Ckd Management Proposal

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COST CONTAINMENT PROPOSAL Introduction Patients with advanced chronic kidney disease have, in addition to transplantation and hospice care, two choices for renal replacement therapy: hemodialysis and peritoneal dialysis. Hospital systems typically incur the largest cost when these patients are about to initiate dialysis and right after the start of dialysis. Reasons for this include: required procedures to establish a vascular access, emergency room visits with subsequent inpatient stays for unplanned dialysis starts, emergent inpatient hemodialysis, and utilization of interventional radiology to place tunneled and untunneled dialysis catheters. Characteristics of patients that will incur the highest costs include: 1. Emergent need for dialysis 2. Starting hemodialysis with a catheter rather than with a fistula or graft 3. Starting dialysis as an inpatient rather than an outpatient During the months surveyed in 2009, some 70% of all patients starting hemodialysis fit some or all of these criteria. Notably, of the remaining 30% virtually all had been enrolled in the Chronic Kidney Disease Management Program. Importance of vascular access for cost containment Multiple studies have shown that a fistula is the best on most cost-effective vascular access, followed by a graft, and that having a catheter as hemodialysis access is by far the worst, having not only the highest initial cost, but also the highest re-admission rates for serious events such as catheter-related bacteremias, which in most cases have to be born by the hospital system given that a large number of patients are uninsured or underinsured. 70% of all patients starting hemodialysis at Jackson Memorial Hospital do so with the worst possible access, namely a tunneled venous catheter. Barriers for decreasing the number of catheter-dependent hemodialysis patients Currently, there

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