TY - JOUR
T1 - Emergency Department/Urgent Care as Usual Source of Care and Clinical Outcomes in CKD
T2 - Findings From the Chronic Renal Insufficiency Cohort Study
AU - Chronic Renal Insufficiency Cohort (CRIC) Study Investigators
AU - Toth-Manikowski, Stephanie M.
AU - Hsu, Jesse Y.
AU - Fischer, Michael J.
AU - Cohen, Jordana B.
AU - Lora, Claudia M.
AU - Tan, Thida C.
AU - He, Jiang
AU - Greer, Raquel C.
AU - Weir, Matthew R.
AU - Zhang, Xiaoming
AU - Schrauben, Sarah J.
AU - Saunders, Milda R.
AU - Ricardo, Ana C.
AU - Lash, James P.
AU - Appel, Lawrence J.
AU - Feldman, Harold I.
AU - Go, Alan S.
AU - Nelson, Robert G.
AU - Rahman, Mahboob
AU - Rao, Panduranga S.
AU - Shah, Vallabh O.
AU - Townsend, Raymond R.
AU - Unruh, Mark L.
N1 - Funding Information:
Funding for the CRIC Study was obtained under a cooperative agreement from the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK U01DK060990, U01DK060984, U01DK061022, U01DK061021, U01DK061028, U01DK060980, U01DK060963, and U01DK060902). In addition, this work was supported in part by: the Perelman School of Medicine at the University of Pennsylvania Clinical and Translational Science Award NIH/National Center for Advancing Translational Sciences (NCATS) UL1TR000003, Johns Hopkins University UL1TR000424, University of Maryland GCRC M01RR16500, Clinical and Translational Science Collaborative of Cleveland, NIH/NCATS UL1TR000439 and NIH Roadmap for Medical Research, Michigan Institute for Clinical and Health Research (MICHR) UL1TR000433, University of Illinois at Chicago CTSA UL1RR029879, Tulane COBRE for Clinical and Translational Research in Cardiometabolic Diseases P20GM109036, Kaiser Permanente NIH/NCRR UCSF-CTSI UL1RR024131. Dr. Toth-Manikowski is funded by the NIDDK 3R01DK072231-13S1. Dr. Ricardo is funded by the NIDDK R01DK118736 Award. Dr. Lash is funded by the NIDDK K24DK092290 and R01DK072231-91 Awards.
Funding Information:
Lawrence J. Appel, MD, MPH, Harold I. Feldman, MD, MSCE, Alan S. Go, MD, Robert G. Nelson, MD, PhD, MS, Mahboob Rahman, MD, Panduranga S. Rao, MD, Vallabh O Shah, PhD, MS, Raymond R. Townsend, MD, and Mark L. Unruh, MD, MS, Stephanie M. Toth-Manikowski, MD, MHS, Jesse Y. Hsu, PhD, Michael J. Fischer, MD, MSPH, Jordana B. Cohen, MD, MSCE, Claudia M. Lora, MD, Thida C. Tan, MPH, Jiang He, MD, PhD, Raquel C. Greer, MD, MHS, Matthew R. Weir, MD, Xiaoming Zhang, MS, PhD, Sarah J. Schrauben, MD, MSCE, Milda R. Saunders, MD, MPH, Ana C. Ricardo, MD, MPH, and James P. Lash, MD on behalf of the Chronic Renal Insufficiency Cohort (CRIC) Study Investigators, Research idea and study design: STM, JPL, ACR; data acquisition: JPL, MRW, TCT, XZ; data analysis/interpretation: STM, JYH, XZ, MJF, JBC, CML, TCT, JH, RCG, SJS, MRS, ACR, JPL; statistical analysis: JYH, XZ; supervision and mentorship: JPL. Each author contributed important intellectual content during manuscript drafting and revision and accepts accountability for the overall work by ensuring that questions pertaining to the accuracy or integrity of any portion of the work are appropriately investigated and resolved. Funding for the CRIC Study was obtained under a cooperative agreement from the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK U01DK060990, U01DK060984, U01DK061022, U01DK061021, U01DK061028, U01DK060980, U01DK060963, and U01DK060902). In addition, this work was supported in part by: the Perelman School of Medicine at the University of Pennsylvania Clinical and Translational Science Award NIH/National Center for Advancing Translational Sciences (NCATS) UL1TR000003, Johns Hopkins University UL1TR000424, University of Maryland GCRC M01RR16500, Clinical and Translational Science Collaborative of Cleveland, NIH/NCATS UL1TR000439 and NIH Roadmap for Medical Research, Michigan Institute for Clinical and Health Research (MICHR) UL1TR000433, University of Illinois at Chicago CTSA UL1RR029879, Tulane COBRE for Clinical and Translational Research in Cardiometabolic Diseases P20GM109036, Kaiser Permanente NIH/NCRR UCSF-CTSI UL1RR024131. Dr. Toth-Manikowski is funded by the NIDDK 3R01DK072231-13S1. Dr. Ricardo is funded by the NIDDK R01DK118736 Award. Dr. Lash is funded by the NIDDK K24DK092290 and R01DK072231-91 Awards. The authors declare that they have no relevant financial interests. Received July 21, 2021 as a submission to the expedited consideration track with 3 external peer reviews. Direct editorial input from the Statistical Editor and the Editor-in-Chief. Accepted in revised form December 5, 2021.
Publisher Copyright:
© 2022 The Authors
PY - 2022/4
Y1 - 2022/4
N2 - Rationale & Objective: Having a usual source of care increases use of preventive services and is associated with improved survival in the general population. We evaluated this association in adults with chronic kidney disease (CKD). Study Design: Prospective, observational cohort study. Setting & Participants: Adults with CKD enrolled in the Chronic Renal Insufficiency Cohort (CRIC) Study. Predictor: Usual source of care was self-reported as: 1) clinic, 2) emergency department (ED)/urgent care, 3) other. Outcomes: Primary outcomes included incident end-stage kidney disease (ESKD), atherosclerotic events (myocardial infarction, stroke, or peripheral artery disease), incident heart failure, hospitalization events, and all-cause death. Analytical Approach: Multivariable regression analyses to evaluate the association between usual source of care (ED/urgent care vs clinic) and primary outcomes. Results: Among 3,140 participants, mean age was 65 years, 44% female, 45% non-Hispanic White, 43% non-Hispanic Black, and 9% Hispanic, mean estimated glomerular filtration rate 50 mL/min/1.73 m2. Approximately 90% identified clinic as usual source of care, 9% ED/urgent care, and 1% other. ED/urgent care reflected a more vulnerable population given lower baseline socioeconomic status, higher comorbid condition burden, and poorer blood pressure and glycemic control. Over a median follow-up time of 3.6 years, there were 181 incident end-stage kidney disease events, 264 atherosclerotic events, 263 incident heart failure events, 288 deaths, and 7,957 hospitalizations. Compared to clinic as usual source of care, ED/urgent care was associated with higher risk for all-cause death (HR, 1.53; 95% CI, 1.05-2.23) and hospitalizations (RR, 1.41; 95% CI, 1.32-1.51). Limitations: Cannot be generalized to all patients with CKD. Causal relationships cannot be established. Conclusions: In this large, diverse cohort of adults with moderate-to-severe CKD, those identifying ED/urgent care as usual source of care were at increased risk for death and hospitalizations. These findings highlight the need to develop strategies to improve health care access for this high-risk population.
AB - Rationale & Objective: Having a usual source of care increases use of preventive services and is associated with improved survival in the general population. We evaluated this association in adults with chronic kidney disease (CKD). Study Design: Prospective, observational cohort study. Setting & Participants: Adults with CKD enrolled in the Chronic Renal Insufficiency Cohort (CRIC) Study. Predictor: Usual source of care was self-reported as: 1) clinic, 2) emergency department (ED)/urgent care, 3) other. Outcomes: Primary outcomes included incident end-stage kidney disease (ESKD), atherosclerotic events (myocardial infarction, stroke, or peripheral artery disease), incident heart failure, hospitalization events, and all-cause death. Analytical Approach: Multivariable regression analyses to evaluate the association between usual source of care (ED/urgent care vs clinic) and primary outcomes. Results: Among 3,140 participants, mean age was 65 years, 44% female, 45% non-Hispanic White, 43% non-Hispanic Black, and 9% Hispanic, mean estimated glomerular filtration rate 50 mL/min/1.73 m2. Approximately 90% identified clinic as usual source of care, 9% ED/urgent care, and 1% other. ED/urgent care reflected a more vulnerable population given lower baseline socioeconomic status, higher comorbid condition burden, and poorer blood pressure and glycemic control. Over a median follow-up time of 3.6 years, there were 181 incident end-stage kidney disease events, 264 atherosclerotic events, 263 incident heart failure events, 288 deaths, and 7,957 hospitalizations. Compared to clinic as usual source of care, ED/urgent care was associated with higher risk for all-cause death (HR, 1.53; 95% CI, 1.05-2.23) and hospitalizations (RR, 1.41; 95% CI, 1.32-1.51). Limitations: Cannot be generalized to all patients with CKD. Causal relationships cannot be established. Conclusions: In this large, diverse cohort of adults with moderate-to-severe CKD, those identifying ED/urgent care as usual source of care were at increased risk for death and hospitalizations. These findings highlight the need to develop strategies to improve health care access for this high-risk population.
KW - Access to health care
KW - chronic kidney disease
KW - emergency department
KW - health care access
KW - usual source of care
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U2 - 10.1016/j.xkme.2022.100424
DO - 10.1016/j.xkme.2022.100424
M3 - Article
C2 - 35372819
AN - SCOPUS:85125533207
SN - 2590-0595
VL - 4
JO - Kidney Medicine
JF - Kidney Medicine
IS - 4
M1 - 100424
ER -