Transition-to-dialysis planning, health care use, and mortality in end-stage renal disease.

Abstract

To evaluate the association of dialysis transition planning factors (eg, nephrologist care, vascular access placement, place of dialysis) with inpatient (IP) stays, emergency department (ED) visits, and mortality. Retrospective cohort study. We used the Humana Research Database to identify 7026 patients with a diagnosis of end-stage renal disease (ESRD) in 2017 who were enrolled in a Medicare Advantage Prescription Drug plan with at least 12 months preindex enrollment, with first ESRD evidence as the index date. Patients with kidney transplant, hospice election, or dialysis preindex were excluded. Transition-to-dialysis planning was defined as optimal (vascular access placed), suboptimal (nephrologist care, but no vascular access), or unplanned (first dialysis in IP stay or ED visit). The cohort was 41% female and 66% White, with a mean age of 70 years. Optimally planned, suboptimally planned, and unplanned transition to dialysis occurred for 15%, 34%, and 44% of the cohort, respectively. Among patients with preindex chronic kidney disease (CKD) stages 3a and 3b, 64% and 55%, respectively, had an unplanned dialysis transition. For patients with preindex CKD stages 4 and 5, 68% and 84%, respectively, had a planned transition. In adjusted models, patients with a suboptimally or optimally planned transition were 57% to 72% less likely to die, 20% to 37% less likely to experience an IP stay, and 80% to 100% more likely to experience an ED visit than patients with an unplanned dialysis transition. A planned transition to dialysis was associated with reduced odds of IP stays and lower mortality.