“In this study, we observed that adults with CKD had a higher hospitalization rate than the general population that is hospitalized, and even moderate reductions in kidney function were associated with elevated rates of hospitalization.”
Hospitalizations among adults with chronic kidney disease in the United States: A cohort study
Schrauben, Lin et al, PLOS Medicine, December 2020
Hospitalizations are some of the most disruptive and costly events for people living with chronic kidney disease (CKD). As kidney function declines and comorbid conditions become more complex, patients face an increased risk of emergency department visits, inpatient admissions, and hospital readmissions. These episodes not only affect patients' health and quality of life but also contribute significantly to the total cost of care.
While some hospitalizations are unavoidable, many occur because opportunities to intervene were missed long before a medical crisis developed. For healthcare organizations operating in value-based care environments, reducing avoidable hospitalizations requires identifying risk early, coordinating care across the continuum, and helping patients manage their health before complications escalate.
CKD rarely exists in isolation. Most patients also live with conditions such as arterial hypertension, diabetes mellitus, or cardiovascular disease, creating a complex clinical picture that requires coordinated, ongoing management.
Cardiovascular disease is the leading cause of hospitalization among people with kidney disease, with heart failure accounting for a particularly high number of hospital admissions and readmissions.1,2 Infections and digestive disorders also contribute significantly to hospitalization risk.
As patients progress to end-stage renal disease (ESRD), additional complications, including fluid overload, electrolyte imbalances, vascular access problems, and dialysis-related infections, can further increase the likelihood of hospitalization.
These overlapping conditions make it clear that preventing hospitalizations is not simply a matter of monitoring kidney function but instead depends on treating the whole patient.
Managing blood pressure, controlling diabetes, reducing cardiovascular risk, monitoring medication use, encouraging healthy lifestyle changes, and ensuring timely specialist involvement all contribute to better outcomes. Early referrals for permanent dialysis access, when appropriate, can also help reduce avoidable hospitalizations for patients approaching kidney failure.
Equally important is helping patients understand their condition. Individuals who recognize worsening symptoms and actively participate in their care are better positioned to avoid complications that may lead to hospital care.
Reducing unnecessary hospitalizations begins with identifying patients whose health is beginning to deteriorate. The use of data analytics enables providers and health plans to identify rising-risk patients, close gaps in care, and intervene before complications become severe.
Such interventions may include:
For many patients, the period immediately following hospital discharge represents one of the highest-risk times for another hospitalization. Well-planned care transitions can significantly reduce that risk.
Best practices include:
These coordinated efforts help ensure that important clinical information is not lost during transitions and that emerging problems are addressed before they require another hospital visit.
Readmission prevention is particularly important because approximately one in five patients is re-hospitalized within 30 days, yet an estimated one in four of those readmissions could be prevented.3,4
For health plans and provider organizations participating in value-based care, reducing hospitalizations is both a clinical priority and a financial imperative.
Healthmap has found that inpatient care, emergency department visits, and skilled nursing facility services account for more than half of total medical costs for patients with CKD stages 3, 4, 5, Unspecified, and end-stage renal disease (ESRD). Preventing avoidable utilization therefore has a meaningful impact on both patient outcomes and healthcare spending.
Through proactive kidney population health management, Healthmap works with health plans and providers to identify patients early at elevated risk, support coordinated management of CKD and related comorbidities, strengthen patient support and engagement, and facilitate timely interventions before complications require emergency care. When patients do require a hospitalization or emergency department visit, Healthmap supports patients through their transitions of care and facilitates timely provider follow-up in the post-discharge setting to reduce preventable readmissions.
These efforts have contributed to reductions of 15% to 25% in hospitalizations, emergency department visits, and 30-day readmissions among Healthmap populations.
Reducing CKD hospitalizations begins with recognizing risk early, coordinating care across medical disciplines, engaging patients in their own health, and intervening before manageable conditions become medical emergencies.
Organizations that successfully combine early identification, proactive care coordination, and comprehensive patient support will be better positioned to improve outcomes while reducing unnecessary utilization.
For people living with chronic kidney disease, that means fewer hospital stays, better quality of life, and greater opportunity to remain healthier over the long term.
References