Potentially Preventable Hospitalization among Patients with CKD and High Inpatient Use

Abstract

Background and objectives: Although patients with CKD are commonly hospitalized, little is known about those with frequent hospitalization and/or longer lengths of stay (high inpatient use). The objective of this study was to explore clinical characteristics, patterns of hospital use, and potentially preventable acute care encounters among patients with CKD with at least one hospitalization.

Design, setting, participants, & measurements: We identified all adults with nondialysis CKD (eGFR<60 ml/min per 1.73 m2) in Alberta, Canada between January 1 and December 31, 2009, excluding those with prior kidney failure. Patients with CKD were linked to administrative data to capture clinical characteristics and frequency of hospital encounters, and they were followed until death or end of study (December 31, 2012). Patients with one or more hospital encounters were categorized into three groups: persistent high inpatient use (upper 5% of inpatient use in 2 or more years), episodic high use (upper 5% in 1 year only), or nonhigh use (lower 95% in all years). Within each group, we calculated the proportion of potentially preventable hospitalizations as defined by four CKD-specific ambulatory care sensitive conditions: heart failure, hyperkalemia, volume overload, and malignant hypertension.

Results: During a median follow-up of 3 years, 57,007 patients with CKD not on dialysis had 118,671 hospitalizations, of which 1.7% of patients were persistent high users, 12.3% were episodic high users, and 86.0% were nonhigh users of hospital services. Overall, 24,804 (20.9%) CKD-related ambulatory care sensitive condition encounters were observed in the cohort. The persistent and episodic high users combined (14% of the cohort) accounted for almost one half (45.5%) of the total ambulatory care sensitive condition hospitalizations, most of which were attributed to heart failure and hyperkalemia. Risk of hospitalization for any CKD-specific ambulatory care sensitive condition was higher among older patients, higher CKD stage, lower income, registered First Nations status, and those with poor attachment to primary care.

Conclusions: Many hospitalizations among patients with CKD and high inpatient use are ambulatory care sensitive condition related, suggesting opportunities to improve outcomes and reduce cost by focusing on better community-based care for this population.

Keywords: Alberta; Ambulatory Care; Canada; Hyperkalemia; Hypertension, Malignant; Inpatients; Primary Health Care; Residence Characteristics; adult; chronic renal insufficiency; follow-up studies; heart failure; hospitalization; humans; renal dialysis; renal insufficiency, chronic.

Copyright © 2016 by the American Society of Nephrology.

Figures

Figure 1.

Criteria to determine the final study cohort. DOB, date of birth.

Figure 2.

Clinical and demographic factors associated with having at least one ambulatory care sensitive hospitalization among high users of inpatient services (n=7957). 95% CI, 95% confidence interval; COPD, chronic obstructive pulmonary disease; GP, general practitioner; OR, odds ratio.