Original Paper Nephron Clin Pract 2014;126:124–127 DOI: 10.1159/000360541
Received: June 27, 2013 Accepted: February 5, 2014 Published online: April 8, 2014
Inpatient and Emergent Resource Use of Patients on Dialysis at an Academic Medical Center Eric Chow a Hannah Wong a, b Shoshana Hahn-Goldberg a Christopher T. Chan c Dante Morra a, d, e a
The Centre for Innovation in Complex Care, University Health Network (UHN), b School of Health Policy and Management, York University, c Division of Nephrology, UHN, d Department of Medicine, and e Centre for Interprofessional Education, University of Toronto, Toronto, Ont., Canada
Key Words Chronic renal failure and dialysis · Health sciences research · Hospitalization
Abstract Background/Aim: End-stage renal disease patients require resources for emergent and inpatient care in addition to ambulatory dialysis. There are two dialysis modalities and settings which patients switch between. Our aim was to characterize the patterns and reasons for switching, as well as the emergent and inpatient utilization of these patients at the University Health Network. Methods: Patients who received chronic dialysis between March 1, 2006, and April 30, 2011, were identified. Utilization was measured by emergency department (ED) visits, inpatient hospitalizations, and beddays occupied per year. Results: Out of 576 patients identified, 18.6% switched modality and/or setting. The majority of switches occurred during the first year of dialysis. Patients who switched had increased utilization compared to those on a continuous modality/setting. Overall, patients had a median rate of 0.91 ED visits per patient-year, compared to 1.56 for patients who switched modality and setting. Median inpatient bed resource requirement was 4.46 bed-days/pa-
© 2014 S. Karger AG, Basel 1660–2110/14/1263–0124$39.50/0 E-Mail [email protected] www.karger.com/nec
tient-year overall, compared to 8.91 for patients who switched modality and setting. Conclusions: Emergent and inpatient utilization is related to the setting and modality of dialysis, although differences are partly explained by comorbidities. Patients who switch modalities use more resources and may be a prime population for interventions. © 2014 S. Karger AG, Basel
Introduction
The prevalence of late stage chronic kidney disease (CKD) has been estimated at 25% among the elderly [1– 3]. CKD patients who progress to end-stage renal disease (ESRD) require dialysis, either hemodialysis (HD) or peritoneal dialysis (PD), performed in an ambulatory or at-home setting [4]. In Ontario, there were an estimated 9,800 prevalent dialysis patients in 2011 [5, 6]. These patients often require inpatient and emergent care outside of regular dialysis treatment. Costs of inpatient care have been estimated to account for up to 37% of total healthcare costs for the dialysis population [7]. In a previous study, reasons for hospitalization were limited to diagnoses attributable only to ESRD Shoshana Hahn-Goldberg Centre for Innovation in Complex Care, University Health Network Toronto General Hospital, 200 Elizabeth Street, Rm GNU403 Toronto, ON M5G 2C4 (Canada) E-Mail shoshana.hahn-goldberg @ uhn.ca
Table 1. Characteristics of dialysis population
Patients, n Mean age at initial dialysis, years (SD) Female, n (%) Angina, n (%) Myocardial infarction, n (%) Coronary artery bypass, n (%) Pulmonary edema, n (%) Cerebrovascular disease, n (%) Peripheral vascular disease, n (%) Malignancy, n (%) Chronic obstructive lung disease, n (%) Hypertension medication, n (%) Other serious illness, n (%) Current smoker, n (%)
In-center HD In-center & home HD
Home HD
Home PD
Home PD & Home PD & in-center HD home HD
238 57.5 (16.9) 105 (44)* 52 (22) 43 (18) 26 (11) 68 (29)* 36 (15) 33 (14) 31 (13) 27 (11) 216 (91) 26 (11)* 32 (13)
52 43.3 (16.4)* 11 (21)* 5 (9.6) 5 (10) 6 (12) 6 (12) 6 (12) 3 (5.8) 7 (14) 3 (5.8) 48 (92) 4 (7.7) 8 (15)
179 60.0 (18.2)* 76 (42) 38 (21) 38 (21) 30 (17) 44 (25) 27 (15) 29 (16) 20 (11) 12 (6.7) 169 (94) 37 (21)* 7 (3.9)*
70 58.1 (15.0) 26 (37) 14 (20) 13 (19) 10 (14) 12 (17) 6 (8.6) 13 (19) 7 (10) 6 (8.6) 62 (89) 9 (13) 13 (19)
30 43.6 (17.1)* 13 (43) 3 (10) 1 (3.3) 2 (6.7) 2 (6.7) 1 (3.3) 4 (13) 4 (13) – 24 (80) 4 (13) 5 (17)
7 40.9 (13.1) 4 (57) – – – – 1 (14) – – – 7 (100) – 1 (14)
χ2 test for gender and comorbidities, t test for age. * p < 0.05.
[8]. We aim to describe all admissions of dialysis patients at the University Health Network (UHN), a network of three hospitals in Toronto, Canada. With increasing efforts to shift dialysis into the home setting [9, 10] or continuous modalities [11], we aim to characterize the assignment of patients to modalities, switching of modality or setting, and effect modality and setting have on emergent and inpatient utilization. UHN starts more patients on home dialysis in their novel ‘home dialysis first’ program.
sions and the number of days that a patient occupied an inpatient bed over a 1-year period (bed-days/patient-year). Statistical analysis was conducted in R 2.14 (R Foundation for Statistical Computing, Vienna, Austria). Multiple imputation used the randomForest 4.6-7 package. Imputed values for missing comorbidities were taken categorically as the value with the largest average proximity. χ2 testing was used to evaluate differences in gender and comorbidities in the population. The t test was used to evaluate differences in age at initial dialysis. ED admissions were modeled logistically, adjusting for dialysis category, age, gender, and imputed comorbidities without interaction terms. ED visits, admissions, and bed-days per patient-year were modeled linearly adjusting for dialysis category, age, gender, and imputed comorbidities without interaction terms. All tests were two-sided with an α of 0.05.
Methods This was a retrospective study of emergency department (ED) visits and inpatient admissions of the adult dialysis population at UHN between March 1, 2006 and April 30, 2011. Patients identified via the electronic health record (EHR) were included in the study if they had at least 5 visits to a UHN dialysis clinic, were 18 years or older at their first visit, and were registered in the Ontario Renal Reporting System (ORRS). Comorbidities were abstracted from patient charts. Patients were categorized according to dialysis setting (at-home vs. in-center) and modality (HD vs. PD). Patient attendance at dialysis clinics was tracked to determine if and when they switched modality or setting. The initial date of dialysis for each patient was obtained from ORRS. The last date of dialysis was the latest recorded dialysis visit or a recorded death. All UHN ED visits and inpatient hospitalizations while the patient was on dialysis during the study period were included in analysis. ED resource use was measured by the proportion of patients visiting the ED and the frequency of visits. Inpatient resource use was measured by the frequency of admis-
Resource Use of Dialysis Patients
Results
576 patients met the inclusion criteria. Patients were assigned to six dialysis categories: patients who only received in-center HD (n = 238); only received home PD (n = 179); only received home HD (n = 52); switched between home PD and in-center HD (home PD & in-center HD) (n = 70); only received HD, but switched settings (in-center & home HD) (n = 30), and only received dialysis at home, but switched modalities (home PD & home HD) (n = 7). The majority (81%) of patients were on a single dialysis modality and setting. Demographic characteristics are summarized in table 1. Of the 107 patients who switched modality and setting, 83 switched during their first year on dialysis, 20 Nephron Clin Pract 2014;126:124–127 DOI: 10.1159/000360541
125
Table 2. Emergency department visits
Dialysis category
n
Patients admitted Total ED to ED during dialysis visits (% of all patients)
Total ED visits that lead to admission (% of ED visits)
Median ED visits per patient-year (IQR)
In-center HD In-center & home HD Home HD Home PD Home PD & in-center HD Home PD & home HD Total
238 30 52 179 70 7 576
207 (87%) 25 (83%) 32 (62%)* 139 (78%)* 67 (96%)* 6 (86%) 476 (83%)
583 (49%) 49 (43%) 47 (43%) 288 (53%) 239 (50%) 18 (53%) 1,224 (49%)
1.13 (0.48 – 2.20) 0.83 (0.36 – 1.86) 0.29 (0.00 – 0.86)* 0.69 (0.19 – 1.67)* 1.56 (0.81 – 2.25) 0.39 (0.33 – 0.60) 0.91 (0.37 – 1.98)
1,199 115 110 547 480 34 2,485
Patient admission to the ED during dialysis was modeled logistically; ED visits per patient-year was modeled linearly. Both adjusted for dialysis category, age, gender, and imputed comorbidities without interaction terms. * p < 0.05.
Table 3. Inpatient admission rates and bed resource requirements
Dialysis category
Median (IQR) years on dialysis
Median (IQR) admissions per patient-year
Median (IQR) inpatient bed resource requirement (bed-days per patient-year)
In-center HD In-center & home HD Home HD Home PD Home PD & in-center HD Home PD & home HD Total
3.7 (2.0 – 5.2) 4.2 (2.9 – 5.2) 4.1 (2.3 – 5.2) 2.8 (1.6 – 4.5) 3.6 (2.9 – 5.1) 5.2 (4.8 – 5.2) 3.5 (2.1 – 5.2)
0.59 (0.19 – 1.40) 0.54 (0.00 – 1.31) 0.32 (0.00 – 0.71)* 0.47 (0.00 – 1.15) 1.08 (0.77 – 1.57)* 0.39 (0.23 – 0.60) 0.59 (0.19 – 1.36)
4.77 (0.29 – 14.2) 3.42 (0.00 – 7.68) 0.64 (0.00 – 3.64)* 3.65 (0.00 – 11.4)§ 8.91 (5.01 – 17.1) 2.07 (0.86 – 8.21) 4.46 (0.14 – 12.6)
Admissions and bed-days per patient-year were modeled linearly adjusting for dialysis category, age, gender, and imputed comorbidities without interaction terms. * p < 0.05; § p = 0.05.
switched after completing their first year of dialysis, and 4 switched during both the first and subsequent years. ED resource utilization is reported in table 2. 83% of patients had at least one ED visit. Controlling for age, gender and comorbidities, receiving dialysis at home was associated with reduced utilization. The home PD & incenter HD category was associated with increased utilization. Overall, 49% of ED visits resulted in hospitalization. Patients had a median of 0.91 ED visits per patient year, compared to 1.56 for home PD & in-center HD. Inpatient resource utilization is reported in table 3. Controlling for age, gender, and comorbidities, the home PD & in-center HD category was associated with increased admissions. Home HD alone was associated with decreased admissions. The median (IQR) days that a patient occupied a bed within a year was 4.46 (0.14–12.6) bed-days/patient-year, compared to 8.91 (5.01–17.1) for 126
Nephron Clin Pract 2014;126:124–127 DOI: 10.1159/000360541
home PD & in center HD and 0.64 (0.00–3.64) for home HD alone. 93% of visits had a documented most responsible diagnosis. The majority of hospitalizations were related to infection (15%), coronary disease (15%), abdominal pain (11%), trauma (8%), volume overload (8%), and ESRD (7%). The ESRD category is represented by a list of ICD10 codes that signify renal failure as the primary reason for hospitalization.
Discussion
In our review, we identified that the majority of dialysis patients received care in a single setting and modality. Patients who received dialysis at home were associated with lower resource needs from both the ED and inpaChow /Wong /Hahn-Goldberg /Chan / Morra
tient care. Conversely, patients who transitioned modality and setting of dialysis (home PD & in-center HD) were associated with higher utilization. Rates of hospitalization and number of days in hospital have been reported with varying results [8] for a variety of single-center studies [12–16]. Our results suggest that inpatient resource needs differ substantially based on the modality and setting of dialysis and that the difference is partly explained by comorbidities. Nephrologists have many reasons for placing a patient on HD versus PD. There are barriers that exclude a patient from being eligible for PD [17], including obesity and abdominal scarring, among others. In addition, PD is conducted in the home, so patients must have assistance in the home or be sufficiently independent to manage that care. PD at UHN often means that a patient received pre-dialysis care prior to their planned start on PD. In contrast, HD patients more commonly have an unplanned start to dialysis as an inpatient. These differences may explain some of the differences in utilization between the modality groups. Patients switch between modalities or settings for one of several reasons: they become more healthy (switch from in-center to home); they had an unplanned start to
dialysis, but have now stabilized (in-center to home); or they become sicker, are admitted to hospital for any reason, or are no longer as independent as they once were (home to in-center). Patients switching modalities are in a state of change and are more vulnerable. They may be good candidates for increased outpatient or home-based care to prevent hospital utilization. The authors acknowledge the following limitations: First, our results may be biased by selection. Despite adjusting for comorbidities, patient independence may be poorly correlated to available data. Second, allocation of modality is complex and the present work does not discern between the many possible determinants. Third, we assume that dialysis patients at UHN will return to the same hospitals for emergency and inpatient treatment, potentially biasing our results towards underreporting of utilization. It is apparent that dialysis patients consume substantial resources through emergent and inpatient care. It would be advisable to plan for inpatient resource needs as adjusted by dialysis setting and modality. This study serves only to highlight this relationship; further modeling is warranted to describe the detailed effects as related to ambulatory dialysis volumes.
References 1 Garg AX, Papaioannou A, Ferko N, Campbell G, Clarke JA, Ray JG: Estimating the prevalence of renal insufficiency in seniors requiring long-term care. Kidney Int 2004; 65: 649– 653. 2 Hemmelgarn BR, Zhang J, Manns BJ, et al: Progression of kidney dysfunction in the community-dwelling elderly. Kidney Int 2006;69:2155–2161. 3 Coresh J, Astor BC, Greene T, Eknoyan G, Levey AS: Prevalence of chronic kidney disease and decreased kidney function in the adult US population: Third National Health and Nutrition Examination Survey. Am J Kidney Dis 2003;41:1–12. 4 Himmelfarb J, Ikizler TA: Hemodialysis. N Engl J Med 2010;363:1833–1845. 5 Lonze BE, Dagher NN, Liu M, et al: Outcomes of renal transplants from Centers for Disease Control and Prevention high-risk donors with prospective recipient viral testing: a single-center experience. Arch Surg 2011; 146: 1261–1266. 6 Quinn RR, Laupacis A, Hux JE, Moineddin R, Paterson M, Oliver MJ: Forecasting the need for dialysis services in Ontario, Canada to 2011. Healthc Policy 2009;4:e151–161.
Resource Use of Dialysis Patients
7 Bruns FJ, Seddon P, Saul M, Zeidel ML: The cost of caring for end-stage kidney disease patients: an analysis based on hospital financial transaction records. J Am Soc Nephrol 1998; 9:884–890. 8 Adeniyi M, Kassam H, Agaba EI, et al: Hospitalizations in patients treated sequentially by chronic hemodialysis and continuous peritoneal dialysis. Adv Perit Dial 2009;25:72–75. 9 Jun M, Jardine MJ, Gray N, et al: Outcomes of extended-hours hemodialysis performed predominantly at home. Am J Kidney Dis 2013; 61:247–253. 10 Marshall MR, van der Schrieck N, Lilley D, et al: Independent community house hemodialysis as a novel dialysis setting: an observational cohort study. Am J Kidney Dis 2013;61: 598–607. 11 Mohr PE, Neumann PJ, Franco SJ, Marainen J, Lockridge R, Ting G: The case for daily dialysis: its impact on costs and quality of life. Am J Kidney Dis 2001;37:777–789. 12 Kumar VA, Ledezma ML, Idroos ML, Burchette RJ, Rasgon SA: Hospitalization rates in daily home hemodialysis versus peritoneal dialysis patients in the United States. Am J Kidney Dis 2008;52:737–744.
13 Johansen KL, Zhang R, Huang Y, et al: Survival and hospitalization among patients using nocturnal and short daily compared to conventional hemodialysis: a USRDS study. Kidney Int 2009;76:984–990. 14 Burton PR, Walls J: A selection adjusted comparison of hospitalization on continuous ambulatory peritoneal dialysis and haemodialysis. J Clin Epidemiol 1989;42:531–539. 15 Charytan C, Spinowitz BS, Galler M: A comparative study of continuous ambulatory peritoneal dialysis and center hemodialysis. Efficacy, complications, and outcome in the treatment of end-stage renal disease. Arch Intern Med 1986;146:1138–1143. 16 Habach G, Bloembergen WE, Mauger EA, Wolfe RA, Port FK: Hospitalization among United States dialysis patients: hemodialysis versus peritoneal dialysis. J Am Soc Nephrol 1995;5:1940–1948. 17 Williams V, Quinn R, Callery S, Kiss A, Oliver M: The impact of treatment modality on infection-related hospitalization rates in peritoneal dialysis and hemodialysis patients. Perit Dial Int 2011;31:440–449.
Nephron Clin Pract 2014;126:124–127 DOI: 10.1159/000360541
127
Copyright: S. Karger AG, Basel 2014. Reproduced with the permission of S. Karger AG, Basel. Further reproduction or distribution (electronic or otherwise) is prohibited without permission from the copyright holder.
Received: June 27, 2013 Accepted: February 5, 2014 Published online: April 8, 2014
Inpatient and Emergent Resource Use of Patients on Dialysis at an Academic Medical Center Eric Chow a Hannah Wong a, b Shoshana Hahn-Goldberg a Christopher T. Chan c Dante Morra a, d, e a
The Centre for Innovation in Complex Care, University Health Network (UHN), b School of Health Policy and Management, York University, c Division of Nephrology, UHN, d Department of Medicine, and e Centre for Interprofessional Education, University of Toronto, Toronto, Ont., Canada
Key Words Chronic renal failure and dialysis · Health sciences research · Hospitalization
Abstract Background/Aim: End-stage renal disease patients require resources for emergent and inpatient care in addition to ambulatory dialysis. There are two dialysis modalities and settings which patients switch between. Our aim was to characterize the patterns and reasons for switching, as well as the emergent and inpatient utilization of these patients at the University Health Network. Methods: Patients who received chronic dialysis between March 1, 2006, and April 30, 2011, were identified. Utilization was measured by emergency department (ED) visits, inpatient hospitalizations, and beddays occupied per year. Results: Out of 576 patients identified, 18.6% switched modality and/or setting. The majority of switches occurred during the first year of dialysis. Patients who switched had increased utilization compared to those on a continuous modality/setting. Overall, patients had a median rate of 0.91 ED visits per patient-year, compared to 1.56 for patients who switched modality and setting. Median inpatient bed resource requirement was 4.46 bed-days/pa-
© 2014 S. Karger AG, Basel 1660–2110/14/1263–0124$39.50/0 E-Mail [email protected] www.karger.com/nec
tient-year overall, compared to 8.91 for patients who switched modality and setting. Conclusions: Emergent and inpatient utilization is related to the setting and modality of dialysis, although differences are partly explained by comorbidities. Patients who switch modalities use more resources and may be a prime population for interventions. © 2014 S. Karger AG, Basel
Introduction
The prevalence of late stage chronic kidney disease (CKD) has been estimated at 25% among the elderly [1– 3]. CKD patients who progress to end-stage renal disease (ESRD) require dialysis, either hemodialysis (HD) or peritoneal dialysis (PD), performed in an ambulatory or at-home setting [4]. In Ontario, there were an estimated 9,800 prevalent dialysis patients in 2011 [5, 6]. These patients often require inpatient and emergent care outside of regular dialysis treatment. Costs of inpatient care have been estimated to account for up to 37% of total healthcare costs for the dialysis population [7]. In a previous study, reasons for hospitalization were limited to diagnoses attributable only to ESRD Shoshana Hahn-Goldberg Centre for Innovation in Complex Care, University Health Network Toronto General Hospital, 200 Elizabeth Street, Rm GNU403 Toronto, ON M5G 2C4 (Canada) E-Mail shoshana.hahn-goldberg @ uhn.ca
Table 1. Characteristics of dialysis population
Patients, n Mean age at initial dialysis, years (SD) Female, n (%) Angina, n (%) Myocardial infarction, n (%) Coronary artery bypass, n (%) Pulmonary edema, n (%) Cerebrovascular disease, n (%) Peripheral vascular disease, n (%) Malignancy, n (%) Chronic obstructive lung disease, n (%) Hypertension medication, n (%) Other serious illness, n (%) Current smoker, n (%)
In-center HD In-center & home HD
Home HD
Home PD
Home PD & Home PD & in-center HD home HD
238 57.5 (16.9) 105 (44)* 52 (22) 43 (18) 26 (11) 68 (29)* 36 (15) 33 (14) 31 (13) 27 (11) 216 (91) 26 (11)* 32 (13)
52 43.3 (16.4)* 11 (21)* 5 (9.6) 5 (10) 6 (12) 6 (12) 6 (12) 3 (5.8) 7 (14) 3 (5.8) 48 (92) 4 (7.7) 8 (15)
179 60.0 (18.2)* 76 (42) 38 (21) 38 (21) 30 (17) 44 (25) 27 (15) 29 (16) 20 (11) 12 (6.7) 169 (94) 37 (21)* 7 (3.9)*
70 58.1 (15.0) 26 (37) 14 (20) 13 (19) 10 (14) 12 (17) 6 (8.6) 13 (19) 7 (10) 6 (8.6) 62 (89) 9 (13) 13 (19)
30 43.6 (17.1)* 13 (43) 3 (10) 1 (3.3) 2 (6.7) 2 (6.7) 1 (3.3) 4 (13) 4 (13) – 24 (80) 4 (13) 5 (17)
7 40.9 (13.1) 4 (57) – – – – 1 (14) – – – 7 (100) – 1 (14)
χ2 test for gender and comorbidities, t test for age. * p < 0.05.
[8]. We aim to describe all admissions of dialysis patients at the University Health Network (UHN), a network of three hospitals in Toronto, Canada. With increasing efforts to shift dialysis into the home setting [9, 10] or continuous modalities [11], we aim to characterize the assignment of patients to modalities, switching of modality or setting, and effect modality and setting have on emergent and inpatient utilization. UHN starts more patients on home dialysis in their novel ‘home dialysis first’ program.
sions and the number of days that a patient occupied an inpatient bed over a 1-year period (bed-days/patient-year). Statistical analysis was conducted in R 2.14 (R Foundation for Statistical Computing, Vienna, Austria). Multiple imputation used the randomForest 4.6-7 package. Imputed values for missing comorbidities were taken categorically as the value with the largest average proximity. χ2 testing was used to evaluate differences in gender and comorbidities in the population. The t test was used to evaluate differences in age at initial dialysis. ED admissions were modeled logistically, adjusting for dialysis category, age, gender, and imputed comorbidities without interaction terms. ED visits, admissions, and bed-days per patient-year were modeled linearly adjusting for dialysis category, age, gender, and imputed comorbidities without interaction terms. All tests were two-sided with an α of 0.05.
Methods This was a retrospective study of emergency department (ED) visits and inpatient admissions of the adult dialysis population at UHN between March 1, 2006 and April 30, 2011. Patients identified via the electronic health record (EHR) were included in the study if they had at least 5 visits to a UHN dialysis clinic, were 18 years or older at their first visit, and were registered in the Ontario Renal Reporting System (ORRS). Comorbidities were abstracted from patient charts. Patients were categorized according to dialysis setting (at-home vs. in-center) and modality (HD vs. PD). Patient attendance at dialysis clinics was tracked to determine if and when they switched modality or setting. The initial date of dialysis for each patient was obtained from ORRS. The last date of dialysis was the latest recorded dialysis visit or a recorded death. All UHN ED visits and inpatient hospitalizations while the patient was on dialysis during the study period were included in analysis. ED resource use was measured by the proportion of patients visiting the ED and the frequency of visits. Inpatient resource use was measured by the frequency of admis-
Resource Use of Dialysis Patients
Results
576 patients met the inclusion criteria. Patients were assigned to six dialysis categories: patients who only received in-center HD (n = 238); only received home PD (n = 179); only received home HD (n = 52); switched between home PD and in-center HD (home PD & in-center HD) (n = 70); only received HD, but switched settings (in-center & home HD) (n = 30), and only received dialysis at home, but switched modalities (home PD & home HD) (n = 7). The majority (81%) of patients were on a single dialysis modality and setting. Demographic characteristics are summarized in table 1. Of the 107 patients who switched modality and setting, 83 switched during their first year on dialysis, 20 Nephron Clin Pract 2014;126:124–127 DOI: 10.1159/000360541
125
Table 2. Emergency department visits
Dialysis category
n
Patients admitted Total ED to ED during dialysis visits (% of all patients)
Total ED visits that lead to admission (% of ED visits)
Median ED visits per patient-year (IQR)
In-center HD In-center & home HD Home HD Home PD Home PD & in-center HD Home PD & home HD Total
238 30 52 179 70 7 576
207 (87%) 25 (83%) 32 (62%)* 139 (78%)* 67 (96%)* 6 (86%) 476 (83%)
583 (49%) 49 (43%) 47 (43%) 288 (53%) 239 (50%) 18 (53%) 1,224 (49%)
1.13 (0.48 – 2.20) 0.83 (0.36 – 1.86) 0.29 (0.00 – 0.86)* 0.69 (0.19 – 1.67)* 1.56 (0.81 – 2.25) 0.39 (0.33 – 0.60) 0.91 (0.37 – 1.98)
1,199 115 110 547 480 34 2,485
Patient admission to the ED during dialysis was modeled logistically; ED visits per patient-year was modeled linearly. Both adjusted for dialysis category, age, gender, and imputed comorbidities without interaction terms. * p < 0.05.
Table 3. Inpatient admission rates and bed resource requirements
Dialysis category
Median (IQR) years on dialysis
Median (IQR) admissions per patient-year
Median (IQR) inpatient bed resource requirement (bed-days per patient-year)
In-center HD In-center & home HD Home HD Home PD Home PD & in-center HD Home PD & home HD Total
3.7 (2.0 – 5.2) 4.2 (2.9 – 5.2) 4.1 (2.3 – 5.2) 2.8 (1.6 – 4.5) 3.6 (2.9 – 5.1) 5.2 (4.8 – 5.2) 3.5 (2.1 – 5.2)
0.59 (0.19 – 1.40) 0.54 (0.00 – 1.31) 0.32 (0.00 – 0.71)* 0.47 (0.00 – 1.15) 1.08 (0.77 – 1.57)* 0.39 (0.23 – 0.60) 0.59 (0.19 – 1.36)
4.77 (0.29 – 14.2) 3.42 (0.00 – 7.68) 0.64 (0.00 – 3.64)* 3.65 (0.00 – 11.4)§ 8.91 (5.01 – 17.1) 2.07 (0.86 – 8.21) 4.46 (0.14 – 12.6)
Admissions and bed-days per patient-year were modeled linearly adjusting for dialysis category, age, gender, and imputed comorbidities without interaction terms. * p < 0.05; § p = 0.05.
switched after completing their first year of dialysis, and 4 switched during both the first and subsequent years. ED resource utilization is reported in table 2. 83% of patients had at least one ED visit. Controlling for age, gender and comorbidities, receiving dialysis at home was associated with reduced utilization. The home PD & incenter HD category was associated with increased utilization. Overall, 49% of ED visits resulted in hospitalization. Patients had a median of 0.91 ED visits per patient year, compared to 1.56 for home PD & in-center HD. Inpatient resource utilization is reported in table 3. Controlling for age, gender, and comorbidities, the home PD & in-center HD category was associated with increased admissions. Home HD alone was associated with decreased admissions. The median (IQR) days that a patient occupied a bed within a year was 4.46 (0.14–12.6) bed-days/patient-year, compared to 8.91 (5.01–17.1) for 126
Nephron Clin Pract 2014;126:124–127 DOI: 10.1159/000360541
home PD & in center HD and 0.64 (0.00–3.64) for home HD alone. 93% of visits had a documented most responsible diagnosis. The majority of hospitalizations were related to infection (15%), coronary disease (15%), abdominal pain (11%), trauma (8%), volume overload (8%), and ESRD (7%). The ESRD category is represented by a list of ICD10 codes that signify renal failure as the primary reason for hospitalization.
Discussion
In our review, we identified that the majority of dialysis patients received care in a single setting and modality. Patients who received dialysis at home were associated with lower resource needs from both the ED and inpaChow /Wong /Hahn-Goldberg /Chan / Morra
tient care. Conversely, patients who transitioned modality and setting of dialysis (home PD & in-center HD) were associated with higher utilization. Rates of hospitalization and number of days in hospital have been reported with varying results [8] for a variety of single-center studies [12–16]. Our results suggest that inpatient resource needs differ substantially based on the modality and setting of dialysis and that the difference is partly explained by comorbidities. Nephrologists have many reasons for placing a patient on HD versus PD. There are barriers that exclude a patient from being eligible for PD [17], including obesity and abdominal scarring, among others. In addition, PD is conducted in the home, so patients must have assistance in the home or be sufficiently independent to manage that care. PD at UHN often means that a patient received pre-dialysis care prior to their planned start on PD. In contrast, HD patients more commonly have an unplanned start to dialysis as an inpatient. These differences may explain some of the differences in utilization between the modality groups. Patients switch between modalities or settings for one of several reasons: they become more healthy (switch from in-center to home); they had an unplanned start to
dialysis, but have now stabilized (in-center to home); or they become sicker, are admitted to hospital for any reason, or are no longer as independent as they once were (home to in-center). Patients switching modalities are in a state of change and are more vulnerable. They may be good candidates for increased outpatient or home-based care to prevent hospital utilization. The authors acknowledge the following limitations: First, our results may be biased by selection. Despite adjusting for comorbidities, patient independence may be poorly correlated to available data. Second, allocation of modality is complex and the present work does not discern between the many possible determinants. Third, we assume that dialysis patients at UHN will return to the same hospitals for emergency and inpatient treatment, potentially biasing our results towards underreporting of utilization. It is apparent that dialysis patients consume substantial resources through emergent and inpatient care. It would be advisable to plan for inpatient resource needs as adjusted by dialysis setting and modality. This study serves only to highlight this relationship; further modeling is warranted to describe the detailed effects as related to ambulatory dialysis volumes.
References 1 Garg AX, Papaioannou A, Ferko N, Campbell G, Clarke JA, Ray JG: Estimating the prevalence of renal insufficiency in seniors requiring long-term care. Kidney Int 2004; 65: 649– 653. 2 Hemmelgarn BR, Zhang J, Manns BJ, et al: Progression of kidney dysfunction in the community-dwelling elderly. Kidney Int 2006;69:2155–2161. 3 Coresh J, Astor BC, Greene T, Eknoyan G, Levey AS: Prevalence of chronic kidney disease and decreased kidney function in the adult US population: Third National Health and Nutrition Examination Survey. Am J Kidney Dis 2003;41:1–12. 4 Himmelfarb J, Ikizler TA: Hemodialysis. N Engl J Med 2010;363:1833–1845. 5 Lonze BE, Dagher NN, Liu M, et al: Outcomes of renal transplants from Centers for Disease Control and Prevention high-risk donors with prospective recipient viral testing: a single-center experience. Arch Surg 2011; 146: 1261–1266. 6 Quinn RR, Laupacis A, Hux JE, Moineddin R, Paterson M, Oliver MJ: Forecasting the need for dialysis services in Ontario, Canada to 2011. Healthc Policy 2009;4:e151–161.
Resource Use of Dialysis Patients
7 Bruns FJ, Seddon P, Saul M, Zeidel ML: The cost of caring for end-stage kidney disease patients: an analysis based on hospital financial transaction records. J Am Soc Nephrol 1998; 9:884–890. 8 Adeniyi M, Kassam H, Agaba EI, et al: Hospitalizations in patients treated sequentially by chronic hemodialysis and continuous peritoneal dialysis. Adv Perit Dial 2009;25:72–75. 9 Jun M, Jardine MJ, Gray N, et al: Outcomes of extended-hours hemodialysis performed predominantly at home. Am J Kidney Dis 2013; 61:247–253. 10 Marshall MR, van der Schrieck N, Lilley D, et al: Independent community house hemodialysis as a novel dialysis setting: an observational cohort study. Am J Kidney Dis 2013;61: 598–607. 11 Mohr PE, Neumann PJ, Franco SJ, Marainen J, Lockridge R, Ting G: The case for daily dialysis: its impact on costs and quality of life. Am J Kidney Dis 2001;37:777–789. 12 Kumar VA, Ledezma ML, Idroos ML, Burchette RJ, Rasgon SA: Hospitalization rates in daily home hemodialysis versus peritoneal dialysis patients in the United States. Am J Kidney Dis 2008;52:737–744.
13 Johansen KL, Zhang R, Huang Y, et al: Survival and hospitalization among patients using nocturnal and short daily compared to conventional hemodialysis: a USRDS study. Kidney Int 2009;76:984–990. 14 Burton PR, Walls J: A selection adjusted comparison of hospitalization on continuous ambulatory peritoneal dialysis and haemodialysis. J Clin Epidemiol 1989;42:531–539. 15 Charytan C, Spinowitz BS, Galler M: A comparative study of continuous ambulatory peritoneal dialysis and center hemodialysis. Efficacy, complications, and outcome in the treatment of end-stage renal disease. Arch Intern Med 1986;146:1138–1143. 16 Habach G, Bloembergen WE, Mauger EA, Wolfe RA, Port FK: Hospitalization among United States dialysis patients: hemodialysis versus peritoneal dialysis. J Am Soc Nephrol 1995;5:1940–1948. 17 Williams V, Quinn R, Callery S, Kiss A, Oliver M: The impact of treatment modality on infection-related hospitalization rates in peritoneal dialysis and hemodialysis patients. Perit Dial Int 2011;31:440–449.
Nephron Clin Pract 2014;126:124–127 DOI: 10.1159/000360541
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