MedicalResearch.com Interview with:
Paul E Ronksley, PhD
Department of Community Health Sciences
Cumming School of Medicine
University of Calgary
MedicalResearch.com: What is the background for this study?
Response: Prior studies have observed high resource use among patients with chronic kidney disease (CKD), which is related to the medical complexity of this patient population. However, there has been limited exploration of how patients with CKD use the emergency department (ED) and whether utilization is associated with disease severity. While the ED is essential for providing urgent or emergent care, identifying ways of improving ED efficiency and decreasing wait times has been recognized as a priority in multiple countries. Improving coordination and management of care for patients with multiple chronic conditions (the norm for CKD) in an outpatient setting may meet health care needs and ultimately improve patient experience and outcomes while reducing the burden currently placed on the ED. However, this requires an understanding of ED use among patients with CKD and the proportion of use that is amenable to outpatient care. Using a large population-based cohort we explored how rates of ED use vary by kidney disease severity and the proportion of these events that are potentially preventable by high quality ambulatory care.
We identified all adults (≥18 years) with eGFR<60 mL/min/1.73m2 (including dialysis-dependent patients) in Alberta, Canada between April 1, 2010 and March 31, 2011. Patients with CKD were linked to administrative data to capture clinical characteristics and frequency of ED encounters, and followed until death or end of study (March 31, 2013). Within each CKD category we calculated adjusted rates of overall emergency departmentt use, as well as rates of potentially preventable ED encounters (defined by 4 CKD-specific ambulatory care sensitive conditions (ACSCs); heart failure, hyperkalemia, volume overload, malignant hypertension).
MedicalResearch.com: What are the main findings?
Response: We found that rates of overall emergency department use were highest among patients with more advanced CKD. 5.8% of all ED encounters were for CKD-specific ACSCs with approximately one-third resulting in hospital admission. Heart failure accounted for over 80% of all potentially preventable ED events among patients in categories G3A, G3B, and G4 CKD, while hyperkalemia accounted for almost half (48%) of all ACSCs among dialysis patients. Adjusted rates of ED events for heart failure showed a U-shaped relationship with the highest rates among category G4 CKD patients. In contrast, there was a graded association between rates of ED use for hyperkalemia and CKD category.
MedicalResearch.com: What should readers take away from your report?
Response: Emergency department use is high among patients with CKD, although only a small proportion of these encounters are for potentially preventable CKD-related care. These findings suggest that strategies to reduce ED use among CKD patients will need to be broad, although strategies targeting CKD-specific ACSCs may reduce a small but potentially important proportion of these emergency department encounters.
MedicalResearch.com: What recommendations do you have for future research as a result of this study?
Response: A better understanding of the comorbid profiles of CKD patients, their health care needs, and the circumstances that result in presentation to the ED would be valuable when proposing strategies to improve care for patients with multi-morbidity. Future work is also needed to determine if improvements in community-based care or dialysis treatments could potentially mitigate the number of CKD-related ED events for heart failure and hyperkalemia respectively among patients with CKD.
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ASN 2016 abstract:
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