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Healio Internal Medicine Nephrology
IN THE JOURNALS

Patients with ESRD use ED 6 times more often than average US adult

Lovasik BP, et al. JAMA Intern Med. 2016;doi:10.1001/jamainternmed.2016.4975.

August 26, 2016

Researchers identified several characteristics of patients with end-stage renal disease who are treated in EDs or hospitals in hopes of improving outcomes, according to findings published in JAMA Internal Medicine.

"Patients with end-stage renal disease (ESRD) have the highest risk for hospitalization among those with chronic medical conditions, including heart failure, pulmonary disease, or cancer," they wrote. "Patients with ESRD use the ED at 6-fold and 4-fold higher rates than the national mean rates for U.S. adults and Medicare beneficiaries, respectively."

Lovasik and colleagues analyzed data from patients in the U.S. Renal Data System between January 2005 and December 2011. Patients were all aged 18 years or older, diagnosed with ESRD and on Medicare Part A or B insurance. The researchers also used the CMS 2728 Medical Evidence Report, which contained clinical and sociodemographic data.

They reported that 769,228 patients began treatment for ESRD during their study period and 535,345 patients (69.6%) visited the ED at least once during that same period. In addition, 422,738 patients (55%) visited the ED during their first year with ESRD.

"In multivariable analysis, factors associated with higher rates of ED use included younger age, female sex, black (vs. white) race, comorbid medical conditions, Medicaid insurance (vs. Medicare alone), catheter or graft hemodialysis access (vs. fistula), tobacco use, institutionalization, and more recent ESRD diagnosis," Lovasik and colleagues detailed. "Factors associated with a lower rate of ED use included pre-ESRD nephrology care, erythropoietin use before ESRD, and private insurance."

Respiratory anomalies, congestive heart failure and chest pain were the most common comorbid conditions in patients during their first year with ESRD.

Lovasik and colleagues also reported that 46.2% of the ED visits resulted in a hospital admission. Hemodialysis access complication, septicemia and congestive heart failure were the most common diagnoses in patients during their first year.

Hyperkalemia and fluid overload accounted for 1.2% of the total ED visits and 2.2% of total hospital admissions.

Lovasik and colleagues discovered that various causes of ED use, such as access to care, may be preventable.

"Catheter hemodialysis access was the strongest predictor of ED use in multivariable analysis, which may reflect catheter-associated problems, such as infections and inadequate dialysis," they wrote. "The hospital admission rate from the ED was 4 times higher than the mean national rate and was influenced by modifiable factors, including infectious and cardiovascular abnormalities."

They concluded: "Focusing on modifiable factors associated with ED use, such as ensuring that patients with chronic kidney disease have early access to nephrology care and placement of fistulas, could lead to improved care for patients with ESRD and decreased costs for health systems." – by Chelsea Frajerman Pardes

Disclosures: Pastan reports owning a minority share in Fresnius College Park Dialysis. No other authors reported any relevant financial disclosures.