Abstract
BackgroundIdeally, care prior to the initiation of dialysis should increase the likelihood that patients start electively outside of the hospital setting with a mature arteriovenous fistula (AVF) or peritoneal dialysis (PD) catheter. However, unplanned dialysis continues to occur in patients both known and unknown to nephrology services, and in both late and early referrals. The objective of this article is to review the clinical and socioeconomic outcomes of unplanned dialysis initiation. The secondary objective is to explore the potential cost implications of reducing the rate of unplanned first dialysis in Canada.MethodsMEDLINE and EMBASE from inception to 2008 were used to identify studies examining the clinical, economic or quality of life (QoL) outcomes in patients with an unplanned versus planned first dialysis. Data were described in a qualitative manner.ResultsEight European studies (5,805 patients) were reviewed. Duration of hospitalization and mortality was higher for the unplanned versus planned population. Patients undergoing a first unplanned dialysis had significantly worse laboratory parameters and QoL. Rates of unplanned dialysis ranged from 24-49%. The total annual burden to the Canadian healthcare system of unplanned dialysis in 2005 was estimated at $33 million in direct hospital costs alone. Reducing the rate of unplanned dialysis by one-half yielded savings ranging from $13.3 to $16.1 million.ConclusionThe clinical and socioeconomic impact of unplanned dialysis is significant. To more consistently characterize the unplanned population, the term suboptimal initiation is proposed to include dialysis initiation in hospital and/or with a central venous catheter and/or with a patient not starting on their chronic modality of choice. Further research and implementation of initiatives to reduce the rate of suboptimal initiation of dialysis in Canada are needed.
Highlights
Care prior to the initiation of dialysis should increase the likelihood that patients start electively outside of the hospital setting with a mature arteriovenous fistula (AVF) or peritoneal dialysis (PD) catheter
Crude cost impact estimates of unplanned dialysis in Canada were performed based on data from the Canadian Organ Replacement Registry Report (CORR) and the Canadian Institute for Health Information (CIHI)
We propose the term suboptimal initiation to include all patients starting in hospital and/or with a central venous catheter, and/or not starting on their chronic modality of choice
Summary
Care prior to the initiation of dialysis should increase the likelihood that patients start electively outside of the hospital setting with a mature arteriovenous fistula (AVF) or peritoneal dialysis (PD) catheter. Unplanned dialysis continues to occur in patients both known and unknown to nephrology services, and in both late and early referrals. The secondary objective is to explore the potential cost implications of reducing the rate of unplanned first dialysis in Canada. Despite advances in nephrological care prior to and after dialysis is initiated, ESRD patients continue to have a high morbidity and mortality, and a significant decline in quality of life. The cost of treating ESRD in Canada is significant. In 2000, the direct health-care expenditures for ESRD were estimated at $1.3 billion [3]. Only 0.1% of Canadians had ESRD, these costs represented 1.3% of Canada's total health-care spending [3]
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