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Author Interview: Dr. Antonios H. Tzamaloukas
Hospitalizations before and after initiation of chronic hemodialysis
Hemodial Int. 2011 May 13. doi: 10.1111/j.1542-4758.2011.00551.x.
Kassam H, Sun Y, Adeniyi M, Agaba EI, Martinez M, Servilla KS, Raj DS, Murata GH, Tzamaloukas AH.
What are the main findings of this study?
The study found a significant increase in the rate and length of hospitalizations after initiation of chronic hemodialysis in 392 patients followed in one hospital. This increase was found for all causes of hospitalization as well as hospitalizations for cardiac disease, infections, vascular access, peripheral vascular disease, metabolic disturbances, gastrointestinal disease, surgery and trauma, and miscellaneous conditions including respiratory diseases and malignancy. Patients with diabetes mellitus had higher rates of hospitalization than those without diabetes both in the pre-hemodialysis and in the hemodialysis period.
Were any of the findings unexpected?
We expected to find an increase in the rate of hospitalizations for dialysis-related conditions, such as those for vascular access and metabolic disturbances. We had no preconceived notions about any change in the rate of hospitalizations for conditions, such as gastrointestinal disease or surgical conditions and trauma, not related to dialysis directly. However, we do not believe that any of our findings were truly “unexpected”.
What should clinicians and patients take away from this study?
The main message for clinicians and investigators in the field of dialysis is that initiation of chronic hemodialysis signals a deterioration of health status, as can be judged by hospital admissions. This deterioration involves not only conditions that are directly linked to the practice of hemodialysis, but also several other important categories of medical conditions that have no direct link to dialysis. The message to clinicians is the need for monitoring the patients for conditions that worsen after the start of hemodialysis and also the need for aggressive prevention of potentially preventable conditions (e.g. trauma). The message to researchers is the need for further research into the hemodialysis-related factors that may cause deterioration of health. Patients should be aware of both the risks that are associated with chronic hemodialysis and the enhanced need for their close collaboration with the dialysis practitioners to prevent and/or manage all their medical conditions.
What recommendations do we have for nephrology health care providers as a result of our study?
This study underlined the need for active participation of the health care providers in several aspects of care of the patients on chronic hemodialysis. Some, but not all, of the specific areas outside the immediate field of dialysis, where nephrology health care providers can make a dent are in the care of extremities of patients with peripheral vascular disease, the prevention of trauma, and the timely diagnosis and management of infections, for example pneumonias. In addition, communication between nephrology and primary care health providers, with the initiative by the nephrology providers, about the aspects of health that deteriorate after the start of hemodialysis is imperative. Finally, research into the factors that affect the outcomes of chronic dialysis can be directed by studies such as ours.
Hospitalizations before and after initiation of chronic hemodialysis.
Hemodial Int. 2011 May 13. doi: 10.1111/j.1542-4758.2011.00551.x.
Kassam H, Sun Y, Adeniyi M, Agaba EI, Martinez M, Servilla KS, Raj DS, Murata GH, Tzamaloukas AH.
Abstract
Department of Surgery, University of New Mexico School of Medicine, Albuquerque, New Mexico Medicine Service, Raymond G. Murphy VA Medical Center, Albuquerque, New Mexico, USA Department of Medicine, University of New Mexico, School of Medicine, Albuquerque, New Mexico, USA Department of Medicine, Nephrology Division, Jos University Teaching Hospital, Jos, Plateau State, Nigeria Nephrology Division, George Washington University, Washington, DC, USA.
Hospitalization rate is high in patients on chronic hemodialysis (HD). We investigated whether initiation of HD changes the rate and length of hospitalization. We analyzed hospitalizations in HD patients in one hospital over 15 years.
We compared annual rate and length of hospitalizations, both presented as mean (95% confidence interval [CI]) between the pre-HD and HD period. Three hundred ninety-two patients, 98% men, 59% diabetic, and 66.3 ± 11.2 years old at the onset of HD, had 1016 hospitalizations in the pre-HD period (60.0 ± 42.9 months) and 1627 hospitalizations in the HD period (32.5 ± 25.9 months).
Higher values were found in the HD than the pre-HD period for rate, (pre-HD 0.557 [95% CI 0.473-0.611], HD 2.198 [95% CI 1.997-2.399] admissions/[patient-year], P<0.001) and length (pre-HD 4.63 [95% CI 3.71-5.55], HD 28.07 [95% CI 23.55-32.59] days/patient-year], P<0.001) of hospitalizations for all causes, cardiac disease, infections, vascular access, peripheral vascular disease, metabolic disturbances, gastrointestinal diseases, and miscellaneous conditions, mainly respiratory illness and malignancy.
Similar differences were found when we compared the year before and the year after the start of HD. Diabetics had higher all cause rate and length of hospitalizations than non-diabetics in the pre-HD and HD periods. The rate and length of hospitalizations was higher in the HD than the pre-HD period for both HD-specific conditions and conditions encountered in both HD and general populations.
Study of factors specific to HD that may affect these conditions should constitute the first step toward improving the morbidity of patients on HD.
Author Interviews: hemodialysis
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Home Dialysis Summit Recommends Policy Changes to Increase Home Dialysis Usage
WASHINGTON, April 25, 2012 /PRNewswire -- On the heels of the first National Summit on Home Dialysis Policy, Summit organizers released a report reflecting the views of the delegates -- leaders in the kidney disease patient, clinician, facility and industry communities -- on federal policy steps to improve utilization of home dialysis for patients who can benefit from this often advantageous form of treatment. Many of the organizers also announced they have formed a new alliance, called the Alliance for Home Dialysis, to advance the recommendations identified at the Summit.
The Summit's "Report of the Delegates" highlights key findings from a March 29th meeting in Washington, DC where experts probed why, despite widely accepted and well-documented benefits of home dialysis -- improved outcomes, enhanced patient satisfaction, improved quality of life, and lower costs-- fewer than ten percent of the more than 390,000 current U.S. dialysis patients receive treatment at home. Current rates of home dialysis utilization reflect a steep decline from the 1970s, when almost 40% of U.S. dialysis patients were treated in-home.
Specifically, delegates found that policymakers should work with stakeholders in the dialysis community to confront three areas:
Accessibility: Patients and clinicians face array of hurdles in education, training, and infrastructure that hinder equalized access to home dialysis.
Accountability: Utilization of home dialysis can be improved through measures within government programs that are designed to recognize and support excellence in the delivery of home dialysis services.
Aligning Incentives: Reimbursement policies, regulation of new technologies and other policy incentives can be realigned to better support federal policy goals of expanding access to home dialysis.
The Report includes 15 recommendations to serve these goals, including that federal policymakers should:
Maintain parity for home and in-center dialysis in Medicare reimbursement;
Support home dialysis mentoring programs, particularly those that use existing patients as mentors; and
Align federal and state regulatory requirements for home therapies, such as revising the Centers for Medicare and Medicaid Services Conditions for Coverage requirements, to reflect differences in home and in-center dialysis.
Summit supporters will begin work through the new Alliance to dialogue with federal policymakers and advance policy improvements in the three consensus areas that emerged at the Summit.
SOURCE National Summit on Home Dialysis Policy
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National Kidney Foundation's Top 10 Things Every Dialysis Patient Should Know.
- You have treatment choices. Options exist for how, where and when you dialyze. Dialysis can be done in a hospital, in a dialysis unit that is not part of a hospital, or at home. You and your doctor will decide which place is best, based on your medical condition and your wishes. There are different types of dialysis - peritoneal and hemodialysis. Work with your health care team to determine a treatment plan that makes you feel comfortable. Recent studies show that the majority of patients beginning in-center hemodialysis (HD) know very little, if anything, about the option to dialyze at home. Once informed, 40% or more of patients are interested in this treatment option, and yet less than 10% actually begin home dialysis. If you're dissatisfied with the type of dialysis treatment that you're receiving, ask your healthcare team if another type of dialysis treatment would be better.
- You can compare in-center dialysis facilities online. Information on over 5,600 US-based dialysis centers is available online through the Medicare website. To help you make choices about your care, you can compare different facilities side-by-side and evaluate each facility based upon clinic characteristics and quality measures. You can search for dialysis facilities by name or geographic proximity. After completing an initial facility comparison to determine which facilities best meet your needs - such as the number of hemodialysis stations at a particular location and whether there are evening shifts available - visit the facilities that you're most interested in. Talk to the staff and other patients, as well as your doctor to ensure that this dialysis facility is a good fit for you.
- There are ways to prepare ahead for an emergency. Ask your dialysis facility about their emergency plan in case of a snow storm, fire, power outage or other natural disaster. As back up, make sure you have the names, locations and phone numbers of other dialysis units and hospitals in your area. Since regular community transportation services may not be working in an emergency, be prepared to make other arrangements for getting to dialysis. You may need to contact the police and Emergency Medical Services (EMS) for assistance. If you dialyze at home, make sure you have at least two weeks' worth of unexpired supplies on hand. If you have to miss a dialysis treatment, begin your emergency meal plan.
- There is an easy way to transfer patient records between clinics. There is an easy, secure way for your health care team to transfer your treatment records online. In 2009, the Centers for Medicare and Medicaid Services (CMS) created a centralized web-based data collection system called CROWNWeb to help reduce and eliminate patient treatment interruptions. This central system helps to streamline patient care regardless of the reason for changing dialysis centers. For example, if you've been admitted to the hospital, or if you needed to relocate during an emergency evacuation, your doctors and health care team can access up-to-date information about your dialysis so that you continue to receive appropriate care no matter where you are.
- You can travel while on dialysis.
Dialysis centers are located in every part of the United States and in many foreign countries. The treatment is standardized, but you need to plan ahead by making an appointment for dialysis at another center before you go. The staff at your center may help you make these appointments.
- You can be your own best advocate. Know what key questions to ask your doctor or other healthcare professionals. Take notes so that you can refer back to them later. Partner with your doctor and decide on a treatment plan together. Advocate for yourself and share how you're feeling.
- You have many rights. You as a patient have a great deal of control over your treatments. Patients have a bill of rights which includes receiving quality care, counseling about your medical information, and an expectation of privacy.
You also have responsibilities. Once you decide on a course of treatment, it's important to follow the recommendations of your health care team. If you decide to receive in-center dialysis, arrive at dialysis on time so that you can receive the full treatment without delays.
- You can receive insurance coverage. If you have end stage renal failure, you are likely eligible for Medicare insurance coverage. Speak with your health care team and social worker for help filling out insurance paperwork.
- You may need to follow a special diet. When your kidneys are not working properly, you may not be able to eat everything you like, and you may need to limit how much you drink. Your diet may vary according to the type of dialysis you receive. It is important to speak with a renal dietitian so that you are able to understand what you can and cannot eat based on your full health history.
- Dialysis patients can work. Many dialysis patients can go back to work or school after they have gotten used to dialysis. After establishing a dialysis routine, many patients have more energy and find that they are able to time to work around this new schedule. Some patients even find creative ways to work remotely from dialysis with the use of a laptop or cell phone, depending on their field of expertise.
More from National Kidney Foundation Press Releases
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New Book to Help Educate Patients with Chronic Kidney Disease who may be facing Dialysis or Hemodialysis: |
Help, I Need Dialysis!
How to have a good future with kidney disease
By Dori Schatell, MS and Dr. John Agar
An internationally known nephrologist and life-long kidney patient educator explain how dialysis works, each of the ways to do it, and how your treatment choice may affect your diet, energy level, work, travel, sexuality and fertility, sleep, and survival. Comprehensive and fully referenced, this book is a must-read if you face the life-changing choices that come with kidney failure. |
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