Emergency department use among kidney transplant recipients in the United States

Abstract

Patients with end-stage renal disease use the emergency department (ED) at a 6-fold higher rate than do other US adults. No national studies have described ED use rates among kidney transplant (KTx) recipients, and the factors associated with higher ED use. We examined a cohort of 132 725 adult KTx recipients in the United States Renal Data System (2005-2013). Data on ED visits, hospitalization, and outpatient nephrology visits were obtained from Medicare claims databases. Nearly half (46.1%) of KTx recipients had at least one ED visit (1.61 ED visits/patient-year [PY]), and 39.7% of ED visits resulted in hospitalization in the first year posttransplantation. ED visit rate was high in the first 30 days (5.26 visits/PY) but declined substantially thereafter (1.81 visits/PY in months 1-3; 1.13 visits/PY in months 3-12 posttransplantation). ED visit rates were higher in the first 30 days versus rates for dialysis patients but less than half the rate thereafter. Female sex, public insurance, medical comorbidities, longer pretransplantation dialysis vintage, and delayed graft function were associated with higher ED use in the first year post-KTx. Policies and strategies addressing potentially preventable ED visits should be promoted to help improve patient care and increase efficient use of ED resources.

Hospital admissions and emergency department visits among kidney transplant recipients

“…Congruent with our findings, previous studies demonstrate that acute care utilization in the year following kidney transplantation within the United States is quite high . In a retrospective analysis of 132 725 kidney transplant recipients in the United States Renal Data System (USRDS), 46.1% of patients visited the ED within the year following kidney transplant .…”

“…Congruent with our findings, previous studies demonstrate that acute care utilization in the year following kidney transplantation within the United States is quite high . In a retrospective analysis of 132 725 kidney transplant recipients in the United States Renal Data System (USRDS), 46.1% of patients visited the ED within the year following kidney transplant . Factors associated with these visits included female sex (rate ratio [RR] = 1.15; 95% CI = 1.14‐1.17), comorbidities (eg, diabetes mellitus, COPD and CHF), time on dialysis prior to transplantation (RR = 1.33; 95% CI = 1.30‐1.36 per 10 years) and delayed graft function (RR = 1.27; 95% CI = 1.25‐1.29).…”

“…Female sex (RR = 1.25; 95% CI = 1.21‐1.29) and comorbidities (eg, depression, diabetes, and peripheral vascular disease [PVD]) were also associated with ED visits, along with age 18‐29 vs >60 years (RR = 1.28; 95% CI = 1.20‐1.36), black race (RR = 1.21; 95% CI = 1.16‐1.26) and pre‐transplantation ED visits (RR = 1.88; 95% CI = 1.82 to 1.95 and RR = 1.58; 95% CI = 1.52‐1.64 for ED visits with and without admission). Approximately 40%‐48% of ED visits resulted in hospitalizations in these studies . Further, Lynch and colleagues found a composite hospitalization rate of 68.9% at 1 year following kidney transplantation among 37 623 patients in the USRDS .…”

“…Further, Lynch and colleagues found a composite hospitalization rate of 68.9% at 1 year following kidney transplantation among 37 623 patients in the USRDS . Factors associated with hospitalizations were similar to predictors of ED visits and included age in years (hazard ratio [HR] = 1.01, P < 0.001), years on dialysis (HR = 1.01, P < 0.001), comorbidities (eg, PVD, CHF, and diabetes), and hospital admission prior to transplantation (HR = 1.50, P < 0.001 for those with >15 inpatient days prior to transplant). Unlike the aforementioned analyses, we measured IP and ED utilization within 4 to 12 months after transplant, rather than 0 to 12 months post‐transplant and specifically focused on high utilizers (ie, at least two encounters) rather than any utilization .…”

Assessing emergency department utilization in the era of population health

“…In the current issue of the American Journal of Transplantation , Lovasik et al present a study examining national rates of emergency department (ED) visits following discharge among approximately 130 000 adult kidney transplant recipients in the United States . As the authors state, approximately one‐eighth of US healthcare expenditures are allocated for ED visits and as such, efforts to address cost‐effective care must consider the high frequency, potentially lower quality of care, and challenges with patient management associated with ED visits.…”