Rationale & Objectives

Dialysis patients frequently experience medication-related problems. We studied the association of a multidisciplinary medication therapy management (MTM) with 30-day readmission rates.

Study Design

Retrospective cohort study.

Setting & Participants

Maintenance dialysis patients discharged home from acute-care hospitals between May 2016 and April 2017 who returned to End-Stage Renal Disease Seamless Care Organization dialysis clinics after discharge were eligible. Patients who were readmitted within 3 days, died, or entered hospice within 30 days were excluded.

Exposure

MTM consisting of nurse medication reconciliation, pharmacist medication review, and nephrologist oversight was categorized into 3 levels of intensity: no MTM, partial MTM (defined as an incomplete MTM process), or full MTM (defined as a complete MTM process).

Outcome

The primary outcome was 30-day readmission.

Analytical Approach

Time-varying Prentice, Williams, and Peterson total time hazards models explored associations between MTM and time to readmission after adjusting for age, race, sex, diabetes comorbidity, albumin level, vascular access type, kidney failure cause, dialysis vintage and modality, marital status, home medications, frequent prior hospitalizations, length of stay, discharge diagnoses, hierarchical condition category, and facility standardized hospitalization rates. Propensity score matching was performed to examine the robustness of the associations in a comparison between the full- and no-MTM exposure groups on time to readmission.

Results

Among 1,452 discharges, 586 received no MTM, 704 received partial MTM, and 162 received full MTM; 30-day readmission rates were 29%, 19%, and 11%, respectively (P < 0.001). Compared with no MTM, discharges with full MTM had the lowest time-varying risk for readmission within 30 days (HR, 0.26; 95% CI, 0.15-0.45); discharges with partial MTM also had lower readmission risk (HR, 0.50; 95% CI, 0.37-0.68). In propensity score–matched sensitivity analysis, full MTM was associated with lower 30-day readmission risk (HR, 0.20; 95% CI, 0.06-0.69).

Limitations

Reliance on observational data. Residual bias and confounding.

Conclusions

MTM services following hospital discharge were associated with fewer 30-day readmissions in dialysis patients. Randomized controlled studies evaluating different MTM delivery models and cost-effectiveness in dialysis populations are warranted.

中文翻译：

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接受维持性透析的患者的多学科药物治疗管理和住院率：一项回顾性队列研究。

基本原理和目标

透析患者经常遇到与药物有关的问题。我们研究了多学科药物治疗管理（MTM）与30天再入院率的关联。

学习规划

回顾性队列研究。

设置与参与者

在2016年5月至2017年4月之间从急诊医院出院的维持性透析患者，出院后返回终末期肾脏疾病无缝护理组织透析诊所就诊。在3天内再次入院，死亡或30天内进入临终关怀的患者被排除在外。

接触

由护士用药和解，药剂师用药审查和肾病医师监督组成的MTM分为3个强度级别：无MTM，部分MTM（定义为不完整的MTM过程）或完整的MTM（定义为完整的MTM过程）。

结果

主要结果是再次入院30天。

分析方法

时变的Prentice，Williams和Peterson总时间危害模型探索了MTM与重新入院时间之间的关系，并调整了年龄，种族，性别，糖尿病合并症，白蛋白水平，血管通路类型，肾衰竭原因，透析时间和方式，婚姻状况，家庭用药，以前的频繁住院治疗，住院时间，出院诊断，病情分类以及设施标准化的住院率。进行倾向得分匹配以比较重新入院时完全和非MTM暴露组之间的关联的稳健性。

结果

在1,452笔放电中，有586笔未收到MTM，704笔未收到部分MTM，而162笔则收到了全部MTM。30天的再入院率分别为29％，19％和11％（P  <0.001）。与没有MTM的患者相比，完全MTM的患者出院后30天内再次入院的时变风险最低（HR，0.26； 95％CI，0.15-0.45）；部分MTM出院也具有较低的再入院风险（HR，0.50; 95％CI，0.37-0.68）。在倾向评分匹配的敏感性分析中，完整的MTM与30天的再次入院风险较低相关（HR，0.20； 95％CI，0.06-0.69）。

局限性

依靠观测数据。残留的偏见和混淆。

结论

出院后进行MTM服务可使透析患者的30天再入院次数减少。有必要进行随机对照研究，以评估透析人群中不同的MTM递送模式和成本效益。