Avoiding Preventable Complications in Hospitalized Patients with CKD

The health care delivery system in developed countries provides increasingly advanced treatment to individuals with complex medical problems and comorbid conditions. Complex treatment often requires hospitalization. The combination of complex treatment and complex patients sometimes results in complications of hospitalization. Hospital complications are associated with increased utilization of health care resources, including readmissions and cost. Complications are also associated with worse patient outcomes. In the past, there was a tendency to consider most hospital complications to be unavoidable consequences of patient and treatment complexity. However, a growing body of research suggests that some hospital complications are preventable through organizational application of specific practices and practice bundles. In turn, various professional and oversight bodies have promoted reporting systems and registries that track complications and outcomes. These reporting systems are increasingly used to generate publicly published scorecards for patients (consumers) to use in selecting health care providers. In recent years, some payers have introduced payment models that are designed to promote safe practices and penalize (financially and otherwise) institutions with high complication rates.

Current thinking on hospital complications originated in the general medical population but undoubtedly applies to patients with kidney disease. Previous studies have found that patients with CKD experience a higher rate of hospital complications than patients without CKD. In this issue of the Clinical Journal of the American Society of Nephrology, Bohlouli et al. (1) specifically examined patient outcomes associated with hospital complications in patients with CKD. The analysis was based on a large administrative database that captures all hospitalizations for the province of Alberta. Among patients with CKD, those with potentially preventable hospital-associated complications had a substantially higher probability of adverse outcomes, including an almost fivefold higher risk of hospital death, a 24% higher risk of readmission, and almost 10 additional hospital days. Extrapolating the results to the entire population of North America, the authors infer that hospital complications result in 45,000 inpatient deaths, 21,000 readmissions, and 4.5 million additional hospital days for patients with CKD (1). They suggest that these adverse outcomes could be prevented if measures were adopted to prevent complications (1).

The authors see this research as a step in efforts to reduce the rate of hospital complications and the associated negative outcomes in patients with CKD (1). A number of additional steps could be proposed. The study should prompt more research into hospital complications of patients with CKD. The study should prompt nephrologists who care for hospitalized patients to review their current practices. It is possible that the study findings could prompt insurers to introduce specific programs designed to create incentives for hospitals and providers that adopt practices that reduce the risk of complications in patients with CKD specifically. As the stakes rise, it is important to consider the limitations of the study.

For this study, the recognition of hospital complications was based on the administrative coding data. After a patient is discharged, the medical chart is scoured by coding specialists who assign diagnosis and procedure codes to the care episode. In the United States, the specific codes are entered into a computer algorithm that classifies the hospitalization into a diagnosis-related group. Depending on the insurer, the assigned diagnosis-related group often determines the insurance payment to the hospital. In recent years, the coding process attempts to identify conditions present on admission. True complications are coded diagnoses that developed during the hospitalization and were not recognized on admission as a presenting or comorbid condition. Accurate distinction among conditions present on admission and true complications requires accurate medical documentation and coding. Physician documentation must clearly identify active and comorbid conditions that were present on admission. Coders must be able to convert text descriptions into accurate codes and recognize evolving diagnostic certainty. For example, the physician progress notes may describe consolidation or an infiltrate on admission and commit more forcefully to pneumonia several days later with the benefit of additional testing and observation. The coding specialists would be expected to connect the two descriptions and recognize that the diagnosis of pneumonia was present on admission and was not hospital acquired. However, the syntheses required to make this distinction are complex. As noted, the degree to which this happens is highly dependent on physician documentation, coder expertise, communication between coders and physicians, and organizational coding rules. Inaccuracies in coding conditions present on admission and hospital complications have been studied for the general medical population (2,3) but have not been studied for renal patients. The use of administrative data for these analyses provides high-volume statistical power and analytic efficiency compared with the alternate process of chart reviews by a trained clinician using clinically accepted documentation standards. However, it is important to recognize that administrative data may incorrectly classify conditions present on admission as complications in a potentially important number of patients. Both situations would be associated with poor patient outcomes. However, inpatient prevention strategies and insurance penalties will not modify the impact of conditions present on admission. One appropriate next step from the study by Bohlouli et al. (1) would be an evaluation of the accuracy of complication coding.

In addition to problems with classification of complications, it is important to consider the evidence behind prevention of complications. Much of the work in this area arose from initiatives advanced by the Agency for Healthcare Research and Quality. This work prompted the Centers for Medicare and Medicaid Services (CMS) to introduce reimbursement penalties for 14 hospital complications (as of 2015) that are considered preventable: retained objects after surgery, air embolism, blood incompatibility, pressure ulcers, falls, poor glycemic control, catheter-associated urinary tract infection, vascular catheter infections, certain surgical site infections, deep venous thrombosis/pulmonary embolus after orthopedic procedures, and iatrogenic pneumothorax (4). A body of evidence supports the general idea that adoption of specific practices (e.g., preprocedure time outs, prophylactic heparin, avoidance of urinary catheters, etc.) at the provider and organizational levels will reduce the risk of these complications (5). CMS and other insurers take the position that these complications should never occur, although some may argue that no medical intervention is unfailingly effective. Nonetheless, it is reasonable to target these specific complications and encourage adoption of accepted, evidence-supported practices. Such targeting efforts have led to public reporting metrics and reimbursement incentives. It is important to realize, however, that the study by Bohlouli et al. (1) used a larger list of potentially preventable hospital complications (1562 diagnostic codes mapped to 63 specific complications) that was based on the opinion of a small group of clinical experts. Compared with the CMS complications list, there is a lower level of evidence and confidence that these complications can be reliably avoided through the implementation of specific practices. The health care system should aspire to avoid all complications. However, it is important to set reasonable and realistic expectations in the minds of patients, families, and policymakers. The risks section of the consent form for any medical procedure reveals the views of providers and hospitals about the potential for complications. Unfortunately, some complications may still not be preventable given the current state of medical knowledge. Clinical and health care policy efforts should focus on demonstrably preventable complications.

Bohlouli et al. (1) have made a useful contribution to our understanding of hospital complications in patients with CKD. The study reminds us that complications occur frequently in patients with CKD and, as in the general medical population, are associated with worse patient outcomes. More work should be done to assure that administrative data accurately distinguish between complications and conditions present on admission. Also, a rigorous approach is needed to better define which complications can be prevented, the expected magnitude of reduction, and specific prevention strategies that providers and hospitals should adopt. Practices that can prevent complications should be aggressively embraced for all hospitalized patients. The renal community should take the lead in exploring preventive measures that apply specifically to patients with kidney disease.

Disclosures

None.