Mental health and addiction service utilization among people living with chronic kidney disease.

BACKGROUND: Mental health problems, particularly anxiety and depression, are common in patients with chronic kidney disease (CKD), and negatively impact quality of life, treatment adherence, and mortality. However, the degree to which mental health and addictions services are utilized by those with CKD is unknown. We examined the history of mental health and addictions service use of individuals across levels of kidney function. METHODS: We performed a population-based cross-sectional study using linked healthcare databases from Ontario, Canada from 2009 to 2017. We abstracted the prevalence of individuals with mental health and addictions service use within the previous 3 years across levels of kidney function (eGFR$\ \ge $60, 45 to < 60, 30 to < 45, 15 to < 30, <15 mL/min per 1.73m2 and maintenance dialysis). We calculated prevalence ratios (PR) to compare prevalence across kidney function strata, while adjusting for age, sex, year of cohort entry, urban versus rural location, area-level marginalization, and Charlson comorbidity scores. RESULTS: Of 5 956 589 adults, 9% (n = 534 605) had an eGFR<60 mL/min per 1.73m2 or were receiving maintenance dialysis. Fewer individuals with eGFR < 60 had a history of any mental health and addictions service utilization (crude prevalence range 28% to 31%), compared to individuals with eGFR ≥ 60 (35%). Compared to eGFR ≥ 60, the lowest prevalence of individuals with any mental health and addictions service utilization was among those with eGFR 15 to < 30 (adjusted PR 0.86, 95% CI 0.85 to 0.88), eGFR < 15 (adjusted PR 0.81, 95% CI 0.76 to 0.86) and those receiving maintenance dialysis (adjusted PR 0.83, 95% CI 0.81 to 0.84). Less use of outpatient services accounted for differences in service utilization. CONCLUSIONS: Mental health and addictions service utilization is common but less so in individuals with advanced CKD in Ontario, Canada.

Outcomes of early hospital readmission after kidney transplantation: Perspectives from a Canadian transplant centre.

BACKGROUND: Early hospital readmissions (EHRs) after kidney transplantation range in incidence from 18%-47% and are important and substantial healthcare quality indicators. EHR can adversely impact clinical outcomes such as graft function and patient mortality as well as healthcare costs. EHRs have been extensively studied in American healthcare systems, but these associations have not been explored within a Canadian setting. Due to significant differences in the delivery of healthcare and patient outcomes, results from American studies cannot be readily applicable to Canadian populations. A better understanding of EHR can facilitate improved discharge planning and long-term outpatient management post kidney transplant. AIM: To explore the burden of EHR on kidney transplant recipients (KTRs) and the Canadian healthcare system in a large transplant centre. METHODS: This single centre cohort study included 1564 KTRs recruited from January 1, 2009 to December 31, 2017, with a 1-year follow-up. We defined EHR as hospitalizations within 30 d or 90 d of transplant discharge, excluding elective procedures. Multivariable Cox and linear regression models were used to examine EHR, late hospital readmissions (defined as hospitalizations within 31-365 d for 30-d EHR and within 91-365 d for 90-d EHR), and outcomes including graft function and patient mortality. RESULTS: In this study, 307 (22.4%) and 394 (29.6%) KTRs had 30-d and 90-d EHRs, respectively. Factors such as having previous cases of rejection, being transplanted in more recent years, having a longer duration of dialysis pretransplant, and having an expanded criteria donor were associated with EHR post-transplant. The cumulative probability of death censored graft failure, as well as total graft failure, was higher among the 90-d EHR group as compared to patients with no EHR. While multivariable models found no significant association between EHR and patient mortality, patients with EHR were at an increased risk of late hospital readmissions, poorer kidney function throughout the 1st year post-transplant, and higher hospital-based care costs within the 1st year of follow-up. CONCLUSION: EHRs are associated with suboptimal outcomes after kidney transplant and increased financial burden on the healthcare system. The results warrant the need for effective strategies to reduce post-transplant EHR.

Patterns of home care assessment and service provision before and during the COVID-19 pandemic in Ontario, Canada.

OBJECTIVE: The objective was to compare home care episode, standardised assessment, and service patterns in Ontario's publicly funded home care system during the first wave of the COVID-19 pandemic (i.e., March to September 2020) using the previous year as reference. STUDY DESIGN AND SETTING: We plotted monthly time series data from March 2019 to September 2020 for home care recipients in Ontario, Canada. Home care episodes were linked to interRAI Home Care assessments, interRAI Contact Assessments, and home care services. Health status measures from the patient's most recent interRAI assessment were used to stratify the receipt of personal support, nursing, and occupational or physical therapy services. Significant level and slope changes were detected using Poisson, beta, and linear regression models. RESULTS: The March to September 2020 period was associated with significantly fewer home care admissions, discharges, and standardised assessments. Among those assessed with the interRAI Home Care assessment, significantly fewer patients received any personal support services. Among those assessed with either interRAI assessment and identified to have rehabilitation needs, significantly fewer patients received any therapy services. Among patients receiving services, patients received significantly fewer hours of personal support and fewer therapy visits per month. By September 2020, the rate of admissions and services had mostly returned to pre-pandemic levels, but completion of standardised assessments lagged behind. CONCLUSION: The first wave of the COVID-19 pandemic was associated with substantial changes in Ontario's publicly funded home care system. Although it may have been necessary to prioritise service delivery during a crisis situation, standardised assessments are needed to support individualised patient care and system-level monitoring. Given the potential disruptions to home care services, future studies should examine the impact of the pandemic on the health and well-being of home care recipients and their caregiving networks.

Outcomes of Kidney Transplantation Abroad: A Single-Center Canadian Cohort Study.

CONTEXT: An increasing demand for kidney transplantation has enticed some patients with end-stage renal disease (ESRD) to venture outside their country of residence, but their posttransplant outcomes may be suboptimal. OBJECTIVE: We compared the risks and clinical outcomes among tourists, or patients who pursue a kidney transplant abroad, versus patients who received a transplant at the Toronto General Hospital (TGH). METHODS: A single-center, 1:3 matched (based on age at transplant, time on dialysis, and year of transplant) cohort study was conducted. Forty-five tourists were matched with 135 domestic transplant recipients between January 1, 2000, and December 31, 2011. Multivariable Cox proportional hazards models were fitted to assess graft and patient outcomes. RESULTS: Among the 45 tourists, the majority (38 of 45) traveled to the Middle East or Far East Asia, and most received living donor kidney transplants (35 of 45). Multivariable Cox proportional hazards models showed that tourists had a higher risk for the composite outcome of acute rejection, death-censored graft failure, or death with graft function (DWGF; hazard ratio [HR] 2.08, 95% confidence interval [CI]: 1.06-4.07). Tourists also showed a higher risk for the individual end points of acute rejection, DWGF, and posttransplant hospitalizations. CONCLUSION: Patients going abroad for kidney transplantation may have inferior outcomes compared to domestic patients receiving kidney transplants. Patients who are contemplating an overseas transplant need to be aware of the increased risk of adverse posttransplant outcomes and should be appropriately counseled by transplant professionals during the pretransplant evaluation process.

Engaging health care providers to improve the referral and evaluation processes for potential transplant candidates--The Toronto General Hospital Experience.

The Kidney Transplant Program (KTP) at the Toronto General Hospital has taken great strides in preparing to meet the needs of patients and health care providers, as the number of end-stage renal disease patients in Ontario increases. The KTP has begun the process of increasing engagement and collaboration with various stakeholders from the pre- to the post-transplant phase through (1) the development of innovative programs to increase the number of live kidney donations, (2) the development and maintenance of information technology solutions that work simultaneously to provide data to manage and treat patients, and conduct research, and (3) the development, implementation, and delivery of educational presentations and tools to various stakeholders both at the referring centres and the transplant program. Future steps for the KTP include evaluating the impact of these programmatic tools and activities on the number of referrals received and the subsequent effect on the number of transplants performed.

Performance measures for the evaluation of patients referred to the Toronto General Hospital's kidney transplant program.

Given the increasing number of patients with end-stage renal disease in Ontario, there is a need to improve the efficiency and effectiveness of the pretransplant evaluation, to allow for a seamless progression through the various steps in the process. Toronto General Hospital's kidney transplant program is evaluating various performance measures, specifically looking at waiting times from referral to initial evaluation and initial evaluation to final disposition, to use as metrics for monitoring program performance and stimulate quality improvement.