Creation of a Risk-scoring Algorithm for Early Mortality Among Elderly ESRD Patie

描述(由申请人提供)：创建老年终末期肾病患者早期死亡率的风险评分算法背景。早期死亡率，即在诊断为终末期肾病(ESRD)后三个月内发生的死亡率，在65岁及以上的患者中高得不成比例。慢性肾脏病(CKD)和终末期肾病(ESRD)患者发病率的不可阻挡的增加促使人们努力减缓和扭转这一紧迫的公共卫生问题。这项研究旨在开发一种风险评分系统，以帮助临床预测老年(65岁)终末期肾病患者的早期死亡。目标。我们假设，透析开始后不久“早期死亡率”高的患者有严重的透析前医疗条件，加上肾脏疾病管理不力，没有为长期透析做好适当的准备。我们的探索性研究项目将在前三项中确定与死亡率相关的因素 在开始永久透析几个月后。我们建议研究以下与早期死亡率相关的因素：1)透析前一年内发现的并存情况(如心血管事件、急性肾功能衰竭、败血症、高血压急症)；2)透析前的医疗管理，包括肾病专家的参与、贫血的处理、营养状况以及透析的血管通路准备，区分“紧急”与“选择性”(即急性发作、“崩溃和烧伤”与计划中的)过渡到ESRD；以及3)CKD后期阶段的医疗服务使用情况。这些分析的结果将被用来开发透析患者早期死亡率的预测模型和评分算法。方法：研究方法。利用联邦医疗保险索赔的历史数据，我们建议进行一项回溯性队列研究，以开发用户友好的预后指数。为了确定研究人群，我们将通过连接透析前和透析后的数据来评估早期死亡的预测因素，从而构建完整的肾功能衰竭患者病史。这项拟议的研究在将2000-2009年ESRD数据文件与最近可用于研究目的的5%慢性肾脏疾病(CKD)样本联系起来方面是独一无二的。这一时期符合Medicare条件的CKD患者总数约为831,000人；其中约10%符合ESRD条件，构成了我们研究人群的基础。多因素Logistic回归模型将被用来检验每个假设，并确定早期死亡的重要危险因素。意义重大。我们计划在从CKD过渡到ESRD需要昂贵的、永久性的和改变生活的透析治疗的人群中，确定与早期死亡相关的潜在的“可改变的”因素。考虑到DIAL后第一年的高死亡率，对那些注定要过早死亡的人的准确预测将有助于患者及其家人、提供者和社会做出治疗决策。

DESCRIPTION (provided by applicant): Creation of a Risk-scoring Algorithm for Early Mortality Among Elderly ESRD Patients Background. The rate of early deaths, those occurring within the three months following the diagnosis of end-stage renal disease (ESRD), are disproportionately high among patients who are 65 and older. Inexorable increases in the incidence of patients with both chronic kidney disease (CKD) and ESRD impel efforts to slow and reverse this urgent public health problem. This study aims to develop a risk-scoring system to aid in the clinical prediction of early death among elderly (>65 years) ESRD patients. Objective. We hypothesize that patients with high rates of "early mortality" soon after dialysis initiation have significant pre-dialysis medical conditions combined with inadequate renal disease management that does not prepare them appropriately for long- term dialysis. Our exploratory research project will identify factors associated with mortality within the first three months after starting permanent dialysis. We propose to examine the following associated with early mortality: 1) comorbid conditions found within one year prior to dialysis (e.g., cardiovascular events, acute renal failure, sepsis, hypertensive emergencies); 2) medical management prior to dialysis including involvement of a nephrology specialist, management of anemia, nutritional status, and vascular access preparation for dialysis that differentiates the 'emergent versus elective' (i.e., acute onset 'crash and burn' versus planned) transition to ESRD; and 3) use of health services in the latter stages of CKD. Results from these analyses will be used to develop a prognostic model and scoring algorithm for early mortality among dialysis patients. Methods. Using historical Medicare claims data, we propose to conduct a retrospective cohort study to develop a user friendly prognostic index. To identify the study population, we will construct a complete renal failure patient history by linking the pre-dialysis and post dialysis data to assess the predictors of early death. The proposed study is unique in linking the 2000-2009 ESRD data files to the 5% Chronic Kidney Disease (CKD) sample that has recently become available for research purposes. The total number of Medicare-eligible CKD patients from this period is approximately 831,000; of these, roughly 10% become ESRD-eligible and form the basis of our study population. Multivariate logistic regression models will b used to test each hypothesis and identify the significant risk factors for early mortality. Significance. We plan to identify potentially "modifiable" factors that are associated with early death among a population that transitions from CKD to ESRD requiring expensive, permanent and life-altering dialysis therapy. Given the high mortality rates during the first year after dialsis, accurate prediction of those destined for early death would be useful to patients and their families, providers, and society in making decisions about treatment.