Factors Associated With Withdrawal From Maintenance Dialysis: A Case-Control Analysis
Factors Associated With Withdrawal From Maintenance Dialysis: A Case-Control Analysis
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DOI：
10.1053/j.ajkd.2017.10.025
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发表时间：
2018-06-01
影响因子：
13.2
通讯作者：
Liu, Jiannong
中科院分区：
文献类型：
--
作者：
Wetmore, James B.;Yan, Heng;Liu, Jiannong
背景：对于接受维持性透析和不退出透析治疗的患者的临床病程差异了解甚少。研究设计：病例-对照分析。背景和参与者：2008年至2011年接受维持性血液透析1年或更长时间的美国医疗保险覆盖患者。预测因素：合并症，住院，熟练护理设施停留，以及基于耐用医疗设备索赔的发病率评分。结果：停止透析治疗。测量：医疗事件率、住院率、熟练护理机构住院率和发病率评分。结果：分析包括18,367例（7.7%）患者退出，220,443例（92.3%）患者未退出。退出治疗的患者年龄较大（平均年龄，75.3 +/- 11.5岁[SD] vs 66.2 +/- 14.1岁），更可能是女性和白人，并且有更高的合并症负担。女性停药的几率比男性高7% （95% CI, 4%-11%）。与65 - 74岁的患者相比，85岁及以上患者的停药调整几率较高（调整or， 1.61; 95% CI, 1.54-1.68），而18 - 44岁患者的停药调整几率较低（调整or， 0.36; 95% CI, 0.32-0.40）。黑人、亚洲人和西班牙裔患者退出治疗的可能性低于白人（调整后的or分别为0.36 [95% CI, 0.35-0.38]、0.47 [95% CI, 0.42-0.53]和0.46 [95% CI, 0.44-0.49]）。基于耐用医疗设备索赔的较高发病率评分与停药有关，即使在对传统合并症和住院进行调整后也是如此；与0分（最低推定发病率）相比，3 - 4分时停药的调整or为3.48 (95% CI, 3.29-3.67), >= 7分时停药的调整or为12.10 （95% CI, 11.37-12.87）。在停药前的几个月里，医疗事件和住院率趋于上升，发病率得分也有所上升。局限性：结果可能无法推广到美国医疗保险患者之外；透析治疗开始后1年内退出治疗的患者未被研究。结论：女性、老年患者和白人患者更有可能退出透析治疗。停药前一段时间的特点是医疗事故率和发病率较高。
Background: Little is known about differences in the clinical course between patients receiving maintenance dialysis who do and do not withdraw from dialysis therapy.Study Design: Case-control analysis.Setting & Participants: US patients with Medicare coverage who received maintenance hemodialysis for 1 year or longer in 2008 through 2011.Predictors: Comorbid conditions, hospitalizations, skilled nursing facility stays, and a morbidity score based on durable medical equipment claims.Outcome: Withdrawal from dialysis therapy.Measurements: Rates of medical events, hospitalizations, skilled nursing facility stays, and a morbidity score.Results: The analysis included 18,367 (7.7%) patients who withdrew and 220,443 (92.3%) who did not. Patients who withdrew were older (mean age, 75.3 +/- 11.5 [SD] vs 66.2 +/- 14.1 years) and more likely to be women and of white race, and had higher comorbid condition burdens. The odds of withdrawal among women were 7% (95% CI, 4%-11%) higher than among men. Compared to age 65 to 74 years, age 85 years or older was associated with higher adjusted odds of withdrawal (adjusted OR, 1.61; 95% CI, 1.54-1.68), and age 18 to 44 years with lower adjusted odds (adjusted OR, 0.36; 95% CI, 0.32-0.40). Blacks, Asians, and Hispanics were less likely to withdraw than whites (adjusted ORs of 0.36 [95% CI, 0.35-0.38], 0.47 [95% CI, 0.42-0.53], and 0.46 [95% CI, 0.44-0.49], respectively). A higher durable medical equipment claims-based morbidity score was associated with withdrawal, even after adjustment for traditional comorbid conditions and hospitalization; compared to a score of 0 (lowest presumed morbidity), adjusted ORs of withdrawal were 3.48 (95% CI, 3.29-3.67) for a score of 3 to 4 and 12.10 (95% CI, 11.37-12.87) for a score >= 7. Rates of medical events and institutionalization tended to increase in the months preceding withdrawal, as did morbidity score.Limitations: Results may not be generalizable beyond US Medicare patients; people who withdrew less than 1 year after dialysis therapy initiation were not studied.Conclusions: Women, older patients, and those of white race were more likely to withdraw from dialysis therapy. The period before withdrawal was characterized by higher rates of medical events and higher levels of morbidity.