Hospital readmission for the dialysis patient: who is (not) responsible?

Hospitalizations of Chronic Dialysis Patients: A National Study in China

Background

Patients receiving chronic dialysis are usually with multiple comorbidities and at high risk for hospitalization, which lead to tremendous health care resource utilization. This study aims to explore the characteristics of hospitalizations among chronic dialysis patients in China.

Methods

Hospital admissions from January 2013 to December 2015 were extracted from a national inpatient database in China. Chronic dialysis, including hemodialysis and peritoneal dialysis, was identified according to inpatient discharge records and International Classification of Diseases-10 (ICD-10) codes. The primary kidney disease, causes of admissions, modalities of dialysis, and comorbidities were analyzed. Multivariable logistic regression model was used to assess the association of patient characteristics with multiple hospitalizations per year.

Results

Altogether, 266,636 hospitalizations from 124,721 chronic dialysis patients were included in the study. The mean age was 54.46 ± 15.63 years and 78.29% of them were receiving hemodialysis. The leading cause of hospitalizations was dialysis access-related, including dialysis access creation (25.06%) and complications of access (21.09%). The following causes were nonaccess surgery (1.89%), cardiovascular disease (1.66%), and infectious diseases (1.43%). One-fourth of the patients were hospitalized more than once per year. Multivariate logistic regression models indicated that the primary kidney disease of diabetic kidney disease (odds ratio [OR]: 1.16, 95% confidence interval [CI]: 1.11-1.22) or hypertensive nephropathy (OR: 1.33, 95% CI: 1.27-1.40), coronary heart disease (OR: 1.09, 95% CI: 1.05-1.14), cancer (OR: 1.21, 95% CI: 1.13-1.30), or modality of peritoneal dialysis (OR: 2.67, 95% CI: 2.59-2.75) was risk factors for multiple hospitalizations.

Conclusion

Our study described characteristics and revealed the burden of hospitalizations of chronic dialysis patients in China. These findings highlight the importance of effective and efficient management strategies to reduce the high burden of hospitalization in dialysis population.

Commentary on the NICE guideline on renal replacement therapy and conservative management

NICE Guideline NG107, “Renal replacement therapy and conservative management” (Renal replacement therapy and conservative management (NG107); 2018:1–33) was published in October 2018 and replaced the existing NICE guideline CG125, “Chronic Kidney Disease (Stage 5): peritoneal dialysis” (Chronic kidney disease (stage 5): peritoneal dialysis | Guidance | NICE; 2011) and NICE Technology Appraisal TA48, “Guidance on home compared with hospital haemodialysis for patients with end-stage renal failure”(Guidance on home compared with hospital haemodialysis for patients with end-stage renal failure (Technology appraisal guideline TA48); 2002) The aim of the NICE guideline (NG107) was to provide guidance on renal replacement therapy (RRT), including dialysis, transplant and conservative care, for adults and children with CKD Stages 4 and 5. The guideline is extremely welcomed by the Renal Association and it offers huge value to patients, clinicians, commissioners and key stakeholders. It overlaps and enhances current guidance published by the Renal Association including “Haemodialysis” (Clinical practice guideline: Haemodialysis; 2019) which was updated in 2019 after the publication of the NICE guideline, “Peritoneal Dialysis in Adults and Children” (Clinical practice guideline: peritoneal Dialysis in adults and children; 2017) and “Planning, Initiation & withdrawal of Renal Replacement Therapy” (Clinical practice guideline: planning, initiation and withdrawal of renal replacement therapy; 2014) (at present there are no plans to update this guideline).

There are several strengths to NICE guideline NG107 and we agree with and support the vast majority of recommendation statements in the guideline. This summary from the Renal Association discusses some of the key highlights, controversies, gaps in knowledge and challenges in implementation. Where there is disagreement with a NICE guideline statement, we have highlighted this and a new suggested statement has been written.

Burden and causes of hospital admissions and readmissions in patients undergoing hemodialysis and peritoneal dialysis: a nationwide study

BACKGROUND

High rates of hospitalization in dialysis patients impose an increasing healthcare burden. We explored and compared hospital admission rates among patients starting hemodialysis (HD) and peritoneal dialysis (PD), and investigated causes of admission/readmission in search of potentially preventable risks.

METHODS

Observational study recruiting 8902 patients (3101 on PD) who started maintenance dialysis in Sweden between 2006 and 2016 and were followed-up for 2 years. We compared the Hazard Ratios (HR) for hospital admission and in-hospital death, and calculated the odds ratios (OR) of readmission within 30 days after discharge.

RESULTS

Six thousand four hundred ninety-three (73%) patients were hospitalized at least once, and 246 admissions ended with in-hospital death. Compared with HD, patients on PD had a higher risk of hospitalization (HR 1.07; 95% CI 1.01-1.13), longer length of stay (mean difference of 2.06; 1.39-2.73 days), and higher risk of in-hospital death (HR 1.18; 1.03-1.37). Peritonitis and cardiovascular events were the most frequent causes of admission. Of 5810 patients discharged from the hospital, 1447 (25%) were readmitted and 124 (2%) died within 30 days. No differences in readmission risk were observed between dialysis modalities. There was frequently discordance between the cause of hospital admission and readmission, and we identified a consistent pattern of readmission attributed to complications from infections and their interplay with cardiovascular diseases.

CONCLUSIONS

Our study illustrates a high burden of hospitalization in patients on dialysis, suggests the risk of longer hospitalizations for patients on PD, and identifies cardiovascular events and infections as complications that may benefit from closer post-discharge monitoring.

Dialysis Provider and Outcomes among United States Veterans Who Transition to Dialysis

BACKGROUND AND OBJECTIVES

Veterans with ESKD initiate dialysis under the Veterans Health Administration (VHA), an integrated health system, or are outsourced to non-VHA providers. It is unknown whether outcomes differ according to their dialysis provider at initiation. We sought to evaluate the association between dialysis provider and mortality and hospitalization among United States veterans initiating dialysis.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

Among 68,727 United States veterans who initiated dialysis in 2007-2014, we examined the association of dialysis provider (VHA versus non-VHA) at initiation with mortality and hospitalization rates in the first 12 months post-initiation. Associations were examined across adjusted models, accounting for demographics and comorbidities.

RESULTS

Patients were 72±11 years, 5% were women, 24% were black, and 10% (n=7584) initiated at VHA dialysis centers. VHA dialysis center patients were younger, more likely to be black, had fewer cardiovascular comorbidities, and lower eGFR at dialysis initiation. VHA provider patients were more likely to be hospitalized in the first 12 months (adjusted incidence rate ratio, 1.10; 95% confidence interval, 1.07 to 1.14), but had lower all-cause mortality risk (adjusted hazard ratio, 0.87; 95% confidence interval, 0.83 to 0.93) in fully adjusted models.

CONCLUSIONS

Veteran patients initiating dialysis with a VHA dialysis provider appear to have a lower mortality risk but higher hospitalization rates than veterans initiating dialysis at non-VHA dialysis units.