Active Management of Patients with Chronic Renal Insufficiency: The Effect on Hospital Days During the Initial Hemodialysis Period.

Introduction: Suboptimal management of patients with chronic renal insufficiency (CRI) is thought to contribute to the high morbidity and early mortality seen after the onset of end-stage renal disease (ESRD), and may therefore impact on healthcare costs associated with patients with ESRD. The objective of this study was to investigate the effects of pre-dialysis patient care on hospital days during the 6 months after hemodialysis initiation. Study Design: Data were obtained from Group Health Cooperative in Seattle, Washington, USA, a staff model health management organization with an established, active, CRI management program, and were analyzed retrospectively. Patients who started long-term hemodialysis between 1 January 1997 and 31 January 2000, and who were referred to the Group Health Cooperative CRI management program, were included in the study. Methods: Demographic and baseline clinical characteristics, details of interventions received by patients prior to dialysis, and hemoglobin (Hb) levels during the 6 months prior to the onset of ESRD were recorded. The numbers of days that each patient spent in hospital during the baseline (1 year to 6 months pre-dialysis), pre-dialysis (180 days pre-dialysis), and post-dialysis initiation (180 days following dialysis initiation) periods were recorded. Hospital days during the post-dialysis initiation period were associated with patient characteristics and pre-dialysis interventions received, and were compared with national data from the US Renal Data System (USRDS). Results: When calculated similarly to data from the USRDS, the mean number of hospital days for patients in this study was lower than that for the national hemodialysis population (9.4 vs 13.9 days). Temporary vascular access and inadequate nephrology visits prior to dialysis were the key factors increasing the risk of a greater number of hospital days. The use of a catheter for initial dialysis significantly increased patients’ risk of hospital days compared with the use of a fistula or graft (median 4 vs 2 days; odds ratio [OR] 2.5); lack of pre-dialysis nephrology visits had a similar effect. Patients’ Hb levels prior to dialysis were also important: a clinically significant decrease in Hb levels (≥1 g/dL), or a decrease resulting in Hb levels <10 g/dL at dialysis initiation, increased hospital days (median 2 vs 3 days; OR 2.0). Conclusion: Early, active management of patients with CRI can reduce hospital days and associated costs in the early months after hemodialysis initiation. [ABSTRACT FROM AUTHOR]