MedicalResearch.com Interview with:
Rachel Patzer, PhD, MPH
Director of Health Services Research,
Emory Transplant Center
Emory University School of Medicine
Department of Surgery
Division of Transplantation
MedicalResearch.com: What is the background for this study?
Response: Patients with End Stage Renal Disease (ESRD) make up less than 1% of all Medicare patients, but account for more than 7% of all Medicare expenses. Patients with ESRD have the highest risk of hospitalization of any patient with a chronic disease, and while hospital admissions have decreased over the last several years, emergency department utilization for this patient population has increased by 3% in the last 3 years. The purpose of the study we conducted was to describe the clinical and demographic characteristics associated with emergency department utilization.
MedicalResearch.com: What are the main findings?
Response: We found that the characteristics that predict higher emergency department utilization in the ESRD population are similar to the general U.S. population (e.g. more comorbidities, tobacco or alcohol use, and socioeconomic factors like public vs., private insurance), however, the absolute rates of emergency department utilization are about six times higher than the general U.S. population. We found that within the first year of starting dialysis, 55% of patients have an emergency department visit, and about half of those patients are admitted to the hospital. Potentially preventable factors associated with higher ED utilization included catheter or graft (vs. a fistula) for dialysis access and not being under the care of a nephrologist visit prior to starting dialysis.
MedicalResearch.com: What should readers take away from your report?
Response: Earlier access to healthcare, including specialty care visits to a nephrologist, could help to ensure patients have better dialysis access (such as fistula rather than a catheter) at the start of dialysis. Ensuring that patients at high risk of end stage kidney disease, such as those with hypertension, diabetes, or obesity, have access to care to slow the progression of kidney disease is key.
Even after the start of dialysis, better identification of the type of patient that may be at high risk for an emergency department or hospital visit is essential to improve the quality of patient care and prevent a poorer quality of life associated with increased hospitalization. Development of dialysis facility or primary care protocols to avoid ED evaluation for ESRD patients who meet indications for direct admission without need for ED stabilization and care coordination in the outpatient setting to avoid ED utilization are potential cost saving interventions.
There are recent CMS and ESRD Quality Incentive Program quality metrics, such as the standardized readmission ratio metric, that will hold dialysis facilities accountable for hospitalization of patients. It will be important for dialysis facilities to understand the characteristics of the patients at highest risk of hospitalization in order to implement quality improvement and care coordination interventions to decrease utilization and improve the quality of care for dialysis patients.
MedicalResearch.com: What recommendations do you have for future research as a result of this study?
Response: More research is planned to examine how ED and hospitalization rates vary by geographic region for these patients, and to identify whether ED and hospitalization use decrease following kidney transplantation, the optimal treatment for patients with end stage renal disease.
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