The Impact of Unplanned Hemodialysis on Healthcare Costs

• Main Authors: I-Ying Tsai, 蔡易穎
• Other Authors: Hui-Chu Lang
• Format: Others
• Language: en_US
• Published: 2013
• Online Access: http://ndltd.ncl.edu.tw/handle/93564326464465902919

碩士 === 國立陽明大學 === 醫務管理研究所 === 101 === Background: The clinical and socioeconomic impact of unplanned dialysis is significant. Access to nephrology care before initiation of chronic dialysis is associated with improved outcomes. There have been no reports of unplanned hemodialysis (HD) initiation in Taiwan. The aim of this study is to evaluate the impact of healthcare utilization and healthcare cost, and to analyze whether the healthcare utilization in the predialysis period correlates with the planned start among incident hemodialysis patients. Study design: retrospective cohort study. Setting &; Participants: We conducted the study of adult patients, who initiated first long-term hemodialysis therapy between January 1, 2005 and December 31, 2007. We used the sampling file of one million people in 2005, in Taiwan National Health Insurance Research Database (NHIRD). The study period for each patient extended from 2 years before to 90 days after the initiation of HD therapy. Predictors: Patient characteristics (sex, age, diabetes, hypertension, peripheral vascular disease, congestive heart failure, myocardial infarction) and healthcare utilization (nephrology care, western medicine outpatient department (OPD) visits, and emergency department (ED) visits) in the predialysis period. Predictors of the planned starts were evaluated with logistic regression. Outcome and measurements: ED visits hospitalization rates, cause-specific hospitalizations, length of hospitalization and total hospitalization costs per patient in the postdialysis period. Results: A total 927 patients were included (mean age, 63 years old; 53% male; 67% unplanned dialysis initiation). In the postdialysis period, the proportion of hospitalization (17.6% vs. 48.5%, p < 0.001) and ED visits (26.7% vs. 37.8%, p = 0.006) were significantly higher in the unplanned group. In all hospitalized patients, the median length of hospitalization (7 days vs. 13 days, p = 0.009) was significantly higher in the unplanned group. For all cardiovascular hospital admissions, the median length of hospitalization (4 days vs. 14 days, p = 0.036), and the median unadjusted total hospitalization costs per patient ($1492 vs. $2711, p = 0.046) were significantly higher in the unplanned group. For all infectious hospital admissions, the median length of hospitalization (8 days vs. 16.5 days, p = 0.003), unadjusted median total hospitalization cost per patient ($1651 vs. $2884, p = 0.033) were also significantly higher in the unplanned group. Total annualized hospital costs related to unplanned dialysis was $ 350,000 (about $10.5 million TWD). Reducing the rate of unplanned dialysis by one-half yielded savings about $208,000 (about 6.2 million TWD), when we used the total number of new ESRD in 2005 as the estimation. In a model using only patients’ characteristics as the risk factor, logistic regression showed lower ORs for advancing age 0.99 (95% CI, 0.99-1.00), diabetes 0.52 (95% CI , 0.38-0.71), and myocardial infarction 0.36 (95% CI, 0.14-0.94), and higher ORs for hypertension 1.72 (95% CI, 1.17-2.63). In the expanded model II, odds were lower for advancing age 0.95 (95% CI, 0.97-1.00), diabetes 0.51 (95% CI, 0.37-0.73), and the number of ED visits 0.73 (95% CI, 0.62-0.87). Odds were higher for predialysis nephrology care for over 90 days before HD 1.97 (95% CI, 1.31-2.96), the number of nephrology care 1.28 (95% CI, 1.21-1.37) and the number of western medical OPD visits, except nephrology care 1.05 (95% CI, 1.03-1.08). Limitations: Clinical outcomes, laboratory data, and social-economic status were not feasible due to the nature of the database. Conclusions: Between 2005 and 2007, the proportion of unplanned starts of HD was high in Taiwan. Unplanned starts are linked to more ED visits and more hospitalizations in the postdialysis period. All infection and all cardiovascular causes related hospitalizations play a major part of the total hospitalization costs, especially in the unplanned group. Increasing predialysis nephrology care, increasing OPD visits and decreasing ED visits were associated with increased odds of planned starts. That said the impact of unplanned dialysis is significant in the healthcare cost and utilization. Further research and the implementation of initiatives are needed to reduce the rate of unplanned HD starts and the significant reduction of related healthcare costs. Key words: unplanned start, hemodialysis, healthcare costs, utilization, hospitalization