title: Waitlist Hospital Admissions Predict Resource Utilization and Survival After Renal Transplantation.
abstract: OBJECTIVE
  To determine whether fitness for transplant can be determined by candidates' hospitalizations although waitlisted.
  
  
  BACKGROUND
  Renal transplantation must increasingly serve a population of multiply comorbid patients in an environment defined by organ scarcity and premiums on value-based care. Determining those at excess risk for transplant is critical to these imperatives.
  
  
  METHODS
  United States Renal Data Systems patient and claims data for all adult renal transplant recipients between 2000 and 2010 with continuous primary Medicare coverage for 1 year before and after transplantation were examined. Outcomes included readmissions within the first-year post-transplant and 3-year graft and patient survival. Chi-square statistics, Kaplan-Meier methods (log-rank test), and goodness of fit calculations (c-statistics) were performed for models of transplant outcome.
  
  
  RESULTS
  Among 37,623 patients, the percentages of patients admitted for 0, 1 to 7, 8 to 14, or 15 or more days in the pretransplant year were 51%, 25%, 11%, and 13%. Overall readmission-free survival at 1 year was 31%. Heavily preadmitted patients were more likely to have a greater length of stay during their transplant admission, and had a greater service needs at discharge. Pretransplant admission strongly predicted more frequent post-transplant admission. Among all factors studied, preadmission was the strongest predictor of post-transplant death, and had a dose-dependent effect on both death and graft loss.
  
  
  CONCLUSIONS
  In summary, hospitalization in the year before transplant is an objective, readily ascertainable, and powerful predictor of excess resource utilization and inferior outcome. Incorporation of a rolling assessment of patient hospitalization has potential policy implications for maximizing value in renal transplantation.
authors.affiliation: *Division of Transplantation, Department of Surgery, Emory University School of Medicine, Atlanta, GA†Department of Biostatistics, Rollins School of Public Health, Emory University, Atlanta, GA‡Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA.
authors.forename: Raymond J
authors.initials: RJ
authors.lastname: Lynch
authors.forename: Rebecca
authors.initials: R
authors.lastname: Zhang
authors.forename: Rachel E
authors.initials: RE
authors.lastname: Patzer
authors.forename: Christian P
authors.initials: CP
authors.lastname: Larsen
authors.forename: Andrew B
authors.initials: AB
authors.lastname: Adams
mesh_terms: D005260:Female; D006760:Hospitalization / Q000706:statistics & numerical data*; D006801:Humans; D053208:Kaplan-Meier Estimate; D016030:Kidney Transplantation / Q000401:mortality; D008297:Male; D008875:Middle Aged; D018570:Risk Assessment; D012307:Risk Factors; D014481:United States; D014850:Waiting Lists