Discharged Dialysis Patients Commonly Readmitted for Different Reasons
In 80% of readmissions, the primary diagnoses differed from initial hospitalization.
New national data show that hemodialysis (HD) patients have high rates of hospital admissions and readmissions, and for the vast majority of patients, a separate diagnosis prompts readmission.
Hospitalization rates are center stage now that the Centers for Medicare and Medicaid Services penalize outpatient dialysis units for excessive readmissions.
Of 390,627 index hospitalizations identified in the 2013 Nationwide Readmission Database, 22% were linked with an unplanned readmission within 30 days, according to findings published online ahead of print in the Clinical Journal of the American Society of Nephrology (CJASN). Results showed that 80% of readmissions were for primary diagnoses that differed from the initial hospitalization. Of 10 main diagnoses, the top and bottom causes for initial hospitalization were vascular access issues (11%) and chest pain (2%). The top and bottom reasons for readmission, however, were acute myocardial infarction (25%) and hypertension (20%). A small group of patients (2%) accounted for 20% of all readmissions and generally had 3 or more.
“Regardless of what patients initially were admitted for, they had similar readmission rates. This along with the low concordance suggests that we need to focus on the patient as a whole rather than their admission diagnoses,” study co-leader Lili Chan, MD, MS, of the Icahn School of Medicine at Mount Sinai in New York, stated in a press release from the American Society of Nephrology, which published CJASN.
Dr Chan and the team used survey logistic regression to identify predictors of readmission. Depression, drug abuse, and discharge against medical advice increased the risk for readmission by 10%, 41%, and 57%, respectively. The database lacked information on other purported predictors, including dialysis vintage, outpatient dialysis unit, laboratory data, shortened or skipped HD treatments, vascular access type, and race, which was a study limitation.
“If we were to attempt to improve readmissions in the vulnerable ESRD population, perhaps a good starting place would be to institute interventions targeted at high utilizers and create a validated risk score incorporating psychosocial factors,” Dr Chan and colleagues stated. They suggested increasing nephrology visits and mental health services.
The 22% readmission rate reported in this study is lower than the 37% rate reported with the US Renal Data System (USRDS) possibly because USRDS contains only Medicare patients. The rate is similar to studies using Dialysis Outcomes and Practice Patterns (DOPPS) data.
Chan L, Chauhan K, Poojary P, Saha A, et al. National estimates of 30-Day unplanned readmissions of patients on maintenance hemodialysis. Clin J Am Soc Nephrol 2017;12. doi: 10.2215/CJN.02600317 [Epub September 28, 2017]
Why are many dialysis patients readmitted to the hospital soon after discharge? American Society of Nephrology; September 28, 2017 [news release]
Assimon MM and Flythe JE. Thirty-Day hospital readmissions in the hemodialysis population: A problem well put, but half-solved. Clin J Am Soc Nephrol 2017;12. doi: 10.2215/CJN.08810817 [Epub September 28, 2017]