Optimizing Revascularization of Coronary Artery Disease in Chronic Kidney Disease

优化慢性肾脏病冠状动脉疾病的血运重建

• 批准号: 8631538
• 负责人: David M Charytan
• 金额: $ 43.22万
• 依托单位: BRIGHAM AND WOMEN'S HOSPITAL
• 依托单位国家: 美国
• 财政年份: 2014
• 资助国家: 美国
• 起止时间: 2014-01-01 至 2017-12-31
• 项目状态: 已结题
• 来源: https://reporter.nih.gov/project-details/8631538
• 关键词: Accounting; Address; Adverse event; Affect; Attenuated; Cardiovascular Diseases; Cardiovascular system; Caring; Cessation of life; Chronic; Chronic Kidney Failure; Clinical; Clinical Data; Clinical Trials; Clinical effectiveness; Coronary; Coronary Arteriosclerosis; Coronary Artery Bypass; Cost of Illness; Data; Data Analyses; Data Set; Dependence; Dialysis procedure; End stage renal failure; Equilibrium; Exclusion; Expenditure; Facilities and Administrative Costs; Fatal Outcome; Fright; Functional disorder; General Population; Growth; Guidelines; Health; Health Care Costs; Health Expenditures; Health Policy; Healthcare; High Prevalence; Incidence; Individual; Information Systems; Injury; Kidney; Kidney Diseases; Kidney Failure; Knowledge; Life; Link; Massachusetts; Measures; Medical; Medicare; Modality; Modeling; Myocardial Infarction; Operative Surgical Procedures; Outcome; Patient Care; Patients; Perioperative; Physicians; Population; Postoperative Period; Prevalence; Procedures; Public Health; Quality of Care; Quality of life; Registries; Renal function; Resources; Risk; Risk Estimate; Risk Factors; Safety; Sampling; Stroke; Time; United States; base; cardiovascular disorder therapy; cardiovascular risk factor; care delivery; clinical decision-making; cohort; comparative; comparative effectiveness; comparative efficacy; cost; cost effectiveness; design; disorder risk; evidence base; follow-up; health related quality of life; high risk; improved; mortality; patient population; percutaneous coronary intervention; public health relevance; standard of care

Chronic kidney disease (CKD) affects > 6% of the U.S. population and accounts for a high share of health care spending. Although patients with CKD have a risk of cardiovascular mortality significantly higher than the general population, they are nevertheless less likely to undergo coronary revascularization or receive standard medical therapies for cardiovascular disease (CVD). The low utilization of potentially life-saving therapies may be influenced by the unique pathophysiology of CVD in CKD, evidence suggesting low efficacy of standard therapies in advanced CKD, and the systematic exclusion of CKD patients from clinical trials that established the benefits of medical therapy (MTX), percutaneous coronary intervention (PCI) and coronary artery bypass surgery (CABG) in the general population. Concerns raised by these factors about extrapolating cardiovascular guidelines from the general population to the care of individuals with CKD are magnified by the threat of procedure-related kidney injury following PCI and CABG. Revascularization may accelerate progression of renal disease and ,when permanent dialysis dependence results, can dramatically reduce quality of life despite relief of angina. Other complications, such as stroke, whose incidence may differ after MTX, PCI and CABG, are likely to have analogous impacts on the benefits of the individual treatment options. Despite the growth in the CKD population, the ubiquity of CVD in CKD, and concerns about the application of the general standard of care, specific evidence of the comparative efficacy of therapies in CKD remains sparse, with little information on comparative costs or overall quality of life. This absence of good data likely results in the inefficient use of these therapies, suboptimal clinical outcomes, and unnecessary burdens on health care resources. To better inform patients, physicians, and other stakeholders, better comparative effectiveness data and an analysis of associated health care expenditures are needed to identify strategies which maximize health gains and cost-efficiency. The proposed studies are critically needed to better inform clinical decision-making and public health discourse. We propose a unique analysis of Medicare data and a linkage of the Massachusetts state PCI and CABG registries with the United States Renal Data System. These data sets will enable analyses designed to address important questions and facilitate optimal use of, MTX, CABG and PCI in CKD. Associations between therapy and relevant outcomes such as death, end stage renal disease, stroke, myocardial infarction, and healthcare associated costs will be estimated. Leveraging these data, we will analyze quality-adjusted survival and incremental cost-effectiveness using decision and cost-utility analytics. PUBLIC HEALTH RELEVANCE: Findings from this study are expected to inform public health discourse and optimize the delivery of care for CAD in the setting of CKD. These findings are expected to improve survival and health related quality of life and to reduce costs of care in a growing, high-risk population poorly served by the existing evidence base. .

慢性肾脏疾病（CKD）影响> 6％的美国人口，占高分的份额 医疗保健支出。尽管CKD患者患心血管死亡率的风险明显更高 与一般人群相比，他们的冠状动脉血运重建或接受的可能性较小 心血管疾病（CVD）的标准医疗疗法。潜在挽救生命的低利用率 疗法可能会受到CKD中CVD独特的病理生理学的影响，证据表明低功效 高级CKD中的标准疗法，以及从临床试验中系统排除CKD患者 建立了医疗疗法（MTX），经皮冠状动脉干预（PCI）和冠状动脉的好处 一般人群中的动脉搭桥手术（CABG）。这些因素提出了推断的问题 从一般人群到CKD个体的护理的心血管指南被放大 PCI和CABG之后，与程序有关的肾脏损伤威胁。血运重建可能会加速 肾脏疾病的进展以及当永久透析依赖性结果时，可以大大减少 生活质量尽管放松了心绞痛。其他并发症，例如中风，其发病率可能会有所不同 MTX，PCI和CABG可能会对单个治疗方案的好处产生类似的影响。 尽管CKD人群的增长，CKD中CVD的普遍性，并且担心 一般护理标准的应用，CKD中疗法比较疗效的具体证据 保持稀疏，几乎没有有关比较成本或整体生活质量的信息。缺乏良好的数据 可能导致这些疗法的使用效率低下，次优临床结果和不必要的负担 关于医疗保健资源。为了更好地告知患者，医生和其他利益相关者 有效性数据和相关医疗保健支出的分析以确定策略 最大化健康增长和成本效益。 拟议的研究需要至关重要，以更好地为临床决策和公共卫生提供信息 话语。我们提出了对Medicare数据的独特分析以及马萨诸塞州PCI和 美国肾脏数据系统的CABG登记处。这些数据集将启用旨在的分析 解决重要的问题，并促进CKD中MTX，CABG和PCI的最佳使用。之间的关联 治疗和相关结果，例如死亡，末期肾脏疾病，中风，心肌梗塞和 医疗保健相关费用将被估算。利用这些数据，我们将分析质量调整的生存 以及使用决策和成本效用分析的增量成本效益。公共卫生相关性： 这项研究的发现有望为公共卫生的话语提供信息，并优化提供护理 CAD在CKD的环境中。这些发现有望改善生存和与健康相关的生活质量 并降低现有证据基础不断增长的高风险人群中的护理成本。 。