Readmission due to pulmonary edema in hemodialysis patients

项目总结 美国终末期肾病患者占医疗保险支出的很大比例，原因是 他们数量庞大(650,000英镑)和高水平的医疗保健利用率。超过三分之一的住院患者 在终末期肾病患者中，接受血液透析治疗的患者会在30天内再次入院。 以改善以患者为中心的结果和降低成本为主要目标，医疗保险和医疗保险中心 医疗补助服务将减少透析患者的再次入院列为优先事项。尽管如此，很少有美国人 研究已经探索了透析患者的再入院，特别是特定原因的再入院。肺 水肿(PE)，也称为液体超载，在血液透析患者中很常见。超滤过程中 血液透析应该可以预防这些事件，但患者缺乏对盐和液体摄入的限制 以及处方透析和提供者评估的困难当前的液体状态和干重可能导致 佩。此外，最近住院的患者可能会经历干重的变化， 更换或添加药物，和/或改变他们的液体摄入量，这可能会导致早期再入院的高风险 由于体育课的原因。包括我们小组在内的许多研究人员已经注意到，透析提供者可以帮助减少 可以预防PE和相关并发症的行为有再次入院的风险，例如更快 获取和审查返回透析设施的患者的医院记录，重新评估干 体重和药物调和。然而，这些行为与 再次入院的风险降低是有限的。使用来自美国肾脏数据系统的公开数据 (包括医疗保险住院和门诊索赔)以及丰富的电子病历和图表数据 来自埃默里大学和维克森林大学附属的19个独立透析诊所，我们的目标是：(1) 评估30天内再次入院和急诊科就诊的国家负担，并确定相关因素 美国血液透析患者中因PE而住院的指数；以及(2)估计 后指标住院提供者行为和因PE再次住院30天和急诊室就诊的风险 东南部的透析人口。目标1的结果将通过以下方式为透析人口的国家政策提供信息 检查经常可以预防的再次住院的负担，并确定可能 对设施一级的重新入院绩效作出重大贡献，这将是2017年的按绩效付费。 Aim 2的结果将为有针对性的提供者行为干预的预期实用试验提供信息 减少在独立机构接受治疗的东南透析患者与PE相关的再入院。这样的一种 可以在区域和全国范围内采用和使用干预措施，以减轻医院的总体负担 透析患者的再入院，增加高危患者结果的公平性 重新入院，帮助透析机构达到质量基准，并降低透析成本。

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.