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Ferguson B, Doan V, Shoker A, Abdelrasoul A. A comprehensive exploration of chronic kidney disease and dialysis in Canada's Indigenous population: from epidemiology to genetic influences. Int Urol Nephrol 2024:10.1007/s11255-024-04122-5. [PMID: 38898356 DOI: 10.1007/s11255-024-04122-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2024] [Accepted: 06/13/2024] [Indexed: 06/21/2024]
Abstract
PURPOSE This study aims to review the escalating prevalence of chronic kidney disease (CKD) and end-stage renal disease (ESRD) among Canada's Indigenous population, focusing on risk factors, hospitalization and mortality rates, and disparities in kidney transplantation. The study explores how these factors contribute to the health outcomes of this population and examines the influence of genetic variations on CKD progression. METHODS The review synthesizes data on prevalence rates, hospitalization and mortality statistics, and transplantation disparities among Indigenous individuals. It also delves into the complexities of healthcare access, including geographical, socioeconomic, and psychological barriers. Additionally, the manuscript investigates the impact of racial factors on blood characteristics relevant to dialysis treatment and the genetic predispositions influencing disease progression in Indigenous populations. RESULTS Indigenous individuals exhibit a higher prevalence of CKD and ESRD risk factors such as diabetes and obesity, particularly in regions like Saskatchewan. These patients face a 77% higher risk of death compared to their non-Indigenous counterparts and are less likely to receive kidney transplants. Genetic analyses reveal significant associations between CKD and specific genomic variations. Through analyses, we found that healthy Indigenous individuals may have higher levels of circulating inflammatory markers, which could become further elevated for those with CKD. In particular, they may have higher levels of C-reactive protein (CRP) fibrinogen, as well as genomic variations that affect IL-6 production and the function of von Willebrand Factor (vWF) which has critical potential influence on the compatibility with dialysis membranes contributing to complications in dialysis. CONCLUSION Indigenous people in Canada are disproportionately burdened by CKD and ESRD due to socioeconomic factors and potential genetic predispositions. While significant efforts have been made to assess the socioeconomic conditions of the Indigenous population, the genetic factors and their potential critical influence on compatibility with dialysis membranes, contributing to treatment complications, remain understudied. Further investigation into these genetic predispositions is essential.
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Affiliation(s)
- Braiden Ferguson
- Division of Biomedical Engineering, University of Saskatchewan, 57 Campus Drive, Saskatoon, SK, S7N 5A9, Canada
| | - Victoria Doan
- Division of Biomedical Engineering, University of Saskatchewan, 57 Campus Drive, Saskatoon, SK, S7N 5A9, Canada
| | - Ahmed Shoker
- Saskatchewan Transplant Program, St. Paul's Hospital, 1702 20Th Street West, Saskatoon, SK, S7M 0Z9, Canada
- Nephrology Division, College of Medicine, University of Saskatchewan, 107 Wiggins Rd, Saskatoon, SK, S7N 5E5, Canada
| | - Amira Abdelrasoul
- Division of Biomedical Engineering, University of Saskatchewan, 57 Campus Drive, Saskatoon, SK, S7N 5A9, Canada.
- Department of Chemical and Biological Engineering, University of Saskatchewan, 57 Campus Drive, Saskatoon, SK, S7N 5A9, Canada.
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Ronksley PE, Scory TD, McRae AD, MacRae JM, Manns BJ, Lang E, Donald M, Hemmelgarn BR, Elliott MJ. Emergency Department Use Among Adults Receiving Dialysis. JAMA Netw Open 2024; 7:e2413754. [PMID: 38809552 PMCID: PMC11137633 DOI: 10.1001/jamanetworkopen.2024.13754] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Accepted: 03/27/2024] [Indexed: 05/30/2024] Open
Abstract
Importance People with kidney failure receiving maintenance dialysis visit the emergency department (ED) 3 times per year on average, which is 3- to 8-fold more often than the general population. Little is known about the factors that contribute to potentially preventable ED use in this population. Objective To identify the clinical and sociodemographic factors associated with potentially preventable ED use among patients receiving maintenance dialysis. Design, Setting, and Participants This cohort study used linked administrative health data within the Alberta Kidney Disease Network to identify adults aged 18 years or older receiving maintenance dialysis (ie, hemodialysis or peritoneal dialysis) between April 1, 2010, and March 31, 2019. Patients who had been receiving dialysis for more than 90 days were followed up from cohort entry (defined as dialysis start date plus 90 days) until death, outmigration from the province, receipt of a kidney transplant, or end of study follow-up. The Andersen behavioral model of health services was used as a conceptual framework to identify variables related to health care need, predisposing factors, and enabling factors. Data were analyzed in March 2024. Main Outcomes and Measures Rates of all-cause ED encounters and potentially preventable ED use associated with 4 kidney disease-specific ambulatory care-sensitive conditions (hyperkalemia, heart failure, volume overload, and malignant hypertension) were calculated. Multivariable negative binomial regression models were used to examine the association between clinical and sociodemographic factors and rates of potentially preventable ED use. Results The cohort included 4925 adults (mean [SD] age, 60.8 [15.5] years; 3071 males [62.4%]) with kidney failure receiving maintenance hemodialysis (3183 patients) or peritoneal dialysis (1742 patients) who were followed up for a mean (SD) of 2.5 (2.0) years. In all, 3877 patients had 34 029 all-cause ED encounters (3100 [95% CI, 2996-3206] encounters per 1000 person-years). Of these, 755 patients (19.5%) had 1351 potentially preventable ED encounters (114 [95% CI, 105-124] encounters per 1000 person-years). Compared with patients with a nonpreventable ED encounter, patients with a potentially preventable ED encounter were more likely to be in the lowest income quintile (38.8% vs 30.9%; P < .001); to experience heart failure (46.8% vs 39.9%; P = .001), depression (36.6% vs 32.5%; P = .03), and chronic pain (60.1% vs 54.9%; P = .01); and to have a longer duration of dialysis (3.6 vs 2.6 years; P < .001). In multivariable regression analyses, potentially preventable ED use was higher for younger adults (incidence rate ratio [IRR], 1.69 [95% CI, 1.33-2.15] for those aged 18 to 44 years) and patients with chronic pain (IRR, 1.35 [95% CI, 1.14-1.61]), greater material deprivation (IRR, 1.57 [95% CI, 1.16-2.12]), a history of hyperkalemia (IRR, 1.31 [95% CI, 1.09-1.58]), and historically high ED use (ie, ≥3 ED encounters in the prior year; IRR, 1.46 [95% CI, 1.23-1.73). Conclusions and Relevance In this study of adults receiving maintenance dialysis in Alberta, Canada, among those with ED use, 1 in 5 had a potentially preventable ED encounter; reasons for such encounters were associated with both psychosocial and medical factors. The findings underscore the need for strategies that address social determinants of health to avert potentially preventable ED use in this population.
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Affiliation(s)
- Paul E. Ronksley
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Tayler D. Scory
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Andrew D. McRae
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
- Department of Emergency Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Jennifer M. MacRae
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
- Department of Cardiac Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Braden J. Manns
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Eddy Lang
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
- Department of Emergency Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Maoliosa Donald
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Brenda R. Hemmelgarn
- Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Meghan J. Elliott
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
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Josephson MA, Becker Y, Budde K, Kasiske BL, Kiberd BA, Loupy A, Małyszko J, Mannon RB, Tönshoff B, Cheung M, Jadoul M, Winkelmayer WC, Zeier M. Challenges in the management of the kidney allograft: from decline to failure: conclusions from a Kidney Disease: Improving Global Outcomes (KDIGO) Controversies Conference. Kidney Int 2023; 104:1076-1091. [PMID: 37236423 DOI: 10.1016/j.kint.2023.05.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Revised: 05/11/2023] [Accepted: 05/12/2023] [Indexed: 05/28/2023]
Abstract
In March 2022, Kidney Disease: Improving Global Outcomes (KDIGO) held a virtual Controversies Conference to address the important but rarely examined phase during which the kidney transplant is failing or has failed. In addition to discussing the definition of a failing allograft, 4 broad areas were considered in the context of a declining functioning graft: prognosis and kidney failure trajectory; immunosuppression strategies; management of medical and psychological complications, and patient factors; and choice of kidney replacement therapy or supportive care following graft loss. Identifying and paying special attention to individuals with failing allografts was felt to be important in order to prepare patients psychologically, manage immunosuppression, address complications, prepare for dialysis and/or retransplantation, and transition to supportive care. Accurate prognostication tools, although not yet widely available, were embraced as necessary to define allograft survival trajectories and the likelihood of allograft failure. The decision of whether to withdraw or continue immunosuppression after allograft failure was deemed to be based most appropriately on risk-benefit analysis and likelihood of retransplantation within a few months. Psychological preparation and support was identified as a critical factor in patient adjustment to graft failure, as was early communication. Several models of care were noted that enabled a medically supportive transition back to dialysis or retransplantation. Emphasis was placed on the importance of dialysis-access readiness before initiation of dialysis, in order to avoid use of central venous catheters. The centrality of the patient to all management decisions and discussions was deemed to be paramount. Patient "activation," which can be defined as engaged agency, was seen as the most effective way to achieve success. Unresolved controversies, gaps in knowledge, and areas for research were also stressed in the conference deliberations.
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Affiliation(s)
- Michelle A Josephson
- Section of Nephrology, Department of Medicine, and Transplant Institute, University of Chicago, Chicago, Illinois, USA.
| | - Yolanda Becker
- Transplantation Institute, Department of Surgery, University of Chicago, Chicago, Illinois, USA
| | - Klemens Budde
- Department of Nephrology and Medical Intensive Care, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Bertram L Kasiske
- Department of Medicine, Hennepin Healthcare, University of Minnesota, Minneapolis, Minnesota, USA
| | - Bryce A Kiberd
- Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Alexandre Loupy
- Université Paris Cité, INSERM U970, Paris Institute for Transplantation and Organ Regeneration, F-75015 Paris, France; Department of Kidney Transplantation, Necker Hospital, Assistance Publique - Hôpitaux de Paris, Paris, France
| | - Jolanta Małyszko
- Department of Nephrology, Dialysis and Internal Diseases, Medical University of Warsaw, Warsaw, Poland
| | - Roslyn B Mannon
- Division of Nephrology, Department of Internal Medicine, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Burkhard Tönshoff
- Department of Pediatrics I, University Children's Hospital Heidelberg, Heidelberg, Germany
| | - Michael Cheung
- Kidney Disease: Improving Global Outcomes (KDIGO), Brussels, Belgium
| | - Michel Jadoul
- Cliniques Universitaires Saint Luc, Université Catholique de Louvain, Brussels, Belgium
| | - Wolfgang C Winkelmayer
- Selzman Institute for Kidney Health, Section of Nephrology, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Martin Zeier
- Division of Nephrology, University of Heidelberg, Heidelberg, Germany.
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Zhang M, Ma J, Xie F, Thabane L. Identifying factors associated with high use of acute care in Canada: a population-based retrospective study. THE EUROPEAN JOURNAL OF HEALTH ECONOMICS : HEPAC : HEALTH ECONOMICS IN PREVENTION AND CARE 2023; 24:1505-1515. [PMID: 36595151 DOI: 10.1007/s10198-022-01558-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Accepted: 12/12/2022] [Indexed: 06/17/2023]
Abstract
OBJECTIVES To determine demographic, socioeconomic, and clinical factors associated with being high-cost users (HCUs) in adult patients (≥ 18 years) who received acute care in Canada. RESEARCH DESIGN We conducted a retrospective study among adults who had at least one encounter with acute care facilities each year from 2011 to 2014 using national linked data sets. We defined HCUs as patients on the top 10% of the highest acute care cost users in the province, where the care was provided. Risk factors associated with being HCUs were identified using multilevel logistic regression. Provincial variations of identified risk factors were examined using logistic regression. Sensitivity analyses were also performed to investigate the influences of using different metrics and different thresholds to define high system users, missing data, and the inclusion of interaction terms on the study results. RESULTS Between 2011 and 2014, a total of 3,891,410 patients with 6,017,430 hospitalizations were included. Patients who were male [odds ratio (OR), 1.60; 95% confidence interval (CI) 1.59-1.61], with low incomes [OR 1.42; 95% CI 1.41-1.43), with higher comorbidity score (OR 1.41; 95% CI 1.40-1.41] and older [OR 1.18; 95% CI 1.17-1.18] were more likely to be acute care HCUs. Significant interactions existed between comorbidity score and age/sex/income status. Across provinces, the associations between socioeconomic factors and being HCUs has the largest variation. When using various high system users (HSUs) definitions, the impacts of living in rural area and being visible minority on the odds of being HSUs differ. CONCLUSIONS A few demographic, socioeconomic, and clinical factors was associated with high acute care expenditures. The associations between included risk factors and being acute care HCUs vary across provinces and different definitions of high system users (HSUs).
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Affiliation(s)
- Mengmeng Zhang
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, L8S 4K1, Canada
| | - Jinhui Ma
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, L8S 4K1, Canada
| | - Feng Xie
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, L8S 4K1, Canada
- Centre for Health Economics and Policy Analysis (CHEPA), McMaster University, Hamilton, ON, L8S 4K1, Canada
| | - Lehana Thabane
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, L8S 4K1, Canada.
- Biostatistics Unit/FSORC, Saint Joseph's Healthcare Hamilton, Hamilton, ON, L8N 4A6, Canada.
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Prabhudesai D, Davis J, Chen JJ, Lim E. Potentially preventable hospitalizations and super-utilization of inpatient services among patients with chronic kidney disease in Hawai'i. BMC Nephrol 2022; 23:409. [PMID: 36564749 PMCID: PMC9789655 DOI: 10.1186/s12882-022-03048-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Accepted: 12/20/2022] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Chronic kidney disease (CKD) is linked to high morbidity and mortality and increased hospitalization burden. If appropriately managed in the outpatient setting, ambulatory care-sensitive conditions (ACSCs) do not lead to hospitalization. Hospitalizations due to ACSCs are considered as potentially preventable hospitalizations. Patients with recurrent hospitalizations are considered as super-utilizers of inpatient services. The aim of this study is to determine prevalence of potentially preventable hospitalizations and super-utilization of inpatient services among patients with CKD in Hawai'i. METHODS Hawai'i statewide inpatient data (2015-2017) were used to identify adult CKD patients with hospitalizations during a 12-month period from the first recorded date of CKD. The associations between the potentially preventable hospitalizations and super-utilization and other key patient demographic and clinical variables (sex, age, ethnicity, insurance type, Charlson comorbidity index (CCI), county of residence, and homelessness indicator) were analyzed using bivariate analysis. Multivariable logistic regression was utilized to assess the associations between the potentially preventable hospitalizations and patient variables. RESULTS Approximately 2% of patients reported potentially preventable hospitalizations, and a total of 12.3% patients reported super-utilization. Out of all CKD-specific ACSC hospitalizations, 74.2% were due to heart failure and 25.8% were due to hyperkalemia. Patients who reported super-utilization were more likely to report potentially preventable hospitalization (OR: 5.98, 95%CI: 4.50-7.93) than patients who did not report super-utilization. CONCLUSION This study showed prevalence of potentially preventable hospitalizations and high inpatient utilization among CKD patients in Hawai'i. Heart failure and hyperkalemia were the two major causes of CKD-specific ACSC hospitalizations in this cohort. Effective strategies should be employed to improve the outpatient CKD management to reduce hospitalizations and in turn reduce cost.
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Affiliation(s)
- Devashri Prabhudesai
- grid.410445.00000 0001 2188 0957Department of Quantitative Health Sciences, John A. Burns School of Medicine, University of Hawaii, Honolulu, HI USA
| | - James Davis
- grid.410445.00000 0001 2188 0957Department of Quantitative Health Sciences, John A. Burns School of Medicine, University of Hawaii, Honolulu, HI USA
| | - John J. Chen
- grid.410445.00000 0001 2188 0957Department of Quantitative Health Sciences, John A. Burns School of Medicine, University of Hawaii, Honolulu, HI USA
| | - Eunjung Lim
- grid.410445.00000 0001 2188 0957Department of Quantitative Health Sciences, John A. Burns School of Medicine, University of Hawaii, Honolulu, HI USA
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Watson KE, Dhaliwal K, Robertshaw S, Verdin N, Benterud E, Lamont N, Drall KM, McBrien K, Donald M, Tsuyuki RT, Campbell DJT, Pannu N, James MT. Consensus Recommendations for Sick Day Medication Guidance for People With Diabetes, Kidney, or Cardiovascular Disease: A Modified Delphi Process. Am J Kidney Dis 2022; 81:564-574. [PMID: 36470530 DOI: 10.1053/j.ajkd.2022.10.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Accepted: 10/12/2022] [Indexed: 12/07/2022]
Abstract
RATIONALE & OBJECTIVE Sick day medication guidance (SDMG) involves withholding or adjusting specific medications in the setting of acute illnesses that could contribute to complications such as hypotension, acute kidney injury (AKI), or hypoglycemia. We sought to achieve consensus among clinical experts on recommendations for SDMG that could be studied in future intervention studies. STUDY DESIGN A modified Delphi process following guidelines for conducting and reporting Delphi studies. SETTING & PARTICIPANTS An international group of clinicians with expertise relevant to SDMG was recruited through purposive and snowball sampling. A scoping review of the literature was presented, followed by 3 sequential rounds of development, refinement, and voting on recommendations. Meetings were held virtually and structured to allow the participants to provide their input and rapidly prioritize and refine ideas. OUTCOME Opinions of participants were measured as the percentage who agreed with each recommendation, whereas consensus was defined as >75% agreement. ANALYTICAL APPROACH Quantitative data were summarized using counts and percentages. A qualitative content analysis was performed to capture the context of the discussion around recommendations and any additional considerations brought forward by participants. RESULTS The final panel included 26 clinician participants from 4 countries and 10 clinical disciplines. Participants reached a consensus on 42 specific recommendations: 5 regarding the signs and symptoms accompanying volume depletion that should trigger SDMG; 6 regarding signs that should prompt urgent contact with a health care provider (including a reduced level of consciousness, severe vomiting, low blood pressure, presence of ketones, tachycardia, and fever); and 14 related to scenarios and strategies for patient self-management (including frequent glucose monitoring, checking ketones, fluid intake, and consumption of food to prevent hypoglycemia). There was consensus that renin-angiotensin system inhibitors, diuretics, nonsteroidal anti-inflammatory drugs, sodium/glucose cotransporter 2 inhibitors, and metformin should be temporarily stopped. Participants recommended that insulin, sulfonylureas, and meglitinides be held only if blood glucose was low and that basal and bolus insulin be increased by 10%-20% if blood glucose was elevated. There was consensus on 6 recommendations related to the resumption of medications within 24-48 hours of the resolution of symptoms and the presence of normal patterns of eating and drinking. LIMITATIONS Participants were from high-income countries, predominantly Canada. Findings may not be generalizable to implementation in other settings. CONCLUSIONS A multidisciplinary panel of clinicians reached a consensus on recommendations for SDMG in the presence of signs and symptoms of volume depletion, as well as self-management strategies and medication instructions in this setting. These recommendations may inform the design of future trials of SDMG strategies.
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Affiliation(s)
- Kaitlyn E Watson
- EPICORE Centre, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Kirnvir Dhaliwal
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Sandra Robertshaw
- Patient partner, Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Nancy Verdin
- Patient partner, Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Eleanor Benterud
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Nicole Lamont
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Kelsea M Drall
- Division of Nephrology, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Kerry McBrien
- Department of Family 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
| | - Maoliosa Donald
- Department of Family 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; Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Ross T Tsuyuki
- EPICORE Centre, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - David J T Campbell
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada; Department of Cardiac Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada; Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Neesh Pannu
- Department of Medicine, and Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Matthew T James
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada; Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.
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Chong C, Campbell D, Elliott M, Aghajafari F, Ronksley P. Determining the Association Between Continuity of Primary Care and Acute Care Use in Chronic Kidney Disease: A Retrospective Cohort Study. Ann Fam Med 2022; 20:237-245. [PMID: 35606125 PMCID: PMC9199056 DOI: 10.1370/afm.2813] [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: 07/05/2021] [Revised: 11/18/2021] [Accepted: 11/23/2021] [Indexed: 11/09/2022] Open
Abstract
PURPOSE Acute care use is high among individuals with chronic kidney disease (CKD). It is unclear how relational continuity of primary care influences downstream acute care use. We aimed to determine if poor continuity of care is associated with greater rates of acute care use and decreased prescriptions for guideline-recommended drugs. METHODS We conducted a population-based retrospective cohort study of adults with stage 3-4 CKD and ≥3 visits to a primary care clinician during the period April 1, 2011 to March 31, 2014 in Alberta, Canada. Continuity was calculated using the Usual Provider Continuity index. Descriptive statistics were used to summarize patient and acute care encounter characteristics. Adjusted rates and incidence rate ratios for all-cause and CKD-related ambulatory care-sensitive condition (ACSC) hospitalizations and emergency department (ED) visits were estimated using negative binomial regression. Adjusted odds ratios for prescription use were estimated by multivariable logistic regression. RESULTS Among 86,475 patients with CKD, 51.3%, 30.0%, and 18.7% had high, moderate, and poor continuity of care, respectively. There were 77,988 all-cause hospitalizations, 6,489 ACSC-related hospitalizations, 204,615 all-cause ED visits, and 8,461 ACSC-related ED visits during a median follow-up of 2.3 years. Rates of all-cause and ACSC hospitalization and ED use increased with poorer continuity of care in a stepwise fashion across CKD stages. Patients with poor continuity were less likely to be prescribed a statin. CONCLUSIONS Poor continuity of care is associated with increased acute care use among patients with CKD. Targeted strategies that strengthen patient-physician relationships and guide physicians regarding guideline-recommended prescribing are needed.
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Affiliation(s)
- Christy Chong
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.,Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - David Campbell
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.,Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.,Department of Cardiac Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Meghan Elliott
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.,Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Fariba Aghajafari
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.,Department of Family Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Paul Ronksley
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
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Golestaneh L, Melamed M, Kim RS, St Clair Russell J, Heisler M, Villalba L, Perry T, Cavanaugh KL. Peer mentorship to improve outcomes in patients on hemodialysis (PEER-HD): a randomized controlled trial protocol. BMC Nephrol 2022; 23:92. [PMID: 35247960 PMCID: PMC8897762 DOI: 10.1186/s12882-022-02701-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Accepted: 02/12/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Patients receiving in-center hemodialysis experience disproportionate morbidity and incur high healthcare-related costs. Much of this cost stems from potentially avoidable hospitalizations. Peer mentorship has been used effectively to improve outcomes for patients with complex chronic diseases. We propose testing the efficacy of peer mentorship on hospitalization rates among patients receiving hemodialysis. METHODS This is a multicenter parallel group randomized controlled pragmatic trial of patients treated at hemodialysis facilities in Bronx, NY and Nashville, TN. The study has two phases. Phase 1 will enroll and train 16 hemodialysis patients (10 in Bronx, NY and 6 in Nashville TN) to be mentors using a program focused on enhancing self-efficacy, dialysis self-management and autonomy-supportive communication skills. Phase 2 will enroll 200 high risk adults receiving hemodialysis (140 in Bronx, NY and 60 in Nashville, TN), half of whom will be randomized to intervention and half to usual care. Intervention participants are assigned to weekly telephone calls with trained mentors (see Phase 1) for a 3-month period. The primary outcome of Phase 1 will be engagement of mentors with training and change in knowledge scores and autonomy skills from pre- to post-training. The primary outcome of Phase 2 will be the composite count of ED visits and hospitalizations at the end of study follow-up in patient participants assigned to intervention as compared to those assigned to usual care. Secondary outcomes for Phase 2 include the change over the trial period in validated survey scores measuring perception of social support and self-efficacy, and dialysis adherence metrics, among intervention participants as compared to usual care participants. DISCUSSION The PEER-HD study will test the feasibility and efficacy of a pragmatic peer-mentorship program designed for patients receiving hemodialysis on ED visit and hospitalization rates. If effective, peer-mentorship holds promise as a scalable patient-centered intervention to decrease hospital resource utilization, and by extension morbidity and cost, for patients receiving maintenance in-center hemodialysis. TRIAL REGISTRATION Clinicaltrials.gov identifier: NCT03595748 ; 7/23/2018. TRIAL SPONSOR National Institutes of Diabetes, Digestive and Kidney Disease (NIDDK) 5R18DK118471. FUNDING Funding for this study was provided by the National Institutes of Diabetes, Digestive and Kidney Disease: R18DK118471. STUDY STATUS This is an ongoing study and not complete. We are still collecting data for observational follow-up on participants. RELATED ARTICLES No related articles for this study have been submitted to any journal. The study sponsor and funders had no role in the design, analysis or interpretation of this data. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.
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Affiliation(s)
- Ladan Golestaneh
- Department of Medicine, Division of Nephrology, Albert Einstein College of Medicine/ Montefiore Medical Center, Bronx, NY, 10467, USA.
| | - Michal Melamed
- Department of Medicine, Division of Nephrology, Albert Einstein College of Medicine/ Montefiore Medical Center, Bronx, NY, 10467, USA
- Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, NY, 10461, USA
| | - Ryung S Kim
- Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, NY, 10461, USA
| | - Jennifer St Clair Russell
- Department of Medicine, Division of General Internal Medicine, Duke University, Durham, NC, 27701, USA
| | - Michele Heisler
- Department of Medicine, Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, 48109, USA
| | - Lisandra Villalba
- Department of Medicine, Division of Nephrology, Albert Einstein College of Medicine/ Montefiore Medical Center, Bronx, NY, 10467, USA
| | - Taylor Perry
- Department of Nephrology and Hypertension, Vanderbilt University Medical Center, Nashville, TN, 37232, USA
| | - Kerri L Cavanaugh
- Department of Nephrology and Hypertension, Vanderbilt University Medical Center, Nashville, TN, 37232, USA
- Vanderbilt Center for Effective Health Communication, Vanderbilt University Medical Center, Nashville, TN, 37232, USA
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9
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Long-Term Outpatient Care and Rehospitalizations in Patients after Cardiac Electrotherapy Device Implantation. Medicina (B Aires) 2022; 58:medicina58020151. [PMID: 35208475 PMCID: PMC8879931 DOI: 10.3390/medicina58020151] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Revised: 01/14/2022] [Accepted: 01/17/2022] [Indexed: 12/13/2022] Open
Abstract
Background and Objectives: Cardiovascular implantable electronic device (CIED) treatment is widely used in modern cardiology. Indications for this type of treatment are increasing. However, a significant proportion of CIED implantation patients require subsequent hospitalization for cardiovascular reasons. Older age and the associated complex clinical picture necessitate multidisciplinary outpatient specialist care for these patients. The aim of this study was to analyze the reasons for subsequent hospitalizations in the cardiology department and the impact of outpatient specialty care on these hospitalizations. To the best of our knowledge, there are no such studies in the available literature. Materials and Methods: This study was conducted on a population of patients treated with CIED. Reasons for subsequent hospitalizations were divided into clinically and statistically valid groups according to the main diagnosis. Using an electronic database, causes of hospitalization were determined based on this diagnosis. Using data on consultations at outpatient specialty clinics, a logistic regression model was created for the probability of subsequent hospitalization for cardiovascular causes according to the specialty of the clinic. Results: The 9-year follow-up included a population of 2071 patients treated with CIED. During the follow-up period, 508 patients (approximately 24.5%) required subsequent hospitalization for cardiovascular reasons. The most common leading causes were heart failure, atrial fibrillation, and coronary artery disease. The need for consultation at outpatient specialty clinics increased the likelihood of hospitalization. Moreover, the need to consult patients in nephrology outpatient, pulmonary disease outpatient, and orthopedic outpatient clinics was the most significant. Conclusions: The use of electronic implantable cardiovascular devices is a very important part of therapy in modern cardiology. The methods for their use are constantly being improved. However, they represent only one stage of cardiac treatment. After CIED procedures, patients require further care in both inpatient and outpatient specialty care settings. In this paper, we outline the reasons for subsequent hospitalizations and the importance of outpatient specialty care in this context. Effective organization of care after CIED procedures may be important in reducing the most expensive component of this care, that is, inpatient treatment.
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10
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Chong C, Wick J, Klarenbach S, Manns B, Hemmelgarn B, Ronksley P. Cost of Potentially Preventable Hospitalizations Among Adults With Chronic Kidney Disease: A Population-Based Cohort Study. Can J Kidney Health Dis 2021; 8:20543581211018528. [PMID: 34158964 PMCID: PMC8182215 DOI: 10.1177/20543581211018528] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Accepted: 04/13/2021] [Indexed: 01/02/2023] Open
Abstract
BACKGROUND Prior studies report high hospitalization rates among patients with chronic kidney disease (CKD) and approximately 10% to 20.9% of hospitalizations are potentially preventable. OBJECTIVE To determine the rate, proportion, and cost of potentially preventable hospitalizations and whether this varied by CKD category. DESIGN Retrospective cohort study using population-based data. SETTING Alberta, Canada. PATIENTS All adults with an outpatient serum creatinine measurement between January 1 and December 31, 2017 in the Alberta Kidney Disease Network data repository. MEASUREMENTS CKD risk categories were based on measures of proteinuria (where available), eGFR, and use of dialysis. Patients were linked to administrative data to capture frequency and cost of hospital encounters and followed until death or end of study (December 31, 2018). The outcomes of interest were the rate and cost of potentially preventable hospitalizations, as identified using the Canadian Institute for Health Information (CIHI)-defined ambulatory care sensitive condition (ACSC) algorithm and a CKD-related ACSC algorithm. METHODS Unadjusted and adjusted rates per 1000-patient years, proportions, and cost attributable to preventable hospitalizations were identified for the cohort as a whole and for patients within each CKD risk category. RESULTS Of the 1,110,895 adults with eGFR and proteinuria measurements, 181,422 had CKD. During a median follow-up of 1 year, there were 62,023 hospitalizations among patients with CKD resulting in a total cost of $946 million CAD; 6907 (11.1%) of these hospitalizations were for CIHI-defined ACSCs while 4323 (7.0%) were for CKD-related ACSCs. Adjusted rates of hospitalization for ACSCs increased with CKD risk category and were highest among patients treated with dialysis. Among CKD patients, the total cost of potentially preventable hospitalizations was $79 million and $58 million CAD for CIHI-defined and CKD-related ACSCs (8.4% and 6.2% of total hospitalization cost, respectively). LIMITATIONS Based on the ACSC construct, we were unable to determine if these hospitalizations were truly preventable. CONCLUSIONS Potentially preventable hospitalizations have a substantial cost and burden on the health care system among people with CKD. Effective strategies that reduce preventable admissions among CKD patients may lead to significant cost savings. TRIAL REGISTRATION Not applicable-observational study design.
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Affiliation(s)
- Christy Chong
- Department of Community Health
Sciences, Cumming School of Medicine, University of Calgary, AB, Canada
| | - James Wick
- Department of Medicine, Cumming School
of Medicine, University of Calgary, AB, Canada
| | - Scott Klarenbach
- Faculty of Medicine and Dentistry,
University of Alberta, Edmonton, Canada
| | - Braden Manns
- 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
| | - Brenda Hemmelgarn
- Faculty of Medicine and Dentistry,
University of Alberta, Edmonton, Canada
| | - Paul Ronksley
- Department of Community Health
Sciences, Cumming School of Medicine, University of Calgary, AB, Canada
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11
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Srivastava A, Cai X, Mehta R, Lee J, Chu DI, Mills KT, Shafi T, Taliercio JJ, Hsu JY, Schrauben SJ, Saunders MR, Diamantidis CJ, Hsu CY, Waikar SS, Lash JP, Isakova T. Hospitalization Trajectories and Risks of ESKD and Death in Individuals With CKD. Kidney Int Rep 2021; 6:1592-1602. [PMID: 34169199 PMCID: PMC8207467 DOI: 10.1016/j.ekir.2021.03.883] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Revised: 02/10/2021] [Accepted: 03/08/2021] [Indexed: 01/13/2023] Open
Abstract
INTRODUCTION Management of chronic kidney disease (CKD) entails high medical complexity and often results in high hospitalization burden. There are limited data on the associations of longitudinal hospital utilization patterns with adverse clinical outcomes in individuals with CKD. METHODS We derived cumulative all-cause hospitalization trajectory groups using latent class trajectory analysis in 3012 participants of the Chronic Renal Insufficiency Cohort (CRIC) Study who were alive and did not reach end-stage kidney disease (ESKD) within 4 years of study entry. Cox proportional hazards models tested the associations between hospitalization trajectory groups and risks of ESKD and death prior to the onset of ESKD (ESKD-censored death). RESULTS Within 4 years of study entry, there were 5658 hospitalizations among 3012 participants. We identified 3 distinct subgroups of individuals with CKD based on cumulative all-cause hospitalization trajectories over 4 years: low-utilizer (n = 1066), intermediate-utilizer (n = 1802), and high-utilizer (n = 144). High-utilizers represented a patient population of lower socioeconomic status who had a greater prevalence of comorbid conditions and lower kidney function compared with intermediate- and low-utilizers. After the 4-year ascertainment period to form the trajectory subgroups, there were 544 ESKD events and 437 ESKD-censored deaths during a median follow-up time of 5.1 years. Compared with low-utilizers, intermediate-utilizers and high-utilizers were at 1.49-fold (95% confidence interval [CI] 1.22-1.84) and 1.75-fold (95% CI 1.20-2.56) higher risk of ESKD in adjusted analyses, respectively. Compared with low-utilizers, intermediate-utilizers and high-utilizers were at 1.48-fold (95% CI 1.17-1.87) and 2.58-fold (95% CI 1.74-3.83) higher risk of ESKD-censored death in adjusted analyses, respectively. CONCLUSIONS Trajectories of cumulative all-cause hospitalization identify subgroups of individuals with CKD who are at high risk of ESKD and death.
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Affiliation(s)
- Anand Srivastava
- Division of Nephrology and Hypertension, Center for Translational Metabolism and Health, Institute for Public Health and Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Xuan Cai
- Division of Nephrology and Hypertension, Center for Translational Metabolism and Health, Institute for Public Health and Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Rupal Mehta
- Division of Nephrology and Hypertension, Center for Translational Metabolism and Health, Institute for Public Health and Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Jungwha Lee
- Division of Biostatistics, Department of Preventative Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - David I. Chu
- Division of Urology, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois, USA
| | - Katherine T. Mills
- Department of Epidemiology, Tulane University School of Public Health and Tropical Medicine, and Tulane University Translational Science Institute, New Orleans, Louisiana, USA
| | - Tariq Shafi
- Department of Medicine, University of Mississippi Medical Center, Jackson, Mississippi, USA
| | - Jonathan J. Taliercio
- Department of Nephrology and Hypertension, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Jesse Y. Hsu
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Sarah J. Schrauben
- Division of Renal-Electrolyte and Hypertension, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Pennsylvania, USA
| | - Milda R. Saunders
- General Internal Medicine, Department of Medicine, University of Chicago, Chicago, Illinois, USA
| | - Clarissa J. Diamantidis
- Divisions of General Internal Medicine and Nephrology and Department of Population Health Science, Duke University School of Medicine, Durham, North Carolina, USA
| | - Chi-yuan Hsu
- Department of Medicine, University of California San Francisco School of Medicine, San Francisco, California, USA
| | - Sushrut S. Waikar
- Section of Nephrology, Boston University School of Medicine and Boston Medical Center, Boston, Massachusetts, USA
| | - James P. Lash
- Division of Nephrology, Department of Medicine, University of Illinois Hospital and Health Sciences Center, University of Illinois College of Medicine, Chicago, Illinois, USA
| | - Tamara Isakova
- Division of Nephrology and Hypertension, Center for Translational Metabolism and Health, Institute for Public Health and Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
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12
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Schrauben SJ, Chen HY, Lin E, Jepson C, Yang W, Scialla JJ, Fischer MJ, Lash JP, Fink JC, Hamm LL, Kanthety R, Rahman M, Feldman HI, Anderson AH. Hospitalizations among adults with chronic kidney disease in the United States: A cohort study. PLoS Med 2020; 17:e1003470. [PMID: 33306688 PMCID: PMC7732055 DOI: 10.1371/journal.pmed.1003470] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2020] [Accepted: 11/05/2020] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND Adults with chronic kidney disease (CKD) are hospitalized more frequently than those without CKD, but the magnitude of this excess morbidity and the factors associated with hospitalizations are not well known. METHODS AND FINDINGS Data from 3,939 participants enrolled in the Chronic Renal Insufficiency Cohort (CRIC) Study between 2003 and 2008 at 7 clinical centers in the United States were used to estimate primary causes of hospitalizations, hospitalization rates, and baseline participant factors associated with all-cause, cardiovascular, and non-cardiovascular hospitalizations during a median follow up of 9.6 years. Multivariable-adjusted Poisson regression was used to identify factors associated with hospitalization rates, including demographics, blood pressure, estimated glomerular filtration rate (eGFR), and proteinuria. Hospitalization rates in CRIC were compared with rates in the Nationwide Inpatient Sample (NIS) from 2012. Of the 3,939 CRIC participants, 45.1% were female, and 41.9% identified as non-Hispanic black, with a mean age of 57.7 years, and the mean eGFR is 44.9 ml/min/1.73m2. CRIC participants had an unadjusted overall hospitalization rate of 35.0 per 100 person-years (PY) [95% CI: 34.3 to 35.6] and 11.1 per 100 PY [95% CI: 10.8 to 11.5] for cardiovascular-related causes. All-cause, non-cardiovascular, and cardiovascular hospitalizations were associated with older age (≥65 versus 45 to 64 years), more proteinuria (≥150 to <500 versus <150 mg/g), higher systolic blood pressure (≥140 versus 120 to <130 mmHg), diabetes (versus no diabetes), and lower eGFR (<60 versus ≥60 ml/min/1.73m2). Non-Hispanic black (versus non-Hispanic white) race/ethnicity was associated with higher risk for cardiovascular hospitalization [rate ratio (RR) 1.25, 95% CI: 1.16 to 1.35, p-value < 0.001], while risk among females was lower [RR 0.89, 95% CI: 0.83 to 0.96, p-value = 0.002]. Rates of cardiovascular hospitalizations were higher among those with ≥500 mg/g of proteinuria irrespective of eGFR. The most common causes of hospitalization were related to cardiovascular (31.8%), genitourinary (8.7%), digestive (8.3%), endocrine, nutritional or metabolic (8.3%), and respiratory (6.7%) causes. Hospitalization rates were higher in CRIC than the NIS, except for non-cardiovascular hospitalizations among individuals aged >65 years. Limitations of the study include possible misclassification by diagnostic codes, residual confounding, and potential bias from healthy volunteer effect due to its observational nature. CONCLUSIONS In this study, we observed that adults with CKD had a higher hospitalization rate than the general population that is hospitalized, and even moderate reductions in kidney function were associated with elevated rates of hospitalization. Causes of hospitalization were predominantly related to cardiovascular disease, but other causes contributed, particularly, genitourinary, digestive, and endocrine, nutritional, and metabolic illnesses. High levels of proteinuria were observed to have the largest association with hospitalizations across a wide range of kidney function levels.
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Affiliation(s)
- Sarah J. Schrauben
- Renal, Electrolyte-Hypertension Division, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, United States of America
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, United States of America
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, United States of America
| | - Hsiang-Yu Chen
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, United States of America
| | - Eugene Lin
- Department of Medicine, Division of Nephrology; Leonard D. Schaeffer Center for Health Policy & Economics, University of Southern California, Los Angeles, California, United States of America
| | - Christopher Jepson
- ECRI Institute, Plymouth Meeting, Pennsylvania, United States of America
| | - Wei Yang
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, United States of America
| | - Julia J. Scialla
- Department of Medicine, Division of Nephrology, University of Virginia School of Medicine, Charlotte, Virginia, United States of America
| | - Michael J. Fischer
- Medical Service, Jesse Brown Veterans Affairs Medical Center, Chicago, Illinois, United States of America
- Department of Medicine, University of Illinois at Chicago, Chicago, Illinois, United States of America
| | - James P. Lash
- Department of Medicine, University of Illinois at Chicago, Chicago, Illinois, United States of America
| | - Jeffrey C. Fink
- Department of Medicine, University of Maryland, Baltimore, Maryland, United States of America
| | - L. Lee Hamm
- Tulane University School of Medicine, New Orleans, Louisiana, United States of America
| | - Radhika Kanthety
- Department of Medicine, Case Western Reserve University, Cleveland, Ohio, United States of America
| | - Mahboob Rahman
- Division of Nephrology and Hypertension, University Hospitals Cleveland Medical Center, Case Western Reserve University, Louis Stokes Cleveland Veterans Affairs Medical Center, Cleveland, Ohio, United States of America
| | - Harold I. Feldman
- Renal, Electrolyte-Hypertension Division, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, United States of America
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, United States of America
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, United States of America
| | - Amanda H. Anderson
- Department of Epidemiology, School of Public Health and Tropical Medicine, Tulane University, New Orleans, Louisiana, United States of America
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13
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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.
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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
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14
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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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15
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Ramer SJ, Baddour NA, Siew ED, Salat H, Bian A, Stewart TG, Wong SPY, Jhamb M, Abdel-Kader K. Nephrology Provider Surprise Question Response and Hospitalizations in Older Adults with Advanced CKD. Am J Nephrol 2020; 51:641-649. [PMID: 32721980 PMCID: PMC7789871 DOI: 10.1159/000509046] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Accepted: 05/13/2020] [Indexed: 11/19/2022]
Abstract
BACKGROUND Older adults with advanced non-dialysis-dependent chronic kidney disease (NDD-CKD) face a high risk of hospitalization and related adverse events. METHODS This prospective cohort study followed nephrology clinic patients ≥60 years old with NDD-CKD stages 4-5. After an eligible patient's office visit, study staff asked the patient's provider to rate the patient's risk of death within the next year using the surprise question ("Would you be surprised if this patient died in the next 12 months?") with a 5-point Likert scale response (1, "definitely not surprised" to 5, "very surprised"). We used a statewide database to ascertain hospitalization during follow-up. RESULTS There were 488 patients (median age 72 years, 51% female, 17% black) with median estimated glomerular filtration rate 22 mL/min/1.73 m2. Over a median follow-up of 2.1 years, the rates of hospitalization per 100 person-years in the respective response groups were 41 (95% confidence interval [CI]: 34-50), "very surprised"; 65 (95% CI: 55-76), "surprised"; 98 (95% CI: 85-113), "neutral"; 125 (95% CI: 107-144), "not surprised"; and 120 (95% CI: 94-151), "definitely not surprised." In a fully adjusted cumulative probability ordinal regression model for proportion of follow-up time spent hospitalized, patients whose providers indicated that they would be "definitely not surprised" if they died spent a greater proportion of follow-up time hospitalized compared with those whose providers indicated that they would be "very surprised" (odds ratio 2.4, 95% CI: 1.0-5.7). There was a similar association for time to first hospitalization. CONCLUSION Nephrology providers' responses to the surprise question for older patients with advanced NDD-CKD were independently associated with proportion of future time spent hospitalized and time to first hospitalization. Additional studies should examine how to use this information to provide patients with anticipatory guidance on their possible clinical trajectory and to target potentially preventable hospitalizations.
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Affiliation(s)
- Sarah J Ramer
- Division of Geriatrics and Palliative Medicine, Department of Medicine, Weill Cornell Medical Center, New York, New York, USA
| | - Nicolas A Baddour
- Department of Medicine, University of Washington School of Medicine, Seattle, Washington, USA
| | - Edward D Siew
- Division of Nephrology and Hypertension, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Vanderbilt Center for Kidney Disease, Nashville, Tennessee, USA
| | - Huzaifah Salat
- Department of Medicine, St. Barnabas Hospital Health System, Bronx, New York, USA
| | - Aihua Bian
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Thomas G Stewart
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Susan P Y Wong
- Health Service Research and Development Center, Veterans Affairs Puget Sound Health Care System, Seattle, Washington, USA
- Division of Nephrology, Department of Medicine, University of Washington School of Medicine, Seattle, Washington, USA
| | - Manisha Jhamb
- Renal-Electrolyte Division, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Khaled Abdel-Kader
- Division of Nephrology and Hypertension, Vanderbilt University Medical Center, Nashville, Tennessee, USA,
- Vanderbilt Center for Kidney Disease, Nashville, Tennessee, USA,
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16
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Elliott MJ, Love S, Donald M, Manns B, Donald T, Premji Z, Hemmelgarn BR, Grinman M, Lang E, Ronksley PE. Outpatient Interventions for Managing Acute Complications of Chronic Diseases: A Scoping Review and Implications for Patients With CKD. Am J Kidney Dis 2020; 76:794-805. [PMID: 32479925 DOI: 10.1053/j.ajkd.2020.04.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2019] [Accepted: 04/02/2020] [Indexed: 11/11/2022]
Abstract
RATIONALE & OBJECTIVE Patients with chronic kidney disease (CKD) have high rates of emergency department (ED) use and hospitalization. Outpatient care may provide an alternative to ED and inpatient care in this population. We aimed to explore the scope of outpatient interventions used to manage acute complications of chronic diseases and highlight opportunities to adapt and test interventions in the CKD population. STUDY DESIGN Scoping review of quantitative and qualitative studies. SETTING & POPULATION Outpatient interventions for adults experiencing acute complications related to 1 of 5 eligible chronic diseases (ie, CKD, chronic respiratory disease, cardiovascular disease, cancer, and diabetes). SELECTION CRITERIA FOR STUDIES MEDLINE, EMBASE, CINAHL, Cochrane Central Register of Controlled Trials, grey literature, and conference abstracts were searched to December 2019. DATA EXTRACTION Intervention and study characteristics were extracted using standardized tools. ANALYTICAL APPROACH Quantitative data were summarized descriptively; qualitative data were summarized thematically. Our approach observed the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) extension for scoping reviews. RESULTS 77 studies (25 randomized controlled trials, 29 observational, 12 uncontrolled before-after, 5 quasi-experimental, 4 qualitative, and 2 mixed method) describing 57 unique interventions were included. Of identified intervention types (hospital at home [n = 16], observation unit [n = 9], ED-based specialist service [n = 4], ambulatory program [n = 18], and telemonitoring [n = 10]), most were studied in chronic respiratory and cardiovascular disease populations. None targeted the CKD population. Interventions were delivered in the home, ED, hospital, and ambulatory setting by a variety of health care providers. Cost savings were demonstrated for most interventions, although improvements in other outcome domains were not consistently observed. LIMITATIONS Heterogeneity of included studies; lack of data for outpatient interventions for acute complications related to CKD. CONCLUSIONS Several interventions for outpatient management of acute complications of chronic disease were identified. Although none was specific to the CKD population, features could be adapted and tested to address the complex acute-care needs of patients with CKD.
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Affiliation(s)
- Meghan J Elliott
- Department of Medicine, University of Calgary, Calgary, AB, Canada; Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada.
| | - Shannan Love
- Department of Medicine, University of Calgary, Calgary, AB, Canada
| | - Maoliosa Donald
- Department of Medicine, University of Calgary, Calgary, AB, Canada
| | - Bryn Manns
- Department of Medicine, University of Calgary, Calgary, AB, Canada
| | - Teagan Donald
- Department of Medicine, University of Calgary, Calgary, AB, Canada
| | - Zahra Premji
- Department of Libraries and Cultural Resources, University of Calgary, Calgary, AB, Canada
| | - Brenda R Hemmelgarn
- Department of Medicine, University of Calgary, Calgary, AB, Canada; Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada
| | - Michelle Grinman
- Department of Medicine, University of Calgary, Calgary, AB, Canada
| | - Eddy Lang
- Department of Emergency Medicine, University of Calgary, Calgary, AB, Canada
| | - Paul E Ronksley
- Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada
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Helmer DA, Dwibedi N, Rowneki M, Tseng CL, Fried D, Rose D, Jani N, Sambamoorthi U. Mental Health Conditions and Hospitalizations for Ambulatory Care Sensitive Conditions Among Veterans with Diabetes. AMERICAN HEALTH & DRUG BENEFITS 2020; 13:61-71. [PMID: 32724500 PMCID: PMC7370828] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Subscribe] [Scholar Register] [Received: 08/14/2019] [Accepted: 11/12/2019] [Indexed: 06/11/2023]
Abstract
BACKGROUND Veterans with diabetes and mental health conditions have a higher risk for suboptimal care and complications related to their diseases than veterans with diabetes who do not have mental health conditions. We hypothesized that among veterans with diabetes, patients with mental health conditions are more likely to be hospitalized for ambulatory care sensitive conditions (ACSC) than those without mental health conditions. OBJECTIVES To examine the association between depression, anxiety, and serious mental illness and hospitalizations for ACSC among veterans with diabetes after controlling for demographics and comorbidities. METHODS We used a retrospective cohort design with merged Veterans Health Administration (VHA) and Medicare electronic health records from 2008 to 2010. Andersen's Behavioral Model of Health Services Use was used to select the variables associated with hospitalizations for ACSC (ie, predisposing, enabling and need characteristics, personal health practices, and external environment). We used chi-square tests and logistic regressions for our analyses. RESULTS Among the dual VHA/Medicare-enrolled veterans with any hospitalization in 2010, 30% had hospitalizations for ACSC. Veterans with diabetes and co-occurring depression were at increased likelihood to be hospitalized for ACSC, after adjusting for all other covariates (adjusted odds ratio, 1.08; 95% confidence interval, 1.04-1.11). Similar findings were observed for anxiety. Veterans with serious mental illness were as likely as veterans without serious mental illness to be hospitalized for ACSC. CONCLUSION Veterans with depression and anxiety were more likely to be hospitalized for any or acute ACSC than veterans without mental health conditions. Patients hospitalized for acute ACSC were more susceptible than patients hospitalized for chronic ACSC to have mental health conditions. As the VHA continues to evolve from care provider to community care payer (per the Veterans Affairs MISSION Act), our results highlight the ongoing importance of care coordination and communication between payers and providers.
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Affiliation(s)
- Drew A Helmer
- Director, War Related Illness and Injury Study Center (WRIISC), Veterans Affairs (VA) New Jersey Healthcare System, East Orange
| | - Nilanjana Dwibedi
- Assistant Professor, Department of Pharmaceutical Systems and Policy, West Virginia University School of Pharmacy, Morgantown
| | - Mazhgan Rowneki
- Health Services Data Analyst, WRIISC, VA New Jersey Healthcare System
| | - Chin-Lin Tseng
- Health Services Scientist, WRIISC, VA New Jersey Healthcare System
| | - Dennis Fried
- Epidemiologist, WRIISC, VA New Jersey Healthcare System
| | - Danielle Rose
- Health Research Scientist, Veteran Affairs Greater Los Angeles Healthcare System, Sepulveda, CA
| | - Nisha Jani
- Epidemiologist, WRIISC, VA New Jersey Healthcare System
| | - Usha Sambamoorthi
- Professor, Department of Pharmaceutical Systems and Policy, West Virginia University School of Pharmacy
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18
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Triozzi JL, Niu J, Walther CP, Winkelmayer WC, Navaneethan SD. [Hospitalization and Critical Illness in Chronic Kidney Disease]. Cardiorenal Med 2020; 10:302-312. [PMID: 32316008 DOI: 10.1159/000507047] [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: 01/13/2020] [Accepted: 03/05/2020] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Patients with chronic kidney disease (CKD) who are hospitalized with a critical illness are at increased risk for adverse outcomes. We studied the predictors of hospitalization with critical illness among patients with non-dialysis-dependent CKD stages 3 and 4 in a safety-net healthcare setting. METHODS A retrospective cohort study was conducted among patients ≥18 years of age with CKD stages 3 and 4 using a CKD registry from a safety-net healthcare system. Hospitalizations with critical illness were identified among patients requiring nonelective admission or transfer to the intermediate or intensive care unit during a 3-year period after the diagnosis of CKD. Poisson regression was used to determine associations between baseline characteristics and hospitalization requiring intermediate or intensive care among all CKD patients and in those with different stages of CKD. Outcomes of these hospitalizations were also tabulated. RESULTS Among 8,302 patients with CKD stages 3 and 4, 1,298 were hospitalized and 495 required intermediate or intensive care during a 3-year follow-up period. In the adjusted analysis, advanced CKD, Hispanics (incident rate ratio [IRR]: 1.88), non-Hispanic Blacks (IRR: 1.48), presence of congestive heart failure (IRR: 2.09), cardiovascular disease (IRR: 1.57), chronic pulmonary disease (IRR: 1.60), liver disease, malignancy, and anemia were associated with higher risk of hospitalization requiring intermediate or intensive care. The association of age, gender, race/ethnicity, congestive heart failure, anemia, and body mass index with hospitalization requiring intermediate or intensive care differed significantly by CKD stage (p value for interaction term <0.05). Congestive heart failure and severity of anemia were associated with a higher risk of hospitalization requiring intermediate or intensive care among patients with mild CKD, and the magnitude of association attenuated among patients with advanced CKD. CONCLUSIONS The burden of hospitalization with critical illness among patients with non-dialysis-dependent CKD stages 3 and 4 remains high and was associated with demographic factors and comorbid medical conditions, especially among those with congestive heart failure and cardiovascular disease. Targeted, effective interventions to reduce the burden of hospitalization and critical illness in CKD patients within safety-net healthcare systems are needed.
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Affiliation(s)
| | - Jingbo Niu
- Selzman Institute for Kidney Health, Section of Nephrology, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Carl P Walther
- Selzman Institute for Kidney Health, Section of Nephrology, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Wolfgang C Winkelmayer
- Selzman Institute for Kidney Health, Section of Nephrology, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Sankar D Navaneethan
- Selzman Institute for Kidney Health, Section of Nephrology, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA, .,Section of Nephrology, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas, USA, .,Institute of Clinical and Translational Research, Baylor College of Medicine, Houston, Texas, USA,
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19
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Silver SA, Bota SE, McArthur E, Clemens KK, Harel Z, Naylor KL, Sood MM, Garg AX, Wald R. Association of Primary Care Involvement with Death or Hospitalizations for Patients Starting Dialysis. Clin J Am Soc Nephrol 2020; 15:521-529. [PMID: 32139363 PMCID: PMC7133142 DOI: 10.2215/cjn.10890919] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2019] [Accepted: 01/22/2020] [Indexed: 12/19/2022]
Abstract
BACKGROUND AND OBJECTIVES It is uncertain whether primary care physician continuity of care associates with a lower risk of death and hospitalization among patients transitioning to maintenance dialysis. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS Using provincial-linked administrative databases in Ontario, Canada, we conducted a population-based study of incident patients who initiated maintenance dialysis between 2005 and 2014 and survived for at least 90 days. We defined high primary care physician continuity as both a high usual provider of care index (where >75% of primary care physician visits occurred with the same primary care physician) in the 2 years before dialysis (an established measure of primary care physician continuity) and at least one visit with the same primary care physician in the 90 days after dialysis initiation. We used propensity scores to match a group of patients with high and low continuity so that indicators of baseline health were similar. The primary outcome was all-cause mortality, and secondary outcomes included all-cause and disease-specific hospitalizations during the 2 years after maintenance dialysis initiation. RESULTS We identified 19,099 eligible patients. There were 6612 patients with high primary care physician continuity, of whom 6391 (97%) were matched to 6391 patients with low primary care physician continuity. High primary care physician continuity was not associated with a lower risk of mortality (14.5 deaths per 100 person-years versus 15.2 deaths per 100 person-years; hazard ratio, 0.96; 95% confidence interval, 0.89 to 1.02). There was no difference in the rate of all-cause hospitalizations (hazard ratio, 0.96; 95% confidence interval, 0.92 to 1.01), and high primary care physician continuity was not associated with a lower risk of any disease-specific hospitalization, except for those related to diabetes (hazard ratio, 0.88; 95% confidence interval, 0.80 to 0.97). CONCLUSIONS High primary care physician continuity before and during the transition to maintenance dialysis was not associated with a lower risk of mortality or all-cause hospitalization.
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Affiliation(s)
- Samuel A Silver
- Division of Nephrology, Kingston Health Sciences Center, Queen's University, Kingston, Ontario, Canada; .,ICES, Toronto, Ontario, Canada
| | | | | | - Kristin K Clemens
- ICES, Toronto, Ontario, Canada.,Division of Endocrinology and Metabolism and Department of Epidemiology and Biostatistics and
| | - Ziv Harel
- ICES, Toronto, Ontario, Canada.,Division of Nephrology and Li Ka Shing Knowledge Institute, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada; and
| | | | - Manish M Sood
- ICES, Toronto, Ontario, Canada.,Department of Medicine and Clinical Epidemiology Program of the Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - Amit X Garg
- ICES, Toronto, Ontario, Canada.,Division of Nephrology, London Health Sciences Centre, Western University, London, Ontario, Canada
| | - Ron Wald
- ICES, Toronto, Ontario, Canada.,Division of Nephrology and Li Ka Shing Knowledge Institute, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada; and
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20
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Moita B, Marques AP, Camacho AM, Leão Neves P, Santana R. One-year rehospitalisations for congestive heart failure in Portuguese NHS hospitals: a multilevel approach on patterns of use and contributing factors. BMJ Open 2019; 9:e031346. [PMID: 31481570 PMCID: PMC6731885 DOI: 10.1136/bmjopen-2019-031346] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
OBJECTIVES Identification of rehospitalisations for heart failure and contributing factors flags health policy intervention opportunities designed to deliver care at a most effective and efficient level. Recognising that heart failure is a condition for which timely and appropriate outpatient care can potentially prevent the use of inpatient services, we aimed to determine to what extent comorbidities and material deprivation were predictive of 1 year heart failure specific rehospitalisation. SETTING All Portuguese mainland National Health Service (NHS) hospitals. PARTICIPANTS A total of 68 565 hospitalisations for heart failure principal cause of admission, from 2011 to 2015, associated to 45 882 distinct patients aged 18 years old or over. OUTCOME MEASURES We defined 1 year specific heart failure rehospitalisation and time to rehospitalisation as outcome measures. RESULTS Heart failure principal diagnosis admissions accounted for 1.6% of total hospital NHS budget, and over 40% of this burden is associated to patients rehospitalised at least once in the 365-day follow-up period. 22.1% of the patients hospitalised for a principal diagnosis of heart failure were rehospitalised for the same cause at least once within 365 days after previous discharge. Nearly 55% of rehospitalised patients were readmitted within 3 months. Results suggest a mediation effect between material deprivation and the chance of 1 year rehospitalisation through the effect that material deprivation has on the prevalence of comorbidities. Heart failure combined with chronic kidney disease or chronic obstructive pulmonary disease increases by 2.8 and 2.2 times, respectively, the chance of the patient becoming a frequent user of inpatient services for heart failure principal cause of admission. CONCLUSIONS One-fifth of patients admitted for heart failure are rehospitalised due to heart failure exacerbation. While the role of material deprivation remained unclear, comorbidities considered increased the chance of 1 year heart failure specific rehospitalisation, in particular, chronic kidney disease and chronic obstructive pulmonary disease.
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Affiliation(s)
- Bruno Moita
- Escola Nacional de Saúde Pública, Universidade Nova de Lisboa, Lisboa, Portugal
- Centro Hospitalar Universitário do Algarve, Faro, Portugal
| | - Ana Patricia Marques
- Departamento de Políticas e Gestão dos Sistemas de Saúde, Escola Nacional de Saúde Pública, Universidade Nova de Lisboa, Lisboa, Portugal
- Centro de Investigação em Saúde Pública, Universidade Nova de Lisboa, Lisboa, Portugal
| | | | - Pedro Leão Neves
- Centro Hospitalar Universitário do Algarve, Faro, Portugal
- Departamento de Ciências Biomédicas e Medicina, Universidade do Algarve, Faro, Portugal
| | - Rui Santana
- Departamento de Políticas e Gestão dos Sistemas de Saúde, Escola Nacional de Saúde Pública, Universidade Nova de Lisboa, Lisboa, Portugal
- Centro de Investigação em Saúde Pública, Universidade Nova de Lisboa, Lisboa, Portugal
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21
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Wong E, Ballew SH, Daya N, Ishigami J, Rebholz CM, Matsushita K, Grams ME, Coresh J. Hospitalization Risk among Older Adults with Chronic Kidney Disease. Am J Nephrol 2019; 50:212-220. [PMID: 31311014 PMCID: PMC6726535 DOI: 10.1159/000501539] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2019] [Accepted: 06/14/2019] [Indexed: 01/05/2023]
Abstract
INTRODUCTION Chronic kidney disease (CKD) risk staging is based on estimated glomerular filtration rate (eGFR) and albumin-creatinine ratio (ACR). However, the relationship between all-cause hospitalization risk and the current CKD staging system has not been well studied among older adults, despite a high prevalence of CKD and a high risk of hospitalization in old age. METHODS Among 4,766 participants of the Atherosclerosis Risk in Communities study, CKD was staged according to Kidney Disease Improving Global Outcomes (KDIGO) criteria, using creatinine-based eGFR (eGFRcr) and ACR. Incidence rates of all-cause hospitalization associated with each CKD risk group were analyzed using negative binomial regression. Additionally, cause-specific hospitalization risks for cardiovascular, infectious, kidney, and other diseases were estimated. The impacts of using cystatin C-based eGFR (eGFRcys) to estimate the prevalence of CKD and risks of hospitalization were also quantified. RESULTS Participants experienced 5,548 hospitalizations and 29% had CKD. Hospitalization rates per 1,000 person-years according to KDIGO risk categories were 208-223 ("low risk"), 288-376 ("moderately increased risk"), 363-548 ("high risk"), and 499-1083 ("very high risk"). The increased risk associated with low eGFR and high ACR persisted in adjusted analyses, examinations of cause-specific hospitalizations, and when CKD was staged by eGFRcys or eGFRcr-cys, a combined equation based on both creatinine and cystatin C. In comparison to eGFRcr, staging by eGFRcys increased the prevalence of CKD to 50%, but hospitalization risks remained similarly high. DISCUSSION/CONCLUSION In older adults, decreased eGFR, increased ACR, and KDIGO risk stages based on a combination of these measures, were strong risk factors for hospitalization. These relationships were consistent, regardless of the marker used to estimate GFR, but the use of cystatin C resulted in a substantially higher prevalence of CKD than the use of creatinine. Older adults in the population with very high risk stages of CKD have hospitalization rates exceeding 500 per 1,000 person-years.
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Affiliation(s)
- Eugenia Wong
- Department of Epidemiology, Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA,
| | - Shoshana H Ballew
- Department of Epidemiology, Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Natalie Daya
- Department of Epidemiology, Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Junichi Ishigami
- Department of Epidemiology, Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Casey M Rebholz
- Department of Epidemiology, Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Kunihiro Matsushita
- Department of Epidemiology, Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
- Department of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | - Morgan E Grams
- Department of Epidemiology, Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
- Department of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | - Josef Coresh
- Department of Epidemiology, Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
- Department of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
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22
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New L, Goodridge D, Kappel J, Groot G, Dobson R. "I just have to take it" - patient safety in acute care: perspectives and experiences of patients with chronic kidney disease. BMC Health Serv Res 2019; 19:199. [PMID: 30922299 PMCID: PMC6437896 DOI: 10.1186/s12913-019-4014-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2018] [Accepted: 03/15/2019] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Frequent hospitalizations and dependency on technology and providers place individuals with chronic kidney disease (CKD) at high risk for multiple safety events. Threats to their safety may be physical, emotional, or psychological. This study sought to explore patient safety from the perspectives and experiences of patients with CKD in acute care settings, and to describe willingness to report incidents utilizing an existing safety reporting system. METHODS This study was conducted using a qualitative interpretive descriptive approach. Face to face interviews were conducted with 30 participants at their bedside during their current hospital admission. The majority of the participants were 50 years or older, of which 75% had a confirmed diagnosis of end stage renal disease with the remainder at stages 3 or 4 of CKD. Eighty percent of the participants were either on hemo- or peritoneal dialysis. RESULTS Participants expected to receive safe care, to be taken care of, and to be cared for. Safety threats included: sharing a room with patients who were on precautions; lack of cleanliness; and roommates perceived to be threatening. The concepts of being taken care of and being cared for constituted the safety threats identified within the interpersonal environment. Participants felt taken care of when their physical needs are met and cared for when their psychological and emotional needs are met. There was a general lack of awareness of the presence of a safety reporting system that was to be accessible to patients and families by telephone. There was also an overall unwillingness to report perceived safety incidents, although participants did distinguish between speaking up and reporting. CONCLUSIONS A key finding was the unwillingness to report incidents using the safety reporting system. Fear of reprisals was the most significant reporting impediment expressed. Actively inviting patients to speak up may be more effective when combined with a psychologically safe environment in order to encourage the involvement of patients in patient safety. System-wide organizational changes may be necessary to mitigate emotional and physical harm for this client population.
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Affiliation(s)
- Lucia New
- College of Medicine Health Sciences Program, University of Saskatchewan, Saskatoon, SK Canada
| | - Donna Goodridge
- Department of Medicine, College of Medicine, University of Saskatchewan, Room 543 Ellis Hall, 108 Hospital Drive, Saskatoon, SK S7N 0W8 Canada
| | - Joanne Kappel
- Department of Medicine, University of Saskatchewan, Saskatoon, Saskatchewan Canada
| | - Gary Groot
- Department of Medicine, University of Saskatchewan, Saskatoon, Saskatchewan Canada
| | - Roy Dobson
- College of Pharmacy and Nutrition, University of Saskatchewan, Saskatoon, SK Canada
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23
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Golestaneh L, Bellin E, Neugarten J, Lo Y. Avoidable visits to the emergency department(ED) and their association with sex, age and race in a cohort of low socio-economic status patients on hemodialysis in the Bronx. PLoS One 2018; 13:e0202697. [PMID: 30142175 PMCID: PMC6108498 DOI: 10.1371/journal.pone.0202697] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2018] [Accepted: 08/06/2018] [Indexed: 12/26/2022] Open
Abstract
Background In national samples drawn from the USRDS, female patients utilize the hospital ED and inpatient services at a higher rate than their male counterparts and have a higher rate of re-hospitalization. We wanted to explore the association of sex with avoidable ED visits made by a cohort of patients on hemodialysis in a mostly minority, lower socioeconomic status (SES), population in the Bronx to test the applicability of the USRDS findings. Methods We used Montefiore’s clinical database to build a cohort of patients on hemodialysis with a first ED visit between 2013 and 2017. All ED visits after the index ED visit and those within one year prior to the index visit were recorded. None of the ED visits resulted in a hospitalization and were thus labeled “avoidable”. Bivariate analysis tested the association of demographic and clinical variables with sex. We used negative binomial regression to test the association of each variable with avoidable ED visit count. The multivariate model used negative binomial regression with avoidable ED visit count as outcome and sex as the exposure variable and included ancestral variables age and race. Potential mediators were added to the model to measure their effects on the association of sex with avoidable ED visits. Results Four thousand six hundred and seventy three subjects on hemodialysis were identified as having at least one avoidable ED visit, in the period of 2013–2017 at one of four ED sites affiliated with Montefiore Medical Center in the Bronx. Over 5 years (2012–2017), the median number of ED visits made by the study sample was 4 (25–75% IQR: 2–8). Female patients on hemodialysis in our cohort were older, more commonly black, had lower SES scores, less commonly had commercial insurance and were less commonly married than their male counterparts. Female sex was not significantly associated with a higher rate of avoidable ED visits in the total cohort.(1.053(0.99–1.12) Female sex was significantly associated with outcome in non-Hispanic whites only and in those subjects younger than 44 years old.(IRR 1.30(1.06–1.69), 1.17(1.00–1.38) in non-Hispanic White and younger age group, respectively.) Marital status, SES and hemoglobin levels possibly mediated the association of sex and outcome in our population. (>25% change in the coefficient for sex with respect to outcome when variable added to the model). Conclusion In this single center study of a lower-socioeconomic status, mostly minority dialysis population, the association of female sex with avoidable ED visits was not significant. These results suggest the association of sex with hospitalization outcomes, described by national datasets that determine quality indicators, are not consistent across different types of populations with some mediation possible by SES and marital status in poorer neighborhoods.
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Affiliation(s)
- Ladan Golestaneh
- Department of Medicine, Renal Division, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, NY, United States of America
- * E-mail:
| | - Eran Bellin
- Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, NY, United States of America
| | - Joel Neugarten
- Department of Medicine, Renal Division, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, NY, United States of America
| | - Yungtai Lo
- Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, NY, United States of America
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24
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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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Bansal N, Szpiro A, Reynolds K, Smith DH, Magid DJ, Gurwitz JH, Masoudi F, Greenlee RT, Tabada GH, Sung SH, Dighe A, Go AS. Long-term Outcomes Associated With Implantable Cardioverter Defibrillator in Adults With Chronic Kidney Disease. JAMA Intern Med 2018; 178:390-398. [PMID: 29404570 PMCID: PMC5885920 DOI: 10.1001/jamainternmed.2017.8462] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Chronic kidney disease (CKD) is common in adults with heart failure and is associated with an increased risk of sudden cardiac death. Randomized trials of participants without CKD have demonstrated that implantable cardioverter defibrillators (ICDs) decrease the risk of arrhythmic death in selected patients with reduced left ventricular ejection fraction (LVEF) heart failure. However, whether ICDs improve clinical outcomes in patients with CKD is not well elucidated. OBJECTIVE To examine the association of primary prevention ICDs with risk of death and hospitalization in a community-based population of potentially ICD-eligible patients who had heart failure with reduced LVEF and CKD. DESIGN, SETTINGS, AND PARTICIPANTS This noninterventional cohort study included adults with heart failure and an LVEF of 40% or less and measures of serum creatinine levels available from January 1, 2005, through December 31, 2012, who were enrolled in 4 Kaiser Permanente health care delivery systems. Chronic kidney disease was defined as an estimated glomerular filtration rate of less than 60 mL/min/1.73 m2. Patients who received and did not receive an ICD were matched (1:3) on CKD status, age, and high-dimensional propensity score to receive an ICD. Follow-up was completed on December 31, 2013. Data were analyzed from 2015 to 2017. EXPOSURES Placement of an ICD. MAIN OUTCOMES AND MEASURES All-cause death, hospitalizations due to heart failure, and any-cause hospitalizations. RESULTS A total of 5877 matched eligible adults with CKD (1556 with an ICD and 4321 without an ICD) were identified (4049 men [68.9%] and 1828 women [31.1%]; mean [SD] age, 72.9 [8.2] years). In models adjusted for demographics, comorbidity, and cardiovascular medication use, no difference was found in all-cause mortality between patients with CKD in the ICD vs non-ICD groups (adjusted hazard ratio, 0.96; 95% CI, 0.87-1.06). However, ICD placement was associated with increased risk of subsequent hospitalization due to heart failure (adjusted relative risk, 1.49; 95% CI, 1.33-1.60) and any-cause hospitalization (adjusted relative risk, 1.25; 95% CI, 1.20-1.30) among patients with CKD. CONCLUSIONS AND RELEVANCE In a large, contemporary, noninterventional study of community-based patients with heart failure and CKD, ICD placement was not significantly associated with improved survival but was associated with increased risk for subsequent hospitalization due to heart failure and all-cause hospitalization. The potential risks and benefits of ICDs should be carefully considered in patients with heart failure and CKD.
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Affiliation(s)
- Nisha Bansal
- Kidney Research Institute, Division of Nephrology, University of, Seattle
| | - Adam Szpiro
- Department of Biostatistics, University of Washington, Seattle
| | - Kristi Reynolds
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena
| | - David H Smith
- Kaiser Permanente Northwest Center for Health Research, Portland, Oregon
| | - David J Magid
- Department of Medicine, Kaiser Permanente Colorado, Denver
| | | | | | | | - Grace H Tabada
- Kaiser Permanente Northern California Division of Research, Oakland
| | - Sue Hee Sung
- Kaiser Permanente Northern California Division of Research, Oakland
| | - Ashveena Dighe
- Kidney Research Institute, Division of Nephrology, University of, Seattle
| | - Alan S Go
- Kaiser Permanente Northern California Division of Research, Oakland.,Department of Epidemiology, University of California, San Francisco.,Department of Biostatistics, University of California, San Francisco.,Department of Medicine, University of California, San Francisco
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26
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Abstract
BACKGROUND For patients waitlisted for a deceased-donor kidney, hospitalization is associated with a lower likelihood of transplantation and worse posttransplant outcomes. However, individual-, neighborhood-, and regional-level risk factors for hospitalization throughout the waitlist period and specific causes of hospitalization in this population are unknown. METHODS We used United States Renal Data System Medicare-linked data on patients waitlisted between 2005 and 2013 with continuous enrollment in Medicare parts A and B (n = 53 810) to examine the association between annual hospitalization rate and a variety of demographic, clinical, and social factors. We used multilevel multivariable ordinal logistic regression to estimate odds ratios. RESULTS Factors associated with significantly increased hospitalization rates among waitlisted individuals included older age, female sex, more years on dialysis before waitlisting, tobacco use, panel-reactive antibody greater than 0, public insurance or no insurance at end-stage renal disease diagnosis, more regional acute care hospital beds, and urban residence (all P < 0.05). Among patients dialysis-dependent when waitlisted, individuals with arteriovenous fistulas were significantly less likely than individuals with indwelling catheters or grafts to be hospitalized (odds ratios, 0.79 and 0.82, respectively, both P < 0.001). The most common causes of hospitalization were complications related to devices, implants, and grafts; hypertension; and sepsis. CONCLUSIONS Individual- and regional-level variables were significantly associated with hospitalization while waitlisted, suggesting that personal, health system, and geographic factors may impact patients' risk. Conditions related to dialysis access and comorbidities were common hospitalization causes, underscoring the importance proper access management and care for additional chronic health conditions.
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27
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Rashidi B, Kobewka DM, Campbell DJT, Forster AJ, Ronksley PE. Clinical factors contributing to high cost hospitalizations in a Canadian tertiary care centre. BMC Health Serv Res 2017; 17:777. [PMID: 29178870 PMCID: PMC5702126 DOI: 10.1186/s12913-017-2746-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2016] [Accepted: 11/20/2017] [Indexed: 11/18/2022] Open
Abstract
Background Like much of the developed world, healthcare costs in Canada are rising. A small proportion of patients account for a large proportion of healthcare spending and much of this spending occurs in acute care settings. The purpose of our study was to determine potentially modifiable factors related to care processes that contribute to high-cost admissions. Methods Using a mixed-methods study design, factors contributing to high-cost admissions were identified from literature and case review. We defined pre- and post-admission factors contributing to high-cost admissions. Pre-admission factors included reason for admission (e.g. complex medical, elective surgery, trauma, etc.). Post-admission factors included medical complications, disposition delays, clinical services delays, and inefficient clinical decision-making. We selected a random sample of admissions in the top decile of inpatient cost from the Ottawa Hospital between January 1 and December 31, 2010. A single reviewer classified cases based on the pre- and post-admission factors. We combined this information with data derived from the Ottawa Hospital Data Warehouse to describe patient-level clinical and demographic characteristics and costs incurred. Results We reviewed 200 charts which represents ~5% of all high cost admissions within the Ottawa Hospital in 2010. Post-admission factors contributing to high-cost admissions were: complications (60%), disposition delays (53%), clinical service delays (39%), and inefficient clinical decision-making (13%). Further, these factors varied substantially across service delivery lines. The mean (standard deviation (SD)) cost per admission was $49,923 CDN ($45,773). The most common reason for admission was “complex medical” (49%) and the overall median (IQR) length of stay was 27 (18–48) days. Approximately 1 in 3 high cost admissions (29%) included time in the intensive care unit (ICU). Conclusions While high cost admissions often include time in ICU and have long lengths of stay, a substantial proportion of costs were attributable to complications and potentially preventable delays in care processes. These findings suggest opportunities exist to improve outcomes and reduce costs for this diverse patient population.
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Affiliation(s)
- Babak Rashidi
- Department of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Daniel M Kobewka
- Department of Medicine, University of Ottawa, Ottawa, ON, Canada.,Department of Epidemiology and Community Medicine, University of Ottawa, Ottawa, ON, Canada
| | - David J T Campbell
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Alan J Forster
- Department of Medicine, University of Ottawa, Ottawa, ON, Canada.,Department of Clinical Epidemiology, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Paul E Ronksley
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, HSC G239, 3330 Hospital Drive NW, Calgary, AB, T2N 4N1, Canada.
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28
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Patzer RE, Schrager JD, Pastan SO. Preventing Emergency Department Use among Patients with CKD: It Starts with Awareness. Clin J Am Soc Nephrol 2017; 12:225-227. [PMID: 28119411 PMCID: PMC5293343 DOI: 10.2215/cjn.12881216] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Affiliation(s)
- Rachel E. Patzer
- Department of Surgery, Division of Transplantation
- Department of Medicine, Renal Division, and
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Justin D. Schrager
- Department of Emergency Medicine, Emory University School of Medicine, Atlanta, Georgia; and
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29
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Affiliation(s)
- Deidra C. Crews
- Division of Nephrology, Department of Medicine and
- Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Waseem Khaliq
- Division of Hospital Medicine, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland; and
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30
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Fink JC. Are Ambulatory Care-Sensitive Conditions the Fulcrum of Hospitalizations for CKD Patients? Clin J Am Soc Nephrol 2016; 11:1927-1928. [PMID: 27821635 PMCID: PMC5108203 DOI: 10.2215/cjn.09160816] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/14/2023]
Affiliation(s)
- Jeffrey C Fink
- Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland
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