Early referral and its impact on emergent first dialyses, health care costs, and outcome
Abstract
Early referral (ER) to nephrologists of patients with chronic renal failure was assessed for its impact on the incidence of emergent first dialyses and choice of dialysis modality (hemodialysis [HD] or peritoneal dialysis [PD]), and survival. We reviewed events preceding first dialyses of 238 patients with end-stage renal disease (ESRD) starting dialysis between January 1990 and April 1997, with follow-up extending through November 1997. Patients referred more than 1 month before needing dialysis (early referral [ER]) were compared with patients presenting within 30 days of needing dialysis (late referral [LR]). The need for emergent HD was significantly less among ER (29%) as compared with LR (90%) (P < 0.0001). Initial modality chosen was similar among ER patients (59% for HD v 41% for PD), a finding that contrasts with national percentages, which approximate 85% and 15%, respectively. Whereas most patients had not changed modality at 4 months, significantly more had changed from HD to PD (36 of 160 or 23%) than from PD to HD (7 of 78 or 9%) (P < 0.0001). Despite starting out on HD, ER and LR patients were amenable to ultimately changing to PD. ER and LR groups had similar numbers of Medicaid patients and patients living 1 hour or more distant to tertiary medical care. Furthermore, no difference was observed in the incidence of emergent HD when ER and LR living more than 1 hour away were compared. LR was not associated with lack of insurance or distance from referral site, although these patients more often required emergent HD, with its higher attendant medical care costs. Controlling for age and cause of ESRD, there was no statistically significant difference in long-term survival when ER patients were compared with LR patients or when patients who had received emergent HD were compared with those who had not. Despite the lack of difference in long-term survival, the financial costs of emergent HD alone merit greater promotion of ER and the psychosocial preparation and modality choice it allows. (Am J Kidney Dis 1998 Aug;32(2):278-83)
References (0)
Cited by (166)
Initiating hemodialysis in Morocco: Impact of late referral
2017, Nephrologie et TherapeutiqueL’insuffisance rénale terminale (IRT) constitue un souci majeur de santé publique au Maroc, avec une incidence en progression constante. Les patients sont souvent adressés tardivement aux néphrologues, ce qui constitue une source de complications reconnue dans plusieurs pays. Pour ces raisons, nous avons essayé d’évaluer, dans notre contexte, la prévalence de cette référence tardive (RT) définie par un suivi néphrologique moins de trois mois avant la mise en hémodialyse.
Il s’agit d’une étude rétrospective menée au service de néphrologie, dialyse et transplantation rénale de l’hôpital militaire d’instruction Mohammed V, ayant inclus tous les patients mis en hémodialyse ou ayant bénéficié de confection d’abord vasculaire dans le centre entre janvier 2007 et décembre 2015. Nous avons relevé l’historique de suivi de ces patients et recherché leurs caractéristiques cliniques au moment de leur mise en hémodialyse.
Durant l’étude, 318 patients ont été admis pour prise en charge d’une IRT. L’âge moyen était de 54,31 ans et la néphropathie diabétique était la cause la plus fréquente avec 41 % des cas. Seulement 105 patients (33 %) avaient un suivi néphrologique spécialisé et dans près des deux tiers des cas, l’hémodialyse a été débutée par recours à un cathéter veineux central temporaire, surtout fémoral. La RT était associée à une anémie et une hypo-albuminémie plus profondes, un syndrome inflammatoire plus marqué, une hospitalisation initiale plus longue, un recours plus important au cathétérisme temporaire comme premier abord pour hémodialyse.
La RT des patients en IRC demeure très fréquente dans notre contexte. Elle est de l’ordre de 67 % et complique la mise en hémodialyse des patients avec plus d’anémie et de recours aux cathéters centraux, qui sont tous des facteurs prédictifs de mortalité déjà décrits dans la littérature. Sur le plan économique, la RT fait progresser de façon significative le coût de prise en charge en augmentant considérablement la durée d’hospitalisation.
End-stage renal disease (ESRD) is a major public health concern in Morocco with an incidence in constant progression according to MAGREDIAL “Morocco Dialysis Registry”. Patients are often sent late to nephrologists, which is a source of complications recognized in several countries. For these reasons, we tried to evaluate, in our context, the prevalence and factors of this late referral (LR).
This is a retrospective study which included all patients initiating hemodialysis between January 2007 and December 2015. We found the history of following these patients and sought their clinical characteristics at the time of setting hemodialysis.
During the study, 318 patients were admitted for management of ESRD. Their average age was 54.31 years and diabetic nephropathy was the most common cause of 41% of cases. Only 105 patients (33%) had a nephrological follw up in almost two thirds of cases, hemodialysis was started by using a temporary central venous catheter especially femoral. we have identified five factors associated with LR: nemia, hypoalbuminemia, inflammatory syndrome, a longer initial hospitalization, a greater use of temporary catheterization as first access.
LR patients with ESRD remains very common in our context. It is about 67% and complicates implementation hemodialysis patients with anemia and more use of central catheters that are predictors of mortality previously described in the literature. Economically, LR significantly increases the cost of care by significantly increasing the duration of hospitalization.
Advance Care Planning for Patients Approaching End-Stage Kidney Disease
2017, Seminars in NephrologySummary: Patients with chronic kidney disease typically suffer a cascade of comorbid conditions, the magnitude of which have formidable impact on advance care planning (ACP). Complex health care decisions are complicated further by contextual issues that may change over time. A dynamic and evolving process, ACP ideally begins early in the continuum of chronic kidney disease, long before end-stage kidney disease is reached. Planning ahead for care is preparatory to making decisions about kidney replacement therapy and can make for a smooth transition in addition to preventing the start of dialysis by default. This article addresses the key components and unique aspects of ACP for patients approaching dialysis, highlighting the importance of shared decision making, and its effect on the execution of multiple aspects of transition.
Inadequate predialysis care and mortality after initiation of renal replacement therapy
2014, Kidney InternationalAdequacy of chronic kidney disease (CKD) care is traditionally measured as early or late, but this does not reflect the effect of cumulative or consistent care. Here we relate alternate measures of CKD care to mortality and other outcomes in patients with end-stage renal disease (ESRD) who started renal replacement therapy (RRT) between 1998 and 2008. CKD care was defined traditionally as early or late, and alternatively as cumulative care (total visits) and consistency of care in the critical period immediately prior to start of RRT (consistent critical period care required visits in 3 or more of the 6 months prior to RRT start). The primary outcome was 1-year mortality, with secondary outcomes of inpatient start and access creation. Of 12,143 patients aged 18–97 years at the start of RRT, 75.9% had early CKD care. Only 38.3% of the early group had high cumulative (over 10 visits) and consistent critical period care. The 1-year mortality of 15.8% was more likely with late care, lower cumulative care, and inconsistent critical period care. Both cumulative care and consistent critical period care independently predicted mortality, as well as secondary outcomes. Alternate measures of CKD care are important predictors of outcomes in ESRD and should be considered when reporting adequacy of care. Thus, patients traditionally classified as receiving early CKD care often do not receive adequate care immediately prior to initiating RRT.
Does a predialysis education program increase the number of pre-emptive renal transplantations?
2013, Transplantation ProceedingsRenal transplantation (RT) is the most appropriate form of treatment for end-stage renal disease (ESRD). Pre-emptive RT decreases the rates of delayed graft function and acute rejection episodes, increasing patient and graft survival, while reducing costs and complications associated with dialysis. In this study, we investigated the relationship between a predialysis education program (PDEP) for patients and their relatives and pre-emptive RT.
We divided 88 live donor kidney transplant recipients into 2 groups: transplantation without education (non-PDEP group; n = 27), and enrollment in an education program before RT (PDEP group n = 61).
Five patients in the non-PDEP group underwent pre-emptive transplantation, versus 26 of the PDEP group. The rate of pre-emptive transplantations was significantly higher among the educated (42.62%) versus the noneducated group (18.51%; P < .001).
PDEP increased the number of pre-emptive kidney transplantations among ESRD patients.
Impact of Health Information Exchange Adoption on Referral Patterns
2023, Management ScienceUnplanned hemodialysis initiation and low geriatric nutritional risk index scores are associated with end-stage renal disease outcomes
2022, Scientific Reports