Spring Clinical Meetings
National Kidney Foundation
April 22-26
MGM Grand
Las Vegas
For more information about the NKF 2014 Spring Clinical Meetings visit www.nkfclinicalmeetings.org

The Spring Clinicals meeting presents a unique opportunity for renal health care providers to learn about new developments related to all aspects of nephrology. One session worthy of highlighting will address re-hospitalization among dialysis patients. Presenters will focus on ways to reduce this alarming trend.

The facts about re-hospitalization

In 2009, Dr. Stephen Jencks, formerly of the Centers for Medicare and Medicaid Services, in collaboration with Mark Williams and Eric Coleman, published an article in the New England Journal of Medicine about hospital readmissions. The article highlighted several important facts, including the following:

  • Almost 20% of all Medicare beneficiaries who had been discharged from a hospital were re-hospitalized within 30 days, and 34% were re-hospitalized within 90 days.
  • More than half of those re-hospitalized within 30 days did not have a visit to a physician’s office between the time of discharge and re-hospitalization.
  • The cost to Medicare of these re-hospitalizations was estimated at $17.4 billion in 2004.

When these authors analyzed the risk factors for re-hospitalization of Medicare patients, “end-stage renal disease” was one of the diagnoses associated with the highest risk (42% higher risk of re-hospitalization within 30 days for ESRD patients compared to other Medicare patients).

More recently, these high rates of re-hospitalizations in Medicare patients have prompted CMS to impose a reimbursement penalty for hospitals that have a high rate of re-hospitalizations or ones where it is not improving. These penalties, which begin at 1% of all Medicare reimbursements, will gradually increase up to 3% on a yearly basis, and will initially apply only to specific discharge diagnoses (MI, CHF, pneumonia). With the ESRD program a leading resource utilizer within Medicare, readmission rates among dialysis patients have come to the forefront of both policy and quality improvement initiatives.

Factors leading to increased re-hospitalizations

A number of studies have highlighted that, in the general population, two major factors may be associated with re-hospitalization: poor medication reconciliation before and after discharge and a lack of compliance with follow-up testing. The Institute for Health Care Improvement (IHI) identified four key changes that may attenuate the high readmission rates in patients who have been recently hospitalized:

  1. Effective real-time handover communications
  2. Enhanced assessment of post-hospital needs
  3. Assurance of post-hospital care follow-up
  4. Effective teaching of patients

The presenters of this NKF session and separately, the U.S. Renal Data System, analyzed re-hospitalization data specific to ESRD patients, arriving at similar conclusions. Among hemodialysis patients prevalent in 2011, 36% of discharges from the hospital were followed by a re-hospitalization within 30 days. Although there were differences in the rate of re-hospitalizations, depending on the cause of the index hospitalization, these were relatively minor, with the highest rate for patients hospitalized for cardiovascular causes (38% re-hospitalization rate), followed by re-hospitalizations after hospitalization for infection (35%) and for vascular access hospitalizations (32%).

More alarming were the findings that rates of death (without re-hospitalization) within 30 days of a hospital discharge were as high as 7%. Thus, the combined end point of re-hospitalizations and/or death within 30 days of a live hospital discharge of a dialysis-dependent patient was close to 40% in all age categories of dialysis patients. Considering that dialysis-dependent patients already have a high rate of hospitalizations (1.8 admissions/patient/year) and longer hospital stays (11.7 days/patient/year) than other Medicare patients, these re-hospitalization and death rates are worrisome.

Our analysis also demonstrated a significantly worse laboratory outcome, specifically serum albumin and hemoglobin levels, as well as a reduction in post-dialysis target weight (the so called “dry weight”) following discharge, suggesting a worsening of malnutrition and loss of muscle mass in patients who had just been hospitalized.

Addressing modifiable factors for high rates of readmissions

It is important to realize that many of the factors that both the IHI and our analysis identified as contributing to the high rate of readmissions are modifiable, particularly in patients receiving hemodialysis. Most of these patients are transitioned from a hospital to an outpatient dialysis facility where they have access to nursing and physician intervention on a regular basis, and could have their new target weight assessed with any number of devices or techniques that are currently available.
It is critical that such high rates of re-hospitalization in the dialysis population be addressed promptly. Overarching strategies must include improved communication between the hospital and the dialysis unit at the time of discharge; coordinated and prompt attention to laboratory parameters that are significantly below the normal range at the time of discharge; and medication reconciliation, particularly as it applies to antibiotics that are often started in the hospital that need to be continued and monitored upon return to the dialysis unit.

Finally, it is in the interest of the patient, the providers of care and society as a whole that a serious effort to reduce re-hospitalization among dialysis patients be implemented as quickly as possible. Not surprisingly, CMS has begun to focus on this topic, convening a technical expert panel in 2012 to help design a quality metric on dialysis re-hospitalizations, and it is likely that a refined version of this metric will impact reimbursement in the near future.

This NKF session will address practical ways to address these re-hospitalization factors, focusing on specific interventions that may reduce 30-day re-hospitalizations, particularly among hemodialysis patients.