Renal Care Management: Avoiding the “Crash”
Well-planned dialysis starts are integral to Healthmap’s NCQA-accredited chronic kidney disease (CKD) management program and critical to improving end-stage renal disease outcomes.
- What is a “crash” dialysis start?
- How many end-stage renal disease (ESRD) patients crash into dialysis?
- How do crash starts affect outcomes?
- How can crash starts be avoided?
While there is no standard definition, a “crash” into dialysis refers to an urgent, unplanned dialysis start. The definition provided by Molnar, et al in an article entitled “Risk Factors for Unplanned and Crash Dialysis Starts,” is as follows:
“A patient is labeled as having a crash dialysis start when he or she is referred late to a nephrologist and therefore has minimal or no nephrology care prior to starting dialysis. An unplanned dialysis start is when a patient does not start dialysis using his or her chosen modality, starts dialysis during a hospitalization, or in certain studies, starts dialysis with a central venous catheter as opposed to a permanent access (arteriovenous fistula, arteriovenous graft, or peritoneal dialysis catheter).”
Because there are no specific criteria for what is considered a “crash,” the percentage of patients reported to crash into dialysis varies widely depending on the source. According to Molnar, et al, the prevalence of unplanned dialysis ranges between 23% and 63%. Given that there are approximately 130,000 new dialysis starts in the U.S. each year, and that this number has been steadily rising since the early 2000s, it is evident that too many Americans are initiating dialysis under suboptimal circumstances.
Why is this a concern? Compared to planned elective starts, crash starts are associated with adverse outcomes, namely increased patient morbidity and mortality.
In her article “Reducing Dialysis Crash Starts,” author Athena Palearas states that too many dialysis patients are “woefully unprepared” and enter dialysis “without significant prior care from a nephrologist.” As a result:
“... many of them ‘crash’ into dialysis, requiring emergency hospitalization, placement of temporary vascular accesses, and costly medications to treat anemia and other life-threatening complications. These incidents also result in longer hospital stays and higher patient mortality rates, not to mention enormous extra costs for patients and their families, hospitals, and insurers.”
Not only are these unnecessary hospitalizations preventable, but they also pose an increased risk of procedural complications, nosocomial infections, and unexpected hospital costs to the patient, to name a few. The use of a central venous catheter (CVC) for vascular access also presents risks. As Palearas states:
“Patients with CVCs usually have to be hospitalized and are far more likely than those with permanent vascular accesses to develop bacterial infections. Yet the lack of advanced patient planning is evident in the fact that close to 80% of U.S. dialysis patients still begin dialysis with a CVC.”
“Under ideal circumstances, patients should be prepared for dialysis by creating a permanent vascular access point, or fistula, in their arm or leg to permit easier withdrawal of blood for external filtration. It usually takes several weeks, and sometimes months, for a new access to heal and be ready to use for dialysis.”
There is also the matter of patient psychology. An unplanned start deprives patients of opportunities to better understand their condition, learn about other available treatment options (e.g., in-home dialysis), and participate in shared decision-making with their healthcare providers, family members, and caregivers. This may rob them of their sense of autonomy and contribute to the high incidence of dissatisfaction with dialysis therapy and depression that is common among dialysis patients.
How can crash starts be avoided? In patients with advanced CKD, the following are necessary:
- Earlier identification of patients with CKD by primary care providers
- Timely referral to a nephrologist
- Improved communication and coordination among all providers
- Comprehensive patient education focused on slowing CKD progression
- And when appropriate, discussing the different dialysis modality options, early dialysis access, and an opportunity for kidney transplant
All of these factors are intrinsic to the Kidney Health Management (KHM) program offered by Healthmap Solutions, which includes supporting planned dialysis starts for CKD patients. Our program begins with deploying Healthmap’s proprietary data mining technology to provide early identification of patients with CKD in a provider’s patient panel.
From there, our Quality Practice Advisors (QPAs) – a team of nurses – work directly with primary care providers to ensure their patients with CKD are being referred to nephrologists in a timely manner, identify any medication or laboratory interventions that will help to slow CKD progression and improve outcomes, assist with patient follow-up, and coordinate communication among all providers. These combined efforts have resulted in improving a patient’s CKD treatment plan and overall health outcomes.
At the same time, our Care Navigators (CNs) – a team of nurses, mental health professionals, and social workers – work directly with our members with CKD to supplement the patient’s treatment plan outside the physician’s office setting. Our CNs not only provide comprehensive education about a member’s comorbidities and explain the need for certain medications, but they also provide detailed education about CKD tailored to their disease stage. In patients with CKD Stages 4 and 5, CNs discuss the different dialysis modalities available (including home hemodialysis and peritoneal dialysis), as well as kidney transplant options. Whenever possible, our CNs emphasize in-home dialysis or kidney transplantation, as we believe these options have numerous health benefits and improve patient satisfaction and healthcare-related quality of life. During these conversations, personal and environmental barriers to care are also identified and addressed. This personalized approach ensures that the patient can keep necessary medical appointments and adhere to their treatment plan. In addition, we have found that patients who are educated about their condition are more likely to advocate for themselves and take on an active role in their treatment plan, thereby reducing their risk of emergency treatments and crash dialysis starts.
Ultimately, for our members facing ESRD, we work with them and their providers to develop individualized plans for timely, well-organized transitions to renal replacement therapy in order to avoid crashing into dialysis.
We Are Committed to avoiding the “crash” and improving kidney disease outcomes for all patients with CKD.