Why the study?
The ageing population with advanced chronic kidney disease increases care pathway complexity, and the association between older patients' predialysis care pathways and early post-dialysis morbidity-mortality needed evaluation.
Do different predialysis care pathways affect early morbidity-mortality in older patients starting dialysis?
Do different predialysis care pathways affect early morbidity-mortality in older patients starting dialysis?
In older patients with advanced CKD, predialysis care pathways lacking nephrology ambulatory care or involving high hospitalization rates are associated with increased early morbidity and mortality after starting dialysis.
Answers are grounded in this paper and cite their sources.
Heterogeneous predialysis pathways were associated with higher early post-dialysis morbidity in older CKD patients; leaves open whether optimizing ambulatory nephrology care improves transitions.
BACKGROUND: The ageing of the population with advanced chronic kidney disease (CKD) increases the complexity of care pathways. Our aim was to identify subgroups of older people according to predialysis care pathways and describe their association with early morbidity-mortality after transition to dialysis. METHODS: This study included 22 128 incident dialysis patients aged ≥75 years during 2009-2017 from the French nationwide registry linked to the National Health Data System. Predialysis care pathways were identified by ascending hierarchical classification based on preselected healthcare use indicators in the previous year. Their association with a composite outcome of death or hospitalization ≥50% of the time off dialysis within the first year of dialysis was studied by multivariable logistic regression accounting for demographics, comorbidities, functional status, conditions of dialysis initiation, socioeconomic deprivation index and home-to-dialysis center travel time. RESULTS: Five care pathway profiles were identified, characterized by limited healthcare use (Cluster 1, 28%), non-nephrology ambulatory care (Cluster 2, 17%), nephrology ambulatory care (Cluster 3, 37%) and a high level of non-nephrology or nephrology hospitalizations (Clusters 4 and 5, both 9%). Profile subgroups did not differ according to patient age and comorbidities, but Clusters 1, 2 and 4 displayed higher levels of social deprivation. Compared with Cluster 3, the odds ratios of primary composite outcome were significantly increased for Clusters 1, 4 and 5 [odds ratio (95% confidence interval) of 1.16 (1.08-1.25), 1.17 (1.05-1.32) and 1.12 (1.01-1.25), respectively]. Moreover, prolonged hospitalizations were also more common in all groups, compared with Cluster 3. CONCLUSION: Despite a similar comorbidity profile, older people with advanced CKD experience very heterogeneous predialysis care pathways, some of which associated with higher burden of hospitalization after the transition to dialysis.
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Hamroun et al. (2024) studied this question.
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