1
|
Chang CH, Lopez K, Wasser T, Mei H. Risk factors for readmission of patients with amputation to acute care from inpatient rehabilitation: A retrospective cohort study. PM R 2024; 16:231-238. [PMID: 37584174 DOI: 10.1002/pmrj.13056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Revised: 04/24/2023] [Accepted: 07/28/2023] [Indexed: 08/17/2023]
Abstract
INTRODUCTION Amputation is a major condition that requires inpatient rehabilitation. Some research has been conducted to explore the risk factors for readmission of patients from inpatient rehabilitation facilities to acute care hospitals. However, few studies have included patients with amputation in the study population. OBJECTIVE To identify the risk factors for readmission of patients with amputation to acute care hospitals from an inpatient rehabilitation facility. DESIGN Retrospective cohort study. SETTING An acute rehabilitation hospital associated with a community-based tertiary medical center. PATIENTS A retrospective review of 156 independent admissions of 145 patients from June 2019 to July 2022. MAIN OUTCOME MEASURE The study outcome measure was readmission to acute care from an acute rehabilitation unit. RESULTS Of the 156 independent admissions, the readmission rate was 19% (29/156). The most common cause of transfer was incision-site complications (9/29, 31%), including wound infection and wound dehiscence. Patients with amputation readmitted to acute care are more likely to be receiving dialysis (p < .001), have a longer length of stay in acute care before admission to the rehabilitation facility (p = .039), and have a lower Section GG score on admission (p < .001). Age, sex, ethnicity, amputation level, and history of diabetes mellitus were not associated with acute care hospital readmission. The logistic regression model revealed that patients being on dialysis was the only significant risk factor predictive of readmission to acute care (odds ratio [OR] 4.82, p = .006). CONCLUSIONS This study showed that incision-site complications were the most common cause of disruption in inpatient rehabilitation via acute hospital readmission in patients with amputation. Being on dialysis was associated with a higher risk of readmission to acute care hospitals. Based on the results of this study, specific rehabilitation plans might be required for patients with amputation who carry certain risk factors to reduce rehospitalization to the acute care unit.
Collapse
Affiliation(s)
- Chin-Hen Chang
- Department of Physical Medicine and Rehabilitation, Reading Hospital, Tower Health System, Reading, Pennsylvania, USA
| | - Kevin Lopez
- Department of Physical Medicine and Rehabilitation, Reading Hospital, Tower Health System, Reading, Pennsylvania, USA
| | - Thomas Wasser
- Consult-Stat: Complete Statistical Service, Wernersville, Pennsylvania, USA
| | - Haiping Mei
- Department of Physical Medicine and Rehabilitation, Reading Hospital, Tower Health System, Reading, Pennsylvania, USA
| |
Collapse
|
2
|
Paik JM, Eberly KE, Kabbara K, Harring M, Younossi Y, Henry L, Verma M, Younossi ZM. Non-alcoholic fatty liver disease is associated with greater risk of 30-day hospital readmission in the United States (U.S.). Ann Hepatol 2023; 28:101108. [PMID: 37088421 DOI: 10.1016/j.aohep.2023.101108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Revised: 03/30/2023] [Accepted: 04/14/2023] [Indexed: 04/25/2023]
Abstract
INTRODUCTION AND OBJECTIVES Data about 30-day readmission for patients with chronic liver disease (CLD) and their contribution to CLD healthcare burden are sparse. Patterns, diagnoses, timing and predictors of 30-day readmissions for CLD from 2010-2017 were assessed. MATERIALS AND METHODS Nationwide Readmission Database (NRD) is an all-payer, all-ages, longitudinal administrative database, representing 35 million discharges in the US population yearly. We identified unique patients discharged with CLD including hepatitis B (HBV) and C (HCV), alcoholic liver disease (ALD) and non-alcoholic fatty liver disease (NAFLD) from 2010 through 2017. Survey-weight adjusted multivariable were used. RESULTS From 2010 to 2017, the 30-day readmission rate for CLD decreased from 18.4% to 17.8% (p=.008), while increased for NAFLD from 17.0% to 19. 9% (p<.001). Of 125,019 patients discharged with CLD (mean age 57.4 years, male 59.0%) in 2017, the most common liver disease was HCV (29.2%), followed by ALD (23.5%), NAFLD (17.5%), and HBV (4.3%). Readmission rates were 20.5% for ALD, 19.9% for NAFLD, 16.8% for HCV and 16.7% for HBV. Compared to other liver diseases, patients with NAFLD had significantly higher risk of 30-day readmission in clinical comorbidities adjusted model (Hazard ratio [HR]=1.08 [95% confidence interval 1.03-1.13]). In addition to ascites, hepatic encephalopathy, higher number of coexisting comorbidities, comorbidities associated with higher risk of 30-day readmission included cirrhosis for NALFD and HCV; acute kidney injury for NAFLD, HCV and ALD; HCC for HCV, and peritonitis for ALD. Cirrhosis and cirrhosis-related complications was the most common reason for 30-day readmission, followed by sepsis. However, a large proportion of patients (43.7% for NAFLD; 28.4% for HCV, 39.0% for HBV, and 29.1% for ALD) were readmitted for extrahepatic reasons. Approximately 20% of those discharged with CLD were readmitted within 30 days but the majority of readmissions occurred within 15 days of discharge (62.8% for NAFLD, 63.7% for HCV, 74.3% for HBV, and 72.9% for ALD). Among readmitted patients, patients admitted ≤30-day had significantly higher cost and risk of in-hospital mortality for patients with NAFLD (+5.69% change [95% confidence interval, 2.54%-8.93%] and odds ratio (OR)=1.58 [1.28-1.95]) and HCV (+9.85% change [6.96%-12.82%] and OR=1.31, 1.08-1.59. CONCLUSIONS Early readmissions for CLD are prevalent causing economic and clinical burden to the US healthcare system, especially NAFLD readmissions. Closer surveillance and attention to both liver and extrahepatic medical conditions immediately after CLD discharge is encouraged.
Collapse
Affiliation(s)
- James M Paik
- Inova Medicine, Inova Health System, Falls Church, VA, United States; Betty and Guy Beatty Center for Integrated Research, Inova Health System, Falls Church, VA, United States
| | - Katherine E Eberly
- Inova Medicine, Inova Health System, Falls Church, VA, United States; Center for Liver Disease, Department of Medicine, Inova Fairfax Medical Campus, Falls Church, VA, United States
| | - Khaled Kabbara
- Inova Medicine, Inova Health System, Falls Church, VA, United States; Center for Liver Disease, Department of Medicine, Inova Fairfax Medical Campus, Falls Church, VA, United States
| | - Michael Harring
- Inova Medicine, Inova Health System, Falls Church, VA, United States; Center for Liver Disease, Department of Medicine, Inova Fairfax Medical Campus, Falls Church, VA, United States
| | - Youssef Younossi
- Center for Outcomes Research in Liver Diseases, Washington DC, United States; Betty and Guy Beatty Center for Integrated Research, Inova Health System, Falls Church, VA, United States
| | - Linda Henry
- Center for Outcomes Research in Liver Diseases, Washington DC, United States
| | - Manisha Verma
- Inova Medicine, Inova Health System, Falls Church, VA, United States; Betty and Guy Beatty Center for Integrated Research, Inova Health System, Falls Church, VA, United States
| | - Zobair M Younossi
- Inova Medicine, Inova Health System, Falls Church, VA, United States; Center for Liver Disease, Department of Medicine, Inova Fairfax Medical Campus, Falls Church, VA, United States; Betty and Guy Beatty Center for Integrated Research, Inova Health System, Falls Church, VA, United States.
| |
Collapse
|
3
|
Jesudian AB, Gagnon-Sanschagrin P, Heimanson Z, Bungay R, Chen J, Guérin A, Bumpass B, Borroto D, Joseph G, Dashputre AA. Impact of rifaximin use following an initial overt hepatic encephalopathy hospitalization on rehospitalization and costs. J Med Econ 2023; 26:1169-1177. [PMID: 37664993 DOI: 10.1080/13696998.2023.2255074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Revised: 08/30/2023] [Accepted: 08/31/2023] [Indexed: 09/05/2023]
Abstract
AIM To assess the impact of rifaximin (± lactulose) use following discharge of an initial overt hepatic encephalopathy (OHE) hospitalization on OHE rehospitalizations and healthcare costs in a real-world setting. METHODS Adults (18-64 years) with an OHE hospitalization were identified from MarketScan® Commercial claims (Q4'15-Q2'20), classified into two mutually exclusive treatment cohorts (i.e. rifaximin and no rifaximin treatment), and further stratified into four subgroups based on decreasing quality of care (QoC; i.e. Type 1 - rifaximin without delay post-discharge; Type 2 - rifaximin with delay post-discharge; Type 3 - lactulose only post-discharge; Type 4 - no rifaximin/lactulose treatment post-discharge). The impact of rifaximin use on 30-day and annualized OHE hospitalizations and healthcare costs were assessed between cohorts and by the QoC subgroup. RESULTS Characteristics were similar between the rifaximin (N = 1,452; Type 1: 1,138, Type 2: 314) and no rifaximin (N = 560; Type 3:337, Type 4: 223) treatment cohorts. The 30-day risk of OHE rehospitalization was lower for the rifaximin vs. no rifaximin treatment cohort (odds ratio 0.56, p < .01) and increased with decreasing QoC. The annual rate of OHE hospitalizations was 59% lower for the rifaximin treatment cohort (incidence rate ratio 0.41, p < .01) and increased with decreasing QoC. Compared to the no rifaximin treatment cohort, the rifaximin treatment cohort had higher pharmacy costs, lower medical costs, and no difference in total healthcare costs. LIMITATIONS This was a claims-based study subject to common data limitations such as billing inaccuracies or omissions in coded claims. Total healthcare costs were reported from a payer's perspective, which do not capture indirect costs associated with patient burden. CONCLUSIONS Initiation of rifaximin after an OHE hospitalization was associated with reduced OHE hospitalizations both in the 30-days following and annually. Further, reduced medical costs offset increased pharmacy costs, and no annual cost differences were observed between cohorts.
Collapse
Affiliation(s)
- Arun B Jesudian
- Division of Gastroenterology and Hepatology, Weill Cornell Medicine, New York, NY, USA
| | | | | | | | | | | | | | | | - George Joseph
- Bausch Health, Bridgewater, NJ, USA
- BioNTech US Inc, Cambridge, MA, USA
| | | |
Collapse
|
4
|
Effectiveness of a Web-Based Provider Communications Platform in Reducing Hospital Readmissions Among Patients Receiving Dialysis: A Pilot Pre-Post Study. Kidney Med 2022; 4:100511. [PMID: 35966283 PMCID: PMC9372774 DOI: 10.1016/j.xkme.2022.100511] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Rationale & Objective Suboptimal care coordination between dialysis facilities and hospitals is an important driver of 30-day hospital readmissions among patients receiving dialysis. We examined whether the introduction of web-based communications platform (“DialysisConnect”) was associated with reduced hospital readmissions. Study Design Pilot pre-post study. Setting & Participants A total of 4,994 index admissions at a single hospital (representing 2,419 patients receiving dialysis) during the study period (January 1, 2019-May 31, 2021). Intervention DialysisConnect was available to providers at the hospital and 4 affiliated dialysis facilities (=intervention facilities) during the pilot period (November 1, 2020-May 31, 2021). Outcomes The primary outcome was 30-day readmission; secondary outcomes included 30-day emergency department visits and observation stays. Interrupted time series and linear models with generalized estimating equations were used to assess pilot versus prepilot differences in outcomes; difference-in-difference analyses were performed to compare these differences between intervention versus control facilities. Sensitivity analyses included a third, prepilot/COVID-19 period (March 1, 2020-October 31, 2020). Results There was no statistically significant difference in the monthly trends in the 30-day readmissions pilot versus prepilot periods (−0.60 vs -0.13, P = 0.85) for intervention facility admissions; the difference-in-difference estimate was also not statistically significant (0.54 percentage points, P = 0.83). Similar analyses including the prepilot/COVID-19 period showed that, despite a substantial drop in admissions at the start of the pandemic, there were no statistically significant differences across the 3 periods. The age-, sex-, race-, and comorbid condition-adjusted, absolute pilot versus prepilot difference in readmissions rate was 1.8% (−3.7% to 7.3%); similar results were found for other outcomes. Limitations Potential loss to follow-up and pandemic effects. Conclusions In this pilot, the introduction of DialysisConnect was not associated with reduced hospital readmissions. Tailored care coordination solutions should be further explored in future, multisite studies to improve the communications gap between dialysis facilities and hospitals.
Collapse
|
5
|
Webb HT, Lieb KM, Stump TE, Unroe KT, Carnahan JL. Describing Transfers Originating Out-of-Facility for Nursing Home Residents. J Am Med Dir Assoc 2022; 23:105-110. [PMID: 34181908 PMCID: PMC8709881 DOI: 10.1016/j.jamda.2021.05.042] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Revised: 05/06/2021] [Accepted: 05/29/2021] [Indexed: 01/03/2023]
Abstract
OBJECTIVES Potentially avoidable hospitalizations are harmful to nursing home residents. Despite extensive care transitions research, no studies have described transfers originating outside the nursing home (eg, visiting family members or at a dialysis center). This article describes 82 out-of-facility (community) transfers and compares them to transfers originating within the nursing home (direct transfers). DESIGN Secondary data analysis with multivariable model for community transfer risk factors. SETTING AND PARTICIPANTS Eighty-two community transfers and 1362 transfers originating in the nursing home, involving 870 residents enrolled in the OPTIMISTIC demonstration project between January 1, 2015, and June 30, 2016. METHODS Transfers were compared using data from the Minimum Data Set and root cause analyses performed at time of transfer. Multivariable associations were assessed at the transfer level to define risk factors for community transfers. Project nurses collected data on community transfers to inform a root cause analysis. RESULTS Residents with community transfers were younger (74.4 years vs 78.2 years), with lower prevalence of cognitive impairment (44.8% vs 70.3%) and higher rates of heart failure (38.7% vs 23.3%) than residents with direct transfers. Community transfers were more likely due to cardiovascular illness (31.2% vs 8.7%), whereas less likely to be for cognitive, behavioral, and psychiatric concerns (11.7% vs 22.7%). Nearly half (46%) of community transfers originated at dialysis centers. Residents transferred outside the nursing home were less likely to have documented limitations to care such as a do not resuscitate code status. Communication during community transfers was identified on root cause analyses as a potential area for improvement. CONCLUSIONS AND IMPLICATIONS Community transfers were more likely to occur in younger residents with higher rates of cardiovascular disease and lower rates of cognitive impairment. Improved communication between nursing home staff and outside providers as well as more extensive advance care planning for residents with cardiovascular disease may reduce community transfers.
Collapse
Affiliation(s)
- Hanna T Webb
- Indiana University School of Medicine, Indianapolis, IN, USA
| | - Kristi M Lieb
- Indiana University School of Medicine, Indianapolis, IN, USA; Roudebush VA Medical Center, Indianapolis, IN, USA
| | - Timothy E Stump
- Department of Biostatistics, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Kathleen T Unroe
- Indiana University School of Medicine, Indianapolis, IN, USA; Regenstrief Institute, IU Center for Aging Research, Indianapolis, IN, USA
| | - Jennifer L Carnahan
- Indiana University School of Medicine, Indianapolis, IN, USA; Regenstrief Institute, IU Center for Aging Research, Indianapolis, IN, USA; Roudebush VA Medical Center, Indianapolis, IN, USA.
| |
Collapse
|
6
|
Li J, Huang N, Zhong Z, Joe P, Wang D, Ai Z, Wu L, Jiang L, Huang F. Risk factors and outcomes of cardiovascular disease readmission within the first year after dialysis in peritoneal dialysis patients. Ren Fail 2021; 43:159-167. [PMID: 33441045 PMCID: PMC7808740 DOI: 10.1080/0886022x.2020.1866009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Background In the first year of dialysis, patients are vulnerable to cardiovascular disease (CVD) hospitalization, but knowledge regarding the risk factors and long-term outcomes of cardiovascular readmission within the first year after dialysis in incident continuous ambulatory peritoneal dialysis (CAPD) patients is limited. Methods This retrospective cohort study was conducted in incident CAPD patients. The demographic characteristics, laboratory parameters, and CVD readmission were collected and analyzed. The primary outcome was all-cause mortality, and the secondary outcomes included CVD mortality, infection-related mortality and technique failure. A logistic regression was used to identify the risk factors associated with CVD readmission within the first year after dialysis. Cox proportional hazards models were used to evaluate the association between CVD readmission and the outcomes. Results In total, 1589 peritoneal dialysis (PD) patients were included in this study, of whom 120 (7.6%) patients had at least one episode of CVD readmission within the first year after dialysis initiation. Advanced age, CVD history, and a lower level of serum albumin were independently associated with CVD readmission. CVD readmission within the first year after dialysis was significantly associated with all-cause (HR 2.66, 95%CI 1.91–3.70, p < 0.001) and CVD (HR 3.42, 95%CI 2.20–5.31, p < 0.001) mortality, but not infection-related mortality or technique failure, after adjusting for confounders. Conclusions Our findings suggest that an advanced age, a history of CVD, and a lower level of serum albumin were independently associated with CVD readmission. Moreover, CVD readmission was associated with all-cause and cardiovascular mortality in incident CAPD patients.
Collapse
Affiliation(s)
- Jianbo Li
- Department of Nephrology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China.,Key Laboratory of Nephrology, National Health Commission and Guangdong Province, Guangzhou, China
| | - Naya Huang
- Department of Nephrology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China.,Key Laboratory of Nephrology, National Health Commission and Guangdong Province, Guangzhou, China
| | - Zhong Zhong
- Department of Nephrology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China.,Key Laboratory of Nephrology, National Health Commission and Guangdong Province, Guangzhou, China
| | - Pema Joe
- Department of Medicine, Linzhi People's Hospital, Linzhi, China
| | - Dan Wang
- Department of Nephrology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China.,Key Laboratory of Nephrology, National Health Commission and Guangdong Province, Guangzhou, China
| | - Zhen Ai
- Department of Nephrology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China.,Key Laboratory of Nephrology, National Health Commission and Guangdong Province, Guangzhou, China
| | - Lisha Wu
- Department of Medicine, Linzhi People's Hospital, Linzhi, China
| | - Lanping Jiang
- Department of Nephrology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China.,Key Laboratory of Nephrology, National Health Commission and Guangdong Province, Guangzhou, China
| | - Fengxian Huang
- Department of Nephrology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China.,Key Laboratory of Nephrology, National Health Commission and Guangdong Province, Guangzhou, China
| |
Collapse
|
7
|
Holmes EG, Cooley BS, Fleisch SB, Rosenstein DL. Against Medical Advice Discharge: A Narrative Review and Recommendations for a Systematic Approach. Am J Med 2021; 134:721-726. [PMID: 33610522 DOI: 10.1016/j.amjmed.2020.12.027] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Accepted: 12/17/2020] [Indexed: 11/26/2022]
Abstract
Approximately 1%-2% of hospitalizations in the United States result in an against medical advice discharge. Still, the practice of discharging patients against medical advice is highly subjective and variable. Discharges against medical advice are associated with physician distress, patient stigma, and adverse outcomes, including increased morbidity and mortality. This review summarizes discharge against medical advice research, proposes a definition for against medical advice discharge, and recommends a standard approach to a patient's request for discharge against medical advice.
Collapse
Affiliation(s)
- Emily G Holmes
- Department of Psychiatry, Indiana University, Indianapolis.
| | | | | | - Donald L Rosenstein
- Departments of Psychiatry and Medicine, University of North Carolina, Chapel Hill
| |
Collapse
|
8
|
Burden and causes of hospital admissions and readmissions in patients undergoing hemodialysis and peritoneal dialysis: a nationwide study. J Nephrol 2021; 34:1949-1959. [PMID: 33987824 DOI: 10.1007/s40620-021-01023-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Accepted: 03/07/2021] [Indexed: 10/21/2022]
Abstract
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.
Collapse
|
9
|
Clemens KK, Ouédraogo AM, Garg AX, Silver SA, Nash DM. Opportunities To Improve Diabetes Care in the Hemodialysis Unit: A Cohort Study in Ontario, Canada. KIDNEY360 2021; 2:653-665. [PMID: 35373046 PMCID: PMC8791316 DOI: 10.34067/kid.0007082020] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Accepted: 02/09/2021] [Indexed: 02/04/2023]
Abstract
Background Patients with diabetes receiving chronic, in-center hemodialysis face healthcare challenges. We examined the prevalence of gaps in their diabetes care, explored regional differences, and determined predictors of care gaps. Methods We conducted a population-based, retrospective study between January 1, 2016 and January 1, 2018 in Ontario, Canada. We included adults with prevalent diabetes mellitus receiving in-center hemodialysis as of January 1, 2018 and examined the proportion with (1) insufficient or excessive glycemic monitoring, (2) suboptimal screening for diabetes-related complications (retinopathy and cardiovascular screening), (3) hospital encounters for hypo- or hyperglycemia, and (4) hospital encounters for hypertension in the 2 years prior (January 1, 2016 to January 1, 2018). We then identified patient, provider, and health-system factors associated with more than one care gap and used multivariable logistic regression to determine predictors. Further, we used geographic information systems to explore spatial variation in gaps. Results There were 4173 patients with diabetes receiving in-center hemodialysis; the mean age was 67 years, 39% were women, and the majority were of lower socioeconomic status. Approximately 42% of patients had more than one diabetes care gap, the most common being suboptimal retinopathy screening (53%). Significant predictors of more than one gap included younger age, female sex, shorter duration of diabetes, dementia, fewer specialist visits, and not seeing a physician for diabetes. There was evidence of spatial variation in care gaps across our region. Conclusions There are opportunities to improve diabetes care in patients receiving in-center hemodialysis, particularly screening for retinopathy. Focused efforts to bring diabetes support to high-risk individuals might improve their care and outcomes.
Collapse
Affiliation(s)
- Kristin K. Clemens
- Division of Endocrinology and Metabolism, Western University, London, Ontario, Canada
- Department of Epidemiology and Biostatistics, Western University, London, Ontario, Canada
- ICES, Ontario, Canada
- Center for Diabetes, Endocrinology and Metabolism, St. Joseph's Health Care London, London, Ontario, Canada
- Lawson Health Research Institute, London, Ontario, Canada
| | | | - Amit X. Garg
- Department of Epidemiology and Biostatistics, Western University, London, Ontario, Canada
- ICES, Ontario, Canada
- Lawson Health Research Institute, London, Ontario, Canada
- Division of Nephrology, Western University, London, Ontario, Canada
| | - Samuel A. Silver
- ICES, Ontario, Canada
- Division of Nephrology, Queen's University, Kingston Health Sciences Centre, Kingston, Ontario, Canada
| | - Danielle M. Nash
- Department of Epidemiology and Biostatistics, Western University, London, Ontario, Canada
- ICES, Ontario, Canada
| |
Collapse
|
10
|
Chen R, Yang C, Zhu M, Chu H, Wang J, Gao B, Liu L, Jiang Y, Lin Y, Wu J, Kong G, Wang F, Zhang L, Zhao M. Association of cardiovascular disease with 30-day hospital readmission in Chinese patients receiving maintenance dialysis. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:617. [PMID: 33987315 PMCID: PMC8106029 DOI: 10.21037/atm-20-2367] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background Previous studies have shown cardiovascular disease (CVD) to be a risk factor in the prediction of 30-day hospital readmission among patients receiving dialysis. However, studies of Asian populations are limited. In the present study, we examined the association between CVD and 30-day hospital readmission in Chinese patients receiving maintenance dialysis. Methods Patients receiving maintenance dialysis were identified by searching a national claims database, the China Health Insurance Research Association (CHIRA) database, using the International Classification of Diseases revision 10 (ICD-10) and items of medical service claims. Patients aged ≥18 years who were discharged after index hospitalization between January 2015 and December 2015 were included in our retrospective analysis. CVD-related diagnoses were divided into three categories: coronary heart disease (CHD), heart failure (HF), and stroke. Thirty-day hospital readmission was defined as any hospital readmission within the 30 days following discharge. Logistic regression models adjusted for logit of propensity scores (PS) were used to assess the association of CVD with 30-day hospital readmission. Results Of 4,700 patients receiving dialysis, the 30-day hospital readmission rate was 10.4%. Compared with patients without CVD, there was an increased risk of 30-day hospital readmission among maintenance dialysis patients with total CVD [odds ratio (OR): 1.33, 95% confidence interval (CI): 1.06–1.66]. Patients with HF (OR: 1.77, CI: 1.27–2.47) and stroke (OR: 2.14, 95% CI: 1.53–2.98) had a greater risk of 30-day hospital readmission. The fully adjusted OR of CHD for the risk of 30-day hospital readmission was 1.22 (95% CI: 0.97–1.55). Conclusions CVDs, especially stroke and HF, are independent predictors of 30-day hospital readmission in Chinese patients receiving dialysis, and could help to guide interventions to improve the quality of care for these patients.
Collapse
Affiliation(s)
- Rui Chen
- Department of Medicine, Peking University First Hospital, Beijing, China
| | - Chao Yang
- Department of Medicine, Peking University First Hospital, Beijing, China
| | - Ming Zhu
- Zhongshan School of Medicine, Sun Yat-sen University, Guangzhou, China
| | - Hong Chu
- Department of Medicine, Peking University First Hospital, Beijing, China
| | - Jinwei Wang
- Department of Medicine, Peking University First Hospital, Beijing, China
| | - Bixia Gao
- Department of Medicine, Peking University First Hospital, Beijing, China
| | - Lili Liu
- Department of Medicine, Peking University First Hospital, Beijing, China
| | - Yifang Jiang
- Department of Medicine, Peking University First Hospital, Beijing, China
| | - Yu Lin
- Department of Epidemiology and Biostatistics, School of Public Health, Peking University, Beijing, China
| | - Jingyi Wu
- Department of Epidemiology and Biostatistics, School of Public Health, Peking University, Beijing, China
| | - Guilan Kong
- National Institute of Health Data Science at Peking University, Beijing, China.,Center for Data Science in Health and Medicine, Peking University, Beijing, China
| | - Fang Wang
- Department of Medicine, Peking University First Hospital, Beijing, China
| | - Luxia Zhang
- Department of Medicine, Peking University First Hospital, Beijing, China.,National Institute of Health Data Science at Peking University, Beijing, China.,Center for Data Science in Health and Medicine, Peking University, Beijing, China
| | - Minghui Zhao
- Department of Medicine, Peking University First Hospital, Beijing, China.,Peking-Tsinghua Center for Life Science, Beijing, China
| |
Collapse
|
11
|
Vandenberg AE, Jaar BG, James KP, Lea J, O'Donnell C, Masud T, Mutell R, Plantinga LC. Making sense of DialysisConnect: a qualitative analysis of stakeholder viewpoints on a web-based information exchange platform to improve care transitions between dialysis clinics and hospitals. BMC Med Inform Decis Mak 2021; 21:47. [PMID: 33563290 PMCID: PMC7871569 DOI: 10.1186/s12911-021-01415-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Accepted: 01/31/2021] [Indexed: 11/10/2022] Open
Abstract
Background U.S. hospitals and dialysis centers are penalized for 30-day hospital readmissions of dialysis patients, despite little infrastructure to facilitate care transitions between these settings. We are developing a third-party web-based information exchange platform, DialysisConnect, to enable clinicians to view and exchange information about dialysis patients during admission, hospitalization, and discharge. This health information technology solution could serve as a flexible and relatively affordable solution for dialysis facilities and hospitals across the nation who are seeking to serve as true partners in the improved care of dialysis patients. The purpose of this study was to evaluate the perceived coherence of DialysisConnect to key clinical stakeholders, to prepare messaging for implementation. Methods As part of a hybrid effectiveness-implementation study guided by Normalization Process Theory, we collected data on stakeholder perceptions of continuity of care for patients receiving maintenance dialysis and a DialysisConnect prototype before completing development and piloting the system. We conducted four focus groups with stakeholders from one academic hospital and associated dialysis centers [hospitalists (n = 5), hospital staff (social workers, nurses, pharmacists; n = 9), nephrologists (n = 7), and dialysis clinic staff (social workers, nurses; n = 10)]. Transcriptions were analyzed thematically within each component of the construct of coherence (differentiation, communal specification, individual specification, and internalization). Results Participants differentiated DialysisConnect from usual care variously as an information dashboard, a quick-exchange communication channel, and improved discharge information delivery; some could not differentiate it in terms of workflow. The purpose of DialysisConnect (communal specification) was viewed as fully coherent only for communicating outside of the same healthcare system. Current system workarounds were acknowledged as deterrents for practice change. All groups delegated DialysisConnect tasks (individual specification) to personnel besides themselves. Partial internalization of DialysisConnect was achieved only by dialysis clinic staff, based on experience with similar technology. Conclusions Implementing DialysisConnect for clinical users in both settings will require presenting a composite picture of current communication processes from all stakeholder groups to correct single-group misunderstandings, as well as providing data about care transitions communication beyond the local context to ease resistance to practice change. Supplementary information The online version contains supplementary material available at 10.1186/s12911-021-01415-y.
Collapse
Affiliation(s)
| | | | - Kyle P James
- Emory University School of Medicine, Atlanta, GA, USA
| | - Janice Lea
- Emory University School of Medicine, Atlanta, GA, USA
| | | | - Tahsin Masud
- Emory University School of Medicine, Atlanta, GA, USA
| | - Rich Mutell
- Apex Health Innovations, Williamsburg, VA, USA
| | | |
Collapse
|
12
|
Doshi S, Wish JB. Strategies to Reduce Rehospitalization in Patients with CKD and Kidney Failure. Clin J Am Soc Nephrol 2021; 16:328-334. [PMID: 32660962 PMCID: PMC7863646 DOI: 10.2215/cjn.02300220] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
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.
Collapse
Affiliation(s)
- Simit Doshi
- Division of Nephrology, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana
| | | |
Collapse
|
13
|
Li J, Yu J, Huang N, Ye H, Wang D, Peng Y, Guo X, Yi C, Yang X, Yu X. Prevalence, risk factors and impact on outcomes of 30-day unexpected rehospitalization in incident peritoneal dialysis patients. BMC Nephrol 2021; 22:4. [PMID: 33407231 PMCID: PMC7786918 DOI: 10.1186/s12882-020-02201-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2020] [Accepted: 12/03/2020] [Indexed: 01/25/2023] Open
Abstract
Background Rehospitalization is a major problem for end stage renal disease (ESRD) populations. However, researches on 30-day unexpected rehospitalzation of incident peritoneal dialysis (PD) patients were limited. This study aimed to investigate the prevalence, risk factors and impact on outcomes of 30-day unexpected rehospitalization in incident PD patients. Methods This was a retrospective cohort study. Patients who accepted PD catheter implantation in our centre from Jan 1, 2006 to Dec 31, 2013 and regular follow-up were included. The demographic characteristics, laboratory parameters, and rehospitalization data were collected and analyzed. The primary outcome was all-cause mortality, and the secondary outcomes included cardiovascular disease (CVD) mortality and technical failure. Results Totally 1632 patients (46.9 ± 15.3 years old, 60.1% male, 25.6% with diabetes) were included. Among them, 149 (9.1%) had a 30-day unexpected rehospitalization after discharge. PD-related peritonitis (n = 48, 32.2%), catheter malfunction (n = 30, 20.1%) and severe fluid overload (n = 19, 12.8%) were the top three causes for the rehospitalization. Multivariate logistic regression analysis showed that length of index hospital stays [Odds ratio (OR) =1.02, 95% confidence interval (CI) 1.00–1.03, P = 0.036) and hyponatremia (OR = 1.85, 95% CI 1.06–3.24, P = 0.031) were independently associated with the rehospitalization. Multivariate Cox regression analysis indicated that 30-day rehospitalization was an independent risk factor for all-cause mortality [Hazard ratio (HR) =1.52, 95% CI 1.07–2.16, P = 0.019) and CVD mortality (HR = 1.73, 95% CI 1.03–2.90, P = 0.038). Conclusions The prevalence of 30-day unexpected rehospitalization for incident PD patients in our centre was 9.1%. The top three causes for the rehospitalization were PD-related peritonitis, catheter malfunction and severe fluid overload. Thirty-day unexpected rehospitalization increased the risk of all-cause mortality and CVD mortality for PD patients.
Collapse
Affiliation(s)
- Jianbo Li
- Department of Nephrology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, 510080, Guangdong, China.,Key Laboratory of Nephrology, National Health Commission and Guangdong Province, Guangzhou, 510080, Guangdong, China
| | - Jing Yu
- Department of Nephrology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, 510080, Guangdong, China.,Key Laboratory of Nephrology, National Health Commission and Guangdong Province, Guangzhou, 510080, Guangdong, China
| | - Naya Huang
- Department of Nephrology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, 510080, Guangdong, China.,Key Laboratory of Nephrology, National Health Commission and Guangdong Province, Guangzhou, 510080, Guangdong, China
| | - Hongjian Ye
- Department of Nephrology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, 510080, Guangdong, China.,Key Laboratory of Nephrology, National Health Commission and Guangdong Province, Guangzhou, 510080, Guangdong, China
| | - Dan Wang
- Department of Nephrology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, 510080, Guangdong, China.,Key Laboratory of Nephrology, National Health Commission and Guangdong Province, Guangzhou, 510080, Guangdong, China
| | - Yuan Peng
- Department of Nephrology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, 510080, Guangdong, China.,Key Laboratory of Nephrology, National Health Commission and Guangdong Province, Guangzhou, 510080, Guangdong, China
| | - Xiaobo Guo
- Department of Statistical Science, School of Mathematics, Sun Yat-sen University, Guangzhou, 510275, Guangdong, China
| | - Chunyan Yi
- Department of Nephrology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, 510080, Guangdong, China.,Key Laboratory of Nephrology, National Health Commission and Guangdong Province, Guangzhou, 510080, Guangdong, China
| | - Xiao Yang
- Department of Nephrology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, 510080, Guangdong, China.,Key Laboratory of Nephrology, National Health Commission and Guangdong Province, Guangzhou, 510080, Guangdong, China
| | - Xueqing Yu
- Department of Nephrology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, 510080, Guangdong, China. .,Key Laboratory of Nephrology, National Health Commission and Guangdong Province, Guangzhou, 510080, Guangdong, China. .,Guangdong Provincial People's Hospital, Guangzhou, 510080, Guangdong, China. .,School of Medicine, South China University of Technology, Guangzhou, 510080, Guangdong, China.
| |
Collapse
|
14
|
Wyatt LH, Xi Y, Kshirsagar A, Di Q, Ward-Caviness C, Wade TJ, Cascio WE, Rappold AG. Association of short-term exposure to ambient PM 2.5 with hospital admissions and 30-day readmissions in end-stage renal disease patients: population-based retrospective cohort study. BMJ Open 2020; 10:e041177. [PMID: 33323443 PMCID: PMC7745516 DOI: 10.1136/bmjopen-2020-041177] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
OBJECTIVES To examine the effect of short-term exposure to ambient fine particulate matter (PM2.5) 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 PM2.5. RESULTS Same-day ambient PM2.5 was associated with increased hospital admission risk for cardiovascular causes (0.9%, 95% CI 0.2 to 1.7). Greater PM2.5-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. PM2.5-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 PM2.5 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 PM2.5-related risk of rehospitalisation was identified for some diagnoses.
Collapse
Affiliation(s)
- Lauren H Wyatt
- Center for Public Health and Environmental Assessment, US Environmental Protection Agency Research Triangle Park Campus, Research Triangle Park, North Carolina, USA
| | - Yuzhi Xi
- US Environmental Protection Agency (ORISE), Chapel Hill, North Carolina, USA
| | - Abhijit Kshirsagar
- University of North Carolina Kidney Center and Division of Nephrology and Hypertension, Chapel Hill, North Carolina, USA
| | - Qian Di
- Tsinghua University, Beijing, Beijing, China
| | - Cavin Ward-Caviness
- Center for Public Health and Environmental Assessment, US Environmental Protection Agency Research Triangle Park Campus, Research Triangle Park, North Carolina, USA
| | - Timothy J Wade
- Center for Public Health and Environmental Assessment, US Environmental Protection Agency Research Triangle Park Campus, Research Triangle Park, North Carolina, USA
| | - Wayne E Cascio
- Center for Public Health and Environmental Assessment, US Environmental Protection Agency Research Triangle Park Campus, Research Triangle Park, North Carolina, USA
| | - Ana G Rappold
- Center for Public Health and Environmental Assessment, US Environmental Protection Agency Research Triangle Park Campus, Research Triangle Park, North Carolina, USA
| |
Collapse
|
15
|
Golestaneh L, Cavanaugh KL, Lo Y, Karaboyas A, Melamed ML, Johns TS, Norris KC. Community Racial Composition and Hospitalization Among Patients Receiving In-Center Hemodialysis. Am J Kidney Dis 2020; 76:754-764. [PMID: 32673736 PMCID: PMC7844565 DOI: 10.1053/j.ajkd.2020.05.019] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2019] [Accepted: 05/21/2020] [Indexed: 02/07/2023]
Abstract
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.
Collapse
Affiliation(s)
- Ladan Golestaneh
- Renal Division, Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, NY.
| | - Kerri L Cavanaugh
- Division of Nephrology and Hypertension, Vanderbilt University Medical Center, Nashville, TN
| | - Yungtai Lo
- Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, NY
| | | | - Michal L Melamed
- Renal Division, Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, NY
| | - Tanya S Johns
- Renal Division, Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, NY
| | - Keith C Norris
- Division of General Internal Medicine, UCLA/David Geffen School of Medicine, Los Angeles, CA; Division of Nephrology, UCLA/David Geffen School of Medicine, Los Angeles, CA
| |
Collapse
|
16
|
The Impact of CKD Anaemia on Patients: Incidence, Risk Factors, and Clinical Outcomes-A Systematic Literature Review. Int J Nephrol 2020; 2020:7692376. [PMID: 32665863 PMCID: PMC7349626 DOI: 10.1155/2020/7692376] [Citation(s) in RCA: 42] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2020] [Accepted: 04/25/2020] [Indexed: 12/15/2022] Open
Abstract
Anaemia is a common consequence of chronic kidney disease (CKD); however, the risk factors for its development and its impact on outcomes have not been well synthesised. Therefore, we undertook a systematic review to fully characterise the risk factors associated with the presence of anaemia in patients with CKD and a contemporary synthesis of the risks of adverse outcomes in patients with CKD and anaemia. We searched MEDLINE, EMBASE, and the Cochrane Library from 2002 until 2018 for studies reporting the incidence or prevalence of anaemia and associated risk factors and/or associations between haemoglobin (Hb) or anaemia and mortality, major adverse cardiac events (MACE), hospitalisation, or CKD progression in adult patients with CKD. Extracted data were summarised as risk factors related to the incidence or prevalence of anaemia or the risk (hazard ratio (HR)) of outcome by Hb level (<10, 10-12, >12 g/dL) in patients not on dialysis and in those receiving dialysis. 191 studies met the predefined inclusion criteria. The risk factor most associated with the prevalence of anaemia was CKD stage, followed by age and sex. Mean HRs (95% CI) for all-cause mortality in patients with CKD on dialysis with Hb <10, 10-12, and >12 g/dL were 1.56 (1.43-1.71), 1.17 (1.09-1.26), and 0.91 (0.87-0.96), respectively. Similar patterns were observed for nondialysis patients and for the risks of hospitalisation, MACE, and CKD progression. This is the first known systematic review to quantify the risk of adverse clinical outcomes based on Hb level in patients with CKD. Anaemia was consistently associated with greater mortality, hospitalisation, MACE, and CKD progression in patients with CKD, and risk increased with anaemia severity. Effective treatments that not only treat the anaemia but also reduce the risk of adverse clinical outcomes are essential to help reduce the burden of anaemia and its management in CKD.
Collapse
|
17
|
Tavares MG, Tedesco-Silva Junior H, Pestana JOM. Early Hospital Readmission (EHR) in kidney transplantation: a review article. J Bras Nefrol 2020; 42:231-237. [PMID: 32227073 PMCID: PMC7427637 DOI: 10.1590/2175-8239-jbn-2019-0089] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2019] [Accepted: 11/24/2019] [Indexed: 12/01/2022] Open
Abstract
Early hospital readmission (EHR), defined as all readmissions within 30 days of initial hospital discharge, is a health care quality measure. It is influenced by the demographic characteristics of the population at risk, the multidisciplinary approach for hospital discharge, the access, coverage, and comprehensiveness of the health care system, and reimbursement policies. EHR is associated with higher morbidity, mortality, and increased health care costs. Monitoring EHR enables the identification of hospital and outpatient healthcare weaknesses and the implementation of corrective interventions. Among kidney transplant recipients in the USA, EHR ranges between 18 and 47%, and is associated with one-year increased mortality and graft loss. One study in Brazil showed an incidence of 19.8% of EHR. The main causes of readmission were infections and surgical and metabolic complications. Strategies to reduce early hospital readmission are therefore essential and should consider the local factors, including socio-economic conditions, epidemiology and endemic diseases, and mobility.
Collapse
|
18
|
Lekoubou A, Bishu KG, Ovbiagele B. Influence of a Comorbid Diagnosis of Seizure on 30-Day Readmission Rates Following Hospitalization for an Index Stroke. J Stroke Cerebrovasc Dis 2019; 29:104479. [PMID: 31784379 DOI: 10.1016/j.jstrokecerebrovasdis.2019.104479] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2019] [Accepted: 10/09/2019] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVE To examine the association of a comorbid seizure diagnosis with early hospital readmission rates following an index hospitalization for stroke in the United States. METHODS Retrospective analysis of the 2014 National Readmission Database. The study population included adult patients (age >18 years old) with stroke, identified using the International Classification of Disease Ninth Revision, Clinical Modification (ICD-9-CM) codes 433.X1, 434.X1, and 436 for ischemic stroke as well as 430, 431, 432.0, 432.1, and 432.9 for hemorrhagic stroke. A subgroup of patients with a secondary discharge diagnosis of seizures was identified using the ICD-9-CM codes 780.39 and 345.X. We computed all-cause 30-day readmission rates for all strokes and by stroke type (ischemic versus hemorrhagic). Finally, we used a multivariable logistic regression model to examine the independent association between seizure and readmission by stroke type. RESULTS Of 271,148 stroke patients, 6.3% (16,970) had a secondary discharge diagnosis of seizures including 5.0% (11,562) of patients with ischemic stroke and 13.4% (5,409) with hemorrhagic stroke. Overall readmission rate for stroke patients was 11.9% (hemorrhagic stroke: 14.2% versus ischemic strokes: 11.6%). Thirty-day readmission rate was higher in patients with seizures for all strokes (15.6% versus 11.7%, P value <.001), ischemic strokes (15.0% versus11.4%, P value <.001), and hemorrhagic strokes (16.7% versus 13.8%, P value <.001). After adjusting for several patient-specific and healthcare system-specific confounders, hospitalized stroke patients with comorbid seizure diagnosis were more likely than those without seizures to be readmitted within 30 days (OR: 1.20, 95% CI: 1.14-1.25). CONCLUSION The presence of a comorbid diagnosis of seizure disorder in a hospitalized stroke patient significantly raises the occurrence of early hospital readmission in the United States.
Collapse
Affiliation(s)
- Alain Lekoubou
- Department of Neurology, Penn State University, Hershey, Pennyslvania.
| | - Kinfe G Bishu
- Department of Medicine, Medical University of South Carolina, Charleston, South Carolina; Section of Health Systems Research and Policy, Medical University of South Carolina, Charleston, South Carolina
| | - Bruce Ovbiagele
- Department of Neurology, University of California, San Francisco, Califonia
| |
Collapse
|
19
|
Ross KH, Jaar BG, Lea JP, Masud T, Patzer RE, Plantinga LC. Long-term outcomes among Medicare patients readmitted in the first year of hemodialysis: a retrospective cohort study. BMC Nephrol 2019; 20:285. [PMID: 31357952 PMCID: PMC6664786 DOI: 10.1186/s12882-019-1473-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2019] [Accepted: 07/19/2019] [Indexed: 11/06/2022] Open
Abstract
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.
Collapse
Affiliation(s)
- Katherine H Ross
- Department of Epidemiology, Emory Rollins School of Public Health, Atlanta, GA, USA
| | - Bernard G Jaar
- Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA.,Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins University, Baltimore, MD, USA.,Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.,Nephrology Center of Maryland, Baltimore, MD, USA
| | - Janice P Lea
- Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Tahsin Masud
- Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Rachel E Patzer
- Department of Epidemiology, Emory Rollins School of Public Health, Atlanta, GA, USA.,Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA.,Department of Surgery, Emory University School of Medicine, Atlanta, GA, USA
| | - Laura C Plantinga
- Department of Epidemiology, Emory Rollins School of Public Health, Atlanta, GA, USA. .,Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA.
| |
Collapse
|
20
|
Sahlie A, Jaar BG, Paez LG, Masud T, Lea JP, Burkart JM, Plantinga LC. Burden and Correlates of Hospital Readmissions among U.S. Peritoneal Dialysis Patients. Perit Dial Int 2019; 39:261-267. [PMID: 30846608 DOI: 10.3747/pdi.2018.00175] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2018] [Accepted: 11/22/2018] [Indexed: 11/15/2022] Open
Abstract
Background:Hospital readmissions are common among in-center hemodialysis patients, but little is known about readmissions among peritoneal dialysis (PD) patients. Using national administrative data, we aimed to examine the burden and correlates of hospital readmissions among U.S. PD patients.Methods:Among 10,505 adult U.S. PD patients with an index admission (first admission after 120 days on dialysis) between 31 January 2011 and 30 November 2014, readmissions were defined as new hospital admissions within 30 days of index discharge. Multivariable logistic regression was used to obtain adjusted odds ratios (ORs) for readmission.Results:Overall, 26.8% of index admissions were followed by a readmission. Readmitted patients were more likely to have congestive heart failure (31.0% vs 25.4%; p < 0.001) and peripheral arterial disease (11.6% vs 8.6%; p < 0.001) and had longer index admission length of stay (median = 4 vs 3 days; p < 0.001) than those who were not; age, sex, and race did not differ by readmission status. After adjustment for patient and index admission characteristics, longer length of stay (≥ 4 vs < 4 days, OR = 1.48, 95% confidence interval [CI] 1.35 - 1.62), peripheral arterial disease (OR = 1.31, 95% CI 1.16 - 1.57), congestive heart failure (OR = 1.25, 95% CI 1.13 - 1.39), and ischemic heart disease (OR = 1.12, 95% CI 1.01 - 1.24) were associated with higher likelihood of readmission; index admission due to peritonitis vs other causes was associated with lower likelihood of readmission (OR = 0.80, 95% CI 0.70 - 0.92).Conclusions:Our results suggest that, particularly in the absence of a PD-related cause of hospitalization such as peritonitis, PD patients may be at high risk for readmission and may benefit from closer post-discharge monitoring.
Collapse
Affiliation(s)
- Abyalew Sahlie
- Department of Medicine, Emory University, Atlanta, GA, USA
| | - Bernard G Jaar
- Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA.,Epidemiology and Clinical Research, Welch Center for Prevention, Johns Hopkins University, Baltimore, MD, USA.,Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.,Nephrology Center of Maryland, Baltimore, MD, USA
| | | | - Tahsin Masud
- Department of Medicine, Emory University, Atlanta, GA, USA
| | - Janice P Lea
- Department of Medicine, Emory University, Atlanta, GA, USA
| | - John M Burkart
- Wake Forest Baptist Medical Center, Winston-Salem, NC, USA
| | - Laura C Plantinga
- Department of Medicine, Emory University, Atlanta, GA, USA .,Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| |
Collapse
|
21
|
Dad T, Weiner DE. Readmissions Metrics in Hemodialysis: Do the Specifics Matter? J Am Soc Nephrol 2019; 30:184-186. [PMID: 30606783 DOI: 10.1681/asn.2018101033] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Affiliation(s)
- Taimur Dad
- William B. Schwartz Division of Nephrology, Tufts Medical Center, Boston, Massachusetts
| | - Daniel E Weiner
- William B. Schwartz Division of Nephrology, Tufts Medical Center, Boston, Massachusetts
| |
Collapse
|
22
|
Lin E, Bhattacharya J, Chertow GM. Prior Hospitalization Burden and the Relatedness of 30-Day Readmissions in Patients Receiving Hemodialysis. J Am Soc Nephrol 2019; 30:323-335. [PMID: 30606782 DOI: 10.1681/asn.2018080858] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2018] [Accepted: 11/15/2018] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND Thirty-day readmissions are common in patients receiving hemodialysis and costly to Medicare. Because patients on hemodialysis have a high background hospitalization rate, 30-day readmissions might be less likely related to the index hospitalization than in patients with other conditions. METHODS In adults with Medicare receiving hemodialysis in the United States, we used multinomial logistic regression to evaluate whether prior hospitalization burden was associated with increased 30-day readmissions unrelated to index hospitalizations with a discharge date from January 1, 2013 to December 31, 2014. We categorized a hospitalization, 30-day readmission pair as "related" if the principal diagnoses came from the same organ system. RESULTS The adjusted probability of unrelated 30-day readmission after any index hospitalization was 19.1% (95% confidence interval [95% CI] 18.9% to 19.3%), 22.6% (95% CI, 22.4% to 22.8%), and 31.2% (95% CI, 30.8% to 31.5%) in patients with 0-1, 2-4, and ≥5 hospitalizations, respectively. Cardiovascular index hospitalizations had the highest adjusted probability of related 30-day readmission: 10.4% (95% CI, 10.2% to 10.7%), 13.6% (95% CI, 13.4% to 13.9%), and 20.8% (95% CI, 20.2% to 21.4%), respectively. Renal index hospitalizations had the lowest adjusted probability of related 30-day readmission: 2.0% (95% CI, 1.8% to 2.3%), 3.9% (95% CI, 3.4% to 4.4%), and 5.1% (95% CI, 4.3% to 5.9%), respectively. CONCLUSIONS High prior hospitalization burden increases the likelihood that patients receiving hemodialysis experience a 30-day readmission unrelated to the index hospitalization. Health care payers such as Medicare should consider incorporating clinical relatedness into 30-day readmission quality measures.
Collapse
Affiliation(s)
- Eugene Lin
- Division of Nephrology, Department of Medicine and .,Leonard D. Schaeffer Center for Health Policy and Economics, University of Southern California, Los Angeles, California.,Kidney Research Center, University of Southern California/University Kidney Research Organization, Los Angeles, California.,Division of Nephrology, Department of Medicine and
| | - Jay Bhattacharya
- Center for Health Policy and Center for Primary Care and Outcomes Research, Stanford University, Stanford, California; and
| | - Glenn M Chertow
- Division of Nephrology, Department of Medicine and.,Center for Health Policy and Center for Primary Care and Outcomes Research, Stanford University, Stanford, California; and.,Department of Health Research and Policy, Stanford University School of Medicine, Stanford, California
| |
Collapse
|
23
|
Adisa O, Jaar BG, Masud T, Sahlie A, Obadina C, Ang J, Lea JP, Plantinga LC. Association of social worker-assessed psychosocial factors with 30-day hospital readmissions among hemodialysis patients. BMC Nephrol 2018; 19:360. [PMID: 30558578 PMCID: PMC6296214 DOI: 10.1186/s12882-018-1162-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2018] [Accepted: 11/29/2018] [Indexed: 02/06/2023] Open
Abstract
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.
Collapse
Affiliation(s)
- Olufunmilola Adisa
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Bernard G Jaar
- Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA.,Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins University, Baltimore, MD, USA.,Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.,Nephrology Center of Maryland, Baltimore, MD, USA
| | - Tahsin Masud
- Division of Renal Medicine, Department of Medicine, Emory University, Atlanta, GA, USA
| | - Abyalew Sahlie
- Division of Renal Medicine, Department of Medicine, Emory University, Atlanta, GA, USA
| | - Catherine Obadina
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Joshua Ang
- Philadelphia College of Osteopathic Medicine, Suwanee, GA, USA
| | - Janice P Lea
- Division of Renal Medicine, Department of Medicine, Emory University, Atlanta, GA, USA
| | - Laura C Plantinga
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, USA. .,Division of Renal Medicine, Department of Medicine, Emory University, Atlanta, GA, USA.
| |
Collapse
|
24
|
Golestaneh L. Decreasing hospitalizations in patients on hemodialysis: Time for a paradigm shift. Semin Dial 2018; 31:278-288. [DOI: 10.1111/sdi.12675] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Affiliation(s)
- Ladan Golestaneh
- Nephrology Division; Department of Medicine; Montefiore Medical Center; Albert Einstein College of Medicine; Bronx NY USA
| |
Collapse
|
25
|
Assimon MM, Flythe JE. Thirty-Day Hospital Readmissions in the Hemodialysis Population: A Problem Well Put, But Half-Solved. Clin J Am Soc Nephrol 2017; 12:1566-1568. [PMID: 28971979 PMCID: PMC5628723 DOI: 10.2215/cjn.08810817] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Affiliation(s)
- Magdalene M. Assimon
- Division of Nephrology and Hypertension, Department of Medicine, University of North Carolina Kidney Center, University of North Carolina School of Medicine, Chapel Hill, North Carolina
- Department of Epidemiology, University of North Carolina Gillings School of Global Public Health, Chapel Hill, North Carolina; and
| | - Jennifer E. Flythe
- Division of Nephrology and Hypertension, Department of Medicine, University of North Carolina Kidney Center, University of North Carolina School of Medicine, Chapel Hill, North Carolina
- Cecil G. Sheps Center for Health Services Research, University of North Carolina, Chapel Hill, North Carolina
| |
Collapse
|