Avoidable visits to the emergency department(ED) and their association with sex, age and race in a cohort of low socio-economic status patients on hemodialysis in the Bronx.

Ladan Golestaneh,Yungtai Lo,Joel Neugarten,Eran Bellin,Pierre Delanaye

doi:10.1371/journal.pone.0202697

Ladan Golestaneh, Yungtai Lo + Show 3 more

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https://doi.org/10.1371/journal.pone.0202697

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Abstract

BackgroundIn national samples drawn from the USRDS, female patients utilize the hospital ED and inpatient services at a higher rate than their male counterparts and have a higher rate of re-hospitalization. We wanted to explore the association of sex with avoidable ED visits made by a cohort of patients on hemodialysis in a mostly minority, lower socioeconomic status (SES), population in the Bronx to test the applicability of the USRDS findings.MethodsWe used Montefiore’s clinical database to build a cohort of patients on hemodialysis with a first ED visit between 2013 and 2017. All ED visits after the index ED visit and those within one year prior to the index visit were recorded. None of the ED visits resulted in a hospitalization and were thus labeled “avoidable”. Bivariate analysis tested the association of demographic and clinical variables with sex. We used negative binomial regression to test the association of each variable with avoidable ED visit count. The multivariate model used negative binomial regression with avoidable ED visit count as outcome and sex as the exposure variable and included ancestral variables age and race. Potential mediators were added to the model to measure their effects on the association of sex with avoidable ED visits.ResultsFour thousand six hundred and seventy three subjects on hemodialysis were identified as having at least one avoidable ED visit, in the period of 2013–2017 at one of four ED sites affiliated with Montefiore Medical Center in the Bronx. Over 5 years (2012–2017), the median number of ED visits made by the study sample was 4 (25–75% IQR: 2–8). Female patients on hemodialysis in our cohort were older, more commonly black, had lower SES scores, less commonly had commercial insurance and were less commonly married than their male counterparts. Female sex was not significantly associated with a higher rate of avoidable ED visits in the total cohort.(1.053(0.99–1.12) Female sex was significantly associated with outcome in non-Hispanic whites only and in those subjects younger than 44 years old.(IRR 1.30(1.06–1.69), 1.17(1.00–1.38) in non-Hispanic White and younger age group, respectively.) Marital status, SES and hemoglobin levels possibly mediated the association of sex and outcome in our population. (>25% change in the coefficient for sex with respect to outcome when variable added to the model).ConclusionIn this single center study of a lower-socioeconomic status, mostly minority dialysis population, the association of female sex with avoidable ED visits was not significant. These results suggest the association of sex with hospitalization outcomes, described by national datasets that determine quality indicators, are not consistent across different types of populations with some mediation possible by SES and marital status in poorer neighborhoods.

Highlights

Patients on hemodialysis comprise 1% of the Medicare population but cost up to 9% of the Medicare budget.[1, 2] Hospitalizations account for up to 40% of this cost
We wanted to explore the association of sex with avoidable ED visits made by a cohort of patients on hemodialysis in a mostly minority, lower socioeconomic status (SES), population in the Bronx to test the applicability of the USRDS findings
Four thousand six hundred and seventy three subjects on hemodialysis were identified as having at least one avoidable ED visit, in the period of 2013–2017 at one of four ED sites affiliated with Montefiore Medical Center in the Bronx

Summary

Introduction

Patients on hemodialysis comprise 1% of the Medicare population but cost up to 9% of the Medicare budget.[1, 2] Hospitalizations account for up to 40% of this cost. The Centers for Medicare Services (CMS) has made readmission rate a Quality Incentive Program (QIP) benchmark tied to dialysis facility reimbursements starting in 2017.[5,6,7] The QIP, does not adjust for case-mix or for socio-economic factors that contribute to the inability of certain vulnerable populations to meet quality benchmarks, opting instead to use benchmarks defined by large, claims based national datasets.[8,9,10] Psychosocial barriers to outpatient care, mental health issues related to the large burden of hemodialysis therapy and the lack of coordination between dialysis facilities, nephrologists and other service providers, contribute to avoidable ED visits, in low socioeconomic class neighborhoods. We wanted to explore the association of sex with avoidable ED visits made by a cohort of patients on hemodialysis in a mostly minority, lower socioeconomic status (SES), population in the Bronx to test the applicability of the USRDS findings

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