Identification of volume overload hospitalizations among hemodialysis patients using administrative claims: a validation study

Receiving hemodialysis in Hispanic ethnic dense communities is associated with better adherence and outcomes among young patients: a retrospective analysis of the Dialysis Outcomes and Practice Patterns Study

BACKGROUND

Hispanic ethnic density (HED) is a marker of better health outcomes among Hispanic patients with chronic disease. It is unclear whether community HED is associated with mortality risk among ethnically diverse patients receiving maintenance hemodialysis.

METHODS

A retrospective analysis of patients in the United States cohort of the Dialysis Outcomes and Practice Patterns Study (DOPPS) database (2011-2015) was conducted (n = 4226). DOPPS data was linked to the American Community Survey database by dialysis facility zip code to obtain % Hispanic residents (HED). One way ANOVA and Kruskal Wallis tests were used to estimate the association between tertiles of HED with individual demographic, clinical and adherence characteristics, and facility and community attributes. Multivariable Cox proportional hazards models were used to estimate the mortality hazard ratio (HR) and 95% CIs by tertile of HED, stratified by age; a sandwich estimator was used to account for facility clustering.

RESULTS

Patients dialyzing in facilities located in the highest HED tertile communities were younger (61.4 vs. 64.4 years), more commonly non-White (62.4% vs. 22.1%), had fewer comorbidities, longer dialysis vintage, and were more adherent to dialysis treatment, but had fewer minutes of dialysis prescribed than those in the lowest tertile. Dialyzing in the highest HED tertile was associated with lower hazard of mortality (HR, 0.86; 95% CI, 0.72-1.00), but this association attenuated with the addition of individual race/ethnicity (HR, 0.92; 95% CI, 0.78-1.09). In multivariable age-stratified analyses, those younger than 64 showed a lower hazard for mortality in the highest (vs. lowest) HED tertile (HR, 0.66; 95% CI, 0.49-0.90). Null associations were observed among patients ≥ 64 years.

CONCLUSIONS

Treating in communities with greater HED and racial/ethnic integration was associated with lower mortality among younger patients which points to neighborhood context and social cohesion as potential drivers of improved survival outcomes for patients receiving hemodialysis.

Validity of operative information in Japanese administrative data: a chart review-based analysis of 1221 cases at a single institution

PURPOSE

To evaluate the validity of operative information recorded in the Diagnosis Procedure Combination (DPC) database, a national inpatient database including administrative claims data.

METHODS

We reviewed the medical charts of 1221 patients who underwent one of six surgeries (breast, esophageal, gastric, thyroid cancer surgery, appendectomy, or inguinal hernia repair) at a surgery department of a university hospital from April 2016 to March 2019. We compared operative information (type, date, laterality of procedure; type of anesthesia; transfusion; and duration of anesthesia) recorded in the DPC database with the information recorded in the medical charts.

RESULTS

The DPC data for type, date, laterality of surgery, and type of anesthesia were accurate in 99% of the reviewed patients. The sensitivity and specificity for identifying whether a patient received a transfusion procedure were 97.5% and 99.6%, respectively. Data regarding the duration of anesthesia in the DPC database were identical to those in medical chart records in 1114 of 1216 cases that received general or spinal anesthesia (91.5%). The duration of anesthesia in the DPC data was 53 min longer on average than the recorded operative time in the medical charts.

CONCLUSION

The DPC database had high validity for operative information.

Temporal Changes in Electrolytes, Acid-Base, QTc Duration, and Point-of-Care Ultrasound during Inpatient Hemodialysis Sessions

Background

Of the more than 550,000 patients receiving maintenance hemodialysis (HD) in the United States, each has an average of 1.6 admissions annually (>880,000 inpatient HD sessions). Little is known about the temporal changes in laboratory values, ECGs, and intravascular and extravascular volume during inpatient HD sessions.

Methods

In this prospective cohort study of hospitalized HD patients, we assessed intradialytic laboratory values (metabolic panels, blood gases, ionized calcium levels), ECGs, and sonographic measures of volume status.

Results

Among 30 participants undergoing HD (mean age 62 years; 53% men, 43% Black) laboratory values had the largest changes in the first hour of HD. There was no significant change in ionized calcium levels pre- to post-HD (change: -0.01±0.07, P=0.24); 12 of 30 and 17 of 30 patients had levels below the lower reference limit at the beginning and end of HD, respectively. The mean pH increased pre- to post-HD (change: 0.06±0.04, P<0.001); 21 of 30 had a pH above the upper reference limit post-HD. There was a trend toward longer median QTc duration from pre- to post-HD (change: 7.5 msec [-5 msec, 19 msec], P=0.07). The sum of B lines on lung ultrasound decreased from pre- to post-HD (median decrease: 3 [1, 7], P<0.01). The collapsibility index of the inferior vena cava increased pre- to post-HD (median increase: 4.8% [1.5%, 13.4%], P=0.01), whereas internal jugular vein diameter did not change (P=0.24).

Conclusions

Among hospitalized patients undergoing HD, we found dynamic changes in laboratory values, QTc duration, and volume status. Further research is required to assess whether HD prescriptions can be tailored to alter these variations to potentially improve patient outcomes.

Peer mentorship to improve outcomes in patients on hemodialysis (PEER-HD): a randomized controlled trial protocol

BACKGROUND

Patients receiving in-center hemodialysis experience disproportionate morbidity and incur high healthcare-related costs. Much of this cost stems from potentially avoidable hospitalizations. Peer mentorship has been used effectively to improve outcomes for patients with complex chronic diseases. We propose testing the efficacy of peer mentorship on hospitalization rates among patients receiving hemodialysis.

METHODS

This is a multicenter parallel group randomized controlled pragmatic trial of patients treated at hemodialysis facilities in Bronx, NY and Nashville, TN. The study has two phases. Phase 1 will enroll and train 16 hemodialysis patients (10 in Bronx, NY and 6 in Nashville TN) to be mentors using a program focused on enhancing self-efficacy, dialysis self-management and autonomy-supportive communication skills. Phase 2 will enroll 200 high risk adults receiving hemodialysis (140 in Bronx, NY and 60 in Nashville, TN), half of whom will be randomized to intervention and half to usual care. Intervention participants are assigned to weekly telephone calls with trained mentors (see Phase 1) for a 3-month period. The primary outcome of Phase 1 will be engagement of mentors with training and change in knowledge scores and autonomy skills from pre- to post-training. The primary outcome of Phase 2 will be the composite count of ED visits and hospitalizations at the end of study follow-up in patient participants assigned to intervention as compared to those assigned to usual care. Secondary outcomes for Phase 2 include the change over the trial period in validated survey scores measuring perception of social support and self-efficacy, and dialysis adherence metrics, among intervention participants as compared to usual care participants.

DISCUSSION

The PEER-HD study will test the feasibility and efficacy of a pragmatic peer-mentorship program designed for patients receiving hemodialysis on ED visit and hospitalization rates. If effective, peer-mentorship holds promise as a scalable patient-centered intervention to decrease hospital resource utilization, and by extension morbidity and cost, for patients receiving maintenance in-center hemodialysis.

TRIAL REGISTRATION

Clinicaltrials.gov identifier: NCT03595748 ; 7/23/2018.

TRIAL SPONSOR

National Institutes of Diabetes, Digestive and Kidney Disease (NIDDK) 5R18DK118471.

FUNDING

Funding for this study was provided by the National Institutes of Diabetes, Digestive and Kidney Disease: R18DK118471.

STUDY STATUS

This is an ongoing study and not complete. We are still collecting data for observational follow-up on participants.

RELATED ARTICLES

No related articles for this study have been submitted to any journal. The study sponsor and funders had no role in the design, analysis or interpretation of this data. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

Serum NT-Pro-BNP versus Noninvasive Bedside Inotropic Index in Paediatric Shock: A Contest of Myocardial Performance in Response to Fluid Loading

Background

Mild elevation of serum amino-terminal pro-B-type natriuretic peptide (NT-pro-BNP) is associated with myocardial dysfunction. A significantly lower Smith-Madigan inotropic index (SMII) has been shown to accurately represent cardiac contractility among heart failure subjects. We aim to monitor the effect of fluid resuscitation on cardiac function among paediatric patients by measuring serum NT-pro-BNP and SMII.

Methods

This is an observational study on 70 paediatric shock patients. NT-pro-BNP and noninvasive bedside haemodynamic monitoring were done by using an ultrasonic cardiac output monitor (USCOM, USCOM, Sydney, Australia). The presence of cardiac diseases was excluded. SMII was obtained from the USCOM. An increase in the stroke volume index (SVI) of ≥15% indicates fluid responders. Measurements were taken before and after fluid loading.

Results

Preloading NT-pro-BNP and SMII category were significantly different between the fluid responsiveness group, p=0.001 and p=0.004, respectively. Higher median NT-pro-BNP (preloading NT-pro-BNP of 1175.00 (254.50-9965.00) ng/mL vs. 196.00 (65.00-509.00) ng/mL, p=0.002) was associated with fluid nonresponders (subjects >12 months old). Preloading NT-pro-BNP <242.5 ng/mL was associated with fluid responders (AUC: 0.768 (0.615-0.921), p=0.003), 82.1% sensitivity, and 68.7% specificity for subjects >12 years old. Delta NT-pro-BNP in fluid responders (15.00 (-16.00-950.00) ng/mL) did not differ from fluid nonresponders (505.00 (-797.00-1600.00) ng/mL), p=0.456. Postloading SMII >1.25 W·m^-2 was associated with fluid responders (AUC: 0.683 (0.553-0.813), p = 0.011), 61.9% sensitivity, and 66.7% specificity, but not preloading SMII. Fluid responders had a higher mean postloading SMII compared to nonresponders (1.36 ± 0.38 vs. 1.10 ± 0.34, p=0.006).

Conclusion

Higher NT-pro-BNP and lower SMII in the absence of cardiac diseases were associated with poor response to fluid loading. The SMII is affected by low preload conditions.

Validity of Incident Opioid Use Disorder (OUD) Diagnoses in Administrative Data: a Chart Verification Study

BACKGROUND

An important strategy to address the opioid overdose epidemic involves identifying people at elevated risk of overdose, particularly those with opioid use disorder (OUD). However, it is unclear to what degree OUD diagnoses in administrative data are inaccurate.

OBJECTIVE

To estimate the prevalence of inaccurate diagnoses of OUD among patients with incident OUD diagnoses.

SUBJECTS

A random sample of 90 patients with incident OUD diagnoses associated with an index in-person encounter between October 1, 2016, and June 1, 2018, in three Veterans Health Administration medical centers.

DESIGN

Direct chart review of all encounter notes, referrals, prescriptions, and laboratory values within a 120-day window before and after the index encounter. Using all available chart data, we determined whether the diagnosis of OUD was likely accurate, likely inaccurate, or of indeterminate accuracy. We then performed a bivariate analysis to assess demographic or clinical characteristics associated with likely inaccurate diagnoses.

KEY RESULTS

We identified 1337 veterans with incident OUD diagnoses. In the chart verification subsample, we assessed 26 (29%) OUD diagnoses as likely inaccurate; 20 due to systems error and 6 due to clinical error; additionally, 8 had insufficient information to determine accuracy. Veterans with likely inaccurate diagnoses were more likely to be younger and prescribed opioids for pain. Clinical settings associated with likely inaccurate diagnoses were non-mental health clinical settings, group visits, and non-patient care settings.

CONCLUSIONS

Our study identified significant levels of likely inaccurate OUD diagnoses among veterans with incident OUD diagnoses. The majority of these cases reflected readily addressable systems errors. The smaller proportion due to clinical errors and those with insufficient documentation may be addressed by increased training for clinicians. If these inaccuracies are prevalent throughout the VHA, they could complicate health services research and health systems responses.

Effects of Lung Ultrasonography-Guided Management on Cumulative Fluid Balance and Other Clinical Outcomes: A Systematic Review

Lung ultrasonography is accurate in detecting pulmonary edema and overcomes most limitations of traditional diagnostic modalities. Whether use of lung ultrasonography-guided management has an effect on cumulative fluid balances and other clinical outcomes remains unclear. In this systematic review, we included 12 studies using ultrasonography guided-management with a total of 2290 patients. Four in-patient studies found a reduced cumulative fluid balance (ranging from -0.3 L to -2.4 L), whereas three out-patient studies found reduction in dialysis dry weight (ranging from -2.6 kg to -0.2 kg) compared with conventionally managed patients. None of the studies found adverse effects related to hypoperfusion. The use of lung ultrasonography-guided management was not associated with other clinical outcomes. This systematic review shows that lung ultrasonography-guided management, exclusively or in concert with other diagnostic modalities, is associated with a reduced cumulative fluid balance. Studies thus far have not shown a consistent effect on clinical outcomes.

The association of neighborhood racial mix and ED visit count in a cohort of patients on hemodialysis

Background

Neighborhood racial mix is associated with dialysis facility performance metrics and mortality outcomes in patients on hemodialysis. We explored the association of neighborhood racial mix with emergency department (ED) visits in patients receiving hemodialysis.

Methods

Using Looking Glass (Montefiore’s clinical database) we identified a cohort of patients on hemodialysis with an index ED visit at any of 4 Montefiore Hospital locations, between January 2013 and December 2017 and followed it for number of ED visits through December of 2017 or dropout due to death. The racial mix data for the Bronx block group of each subject’s residence was derived from the Census Bureau. We then used negative binomial regression to test the association of quintile of percent of Black residents per residential block group with ED visits in unadjusted and adjusted models. To adjust further for quality offered by local dialysis facilities, with the facility zip code as the locus, we used data from the “Dialysis Compare” website.

Results

Three thousand nine-hundred and eighteen subjects were identified and the median number of ED visits was 3 (interquartile range (IQR) 1–7) during the study period. Subjects living in the highest quintile of percent Black residents were older, more commonly female and had lower poverty rates and higher rates of high school diplomas. Unadjusted models showed a significant association between the highest quintiles of Black neighborhood residence and count of ED visits. Fully adjusted, stratified models revealed that among males, and Hispanic and White subjects, living in neighborhoods with the highest quintiles of Black residents was associated with significantly more ED visits (p-trend =0.001, 0.02, 0.01 respectively). No association was found between dialysis facility locations’ quintile of Black residents and quality metrics.

Conclusions

Living in a neighborhood with a higher percentage of Black residents is associated with a higher number of ED visits in males and non-Black patients on hemodialysis.

Electronic supplementary material

The online version of this article (10.1186/s12882-019-1520-x) contains supplementary material, which is available to authorized users.

Using Technology to Inform and Deliver Precise Personalized Care to Patients With End-Stage Kidney Disease

Consistent with the increase of precision medicine, the care of patients with end-stage kidney disease (ESKD) requiring maintenance dialysis therapy should evolve to become more personalized. Precise and personalized care is nuanced and informed by a number of factors including an individual's needs and preferences, disease progression, and response to and tolerance of treatments. Technology can support the delivery of more precise and personalized care through multiple mechanisms, including more accurate and real-time assessments of key care elements, enhanced treatment monitoring, and remote monitoring of home dialysis therapies. Data from health care and non-health care sources and advanced analytical methods such as machine learning can be used to create novel insights, and large volumes of data can be integrated to support clinical decisions. Health care models continue to evolve and the opportunities and need for novel care approaches supported by technology and health informatics continue to expand as the delivery and organization of health care changes. Ultimately, precise personalized care for ESKD, including dialysis therapy, will become more feasible as the biological, social, and environmental determinants of health are more broadly understood and as advances in science, engineering, and information management create the means to provide truly precise care for ESKD.

Fluid status assessment in hemodialysis patients and the association with outcome: review of recent literature

PURPOSE OF REVIEW

In this review, we will discuss the most recent literature regarding fluids status assessment in hemodialysis patients, and the associations with outcome.

RECENT FINDINGS

Research toward technique-assisted assessment of fluid status in hemodialysis patients has been going on for many years. However, there is no absolute agreement between techniques, such as bioimpedance, lung ultrasound, biochemical markers or vena caval diameter, likely because they reflect different fluid compartments with potentially altered distribution in hemodialysis patients. Recent studies, mostly based on bioimpedance, have shown not only an association of severe, but also of moderate predialysis fluid overload with overall survival. Also predialysis fluid depletion has been found to associate with and increased mortality risk. Interventional studies with fluid-guided management are scarce and outline the difficulties of achieving dry weight is the dialysis population.

SUMMARY

Optimal estimation of predialysis fluid status remains challenging and may require a combination of clinical and technical derived parameters. There appears to be a narrow window of optimal predialysis fluid status. Further clinical studies are necessary to identify strategies to improve survival in hemodialysis patients with abnormalities in fluid status.

Association of social worker-assessed psychosocial factors with 30-day hospital readmissions among hemodialysis patients

Background

Evidence regarding the effect of psychosocial factors on hospital readmission in the setting of hemodialysis is limited. We examined whether social worker-assessed factors were associated with 30-day readmission among prevalent hemodialysis patients.

Methods

Data on 14 factors were extracted from the first available psychosocial assessment performed by social workers at three metropolitan Atlanta dialysis centers. Index admissions (first admission preceded by ≥30 days without a previous hospital discharge) were identified in the period 2/1/10–12/31/14, using linked national administrative hospitalization data. Readmission was defined as any admission within 30 days after index discharge. Associations of each of the psychosocial factors with readmission were assessed using multivariable logistic regression with adjustment for patient and index admission characteristics.

Results

Among 719 patients with index admissions, 22.1% were readmitted within 30 days. No psychosocial factors were statistically significantly associated with readmission risk. However, history of substance abuse vs. none was associated with a 29% higher risk of 30-day readmission [OR: 1.29, 95% CI: 0.75–2.23], whereas depression/anxiety was associated with 20% lower risk [OR: 0.80, 95% CI: 0.47–1.36]. Patients who were never married and those who were divorced, or widowed had 38 and 17% higher risk of 30-day readmission, respectively, than those who were married [OR: 1.38, 95% CI: 0.84–2.72; OR: 1.17, 95% CI: 0.73–1.90].

Conclusions

Results suggest that psychosocial issues may be associated with risk of 30-day readmission among dialysis patients. Despite the limitations of lack of generalizability and potential misclassification due to patient self-report of psychosocial factors to social workers, further study is warranted to determine whether addressing these factors through targeted interventions could potentially reduce readmissions among hemodialysis patients.

Post-hospitalization dialysis facility processes of care and hospital readmissions among hemodialysis patients: a retrospective cohort study

Background

Both dialysis facilities and hospitals are accountable for 30-day hospital readmissions among U.S. hemodialysis patients. We examined the association of post-hospitalization processes of care at hemodialysis facilities with pulmonary edema-related and other readmissions.

Methods

In a retrospective cohort comprised of electronic medical record (EMR) data linked with national registry data, we identified unique patient index admissions (n = 1056; 2/1/10–7/31/15) that were followed by ≥3 in-center hemodialysis sessions within 10 days, among patients treated at 19 Southeastern dialysis facilities. Indicators of processes of care were defined as present vs. absent in the dialysis facility EMR. Readmissions were defined as admissions within 30 days of the index discharge; pulmonary edema-related vs. other readmissions defined by discharge codes for pulmonary edema, fluid overload, and/or congestive heart failure. Multinomial logistic regression to estimate odds ratios (ORs) for pulmonary edema-related and other vs. no readmissions.

Results

Overall, 17.7% of patients were readmitted, and 8.0% had pulmonary edema-related readmissions (44.9% of all readmissions). Documentation of the index admission (OR = 2.03, 95% CI 1.07–3.85), congestive heart failure (OR = 1.87, 95% CI 1.07–3.27), and home medications stopped (OR = 1.81, 95% CI 1.08–3.05) or changed (OR = 1.69, 95% CI 1.06–2.70) in the EMR post-hospitalization were all associated with higher risk of pulmonary edema-related vs. no readmission; lower post-dialysis weight (by ≥0.5 kg) after vs. before hospitalization was associated with 40% lower risk (OR = 0.60, 95% CI 0.37–0.96).

Conclusions

Our results suggest that some interventions performed at the dialysis facility in the post-hospitalization period may be associated with reduced readmission risk, while others may provide a potential existing means of identifying patients at higher risk for readmissions, to whom such interventions could be efficiently targeted.

Electronic supplementary material

The online version of this article (10.1186/s12882-018-0983-5) contains supplementary material, which is available to authorized users.

Failed Target Weight Achievement Associates with Short-Term Hospital Encounters among Individuals Receiving Maintenance Hemodialysis

Background Hospitalizations and 30-day readmissions are common in the hemodialysis population. Actionable clinical markers for near-term hospital encounters are needed to identify individuals who require swift intervention to avoid hospitalization. Aspects of volume management, such as failed target weight (i.e, estimated dry weight) achievement, are plausible modifiable indicators of impending adverse events. The short-term consequences of failed target weight achievement are not well established.Methods Statistically deidentified data were taken from a cohort of Medicare-enrolled, prevalent hemodialysis patients treated at a large dialysis organization from 2010 to 2012. We used a retrospective cohort design with repeated intervals, each consisting of 180-day baseline, 30-day exposure assessment, and 30-day follow-up period, to estimate the associations between failed target weight achievement and the risk of 30-day emergency department visits and hospitalizations. We estimated adjusted risk differences using inverse probability of exposure weighted Kaplan-Meier methods.Results A total of 113,561 patients on hemodialysis contributed 788,722 study intervals to analyses. Patients who had a postdialysis weight >1.0 kg above the prescribed target weight in ≥30% (versus <30%) of exposure period treatments had a higher absolute risk (risk difference) of 30-day: emergency department visits (2.13%; 95% confidence interval, 2.00% to 2.32%); and all-cause (1.47%; 95% confidence interval, 1.34% to 1.62%), cardiovascular (0.31%; 95% confidence interval, 0.24% to 0.40%), and volume-related (0.15%; 95% confidence interval, 0.11% to 0.21%) hospitalizations.Conclusions In the absence of objective measures of volume status, recurrent failure to achieve target weight is an easily identifiable clinical risk marker for impending hospital encounters among patients on hemodialysis.

Intradialytic Hypertension Frequency and Short-Term Clinical Outcomes Among Individuals Receiving Maintenance Hemodialysis

BACKGROUND

Intradialytic hypertension occurs in 5-20% of hemodialysis treatments. Observational data support an association between intradialytic hypertension and long-term mortality. However, the short-term consequences of recurrent intradialytic hypertension are unknown.

METHODS

Data were taken from a cohort of prevalent hemodialysis patients receiving treatment at a large United States dialysis organization on 1 January 2010. A retrospective cohort design with a 180-day baseline, 30-day exposure assessment, and 30-day follow-up period was used to estimate the associations between intradialytic hypertension frequency and 30-day outcomes. Intradialytic hypertension frequency was defined as the proportion of exposure period hemodialysis treatments with a predialysis to postdialysis systolic blood pressure rise >0 mm Hg. Multivariable Cox proportional hazards regression, adjusted for baseline clinical, laboratory, and dialysis treatment covariates, was used to estimate hazard ratios and 95% confidence intervals.

RESULTS

Of the 37,094 study patients, 5,242 (14.1%), 17,965 (48.4%), 10,821 (29.2%), 3,066 (8.3%) had intradialytic hypertension in 0%, 1-32%, 33-66%, and ≥67% of exposure period treatments, respectively. More frequent intradialytic hypertension was associated with incremental increases in 30-day mortality and hospitalizations. Patients with intradialytic hypertension in ≥67% (vs. 0%) of exposure period treatments had the highest risk of all-cause death, hazard ratio [95% confidence interval]: 2.57 [1.68, 3.94]; cardiovascular (CV) death, 3.68 [1.89, 7.15]; all-cause hospitalizations, 1.42 [1.26, 1.62]; CV hospitalizations, 1.71 [1.36, 2.15]; and volume-related hospitalizations, 2.25 [1.25, 4.04].

CONCLUSIONS

Among prevalent hemodialysis patients, more frequent intradialytic hypertension was incrementally associated with increased 30-day morbidity and mortality. Intradialytic hypertension may be an important short-term risk marker in the hemodialysis population.