Healthcare Intensity at Initiation of Chronic Dialysis among Older Adults

Abstract

Little is known about the circumstances under which older adults initiate chronic dialysis and subsequent outcomes. Using national registry data, we conducted a retrospective analysis of 416,657 Medicare beneficiaries aged $67 years who initiated chronic dialysis between January 1995 and December 2008. Our goal was to define the relationship between health care intensity around the time of dialysis initiation and subsequent survival and patterns of hospitalization, use of intensive procedures (mechanical ventilation, feeding tube placement, and cardiopulmonary resuscitation), and discontinuation of dialysis before death. We found that most patients (64.5%) initiated dialysis in the hospital, including 36.6% who were hospitalized for $2 weeks and 7.4% who underwent one or more intensive procedures. Compared with patients who initiated dialysis in the outpatient setting, those who received the highest intensity of care at dialysis initiation (those hospitalized $2 weeks and receiving at least one intensive procedure) had a shorter median survival (0.7 versus 2.1 years; P,0.001), spent a greater percentage of remaining followup time in the hospital (median, 22.9% versus 3.1%; P,0.001), were more likely to undergo subsequent intensive procedures (44.9% versus 26.0%; adjusted hazard ratio, 2.33; 95% confidence interval [CI], 2.27 to 2.39), and were less likely to have discontinued dialysis before death (19.1% versus 26.2%; adjusted odds ratio, 0.68; 95% CI, 0.65 to 0.72). In conclusion, most older adults initiate chronic dialysis in the hospital. Those who have a prolonged hospital stay and receive other forms of life support around the time of dialysis initiation have limited survival and more intensive patterns of subsequent healthcare utilization.

A Palliative Approach to Dialysis Care

“…In addition to the burdens of the dialysis procedure itself, initiation of dialysis often means that patients are committing themselves to intensive patterns of health care utilization, in many instances without full understanding and adequate discussion of the implications (23). Only 6%-35% of dialysis patients complete advance directives planning; the default then becomes intensive care patterns, including multiple admissions, surgical procedures, and resuscitation attempts at the end of life (13).…”

“…Only 6%-35% of dialysis patients complete advance directives planning; the default then becomes intensive care patterns, including multiple admissions, surgical procedures, and resuscitation attempts at the end of life (13). Most older dialysis patients in the United States initiate dialysis in the hospital, and many experience high rates of subsequent hospitalization (23). In a study of older Medicare patients starting dialysis, patients were classified into five levels of intensity of care, with the highest level being those who had longer than a 2-week hospital stay and received at least one intensive procedure, such as cardiopulmonary resuscitation, mechanical ventilation, or a feeding tube.…”

“…In a study of older Medicare patients starting dialysis, patients were classified into five levels of intensity of care, with the highest level being those who had longer than a 2-week hospital stay and received at least one intensive procedure, such as cardiopulmonary resuscitation, mechanical ventilation, or a feeding tube. In patients$85 years who received the highest intensity of care, the median duration of survival after dialysis initiation was ,6 months, with more than a third of that time spent in the hospital (23).…”

Patient-Centered Care

“…The majority of older dialysis patients in the United States initiate dialysis in the hospital and many go on to experience high rates of hospitalization after initiation (36). In a study of older Medicare beneficiaries starting dialysis, patients were classified into five levels of intensity of care around the time of dialysis initiation, ranging from outpatient initiation at one extreme to spending .2 weeks in the hospital and receiving at least one intensive procedure such as cardiopulmonary resuscitation, mechanical ventilation, or feeding tube placement at the other.…”

“…In a study of older Medicare beneficiaries starting dialysis, patients were classified into five levels of intensity of care around the time of dialysis initiation, ranging from outpatient initiation at one extreme to spending .2 weeks in the hospital and receiving at least one intensive procedure such as cardiopulmonary resuscitation, mechanical ventilation, or feeding tube placement at the other. For patients aged $85 years who received the highest level of intensity of care, median survival after dialysis initiation was ,6 months, with more than one third of that time spent in the hospital (36). Many patients continue to receive very aggressive care focused on life prolongation toward the end of their lives.…”