Predialysis Care Trajectories of Patients With ESKD Starting Dialysis in Emergency in France

Abstract

Introduction: Emergency dialysis start (EDS) is frequent for patients with chronic kidney disease (CKD). To improve CKD management, new trajectory-based care policies are currently being introduced both in France and in the United States. This study describes the different types of predialysis care trajectories and factors associated with EDS.Methods: Adults patients who started dialysis in France in 2015 were included. Individual clinical and health care consumption data were retrieved from the French national end-stage kidney disease (ESKD) registry (Renal Epidemiology and Information Network [REIN]) and the French National Health Data system (SNDS), respectively. Hierarchical Clustering on Principal Component was used to identify groups of patients with the same health care consumption profile during the 2 years before dialysis start. Logistic regression analysis was used to identify factors associated with EDS.Results: Among the 8856 patients included in the analysis, 2681 (30.3%) had EDS. The Hierarchical Clustering on Principal Component identified six types of predialysis care trajectories in which EDS rate ranged from 13.8% to 61.8%. After adjustment for the patients' characteristics, less frequent or lack of follow-up with a nephrologist was associated with higher risk of EDS (odds ratio [OR]: 1.32; 95% confidence interval [CI]: 1.17-1.50 and OR: 1.83; 95% CI: 1.58-2.12), but not follow-up with a general practitioner. Conclusions:The care trajectories during the 2 years before dialysis start were heterogeneous and patients with a lesser or lack of follow-up with a nephrologist were more likely to start dialysis in emergency, regardless of the frequency of follow-up by a general practitioner (GP). New CKD policies should include actions to strengthen CKD screening and referral to nephrologists.

Balancing Nephrology Referrals With Nephrologist Capacity to Decrease Emergency Dialysis Starts

“…This requires a partnership among GPs, nephrologists, interventional radiologists, vascular surgeons, cardiologists, diabetologists, patient education staff as well other care providers, each reinforcing with the patient the importance of taking ownership of their health care. Recognizing that every healthcare system is different, the report from Raffray et al 4 should serve as a model for similar studies from other countries to identify unique barriers to planned dialysis starts that can be addressed with targeted systemwide reforms specific to the patient demographics, healthcare provider resources, and payer structure of that country.…”

“…In this issue of Kidney International Reports, Raffray and colleagues 4 have linked two large national registries in France: the Renal Epidemiology and Information Network (REIN) which includes data on incident ESKD patients, and the National Health Information System Database (SNDS) which covers the health care utilization data of the population. EDS is a hard outcome that has adverse consequences for all stakeholders: patients, nephrologists, general practitioners (GPs), health care systems and payers.…”

Recent International Progress in Preventive Nephrology and the Road Less Traveled Ahead

“…7 A recent large French study showed that emergency dialysis starts comprised about 30% of incident patients (2681 of 8856) a finding that was strongly associated with inconsistent nephrology service patterns. 8 Several guideline implementation variables in nephrology practice are not addressed that may be further assessed by future CKDopps studies or other investigations, including vintage following the guideline publication, evidence level, national health policy and reimbursement influence and most of all associations with hard outcomes. How has adherence to guideline statements changed over the consecutive years following publication in January 2013?…”

“…7 A recent large French study showed that emergency dialysis starts comprised about 30% of incident patients (2681 of 8856), a finding that was strongly associated with inconsistent nephrology service patterns. 8 …”

“…Guidelines from the USA endorsed the KDIGO CKD guideline, 2 whereas those in France were different. 8 For example, nephrology consultation indications from France national guidelines are for eGFR <45 ml/min per 1.73 m 2 in contrast to KDIGO’s <30 ml/min per 1.73 m 2 that resulted in both higher mean eGFR and a greater proportion of the population with eGFR of 30 to 60 ml/min per 1.73 m 2 in France (54%) versus the 3 other countries evaluated. Reimbursement policies in France impacted increased urine testing, as noted previously.…”