Preventable Hospitalizations and Kidney Care

Among individuals with kidney disease hospitalization rates are up to 38% higher than the general population, increase proportionally with each stage of CKD, and significantly contribute to over $130 billion in annual care costs in the United States (US). Many hospitalizations, including readmissions, are potentially preventable, and their avoidance could substantially lessen the burden and cost of kidney disease. Across the spectrum of types of kidney disease, shared drivers of preventable hospitalizations include clinical complexity and difficulty with self-management at the patient level; clinical inertia, under-recognition of kidney disease, and lack of awareness of guidelines at the provider level; and fragmented care and underinvestment in supportive strategies for individuals with social needs at the system level. The mechanisms by which these drivers lead to preventable hospitalizations, however, differ by the categories of kidney disease. Although community-acquired AKI, because of environmental exposures and infectious disease, frequently leads to incident hospitalization, hospital-acquired AKI raises the risk of readmission after index hospitalization for another cause. Among individuals with CKD, complex comorbidities, polypharmacy, and barriers to timely and coordinated ambulatory care lead to emergency department visits for ambulatory care needs at which point admissions occur at higher rates than the general population. Among individuals with kidney failure, preventable hospitalizations are most commonly related to fluid overload, dialysis access dysfunction, and infections. Accessible and timely ambulatory care combined with multidisciplinary collaboration, postdischarge transitional care programs to prevent readmissions, and support for patient self-management are strategies to reduce the rate of preventable hospitalizations. In this article, we review the drivers of preventable hospitalizations for AKI, CKD, and dialysis-dependent kidney failure. We also explore the evidence for multi-level models of care that target risks of preventable hospitalizations and readmissions, and federal programs that financially incentivize such models.