Center for Data Science and Outcomes Research, Veterans Affairs Medical Center, Washington, District of Columbia, USA.
Department of Medicine, George Washington University, Washington, District of Columbia, USA.
Am J Nephrol. 2023;54(11-12):508-515. doi: 10.1159/000532105. Epub 2023 Jul 31.
According to the US Renal Data System (USRDS), patients with end-stage kidney disease (ESKD) on maintenance dialysis had higher mortality during early COVID-19 pandemic. Less is known about the effect of the pandemic on the delivery of outpatient maintenance hemodialysis and its impact on death. We examined the effect of pandemic-related disruption on the delivery of dialysis treatment and mortality in patients with ESKD receiving maintenance hemodialysis in the Veterans Health Administration (VHA) facilities, the largest integrated national healthcare system in the USA.
Using national VHA electronic health records data, we identified 7,302 Veterans with ESKD who received outpatient maintenance hemodialysis in VHA healthcare facilities during the COVID-19 pandemic (February 1, 2020, to December 31, 2021). We estimated the average change in the number of hemodialysis treatments received and deaths per 1,000 patients per month during the pandemic by conducting interrupted time-series analyses. We used seasonal autoregressive moving average (SARMA) models, in which February 2020 was used as the conditional intercept and months thereafter as conditional slope. The models were adjusted for seasonal variations and trends in rates during the pre-pandemic period (January 1, 2007, to January 31, 2020).
The number (95% CI) of hemodialysis treatments received per 1,000 patients per month during the pre-pandemic and pandemic periods were 12,670 (12,525-12,796) and 12,865 (12,729-13,002), respectively. Respective all-cause mortality rates (95% CI) were 17.1 (16.7-17.5) and 19.6 (18.5-20.7) per 1,000 patients per month. Findings from SARMA models demonstrate that there was no reduction in the dialysis treatments delivered during the pandemic (rate ratio: 0.999; 95% CI: 0.998-1.001), but there was a 2.3% (95% CI: 1.5-3.1%) increase in mortality. During the pandemic, the non-COVID hospitalization rate was 146 (95% CI: 143-149) per 1,000 patients per month, which was lower than the pre-pandemic rate of 175 (95% CI: 173-176). In contrast, there was evidence of higher use of telephone encounters during the pandemic (3,023; 95% CI: 2,957-3,089), compared with the pre-pandemic rate (1,282; 95% CI: 1,241-1,324).
We found no evidence that there was a disruption in the delivery of outpatient maintenance hemodialysis treatment in VHA facilities during the COVID-19 pandemic and that the modest rise in deaths during the pandemic is unlikely to be due to missed dialysis.
根据美国肾脏数据系统（USRDS）的数据，在 COVID-19 大流行期间，维持性透析的终末期肾病（ESKD）患者的死亡率更高。关于大流行对门诊维持性血液透析的提供及其对死亡的影响，人们知之甚少。我们研究了与大流行相关的中断对退伍军人健康管理局（VHA）设施中接受维持性血液透析的 ESKD 患者的透析治疗提供和死亡率的影响，VHA 是美国最大的综合性国家医疗保健系统。
我们使用国家 VHA 电子健康记录数据，确定了 7302 名在 COVID-19 大流行期间（2020 年 2 月 1 日至 2021 年 12 月 31 日）在 VHA 医疗机构接受门诊维持性血液透析的退伍军人。我们通过进行中断时间序列分析来估计大流行期间每千名患者每月接受的血液透析治疗次数和死亡人数的平均变化。我们使用季节性自回归移动平均（SARMA）模型，其中 2020 年 2 月用作条件截距，此后的月份用作条件斜率。该模型调整了大流行前期间（2007 年 1 月 1 日至 2020 年 1 月 31 日）的季节性变化和趋势。
大流行前和大流行期间每千名患者每月接受的血液透析治疗次数分别为 12670（12525-12796）和 12865（12729-13002）。各自的全因死亡率（95%CI）分别为 17.1（16.7-17.5）和 19.6（18.5-20.7）每千名患者每月。SARMA 模型的研究结果表明，大流行期间的透析治疗没有减少（比率比：0.999；95%CI：0.998-1.001），但死亡率增加了 2.3%（95%CI：1.5-3.1%）。大流行期间，非 COVID 住院率为每千名患者每月 146（95%CI：143-149），低于大流行前的 175（95%CI：173-176）。相比之下，大流行期间有证据表明电话就诊的使用有所增加（3023；95%CI：2957-3089），而大流行前的使用率为 1282（95%CI：1241-1284）。
我们没有发现 COVID-19 大流行期间 VHA 设施门诊维持性血液透析治疗提供中断的证据，而且大流行期间死亡率的适度上升不太可能是由于透析治疗不及时造成的。
