Characterizing Hospitalizations of End-Stage Renal Disease Patients on Dialysis and Inpatient Utilization of Erythropoiesis-Stimulating Agent Therapy

Causes of Hospitalization among End-Stage Kidney Disease Cohort before and after Hemodialysis

Patients with end-stage kidney disease (ESKD) have a greater risk of comorbidities, including diabetes and anemia, and have higher hospital admission rates than patients with other diseases. The cause of hospital admissions is associated with ESKD prognosis. This retrospective cohort study involved patients with ESKD who received hemodialysis and investigated whether the cause of hospital admission changed before versus after they started hemodialysis. This study recruited 592 patients with ESKD who received hemodialysis at any period between January 2005 and November 2017 and had been assigned the International Classification of Diseases Ninth Revision Clinical Modification (ICD-9-CM) code for ESKD. The patients' demographic data and hospitalization status one year before and two years after they received hemodialysis were analyzed. A McNemar test was conducted to analyze the diagnostic changes from before to after hemodialysis in patients with ESKD. The study's sample of patients with ESKD comprised more women (51.86%) than men and had an average age of 67.15 years. The numbers of patients admitted to the hospital for the following conditions all decreased significantly after they received hemodialysis: type 2 (non-insulin-dependent and adult-onset) diabetes; native atherosclerosis; urinary tract infection; gastric ulcer without mention of hemorrhage, perforation, or obstruction; pneumonia; reflux esophagitis; duodenal ulcer without mention of hemorrhage, perforation, or obstruction; and bacteremia. Most patients exhibited one or more of the following comorbidities: diabetes (n = 407, 68.75%), hypertension (n = 491, 82.94%), congestive heart failure (n = 161, 27.20%), ischemic heart disease (n = 125, 21.11%), cerebrovascular accident (n = 93, 15.71%), and gout (n = 96, 16.22%). An analysis of variance (ANOVA) indicated that changes in the ICD-9-CM codes for native atherosclerosis, urinary tract infection, pneumonia, and hyperkalemia were associated with age. Patients who developed pneumonia before or after they received hemodialysis tended to be older (range: 69-70 years old). This study investigated the causes of hospital admission among patients with ESKD one year before and two years after they received hemodialysis. This study's results revealed hypertension to be the most common comorbidity. Regarding the cause of admission, pneumonia was more prevalent in older than in younger patients. Moreover, changes in the ICD-9-CM codes of native atherosclerosis, urinary tract infection, pneumonia, and hyperkalemia were significantly correlated with age. Therefore, when administering comprehensive nursing care and treatment for ESKD, clinicians should not only focus on comorbidities but also consider factors (e.g., age) that can affect patient prognosis.

Treatment of anemia in difficult-to-manage patients with chronic kidney disease

The management of anemia of chronic kidney disease (CKD) is often challenging. In particular, for patients with underlying inflammation, comorbid type 2 diabetes or cancer, those hospitalized, and recipients of a kidney transplant, the management of anemia may be suboptimal. Responsiveness to iron and/or erythropoiesis-stimulating agents, the mainstay of current therapy, may be reduced and the risk of adverse reactions to treatment is increased in these difficult-to-manage patients with anemia of CKD. This review discusses the unique patient and disease characteristics leading to complications and suboptimal treatment response. New treatment options in clinical development, such as hypoxia-inducible factor-prolyl hydroxylase (HIF-PH) inhibitors, may be particularly useful for difficult-to-treat patients. In clinical studies, HIF-PH inhibitors provided increased hemoglobin levels and improved iron utilization in anemic patients with non-dialysis-dependent and dialysis-dependent CKD, and preliminary data suggest that HIF-PH inhibitors may be equally effective in patients with or without underlying inflammation. The availability of new treatment options, including HIF-PH inhibitors, may improve treatment outcomes in difficult-to-manage patients with anemia of CKD.

Predictors of adherence to a new erythropoiesis-stimulating agent inpatient ordering policy: A cross-sectional study

Background

Erythropoiesis-stimulating agents (ESAs) are recommended for treating anemia in patients with chronic kidney disease and end-stage renal disease. However, misappropriate and over-use of these agents can be costly and unnecessary in some settings.

Objective

The primary aim was to identify predictors of adherence to a newly approved ESA inpatient ordering policy. The secondary aims were to evaluate the impact of a 5-day delay in the initiation of ESA therapy on ESA usage, hemoglobin (Hb) levels, and costs.

Methods

This retrospective observational record review included a sample of adult patients admitted to four tertiary care hospitals from November 1, 2013 to August 31, 2014. Multivariable logistic and linear regression analyses were used to calculate the odds of adherence to the new ESA inpatient ordering policy and the impact of this policy on discharge Hb level, respectively.

Results

A total of 242 patients were included. The majority of the prescribers (77%) adhered to the new ESA ordering policy. Hemoglobin (OR = 1.306; 95% CI: 1.03–1.65) and ferritin (OR = 3.91; 95% CI: 1.23–12.51) levels at admission and length of hospital stay were positively correlated with the odds of patients receiving ESAs after day 5 (OR = 1.12; 95% CI:1.05–1.20). Furthermore, adherence to the new policy did not have a significant impact on discharge Hb level (β = 0.02349; P = 0.895).

Conclusions

Prescribers were adherent to a 5-day delay in the initiation of ESA therapy policy which resulted in a reduction in ESA usage, did not impact the discharge Hb levels, and was proven to be cost effective.

On-label and off-label prescribing patterns of erythropoiesis-stimulating agents in inpatient hospital settings in the US during the period of major regulatory changes

BACKGROUND

A number of policy and labeling interventions aimed at reducing inappropriate prescribing of erythropoiesis-stimulating agents (ESAs) were implemented in the U.S. between 2006 and 2010. These interventions included the addition of an FDA Black Box Warning to ESA labeling, the implementation of a Risk Evaluation and Mitigation Strategy program, and the adoption of payment restrictions by the Centers for Medicare and Medicaid Services (CMS). The impact of these safety interventions on different types of ESA prescribing (on-label, off-label; evidence-based, not evidence-based) has not been investigated in a single study.

OBJECTIVES

The objective of this study was to explore the prescribing patterns of ESAs for on- and off-label indications in the U.S. hospital inpatients during the period of major policy and labeling changes.

METHODS

A retrospective analysis of ESAs utilization patterns was conducted using Cerner Health Facts^® database from January 1, 2005 to June 30, 2011. The study population consisted of adult patients admitted to hospitals during the study period who received at least one ESAs order. Indications for ESA use were assigned based on ICD-9 CM diagnosis codes, procedure codes, and medication records. ESA use was then classified based on FDA-approval and the strength of scientific evidence supporting its use. Indication categories included (1) on-label use (ONS); (2) off-label use, supported (OFS); and (3) off-label use, unsupported (OFU). Descriptive statistics were used to examine ESA use by patient, hospital, and physician characteristics and over time.

RESULTS

ESAs were most frequently prescribed for ONS (48.7%), followed by OFU (42.7%) and OFS indications (8.6%). Of all off-label use, 83.2% were for unsupported indications. Between 2005 and 2010, the percent of inpatient visits with ESA use decreased for supported indications, both on-label (-63.2%) and off-label (-78.2%), but increased for unsupported indications (80%). OFU use surpassed ONS use as the most common type of ESA use in 2009.

CONCLUSIONS

Total and ONS ESA use decreased markedly, while OFU ESA use continued to increase during the period of major policy and labeling changes.

The impact of dialysis therapy on older patients with advanced chronic kidney disease: a nationwide population-based study

BACKGROUND

Older patients with advanced chronic kidney disease (CKD) face the decision of whether to undergo dialysis. Currently available data on this issue are limited because they were generated by small, short-term studies with statistical drawbacks. Further research is urgently needed to provide objective information for dialysis decision making in older patients with advanced CKD.

METHODS

This nationwide population-based cohort study was conducted using Taiwan's National Health Insurance Research Database. Data from 2000 to 2010 were extracted. A total of 8,341 patients≥70 years old with advanced CKD and serum creatinine levels>6 mg/dl, who had been treated with erythropoiesis-stimulating agents were included. Cox proportional hazard models in which initiation of chronic dialysis was defined as the time-dependent covariate were used to calculate adjusted hazard ratios for mortality. The endpoint was all-cause mortality.

RESULTS

During a median follow-up period of 2.7 years, 6,292 (75.4%) older patients chose dialysis therapy and 2,049 (24.6%) received conservative care. Dialysis was initiated to treat kidney failure a median of 6.4 months after enrollment. Dialysis was associated with a 1.4-fold increased risk of mortality compared with conservative care (adjusted hazard ratio 1.39, 95% confidence interval 1.30 to 1.49). In subgroup analyses, the risk of mortality remained consistently increased, independent of age, sex and comorbidities.

CONCLUSIONS

In older patients, dialysis may be associated with increased mortality risk and healthcare cost compared with conservative care. For patients who are ≥70 years old with advanced CKD, decision making about whether to undergo dialysis should be weighted by consideration of risks and benefits.

Trends in US hospital stays for Streptococcus pneumoniae-associated hemolytic uremic syndrome

BACKGROUND

Hemolytic uremic syndrome (HUS) is usually associated with diarrheal illness but can also occur in children with Streptococcus pneumoniae infection (SpHUS), particularly those with complicated pneumonia. Based on recent reports that hospital discharges for complicated pneumococcal pneumonia are increasing in US children, we studied whether discharges for SpHUS might also be increasing.

METHODS

We used the Kids' Inpatient Database samples from 1997, 2000, 2003, 2006 and 2009 to estimate trends in US hospital discharges of children (0-18 years) for whom diagnosis codes indicated invasive pneumococcal disease, HUS, or both (SpHUS). Univariate and multivariate analyses were based on 2009 discharges.

RESULTS

During the 5 study years, annual numbers of US hospital discharges for SpHUS approximately doubled (P = 0.025 for linear trend) and cumulatively totaled an estimated 211 discharges. In 2009, SpHUS accounted for 4.6% (95% confidence interval [CI]: 3.0%-6.7%) of HUS discharges, 0.7% (95% CI: 0.5%-1.0%) of invasive pneumococcal disease discharges and 3.0% (95% CI: 2.0%-3.9%) of discharges for complicated pneumococcal pneumonia. Discharges for SpHUS were more likely than those for other invasive pneumococcal disease to occur in children <3 years of age and to incur longer length of stay and greater hospital charges. SpHUS was independently associated with pneumococcal sepsis/bacteremia (age-adjusted odds ratio 3.8; 95% CI: 1.9-7.8) and complicated pneumonia (odds ratio 9.2; 95% CI: 4.1-20.7).

CONCLUSIONS

SpHUS is an uncommon but severe illness that primarily affects young children and is strongly associated with complicated pneumococcal pneumonia. US hospital stays for SpHUS appear to be increasing along with those for complicated pneumococcal pneumonia.

Impact of sevelamer versus calcium-based binders on hospitalizations and missed in-center dialysis treatments among CKD patients on dialysis: a modeled analysis

PURPOSE

The avoidance of hospitalizations and the maintenance of in-center dialysis sessions in patients receiving dialysis for end-stage renal disease (ESRD) have obvious benefits to patients, dialysis providers and payers. Benefits include better continuity of care, better patient outcomes, improved quality of life, and reduced healthcare expenditures. The objective of this study was to quantify, from the perspective of a dialysis provider in the US, the potential impact of sevelamer versus calcium-based binders (CBBs) on hospitalization days and maintenance of in-center dialysis sessions among hyperphosphatemic dialysis patients.

METHODS

A Microsoft Excel-based model was developed to simulate the number of missed dialysis sessions among three hypothetical cohorts of hyperphosphatemic patients treated with either sevelamer or CBBs. The cohorts were characterized by their size to represent a small, mid-size, or large dialysis organization (75, 30,000, and 120,000 patients, respectively). In any given month, a patient in the model could receive dialysis treatments within the center, experience a hospitalization, or die. Treatment-specific monthly survival rates, hospitalization rates, length of stay, and binder dosages were derived from the Dialysis Clinical Outcomes Revisited (DCOR) study. A dialysis schedule of three treatments per week was assumed. Analyses were conducted for a 1-year time horizon.

RESULTS

For a small dialysis center, CBBs were associated with an increased number of missed in-center dialysis treatments (447) compared to sevelamer (395). Thus, sevelamer use avoided 52 missed in-center dialysis sessions during 1 year of treatment compared to CBBs. The magnitude of sevelamer's impact on maintaining in-center dialysis treatments increased with the size of the dialysis organization; for a mid-size dialysis organization sevelamer use avoided 20,571 missed in-center dialysis sessions and for a large dialysis organization sevelamer use avoided 82,286 missed in-center dialysis sessions.

CONCLUSIONS

Treatment of hyperphosphatemic dialysis patients with sevelamer relative to CBBs was associated with a reduction in the number of missed in-center dialysis treatments across small, mid-size, and large dialysis organizations. This reduction could contribute to improved patient outcomes via undisrupted delivery of care within the dialysis clinic. The use of sevelamer versus CBBs could also result in an increased number of reimbursement payments to dialysis clinics and providers by avoiding missed in-center dialysis sessions due to hospitalization.

Glycated albumin, not hemoglobin A1c, predicts cardiovascular hospitalization and length of stay in diabetic patients on dialysis

BACKGROUND

The utility of glycated hemoglobin (HbA1c) and glycated albumin (GA) in diabetic dialysis patients remains unknown. GA was previously associated with all-cause hospitalization and patient survival. Relationships between GA, HbA1c, and casual plasma glucose (PG) with cause-specific cardiovascular (CV) disease, infectious disease (ID), and vascular access- (VA) related hospitalization rates and length of stay (LOS) were assessed.

METHODS

444 prevalent diabetic dialysis patients had monthly PG, quarterly GA, and all HbA1c values recorded for 2.33 years; hospitalizations within 17 and 30 days of testing were evaluated. Best-fit, time-dependent Cox models were constructed in unadjusted, case-mix-adjusted (age, sex, race, BMI, diabetes duration, dialysis vintage), and case-mix- plus lab-adjusted (hemoglobin, albumin, phosphorus) models.

RESULTS

Mean ± SD diabetes duration was 18.5 ± 10.8 years and dialysis vintage 2.9 ± 2.6 years. In fully adjusted models, CV hospitalization rates were associated with increasing GA (HR 1.32; 95% CI 1.11-1.57; p = 0.002 at 17 days; HR 1.21; p = 0.02 at 30 days) and PG (HR 1.10; 95% CI 1.02-1.17; p = 0.01 at 17 days; HR 1.07; p = 0.03 at 30 days), not HbA1c (HR 1.24; 95% CI 0.89-1.73; p = 0.21 at 17 days; HR 1.26; p = 0.10 at 30 days). LOS for CV admissions was positively associated with GA (HR 1.18; 95% CI 1.01-1.39; p = 0.03), not PG (HR 1.04; 95% CI 0.99-1.10; p = 0.15) or HbA1c (HR 1.03; 95% CI 0.92-1.15; p = 0.21). Admissions due to ID and VA complications (and LOS) did not correlate with these assays.

CONCLUSIONS

Improved glycemic control based on GA and PG predicted CV-related hospitalizations; GA also predicted CV hospitalization LOS. HbA1c did not predict cause-specific hospitalizations in dialysis populations.

An Epidemiological Study of Anemia and Renal Dysfunction in Patients Admitted to ICUs across the United States

The aims of this study were to determine the associations between anemia of critical illness, erythropoietin stimulating agents (ESA), packed red blood cell transfusions and varying degrees of renal dysfunction with mortality, and ICU- and hospital length of stay (LOS). This was a cross-sectional retrospective study of 5,314 ICU patients from USA hospitals. Hospital, patient demographics, and clinical characteristics were collected. Predictors of mortality and hospital and ICU LOS were evaluated using multivariate logistic regression models. The mean ICU admission hemoglobin in this study was 9.4 g/dL. The prevalence of ESA use was 13% and was associated with declining renal function; 26% of the ICU patients in this study received transfusion. ESA utilization was associated with 28% longer hospital LOS (P < 0.001). ICU LOS was increased by up to 18% in patients with eGFR rates of <30 and 30-59 mL/min/1.73 m(2), respectively (P < 0.05) but not in those receiving dialysis. Mortality was significantly associated with renal dysfunction and dialysis with odds ratios of 1.94, 2.66 and 1.40 for the dialysis, and eGFR rates of <30 and 30-59 and mL/min/1.73 m(2), respectively (P < 0.05). These data provide a snapshot of anemia treatment practices and outcomes in USA ICU patients with varying degrees of renal dysfunction.

Simplifying anemia management in hemodialysis patients: ESAs administered at longer dosing intervals can enhance opportunities to provide patient-focused care

OBJECTIVE

To review issues and challenges in caring for hemodialysis patients with anemia of chronic kidney disease, specifically focusing on the effects of longer erythropoiesis-stimulating agent (ESA) dosing intervals on processes of care.

METHODS

PubMed searches were performed limited to the last 10 years to February 2011, focusing on articles in English that were 'clinical trials,' assessed processes of care, measured associations of hemoglobin (Hb) with outcomes, and explored/analyzed extended dosing intervals of ESAs in hemodialysis patients and recommendations for increasing the quality of care of these patients. Some limitations included the fact that a meta-analysis was not conducted; many studies were associative and therefore unable to prove causality; and none of the clinical trials directly compared the impact of more frequent or less frequent ESA dosing strategies on patient care and outcomes.

FINDINGS

Progress over the past several decades has been substantial; however, unmet needs remain and there is room for improvement in efficiencies of care. Many patients fail to meet Hb targets, and nephrology professionals' time is consumed with preparing, administering, and monitoring therapy. Direct interaction between patients and care providers has been lost as attention has shifted to 'cost-effective' (not necessarily patient-centered) ways to deliver care. Use of ESAs at longer dosage intervals represents one opportunity to improve efficiency of care. Newer ESAs have been developed for less frequent dosing. Once-monthly dosing decreases time spent administering/monitoring therapy and allows nephrology professionals to provide comprehensive renal care, wherein the patient rather than task-oriented processes becomes the primary focus.

CONCLUSIONS

A fragmented, uncoordinated care-delivery model heightens the urgency to systematically address issues related to delivery of care and improve efficiencies in anemia management as part of the patient-centered approach. ESAs designed for administration at longer intervals may effectively and reliably achieve Hb targets with once-monthly dosing, thereby decreasing time spent administering/monitoring therapy.