Abstract
BackgroundEnd stage renal disease (ESRD) patients on maintenance hemodialysis, are high utilizers of inpatient services. Because of data showing improved outcomes in medical patients admitted to hospitalist-run, non-teaching services, we hypothesized that discharge from a hospitalist-run, non-teaching service is associated with lower risk of 30-day re-hospitalization in a cohort of patients on hemodialysis.MethodsOne thousand and 84 consecutive patients with ESRD on maintenance hemodialysis who were admitted to Montefiore, a tertiary care center, in 2014 were analyzed using the electronic medical records. We evaluated factors associated with 30-day readmission in multivariable regression models. We then tested the association of care by a hospitalist-run, non-teaching service with 30-day readmission in a propensity score matched analysis.ResultsPatients cared for on the hospitalist-run, non-teaching service had lower socio-economic scores (SES) and had longer lengths of stay (LOS), as compared to a standard teaching service, but otherwise the populations were similar. In multivariable testing, severity of illness, (OR 2.40, (95%CI: 1.43–4.03) for highest quartile) number of previous hospitalizations (OR 1.22 (95%CI:1.16–1.28) for each admission), and discharge to a skilled nursing facility (SNF)(OR 1.56 (95%CI:1.01–2.43) were significantly associated with 30-day re-admissions. Care by the non-teaching service was associated with a lower risk of 30-day readmission, even after adjusting for clinical factors and matching based on propensity score (OR 0.65(95%CI:0.46–0.91) and 0.71(95%CI:0.66–0.77) respectively).ConclusionsPatients with ESRD on hemodialysis discharged from a hospitalist-run, non-teaching medicine service had lower odds of readmission as compared to those patients discharged from a standard teaching service.
Highlights
End stage renal disease (ESRD) patients on maintenance hemodialysis, are high utilizers of inpatient services
Baseline characteristics of the total cohort Out of a total of 1084 subjects discharged from a medical service in 2014 with a diagnosis of ESRD and on maintenance hemodialysis, 284 or 19.8% were readmitted within 30 days to the Montefiore system while 79 or 5.4% expired or were discharged to hospice (Fig. 1 and Table 2)
Forty -2 % of all patients were discharged from the hospitalist-run, non-teaching medicine service, 45.1% of patients were discharged home, 21.9% were discharged to Skilled nursing facility (SNF) and 24.4% were discharged home with homecare
Summary
End stage renal disease (ESRD) patients on maintenance hemodialysis, are high utilizers of inpatient services. Studies show that risk factors for frequent hospitalizations in hemodialysis patients include inadequate transitions and discharge plans between institutions [2,3,4, 12,13,14,15]. It is remarkable that this high hospitalization rate occurs even though outpatients receiving hemodialysis have at least 3 interactions per week with healthcare staff [8, 18]. These findings highlight the institutional and clinical complexities of ESRD care. Discharge planning and discharge instructions have been evaluated as interventions in hospitalized patient populations and those interventions that support self-care and include short term follow-up, are effective in reducing hospital readmissions [21, 22]
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