Early hospital readmission among hemodialysis patients in the United States is associated with subsequent mortality

Association of Nutritional Risk Index With Infection-Related Hospitalization and Death After Hospitalization in Patients Undergoing Maintenance Hemodialysis

OBJECTIVE

Patients undergoing dialysis frequently experience hospitalization due to cardiovascular disease (CVD) and infection. This population is also at high risk of rehospitalization and subsequent death. In addition to serious outcomes, hospitalization incurs substantial medical cost. Prevention of hospitalization is accordingly an urgent matter. Here, we examined whether nutritional disorder was associated with hospitalization and subsequent death.

METHODS

The study was conducted under a prospective design using data from the Japanese Dialysis Outcomes and Practice Pattern Study. The exposure was the Nutritional Risk Index for Japanese Hemodialysis (NRI-JH), through which patients were divided into low-, medium-, and high-risk groups, with the low-risk group as referent. The primary outcome was CVD-related or infection-related hospitalization. Secondary outcome was all-cause mortality. For exploratory analyses, the associations of baseline or latest NRI-JH just before hospitalization, with death after hospitalizations, were examined.

RESULTS

Of 4021 patients, 566 patients had CVD-related hospitalization and 375 had infection-related hospitalization during a median follow-up of 2.6 years. NRI-JH at baseline was significantly associated with infection-related hospitalization but not with CVD-related hospitalization, in multivariable Cox models (hazard ratio [HR] 1.46, 95% confidential interval [CI]: 1.09 to 1.97, P = .012 for medium-risk vs. low-risk group) (HR 2.46, 95% CI: 1.81 to 3.35, P < .001 for high-risk vs. low-risk group). NRI-JH was also associated with all-cause mortality. In addition, the baseline and latest high-risk NRI-JH groups were significantly associated with death after both CVD-related and infection-related hospitalizations.

CONCLUSIONS

A higher nutritional risk as evaluated by NRI-JH was associated with infection-related hospitalization but not with CVD-related hospitalization. However, NRI-JH was significantly associated with death after both CVD-related and infection-related hospitalizations, suggesting that nutritional risk may be separately involved in hospitalization or subsequent death. NRI-JH may be useful in the planning of individual care to improve outcomes.

Recurrent Hospitalizations for Fluid Overload in Diabetes with Kidney Failure Treated with Dialysis

INTRODUCTION

Diabetes mellitus is the most common cause of end-stage kidney disease (ESKD) in Singapore. ESKD patients have high disease burden and are at increased risk of recurrent hospitalizations, including fluid overload. This study aimed to characterize the risk factors associated with readmissions for fluid overload that will identify high-risk hospitalizations for interventions to reduce readmissions.

METHODS

Retrospective cohort study of all hospitalizations for fluid overload in adults with diabetes and ESKD on dialysis in SingHealth hospitals between 2018 and 2021. Fluid overload was defined by discharge codes for fluid overload, heart failure, pulmonary edema, and generalized edema. Multivariable Cox regression analysis using the Prentice, Williams and Peterson Total Time model was performed for the outcomes of readmissions for fluid overload within 30 days and 90 days of discharge.

RESULTS

Among 3,234 hospitalizations for fluid overload, readmission for fluid overload within 30 days and 90 days occurred in 585 (18.1%) and 967 (29.9%) hospitalizations, respectively. Ischemic heart disease, peripheral vascular disease, and lower hemoglobin level were independently associated with readmissions for fluid overload within 30 and 90 days. Additionally, heart failure, hemodialysis (compared to peritoneal dialysis), and lack of statin at discharge were associated with increased 90-day readmission risk.

CONCLUSION

Modifiable (hemoglobin level, statin use) and non-modifiable factors (ischemic heart disease, peripheral vascular disease, and heart failure) influenced the risk of readmission for fluid overload. These results may guide risk stratification and inform targeted interventions to reduce avoidable, unplanned readmissions for recurrent fluid overload among individuals with diabetes and ESKD.

Dialysis Outcomes Across Countries and Regions: A Global Perspective From the International Society of Nephrology Global Kidney Health Atlas Study

Introduction

Kidney failure treated with hemodialysis (HD), or peritoneal dialysis (PD) is a major global health problem that is associated with increased risks of death and hospitalization. This study aimed to compare the incidence and causes of death and hospitalization during the first year of HD or PD among countries.

Methods

The third iteration of the International Society of Nephrology Global Kidney Health Atlas (ISN-GKHA) was conducted between June and September 2022. For this analysis, data were obtained from the cross-sectional survey of key stakeholders from ISN-affiliated countries.

Results

A total of 167 countries participated in the survey (response rate 87.4%). In 48% and 58% of countries, 1% to 10% of people treated with HD and PD died within the first year, respectively, with cardiovascular disease being the main cause. Access-related infections or treatment withdrawal owing to cost were important causes of death in low-income countries (LICs). In most countries, <30% and <20% of patients with HD and PD, respectively, required hospitalization during the first year. A greater proportion of patients with HD and PD in LICs were hospitalized in the first year than those in high-income countries (HICs). Access-related infection and cardiovascular disease were the commonest causes of hospitalization among patients with HD, whereas PD-related infection was the commonest cause in patients with PD.

Conclusion

There is significant heterogeneity in the incidence and causes of death and hospitalization in patients with kidney failure treated with dialysis. These findings highlight opportunities to improve care, especially in LICs where infectious and social factors are strong contributors to adverse outcomes.

Pay-for-performance programs effectiveness in healthcare: the case of the end-stage renal disease quality incentive program

This paper focuses on Medicare's End-Stage Renal Disease Quality Incentive Program (QIP). QIP aims to promote high-quality services in outpatient dialysis facilities by tying their payments to their performance on pre-specified quality measures. In this paper, employing principal-agent theory, we examine the effectiveness of QIP by exploring the changes in various clinical/operational measures when they become a part of the program as a performance measure. We study five QIP quality measures; two are operational: hospitalization and readmission. And three others are clinical: blood transfusion, hypercalcemia, and dialysis adequacy. Overall, we observe a significant improvement in all QIP quality measures after being included in the program, except for readmission. We recommend adjusting the weight and redesigning the readmission measure for Medicare to incentivize providers to reduce readmission. We also discuss establishing care coordination and employing data-driven clinical decision support systems as opportunities for dialysis facilities to improve the care delivery process.

Factors associated with readmission in chronic kidney disease: Systematic review and meta-analysis

BACKGROUND

Risk factors associated with all-cause hospital readmission are poorly characterised in patients with chronic kidney disease.

OBJECTIVE

A systematic review and meta-analysis were conducted to identify risk factors and protectors of hospital readmission in chronic kidney disease.

DESIGN, PARTICIPANTS & MEASUREMENTS

Studies involving adult patients were identified from four databases from inception to 31/03/2020. Random-effects meta-analyses were conducted to determine factors associated with all-cause 30-day hospital readmission in general chronic kidney disease, in dialysis and in kidney transplant recipient groups.

RESULTS

Eighty relevant studies (chronic kidney disease, n = 14 studies; dialysis, n = 34 studies; and transplant, n = 32 studies) were identified. Meta-analysis revealed that in both chronic kidney disease and transplant groups, increasing age in years and days spent at the hospital during the initial stay were associated with a higher risk of 30-day readmission. Other risk factors identified included increasing body mass index (kg/m2 ) in the transplant group, and functional impairment and discharge destination in the dialysis group. Within the chronic kidney disease ​​​​group, having an outpatient follow-up appointment with a nephrologist within 14 days of discharge was protective against readmission but this was not protective if provided by a primary care provider or a cardiologist.

CONCLUSION

Risk-reduction interventions that can be implemented include a nephrologist appointment within 14 days of hospital discharge, rehabilitation programme for functional improvement in the dialysis group and meal plans in the transplant group. Future risk analysis should focus on modifiable factors to ensure that strategies can be tested and implemented in those who are more at risk.

Interventions to Reduce Hospital Readmissions in Older African Americans: A Systematic Review of Studies Including African American Patients

OBJECTIVES

This systematic review aims to summarize interventions that effectively reduced hospital readmission rates for African Americans (AAs) aged 65 and older.

METHODS

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were followed for this review. Studies were identified by searching PubMed for clinical trials on reducing hospital readmission among older patients published between 1 January 1990 and 31 January 2020. Eligibility criteria for the included studies were mean or median age ≥ 65 years, AAs included in the study, randomized clinical trial or quasi-experimental design, presence of an intervention, and hospital readmission as an outcome.

RESULTS

There were 5270 articles identified and 11 were included in the final review based on eligibility criteria. The majority of studies were conducted in academic centers, were multi-center trials, and included over 200 patients, and 6-90% of participants were older AAs. The length of intervention ranged from 1 week to over a year, with readmission assessed between 30 days and 1 year. Four studies which reported interventions that significantly reduced readmissions included both inpatient (e.g., discharge planning prior to discharge) and outpatient care components (e.g., follow-ups after discharge), and the majority used a multifaceted approach.

CONCLUSION

Findings from the review suggest successful interventions to reduce readmissions among AAs aged 65 and older should include inpatient and outpatient care components at a minimum. This systematic review showed limited evidence of interventions successfully decreasing readmission in older AAs, suggesting a need for research in the area to reduce readmission disparities and improve overall health.

A novel model for predicting hospitalization risk among hemodialysis patients based on blood test variables

Hemodialysis patients are at high risk of hospitalization. Predicting such risk in dialysis patients may be critical to maintaining quality of life and reducing costs to the healthcare system. In this paper, we present and fractional polynomial stepwise logistic regression model to specify how routinely collected blood test variables could be linked to a significant increase in hospitalization risk. We found that eight of nineteen variables were significantly able to predict hospitalization risk; albumin (p<0.05), creatinine (p<0.05), calcium (p<0.01), bicarbonate (p<0.01), hemoglobin (p<0.05), mean cell hemoglobin concentration (MCHC) (p<0.0001), mean corpuscular volume (MCV) (p<0.0001), and potassium (p<0.01). The model achieved accuracy, sensitivity, and specificity of 77.31%, 83.03%, and 69.05%, respectively.

Hospitalization in maintenance peritoneal dialysis: a review

Although hemodialysis continues to be the dominant form of dialysis in the United States, peritoneal dialysis rates continue to rise both nationally and worldwide. Peritoneal dialysis offers patients increased flexibility due to the ability to dialyze at home, leading to potential quality of life benefits for patients. However, questions exist regarding clinical outcomes in patients on peritoneal dialysis and the literature has not recently been reviewed. This review examines hospitalizations within patients utilizing peritoneal dialysis, including comparison to other dialysis modalities. Much heterogeneity exists within the literature, often explained by patient population. Recent data show all-cause, cardiovascular, and infection-related hospitalizations to be high in patients on peritoneal dialysis, although data variation limits conclusions in comparison to other modalities. This review found there is insufficient evidence to suggest admission rates are different in peritoneal dialysis than in-center hemodialysis. While the rate is similar to infectious causes, most studies report cardiovascular complications to be the leading cause of hospitalization. Some evidence suggests that cardiovascular hospitalizations occur at a higher rate in peritoneal dialysis, but further studies are required. The infection-related hospitalization rate appears to be higher in peritoneal dialysis due to rates of peritonitis, but rates of life-threatening bacteremia are lower. Differences in reporting of hospital days vs. length of stay challenge the interpretability of length of stay data between modalities, but patients on PD may spend more days per year in the hospital. In summary, hospitalization is highly prevalent in patients on peritoneal dialysis and few definitive conclusions can be drawn in comparison to other dialysis modalities. In eligible patient populations who desire increased flexibility, peritoneal dialysis is a reasonable modality choice.

Atrial fibrillation and anticoagulation are associated with hospitalisations in patients with end-stage kidney disease on haemodialysis: a prospective population-based cohort study

BACKGROUND

Patients with end-stage kidney disease on haemodialysis suffer from frequent complications requiring hospitalisation. Atrial fibrillation is a burdensome comorbidity amongst patients on haemodialysis. We aimed to assess frequency, reasons, and duration of hospitalisations in haemodialysis patients and their association with atrial fibrillation and anticoagulation.

METHODS

Prevalent patients with end-stage kidney disease on haemodialysis were recruited into a prospective cohort study and observed for a median observation time of 3.4 years. Hospitalisations were recorded from discharge letters, medical records, and patient interviews. The association of atrial fibrillation, anticoagulation, and time-in-therapeutic range of vitamin K antagonist treatment with hospitalisations was analysed using negative binomial regression.

RESULTS

Out of 625 patients, 238 (38.1%) had atrial fibrillation. Median number of hospitalisations per patient was 3.0 (1.0-5.0). Incidence rate of hospitalisation was 1.7 per patient-year in all and 1.9 in atrial fibrillation patients, median duration per hospitalisation was 7.9 (4.8-12.9) and 8.8 (5.7-13.3) days, respectively. Most frequent reasons for hospitalisation were vascular access complication/intervention (11.7%) and infection/fever (11.4%), while bleeding events comprised 6.0% of all hospitalisations. Atrial fibrillation patients had 27% higher risk of hospitalisation than patients without atrial fibrillation (incidence rate ratio [IRR] 1.27, 95% confidence interval [CI] 1.10-1.47). In atrial fibrillation patients, anticoagulation (enoxaparin or phenprocoumon, 41.6% of AF patients) was associated with increased risk of all-cause (IRR 1.38, 95%CI 1.14-1.69) and bleeding-related hospitalisation (IRR 1.96, 95%CI 1.06-3.63). There was no association between anticoagulation and stroke-related hospitalisation. In atrial fibrillation patients on phenprocoumon, increasing time-in-therapeutic range was associated with decreased risk of all-cause (IRR 0.35, 95%CI 0.14-0.87), but not bleeding-related hospitalisation (IRR 0.13, 95%CI 0.01-1.38).

CONCLUSION

In haemodialysis patients, presence of atrial fibrillation and, among those with atrial fibrillation, anticoagulation were associated with higher risk of all-cause hospitalisation, including bleeding-related hospitalisation in the latter. Increasing time-in-therapeutic range in patients on vitamin K antagonist treatment was associated with decreased risk of all-cause, but not bleeding-related hospitalisation.

Effectiveness of a Web-Based Provider Communications Platform in Reducing Hospital Readmissions Among Patients Receiving Dialysis: A Pilot Pre-Post Study

Rationale & Objective

Suboptimal care coordination between dialysis facilities and hospitals is an important driver of 30-day hospital readmissions among patients receiving dialysis. We examined whether the introduction of web-based communications platform (“DialysisConnect”) was associated with reduced hospital readmissions.

Study Design

Pilot pre-post study.

Setting & Participants

A total of 4,994 index admissions at a single hospital (representing 2,419 patients receiving dialysis) during the study period (January 1, 2019-May 31, 2021).

Intervention

DialysisConnect was available to providers at the hospital and 4 affiliated dialysis facilities (=intervention facilities) during the pilot period (November 1, 2020-May 31, 2021).

Outcomes

The primary outcome was 30-day readmission; secondary outcomes included 30-day emergency department visits and observation stays. Interrupted time series and linear models with generalized estimating equations were used to assess pilot versus prepilot differences in outcomes; difference-in-difference analyses were performed to compare these differences between intervention versus control facilities. Sensitivity analyses included a third, prepilot/COVID-19 period (March 1, 2020-October 31, 2020).

Results

There was no statistically significant difference in the monthly trends in the 30-day readmissions pilot versus prepilot periods (−0.60 vs -0.13, P = 0.85) for intervention facility admissions; the difference-in-difference estimate was also not statistically significant (0.54 percentage points, P = 0.83). Similar analyses including the prepilot/COVID-19 period showed that, despite a substantial drop in admissions at the start of the pandemic, there were no statistically significant differences across the 3 periods. The age-, sex-, race-, and comorbid condition-adjusted, absolute pilot versus prepilot difference in readmissions rate was 1.8% (−3.7% to 7.3%); similar results were found for other outcomes.

Limitations

Potential loss to follow-up and pandemic effects.

Conclusions

In this pilot, the introduction of DialysisConnect was not associated with reduced hospital readmissions. Tailored care coordination solutions should be further explored in future, multisite studies to improve the communications gap between dialysis facilities and hospitals.

Epidemiology of End-Stage Renal Disease in Mogadishu, Somalia: First Report at a Tertiary Care Hospital

Background

End-stage renal disease (ESRD) in Somalia remains unexamined due to a lack of a national registry system, and the impact of the disease in the country is not estimated yet. The present study is the first report that aims to evaluate the epidemiological characteristics, causes, and dialysis-related factors associated with readmissions in ESRD patients who were going to routine hemodialysis.

Patients and methods

This cross-sectional observational study enrolled 208 patients with ESRD. Also, this study investigated patients readmitted to the hospital (n=135) after they enrolled in hemodialysis. The sociodemographic characteristics, risk factors, and comorbidities associated with these patients were reviewed. Admission site, length of hospital stay, outcome, and dialysis-related factors associated with readmissions in the first six months after being on a regular hemodialysis program were also assessed.

Results

The mean age of the patients was 52.7±15.0 years, 43.3% were >60 years, and 61.5% were male. The most common cause was diabetes at 39.4%, followed by hypertension (35.6%) and 12.5% for postrenal obstruction. The prevalence of 6-month hospital readmissions was 65%. The most common dialysis-related factor associated with readmissions was uremic complications due to missed hemodialysis sessions (40%), vascular access/catheter infection (20%), and anemia (17.8%) (95% CI: 0.825–5.357, OR: 3.017, p<0.04). Female cases were more vulnerable to vascular catheter site infection, anemia, and hyponatremia (p<0.001). 27.5% of the patients were admitted to the intensive care unit (ICU), and the most common reason for ICU admissions was pulmonary edema (53.8%), sepsis (42.8%), and uremia due to hemodialysis skip (26.4%) (95% CI: 1.507–13.632, OR: 2.08, p=0.01). The mortality rate was 5.2%.

Conclusion

The prevalence of unplanned hospital readmissions within six months was very high, and a missed hemodialysis session was identified as the leading cause. Inadequate knowledge, wrong social beliefs about the concept of dialysis and a lack of a health insurance system that covers the higher costs of each dialysis session are believed to be the causes of missed dialysis occasions.

Hospitalization patterns in HD patients in the Kingdom of Saudi Arabia: A comprehensive cohort study

INTRODUCTION

The rate of hospitalization represents a morbidity indicator in HD patients. The study aimed to evaluate hospitalization patterns in a large HD cohort.

METHODS

All DaVita-KSA HD patients from October 2014 to December 2019 were included. Demographical and clinical characteristics and hospitalization data were recorded. Less than 24 h admission was excluded. Overall and cause-specific hospitalization rates were calculated.

RESULTS

During the follow-up period, 3982 patients with a mean age of 52.5 ± 16.8 years, 2667 hospitalizations were recorded in 34.1% of the patients and 45.6% had repeated admissions. Infectious causes accounted for 26.6% of all recorded causes vs. 15.6% for cardiovascular complications. The median hospital stay length was 11 days, while the overall annual hospitalization rate of 34.9% and the annual duration of 3.7 days per patient. Hospitalized patients had a higher risk of mortality (p < 0.001).

CONCLUSION

Infectious complications were the leading cause of hospitalization and had the longest hospital stay.

Hospitalization in patients with dialysis in Taiwan: A nationwide population-based observational study

BACKGROUND

The hospitalization rate is higher in patients with end-stage kidney disease (ESKD) than in the general population. However, the national estimates in Taiwan remain unclear. Therefore, we investigated the hospitalization rates of ESKD patients in a disease-specific manner from 2010 to 2018 in Taiwan.

METHODS

This population-based study was conducted using data from the National Health Insurance Research Database. We analyzed the hospitalization rates of patients with ESKD, defined as continuous dialysis for at least three successive months. The first diagnosis at discharge for each hospitalization was defined as the main diagnosis of hospitalization. The hospitalization rate in a certain year was calculated as the number of hospitalizations divided by the number of patients undergoing chronic dialysis in the respective year.

RESULTS

Hospitalization occurred in half of all prevalent ESKD patients, with an increasing trend over time. The hospitalization rate increased from 964.1 per 1000 person-years in 2010 to 1037.9 per 1000 person-years in 2018. ESKD patients who were male, aged over 75 years, and receiving hemodialysis had higher hospitalization rates. Infection-related hospitalization was the main cause of hospitalization, followed by cardiovascular disease. The 30-day re-admission rate was 19%, and the in-hospital mortality rate was 9%.

CONCLUSION

Hospitalization rates continued to increase from 2010 to 2018. The high hospitalization rates for infection-related diseases and hemodialysis patients call for further strategies to be developed that reduce the hospitalization burden.

A Web-based, Provider-driven Mobile App to Enhance Patient Care Coordination between Dialysis Facilities and Hospitals: Development and Pilot Implementation Study (Preprint)

Background

Objective

Methods

Results

Conclusions

Quality of life assessment in patients on chronic dialysis: Comparison between haemodialysis and peritoneal dialysis at a national hospital in Vietnam

OBJECTIVES

End-stage renal disease (ESRD) is a chronic disease that can adversely affect the patient's quality of life (QoL) in terms of functional limitation and cognitive impairment. This study aimed to identify the factors associated with QoL in patients with ESRD undergoing dialysis at a national hospital in Vietnam.

METHODS

A descriptive cross-sectional study was conducted among outpatients aged ≥18 years who underwent haemodialysis (HD) or peritoneal dialysis (PD) for at least 3 months at Thong Nhat Hospital, Ho Chi Minh City, Vietnam from May 2020 to July 2021. QoL was measured using the validated Vietnamese version of the EuroQol-5 Dimensional-5 Level (EQ-5D-5L). The factors associated with the QoL of patients with ESRD undergoing dialysis were identified using multiple linear regression analysis.

RESULTS

In total, 131 (73.6%) and 47 (26.4%) patients underwent HD and PD, respectively. Overall, 178 (55.6%) patients were men (median age, 66 [56-79] years). The mean EQ-5D-5L score was significantly higher in patients undergoing PD than in those undergoing HD (0.848 ± 0.183 vs. 0.766 ± 0.231; p = 0.030). Older age (β = -0.006; p < 0.001) and peptic ulcer disease (β = -0.083; p = 0.029) were associated with lower QoL scores. PD treatment was associated with higher QoL scores (β = 0.065; p = 0.046).

CONCLUSIONS

It is necessary to improve the QoL of patients undergoing dialysis, especially of elderly patients and patients with peptic ulcer disease. PD may be a better method for maintenance dialysis, if applicable, in terms of QoL.

Home versus In-Center Dialysis and Day of the Week Hospitalization: A Cohort Study

Background

The dialysis treatment day after the 2-day interdialytic interval (Monday/Tuesday) is associated with a heightened risk of hospitalization for patients on in-center hemodialysis (ICHD). In this national cohort study, we sought to characterize hospitalizations by day of the week for patients receiving ICHD, home HD (HHD), and peritoneal dialysis (PD) and to identify whether there were differences in the probability of a Monday/Tuesday admission for each modality type.

Methods

Patients on maintenance dialysis in Canada were analyzed from 2005 to 2014 using the Canadian Organ Replacement Register. Patients on hemodialysis were categorized as those receiving ICHD, HHD, frequent ICHD, or frequent HHD (the latter two included short daily and nocturnal HD). Hospitalizations were attributed to the previous treatment if they occurred within 30 days of a treatment change. Differences in the proportion of patients experiencing a Monday/Tuesday admission with all other days of the week were compared using a generalized linear model with binomial distribution and reported using adjusted odds ratios (OR) with 95% CIs.

Results

Overall, 27,430 individuals experienced 111,748 hospitalization episodes. Rates per 1000 patient days were 3.76, 2.98, 2.71, 2.16, and 2.13 for each of frequent ICHD, ICHD, PD, HHD, and frequent HHD, respectively. Compared with those on ICHD, only patients receiving frequent HHD (OR, 0.89; 95% CI, 0.81 to 0.97) and PD (OR, 0.95; 95% CI, 0.93 to 0.97) had a lower odds of experiencing a Monday/Tuesday admission. The OR was lower when restricted to hospitalization episodes for cardiovascular reasons comparing frequent HHD with ICHD (OR, 0.68; 95% CI, 0.48 to 0.96).

Conclusion

In this nationally representative cohort, we identified that the probability of a Monday/Tuesday admission was lower for frequent HHD and PD compared with ICHD, most notably for hospitalizations due to cardiovascular causes. Gaining a better understanding of the reasons behind this observation may help to develop future strategies to reduce overall and cause-specific hospitalization for patients receiving dialysis.

Association of cardiovascular disease with 30-day hospital readmission in Chinese patients receiving maintenance dialysis

Background

Previous studies have shown cardiovascular disease (CVD) to be a risk factor in the prediction of 30-day hospital readmission among patients receiving dialysis. However, studies of Asian populations are limited. In the present study, we examined the association between CVD and 30-day hospital readmission in Chinese patients receiving maintenance dialysis.

Methods

Patients receiving maintenance dialysis were identified by searching a national claims database, the China Health Insurance Research Association (CHIRA) database, using the International Classification of Diseases revision 10 (ICD-10) and items of medical service claims. Patients aged ≥18 years who were discharged after index hospitalization between January 2015 and December 2015 were included in our retrospective analysis. CVD-related diagnoses were divided into three categories: coronary heart disease (CHD), heart failure (HF), and stroke. Thirty-day hospital readmission was defined as any hospital readmission within the 30 days following discharge. Logistic regression models adjusted for logit of propensity scores (PS) were used to assess the association of CVD with 30-day hospital readmission.

Results

Of 4,700 patients receiving dialysis, the 30-day hospital readmission rate was 10.4%. Compared with patients without CVD, there was an increased risk of 30-day hospital readmission among maintenance dialysis patients with total CVD [odds ratio (OR): 1.33, 95% confidence interval (CI): 1.06–1.66]. Patients with HF (OR: 1.77, CI: 1.27–2.47) and stroke (OR: 2.14, 95% CI: 1.53–2.98) had a greater risk of 30-day hospital readmission. The fully adjusted OR of CHD for the risk of 30-day hospital readmission was 1.22 (95% CI: 0.97–1.55).

Conclusions

CVDs, especially stroke and HF, are independent predictors of 30-day hospital readmission in Chinese patients receiving dialysis, and could help to guide interventions to improve the quality of care for these patients.

Strategies to Reduce Rehospitalization in Patients with CKD and Kidney Failure

Readmissions in patients with nondialysis-dependent CKD and kidney failure are common and are associated with significant morbidity, mortality, and economic consequences. In 2013, the Centers for Medicare and Medicaid Services implemented the Hospital Readmissions Reduction Program in an attempt to reduce high hospitalization-associated costs. Up to 50% of all readmissions are deemed avoidable and present an opportunity for intervention. We describe factors that are specific to the patient, the index hospitalization, and underlying conditions that help identify the "high-risk" patient. Early follow-up care, developing volume management strategies, optimizing nutrition, obtaining palliative care consultations for seriously ill patients during hospitalization and conducting goals-of-care discussions with them, instituting systematic advance care planning during outpatient visits to avoid unwanted hospitalizations and intensive treatment at the end of life, and developing protocols for patients with incident or prevalent cardiovascular conditions may help prevent avoidable readmissions in patients with kidney disease.

Prevalence, risk factors and impact on outcomes of 30-day unexpected rehospitalization in incident peritoneal dialysis patients

Background

Rehospitalization is a major problem for end stage renal disease (ESRD) populations. However, researches on 30-day unexpected rehospitalzation of incident peritoneal dialysis (PD) patients were limited. This study aimed to investigate the prevalence, risk factors and impact on outcomes of 30-day unexpected rehospitalization in incident PD patients.

Methods

This was a retrospective cohort study. Patients who accepted PD catheter implantation in our centre from Jan 1, 2006 to Dec 31, 2013 and regular follow-up were included. The demographic characteristics, laboratory parameters, and rehospitalization data were collected and analyzed. The primary outcome was all-cause mortality, and the secondary outcomes included cardiovascular disease (CVD) mortality and technical failure.

Results

Totally 1632 patients (46.9 ± 15.3 years old, 60.1% male, 25.6% with diabetes) were included. Among them, 149 (9.1%) had a 30-day unexpected rehospitalization after discharge. PD-related peritonitis (n = 48, 32.2%), catheter malfunction (n = 30, 20.1%) and severe fluid overload (n = 19, 12.8%) were the top three causes for the rehospitalization. Multivariate logistic regression analysis showed that length of index hospital stays [Odds ratio (OR) =1.02, 95% confidence interval (CI) 1.00–1.03, P = 0.036) and hyponatremia (OR = 1.85, 95% CI 1.06–3.24, P = 0.031) were independently associated with the rehospitalization. Multivariate Cox regression analysis indicated that 30-day rehospitalization was an independent risk factor for all-cause mortality [Hazard ratio (HR) =1.52, 95% CI 1.07–2.16, P = 0.019) and CVD mortality (HR = 1.73, 95% CI 1.03–2.90, P = 0.038).

Conclusions

The prevalence of 30-day unexpected rehospitalization for incident PD patients in our centre was 9.1%. The top three causes for the rehospitalization were PD-related peritonitis, catheter malfunction and severe fluid overload. Thirty-day unexpected rehospitalization increased the risk of all-cause mortality and CVD mortality for PD patients.

Retracted: Transforming Growth Factor Beta-1 Promotes Smooth Muscle Cell Proliferation and Migration in an Arteriovenous Fistulae: The Role of Wall Shear Stress

Retraction: Lan Jia, Fang Wei, Lihua Wang, Haiyan Chen, Haibo Yu, Zhe Wang and Aili Jiang "Transforming Growth Factor Beta-1 Promotes Smooth Muscle Cell Proliferation and Migration in an Arteriovenous Fistulae: The Role of Wall Shear Stress" Therapeutic Apheresis and Dialysis (https://onlinelibrary.wiley.com/doi/10.1111/1744-9987.12781). The above article, published online on 06 December 2018 in Wiley Online Library (wileyonlinelibrary.com), has been retracted by agreement between the authors, the journal Editor in Chief, Tadao Akizawa, and John Wiley and Sons Australia Ltd. The retraction has been agreed due to major overlap with a previously published article.

Early Hospital Readmission (EHR) in kidney transplantation: a review article

Early hospital readmission (EHR), defined as all readmissions within 30 days of initial hospital discharge, is a health care quality measure. It is influenced by the demographic characteristics of the population at risk, the multidisciplinary approach for hospital discharge, the access, coverage, and comprehensiveness of the health care system, and reimbursement policies. EHR is associated with higher morbidity, mortality, and increased health care costs. Monitoring EHR enables the identification of hospital and outpatient healthcare weaknesses and the implementation of corrective interventions. Among kidney transplant recipients in the USA, EHR ranges between 18 and 47%, and is associated with one-year increased mortality and graft loss. One study in Brazil showed an incidence of 19.8% of EHR. The main causes of readmission were infections and surgical and metabolic complications. Strategies to reduce early hospital readmission are therefore essential and should consider the local factors, including socio-economic conditions, epidemiology and endemic diseases, and mobility.

Long-term outcomes among Medicare patients readmitted in the first year of hemodialysis: a retrospective cohort study

Background

Readmission within 30 days of hospital discharge is common and costly among end-stage renal disease (ESRD) patients. Little is known about long-term outcomes after readmission. We estimated the association between hospital admissions and readmissions in the first year of dialysis and outcomes in the second year.

Methods

Data on incident dialysis patients with Medicare coverage were obtained from the United States Renal Data System (USRDS). Readmission patterns were summarized as no admissions in the first year of dialysis (Admit-), at least one admission but no readmissions within 30 days (Admit+/Readmit-), and admissions with at least one readmission within 30 days (Admit+/Readmit+).We used Cox proportional hazards models to estimate the association between readmission pattern and mortality, hospitalization, and kidney transplantation, accounting for demographic and clinical covariates.

Results

Among the 128,593 Medicare ESRD patients included in the study, 18.5% were Admit+/Readmit+, 30.5% were Admit+/Readmit-, and 51.0% were Admit-. Readmit+/Admit+ patients had substantially higher long-term risk of mortality (HR = 3.32 (95% CI, 3.21–3.44)), hospitalization (HR = 4.46 (95% CI, 4.36–4.56)), and lower likelihood of kidney transplantation (HR = 0.52 (95% CI, 0.44–0.62)) compared to Admit- patients; these associations were stronger than those among Admit+/Readmit- patients.

Conclusions

Patients with readmissions in the first year of dialysis were at substantially higher risk of poor outcomes than either patients who had no admissions or patients who had hospital admissions but no readmissions. Identifying strategies to both prevent readmission and mitigate risk among patients who had a readmission may improve outcomes among this substantial, high-risk group of ESRD patients.

Electronic supplementary material

The online version of this article (10.1186/s12882-019-1473-0) contains supplementary material, which is available to authorized users.

National Study of Index and Readmission Mortality and Costs for Thoracic Endovascular Aortic Repair in Patients With Renal Disease

BACKGROUND

In the current era of value-based health care delivery, an understanding of patient populations at greatest risk for mortality, complications, and readmissions after thoracic endovascular aortic repair (TEVAR) is warranted. Thus, the present study aimed to evaluate outcomes after TEVAR for patients with varying degrees of renal dysfunction.

METHODS

All patients who underwent TEVAR from 2010 to 2015 in the Nationwide Readmissions Database were identified. These patients were further stratified into four groups: no chronic kidney disease (NCKD), chronic kidney disease (CKD) stages 1 to 3 (CKD1-3), CKD 4 to 5 (CKD4-5), and end-stage renal disease (ESRD) requiring dialysis. Multivariable regression analysis was used to study index mortality, early (30 days) and intermediate (31-90 days) readmissions, costs, and length of stay. Kaplan-Meier analyses were performed to compare readmission performance among all four groups.

RESULTS

An estimated 121,046 patients underwent TEVAR with 26,653 (22.1%) being elective. Patients with ESRD comprised 2.7% of elective and 5.4% of nonelective TEVAR operations. Patients with CKD4-5 (17.8%; P = .01) and with ESRD (21.1%; P < .001), but not with CKD1-3 (14.1%; P = .12), had remarkably higher early readmission rate than the NCKD cohort (9.2%). Patients with ESRD had remarkably higher hospitalization costs than the NCKD group ($7456; 95% confidence interval, $2629-$12,283). Cardiovascular, infectious, and vascular complications were the most prevalent diagnoses on readmission, with no remarkable difference among the NCKD and CKD4-5/ESRD groups.

CONCLUSIONS

Nearly 10% of all patients with TEVAR have evidence of chronic kidney disease of varying severity. Only patients with ESRD are at risk of substantially higher odds of mortality, readmissions, index length of stay, and costs compared with the non-CKD cohort.

Burden and Correlates of Hospital Readmissions among U.S. Peritoneal Dialysis Patients

Background:Hospital readmissions are common among in-center hemodialysis patients, but little is known about readmissions among peritoneal dialysis (PD) patients. Using national administrative data, we aimed to examine the burden and correlates of hospital readmissions among U.S. PD patients.Methods:Among 10,505 adult U.S. PD patients with an index admission (first admission after 120 days on dialysis) between 31 January 2011 and 30 November 2014, readmissions were defined as new hospital admissions within 30 days of index discharge. Multivariable logistic regression was used to obtain adjusted odds ratios (ORs) for readmission.Results:Overall, 26.8% of index admissions were followed by a readmission. Readmitted patients were more likely to have congestive heart failure (31.0% vs 25.4%; p < 0.001) and peripheral arterial disease (11.6% vs 8.6%; p < 0.001) and had longer index admission length of stay (median = 4 vs 3 days; p < 0.001) than those who were not; age, sex, and race did not differ by readmission status. After adjustment for patient and index admission characteristics, longer length of stay (≥ 4 vs < 4 days, OR = 1.48, 95% confidence interval [CI] 1.35 - 1.62), peripheral arterial disease (OR = 1.31, 95% CI 1.16 - 1.57), congestive heart failure (OR = 1.25, 95% CI 1.13 - 1.39), and ischemic heart disease (OR = 1.12, 95% CI 1.01 - 1.24) were associated with higher likelihood of readmission; index admission due to peritonitis vs other causes was associated with lower likelihood of readmission (OR = 0.80, 95% CI 0.70 - 0.92).Conclusions:Our results suggest that, particularly in the absence of a PD-related cause of hospitalization such as peritonitis, PD patients may be at high risk for readmission and may benefit from closer post-discharge monitoring.

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

Background

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

Methods

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

Results

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

Conclusions

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

Electronic supplementary material

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

Hospital readmission for the dialysis patient: who is (not) responsible?

A new study in dialysis patients demonstrates that more than one-third of rehospitalizations within 30 days of discharge occur within the first week, and these rehospitalizations are associated with worse survival. Imposing a penalty on the dialysis provider for these rehospitalizations, as mandated by the Hospital Readmissions Reduction Program, may be inefficient in reducing health care costs and improving patient outcomes. Systems for improving communication between the hospital and posthospitalization nephrologist about patient care are needed.

Hospitalizations in Dialysis Patients in Canada: A National Cohort Study

Background:

Hospitalizations of chronic dialysis patients have not been previously studied at a national level in Canada. Understanding the scope and variables associated with hospitalizations will inform measures for improvement.

Objective:

To describe the risk of all-cause and infection-related hospitalizations in patients on dialysis.

Design:

Retrospective cohort study using health care administrative databases.

Setting:

Provinces and territories across Canada (excluding Manitoba and Quebec).

Patients:

Incident chronic dialysis patients with a dialysis start date between January 1, 2005, and March 31, 2014. Patients with a prior history of kidney transplantation were excluded.

Measurements:

Patient characteristics were recorded at baseline. Dialysis modality was treated as a time-varying covariate. The primary outcomes of interest were all-cause and dialysis-specific infection-related hospitalizations.

Methods:

Crude rates for all-cause hospitalization and infection-related hospitalization were determined per patient year (PPY) at 7 and 30 days, and at 3, 6, and 12 months postdialysis initiation. A stratified, gamma-distributed frailty model was used to assess repeat hospital admissions and to determine the inter-recurrence dependence of hospitalizations within individuals, as well as the hazard ratio (HR) attributed to each covariate of interest.

Results:

A total of 38 369 incident chronic dialysis patients were included: 38 088 adults and 281 pediatric patients (age less than 18 years). There were 112 374 hospitalizations, of which 11.5% were infection-related hospitalizations. The all-cause hospitalization rate was similar for all adult age groups (age 65 years and older: 1.40, 1.35, and 1.18 admissions PPY at 7 days, 30 days, and 6 months, respectively). The all-cause hospitalization rate was higher for pediatric patients (1.67, 2.48, and 2.47 admissions PPY at 7 days, 30 days, and 6 months, respectively; adjusted HR: 2.73, 95% confidence interval [CI]: 2.37-3.15, referent age group: 45-64 years). Within the first 7 days after dialysis initiation, patients on peritoneal dialysis had a higher risk of all-cause hospitalization (HR: 1.27, 95% CI: 1.07-1.50) and infection-related hospitalization (HR: 2.05, 95% CI: 1.19-3.55) compared with patients on hemodialysis. Beyond 7 days, the risk did not differ significantly by dialysis modality. Female sex and Indigenous race were significant risk factors for all-cause hospitalization.

Limitations:

The cohort had too few home hemodialysis patients to examine this subgroup. The outcome of infection-related hospitalization was determined using diagnostic codes. Dialysis patients from Manitoba and Quebec were not included.

Conclusions:

In Canada, the rates of hospitalization were not influenced by dialysis modality beyond the initial 7-day period following dialysis initiation; however, the rate of hospitalization in pediatric patients was higher than in adults at every time frame examined.

Hospital Readmission among New Dialysis Patients Associated with Young Age and Poor Functional Status

BACKGROUND/AIMS

Over one-third of hospital discharges among dialysis patients are followed by 30-day readmission. The first year after dialysis start is a high-risk time frame. We examined the rate, causes, timing, and predictors of 30-day readmissions among adult, incident dialysis patients.

METHODS

Hospital readmissions were assessed from the 91st day to the 15th month after the initiation of dialysis using a Mayo Clinic registry linkage to United States Renal Data System claims during the period January 2001-December 2010.

RESULTS

Among 1,727 patients with ≥1 hospitalization, 532 (31%) had ≥1, and 261 (15%) had ≥2 readmissions. Readmission rate was 1.1% per person-day post-discharge, and the highest rates (2.5% per person-day) occurred ≤5 days after index admission. The overall cumulative readmission rate was 33.8% at day 30. Common readmission diagnoses included cardiac issues (22%), vascular disorders (19%), and infection (13%). Similar-cause readmissions to index hospitalization were more common during days 0-14 post-discharge than days 15-30 (37.5 vs. 22.9%; p = 0.004). Younger age at dialysis initiation, inability to transfer/ambulate, serum creatinine ≤5.3 mg/dL, higher number of previous hospitalizations, and longer duration on dialysis were associated with higher readmission rates in multivariable analyses. Patients aged 18-39 were few (8.3%) but comprised 17.7% of "high-readmission" users such that a 30-year-old patient had an 87% chance of being readmitted within 30 days of any hospital discharge, whereas an 80-year-old patient had a 25% chance.

CONCLUSIONS

Overall, 30-day readmissions are common within the first year of dialysis start. The first 10-day period after discharge, young patients, and those with poor functional status represent key areas for targeted interventions to reduce readmissions.