title: An integrated review of "unplanned" dialysis initiation: reframing the terminology to "suboptimal" initiation.
abstract: BACKGROUND
  Ideally, care prior to the initiation of dialysis should increase the likelihood that patients start electively outside of the hospital setting with a mature arteriovenous fistula (AVF) or peritoneal dialysis (PD) catheter. However, unplanned dialysis continues to occur in patients both known and unknown to nephrology services, and in both late and early referrals. The objective of this article is to review the clinical and socioeconomic outcomes of unplanned dialysis initiation. The secondary objective is to explore the potential cost implications of reducing the rate of unplanned first dialysis in Canada.
  
  
  METHODS
  MEDLINE and EMBASE from inception to 2008 were used to identify studies examining the clinical, economic or quality of life (QoL) outcomes in patients with an unplanned versus planned first dialysis. Data were described in a qualitative manner.
  
  
  RESULTS
  Eight European studies (5,805 patients) were reviewed. Duration of hospitalization and mortality was higher for the unplanned versus planned population. Patients undergoing a first unplanned dialysis had significantly worse laboratory parameters and QoL. Rates of unplanned dialysis ranged from 2449%. The total annual burden to the Canadian healthcare system of unplanned dialysis in 2005 was estimated at $33 million in direct hospital costs alone. Reducing the rate of unplanned dialysis by one-half yielded savings ranging from $13.3 to $16.1 million.
  
  
  CONCLUSIONS
  The clinical and socioeconomic impact of unplanned dialysis is significant. To more consistently characterize the unplanned population, the term suboptimal initiation is proposed to include dialysis initiation in hospital and/or with a central venous catheter and/or with a patient not starting on their chronic modality of choice. Further research and implementation of initiatives to reduce the rate of suboptimal initiation of dialysis in Canada are needed.
authors.affiliation: Humber River Regional Hospital and University of Toronto, Toronto, Canada. dmendy@gmail.com
authors.forename: David C
authors.initials: DC
authors.lastname: Mendelssohn
authors.forename: Christine
authors.initials: C
authors.lastname: Malmberg
authors.forename: Bassem
authors.initials: B
authors.lastname: Hamandi
mesh_terms: D005060:Europe / Q000453:epidemiology; D017048:Health Care Costs / Q000706:statistics & numerical data*; D006801:Humans; D015994:Incidence; D011788:Quality of Life; D006435:Renal Dialysis / Q000145:classification / Q000191:economics* / Q000706:statistics & numerical data*; D051437:Renal Insufficiency / Q000191:economics* / Q000453:epidemiology / Q000517:prevention & control*; D009626:Terminology as Topic; D016896:Treatment Outcome
references.citation: Kidney Int. 2007 Mar;71(6):555-61
references.pmid: 17245396
references.citation: Am J Kidney Dis. 2001 Nov;38(5):1122-8
references.pmid: 11684571
references.citation: Am J Kidney Dis. 2004 Oct;44(4):706-14
references.pmid: 15384022
references.citation: J Am Soc Nephrol. 2007 Mar;18(3):993-9
references.pmid: 17267742
references.citation: Nefrologia. 2006;26(4):445-51
references.pmid: 17058856
references.citation: Nephrol Dial Transplant. 2007 Nov;22(11):3240-5
references.pmid: 17616535
references.citation: Kidney Int Suppl. 2002 May;(80):27-34
references.pmid: 11982809
references.citation: Nephrol Dial Transplant. 2006 Jul;21 Suppl 2:ii51-5
references.pmid: 16825262
references.citation: Nephrol Dial Transplant. 2006 Mar;21(3):721-8
references.pmid: 16311264
references.citation: Am J Kidney Dis. 2002 Feb;39(2 Suppl 1):S1-266
references.pmid: 11904577
references.citation: Kidney Int. 2007 Nov;72(9):1122-9
references.pmid: 17700643
references.citation: Clin Nephrol. 2002 Oct;58(4):282-8
references.pmid: 12400843
references.citation: Nefrologia. 2002;22(1):49-59
references.pmid: 11987685
references.citation: Nephrol Dial Transplant. 2003 Jul;18(7):1330-8
references.pmid: 12808170
references.citation: Nephrol Dial Transplant. 2007 Nov;22(11):3246-54
references.pmid: 17616533
references.citation: Kidney Int. 2000 Jun;57(6):2539-45
references.pmid: 10844623
references.citation: Am J Med. 2007 Dec;120(12):1063-70
references.pmid: 18060927
references.citation: Am J Kidney Dis. 2004 Jun;43(6):999-1007
references.pmid: 15168379
references.citation: J Am Geriatr Soc. 2003 Feb;51(2):229-33
references.pmid: 12558720
references.citation: Clin J Am Soc Nephrol. 2009 Feb;4(2):456-60
references.pmid: 19158368