Quality Improvement Project Addressing Involuntary Discharged Hemodialysis Patients in an Urban, Predominantly Black US Population

Background: Insurable, involuntarily discharged hemodialysis (HD) patients receiving maintenance HD in the hospital are a growing, vulnerable population. We present a quality improvement (QI) project examining second chance placement of involuntary discharged HD patients receiving maintenance HD through inpatient care in our urban predominantly Black population Methods: QI project at Emory Hospitals and Grady Memorial Hospital. We included all patients involuntarily discharged from a HD center, and those who started HD as inpatient and were seen for inpatient dialysis >60 days, from 1/2020 – 9/2023. Clinical information followed until 3/2024 Results: We included 30 ESKD patients. 21 (70%) male Mean age 49.8 years.100% (n=30) identified as Black, and 77% (n=23) with Medicaid insurance. Most common reasons for discharge: noncompliance (n=17) & disruptive behavior (n=9). 11 (37%) patients had documented substance abuse, and 12 (40%) documented psychiatric disorders. 6 patients with HIV and 6 were homeless. 16 patients received second chance HD placement prior to QI project and 9 patients received second chance HD placement as our QI intervention (5/2023 – 9/2023). 6 of the 9 second-chance placement patients had reduced admissions. 1 patient was an outlier with 43% of HD admissions. The remaining patients had 52 admissions for HD prior, and only 5 admissions after with a 90% reduction. Average outpatient HD billing is approximately $280 to 335 per treatment and inpatient cost for HD only admissions is approximately $1300 Conclusion: This QI project brings attention to a vulnerable nephrology patient population. The subjective analyses used to adjudicate the 'lack of adherence' and 'disruptive behaviors' may be vulnerable to cultural bias and lead to discrimination against these patients. This QI project demonstrated 9 patients were successfully placed with a dramatic decrease in HD associated admissions. Considering that outpatient dialysis billing averages about 25% of the cost of inpatient dialysis admissions, this in turn adds to the significant financial costs. Further investigations of insurable HD patients receiving maintenance HD in the hospital settings are warranted to determine the prevalence, financial burden and possible interventions to improve outcomes