Patient-centered rehabilitation program improves outcomes for patients with acute kidney injury

DANVILLE, Pa. – A patient-centered rehabilitation program reduced hospital readmissions and mortality for patients with acute kidney injury, a Geisinger-led study found.

Acute kidney injury (AKI) developed during hospitalization increases mortality and leads to longer hospital stays and higher health care costs. Twenty percent of AKI survivors are readmitted to the hospital within 30 days of discharge, often due to a lack of education and awareness of their condition, the research team wrote. Prior research has shown that timely follow-up with a kidney specialist, along with patient education and support, improves overall outcomes for patients with AKI.

The research team developed a rehabilitation program based on these interventions, enrolling a group of 52 high-risk patients who developed AKI over a six-month period. An algorithm to identify patients with AKI was integrated into Geisinger’s electronic health record (EHR) to improve diagnosis, and patients were connected with a nurse case manager prior to discharge. The nurse case manager provided education and self-management guidance, including assistance with barriers to care like transportation or financial need, and followed up with patients by phone to coordinate care and answer questions. Follow-up appointments with a nephrologist were scheduled within three weeks of discharge, with additional appointments scheduled as necessary.

Patients enrolled in the program had significantly lower rates of rehospitalization and mortality than those who had not participated; after 30 days, 15% of participants had been readmitted to the hospital and 2% had died, compared to 34% and 12%, respectively, of nonparticipants.

“The results of this study show promise that a dedicated rehabilitation program can reduce hospital readmissions and death in people with acute kidney injury,” said Gurmukteshwar Singh, M.D., Geisinger nephrologist and lead author of the study. “We hope that these interventions present a roadmap to improve enrollment in future randomized trials.”

The results were published in Kidney360 and presented at the American Society of Nephrology’s Kidney Week 2021, where the paper was selected as a “Best of ASN Journals.” The research team also recently received a $100,000 Innovation Grant from the Pennsylvania Medical Society to implement and expand the program at Geisinger in the coming year.

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Geisinger is committed to making better health easier for the more than 1 million people it serves. Founded more than 100 years ago by Abigail Geisinger, the system now includes nine hospital campuses, a health plan with more than half a million members, a Research Institute and the Geisinger Commonwealth School of Medicine. With nearly 24,000 employees and more than 1,600 employed physicians, Geisinger boosts its hometown economies in Pennsylvania by billions of dollars annually. Learn more at www.geisinger.org, or connect with us on Facebook, Instagram, LinkedIn and Twitter.