Three in 10 patients receiving a kidney transplant require readmission to the hospital within 30 days of discharge following surgery, according to a Johns Hopkins analysis of six years of national U.S. data.
The findings, published online in the American Journal of Transplantation, suggest more needs to be done to manage patients outside the hospital to keep them from costly and potentially preventable return visits. Readmissions are said to cost the U.S. health care system $25 billion a year. The Centers for Medicare and Medicaid Services has begun the process of decreasing reimbursements to hospitals with high readmission rates, using readmissions as a surrogate measure of hospital quality.
"We need to be aware that kidney transplant recipients have an extremely high risk of returning to the hospital in the first 30 days after discharge, and that readmissions may very well be prevented by putting in place better systems for outpatient management," says study leader Dorry L. Segev, M.D., Ph.D., an associate professor of surgery at the Johns Hopkins University School of Medicine. "Some patients just need more intense monitoring."
Segev and his colleagues examined data provided by the Organ Procurement and Transplantation Network, Medicare, and the United States Renal Data System from more than 32,000 patients who received kidney transplants in U.S. hospitals between Jan. 1, 2000 and Dec. 31, 2005. While 31 percent of transplant recipients required readmission within 30 days, the percent of patients returning varied by hospital, from 18 percent to nearly 50 percent, a variation that could not be accounted for by conventional issues of center volume or demographics.
Age, race, body mass index, diabetes, heart disease and several other factors were associated with early hospital readmission. African-Americans had an 11 percent increased risk of readmission, and obese patients had a 15 percent increased risk, while diabetic women were at a 29 percent increased risk. Interestingly, those patients who stayed in the hospital for five or more days at the time of their transplants were more likely to be readmitted within 30 days. Segev says this may be a sign that the more complex cases early on appear to remain complex and more likely to require additional care.
Patients who bounce back to the hospital are not returning only for complications related to their new organs -- such as infections or problems related to immunosuppressant drugs they need to keep from rejecting the new organ -- but often for problems related to other illnesses they had before they received their transplants. Segev says even though medical teams make sure that the heart disease or diabetes a transplant candidate may have is stable before a transplant takes place, those conditions can still cause complications after surgery. The entire medical team needs to be sure people with co-morbidities are very closely followed, he says.
"Kidney transplant is complex and the management of the first 30 days is complex," he adds. "We will never get the readmission rate down to zero, but it's highly likely we can get it down from nearly one-third."
Segev says he hopes that transplant centers with higher rates of readmission can learn lessons from centers with lower rates. They may find that those centers schedule more frequent outpatient visits, offer more opportunities to communicate with clinicians via email or the telephone, or are better at coordinating services such as blood work that may be needed after discharge so that critical post-transplant medication adjustments can be made quickly before a readmission is required.
Other Johns Hopkins researchers involved in the study include Mara A. McAdams-DeMarco, Ph.D.; Morgan E. Grams, M.D., M.H.S.; Erin Carlyle Hall, M.D., M.P.H.; and Josef Coresh, M.D.
The study was supported by grants from the National Kidney Foundation of Maryland, the American Federation for Aging Research, the National Institutes of Health's National Institute on Aging (K23AG032885) and NIH's National Institute of Diabetes and Digestive and Kidney Diseases (R21DK085409).
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