Thirty-day and 90-day hospital readmission after outpatient upper extremity hemodialysis access creation

Abstract

Objective: Patients with end-stage renal disease have multiple comorbidities and are at increased risk for postoperative complications and resource utilization. Our goal was to determine the rate and causes of 30-day and 90-day hospital readmissions after the creation of outpatient hemodialysis access.

Methods: We retrospectively reviewed all outpatient upper extremity hemodialysis access creations performed at our medical center from 2008 to 2015. Readmission was defined as any inpatient status admission ≤30 and 90 days. Reasons for such admissions were analyzed, and multivariate analyses assessed risk factors.

Results: We identified 537 patients (60% male). Average age was 59 years. Access type included radiocephalic (4.5%), brachiocephalic (50.7%), brachiobasilic (22.5%), and prosthetic (20%) arteriovenous fistulas. The 90-day mortality rate was 0.7%. Postoperative hospital readmission rates were 25.5% at 30 days and 47.7% at 90 days. Reasons for admission were access related in 10.9% and dialysis catheter related in 6.9%. Other reasons for admission included shortness of breath/volume overload (15.8%), gastrointestinal (11.9%), cardiac/chest pain (10.9%), unrelated infectious causes (11.9%), failure to thrive (5%), altered mental status (4%), electrolyte abnormalities (3%), and musculoskeletal (2.5%). Preoperative predictors of all cause 30-day readmission included dementia (odds ratio [OR], 5.76; 95% confidence interval [CI], 1.34-24.8; P = .018), hypertension (OR, 3.92; 95% CI, 1.07-14.4; P = .039), chronic obstructive pulmonary disease (OR, 2.19; 95% CI, 1.01-4.76; P = .046), and current smoking (OR, 2.14; 95% CI, 1.32-3.47; P = .002). Predictors of all cause 90-day readmission were hepatic insufficiency (OR, 6.08; 95% CI, 1.2-30.8; P = .029), hypertension (OR, 3.43; 95% CI, 1.36-8.65; P = .009), black race (OR, 2.47; 95% CI, 1.48-4.14; P = .001), Hispanic ethnicity (OR, 2.04; 95% CI, 1.01-4.11; P = .046), and obesity (OR, 1.5; 95% CI, 1.02-2.19; P = .039). Predictors of 90-day access-related readmission included chronic obstructive pulmonary disease (OR, 5.27; 95% CI, 1.38-20.0; P = .015), previous stroke (OR, 3.76; 95% CI, 1.5-9.4; P = .005), being on dialysis at time of the operation (OR, 2.8; 95% CI, 1.17-6.84; P = .022), and prosthetic graft placement (OR, 2.86; 95% CI, 1.07-7.6; P = .036). An additional 9.7% had at least one emergency department presentation ≤90 days but were not admitted.

Conclusions: Patients undergoing placement of hemodialysis access are at high risk for readmission mostly from causes unrelated to their operation. This has an effect for global care for these patients as well as care of these patients in accountable care organizations.