Readmission due to pulmonary edema in hemodialysis patients

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PROJECT SUMMARY U.S. end-stage renal disease patients account for a substantial proportion of Medicare expenditures, due to their large numbers (>650,000) and high levels of healthcare utilization. More than one-third of hospitalizations in end-stage renal disease patients who are treated with hemodialysis result in a readmission within 30 days. With the primary goal of improving patient-centered outcomes and reducing costs, the Centers for Medicare & Medicaid Services has prioritized reduction of hospital readmissions in dialysis patients. Despite this, few U.S. studies have explored readmissions, particularly cause-specific readmissions, in dialysis patients. Pulmonary edema (PE), also known as fluid overload, is common in hemodialysis patients. Ultrafiltration during hemodialysis should prevent these episodes, but patient lack of adherence to salt and fluid intake restrictions and to prescribed dialysis and difficulties in provider assessment current fluid status and dry weight can lead to PE. Additionally, patients who have recently been hospitalized may experience changes in their dry weight, change or add medications, and/or change their fluid intake, which may result in high risk for early readmission due to PE. Many investigators, including our group, have noted that dialysis providers could help reduce readmission risk via behaviors that could prevent PE and associated complications, such as more rapid acquisition and review of hospital records for patients returning to the dialysis facility, reassessment of dry weight, and reconciliation of medications. However, evidence for the association of these behaviors with reduced risk of readmission is limited. Using publicly available data from the United States Renal Data System (including Medicare inpatient and outpatient claims) as well as rich electronic medical record and chart data from 19 independent dialysis clinics affiliated with Emory University and Wake Forest University, we aim to: (1) estimate the national burden of, and identify correlates of, readmissions and ED visits within 30 days of an index hospitalization due to PE among U.S. hemodialysis patients; and (2) estimate associations between post-index hospitalization provider behaviors and risk of 30-day readmission and ED visits due to PE in a Southeastern dialysis population. The results from Aim 1 will inform national policy in the dialysis population by examining the burden of often-preventable readmissions and by identifying patient factors that may substantially contribute to facility-level readmissions performance, which will be pay-for-performance in 2017. The results from Aim 2 will inform a prospective pragmatic trial of a targeted provider behavior intervention to reduce readmissions related to PE in Southeastern dialysis patients treated at independent facilities. Such an intervention could be adapted and used both regionally and nationally to reduce the overall burden of hospital readmissions among dialysis patients, increase equity in outcomes among patients at high risk for readmissions, help dialysis facilities meet quality benchmarks, and lower costs of dialysis.