Hospitalizations and Nursing Facility Stays During the Transition from CKD to ESRD on Dialysis: An Observational Study

Abstract

Background: There is little information on hospital and nursing facility stays during the transition from pre-dialysis kidney disease to end-stage renal disease treated with dialysis.

Objectives: To examine hospital and nursing facility stays in the years pre- and post-dialysis initiation, and to develop a novel method for visualizing these data.

Design: Observational study of patients in the US Renal Data System initiating dialysis from October 2011 to October 2012.

Participants: Patients aged ≥67 years with Medicare Part A/B coverage for 1 year pre-dialysis initiation.

Main measures: Proportion of patients with ≥1 facility day, and among these, the mean number of days and the mean proportion of time spent in a facility in the first year post-dialysis initiation. We created "heat maps" to represent data visually.

Key results: Among 28,049 patients, > 60% initiated dialysis in the hospital. Patients with at least 1 facility day spent 37-42 days in a facility in the year pre-dialysis initiation and 59-67 facility days in the year post-dialysis initiation. The duration of facility stay varied by age: patients aged 67-70 years spent 60 (95% CI 57-62) days or 25.8% of the first year post-dialysis initiation in a facility, while patients aged >80 years spent 67 (CI 65-69) days or 36.8% of the first year post-dialysis initiation in a facility. Patterns varied depending on the presence or absence of certain comorbid conditions, with dementia having a particularly large effect: patients with dementia spent approximately 50% of the first year post-dialysis initiation in a facility, regardless of age.

Conclusions: Older patients, particularly octogenarians and patients with dementia or other comorbidities, spend a large proportion of time in a facility during the first year after dialysis initiation. Our heat maps provide a novel and concise visual representation of a large amount of quantitative data regarding expected outcomes after initiation of dialysis.

Keywords: dialysis; hospitalization; kidney failure; nursing facility.

Figure 1

Schematic representation of the “heat map.” For illustrative purposes, the schematic shows only 3 days pre-dialysis initiation and 10 days post-dialysis initiation for five hypothetical patients, while the actual heat maps extend to 120 days pre-dialysis and 365 days post-dialysis initiation. Each day is represented by a single box that is color-coded as indicated in the legend. Each patient is represented by one row in the heat map. For example, patient (Pt) 1 spent the 3 days pre- and 10 days post-dialysis initiation at home. Patient 2 had no facility days pre-dialysis initiation, was hospitalized at the time of dialysis initiation, and then spent 2 days in a nursing facility before going home. Patients 3 and 4 spent variable lengths of time in a facility before dying on days 10 and 7 post-dialysis initiation, respectively. Patient 5 was hospitalized from 3 days pre- through 4 days post-dialysis initiation before dying on day 5 post-dialysis initiation.

Figure 2

Heat maps showing the status of patients aged a) 67–70 years, b) 71–75 years, c) 76–80 years, and d) >80 years during the 120 days pre- and 365 days post-dialysis initiation. *Post-dialysis initiation.

Figure 3

Heat maps showing the status of patients aged 67–70 years a) without cardiovascular disease (CVD) and b) with CVD, and patients aged >80 years c) without CVD and d) with CVD, during the 120 days pre- and 365 days post-dialysis initiation. ^In the 365 days post-dialysis initiation. *Post-dialysis initiation.

Figure 4

Heat maps showing the status of patients aged 67–70 years a without dementia and b with dementia, and patients aged >80 years c without dementia and d with dementia, during the 120 days pre- and 365 days post-dialysis initiation. *Post-dialysis initiation.