Length of Stay: All-Cause Hospitalization.

During the first year of dialysis, hospitalized days per patient year for all-cause hospitalization fell almost 14 percent between 2003 and 2010, from 21.8 to 18.9. Among prevalent patients, the rate also fell 14 percent, from 14.3 in 2004 to 12.0 in 2011. In both populations, the rate was highest in the Middle Atlantic area and lowest in the Mountain and Pacific divisions, with very little reordering of the Census Divisions during the study era.

Hospitalized days per patient year may change as a result of three factors. First and foremost: admission rates. Data presented earlier in this section show that these rates have declined since 2006. Second, the distribution of major diagnostic categories among admissions, which may change if cause-specific admission rates change differentially. As we have shown, admission rates for cardiovascular disease have declined in recent years, but those for infection have not. In the dialysis population, hospital stays for infectious complications tend to be longer than those for cardiovascular complications. And third, the length of stay per admission, which can be affected by hospitals discharging patients sooner in an attempt to control costs.

Admissions per patient year declined during the study era, but hospitalized days declined more rapidly. This pattern is compatible with a theoretical shift toward more admissions for cardiovascular disease, but in reality, cardiovascular-related admissions were declining more rapidly than infection-related admissions. The conclusion, therefore, is that dialysis patients were progressively discharged more quickly after admission.

Shortened lengths of stay raise concerns, because readmission may be related to inadequate preparation for discharge. Dialysis patients have a complex set of issues to address after discharge, but dialysis facilities have had difficulty acquiring adequate information from discharging hospitals. Facility staff must have information about a patient’s new dry weight and changes in the dialysis prescription. Potassium and calcium baths may have been altered in the hospital, where there is more dietary control. Changes in medication must be resolved, particularly with respect to cardiovascular agents and antibiotics. Facility staff must also be apprised of anticipated follow-up care, so that outpatient plans can be coordinated.

New regulations on conditions of participation, issued by CMS in May 2013, indicate that dialysis units should receive the same information that hospitals release to nursing homes and rehabilitation centers. Whether hospitals are being held accountable for the transfer of this information is unclear.

Incident Patients

FIRST-YEAR ADMISSION RATES, BY ANNUAL & QUARTERLY COHORTS
ADMISSION RATES, OVERALL & BY U.S. CENSUS DIVISION
ADMISSION RATES IN THE FIRST YEAR, BY MONTH

Prevalent Patients

ADMISSION RATES, WITHIN QUARTER & YEAR
ADMISSION RATES, OVERALL & BY U.S. CENSUS DIVISION
ADMISSION RATES, WITHING CALENDAR MONTH
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