Does CKD Result in Increased Unnecessary Hospitalization?

Invited commentary from Dr. Swapnil Hiremath

Chronic Kidney Disease (CKD) has been recognized as a risk factor for increased morbidity and mortality ever since the seminal report from Go et al using the Kaiser Permanente data. It is thus fitting that Wiebe et al, on behalf of the Alberta Kidney Disease Network, now report in AJKD the association of CKD with potentially preventable hospitalization.

Potentially preventable hospitalizations have become an area of great interest not only for health services researchers, but also for health policy makers and healthcare payers (Bindman et al and Rosano et al). These represent important clinical outcomes for patients, and significant expenses for payors. More interestingly, the ‘potentially preventable’ modifier refers to the concept that these are the result of deficiencies in outpatient ambulatory care, and thus an opportunity for improvement. Tonelli and colleagues build on previous work with potentially preventable hospitalization conditions in CKD patients, focusing on hyperkalemia, congestive heart failure, volume overload, and malignant hypertension.

Of the approximately 2 million individuals included in the database, almost 12% were identified as having CKD. Not to anyone’s surprise, there was an increase in potentially preventable hospitalizations in these patients compared to those without CKD. Interestingly, there was a biological gradient with greater rates seen in those with more severe CKD and albuminuria, strengthening the case for causation versus correlation alone. However, CKD does associate with many other chronic diseases, such as diabetes and cardiovascular disease. The authors had a wealth of co-morbidities to adjust for, and there was an impressive attenuation in the fully adjusted rate ratios. Of additional interest is the role of geography, with many communities in Alberta scattered and remote, and access to physicians limited or difficult. This does seem to play a role since there was an association between increasing distance (between individual residence locations and physician location) and heart failure and malignant hypertension hospitalization rates.

Overall, Wiebe and colleagues report what is undoubtedly a strong association between CKD and potentially preventable hospitalizations. CKD patients could be the low-hanging fruit to focus efforts and resources on preventing these important clinical outcomes.

Dr. Swapnil Hiremath
Nephrologist, The Ottawa Hospital

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