High Emergency Room Department and Hospital Utilization
End-Stage Renal Disease (ESRD) patients have some of the highest rates of emergency room department (ED) visits and hospital admissions in the nation. Approximately 26 million Americans have chronic kidney disease of varying degrees, of which 600,000 have ESRD. These patients are often elderly, frail, and comorbid, which puts them at high risk for ED visits and admissions. In fact, they present to the ED 8.5 times more often than age and sex adjusted cohorts. ESRD patients requiring hemodialysis (HD) are hospitalized 1.7 times per year on average. In a cohort of 769,228 ESRD patients followed over 6 years, 69% visited the ED at least once. Some patients visit the ED so often (eg, more than 50 times per year) that it is assumed that they receive their regular dialysis services through ED visitation.
Downstream Impact on Care
A study of 182,536 ESRD patients and 44 million HD treatments over 5 years found that patients on average miss 7.1 treatment appointments per year. Approximately half of missed appointments are due to hospitalizations. Not surprisingly, for patients who miss appointments due to nonadherence, the risk of subsequent hospitalization, ED visitation, and ICU admission increased substantially after a single missed treatment, putting that patient at risk for additional downstream appointment absences. A single missed appointment is associated with a 1.4-fold increased risk of hospitalization and a 2.2-fold increase in 30-day mortality.
Missed appointments due to ED visit or hospitalization and the dialysis center’s lack of visibility to these events have several downstream consequences:
The dialysis chair—a precious resource—goes underutilized.
The dialysis center loses the unused dialysis supplies set up for that patient.
The dialysis technician is left idle.
The cycle repeats itself as the patient remains in the hospital without the dialysis centers’ knowledge. Without clear transparency into when the patient is being discharged from the hospital or post-acute care facility, it is impossible for the dialysis center to repatriate the patient into the schedule effectively. This again increases the risk of missed appointments and its attendant downstream health risks. As such, a system that provides real-time notifications to dialysis providers when a patient has entered the ED, been admitted to the hospital, and discharged from it, could be extremely useful to dialysis providers. It could help increase the coordination and continuity of care that is absolutely essential for safety in this complex population. It would also help increase the efficient utilization of dialysis chairs and reduce the waste from unused dialysis setups.
What Happens Today
Opportunity to Improve Care
Immediate notification of ED visitation, hospital admission, and discharge enables the HD center to plan for the patient’s absence and to plan for repatriation of the patient into dialysis program. Furthermore, this advanced notice:
Reduces the cost of absenteeism.
Utilizes open chairs for other patents in need.
Reduces unused equipment set up.
Allows providers to stay connected to patient throughout their hospital stay.
Ensures that an appropriate transition plan is in place.
An additional benefit to the real-time notifications that Position Health provides is that communication with the ED physician, if the patient is in ED to receive HD, allows the primary provider to arrange to bring the patient back to dialysis center for immediate HD, avoiding the patient getting ED and potential hospital admission simply for dialysis. In summary, real-time notifications enable better, more connected, more efficient, less costly care.