On Oct 29, 2012, Hurricane Sandy made landfall in the United States, and proceeded to affect millions of individuals across multiple states. While natural disasters like Sandy affect all individuals, the elderly and those with vulnerable medical conditions requiring treatment are often more severely affected. In the January issue of AJKD, Kelman and colleagues from the Dept of Health and Human Services critically evaluate and describe the impact of Hurricane Sandy on the lives of patients on dialysis residing in some of the hurricane’s worst affected areas. Corresponding author Dr. Nicole Lurie (NL) discusses this study with Dr. Navdeep Tangri (eAJKD), eAJKD Contributor.
eAJKD: What prompted you to study the effects on Hurricane Sandy on dialysis care and outcomes?
NL: We know that every disaster holds the potential to impact healthcare delivery, and that’s especially true for medically vulnerable populations. Disaster-induced damage to facilities can reduce an individual’s ability to access and utilize healthcare services, particularly when there is widespread and prolonged power outages or water restrictions. We’ve seen many times with large and small events that people requiring dialysis care have problems. For example, we spent considerable time trying to find a generator for a single dialysis center after Hurricane Sandy. After that response, I wanted to be sure we could learn from this experience and improve. So, in collaboration with the Centers for Medicare & Medicaid Services, we performed this study.
eAJKD: How did you choose the specific comparison groups?
NL: We needed to find a way to compare what happened during Sandy to what happens in ‘peace time’. On the one hand, comparing the population affected by Sandy to the rest of the U.S. end-stage renal disease (ESRD) population made sense, but they are demographically distinct. Alternatively, comparing the experience during Sandy to the experience in the same population a year earlier made logical sense. In the end, having two comparison groups helped us better understand whether the patterns of care and outcomes for the study group were associated with Sandy, or other regional and seasonal factors.
eAJKD: Can you briefly describe the principal findings of your study?
NL: We looked at the utilization experience and mortality of ESRD patients that rely upon regular dialysis care in New York City and the State of New Jersey. Nearly 60% of the study patients received early dialysis as a protective measure in advance of Hurricane Sandy’s landfall. Despite this, there were significantly more emergency department visits and hospitalizations during the week of the storm than in either comparison group. Approximately 23% of the study patients who had an emergency department (ED) visit received dialysis during their visit. There was a small increase in mortality for ESRD patients in Sandy-affected areas versus those in the comparison groups in the 30 days following Hurricane Sandy.
Our findings demonstrated that the best-practice of proactively providing early dialysis was widely implemented by facilities ahead of Hurricane Sandy’s landfall. Although regional variability was found, 70% of the dialysis facilities located in the study areas provided early dialysis to 59% of dialysis patients on Sunday, October 28, 2012. The ability to organize dialysis on this large scale requires strong day-to-day healthcare delivery systems as well as integrated emergency planning and clear communications between state and local health officials, the Kidney Community Emergency Response Coalition (KCER), kidney networks, dialysis facilities, and the patient population. Facility preparedness likely played a significant role as many had previously conducted risk assessments, established emergency plans, and identified alternative energy sources, such as back-up generators, for events that could result in prolonged power outages. That said, we found that approximately 30% of facilities did not provide and 40% of patients did not receive early dialysis. In other words, there is plenty of room for improvement.
eAJKD: Are there other natural disasters which have been studied in a similar fashion where we can draw parallels?
NL: Following Hurricanes Katrina, Gustav, and Ike, a few small surveys were conducted to assess morbidity following a disaster. Authors of these studies proposed protective measures, such as early dialysis, to minimize the potential for treatment disruptions. This, however, is the first time that Medicare data have been used for a comprehensive study on the ESRD population.
eAJKD: Do private dialysis organizations need to be involved in disaster planning for patients with kidney failure?
NL: I think that is important. Facilities not only should prepare individually, but also seek opportunities to collaborate with their network, public health officials, KCER, and other coalitions in community emergency planning, training, and exercise activities. Hurricane Sandy significantly impacted critical infrastructure, and as a result, many were unable to communicate by phone or internet in the days and weeks following the disaster. A significant lesson learned was the need for patients and providers to have redundant ways to communicate and an understanding of what protective measures to implement prior to, during, and after a disaster. For example, in advance of an emergency, providers and facilities should discuss potential renal diet options and supplies to have on hand with their patients and their caretakers, as well as the protocol for obtaining early dialysis from their facility. Patients should share with their provider and facility an emergency plan that includes information on how they would shelter in their home, locations they might evacuate to, and redundant contact information for their caretakers and loved ones who could be reached if their phone is not working. Providers and facilities should ensure their patients have an updated copy of their medical records, dialysis treatment prescription, and list of medications; all of which expedite care coordination during an emergency. Finally, facilities should ensure their patients understand who to contact if their facility is unreachable by phone. The contact information should at a minimum include their regional network and the KCER contact at: http://kcercoalition.com/.
eAJKD: How do the findings of your study influence HHS and CMS plans for the next natural disaster?
NL: We will continue to work with our healthcare, public health, and emergency management partners to improve emergency plans and implement evidence based protective measures for medically vulnerable populations in advance of emergencies, such as a hurricane. Since this study was done, we have taken steps to identify and map de-identified ESRD patient population data throughout the country, so populations instead of individuals are mapped. While we keep this information de-identified and protected, we now have the ability to share it with local health departments in advance of a coming storm to support emergency preparedness, response, and recovery activities. They, in turn, can work with dialysis providers and KCER to contact patients, make arrangements for early dialysis, and facilitate other care until the emergency is over.