum creatinine-based eGFR at baseline and 5 years. Participants were classified into a normal eGFR (n = 514), mildly impaired eGFR (n = 286) and a severely impaired eGFR (n = 53) group based on baseline values.
At 5 years, both the Mediterranean and low-fat diets were associated with a decline in eGFR. Participants following a Mediterranean diet had an eGFR decline rate that was 1.58 mL/min/1.73 m2 lower compared with those on the low-fat diet at 5 years (P = .033).
Adults with a mildly impaired eGFR at baseline on the Mediterranean diet had a 2.49 mL/min/1.73 m2 lower decline in eGFR compared with those in the low-fat group (P = .04). However, no differences in eGFR decline were observed between the two dietary patterns for participants with a normal or severely impaired eGFR at baseline.
Among adults with type 2 diabetes, those consuming a Mediterranean diet had an eGFR decline rate that was 2.07 mL/min/1.73 m2 lower compared with the low-fat diet at 5 years (P = .04), though both dietary patterns were associated with decreased eGFR compared with baseline.
In linear regression analysis, the baseline eGFR of participants was the biggest factor contributing to eGFR changes during the study period (beta = –6.082; P < .001). Other factors included sex (beta = –3.107; P = .001), the presence of diabetes (beta = –2.387; P = .001), allocation to the Mediterranean diet (beta = 1.474; P = .041) and age (beta = –0.153; P = .001).
“Given the bidirectional association between CHD and chronic kidney disease, our results present a dietary strategy as a clinical and therapeutic tool that could better reduce the high recurrence of cardiovascular and/or CKD complications in these patients through the consumption of a Mediterranean diet than a low-fat diet,” the researchers wrote.
Lopez Miranda and Yubero-Serrano said future research is focused on the potential molecular mechanisms and pathways associated with improved kidney function with a Mediterranean diet.
Lower left atrial function associated with higher risk for dementia
Echocardiographic measures of lower left atrial function were significantly associated with an increased risk of subsequent dementia, experts reported in JAMA.
“Although the evidence linking atrial myopathy to adverse cardiovascular outcomes is compelling, less is known about the association of atrial myopathy with dementia,” Wendy Wang, MPH, a research assistant at the University of Minnesota School of Public Health, and colleagues wrote.
To assess whether a correlation exists between left atrial function and size and dementia, Wang and colleagues conducted an exploratory, retrospective analysis of a four-state Atherosclerosis Risk in Communities cohort study. Participants without prevalent atrial fibrillation and stroke and who underwent two-dimensional echocardiograms between 2011 and 2013 (considered baseline for the study) were monitored through Dec. 31, 2019.
A total of 4,096 participants were included (mean age, 75 years; 60% women; 22% Black), and over the 6-year median follow-up period, 531 dementia cases were identified.
For all left atrial function measures, the incidence of dementia was highest in the lowest quintile: 4.8, reservoir strain; 3.94, conduit strain; 3.29, contractile strain; 4.2, emptying fraction; 3.67, passive emptying fraction; and 3.27, active emptying fraction per 100 person-years.
Following full-model adjustments, there were significant associations between the highest and lowest quintiles for measures of left atrial function and dementia, including reservoir strain (HR = 1.98; 95% CI, 1.42-2.75), conduit strain (HR = 1.5; 95% CI, 1.09-2.06), contractile strain (HR = 1.57; 95% CI, 1.16-2.14), emptying fraction (HR = 1.87; 95% CI, 1.31-2.65) and active emptying fraction (HR = 1.43; 95% CI, 1.04-1.96). Passive emptying fraction was not associated with dementia, the authors noted (HR = 1.26; 95% CI, 0.93-1.71).
Left atrial size was not significantly associated with incident dementia, after full-model adjustment comparing the highest and lowest quintiles of maximal left atrial volume index (HR = 0.77; 95% CI, 0.58-1.02) and minimal volume index (HR = 0.95; 95% CI, 0.71-1.28).
Dementia incidence for the highest maximal volume index quintile was 3.18 per 100 person-years and 3.5 per 100 person-years for the highest minimal volume index. Both measures were not associated with dementia.
“To our knowledge, this is the first study to report an independent association between echocardiographic measures of [left atrial] function with dementia,” the authors wrote. “By interrogating a comprehensive set of [left atrial] function measures — quantified by speckle tracking and volumetric analysis — this study advances the field by linking [left atrial] function measures to dementia risk for the first time.”
In related editorial, Shyam Prabhakaran, MD, MS, of the department of neurology at the University of Chicago, and Philip Greenland, MD, of the department of preventative medicine at Northwestern University, state that Wang and colleagues’ study “introduces some interesting concepts regarding the mechanisms by which atrial myopathy, however defined, may contribute to dementia risk.”
Prabhakaran and Greenland wrote that although Wang and colleagues used echocardiographic measures, there are more advanced imaging tools available to assess left atrial flow patterns and areas of atrial blood stasis.
“Given the exploratory nature of the study findings, prospective validation in other cohorts is clearly necessary,” Prabhakaran and Greenland wrote. “In addition to identification of the precise biomarkers of atrial myopathy, randomized clinical trials testing treatments in patients with atrial myopathy could further establish a causal effect on dementia.”
References:
Prabhakaran S, Greenland P. JAMA. 2022;doi:10.1001/jama.2022.2374.
Small airways disease may persist for many with long COVID
Small airways disease was common in patients with persistent symptoms following COVID-19, independent of severity of initial infection, according to a single-center study published in Radiology.
“For the first time, we’re describing small airways disease in this population of COVID-19 patients with persistent symptoms,”Alejandro P. Comellas, MD, professor of internal medicine and faculty in thedivision of pulmonary, critical care and occupational medicine at Carver College of Medicine at the University of Iowa, Iowa City, said in a related press release. “Something is going on in the distal airways related to either inflammation or fibrosis that is giving us a signal of air trapping.”
The single-center study included 100 participants (median age, 48 years; 66% women) with post-acute sequelae of COVID-19 for at least 30 days enrolled from June to December 2020 and 106 matched healthy participants enrolled from March to August 2018. Those with post-acute sequelae of COVID-19, or long COVID, were categorized based on the highest level of acute care received: ambulatory (67%), hospitalized (17%) or requiring ICU care (16%). Researchers collected symptoms, pulmonary function tests and chest CT images, and performed inspiratory CT after inhalation and evaluated post-exhalation expiratory scans to assess air trapping and compare the two groups.
The mean percent of total lung classified as ground glass opacities was 3.7% in the ambulatory group compared with 13.2% in the hospitalized group and 28.7% in the ICU group (P < .001 for both comparisons).
The mean percentage of total lung affected by air trapping was 25.4% in the ambulatory group, 34.6% in the hospitalized group and 27.3% in the ICU group compared with 7.2% among healthy participants (P < .001). This air trapping persisted among eight of nine participants who underwent imaging more than 200 days after diagnosis.
Quantitative analysis of expiratory chest CT images, performed with supervised machine learning, showed evidence of small airways disease, according to the release.
Median time from diagnosis to chest CT imaging was about 75 days. The researchers noted that persistence of respiratory abnormalities in this period raises concern for permanent airway remodeling and fibrosis following SARS-CoV-2 infection, according to the release.
“There is some disease happening in the small airways independent of the severity of COVID-19,” Comellas said in the release. “We need to investigate further to see whether it is transient or more permanent.”
The researchers plan to follow the patients to evaluate how many improve and how many remain with abnormal findings.
“If a portion of patients continues to have small airways disease, then we need to think about the mechanisms behind it,” Comellas said in the release. “It could be something related to inflammation that’s reversible, or it may be something related to a scar that is irreversible, and then we need to look at ways to prevent further progression of the disease.”
Brett M. Elicker, MD, clinical professor in the department of radiology and biomedical imaging at the University of California, San Francisco, discussed the findings in an accompanying editorial in Radiology. Elicker said “it is important to note that not all pulmonary fibrosis … is permanent. … Regardless of the imaging findings, the most important question is whether the airway obstruction and post-[organizing pneumonia]/[diffuse alveolar damage] fibrosis contribute to persistent symptoms after COVID-19 infection with the contribution of airways disease higher in the outpatients, and the contribution of OP/DAD greater in the patients admitted to ICU. Longer-term studies assessing the clinical and imaging manifestations 1-2 years after the initial infection are needed to fully ascertain the permanent manifestations of post-COVID fibrosis.”
References:
- Elicker BM. Radiology. 2022;doi:10.1148/radiol.220449.
- ‘Long COVID’ linked to lasting airways disease. Published March 15, 2022. Accessed March 22, 2022.
Rates of neurological events higher with SARS-CoV-2 infection than with COVID-19 vaccine
Incidence rates for Bell’s palsy, encephalomyelitis and Guillain-Barré syndrome were higher in unvaccinated people with SARS-CoV-2 infection compared with those vaccinated against COVID-19, researchers reported in BMJ.
“Immune-mediated neurological disorders have been identified as adverse events of special interest by regulators, such as the FDA in the U.S. and the EMA in Europe,” Xintong Li, MHS, a doctoral student at the Center for Statistics in Medicine at the University of Oxford, and colleagues wrote. “These adverse events of special interest have been closely monitored during immunization campaigns, and several severe neurological disorders were reported as rare adverse events during the first clinical trials of COVID-19 vaccines.”
Li and colleagues conducted a population-based, historical rate comparison study using primary care records from the United Kingdom and Spain to assess rates of neurological events in 8,330,497 individuals who received at least one dose of a COVID-19 vaccine and in 735,870 unvaccinated individuals who tested positive for SARS-CoV-2.
Investigators assessed incidence rates for Bell’s palsy, encephalomyelitis and Guillain- Barré syndrome for the vaccinated group 21 days after receiving a vaccine dose and 90 days post-infection for those who were unvaccinated.
Among 3,776,803 participants who received a vaccine dose from AstraZeneca, there were 117 observed cases of Bell’s palsy, compared with 164.5 expected cases (standardized incidence ratio = 0.71; 95% CI, 0.59-0.85). Among 1,693,453 participants who received a dose from Pfizer, 46 cases of Bell’s palsy were observed compared with 116.4 expected cases (SIR = 0.40; 95% CI, 0.30-0.53). Participants who tested positive for SARS-CoV-2 infection had a reported 53 cases, higher than the 39.8 expected cases (SIR = 1.33; 95% CI, 1.02-1.74).
Post-vaccine rates of encephalomyelitis and Guillain-Barré syndrome were consistent with expected rates in both vaccination groups. However, higher rates for both conditions were reported in the SARS-CoV-2 group (encephalomyelitis: SIR = 6.89; 95% CI, 3.82-12.44 and Guillain-Barré syndrome: SIR = 3.53; 95% CI, 1.83-6.77).
“We found no safety signal for any of the studied immune-mediated neurological events after vaccination against COVID-19,” Li and colleagues wrote. “Infection with SARS-CoV-2 was, however, associated with an increased risk of Bell’s palsy, encephalomyelitis and Guillain-Barré syndrome.”
Pathway Project offers three new practices for end-of-life care, goals
Pathway Project results were presented for the first time at ASN Kidney Week, revealing three new best practices for end-of-life care, specific to the kidney community.
“Although there’s an increasing body of evidence outside of nephrology that says care practices can improve quality of life, confidence in end-of-life decision-making and bereavement, there is a lag in translating these findings into practice,” Manjula Kurella Tamura, MD, MPH, director of the Geriatric Research and Education Clinical Center at the Veterans Affairs Palo Alto Health Care System and professor of medicine at Stanford University, said.
The Pathway Project identified and presented 14 evidence-based best practices that could be incorporated into kidney care to dialysis organizations, then refined the final package to prioritize three best practices. These practices focused on seriously ill patients.
The first best practice of the Pathway Project encourages nephrologists to screen patients by asking themselves the “surprise” question: “Would I be surprised if this patient died in the next 6 or 12 months?” Answering no would mean that the patient is seriously ill. The second best practice is to prioritize goals of care conversations with seriously ill patients. The third best practice is offering palliative care pathways that allow patients to transition to less frequent dialysis, hospice or dialysis discontinuation based on their goals of care.
Ten hemodialysis centers voluntarily adopted and implemented these practices after two learning sessions. The serious illness screening was implemented and sustained, even after the beginning of the COVID-19 pandemic, in early 2020 throughout all the centers.
“In terms of the next best practice, conducting goals of care conversations, sites monitored the implementation of this practice by tracking the percent of seriously ill patients who had a goals of care conversation within 30 days of hospital discharge,” Kurella Tamura said. “What they found is that goals of care discussions were implemented, but unevenly, over the course of the implementation.”
She said a few reasons that implementation was challenging were scheduling issues, lack of confident caregivers to have these conversations and some patients felt they could continue putting off the conversation.
The third best practice, the palliative care pathway, was implemented the least, and no centers developed protocols to transition patients to hospice or dialysis withdrawal. A given reason for this was the CMS payment structure and that removing a patient from dialysis could negatively affect paid caregivers.
When interviewed 18 months after implementing the Project Pathway practices, many caregivers involved expressed positive thoughts about the practices.
“We found that all of the sites encountered challenges, but also found this experience incredibly rewarding both for their own individual practice, as well as the practice for their center as a whole,” Kurella Tamura said. “While there were many successes, there were still some hurdles that couldn’t be overcome in the project, particularly the policy and resource barriers that are inherent in our current health care system. So, in some ways, it’s not surprising that a learning collaborative just by itself was not able to overcome these barriers. Maybe one of our takeaways is that the learning collaborative needs to be coupled with changes at the policy and health care structure level to be able to see meaningful changes in health care utilization and patient experience near the end of life.”
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