Hurricane Sandy Adversely Affected ESRD Patients

Emergency department visit and hospitalization rates increased in wake of storm, which highlights the need for pre-planning.
Emergency department visit and hospitalization rates increased in wake of storm, which highlights the need for pre-planning.

Patients with end-stage renaldisease (ESRD) in the regions affected by Hurricane Sandy in October 2012 experienced higher rates of emergency department (ED) visits and hospitalization as well as a slightly higher 30-day mortality rate, according to a new study. 

Using claims data from the Centers for Medicare & Medicaid Services, researchers compared a study group of ESRD patients in the areas most affected by the hurricane (New Jersey and New York City) with 2 comparison groups: (1) ESRD patients living in states unaffected by Sandy during the same period; and (2) ESRD patients living in the Sandy-affected region a year prior to Sandy (October 1, 2011 through October 30, 2011). 

Of 13,264 study group patients, 59% received early dialysis in 70% of the New York City and New Jersey dialysis facilities. The ED visit rate was 4.1% for the study group compared with 2.6% and 1.7% of comparison groups 1 and 2, respectively, the researchers reported in the American Journal of Kidney Diseases (2015;65:109–115). The hospitalization rate for the study group was 4.5%, which was significantly higher than the 3.2% and 3.8% rates for comparison groups 1 and 2, respectively. 

In addition, among patients who visited the ED, those in the study group were significantly more likely to receive dialysis there than those in comparison groups 1 and 2 (23% vs. 9.3% and 6.3%, respectively). 

The 30-day mortality rate for the study group was significantly higher than that of comparison group 1 (1.47%) and slightly but not significantly higher than that of comparison group 2 (1.6%). 

Early dialysis important 

“Our findings support the feasibility of using early dialysis as a potential standard of care and protective measure when a hurricane or other ‘notice event' is anticipated to interrupt dialysis treatment,” the authors wrote.

 “Emergency preparedness and response depend on good planning and strong day-to-day systems. Many dialysis providers routinely organize early dialysis for patients in advance of major holidays, suggesting that systems are in place to provide such care in advance of a major storm.” 

The investigators stated that, from a preparedness perspective, “dialysis facilities should consider having plans in place to provide early dialysis to patients in advance of predictable disasters such as hurricane and to ensure their ability to function in a disaster.”

In a statement prepared by the National Kidney Foundation (NKF), which publishes the American Journal of Kidney Diseases, corresponding author Nicole Lurie, MD, Department of Health and Human Services Assistant Secretary for Preparedness and Response, stated that the research clearly showed that delaying dialysis can have devastating health effects for patients with ESRD. 

“The good news is that we saw a lot of patients receiving dialysis before the storm hit. That type of advance planning by patients and their facilities should become routine nationwide,” she said. “Everyone involved should know what to do when their facilities might close—patients should know where to go, and facilities should be able to provide a surge in early dialysis care so treatment is not delayed. At the end of the day, that helps people and their communities be more resilient.” 

Room for improvement 

Dr. Lurie pointed out that 40% of patients did not receive early dialysis, meaning “there is still plenty of room for dialysis patient and facility improvement. I hope these findings serve as a rallying cry not just for the dialysis community, but for all people with any type of chronic health condition and their care providers to plan for emergencies.” 

“This is an important analysis of the impact of Hurricane Sandy in October 2012 on individuals treated with in-center hemodialysis that ultimately helps the dialysis community better anticipate what might go wrong, improve emergency plans for disaster scenarios, and more rapidly respond to protect the health of our patients during emergencies,” said Joseph Vassalotti, MD, NKF's Chief Medical Officer. “The study reflects another step forward to improve the education and training of patients and dialysis clinic staff, following the widely recognized poor response to Hurricane Katrina in August 2005.” 

Although the new study had a number of strengths—such as the use of Medicare data, which cover nearly all of the nation's ESRD patients—it also had some limitations, including lack of access to sufficiently granular data on sustained power outages and facility damage, “which may have enabled us to better understand the utilization pattern seen.” 

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