Potentially Avoidable Readmissions in United States Hemodialysis Patients

Privatization and Oligopolies of the Renal Replacement Therapy Sector on Contemporary Capitalism: A Systematic Review and the Brazilian Scenario

Worldwide the assistance on renal replacement therapy (RRT) is carried out mainly by private for-profit services and in a market with increase in mergers and acquisitions. The aim of this study was to conduct an integrative systematic review on privatization and oligopolies in the RRT sector in the context of contemporary capitalism. The inclusion criteria were scientific articles without language restrictions and that addressed the themes of oligopoly or privatization of RRT market. Studies published before 1990 were excluded. The exploratory search for publications was carried out on February 13, 2024 on the Virtual Health Library Regional Portal (VHL). Using the step-by-step of PRISMA flowchart, 34 articles were retrieved, of which 31 addressed the RRT sector in the United States and 26 compared for-profit dialysis units or those belonging to large organizations with non-profit or public ones. The main effects of privatization and oligopolies, evaluated by the studies, were: mortality, hospitalization, use of peritoneal dialysis and registration for kidney transplantation. When considering these outcomes, 19 (73%) articles showed worse results in private units or those belonging to large organizations, six (23%) studies were in favor of privatization or oligopolies and one study was neutral (4%). In summary, most of the articles included in this systematic review showed deleterious effects of oligopolization and privatization of the RRT sector on the patients served. Possible explanations for this result could be the presence of conflicts of interest in the RRT sector and the lack of incentive to implement the chronic kidney disease care line. The predominance of articles from a single nation may suggest that few countries have transparent mechanisms to monitor the quality of care and outcomes of patients on chronic dialysis.

Service Utilization Patterns and Direct Medical Costs of Hospitalization in Patients With Renal Failure Before and After Initiating Home Peritoneal Dialysis

OBJECTIVES

This study aimed to determine the hospital service utilization patterns and direct healthcare hospital costs before and during peritoneal dialysis (PD) at home.

METHODS

A retrospective cohort study of patients with kidney failure (KF) was conducted at a Mexican Social Security Institute hospital for the year 2014. Cost categories included inpatient emergency room stays, inpatient services at internal medicine or surgery, and hospital PD. The study groups were (1) patients with KF before initiating home PD, (2) patients with less than 1 year of home PD (incident), and (3) patients with more than 1 year of home PD (prevalent). Costs were actualized to international dollars (Int$) 2023.

RESULTS

We found that 53% of patients with KF used home PD services, 42% had not received any type of PD, and 5% had hospital dialysis while waiting for home PD. The estimated costs adjusting for age and sex were Int$5339 (95% CI 4680-9746) for patients without home PD, Int$17 556 (95% CI 15 314-19 789) for incident patients, and Int$7872 (95% CI 5994-9749) for prevalent patients; with significantly different averages for the 3 groups (P < .001).

CONCLUSIONS

Although the use of services and cost is highest at the time of initiating PD, over time, using home PD leads to a significant reduction in use of hospital services, which translates into institutional cost savings. Our findings, especially considering the high rates of KF in Mexico, suggest a pressing need for interventions that can reduce healthcare costs at the beginning of renal replacement therapy.

Structured handoff to improve communication from inpatient to outpatient dialysis units: A quality improvement project

BACKGROUND

Patients with end-stage kidney disease requiring dialysis encounter high hospital readmission rates. One contributor is poor communication between hospitals and outpatient dialysis facilities. We hypothesized that improved communication may reduce 30-day hospital readmissions for patients on dialysis at an urban, safety net hospital.

METHODS

We created a standardized discharge handoff tool that is easy to use and provides concise data for dialysis centers. The handoff tool is a novel, electronic MACRO template (called a "dot-phrase") to be included in discharge documentation. Instructions for the dot-phrase and electronic facsimile (e-faxing) were sent to Internal Medicine residents immediately prior to their rotation on an inpatient Renal service. We then measured the intervention implementation rate and its impact on hospital readmission metrics.

RESULTS

We compared 3 months of preintervention and 6 months of postintervention data, identifying 82 and 135 index discharges in each respective study period. Patients were predominantly male (56.2%) and receiving hemodialysis (89.8%); a minority (9.2%) were undomiciled at the time of discharge. Mean age was 60.5 years (SD 14.0). Renal discharges followed by 30-day Renal readmission were not statistically lower in the postintervention group for the index discharge alone (26.8% vs. 20.0%, p = 0.12), but were for overall discharges (51.2% vs. 25.7%, p < 0.0001). The dot-phrase was used in 95.4% of discharge summaries, and 74.7% of discharge summaries were e-faxed within 24 h of discharge.

CONCLUSION

There was high uptake of a standardized discharge handoff tool among Internal Medicine residents on a Renal inpatient service. Using a handoff tool and e-faxing may improve communication with outpatient dialysis centers and may reduce readmissions among some patients but is likely insufficient to fully address high readmission rates. Subsequent intervention iterations would benefit from further collaboration with outpatient dialysis units for customization of the handoff tool to meet local communication needs.

Epidemiology of End-Stage Renal Disease in Mogadishu, Somalia: First Report at a Tertiary Care Hospital

Background

End-stage renal disease (ESRD) in Somalia remains unexamined due to a lack of a national registry system, and the impact of the disease in the country is not estimated yet. The present study is the first report that aims to evaluate the epidemiological characteristics, causes, and dialysis-related factors associated with readmissions in ESRD patients who were going to routine hemodialysis.

Patients and methods

This cross-sectional observational study enrolled 208 patients with ESRD. Also, this study investigated patients readmitted to the hospital (n=135) after they enrolled in hemodialysis. The sociodemographic characteristics, risk factors, and comorbidities associated with these patients were reviewed. Admission site, length of hospital stay, outcome, and dialysis-related factors associated with readmissions in the first six months after being on a regular hemodialysis program were also assessed.

Results

The mean age of the patients was 52.7±15.0 years, 43.3% were >60 years, and 61.5% were male. The most common cause was diabetes at 39.4%, followed by hypertension (35.6%) and 12.5% for postrenal obstruction. The prevalence of 6-month hospital readmissions was 65%. The most common dialysis-related factor associated with readmissions was uremic complications due to missed hemodialysis sessions (40%), vascular access/catheter infection (20%), and anemia (17.8%) (95% CI: 0.825–5.357, OR: 3.017, p<0.04). Female cases were more vulnerable to vascular catheter site infection, anemia, and hyponatremia (p<0.001). 27.5% of the patients were admitted to the intensive care unit (ICU), and the most common reason for ICU admissions was pulmonary edema (53.8%), sepsis (42.8%), and uremia due to hemodialysis skip (26.4%) (95% CI: 1.507–13.632, OR: 2.08, p=0.01). The mortality rate was 5.2%.

Conclusion

The prevalence of unplanned hospital readmissions within six months was very high, and a missed hemodialysis session was identified as the leading cause. Inadequate knowledge, wrong social beliefs about the concept of dialysis and a lack of a health insurance system that covers the higher costs of each dialysis session are believed to be the causes of missed dialysis occasions.

Development and validation of an interpretable machine learning scoring tool for estimating time to emergency readmissions

BACKGROUND

Emergency readmission poses an additional burden on both patients and healthcare systems. Risk stratification is the first step of transitional care interventions targeted at reducing readmission. To accurately predict the short- and intermediate-term risks of readmission and provide information for further temporal risk stratification, we developed and validated an interpretable machine learning risk scoring system.

METHODS

In this retrospective study, all emergency admission episodes from January 1st 2009 to December 31st 2016 at a tertiary hospital in Singapore were assessed. The primary outcome was time to emergency readmission within 90 days post discharge. The Score for Emergency ReAdmission Prediction (SERAP) tool was derived via an interpretable machine learning-based system for time-to-event outcomes. SERAP is six-variable survival score, and takes the number of emergency admissions last year, age, history of malignancy, history of renal diseases, serum creatinine level, and serum albumin level during index admission into consideration.

FINDINGS

A total of 293,589 ED admission episodes were finally included in the whole cohort. Among them, 203,748 episodes were included in the training cohort, 50,937 episodes in the validation cohort, and 38,904 in the testing cohort. Readmission within 90 days was documented in 80,213 (27.3%) episodes, with a median time to emergency readmission of 22 days (Interquartile range: 8-47). For different time points, the readmission rates observed in the whole cohort were 6.7% at 7 days, 10.6% at 14 days, 13.6% at 21 days, 16.4% at 30 days, and 23.0% at 60 days. In the testing cohort, the SERAP achieved an integrated area under the curve of 0.737 (95% confidence interval: 0.730-0.743). For a specific 30-day readmission prediction, SERAP outperformed the LACE index (Length of stay, Acuity of admission, Charlson comorbidity index, and Emergency department visits in past six months) and the HOSPITAL score (Hemoglobin at discharge, discharge from an Oncology service, Sodium level at discharge, Procedure during the index admission, Index Type of admission, number of Admissions during the last 12 months, and Length of stay). Besides 30-day readmission, SERAP can predict readmission rates at any time point during the 90-day period.

INTERPRETATION

Better performance in risk prediction was achieved by the SERAP than other existing scores, and accurate information about time to emergency readmission was generated for further temporal risk stratification and clinical decision-making. In the future, external validation studies are needed to evaluate the SERAP at different settings and assess their real-world performance.

FUNDING

This study was supported by the Singapore National Medical Research Council under the PULSES Center Grant, and Duke-NUS Medical School.

Quantitative Lung Ultrasonography for the Nephrologist: Applications in Dialysis and Heart Failure

Volume overload, and its attendant increase in acute care utilization and cardiovascular morbidity and mortality, represents a critical challenge for the practicing nephrologist. This is particularly true among patients with ESKD on HD, where predialysis volume overload and intradialytic and postdialytic hypovolemia account for almost a third of all cost for the Medicare dialysis benefit. Quantitative lung ultrasound is a tool for assessing the extent of extravascular lung water that outperforms physical exam and plain chest radiography. B-lines are vertical hyperechoic artifacts present in patients with increased extravascular lung water. B-lines have been shown to decrease dynamically during the hemodialysis treatment in proportion to ultrafiltration volume. Among patients with chronic heart failure, titration of diuretics on the basis of the extent of pulmonary congestion noted on lung ultrasonography has been shown to decrease recurrent acute care utilization. Early data from randomized controlled trials of lung ultrasound-guided ultrafiltration therapy among patients with ESKD on HD have shown promise for potential reduction in recurrent episodes of decompensated heart failure and cardiovascular events. Ultimately, lung ultrasound may predict those who are ultrafiltration tolerant and could be used to decrease acute care utilization and, thus, cost in this population.

Value-Based Care and Kidney Disease: Emergence and Future Opportunities

The United States health care system has increasingly embraced value-based programs that reward improved outcomes and lower costs. Health care value, defined as quality per unit cost, was a major goal of the 2010 Patient Protection and Affordable Care Act amid high and rising US health care expenditures. Many early value-based programs were specifically designed for patients with end-stage renal disease (ESRD) and targeted toward dialysis facilities, including the ESRD Prospective Payment System, ESRD Quality Incentive Program, and ESRD Seamless Care Organizations. While a great deal of attention has been paid to these ESRD-focused programs, other value-based programs targeted toward hospitals and health systems may also affect the quality and costs of care for a broader population of patients with kidney disease. Value-based care for kidney disease is increasingly relevant in light of the Advancing American Kidney Health initiative, which introduces new value-based payment models: the mandatory ESRD Treatment Choices Model in 2021 and voluntary Kidney Care Choices Model in 2022. In this review article, we summarize the emergence and impact of value-based programs on the quality and costs of kidney care, with a focus on federal programs. Key opportunities in value-based kidney care include shifting the focus toward chronic kidney disease, enhancing population health management capabilities, improving quality measurement, and leveraging programs to advance health equity.

Using Routinely Collected Electronic Health Record Data to Predict Readmission and Target Care Coordination

ABSTRACT

Patients with chronic renal failure (CRF) are at high risk of being readmitted to hospitals within 30 days. Routinely collected electronic health record (EHR) data may enable hospitals to predict CRF readmission and target interventions to increase quality and reduce readmissions. We compared the ability of manually extracted variables to predict readmission compared with EHR-based prediction using multivariate logistic regression on 1 year of admission data from an academic medical center. Categorizing three routinely collected variables (creatinine, B-type natriuretic peptide, and length of stay) increased readmission prediction by 30% compared with paper-based methods as measured by C-statistic (AUC). Marginal effects analysis using the final multivariate model provided patient-specific risk scores from 0% to 44.3%. These findings support the use of routinely collected EHR data for effectively stratifying readmission risk for patients with CRF. Generic readmission risk tools may be evidence-based but are designed for general populations and may not account for unique traits of specific patient populations-such as those with CRF. Routinely collected EHR data are a rapid, more efficient strategy for risk stratifying and strategically targeting care. Earlier risk stratification and reallocation of clinician effort may reduce readmissions. Testing this risk model in additional populations and settings is warranted.

Strategies to Reduce Rehospitalization in Patients with CKD and Kidney Failure

Readmissions in patients with nondialysis-dependent CKD and kidney failure are common and are associated with significant morbidity, mortality, and economic consequences. In 2013, the Centers for Medicare and Medicaid Services implemented the Hospital Readmissions Reduction Program in an attempt to reduce high hospitalization-associated costs. Up to 50% of all readmissions are deemed avoidable and present an opportunity for intervention. We describe factors that are specific to the patient, the index hospitalization, and underlying conditions that help identify the "high-risk" patient. Early follow-up care, developing volume management strategies, optimizing nutrition, obtaining palliative care consultations for seriously ill patients during hospitalization and conducting goals-of-care discussions with them, instituting systematic advance care planning during outpatient visits to avoid unwanted hospitalizations and intensive treatment at the end of life, and developing protocols for patients with incident or prevalent cardiovascular conditions may help prevent avoidable readmissions in patients with kidney disease.

Association of short-term exposure to ambient PM2.5 with hospital admissions and 30-day readmissions in end-stage renal disease patients: population-based retrospective cohort study

OBJECTIVES

To examine the effect of short-term exposure to ambient fine particulate matter (PM_2.5) on all-cause, cardiovascular and respiratory-related hospital admissions and readmissions among patients receiving outpatient haemodialysis.

DESIGN

Retrospective cohort study.

SETTING

Inpatient hospitalisation claims identified from the US Renal Data System in 530 US counties.

PARTICIPANTS

All patients receiving in-centre haemodialysis between 2008 and 2014.

PRIMARY AND SECONDARY OUTCOME MEASURES

Risk of all-cause, cardiovascular and respiratory-related hospital admissions and 30-day all-cause and cause-specific readmission following an all-cause, cardiovascular, and respiratory-related discharges. Readmission risk was evaluated for early (1-7 days postdischarge) and late (8-30 days postdischarge) readmission time periods. Relative risk is expressed per 10 μg/m³ of PM_2.5.

RESULTS

Same-day ambient PM_2.5 was associated with increased hospital admission risk for cardiovascular causes (0.9%, 95% CI 0.2 to 1.7). Greater PM_2.5-related associations were observed with 30-day readmission risk. Early-readmission risk was increased by 1.6%-1.8% following all-cause (1.6%, 95% CI 0.6% to 2.6%), cardiovascular (1.8%, 95% CI 0.4% to 3.2%) and respiratory (1.8%, 95% CI 0.4% to 3.2%) discharges; while late-readmission risk increased by 1.2%-1.3% following all-cause and cardiovascular discharges. PM_2.5-related associations with readmission risk were greatest for certain cause-specific readmissions ranging 4.0%-6.5% for dysrhythmia and conduction disorder, heart failure, chronic obstructive pulmonary disease, other non-cardiac chest pain or respiratory syndrome and pneumonia. Following all-cause discharges, the cause-specific early-readmission risk was increased by 6.5% (95% CI 3.5% to 9.6%) for pneumonia, 4.8% (95% CI 2.3% to 7.4%) for dysrhythmia and conduction disorder, 3.7% (95% CI 1.4% to 6.0%) for heart failure and 2.7% (95% CI 1.2% to 4.2%) for other non-cardiac chest pain or respiratory syndrome-related causes.

CONCLUSIONS

Daily ambient PM_2.5 was associated with an increased risk of cardiovascular admissions and 30-day readmissions following cardiopulmonary-related discharges in a vulnerable end-stage renal disease population. In the first week following discharge, greater PM_2.5-related risk of rehospitalisation was identified for some diagnoses.

Community Racial Composition and Hospitalization Among Patients Receiving In-Center Hemodialysis

RATIONALE & OBJECTIVE

Community racial composition has been shown to be associated with mortality in patients receiving maintenenance dialysis. It is unclear whether living in communities with predominantly Black residents is also associated with risk for hospitalization among patients receiving hemodialysis.

STUDY DESIGN

Retrospective analysis of prospectively collected data from a cohort of patients receiving hemodialysis.

SETTING & PARTICIPANTS

4,567 patients treated in 154 dialysis facilities located in 127 unique zip codes and enrolled in US Dialysis Outcomes and Practice Patterns Study (DOPPS) phases 4 to 5 (2010-2015).

EXPOSURE

Tertile of percentage of Black residents within zip code of patients' dialysis facility, defined through a link to the American Community Survey.

OUTCOME

Rate of hospitalizations during the study period.

ANALYTIC APPROACH

Associations of patient-, facility-, and community-level variables with community's percentage of Black residents were assessed using analysis of variance, Kruskal-Wallis, or χ2/Fisher exact tests. Negative binomial regression was used to estimate the incidence rate ratio for hospitalizations between these communities, with and without adjustment for potential confounding variables.

RESULTS

Mean age of study patients was 62.7 years. 53% were White, 27% were Black, and 45% were women. Median and threshold percentages of Black residents in zip codes in which dialysis facilities were located were 34.2% and≥14.4% for tertile 3 and 1.0% and≤1.8% for tertile 1, respectively. Compared with those in tertile 1 facilities, patients in tertile 3 facilities were more likely to be younger, be Black, live in urban communities with lower socioeconomic status, have a catheter as vascular access, and have fewer comorbid conditions. Patients dialyzing in communities with the highest tertile of Black residents experienced a higher adjusted rate of hospitalization (adjusted incidence rate ratio, 1.32; 95% CI, 1.12-1.56) compared with those treated in communities within the lowest tertile.

LIMITATIONS

Potential residual confounding.

CONCLUSIONS

The risk for hospitalization for patients receiving maintenance dialysis is higher among those treated in communities with a higher percentage of Black residents after adjustment for dialysis care, patient demographics, and comorbid conditions. Understanding the cause of this association should be a priority of future investigation.

Long-term outcomes among Medicare patients readmitted in the first year of hemodialysis: a retrospective cohort study

Background

Readmission within 30 days of hospital discharge is common and costly among end-stage renal disease (ESRD) patients. Little is known about long-term outcomes after readmission. We estimated the association between hospital admissions and readmissions in the first year of dialysis and outcomes in the second year.

Methods

Data on incident dialysis patients with Medicare coverage were obtained from the United States Renal Data System (USRDS). Readmission patterns were summarized as no admissions in the first year of dialysis (Admit-), at least one admission but no readmissions within 30 days (Admit+/Readmit-), and admissions with at least one readmission within 30 days (Admit+/Readmit+).We used Cox proportional hazards models to estimate the association between readmission pattern and mortality, hospitalization, and kidney transplantation, accounting for demographic and clinical covariates.

Results

Among the 128,593 Medicare ESRD patients included in the study, 18.5% were Admit+/Readmit+, 30.5% were Admit+/Readmit-, and 51.0% were Admit-. Readmit+/Admit+ patients had substantially higher long-term risk of mortality (HR = 3.32 (95% CI, 3.21–3.44)), hospitalization (HR = 4.46 (95% CI, 4.36–4.56)), and lower likelihood of kidney transplantation (HR = 0.52 (95% CI, 0.44–0.62)) compared to Admit- patients; these associations were stronger than those among Admit+/Readmit- patients.

Conclusions

Patients with readmissions in the first year of dialysis were at substantially higher risk of poor outcomes than either patients who had no admissions or patients who had hospital admissions but no readmissions. Identifying strategies to both prevent readmission and mitigate risk among patients who had a readmission may improve outcomes among this substantial, high-risk group of ESRD patients.

Electronic supplementary material

The online version of this article (10.1186/s12882-019-1473-0) contains supplementary material, which is available to authorized users.

Medication Regimen Complexity and Hospital Readmission in Older Adults With Chronic Kidney Disease

BACKGROUND

Chronic kidney disease (CKD) is characterized by high rates of hospital admissions and readmissions. However, there is a scarcity of research into medication-related factors predicting such outcomes in this patient group.

OBJECTIVE

To evaluate the effect of medication regimen complexity at hospital discharge on subsequent readmissions and their timing in older adults with CKD.

METHODS

This was a 12-month retrospective cohort study of 204 older (⩾65 years) CKD patients in an Australian tertiary care hospital. Medication regimen complexity was quantified using the 65-item medication regimen complexity index (MRCI). The outcomes were the occurrence of readmission in 30 days and time to readmission within 12 months. Logistic regression was used to identify factors predicting 30-day readmission, and a competing risks proportional subdistribution hazard model, accounting for deaths, was used for factors predicting time to readmission.

RESULTS

Overall, 50 (24%) patients, predominantly men (72%), were readmitted within 30 days of follow-up. MRCI was not significantly associated with 30-day readmission (odds ratio [OR] = 1.27; 95% CI = 0.94-1.73). The median (interquartile range) time to readmission within 12 months was 145 (31-365) days. On a multivariate analysis, a 10-unit increase in MRCI was associated with a shorter time to readmission within 12 months (subdistribution HR = 1.18; 95% CI = 1.01-1.36). Conclusion and Relevance: Medication regimen complexity was not significantly associated with 30-day readmission; however, it was associated with a significantly shorter time to 12-month readmission in older CKD patients. This finding highlights the importance of medication regimen complexity as a potential target for medical interventions to reduce readmission risks.