title: Association of Nondisease-Specific Problems with Mortality, Long-Term Care, and Functional Impairment among Older Adults Who Require Skilled Nursing Care after Dialysis Initiation.
abstract: The majority of older adults who initiate dialysis do so during a hospitalization, and these patients may require post-acute skilled nursing facility (SNF) care. For these patients, a focus on nondisease-specific problems, including cognitive impairment, depressive symptoms, exhaustion, falls, impaired mobility, and polypharmacy, may be more relevant to outcomes than the traditional disease-oriented approach. However, the association of the burden of nondisease-specific problems with mortality, transition to long-term care (LTC), and functional impairment among older adults receiving SNF care after dialysis initiation has not been studied.
  
  
  
  We identified 40,615 Medicare beneficiaries ≥65 years old who received SNF care after dialysis initiation between 2000 and 2006 by linking renal disease registry data with the Minimum Data Set. Nondisease-specific problems were ascertained from the Minimum Data Set. We defined LTC as ≥100 SNF days and functional impairment as dependence in all four essential activities of daily living at SNF discharge. Associations of the number of nondisease-specific problems (≤1, 2, 3, and 4-6) with 6-month mortality, LTC, and functional impairment were examined.
  
  
  
  Overall, 39.2% of patients who received SNF care after dialysis initiation died within 6 months. Compared with those with ≤1 nondisease-specific problems, multivariable adjusted hazard ratios (95% confidence interval) for mortality were 1.26 (1.19 to 1.32), 1.40 (1.33 to 1.48), and 1.66 (1.57 to 1.76) for 2, 3, and 4-6 nondisease-specific problems, respectively. Among those who survived, 37.1% required LTC; of those remaining who did not require LTC, 74.7% had functional impairment. A higher likelihood of transition to LTC (among those who survived 6 months) and functional impairment (among those who survived and did not require LTC) was seen with a higher number of problems.
  
  
  
  Identifying nondisease-specific problems may help patients and families anticipate LTC needs and functional impairment after dialysis initiation.
authors.affiliation: Department of Veterans Affairs, Birmingham/Atlanta Geriatric Research, Education, and Clinical Center, Atlanta Veterans Affairs Medical Center (VAMC), Decatur, Georgia.|Division of General Medicine and Geriatrics, Department of Medicine.
authors.forename: C Barrett
authors.initials: CB
authors.lastname: Bowling
authors.affiliation: Division of General Medicine and Geriatrics, Department of Medicine.|Division of Renal Medicine, Department of Medicine.|Department of Epidemiology.
authors.forename: Laura
authors.initials: L
authors.lastname: Plantinga
authors.affiliation: Department of Veterans Affairs, Geriatric Research, Education and Clinical Center and.|Renal Section, Durham VAMC, Durham, North Carolina; and.|Division of Nephrology, Department of Medicine, Duke University Medical Center, Durham, North Carolina.
authors.forename: Rasheeda K
authors.initials: RK
authors.lastname: Hall
authors.affiliation: Department of Veterans Affairs, Birmingham/Atlanta Geriatric Research, Education, and Clinical Center, Atlanta Veterans Affairs Medical Center (VAMC), Decatur, Georgia.|Division of General Medicine and Geriatrics, Department of Medicine.
authors.forename: Anna
authors.initials: A
authors.lastname: Mirk
authors.affiliation: Rehabilitation/Quality of Life Special Studies Center, United States Renal Data System, and.|Department of Biostatistics and Bioinformatics, Emory University, Atlanta, Georgia.
authors.forename: Rebecca
authors.initials: R
authors.lastname: Zhang
authors.affiliation: Rehabilitation/Quality of Life Special Studies Center, United States Renal Data System, and.
authors.forename: Nancy
authors.initials: N
authors.lastname: Kutner
mesh_terms: D000058:Accidental Falls / Q000706:statistics & numerical data; D000203:Activities of Daily Living; D000368:Aged; D000369:Aged, 80 and over; D060825:Cognitive Dysfunction / Q000453:epidemiology*; D015897:Comorbidity; D003863:Depression / Q000453:epidemiology*; D005221:Fatigue / Q000453:epidemiology*; D005260:Female; D006801:Humans; D007676:Kidney Failure, Chronic / Q000453:epidemiology* / Q000401:mortality / Q000628:therapy*; D008134:Long-Term Care / Q000706:statistics & numerical data*; D008297:Male; D006278:Medicare; D051346:Mobility Limitation; D010360:Patient Transfer / Q000706:statistics & numerical data; D019338:Polypharmacy; D015995:Prevalence; D006435:Renal Dialysis; D012189:Retrospective Studies; D012866:Skilled Nursing Facilities / Q000706:statistics & numerical data; D019467:Subacute Care; D014481:United States / Q000453:epidemiology
keywords: Accidental Falls; Activities of Daily Living; Cognition Disorders; Humans; Long-Term Care; Medicare; Patient Discharge; Polypharmacy; Registries; Skilled Nursing Facilities; United States; depression; dialysis; geriatric nephrology; hospitalization; mortality; renal dialysis