Effects of Early Frequent Nephrology Care on Emergency Department Visits among Patients with End-stage Renal Disease

Abstract

In this retrospective cohort study, we examined the association between predialysis nephrology care status and emergency department (ED) events among patients with end-stage renal disease. Data pertaining to 76,702 patients who began dialysis treatment between 1999 and 2010 were obtained from the National Health Insurance Research Database of Taiwan (NHIRD). The patients were divided into three groups based on the timing of the first nephrology care visit prior to the initiation of maintenance dialysis, and the frequency of nephrologist visits (i.e., early referral/frequent consultation, early referral/infrequent consultation, late referral). At 1-year post-dialysis initiation, a large number of the patients had experienced at least one all-cause ED visit (58%), infection-related ED visit (17%), or potentially avoidable ED visit (7%). Cox proportional hazard models revealed that patients who received early frequent care faced an 8% lower risk of all-cause ED visit (HR: 0.92; 95% CI: 0.90–0.94), a 24% lower risk of infection-related ED visit (HR: 0.76; 95% CI: 0.73–0.79), and a 24% lower risk of avoidable ED visit (HR: 0.76; 95% CI: 0.71–0.81), compared with patients in the late referral group. With regard to the patients undergoing early infrequent consultations, the only marginally significant association was for infection-related ED visits. Recurrent event analysis revealed generally consistent results. Overall, these findings indicate that continuous nephrology care from early in the predialysis period could reduce the risk of ED utilization in the first year of dialysis treatment.

Emergency Department Utilization Among Maintenance Hemodialysis Patients: A Systematic Review

“…63 These findings suggest that reducing rates of missed dialysis may help reduce ED visits, although predictors of both missed dialysis and increased ED visits warrant further investigation. Although we did not identify any interventions in this subgroup, Chen et al 21 found that more frequent predialysis care by a nephrologist was associated with lower ED visit rates following HD initiation, suggesting that optimized predialysis care may help HD patients avoid the ED. Furthermore, Harel et al 3 observed that dialysis centers in Canada frequently share records systems with hospitals and have lower hospitalization rates for their patients than American dialysis centers.…”

“…Higher ED utilization was predicted by missed dialysis, longer interdialytic intervals, dialysis through catheters instead of arteriovenous fistulas, dialysis initiation, frequent postdialysis weights above target, prior hospitalization for dialysis, and infrequent predialysis care. 3,7,[18][19][20][21][22][23][24][25] Higher ED utilization was also predicted by the following social determinants of health: racial segregation, lower community income, female sex, Black race, reliance on public transport, and lower health literacy. [26][27][28][29][30] The undocumented and social determinants of health concept subgroups were treated separately to reflect the unique barriers to care that undocumented persons face in the United States, such as their ineligibility for Medicare.…”

“…16 This checklist consists of 27 questions designed to evaluate both randomized and nonrandomized studies for the overall quality of reporting and for internal and external validity. Quality levels were assigned to each included study, using the categories proposed by Hooper et al 17 : excellent (Downs and Black score ≥ 26), good (20)(21)(22)(23)(24)(25), fair (15)(16)(17)(18)(19), and poor (≤14). GH, HS, KM, and PS scored each included study individually, with quality levels assigned after consensus was reached (Table S2).…”

Factors Impacting the Referral Time to Nephrologists in Chronic Kidney Disease Patients in South Punjab, Pakistan

“…Similarly, CKD patients with diabetes mellitus are also referred early to increase the chances of survival and disease treatment (Smart et al, 2014;Wu et al, 2020). Other studies have also reported the early referral of diabetes mellitus patients before the start of dialysis (Chen et al, 2019;Mutatiri et al, 2022). Kessler et al (Kessler et al, 2003) and Kinchen et al (Kinchen et al, 2002) noted an average time of 4 to 12 months for referral of diabetes mellitus patients.…”

Adding creatinine to routine pregnancy tests: a decision tree for calculating the cost of identifying patients with CKD in pregnancy

“…Furthermore, even if the indications of several nephrology societies, including ours, are in favour of early identification of all cases of CKD, no randomized study has assessed the advantages of such a demanding policy [ 59–61 ]. We do, however, know the effects of a late CKD diagnosis, which involves lost opportunities for individuals and for society [ 62–64 ].…”