Hospital Case Volume and Clinical Outcomes in Critically Ill Patients with Acute Kidney Injury Treated with Dialysis
CCCF ePoster library. Chimunda T. Nov 9, 2018; 233370
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Dr. Timothy Chimunda
Dr. Timothy Chimunda
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Abstract
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Introduction: The safe and effective delivery of dialysis to critically ill patients with acute kidney injury (AKI) requires the collaboration of physicians, nurses and interdisciplinary hospital staff. This coordination is superimposed on the multi-faceted medical and surgical needs of the patients. As observed for other conditions afflicting critically ill patients, the outcomes of patients with AKI who receive dialysis (AKI-D) might be enhanced when delivered by providers and clinical teams with more extensive experience [1-3]. Case volume, both at the level of individual providers and hospitals, has been cited as a potentially important determinant of outcome. Patients who are hospitalized for the management of a particular illness might benefit from being admitted to hospitals with more experience in the care of that condition [4-7]. Outcomes of specialized procedures might be enhanced when performed by individual operators and hospital-based teams that perform more cases [8-13]. Volume-outcome association studies have paved the way for clinical benchmarks that define the minimum volume a given surgeon must handle or cases that a hospital must manage to assure expertise and optimal outcomes [14]. In addition to greater clinical experience, higher volume hospitals may possess the infrastructure to deliver superior care [2]. For AKI-D, potential mechanisms for improved outcomes in high-volume hospitals include protocols for the prescription and troubleshooting of acute dialysis, on-site training and mentoring sessions for clinical staff, and quality improvement programs. To date, studies that examined volume-outcome relationships in the setting of AKI-D were limited in scope and yielded conflicting results [15, 16]. The objective of this study was to determine whether hospital case volume of AKI-D was associated with patient outcomes across a large population in a jurisdiction with universal health coverage for all residents. We hypothesized that the receipt of care at high-volume hospitals would be associated with improved patient survival and a higher likelihood of kidney recovery. Objectives: To determine whether patients with severe acute kidney injury who receive dialysis (AKI-D) experience better outcomes at centres that care for more patients with AKI-D.Methods: Linked administrative datasets where used to perform a retrospective cohort study of all critically ill patients in Ontario, Canada, who had the first episode of AKI-D between 2002 and 2011. Centre volume for a given year was designated by calculating the mean number of patients treated with acute dialysis at that centre during that year and the one preceding it. Patients treated at that centre were then assigned to a centre volume quartile for that year.

Results: The primary outcome was 90-day mortality; secondary outcomes included 365-day mortality as well as dialysis dependence among survivors at 90 and 365 days from the first acute dialysis session. We identified 19,658 critically ill patients with AKI-D who were treated at 54 Ontario hospitals. Mortality and dialysis dependence at 90-days were 46% and 31%, respectively.  Centre volume was not associated with mortality at 90 days (with quartile 1 as the reference, adjusted odds ratio (
aOR) 1.16 (95% CI, 0.87 - 1.54) in quartile 2, aOR 1.17 (95% CI, 0.91 - 1.50) in quartile 3, and aOR 1.06 (95% CI, 0.81 - 1.41) in quartile 4).  Conclusions: There are no Centre volume survival associations in the management of AKI-D despite high mortality and dependence rate.


 

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