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Chen S, Slowey M, Ashby VB, Barnes L, Pearson A, Kang J, Messana JM. Nursing Home Status Adjustment for Standardized Mortality and Hospitalization in Dialysis Facility Reports. Kidney Med 2022; 5:100580. [PMID: 36712314 PMCID: PMC9879984 DOI: 10.1016/j.xkme.2022.100580] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Rationale & Objective Compared to the original nursing home status (any nursing home stay in the previous calendar year), new nursing home status variables were developed to improve the risk adjustment of Standardized Mortality/Hospitalization Ratio (SMR/SHR) models used in public reporting of dialysis quality of care, such as the Annual Dialysis Facility Report. Study Design Retrospective observational study. Setting & Participants 625,040 US maintenance dialysis patients with >90 kidney failure days in 2019. Predictors Nursing home status variables; patient characteristics; comorbid conditions. Outcomes Mortality/hospitalization. Analytical Approach We assigned patients and patient times (SMR/SHR model) to one of 3 mutually exclusive categories: long-term care (≥90 days), short-term care (1-89 days), or non-nursing home, based on nursing home stay during the previous 365 days from the first day of the time period at risk. Nursing home status was derived from the Nursing Home Minimum Data Set. Comparisons of hazard ratios from adjusted models, facility SMR/SHR performance, and model C-statistics between the original/new models were performed. Results SMR's hazard ratio of original nursing home status (2.09) was lower than both ratios of short-term care (2.38) and long-term care (2.43), whereas SHR's hazard ratio of original nursing home status (1.10) was between the ratios of long-term care (1.01) and short-term care (1.20). There was a difference in hazard ratios between short-term care and long-term care for both measures. Small percentages of facilities changed performance categories: 0.7% for SMR and 0.4% for SHR. The SMR C-statistic improved whereas the SHR C-statistic was relatively unchanged. Limitations Limited capture of subacute rehabilitation stays in the nursing home by using a 90-day cutoff for short-term care and long-term care; unable to draw causal inference about nursing home care. Conclusions Use of a nursing home metric that effectively separates short-term from long-term nursing home utilization results in more meaningful risk adjustment that generally comports with Medicare payment policy, potentially resulting in more interpretable results for dialysis stakeholders.
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Affiliation(s)
- Shu Chen
- Kidney Epidemiology and Cost Center, University of Michigan, Ann Arbor, Michigan,Department of Biostatistics, University of Michigan, Ann Arbor, Michigan
| | - Megan Slowey
- Kidney Epidemiology and Cost Center, University of Michigan, Ann Arbor, Michigan,Department of Biostatistics, University of Michigan, Ann Arbor, Michigan
| | - Valarie B. Ashby
- Kidney Epidemiology and Cost Center, University of Michigan, Ann Arbor, Michigan,Department of Biostatistics, University of Michigan, Ann Arbor, Michigan
| | - Lonnie Barnes
- Kidney Epidemiology and Cost Center, University of Michigan, Ann Arbor, Michigan
| | - Aaron Pearson
- Kidney Epidemiology and Cost Center, University of Michigan, Ann Arbor, Michigan,Department of Biostatistics, University of Michigan, Ann Arbor, Michigan
| | - Jian Kang
- Kidney Epidemiology and Cost Center, University of Michigan, Ann Arbor, Michigan,Department of Biostatistics, University of Michigan, Ann Arbor, Michigan
| | - Joseph M. Messana
- Kidney Epidemiology and Cost Center, University of Michigan, Ann Arbor, Michigan,Department of Internal Medicine-Nephrology Division, University of Michigan, Ann Arbor, Michigan,Address for Correspondence: Joseph M. Messana, MD, School of Public Health, University of Michigan, Kidney Epidemiology and Cost Center, 1415 Washington Heights, Suite 3645 SPH I, Ann Arbor, MI 48109-2029.
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2
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Aryal K, Mowbray F, Gruneir A, Griffith LE, Howard M, Jabbar A, Jones A, Tanuseputro P, Lapointe-Shaw L, Costa AP. Nursing Home Resident Admission Characteristics and Potentially Preventable Emergency Department Transfers. J Am Med Dir Assoc 2021; 23:1291-1296. [PMID: 34919839 DOI: 10.1016/j.jamda.2021.11.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Revised: 11/12/2021] [Accepted: 11/16/2021] [Indexed: 01/15/2023]
Abstract
OBJECTIVES To determine which nursing home (NH) resident-level admission characteristics are associated with potentially preventable emergency department (PPED) transfers. DESIGN We conducted a population-level retrospective cohort study on NH resident data collected using the Resident Assessment Instrument-Minimum Data Set Version 2.0 and linked to the National Ambulatory Care Reporting System for ED transfers. SETTING We used all NH resident admission assessments from January 1, 2017, to December 31, 2018, in Ontario. PARTICIPANTS The cohort included the admission assessment of 56,433 NH residents. METHODS PPED transfers were defined based on the International Classification of Disease, Version 10 (Canadian) We used logistic regression with 10-fold cross-validation and computed average marginal effects to identify the association between resident characteristics at NH admission and PPED transfers within 92 days after admission. RESULTS Overall, 6.2% of residents had at least 1 PPED transfer within 92 days of NH admission. After adjustment, variables that had a prevalence of 10% or more that were associated with a 1% or more absolute increase in the risk of a PPED transfer included polypharmacy [of cohort (OC) 84.4%, risk difference (RD) 2.0%], congestive heart failure (OC 29.0%, RD 3.0%), and renal failure (OC 11.6%, RD 1.2%). Female sex (OC 63.2%, RD -1.3%), a do not hospitalize directive (OC 24.4%, RD -2.6%), change in mood (OC 66.9%, RD -1.2%), and Alzheimer's or dementia (OC 62.1%, RD -1.2%) were more than 10% prevalent and associated with a 1% or more absolute decrease in the risk of a PPED. CONCLUSIONS AND IMPLICATIONS Though many routinely collected resident characteristics were associated with a PPED transfer, the absence of sufficiently discriminating characteristics suggests that emergency department visits by NH residents are multifactorial and difficult to predict. Future studies should assess the clinical utility of risk factor identification to prevent transfers.
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Affiliation(s)
- Komal Aryal
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada; ICES, Toronto, Ontario, Canada
| | - Fabrice Mowbray
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada; ICES, Toronto, Ontario, Canada
| | - Andrea Gruneir
- ICES, Toronto, Ontario, Canada; Department of Family Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Lauren E Griffith
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Michelle Howard
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada; Department of Family Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Amina Jabbar
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada; Trillium Health Partners, Toronto, Ontario, Canada
| | - Aaron Jones
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada; ICES, Toronto, Ontario, Canada
| | - Peter Tanuseputro
- ICES, Toronto, Ontario, Canada; Department of Medicine, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada; Bruyère Research Institute, Ottawa, Ontario, Canada
| | - Lauren Lapointe-Shaw
- ICES, Toronto, Ontario, Canada; Departments of Medicine, University of Toronto and University Health Network, Toronto, Ontario, Canada
| | - Andrew P Costa
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada; ICES, Toronto, Ontario, Canada.
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Niu J, Saeed MK, Winkelmayer WC, Erickson KF. Patient Health Outcomes following Dialysis Facility Closures in the United States. J Am Soc Nephrol 2021; 32:2613-2621. [PMID: 34599037 PMCID: PMC8722806 DOI: 10.1681/asn.2021020244] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Accepted: 06/16/2021] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Ongoing changes to reimbursement of United States dialysis care may increase the risk of dialysis facility closures. Closures may be particularly detrimental to the health of patients receiving dialysis, who are medically complex and clinically tenuous. METHODS We used two separate analytic strategies-one using facility-based matching and the other using propensity score matching-to compare health outcomes of patients receiving in-center hemodialysis at United States facilities that closed with outcomes of similar patients who were unaffected. We used negative binomial and Cox regression models to estimate associations of facility closure with hospitalization and mortality in the subsequent 180 days. RESULTS We identified 8386 patients affected by 521 facility closures from January 2001 through April 2014. In the facility-matched model, closures were associated with 9% higher rates of hospitalization (relative rate ratio [RR], 1.09; 95% confidence interval [95% CI], 1.03 to 1.16), yielding an absolute annual rate difference of 1.69 hospital days per patient-year (95% CI, 0.45 to 2.93). Similarly, in a propensity-matched model, closures were associated with 7% higher rates of hospitalization (RR, 1.07; 95% CI, 1.00 to 1.13; P=0.04), yielding an absolute rate difference of 1.08 hospital days per year (95% CI, 0.04 to 2.12). Closures were associated with nonsignificant increases in mortality (hazard ratio [HR], 1.08; 95% CI, 1.00 to 1.18; P=0.05 for the facility-matched comparison; HR, 1.08; 95% CI, 0.99 to 1.17; P=0.08 for the propensity-matched comparison). CONCLUSIONS Patients affected by dialysis facility closures experienced increased rates of hospitalization in the subsequent 180 days and may be at increased risk of death. This highlights the need for effective policies that continue to mitigate risk of facility closures.
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Affiliation(s)
- Jingbo Niu
- Selzman Institute for Kidney Health and Section of Nephrology, Baylor College of Medicine, Houston, Texas
| | - Maryam K. Saeed
- Selzman Institute for Kidney Health and Section of Nephrology, Baylor College of Medicine, Houston, Texas
| | - Wolfgang C. Winkelmayer
- Selzman Institute for Kidney Health and Section of Nephrology, Baylor College of Medicine, Houston, Texas
| | - Kevin F. Erickson
- Selzman Institute for Kidney Health and Section of Nephrology, Baylor College of Medicine, Houston, Texas,Baker Institute for Public Policy, Rice University, Houston, Texas
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4
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Weerahandi H, Li L, Bao H, Herrin J, Dharmarajan K, Ross JS, Kim KL, Jones S, Horwitz LI. Risk of Readmission After Discharge From Skilled Nursing Facilities Following Heart Failure Hospitalization: A Retrospective Cohort Study. J Am Med Dir Assoc 2020; 20:432-437. [PMID: 30954133 DOI: 10.1016/j.jamda.2019.01.135] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2018] [Revised: 01/15/2019] [Accepted: 01/16/2019] [Indexed: 11/18/2022]
Abstract
OBJECTIVE Discharge to skilled nursing facilities (SNFs) is common in patients with heart failure (HF). It is unknown whether the transition from SNF to home is risky for these patients. Our objective was to study outcomes for the 30 days after discharge from SNF to home among Medicare patients hospitalized with HF who had subsequent SNF stays of 30 days or less. DESIGN Retrospective cohort study. SETTING AND PARTICIPANTS All Medicare fee-for-service beneficiaries 65 and older admitted during 2012-2015 with a HF diagnosis discharged to SNF then subsequently discharged home. MEASURES Patients were followed for 30 days following SNF discharge. We categorized patients by SNF length of stay: 1 to 6 days, 7 to 13 days, and 14 to 30 days. For each group, we modeled time to a composite outcome of unplanned readmission or death after SNF discharge. Our model examined 0-2 days and 3-30 days post-SNF discharge. RESULTS Our study included 67,585 HF hospitalizations discharged to SNF and subsequently discharged home. Overall, 16,333 (24.2%) SNF discharges to home were readmitted within 30 days of SNF discharge. The hazard rate of the composite outcome for each group was significantly increased on days 0 to 2 after SNF discharge compared to days 3 to 30, as reflected in their hazard rate ratios: for patients with SNF length of stay 1 to 6 days, 4.60 (4.23-5.00); SNF length of stay 7 to 13 days, 2.61 (2.45-2.78); SNF length of stay 14 to 30 days, 1.70 (1.62-1.78). CONCLUSIONS/IMPLICATIONS The hazard rate of readmission after SNF discharge following HF hospitalization is highest during the first 2 days home. This risk attenuated with longer SNF length of stay. Interventions to improve postdischarge outcomes have primarily focused on hospital discharge. This evidence suggests that interventions to reduce readmissions may be more effective if they also incorporate the SNF-to-home transition.
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Affiliation(s)
- Himali Weerahandi
- Division of General Internal Medicine and Clinical Innovation, Department of Medicine, NYU School of Medicine, New York, NY.
| | - Li Li
- Center for Outcomes Research & Evaluation, Yale University, New Haven, CT
| | - Haikun Bao
- Center for Outcomes Research & Evaluation, Yale University, New Haven, CT
| | - Jeph Herrin
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT
| | | | - Joseph S Ross
- Center for Outcomes Research & Evaluation, Yale University, New Haven, CT; Section of General Internal Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT
| | - Kunhee Lucy Kim
- Division of Healthcare Delivery Science, Department of Population Health, NYU School of Medicine, New York, NY
| | - Simon Jones
- Division of Healthcare Delivery Science, Department of Population Health, NYU School of Medicine, New York, NY
| | - Leora I Horwitz
- Division of Healthcare Delivery Science, Department of Population Health, NYU School of Medicine, New York, NY
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Ronksley PE, Wick JP, Elliott MJ, Weaver RG, Hemmelgarn BR, McRae A, James MT, Harrison TG, MacRae JM. Derivation and Internal Validation of a Clinical Risk Prediction Tool for Hyperkalemia-Related Emergency Department Encounters Among Hemodialysis Patients. Can J Kidney Health Dis 2020; 7:2054358120953287. [PMID: 32953128 PMCID: PMC7485157 DOI: 10.1177/2054358120953287] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Accepted: 07/16/2020] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND Approximately 10% of emergency department (ED) visits among dialysis patients are for conditions that could potentially be managed in outpatient settings, such as hyperkalemia. OBJECTIVE Using population-based data, we derived and internally validated a risk score to identify hemodialysis patients at increased risk of hyperkalemia-related ED events. DESIGN Retrospective cohort study. SETTING Ten in-center hemodialysis sites in southern Alberta, Canada. PATIENTS All maintenance hemodialysis patients (≥18 years) between March 2009 and March 2017. MEASUREMENTS Predictors of hyperkalemia-related ED events included patient demographics, comorbidities, health-system use, laboratory measurements, and dialysis information. The outcome of interest (hyperkalemia-related ED events) was defined by International Classification of Diseases (10th Revision; ICD-10) codes and/or serum potassium [K+] ≥6 mmol/L. METHODS Bootstrapped logistic regression was used to derive and internally validate a model of important predictors of hyperkalemia-related ED events. A point system was created based on regression coefficients. Model discrimination was assessed by an optimism-adjusted C-statistic and calibration by deciles of risk and calibration slope. RESULTS Of the 1533 maintenance hemodialysis patients in our cohort, 331 (21.6%) presented to the ED with 615 hyperkalemia-related ED events. A 9-point scale for risk of a hyperkalemia-related ED event was created with points assigned to 5 strong predictors based on their regression coefficients: ≥1 laboratory measurement of serum K+ ≥6 mmol/L in the prior 6 months (3 points); ≥1 Hemoglobin A1C [HbA1C] measurement ≥8% in the prior 12 months (1 point); mean ultrafiltration of ≥10 mL/kg/h over the preceding 2 weeks (2 points); ≥25 hours of cumulative time dialyzing over the preceding 2 weeks (1 point); and dialysis vintage of ≥2 years (2 points). Model discrimination (C-statistic: 0.75) and calibration were good. LIMITATIONS Measures related to health behaviors, social determinants of health, and residual kidney function were not available for inclusion as potential predictors. CONCLUSIONS While this tool requires external validation, it may help identify high-risk patients and allow for preventative strategies to avoid unnecessary ED visits and improve patient quality of life. TRIAL REGISTRATION Not applicable-observational study design.
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Affiliation(s)
- Paul E. Ronksley
- Department of Community Health Sciences,
Cumming School of Medicine, University of Calgary, AB, Canada
| | - James P. Wick
- Department of Medicine, Cumming School
of Medicine, University of Calgary, AB, Canada
| | - Meghan J. Elliott
- Department of Medicine, Cumming School
of Medicine, University of Calgary, AB, Canada
| | - Robert G. Weaver
- Department of Medicine, Cumming School
of Medicine, University of Calgary, AB, Canada
| | - Brenda R. Hemmelgarn
- Department of Community Health Sciences,
Cumming School of Medicine, University of Calgary, AB, Canada
- Department of Medicine, Cumming School
of Medicine, University of Calgary, AB, Canada
| | - Andrew McRae
- Department of Emergency Medicine,
Cumming School of Medicine, University of Calgary, AB, Canada
| | - Matthew T. James
- Department of Community Health Sciences,
Cumming School of Medicine, University of Calgary, AB, Canada
- Department of Medicine, Cumming School
of Medicine, University of Calgary, AB, Canada
| | - Tyrone G. Harrison
- Department of Community Health Sciences,
Cumming School of Medicine, University of Calgary, AB, Canada
- Department of Medicine, Cumming School
of Medicine, University of Calgary, AB, Canada
| | - Jennifer M. MacRae
- Department of Medicine, Cumming School
of Medicine, University of Calgary, AB, Canada
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Levin SR, Farber A, Cheng TW, Arinze N, Jones DW, Kalish JA, Rybin D, Siracuse JJ. Risk assessment of significant upper extremity arteriovenous graft infection in the Vascular Quality Initiative. J Vasc Surg 2019; 71:913-919. [PMID: 31327606 DOI: 10.1016/j.jvs.2019.04.491] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2019] [Accepted: 04/28/2019] [Indexed: 11/17/2022]
Abstract
OBJECTIVE Infectious complications of arteriovenous grafts (AVGs) are a major source of morbidity. Our aim was to characterize contemporary risk factors for upper extremity AVG infection. METHODS The Vascular Quality Initiative (2011-2018) was queried for all patients undergoing upper extremity AVG creation. AVG infection was classified as an infection treated with antibiotics, incision and drainage, or graft removal. Multivariable analyses were used to evaluate risk factors for short- and long-term AVG infection. RESULTS Of 1758 upper extremity AVGs, 49 (2.8%) developed significant infection within 3 months, resulting in incision and drainage in 24% and graft removal in 76% of cases. None were managed with antibiotics alone in the study sample. Patients with significant AVG infection were more likely to be white, to be insured, to have a history of coronary artery bypass graft and intravenous (IV) drug use, to be undergoing a concomitant vascular procedure, and to be discharged on an anticoagulant. In multivariable analysis, significant AVG infection within 3 months was associated with IV drug use history (odds ratio [OR], 5; 95% confidence interval [CI], 1.75-14.3; P = .003), discharge to a health care facility (OR, 2.66; 95% CI, 1.07-6.63; P = .035), discharge on an anticoagulant (OR, 2.31; 95% CI, 1.13-4.72; P = .021), white race (OR, 2.3; 95% CI, 1.21-4.34; P = .011), and female sex (OR, 2.02; 95% CI, 1.06-3.85; P = .033). Kaplan-Meier analysis showed that freedom from graft site infection at 1 year was 96.4%. Longer term graft infection at 1 year was independently associated with IV drug use history (hazard ratio [HR], 1.98; 95% CI, 1.06-3.68; P = .032), initial discharge to a health care facility (HR, 1.88; 95% CI, 1.19-2.97; P = .007), and white race (HR, 1.64; 95% CI, 1.23-2.19; P = .001). CONCLUSIONS Although significant AVG infection was uncommon in the Vascular Quality Initiative, the majority were treated with graft removal. In select high-risk patients, extra care should be taken and alternative forms of arteriovenous access may be considered.
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Affiliation(s)
- Scott R Levin
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University School of Medicine, Boston, Mass
| | - Alik Farber
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University School of Medicine, Boston, Mass
| | - Thomas W Cheng
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University School of Medicine, Boston, Mass
| | - Nkiruka Arinze
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University School of Medicine, Boston, Mass
| | - Douglas W Jones
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University School of Medicine, Boston, Mass
| | - Jeffrey A Kalish
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University School of Medicine, Boston, Mass
| | - Denis Rybin
- Department of Biostatistics, Boston University, School of Public Health, Boston, Mass
| | - Jeffrey J Siracuse
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University School of Medicine, Boston, Mass.
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7
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Lin YC, Hsu HK, Lai TS, Chiang WC, Lin SL, Chen YM, Chen CC, Chu TS. Emergency department utilization and resuscitation rate among patients receiving maintenance hemodialysis. J Formos Med Assoc 2019; 118:1652-1660. [PMID: 30711255 DOI: 10.1016/j.jfma.2019.01.007] [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: 09/20/2018] [Revised: 01/03/2019] [Accepted: 01/09/2019] [Indexed: 01/16/2023] Open
Abstract
BACKGROUND End-stage renal disease (ESRD) is a growing global health concern with increased disease burden and high medical costs. Utilization of the emergency department (ED) among dialyzed patients and the associated risk factors remain unknown. METHODS Participants of this study, selected from the National Health Insurance Database in Taiwan, were aged 19-90 years and received maintenance hemodialysis from January 1, 2010, to December 31, 2010. A control group consisting of individuals who did not receive dialysis, selected from the same data source, were matched for age, sex, and the Charlson Comorbidity Index (CCI). Subgroup analysis with hemodialysis frequency was also performed. ED utilization among enrolled individuals was assessed in 2012. Generalized estimating equations with multiple variable adjustments were used to identify risk factors associated with resuscitation during ED visits. RESULTS One group of 2985 individuals who received maintenance hemodialysis, and another group of 2985 patients that did not receive hemodialysis, between January 1, 2010, and December 31, 2010, were included in this study. There were 4822 ED visits in the hemodialysis group, and 1755 ED visits in the non-dialysis group between January 1, 2012, and December 31, 2012. Analysis of multivariable generalized estimating equations identified the risk associated with resuscitation during ED visits to be greater in individuals who were receiving maintenance hemodialysis, aged older than 55 years, hospitalized in the past year, and assigned first and second degree of triage. CONCLUSION Patients receiving maintenance hemodialysis had higher ED utilization and a significantly higher risk of resuscitation during ED visits than those without hemodialysis.
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Affiliation(s)
- Yi-Chih Lin
- Department of Medicine, National Taiwan University Hospital Jinshan Branch, New Taipei City, Taiwan
| | - Hua-Kuei Hsu
- Department of Health Care Management, National Taipei University of Nursing and Health Science, Taipei, Taiwan
| | - Tai-Shuan Lai
- Division of Nephrology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan.
| | - Wen-Chih Chiang
- Division of Nephrology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Shuei-Liong Lin
- Division of Nephrology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Yung-Ming Chen
- Division of Nephrology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Chu-Chieh Chen
- Department of Health Care Management, National Taipei University of Nursing and Health Science, Taipei, Taiwan.
| | - Tzong-Shinn Chu
- Division of Nephrology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
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Eckardt KU, Bansal N, Coresh J, Evans M, Grams ME, Herzog CA, James MT, Heerspink HJL, Pollock CA, Stevens PE, Tamura MK, Tonelli MA, Wheeler DC, Winkelmayer WC, Cheung M, Hemmelgarn BR. Improving the prognosis of patients with severely decreased glomerular filtration rate (CKD G4+): conclusions from a Kidney Disease: Improving Global Outcomes (KDIGO) Controversies Conference. Kidney Int 2018; 93:1281-1292. [PMID: 29656903 PMCID: PMC5998808 DOI: 10.1016/j.kint.2018.02.006] [Citation(s) in RCA: 55] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2017] [Revised: 01/24/2018] [Accepted: 02/05/2018] [Indexed: 12/22/2022]
Abstract
Patients with severely decreased glomerular filtration rate (GFR) (i.e., chronic kidney disease [CKD] G4+) are at increased risk for kidney failure, cardiovascular disease (CVD) events (including heart failure), and death. However, little is known about the variability of outcomes and optimal therapeutic strategies, including initiation of kidney replacement therapy (KRT). Kidney Disease: Improving Global Outcomes (KDIGO) organized a Controversies Conference with an international expert group in December 2016 to address this gap in knowledge. In collaboration with the CKD Prognosis Consortium (CKD-PC) a global meta-analysis of cohort studies (n = 264,515 individuals with CKD G4+) was conducted to better understand the timing of clinical outcomes in patients with CKD G4+ and risk factors for different outcomes. The results confirmed the prognostic value of traditional CVD risk factors in individuals with severely decreased GFR, although the risk estimates vary for kidney and CVD outcomes. A 2- and 4-year model of the probability and timing of kidney failure requiring KRT was also developed. The implications of these findings for patient management were discussed in the context of published evidence under 4 key themes: management of CKD G4+, diagnostic and therapeutic challenges of heart failure, shared decision-making, and optimization of clinical trials in CKD G4+ patients. Participants concluded that variable prognosis of patients with advanced CKD mandates individualized, risk-based management, factoring in competing risks and patient preferences.
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Affiliation(s)
- Kai-Uwe Eckardt
- Department of Nephrology and Medical Intensive Care, Charité - Universitätsmedizin Berlin, Berlin, Germany.
| | - Nisha Bansal
- Kidney Research Institute, Division of Nephrology, University of Washington, Seattle, Washington, USA
| | - Josef Coresh
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Marie Evans
- Division of Renal Medicine, CLINTEC, Karolinska Institutet, Stockholm, Sweden; Swedish Renal Registry, Jönköping, Sweden
| | - Morgan E Grams
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA; Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Charles A Herzog
- Chronic Disease Research Group, Minneapolis Medical Research Foundation, Minneapolis, Minnesota, USA; Division of Cardiology, Department of Medicine, Hennepin County Medical Center and University of Minnesota, Minneapolis, Minnesota, USA
| | - Matthew T James
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada; Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Hiddo J L Heerspink
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Carol A Pollock
- Department of Renal Medicine, Royal North Shore Hospital, Sydney, New South Wales, Australia; Sydney Medical School, The University of Sydney, Sydney, New South Wales, Australia
| | - Paul E Stevens
- Kent Kidney Care Centre, East Kent Hospitals, University NHS Foundation Trust, Canterbury, Kent, UK
| | - Manjula Kurella Tamura
- VA Palo Alto Geriatric Research and Education Clinical Center, Palo Alto, California, USA; Division of Nephrology, Stanford University School of Medicine, Palo Alto, California, USA
| | - Marcello A Tonelli
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | | | - Wolfgang C Winkelmayer
- Selzman Institute for Kidney Health, Section of Nephrology, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
| | | | - Brenda R Hemmelgarn
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada; Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.
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9
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Hall RK, McAdams-DeMarco MA. Breaking the cycle of functional decline in older dialysis patients. Semin Dial 2018; 31:462-467. [PMID: 29642268 DOI: 10.1111/sdi.12695] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Currently, older adults comprise nearly one-third of prevalent US dialysis patients, and this proportion will increase as the population ages. Older dialysis patients experience greater morbidity and mortality than nondialysis patients of the same age, and in part, it is related to progressive functional decline. Progressive functional decline, characterized by need for assistance with more than 2 activities of daily living, contributes to risk of hospitalization, further functional decline, and subsequent nursing home placement when a patient no longer functions independently at home. Progressive functional decline may appear to be unavoidable for older dialysis patients; however, comprehensive geriatric assessment (CGA) may alleviate the prevalence and severity of functional decline. This editorial summarizes common risk factors of functional decline and introduces CGA as a potentially transformative approach to breaking the cycle of functional decline in older dialysis patients.
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Affiliation(s)
- Rasheeda K Hall
- Durham VA Geriatric Research, Education and Clinical Center, Durham, NC, USA.,Division of Nephrology, Department of Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Mara A McAdams-DeMarco
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA.,Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, MD, USA
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10
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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
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11
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Golestaneh L, Bellin E, Southern W, Melamed ML. Discharge service as a determinant of 30-day readmission in a cohort of maintenance hemodialysis patients: a retrospective cohort study. BMC Nephrol 2017; 18:352. [PMID: 29202796 PMCID: PMC5716258 DOI: 10.1186/s12882-017-0761-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2017] [Accepted: 11/17/2017] [Indexed: 01/25/2023] Open
Abstract
Background End stage renal disease (ESRD) patients on maintenance hemodialysis, are high utilizers of inpatient services. Because of data showing improved outcomes in medical patients admitted to hospitalist-run, non-teaching services, we hypothesized that discharge from a hospitalist-run, non-teaching service is associated with lower risk of 30-day re-hospitalization in a cohort of patients on hemodialysis. Methods One thousand and 84 consecutive patients with ESRD on maintenance hemodialysis who were admitted to Montefiore, a tertiary care center, in 2014 were analyzed using the electronic medical records. We evaluated factors associated with 30-day readmission in multivariable regression models. We then tested the association of care by a hospitalist-run, non-teaching service with 30-day readmission in a propensity score matched analysis. Results Patients cared for on the hospitalist-run, non-teaching service had lower socio-economic scores (SES) and had longer lengths of stay (LOS), as compared to a standard teaching service, but otherwise the populations were similar. In multivariable testing, severity of illness, (OR 2.40, (95%CI: 1.43–4.03) for highest quartile) number of previous hospitalizations (OR 1.22 (95%CI:1.16–1.28) for each admission), and discharge to a skilled nursing facility (SNF)(OR 1.56 (95%CI:1.01–2.43) were significantly associated with 30-day re-admissions. Care by the non-teaching service was associated with a lower risk of 30-day readmission, even after adjusting for clinical factors and matching based on propensity score (OR 0.65(95%CI:0.46–0.91) and 0.71(95%CI:0.66–0.77) respectively). Conclusions Patients with ESRD on hemodialysis discharged from a hospitalist-run, non-teaching medicine service had lower odds of readmission as compared to those patients discharged from a standard teaching service.
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Affiliation(s)
- Ladan Golestaneh
- Department of Medicine/ Renal Division, Montefiore Medical Center/Albert Einstein College of Medicine, 3411 Wayne Ave, Suite 5H, Bronx, NY, 10467, USA.
| | - Eran Bellin
- Department of Epidemiology and Population Health, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, USA
| | - William Southern
- Division of Hospitalist Medicine, Montefiore Medical Center, Bronx, USA
| | - Michal L Melamed
- Department of Medicine/ Renal Division, Montefiore Medical Center/Albert Einstein College of Medicine, 3411 Wayne Ave, Suite 5H, Bronx, NY, 10467, USA
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12
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Abstract
Cardiovascular disease (CVD) remains the leading cause of morbidity and mortality in patients with chronic kidney disease (CKD) and end-stage renal disease (ESRD). The rate of death in incident dialysis patients remains high. This has led to interest in the study of the evolution of CVD during the critical transition period from CKD to ESRD. Understanding the natural history and risk factors of clinical and subclinical CVD during this transition may help guide the timing of appropriate CVD therapies to improve outcomes in patients with kidney disease. This review provides an overview of the epidemiology of subclinical and clinical CVD during the transition from CKD to ESRD and discusses clinical trials of CVD therapies to mitigate risk of CVD in CKD and ESRD patients.
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Affiliation(s)
- Nisha Bansal
- Division of Nephrology, Kidney Research Institute, University of Washington, Seattle, WA.
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13
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Ronksley PE, Tonelli M, Manns BJ, Weaver RG, Thomas CM, MacRae JM, Ravani P, Quinn RR, James MT, Lewanczuk R, Hemmelgarn BR. Emergency Department Use among Patients with CKD: A Population-Based Analysis. Clin J Am Soc Nephrol 2017; 12:304-314. [PMID: 28119410 PMCID: PMC5293336 DOI: 10.2215/cjn.06280616] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2016] [Accepted: 10/19/2016] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND OBJECTIVES Although prior studies have observed high resource use among patients with CKD, there is limited exploration of emergency department use in this population and the proportion of encounters related to CKD care specifically. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS We identified all adults (≥18 years old) with eGFR<60 ml/min per 1.73 m2 (including dialysis-dependent patients) in Alberta, Canada between April 1, 2010 and March 31, 2011. Patients with CKD were linked to administrative data to capture clinical characteristics and frequency of emergency department encounters and followed until death or end of study (March 31, 2013). Within each CKD category, we calculated adjusted rates of overall emergency department use as well as rates of potentially preventable emergency department encounters (defined by four CKD-specific ambulatory care-sensitive conditions: heart failure, hyperkalemia, volume overload, and malignant hypertension). RESULTS During mean follow-up of 2.4 years, 111,087 patients had 294,113 emergency department encounters; 64.2% of patients had category G3A CKD, and 1.6% were dialysis dependent. Adjusted rates of overall emergency department use were highest among patients with more advanced CKD; 5.8% of all emergency department encounters were for CKD-specific ambulatory care-sensitive conditions, with approximately one third resulting in hospital admission. Heart failure accounted for over 80% of all potentially preventable emergency department events among patients with categories G3A, G3B, and G4 CKD, whereas hyperkalemia accounted for almost one half (48%) of all ambulatory care-sensitive conditions among patients on dialysis. Adjusted rates of emergency department events for heart failure showed a U-shaped relationship, with the highest rates among patients with category G4 CKD. In contrast, there was a graded association between rates of emergency department use for hyperkalemia and CKD category. CONCLUSIONS Emergency department use is high among patients with CKD, although only a small proportion of these encounters is for potentially preventable CKD-related care. Strategies to reduce emergency department use among patients with CKD will, therefore, need to target conditions other than CKD-specific ambulatory care-sensitive conditions.
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Affiliation(s)
| | - Marcello Tonelli
- Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Braden J. Manns
- Departments of Community Health Sciences and
- Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Robert G. Weaver
- Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Chandra M. Thomas
- Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Jennifer M. MacRae
- Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Pietro Ravani
- Departments of Community Health Sciences and
- Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Robert R. Quinn
- Departments of Community Health Sciences and
- Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Matthew T. James
- Departments of Community Health Sciences and
- Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Richard Lewanczuk
- Provincial Primary Health Care, Alberta Health Services, Edmonton, Alberta, Canada; and
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Brenda R. Hemmelgarn
- Departments of Community Health Sciences and
- Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
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14
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Shafi T, Sozio SM, Luly J, Bandeen-Roche KJ, St. Peter WL, Ephraim PL, McDermott A, Herzog CA, Crews DC, Scialla JJ, Tangri N, Miskulin DC, Michels WM, Jaar BG, Zager PG, Meyer KB, Wu AW, Boulware LE. Antihypertensive medications and risk of death and hospitalizations in US hemodialysis patients: Evidence from a cohort study to inform hypertension treatment practices. Medicine (Baltimore) 2017; 96:e5924. [PMID: 28151871 PMCID: PMC5293434 DOI: 10.1097/md.0000000000005924] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
Antihypertensive medications are commonly prescribed to hemodialysis patients but the optimal regimens to prevent morbidity and mortality are unknown. The goal of our study was to compare the association of routinely prescribed antihypertensive regimens with outcomes in US hemodialysis patients.We used 2 datasets for our analysis. Our primary cohort (US Renal Data System [USRDS]) included adult patients initiating in-center hemodialysis from July 1, 2006 to June 30, 2008 (n = 33,005) with follow-up through December 31, 2009. Our secondary cohort included adult patients from Dialysis Clinic, Inc. (DCI), a national not-for-profit dialysis provider, initiating in-center hemodialysis from January 1, 2003 to June 30, 2008 (n = 11,291) with follow-up through December 31, 2008. We linked the USRDS cohort with Medicare part D prescriptions-fill data and the DCI cohort with USRDS data. Unique aspect of USRDS cohort was pharmacy prescription-fill data and for DCI cohort was detailed clinical data, including blood pressure, weight, and ultrafiltration. We classified prescribed antihypertensives into the following mutually exclusive regimens: β-blockers, renin-angiotensin system blocking drugs-containing regimens without a β-blocker (RAS), β-blocker + RAS, and others. We used marginal structural models accounting for time-updated comorbidities to quantify each regimen's association with mortality (both cohorts) and cardiovascular hospitalization (DCI-Medicare Subcohort).In the USRDS and DCI cohorts there were 9655 (29%) and 3200 (28%) deaths, respectively. In both cohorts, RAS compared to β-blockers regimens were associated with lower risk of death; (hazard ratio [HR]) (95% confidence interval [CI]) for all-cause mortality, (0.90 [0.82-0.97] in USRDS and 0.87 [0.76-0.98] in DCI) and cardiovascular mortality (0.84 [0.75-0.95] in USRDS and 0.88 [0.71-1.07] in DCI). There was no association between antihypertensive regimens and the risk of cardiovascular hospitalizations.In hemodialysis patients undergoing routine care, renin-angiotensin system blocking drugs-containing regimens were associated with a lower risk of death compared with β-blockers-containing regimens but there was no association with cardiovascular hospitalizations. Pragmatic clinical trials are needed to specifically examine the effectiveness of these commonly used antihypertensive regimens in dialysis patients.
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Affiliation(s)
- Tariq Shafi
- Division of Nephrology, Johns Hopkins University School of Medicine
- Welch Center for Prevention, Epidemiology, and Clinical Research
| | - Stephen M. Sozio
- Division of Nephrology, Johns Hopkins University School of Medicine
- Welch Center for Prevention, Epidemiology, and Clinical Research
| | - Jason Luly
- Department of Health Policy and Management
| | - Karen J. Bandeen-Roche
- Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Wendy L. St. Peter
- College of Pharmacy, University of Minnesota
- Chronic Disease Research Group, Minneapolis Medical Research Foundation, Minneapolis, MN
| | - Patti L. Ephraim
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Aidan McDermott
- Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Charles A. Herzog
- Department of Internal Medicine, Hennepin County Medical Center, University of Minnesota
- Cardiovascular Special Studies Center, United States Renal Data System, Minneapolis, MN
| | - Deidra C. Crews
- Division of Nephrology, Johns Hopkins University School of Medicine
- Welch Center for Prevention, Epidemiology, and Clinical Research
| | - Julia J. Scialla
- Department of Nephrology, Duke University School of Medicine, Durham, NC
| | - Navdeep Tangri
- Department of Medicine, Division of Nephrology, Seven Oaks General Hospital, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Dana C. Miskulin
- Division of Nephrology, Tufts University School of Medicine, Boston, MA
| | - Wieneke M. Michels
- Division of Nephrology, Department of Medicine, Academic Medical Center, Amsterdam, The Netherlands
| | - Bernard G. Jaar
- Division of Nephrology, Johns Hopkins University School of Medicine
- Welch Center for Prevention, Epidemiology, and Clinical Research
- Nephrology Center of Maryland, Baltimore, MD
| | - Philip G. Zager
- Division of Nephrology, University of New Mexico, Albuquerque, New Mexico
| | - Klemens B. Meyer
- Division of Nephrology, Tufts University School of Medicine, Boston, MA
| | - Albert W. Wu
- Department of Health Policy and Management
- Department of International Health
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - L. Ebony Boulware
- Division of General Internal Medicine, Duke University School of Medicine, Durham, NC, USA
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15
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Bowling CB, Plantinga L, Hall RK, Mirk A, Zhang R, Kutner N. Association of Nondisease-Specific Problems with Mortality, Long-Term Care, and Functional Impairment among Older Adults Who Require Skilled Nursing Care after Dialysis Initiation. Clin J Am Soc Nephrol 2016; 11:2218-2224. [PMID: 27733436 PMCID: PMC5142055 DOI: 10.2215/cjn.01260216] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2016] [Accepted: 08/22/2016] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND OBJECTIVES The majority of older adults who initiate dialysis do so during a hospitalization, and these patients may require post-acute skilled nursing facility (SNF) care. For these patients, a focus on nondisease-specific problems, including cognitive impairment, depressive symptoms, exhaustion, falls, impaired mobility, and polypharmacy, may be more relevant to outcomes than the traditional disease-oriented approach. However, the association of the burden of nondisease-specific problems with mortality, transition to long-term care (LTC), and functional impairment among older adults receiving SNF care after dialysis initiation has not been studied. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS We identified 40,615 Medicare beneficiaries ≥65 years old who received SNF care after dialysis initiation between 2000 and 2006 by linking renal disease registry data with the Minimum Data Set. Nondisease-specific problems were ascertained from the Minimum Data Set. We defined LTC as ≥100 SNF days and functional impairment as dependence in all four essential activities of daily living at SNF discharge. Associations of the number of nondisease-specific problems (≤1, 2, 3, and 4-6) with 6-month mortality, LTC, and functional impairment were examined. RESULTS Overall, 39.2% of patients who received SNF care after dialysis initiation died within 6 months. Compared with those with ≤1 nondisease-specific problems, multivariable adjusted hazard ratios (95% confidence interval) for mortality were 1.26 (1.19 to 1.32), 1.40 (1.33 to 1.48), and 1.66 (1.57 to 1.76) for 2, 3, and 4-6 nondisease-specific problems, respectively. Among those who survived, 37.1% required LTC; of those remaining who did not require LTC, 74.7% had functional impairment. A higher likelihood of transition to LTC (among those who survived 6 months) and functional impairment (among those who survived and did not require LTC) was seen with a higher number of problems. CONCLUSIONS Identifying nondisease-specific problems may help patients and families anticipate LTC needs and functional impairment after dialysis initiation.
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Affiliation(s)
- C. Barrett Bowling
- Department of Veterans Affairs, Birmingham/Atlanta Geriatric Research, Education, and Clinical Center, Atlanta Veterans Affairs Medical Center (VAMC), Decatur, Georgia
- Division of General Medicine and Geriatrics, Department of Medicine
| | - Laura Plantinga
- Division of General Medicine and Geriatrics, Department of Medicine
- Division of Renal Medicine, Department of Medicine
- Department of Epidemiology
| | - Rasheeda K. Hall
- Department of Veterans Affairs, Geriatric Research, Education and Clinical Center and
- Renal Section, Durham VAMC, Durham, North Carolina; and
- Division of Nephrology, Department of Medicine, Duke University Medical Center, Durham, North Carolina
| | - Anna Mirk
- Department of Veterans Affairs, Birmingham/Atlanta Geriatric Research, Education, and Clinical Center, Atlanta Veterans Affairs Medical Center (VAMC), Decatur, Georgia
- Division of General Medicine and Geriatrics, Department of Medicine
| | - Rebecca Zhang
- Rehabilitation/Quality of Life Special Studies Center, United States Renal Data System, and
- Department of Biostatistics and Bioinformatics, Emory University, Atlanta, Georgia
| | - Nancy Kutner
- Rehabilitation/Quality of Life Special Studies Center, United States Renal Data System, and
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16
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Wang CL, Ding ST, Hsieh MJ, Shu CC, Hsu NC, Lin YF, Chen JS. Factors associated with emergency department visit within 30 days after discharge. BMC Health Serv Res 2016; 16:190. [PMID: 27225191 PMCID: PMC4879744 DOI: 10.1186/s12913-016-1439-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2015] [Accepted: 05/24/2016] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Post-discharge care remains a challenge because continuity of care is often interrupted and adverse events frequently occur. Previous studies have focused on early readmission but few have investigated emergency department (ED) visit after discharge. METHODS This retrospective observational study was conducted between April 2011 and March 2012 in a referral center in Taiwan. Patients discharged from the general medical wards during the study period were analyzed and their characteristics, hospital course, and associated factors were collected. An ED visit within 30 days of discharge was the primary outcome while readmission or death at home were secondary outcomes. RESULTS There were 799 discharged patients analyzed, including 96 (12 %) with an ED visit of 12.4 days post-discharge and 111 (14 %) with readmissions at 13.3 days post-discharge. Sixty patients were admitted after their ED visit. Underlying chronic illnesses were associated with 72 % of ED visits. By multivariate analysis, Charlson score and the use of naso-gastric tube were independent risk factors for ED visit within 30 days after discharge. CONCLUSIONS Early ED visit after discharge is as high as 12 %. Patients with chronic illness and those requiring a naso-gastric tube or external biliary drain are at high risk for post-discharge ED visit.
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Affiliation(s)
- Chuan-Lan Wang
- Department of Nursing, National Taiwan University Hospital, Taipei, Taiwan.,Department of Traumatology, Hospital Medicine Group, National Taiwan University Hospital, #7, Chung-Shan South Road, Taipei, 100, Taiwan
| | - Shih-Tan Ding
- Department of Nursing, National Taiwan University Hospital, Taipei, Taiwan.,Department of Traumatology, Hospital Medicine Group, National Taiwan University Hospital, #7, Chung-Shan South Road, Taipei, 100, Taiwan
| | - Ming-Ju Hsieh
- Department of Emergency Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Chin-Chung Shu
- Department of Traumatology, Hospital Medicine Group, National Taiwan University Hospital, #7, Chung-Shan South Road, Taipei, 100, Taiwan. .,Graduate Institute of Clinical Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan. .,College of Medicine, National Taiwan University, Taipei, Taiwan.
| | - Nin-Chieh Hsu
- Department of Traumatology, Hospital Medicine Group, National Taiwan University Hospital, #7, Chung-Shan South Road, Taipei, 100, Taiwan.,College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Yu-Feng Lin
- Department of Traumatology, Hospital Medicine Group, National Taiwan University Hospital, #7, Chung-Shan South Road, Taipei, 100, Taiwan.,Graduate Institute of Clinical Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan.,College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Jin-Shing Chen
- Department of Traumatology, Hospital Medicine Group, National Taiwan University Hospital, #7, Chung-Shan South Road, Taipei, 100, Taiwan.,College of Medicine, National Taiwan University, Taipei, Taiwan.,Department of Surgery, National Taiwan University Hospital, Taipei, Taiwan
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17
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Toles M, Colón-Emeric C, Naylor MD, Barroso J, Anderson RA. Transitional care in skilled nursing facilities: a multiple case study. BMC Health Serv Res 2016; 16:186. [PMID: 27184902 PMCID: PMC4869313 DOI: 10.1186/s12913-016-1427-1] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2015] [Accepted: 05/05/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Among hospitalized older adults who transfer to skilled nursing facilities (SNF) for short stays and subsequently transfer to home, twenty two percent require additional emergency department or hospital care within 30 days. Transitional care services, that provide continuity and coordination of care as older adults transition between settings of care, decrease complications during transitions in care, however, they have not been examined in SNFs. Thus, this study described how existing staff in SNFs delivered transitional care to identify opportunities for improvement. METHODS In this prospective, multiple case study, a case was defined as an individual SNF. Using a sampling plan to assure maximum variation among SNFs, three SNFs were purposefully selected and 54 staff, patients and family caregivers participated in data collection activities, which included observations of care (N = 235), interviews (N = 66) and review of documents (N = 35). Thematic analysis was used to describe similarities and differences in transitional care provided in the SNFs as well as organizational structures and the quality of care-team interactions that supported staff who delivered transitional care services. RESULTS Staff in Case 1 completed most key transitional care services. Staff in Cases 2 and 3, however, had incomplete and/or absent services. Staff in Case 1, but not in Cases 2 and 3, reported a clear understanding of the need for transitional care, used formal transitional care team meetings and tracking tools to plan care, and engaged in robust team interactions. CONCLUSIONS Organizational structures in SNFs that support staff and interactions among patients, families and staff appeared to promote the ability of staff in SNFs to deliver evidence-based transitional care services. Findings suggest practical approaches to develop new care routines, tools, and staff training materials to enhance the ability of existing SNF staff to effectively deliver transitional care.
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Affiliation(s)
- Mark Toles
- University of North Carolina at Chapel Hill, School of Nursing, 7460 Carrington Hall, Chapel Hill, NC, 27599, USA.
| | - Cathleen Colón-Emeric
- School of Medicine and the Geriatric Research, Education and Clinical Center (GRECC), Durham Veterans Affairs Medical Center, Duke University, DUMC 3469, Durham, NC, 27710, USA
| | - Mary D Naylor
- NewCourtland Center for Transitions and Health, University of Pennsylvania School of Nursing, Room 341 Fagin Hall, 418 Curie Blvd., Philadelphia, PA, 19104-4217, USA
| | - Julie Barroso
- Medical University of South CarolinaCollege of Nursing, Room 508 99 Jonathan Lucas St., Charleston, SC, 29425-1600, USA
| | - Ruth A Anderson
- University of North Carolina at Chapel Hill, School of Nursing, 7460 Carrington Hall, Chapel Hill, NC, 27599, USA
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18
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Sherman RA. Briefly Noted. Semin Dial 2015. [DOI: 10.1111/sdi.12391] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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19
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Erickson KF, Kurella Tamura M. Overlooked care transitions: an opportunity to reduce acute care use in ESRD. Clin J Am Soc Nephrol 2015; 10:347-9. [PMID: 25649156 DOI: 10.2215/cjn.00220115] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Affiliation(s)
- Kevin F Erickson
- Division of Nephrology and Center for Primary Care and Outcomes Research, Department of Medicine, Stanford University School of Medicine, Stanford, California; and
| | - Manjula Kurella Tamura
- Division of Nephrology and Geriatric Research and Education Clinical Center, Veterans Affairs Palo Alto Health Care System, Palo Alto, California
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