Fatality and hospitalization in hemodialysis patients in a health plan

Sérgio Adriano Loureiro Bersan Carlos Faria Santos Amaral Isabel Cristina Gomes Mariângela Leal Cherchiglia About the authors

Abstract

OBJECTIVE:

To analyze clinical outcomes of patients on hemodialysis linked to health care plan provider.

METHODS:

Cohort study of hemodialysis events in Belo Horizonte, MG, Southeastern Brazil, between 2004 and 2008, based on records from health care plan provider databases. The independent variables were: sex, age, time between first appointment with nephrologist and starting hemodialysis, type of first vascular access, diabetes mellitus, length of time spent in hospital/year of treatment and death. Dependent variables: time between starting hemodialysis and death and length of time spent in hospital/year of treatment > 7.5 days. Statistical analysis was carried out using Pearson's Chi-squared test in the univariate analysis for the outcomes 'death' and 'length of time spent in hospital/year of treatment'; the Kaplan-Meier method was used to analyze survival; the Cox model and Poisson regression were used for risk of death and chance of length of time spent in hospital/year of treatment > 7.5 days. The Business Intelligence tool and Stata(r) 10.0 software were used to extract data.

RESULTS:

There were 311 patients on hemodialysis included in the study, with a mean age of 62 (sd 16.6 years), of whom 55.5% were male. Prevalence increased 160% during the period in question. Survival analysis showed a higher mortality among older patients, patients that did not consult a nephrologists, those whose first vascular access was using a temporary catheter, those with diabetes mellitus, those admitted to hospital within a month of beginning hemodialysis. The Cox model showed that a higher risk of death was associated with age, diabetes mellitus, not consulting a nephrologists and those that were hospitalized within a month of beginning hemodialysis. Greater length of time spent in hospital/year of treatment was not associated with sex or diabetes. According to Poisson regression, the variables were not significant.

CONCLUSIONS:

Assessment by a specialist before starting hemodialysis decreases the risk of death in cases of chronic kidney disease, whereas the presence of diabetes and being hospitalized within a month of beginning hemodialysis are markers of risk of death.

Renal Insufficiency, Chronic, complications; Renal Dialysis, mortality; Risk Factors; Diabetes Complications; Prepaid Health Plans


INTRODUCTION

Chronic renal disease (CRD) is an important condition in the epidemiological and demographic transition of various countries, including Brazil. Among its etiological factors, diabetes mellitus and systemic arterial hypertension stand out as the most frequent underlying causes. 16 16. Rayner HC, Pisoni RL, Bommer J, Canaud B, Hecking E, Locatelli F, et al. Mortality and hospitalization in haemodialysis patients in five European countries: results from the Dialysis Outcomes and Practice Patterns Study (DOPPS). Nephrol Dial Transplant. 2004;19(1):108-20. DOI:10.1093/ndt/gfg483
https://doi.org/10.1093/ndt/gfg483...

Cases of CRD almost quadrupled in the United States in the 1990s. The Brazilian Nephrology Society (BNS) identified 73,605 patients with TCRD (terminal) in dialysis treatment in Brazil in 2007. The prevalence rate was 333 per million inhabitants (pmp) in 2004, increasing to 391 pmp in 2007 (increase of 8.1%). 21 21. Sesso R, Lopes AA, Thomé FS, Bevilacqua JL, Romão Jr JE, Lugon J. Resultados do Censo de Diálise da SBN, 2007. J Bras Nefrol. 2007;29(4):197-202.

The impact on the life expectancy of TCRD patients on renal replacement therapy (RRT) - dialysis (hemodialysis - HD) and peritoneal dialysis and kidney transplantation - are well established. Individuals on RRT have a lower life expectancy than those of the same age and sex in the general population. 7 7. Evans M, Frysek JP, Elinder CG, Cohen SS, McLaughlin JK, Nyrén O, et al. The natural history of chronic renal failure: results from an unselected, population-based, inception cohort in Sweden. Am J Kidney Dis. 2005;46(5):863-70. DOI:10.1053/j.ajkd.2005.07.040
https://doi.org/10.1053/j.ajkd.2005.07.0...
, 9 9. Jager KJ, van Dijk PCW, Dekker FW, Stengel B, Simpson K, Briggs JD, et al. The epidemic of aging in renal replacement therapy: an update on elderly patients and their outcomes. Clin Nephrol. 2003;60(5):352-60. Mortality is influenced by individual factors such as age, underlying cause of CRD and comorbidities and factors relating to the use of health care services such as delayed referral to a nephrologist, use of temporary vascular access and hospitalizations. 16 16. Rayner HC, Pisoni RL, Bommer J, Canaud B, Hecking E, Locatelli F, et al. Mortality and hospitalization in haemodialysis patients in five European countries: results from the Dialysis Outcomes and Practice Patterns Study (DOPPS). Nephrol Dial Transplant. 2004;19(1):108-20. DOI:10.1093/ndt/gfg483
https://doi.org/10.1093/ndt/gfg483...
, 19 19. Ross EA, Alza RE, Jadeja, NN. Hospital resource utilization that occurs with, rather than because of, kidney failure in patients with end-stage renal disease. Clin J Am Soc Nephrol. 2006;1(6):1234-40. DOI:10.2215/CJN.01210406
https://doi.org/10.2215/CJN.01210406...
, 25 25. Tadaki F, Inagaki M, Miyamoto Y, Tanaka SI, Tanaka R, Kakuta T, et al. Early hospital readmission was less likely for hemodialysis patients from facilities with longer median length of stay in the DOPPS study. Hemodial Int. 2005;9(1):23-9. DOI:10.1111/j.1492-7535.2005.01114.x
https://doi.org/10.1111/j.1492-7535.2005...

The increased incidence and prevalence of patients with TCRD and the impact of treatment of RRT on national health systems' spending has attracted the attention of managers. Similarly to what has happened in the world, the challenges faced in Brazil range from the systematic collection of data, through the interventions in determinants of risk, adequate supply of quality services and the financing of the sector.

In spite of additional regulation (law 9,656/98) having RRT coverage compulsory, until recently the panorama of provision of these services and the sources of financing did not substantially change. The Brazilian Unified Health System (SUS) for around 90% of RRT. The same is seen in publications in which the majority of studies on the epidemiological, clinical and economic aspects of RRT in Brazil use data from patients and services funded by the SUS. The analyses referring to TCRD patients in health care plans are incipient.

This study aimed to analyze clinical outcomes of patients on hemodialysis linked to a health care plan provider.

METHODS

Observational, non-concurrent study using an open historical cohort of patients on HD between January 2004 and December 2008 and registered in the database of a health care plan provider in the metropolitan region of Belo Horizonte, MG, Southeastern Brazil, with around 600,000 beneficiaries. The Ministry of Health Department of Health Monitoring Mortality Information System was used to confirm deaths.

Individuals who started hemodialysis in the period, were aged over 18 and received treatment for more than three consecutive months in a service network directly contracted by the provider were eligible. Patients who had declared chronic renal disease as e pre-existing condition when they signed up with the provider and who had a difference of more than 12 months between starting coverage by the provider and the date of their first HD session were excluded.

There were 592,707 beneficiaries registered with the provider in July 2008, 45% males, with a mean age of 42 (standard deviation - sd 17.2 years); 13% of the beneficiaries were aged over 65. There were 311 individuals in hemodialysis included in the study, 55% were men, the mean age was 62 (sd: 16.6 years) and 48% were > 65. The median length of contract with the provider was nine years.

The independent variables were: a) demographic characteristics (sex, age); b) clinical characteristics: consultation with nephrologist (early referral - the consultation took place up to four months before HD started; delayed consultation - the consultation took place less than four months before HD started; no consultation); first vascular access (temporary vascular catheter - TVC); arteriovenous fistula; presence of diabetes mellitus as a comorbidity; length or treatment; hospitalizations (occurring in the same month as the start of treatment until the outcome, excluding those lasting only one day and those related to kidney donation for the beneficiary); time spent in hospital per year of treatment (THYT) starting from the first day of HD, excluding the days of hospitalizations for which death was the outcome; and c) outcome characteristics (death, continuing in treatment or lost follow up). The THYT was described in two categories, using the median as reference: fewer or more than 7.5 days of hospitalization per year of treatment.

The dependent variables were: time between date of starting hemodialysis until date of death and THYT > 7.5 days.

Descriptive analysis was performed using frequency distributions, measures of central tendency and variability for the characteristics studied. The χ 2 test was used to analyze differences in proportions between the categorical variables. The rate of prevalence of patients in HD was calculated per million patients.

There were 49 patients whom the study was unable to follow up, nine who left the provider and 19 who underwent kidney transplants.

The Kaplan-Meier method was used to estimate survival curves compared using the log-rank test, with 5% being the level of significance. The Cox proportional hazard model (hazard ratio) was used to identify independent effect of the explanatory variables of survival. The assumption of the proportionality of risk was assessed by graphical analysis of Schoenfeld residuals. The relevance of each variable included in the multiple model was verified using the Wald statistic, those which did not contribute significantly being excluded from the model and those which were statistically significant remaining in the final model (p < 0.05).

The BI (Business Intelligence) Prodige(r) tool was used to extract data from the provider's database (Data Warehouse) and Stata(r) 10.0 for the statistical analysis.

This study was approved by the Research Ethics Committee of the Faculdade de Medicina, Universidade Federal de Minas Gerais (Process nº ETIC 437/08) and authorized by the Research Committee of the Medical Work Cooperative, Belo Horizonte.

RESULTS

There were 592,707 beneficiaries registered with the provider in July 2008, 45% were male, the mean age was 42 (standard deviation - sd 17.2 years); 13% of the beneficiaries were aged over 65. There were 311 individuals on hemodialysis included in the study, 55.5% were male, the mean age was 62 (sd: 16.6 years) and 48% were aged over 65. The median length of contract with the provider was nine years.

The increase in prevalence was 160%: from 127 pmp in 2004 to 331 pmp in 2008 (p < 0.001 Cochran-Armitage).

Most of the patients undergoing hemodialysis had seen a nephrologist before starting renal replacement therapy, used TVC as the initial access, had spent < 12 months in treatment and had been hospitalized in the same month as HD started. Almost half of the beneficiaries had diabetes mellitus (Table 1).

Table 1
Deaths according to demographic characteristics and health care service use by patients on hemodialysis. Belo Horizonte, MG, Southeastern Brazil, 2004 to 2008.

Death was linked to age in the uni-variate analysis of the first model and 68% of deaths occurred in individuals aged > 65. The majority of those who did not die had consulted a nephrologist up to four months before starting HD. The majority of patients who went on to die had been in treatment for < 1 year (77%) and had been hospitalized in the same month in which HD started (84%). There were more deaths in diabetic individuals.

There was no association between THYT or sex and death (Table 1). The older beneficiaries, those with no recorded consultation with a nephrologist, those using TVC as the initial access for HD, diabetics and those who had been hospitalized in the same month in which HD started had lower survival rates (Figure). Survival rates of diabetics in the 1st, 2nd and 5th year were, respectively, 61.4%, 48.7% and 18.6%; in the non-diabetics they were 71.9%, 65.2% and 46.8%, respectively.

Figure
Kaplan-Meier curves for the event of death with the following co-variables: (a) Diabetes, (b) Age group, (c) Consultation with nephrologist, (d) First vascular access, (e) Hospitalizations. Belo Horizonte, MG, Southeastern Brazil, 2004.

In the final Cox model of proportional hazard, risk of death increased with age, with not having seen a nephrologist, with diabetes mellitus and with being hospitalized in the same month in which HD started (Table 2). Analysis of Schoenfeld residuals confirmed the assumption of the proportionality of risks, as no trend was observed in the residual diagrams.

Table 2
Cox proportional hazard model with hazard ratios for death by clinic and epidemiological characteristics of hemodialysis patients. Belo Horizonte, MG, Southeastern Brazil, January/2004 to December/2008.

The majority of patients with THYT > 7.5 days were aged 65 and over, with TVC as the first vascular access, were in dialysis treatment for a period < 12 months, were diabetic, had been hospitalized in the same month in which HD started and had diabetes mellitus, according to uni-variate analysis of the second model (Table 3). None of the variables tested using Poisson Regression were significant.

Tabela 3
Length of hospital stay per year of treatment and clinical and epidemiological characteristics of patients on hemodialysis. Belo Horizonte, MG, Southeastern Brazil, January/2004 to December /2008.

DISCUSSION

This is the first Brazilian study in the field of supplementary health care which approaches the epidemiological profile of service use and of HD patients. The study shows an increase in the prevalence of TCRD in the provider, greater risk of this leading to death linked to age, patients failing to be seen by a nephrologist beforehand, diabetes and being hospitalized in the same month in which HD started.

An increase of 160% was observed in the prevalence of patients in hemodialysis treatment between 2004 and 2008. The prevalence of TCRD in Latin America has increased by around 10% per year. 6 6. Cusumano A, Garcia Garcia G, Gonzalez Bedat C. The Latin American dialysis and transplant registry: report 2006. Ethn Dis. 2009;19(1 Suppl 1):S1-3-6. On the other hand, incidence increased by less in the period analyzed. Some factors may have contributed to this, such as not including patients who had declared renal disease as a pre-existing condition or who opted to temporarily suspend coverage. Patients whose health care plans did not include chronic HD and, thus, carried out their treatment through the SUS or changed provider were also not calculated.

Males were more prevalent, similar to data recorded in other studies. 7 7. Evans M, Frysek JP, Elinder CG, Cohen SS, McLaughlin JK, Nyrén O, et al. The natural history of chronic renal failure: results from an unselected, population-based, inception cohort in Sweden. Am J Kidney Dis. 2005;46(5):863-70. DOI:10.1053/j.ajkd.2005.07.040
https://doi.org/10.1053/j.ajkd.2005.07.0...
, 15 15. Peres LAB, Matsuo T, Delfino VDA, Peres CPA, Almeida Netto JH, Ann HK, et al. Aumento na prevalência de diabete melito como causa de insuficiência renal crônica dialítica: análise de 20 anos na região Oeste do Paraná. Arq Bras Endocrinol Metab. 2007;51(1):111-5. DOI:10.1590/S0004-27302007000100018
https://doi.org/10.1590/S0004-2730200700...
, 16 16. Rayner HC, Pisoni RL, Bommer J, Canaud B, Hecking E, Locatelli F, et al. Mortality and hospitalization in haemodialysis patients in five European countries: results from the Dialysis Outcomes and Practice Patterns Study (DOPPS). Nephrol Dial Transplant. 2004;19(1):108-20. DOI:10.1093/ndt/gfg483
https://doi.org/10.1093/ndt/gfg483...
The mean age of the participants was 62. The global mean age, in a European study, was 60.4 years old (sd: 15.2 years)16 and in the dialysis center - Centro de Diálise Einstein in Sao Paulo the mean was 63.1 (sd: 16.1 years). 12 12. Matos ACC, Sardenberg C, Carvalho COM, Rangel EB, Andreoli CC, Oliveira M, et al. Índice de doenças coexistentes e idade avançada como preditores de sobrevida em pacientes em diálise. Einstein (Sao Paulo). 2007;5(3):239-45. Studies of SUS patients showed a median age of 45 3 3. Barbosa DA, Gunji CK, Bittencourt ARC, Belasco AGS, Diccini S, Vattimo F, et al. Co-morbidade e mortalidade de pacientes em início de diálise. Acta Paul Enferm. 2006;19(3):304-9. DOI:10.1590/S0103-21002006000300008
https://doi.org/10.1590/S0103-2100200600...
and the mean age was 48.9 (sd: 14.8 years). 11 11. Lopes AA, Batista PBP, Costa FA, Nery MM, Lopes GB. Número de anos em tratamento dialítico crônico e risco de morte em pacientes com e sem diabetes melito. Rev Assoc Med Bras. 2003;49(3):266-9. DOI:10.1590/S0104-42302003000300029
https://doi.org/10.1590/S0104-4230200300...
In a study by Sesso et al 22 22. Sesso R, Silva CB, Kowalski SC, Manfredi SR, Canziani ME, Draibe SA, et al. Dialysis care, cardiovascular disease, and costs in end-stage renal disease in Brazil. Int J Technol Assess Health Care. 2007;23(1):126-30. DOI:10.1017/S0266462307051665
https://doi.org/10.1017/S026646230705166...
of patients treated by the SUS and by private providers, the mean age was 59 years old (sd: 23 years). 22 22. Sesso R, Silva CB, Kowalski SC, Manfredi SR, Canziani ME, Draibe SA, et al. Dialysis care, cardiovascular disease, and costs in end-stage renal disease in Brazil. Int J Technol Assess Health Care. 2007;23(1):126-30. DOI:10.1017/S0266462307051665
https://doi.org/10.1017/S026646230705166...
The figures suggest that patients with TCRD studied in this cohort had a similar age profile to those in the European countries studied and to those in other services which only treat patients with private health insurance, such as the Albert Einstein Hospital, and different to that described in studies of the population treated by the SUS. The influence of socioeconomic status on the prevalence of treatment in elderly merits greater detail.

SUS patients in HD had a median monthly income of R$ 120.00 in 2000 and, in 83% of cases, had not completed primary education. 3 3. Barbosa DA, Gunji CK, Bittencourt ARC, Belasco AGS, Diccini S, Vattimo F, et al. Co-morbidade e mortalidade de pacientes em início de diálise. Acta Paul Enferm. 2006;19(3):304-9. DOI:10.1590/S0103-21002006000300008
https://doi.org/10.1590/S0103-2100200600...
The patterns of income and the educational profile of those with HD incidents using the provider in this study were not examined, as this information was not recorded in the provider's database. Albuquerque et al 10 10. Lee T, Barker J, Allon M. Associations with predialysis vascular access mangement. Am J Kidney Dis. 2004;43(6):1008-13. DOI:10.1053/j.ajkd.2004.02.013
https://doi.org/10.1053/j.ajkd.2004.02.0...
(2008) indicated that having a health care plan increased with per capita household income.

Diabetes mellitus was the most common comorbidity in HD patients. Data from America report variable proportions of the presence of diabetes mellitus (from 44% 13 13. Miskulin DC, Martin AA, Brown R, Fink NE, Coresh J, Powe NR, et al. Predicting 1 year mortality in an outpatient haemodialysis population: a comparison of comorbidity instruments. Nephrol Dial Transplant. 2004;19(2):413-20. DOI:10.1093/ndt/gfg571
https://doi.org/10.1093/ndt/gfg571...
to 58.8% 20 20. Sands JJ, Etheredge GD, Shankar A, Graff J, Loeper J, McKendry M, et al. Predicting hospitalization and mortality in end-stage renal disease (ESRD) patients using an Index of Coexisting Disease (ICED): based risk stratification model. Dis Manag. 2006;9(4):224-35. DOI:10.1089/dis.2006.9.224
https://doi.org/10.1089/dis.2006.9.224...
), where as the reported prevalence for Brazil and for the Southeast was 26% in the 2008 SBN Census.21

Analyzing survival, the outcome death was statistically significant for age, diabetes mellitus, first vascular access and being seen by a nephrologist, as observed by other authors. 5 5. Chandna SM, Schulz J, Lawrence C, Greenwood RN, Farrington K. Is there a rationale for rationing chronic dialysis? A hospital based cohort study of factors affecting survival and morbidity. BMJ. 1999;318(7178):217-23. DOI:10.1136/bmj.318.7178.217
https://doi.org/10.1136/bmj.318.7178.217...
, 17 17. Rocco MV, Bleyer AJ, Burkart JM. Utilization of inpatient and outpatient resources for the management of hemodialysis access complications. Am J Kidney Dis. 1996;28(2):250-6. , 23 23. Stoves J, Bartlett CN, Newstead CG. Specialist follow up of patients before end-stage renal failure and its relationship to survival on dialysis. Postgrad Med J. 2001;77(911):586-8. DOI:10.1136/pmj.77.911.586
https://doi.org/10.1136/pmj.77.911.586...
Among diabetics, the highest number of deaths were observed in the 1st, 2nd and 5th years of treatment compared with non-diabetics and they were at greater risk of this outcome compared with non-diabetics. Similar results were observed in other studies. 11 11. Lopes AA, Batista PBP, Costa FA, Nery MM, Lopes GB. Número de anos em tratamento dialítico crônico e risco de morte em pacientes com e sem diabetes melito. Rev Assoc Med Bras. 2003;49(3):266-9. DOI:10.1590/S0104-42302003000300029
https://doi.org/10.1590/S0104-4230200300...
, 13 13. Miskulin DC, Martin AA, Brown R, Fink NE, Coresh J, Powe NR, et al. Predicting 1 year mortality in an outpatient haemodialysis population: a comparison of comorbidity instruments. Nephrol Dial Transplant. 2004;19(2):413-20. DOI:10.1093/ndt/gfg571
https://doi.org/10.1093/ndt/gfg571...
, 15 15. Peres LAB, Matsuo T, Delfino VDA, Peres CPA, Almeida Netto JH, Ann HK, et al. Aumento na prevalência de diabete melito como causa de insuficiência renal crônica dialítica: análise de 20 anos na região Oeste do Paraná. Arq Bras Endocrinol Metab. 2007;51(1):111-5. DOI:10.1590/S0004-27302007000100018
https://doi.org/10.1590/S0004-2730200700...
, 16 16. Rayner HC, Pisoni RL, Bommer J, Canaud B, Hecking E, Locatelli F, et al. Mortality and hospitalization in haemodialysis patients in five European countries: results from the Dialysis Outcomes and Practice Patterns Study (DOPPS). Nephrol Dial Transplant. 2004;19(1):108-20. DOI:10.1093/ndt/gfg483
https://doi.org/10.1093/ndt/gfg483...
In 2003, Lopes et al 11 11. Lopes AA, Batista PBP, Costa FA, Nery MM, Lopes GB. Número de anos em tratamento dialítico crônico e risco de morte em pacientes com e sem diabetes melito. Rev Assoc Med Bras. 2003;49(3):266-9. DOI:10.1590/S0104-42302003000300029
https://doi.org/10.1590/S0104-4230200300...
described a higher risk of death in SUS patients among those who had been in HD for less than a year (RR = 1.4) and smaller risk in those who had been in treatment for between three (RR = 0.79) and ten years (RR = 0.88).

The majority of incident patients were seen by a nephrologist before beginning HD treatment (68%). Lee et al10 (2004) reported that 73.3% of incident patients had been seen by a nephrologist. In the United Kingdom, where consultation with a nephrologist needs to be by referral, this was between 35% and 38%; in Germany, the proportion was 48%4 and in this study the rate was 10.3%. Around 30% of those with HD incidents had no record of having been seen by a nephrologist before starting HD. This high percentage of patients not being seen by a nephrologist may be related to ignorance of the disease and its evolution, delaying diagnosis in the initial stages. In this group, a greater risk of the outcome being death was identified (HR = 1.94) when compared with beneficiaries referred later.

The existence of barriers to access may contribute to the rate of patients who are not seen by a nephrologist before starting HD. The rate of incident patients per nephrologist was analyzed, of which 1.6 did not confirm the theory of barrier to access. In England, this rate was 26.5, in Wales 46.1 and in Germany 10.1.4 Lee et al10 identified that diabetic patients had a greater chance of early referral to a nephrologist than non-diabetic patients, attributing this result to greater knowledge of the evolution of diabetes and the role of endocrinologists. The performance of health care professional in early referrals to a nephrologist affects the outcome and is well described.23

Inadequate preparation for HD is one of the principal consequences of delayed referral and lack of previous evaluation by a nephrologist. One of the most important, with repercussions on the outcome, is the preparation of the arteriovenous fistula. The TVC was the first type of access in 65% of incidents, a pattern similar to that of America (66%) and different to the European results (34%). 24 24. St Peter WL, Khan SS, Ebben JP, Pereira BJG, Collins AJ. Chronic kidney disease: the distribution of health care dollars. Kidney Int. 2004;66(1):313-21. DOI:10.1111/j.1523-1755.2004.00733.x
https://doi.org/10.1111/j.1523-1755.2004...
Changing this pattern of TVC prevalence in the provider is important due to the recognized connection between TVC and longer hospitalizations, the principal cause of infections. 8 8. Gonçalves EAP, Andreoli MCC, Watanabe R, Freitas MCS, Pedrosa AC, Manfredi SR, et al. Effect of temporary catheter and late referral on hospitalization and mortality during the first year of hemodialysis treatment. Artif Organs. 2004;28(11):1043-9. DOI:10.1111/j.1525-1594.2004.00016.x
https://doi.org/10.1111/j.1525-1594.2004...

Metcalfe et al, 14 14. Metcalfe W, Khan IH, Prescott GJ, Simpson K, Macleod AM. Hospitalization in the first year of renal replacement therapy for end-stage renal disease. QJM. 2003;96(12):899-909. DOI:10.1093/qjmed/hcg155
https://doi.org/10.1093/qjmed/hcg155...
(2003) described how the majority of TCRD patients started HD treatment under a regime of hospitalization, a practice considered common, the principal motive being to prepare the vascular access. These hospitalizations were excluded from this study.

Being hospitalized in the same month in which HD was started was associated with death, which may be related to the patients' clinical conditions. However, this is not supported by the provider's database. Longer hospital stays occurred in diabetic patients and in those who used TVC as the first access for HD. The majority of those who were hospitalized in the same month in which HD started (65%) or within three months of starting treatment (72%) remained in hospital for a longer time than those who were hospitalized more than 90 days after treatment started. The link between more advanced age, TVC and diabetes and longer THYT has been described by other authors. 2 2. Arora P, Kausz AT, Obrador GT, Ruthazer R, Khan S, Jenuleson CS, et al. Hospital utilization among chronic dialysis patients. J Am Soc Nephrol. 2000;11(4):740-6. , 14 14. Metcalfe W, Khan IH, Prescott GJ, Simpson K, Macleod AM. Hospitalization in the first year of renal replacement therapy for end-stage renal disease. QJM. 2003;96(12):899-909. DOI:10.1093/qjmed/hcg155
https://doi.org/10.1093/qjmed/hcg155...
, 18 18. Rocco MV, Soucie JM, Reboussin DM, McClellan WM. Risk factors for hospital utilization in chronic dialysis patients. J Am Soc Nephrol. 1996;7(6):889-96. , 23 23. Stoves J, Bartlett CN, Newstead CG. Specialist follow up of patients before end-stage renal failure and its relationship to survival on dialysis. Postgrad Med J. 2001;77(911):586-8. DOI:10.1136/pmj.77.911.586
https://doi.org/10.1136/pmj.77.911.586...

The limitations of this study are those inherent in using an administrative database, thus the lack of socio-economic data, bio-medical measures and causes of CRD. Other variables which are not analyzed in this study may have affected the length of hospitalizations, as none of them were significant in the multiple analysis. Including the patients' clinical and socio-economic data in the provider's database could contribute to widening the analysis of variables related to clinical outcomes of patients with TCRD in HD treatment.

The results found in the cohort of incident patients of TCRD in HD in the provider were close to those obtained in health care systems in developed countries when prevalence and demographic variables such as sex and age are analyzed.

The health care path of patients with CRD in the supplementary health care system has consequences for the outcome. Being seen by a nephrologist and the first vascular access are stages which determine the success of the chronic renal patient's health care process. Guaranteeing access to health care services within the time necessary should be part of health care managers' strategies. It is not only access which needs to be guaranteed, but also suitable follow up care and the adoption of strategies for the early identification of chronic diseases. Thus, it is necessary to have health care professionals whose knowledge is up to date and public information to guide health care service users in the optimum use of resources.

HIGHLIGHTS

Between 2004 and 2008, an increase of 160% was observed in the prevalence of chronic renal disease and in the number of patients using renal replacement therapy (RRT) among the clientele of the healthcare plan provider studied.

The indicators of mortality were age, lack of consultation with a nephrologist before starting RRT, diabetes mellitus, short follow-up period, and hospitalization in the same month in which hemodialysis was initiated.

The length of hospital stay per year of treatment did not show a significant association with mortality after controlling for other variables.

Survival rates in the first, second, and fifth years of follow-up were significantly lower in patients with diabetes.

The demographic characteristics of the clientele studied were similar to those of the other centers in Brazil that treat people with health insurance, as well as to those in developed countries.

Studies including clientele of the Brazilian Unified Health System (SUS) showed that the population mainly comprised adults with an average age around 10 to 12 years lower.

The results call for the attention of managers from both public and private healthcare services regarding the importance of offering specialized services and guaranteeing early access to treatment for patients with chronic renal disease.

Rita de Cássia Barradas Barata

Scientific Editor

References

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Publication Dates

  • Publication in this collection
    June 2013

History

  • Received
    05 Dec 2011
  • Accepted
    12 Nov 2012
Faculdade de Saúde Pública da Universidade de São Paulo São Paulo - SP - Brazil
E-mail: revsp@org.usp.br