Action Points

Patients with kidney disease who received early dialysis ahead of Sandy, the 2012 hurricane that pummeled New York and New Jersey, had better outcomes than those who didn't, says a new study.

Hurricane Sandy proved to be deadly to patients on dialysis, as their 30-day mortality rates rose after flooding and structural damage affected power and transportation. But 60% of the nearly 14,000 patients included in this latest analysis received early dialysis, and they had lower odds of going to the emergency department (odds ratio 0.80, 95% CI 0.67-0.96; P=0.01) and to the hospital (OR 0.79, 95% CI 0.66-0.94; P=0.01), and had a lower 30-day mortality (OR 0.72, 95% CI 0.52-0.997; P=0.048) in the week after the storm, according to the study.

Nicole Lurie, MD, the assistant secretary for preparedness and response at the U.S. Department of Health and Human Services (HHS) led the study, which was published in the American Journal of Kidney Diseaseslast week.

"Every disaster holds the potential to impact health and often disproportionately affect people who are medically vulnerable, including people who require dialysis," said Lurie in a press release from the HHS. "This study provides the first evidence that receiving early dialysis in advance of potential disasters helps protect health and saves lives for dialysis patients and suggests that early dialysis should become a standard practice and protective measure."

Rahul Dhawan, DO, at the University of Southern California and the White Memorial Medical Center added that education for dialysis patients and caregivers is important when there's the possibility of a natural disaster.

"This study is an excellent example of how education regarding early dialysis during a storm or natural disaster needs to be more widespread," he wrote in an email to MedPage Today.

Before Hurricane Sandy arrived, nearly 70% of dialysis centers offered early dialysis care on Sunday to their patients who usually came in on Monday, Wednesday, and Friday. Fewer than 5% of patients with end-stage renal disease had to visit the emergency department following the storm, according to the authors.

They took their data from the CMS Datalink Project. All of the patients were enrolled in Medicare and had at least one claim for maintenance dialysis treatment from Oct. 1 to Oct. 28, 2012, and a discernible dialysis schedule. Patients who received dialysis at home and patients who were in the hospital for the week of the storm were excluded.

Researchers looked at the patients' schedules in the days leading up to the storm and whether they were altered in the few days leading up to the storm. Information about age, sex, race, and onset of dialysis care was also gathered.

Most of the facilities in the analysis (92%) treated at least some patients with early dialysis in the four days before the storm, according to the study. In an unadjusted analysis that didn't control for patient characteristics, patients were also more likely to visit the emergency room (OR 0.75, 95% CI 0.63-0.89; P=0.001) and the hospital (OR 0.77, 95% CI 0.65-0.92; P=0.004), but had similar 30-day mortality rates (OR 0.80, 95% CI 0.58-1.09; P=0.2).

Patients who were eligible for both Medicare and Medicaid had worse outcomes than single eligibility patients (P<0.001). And being nonwhite was associated with a decreased odds for an emergency department visit and for hospitalization (P=0.001).

In addition:

• Those with cardiovascular comorbid condition in the month before the storm had higher odds of hospitalization and a higher mortality.
• Being hospitalized or visiting the emergency department before the storm was associated with likelihood of returning after the storm and with a higher 30-day mortality.
• Being nonwhite and younger was associated with a decreased 30-day mortality rate.

There was widespread variation across the five boroughs of New York City as to the number of centers that offered early dialysis, according to Lurie and colleagues. "These findings suggest that routine availability of early dialysis in advance of a storm is generally achievable and should become standard practice," they wrote.

"These patients, especially those who are at an economic disadvantage (the dual eligible population) must be educated regarding the importance of early dialysis when a natural disaster is on the horizon," added Dhawan. "By emphasizing the importance of this to nurses, primary care doctors, and especially nephrologists, outcomes can improve dramatically during a time when we need to conserve every resource possible."

The authors also suggested that both patient and provider characteristics played a role in determining who was able to receive early dialysis. Many of the dialysis centers had emergency plans that helped them be prepared. "Ensuring that hemodialysis patients can maintain access to appropriate renal care through the duration of an emergency is important for both individual and community resilience," the authors added.

They weren't able to determine which patients were offered early dialysis and declined, an important limitation. In addition, there may have been patient character traits not taken into account that could have led them to seek early dialysis.

The research was supported through a CMS DataLink contract with Acumen.

The authors disclosed no relevant relationships with industry.

• Reviewed by F. Perry Wilson, MD, MSCE Assistant Professor, Section of Nephrology, Yale School of Medicine and Dorothy Caputo, MA, BSN, RN, Nurse Planner

last updated 07.06.2015

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