Healthcare Intensity at Dialysis Initiation Affects Survival

Compared with patients who begin dialysis as outpatients, those who begin the treatment during a hospital stay of at least two weeks and had undergone at least one intensive procedure had a shorter median survival (0.7 vs. 2.1 years, respectively).

The retrospective analysis that yielded this finding examined data from 416,657 Medicare beneficiaries aged 67 years and older who initiated chronic dialysis between January 1995 and December 2008. As Susan P.Y. Wong, MD, of the University of Washington in Seattle, and fellow investigators reported online ahead of print in the Journal of the American Society of Nephrology, they used the information to help define the relationship between healthcare intensity around the time of dialysis information and subsequent survival and patterns of hospitalization, use of intensive procedures (mechanical ventilation, feeding tube placement, and cardiopulmonary resuscitation), and discontinuation of dialysis before death.

The researchers found that 64.5% of patients initiated dialysis in the hospital, including 36.6% who were hospitalized for two or more weeks and 7.4% who underwent at least one intensive procedure. Initiation of chronic dialysis in the inpatient setting has been rising in recent years, Dr. Wong and colleagues noted.

In addition to having shorter median survival times compared with those who initiated dialysis as outpatients, the highest-intensity inpatients beginning dialysis spent a greater percentage of remaining follow-up time in the hospital (22.9% vs. 3.1% for outpatients initiating dialysis), were more likely to undergo subsequent intensive procedures (44.9% vs. 26.0%), and were less likely to have discontinued dialysis before death (19.1% vs. 26.2%).

“Many older patients are unaware of their illness trajectory after starting chronic dialysis, and many nephrologists are not comfortable with discussing prognosis, although patients express wanting this information,” Dr. Wong commented in an American Society of Nephrology statement announcing the study results. “We hope that our findings can be used to supplement providers' knowledge and increase their confidence and willingness to discuss prognosis with their patients.”

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