Health service utilisation during the last year of life: a prospective, longitudinal study of the pathways of patients with chronic kidney disease stages 3-5

Abstract

BackgroundChronic kidney disease (CKD) is a growing global problem affecting around 10% of many countries’ populations. Providing appropriate palliative care services (PCS) to those with advanced kidney disease is becoming paramount. Palliative/supportive care alongside usual CKD clinical treatment is gaining acceptance in nephrology services although the collaboration with and use of PCS is not consistent.MethodsThe goal of this study was to track and quantify the health service utilisation of people with CKD stages 3-5 over the last 12 months of life. Patients were recruited from a kidney health service (Queensland, Australia) for this prospective, longitudinal study. Data were collected for 12 months (or until death, whichever was sooner) during 2015-17 from administrative health sources. Emergency department presentations (EDP) and inpatient admissions (IPA) (collectively referred to as critical events) were reviewed by two Nephrologists to gauge if the events were avoidable.ResultsParticipants (n = 19) with a median age of 78 years (range 42-90), were mostly male (63%), 79% had CKD stage 5, and were heavy users of health services during the study period. Fifteen patients (79%) collectively recorded 44 EDP; 61% occurred after-hours, 91% were triaged as imminently and potentially life-threatening and 73% were admitted. Seventy-four IPA were collectively recorded across 16 patients (84%); 14% occurred on weekends or public holidays. Median length of stay was 3 days (range 1-29). The median number of EDP and IPA per patient was 1 and 2 (range 0-12 and 0-20) respectively. The most common trigger to both EDP (30%) and IPA (15%) was respiratory distress. By study end 37% of patients died, 63% were known to PCS and 11% rejected a referral to a PCS. All critical events were deemed unavoidable.ConclusionsFew patients avoided using acute health care services in a 12 month period, highlighting the high service needs of this cohort throughout the long, slow decline of CKD. Proactive end-of-life care earlier in the disease trajectory through integrating renal and palliative care teams may avoid acute presentations to hospital through better symptom management and planned care pathways.

Cuidados paliativos en la calidad de vida de los pacientes con enfermedad renal crónica avanzada sin terapia de sustitución renal.

“…(28) Una investigación realizada por Aoife C. Lowney et.al (30) , a través de la aplicación de la escala HRQoL (Health-related quality of life) a diversos pacientes (todos mayores de 18 años), postula que existe una disminución de la calidad de vida asociada a la ERCA en pacientes sometidos a diálisis. (31) Otro punto para considerar es la necesidad de recibir atención de salud durante el transcurso de la ERCA. Esto se aborda en el estudio realizado por Chambers S et al (30) donde se cuantificó la utilización de servicios de salud, incluyendo la asistencia a unidad de emergencia y requerimiento de hospitalización, tanto en pacientes en diálisis como en manejo conservador y se estableció que aquellos en diálisis presentaban más hospitalizaciones y visitas al servicio de urgencias que aquellos con manejo conservador.…”

Applying M-Health to Palliative Care: A Systematic Review on the Use of M-Health in Monitoring Patients With Chronic Diseases and its Transposition in Palliative Care

“…This has been highlighted independent of the responsible disease, whether it is cancer or organ failure, with a growing resort to emergency and hospital services during their last year of life. 42 –45 Moreover, it has been shown that home palliative care allows reducing the feeling of burden related to the symptoms. 41…”

“…This has been highlighted independent of the responsible disease, whether it is cancer or organ failure, with a growing resort to emergency and hospital services during their last year of life. [42][43][44][45] Moreover, it has been shown that home palliative care allows reducing the feeling of burden related to the symptoms. 41 Among patients receiving early palliative care, this followup would allow to rapidly detect the onset of complications that could be specifically treated, with an impact as much on quality of life as on survival.…”

Radically Rethinking Renal Supportive and Palliative Care in South Africa

“…The majority (79%) visited the emergency department, multiple visits were common, and 84% required in-patient admission. 23 There are limited data on the cost effectiveness of RSC frameworks 22 ; however, there is a well-established cost benefit in oncology. 24 RSC/PC may decrease hospitalizations, intensive care, and emergency department admissions.…”

“…The aim is to reduce the deaths in acute care facilities through better symptom management and planned care pathways. 23 Further research evaluating cost and health outcomes in ESKD is required.…”