Study: Patterns of Emergency Department Visits among Dialysis Patients in the United States

As always, it is our goal as health care providers to keep our patients healthy and out of hospital or emergency department (ED). This goal may be even more important now with the COVID-19 (coronavirus) pandemic and the potential for at-risk dialysis patients being exposed to the virus in the ED. This post reports results from an analysis conducted by DaVita Clinical Research (DCR) on patterns of ED visits among dialysis patients in the United States.

Patients with end stage kidney disease (ESKD) treated with dialysis are at risk for medical events requiring immediate intervention in settings such as the ED. These ED visits may directly precede hospital admission. Despite the frequency and importance of ED visits among dialysis patients, patterns of these events among the contemporary dialysis population have not been described. Therefore, DCR examined patterns of ED visits and subsequent hospital admissions for the contemporary U.S. dialysis population across different dialysis modalities.

Derived from the 2016 Centers for Medicare & Medicaid claims, study data included adult patients (age ≥ 18 years) who, in a given calendar month and for the 3 months prior, met the following criteria:

• Were eligible for Medicare Parts A & B
• Had a diagnosis of ESKD
• Were on active dialysis
• Had an identifiable dialysis modality

The results of this study show that compared with patients with fewer ED visits per patient-year, patients with more ED visits per patient-year tended to be younger, and were more likely to be female, of black race, to reside in a rural area, and to be treated with in-center hemodialysis (ICHD) vs. peritoneal dialysis (PD).

Patients treated with ICHD had 2.9 ED visits/patient-year, of which 38.3% resulted in hospital admission. The rate of ED visits was higher in rural patients (3.0 visits/year) vs. urban patients (2.8 visits/patient-year); the percent of ED visits that resulted in hospital admission was higher among urban (40.0%) vs. rural patients (30.5%).

Similar patterns were observed with respect to patients treated with PD, where the overall ED visit rate was 2.1 visits/patient-year. The ED visit rate was higher among rural patients (2.3 visits/patient-year) vs urban patients (2.1 visits/patient-year); the percent of ED visits resulting in hospital admission was higher among urban (44.9%) vs rural (37.5%) patients.

Among patients treated with ICHD who had ED visits that did not result in hospital admission, receipt of dialysis treatment in the ED was relatively rare (0.2 events/patient-year). Dialysis in the ED was more common among urban vs. rural patients (0.3 vs 0.2 events/patient-year, respectively).

Among patients treated with ICHD, 80.1% of hospital admissions originated in the ED. The proportion of admissions originating in the ED was greater among urban vs. rural patients (81.4 vs 73.7%, respectively). Similar patterns were observed among patients treated with PD, where 74.8% of hospital admissions originated in the ED.

Across modalities, ED visits attributed to “Diseases of the Circulatory System” and “Injury and Poisoning” were common and likely to result in hospital admission. Diseases of the Circulatory System includes hypertension and congestive heart failure. Injury and Poisoning includes codes for issues arising from devices and grafts. The majority of ED visits attributed to “Infectious and Parasitic Diseases” resulted in hospital admission, regardless of modality.

In summary of overall patterns, ED visits were shown in this study to occur more frequently among:

• ICHD vs PD patients
• Rural vs. urban patients

Delivery of dialysis in the ED in the absence of a hospital admission is rare, and the majority of hospital admissions among ESKD patients begin with an ED visit. ED visits were more likely to result in hospital admission in this analysis among:

• PD patients
• Urban patients

ED visits arise from a range of causes, some of which are more likely to result in hospital admission vs. discharge without admission. Improved understanding of the patterns of ED visits among ESKD patients may inform strategies for interventions that improve health outcomes and quality of life. Considering the impact of hospitalizations on PD technique failure, avoiding ED visits should be a focused priority for health care teams managing home programs.

For more information, read the research poster (which was presented at ASN), here.