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Theses and Dissertations

Outcomes associated with Hospital Acquired Complications in patients with Chronic Kidney Diseases Open Access


Other title
never event
Chronic kidney disease
hospital acquired complications
health care costs
preventable hospital acquired complications
Type of item
Degree grantor
University of Alberta
Author or creator
Bohlouli, Babak
Supervisor and department
Marcello Tonelli, Cumming School of Medicine, University of Calgary
Scott Klarenbach, Division of Nephrolody
Terri Jackson, Melbourne Institute of Applied Social and Economic Research and School of Population and Global Health
Examining committee member and department
Brent, Hagel, Departments of Paediatrics and Community Health Sciences, university of Calgary
Devidas, Menon, School of public Health
Arto, Ohinmaa, School of public Health
Philip Jacobs, Medicine Department
Department of Medicine

Date accepted
Graduation date
2017-06:Spring 2017
Doctor of Philosophy
Degree level
Improving the quality of healthcare has been a focus for researchers and policy makers during the last two decades. Hospital acquired complications (HACs) are unintended harms to patient (e.g. urinary tract infection, wound infection), yet many are potentially preventable. They are common and associated with deleterious clinical and economic outcomes. Patients with chronic disease may be at increased risk of preventable HACs, partly due to complexity of those patients’ clinical condition. Chronic kidney disease (CKD) is common, patients with CKD are hospitalized frequently, and the nature of CKD may make them particularly vulnerable to complications. It is not yet clearly known the extent to which HACs and clinical and economic consequences attributable to HACs occur with CKD. Reducing the incidence of preventable HACs in hospitals is a critical component of efforts to provide higher quality of health care. A greater understanding will facilitate targeted implementation of preventative strategies aimed at reducing complications in this readily identifiable high-risk population to improve medical and surgical safety, and efficiency of care in hospitals in Canada. In this thesis, population based linked administrative and laboratory data were used to create a population based cohort of hospitalized adult patients from April 2003 to March 2008 in Alberta (Appendix A). Outpatient creatinine and proteinuria measurements were used to define CKD within 365 to 90 days prior to hospitalization and were categorized according to Clinical Practice Guidelines developed by Kidney Disease Improving Global Outcome (KDIGO)in 2012. A specific indicator in administrative data was used to identify HACs, and published literature was used to identify potentially preventable HACs. Regression models were used to assess the independent association of CKD with any severity with risk of developing ≥1 HACs. Further, the association of HACs and outcomes were assessed; mortality in the index hospitalization and within 90 days after hospital discharge, incremental length of stay, readmission within 90 days, and incremental hospital costs from admission to 90 days after discharge in patients with CKD with ≥1 HACs, accounting for potential clinical confounders. Of 536,549 eligible patients, 8.5% had CKD who were older and more likely to be admitted for cardiovascular diseases than those without CKD. In fully adjusted models the odds ratio (OR) of ≥ 1 preventable HAC in patients with CKD (reference: no CKD) was 1.20 (95% CI: 1.16 – 1.24). There was a graded relation between the risk of HACs and CKD severity, with an OR of 1.81 (95% CI: 1.51 – 2.17) in those with the most severe CKD. In patients with CKD, 9.8% had preventable HACs vs 5.4% in patients without CKD. Fully adjusted odds ratio (OR) of mortality during index hospitalization and from hospital discharge to 90 days in patients with ≥ 1 preventable HAC (reference: no preventable HAC) was 4.67 (95% CI: 4.17 – 5.22) and 1.08 (95% CI: 0.94 – 1.25), respectively. Median incremental length of stay in patients with CKD and with ≥ 1 preventable HAC was 9.86 days (95% CI 9.25 – 10.47). The OR for readmission in patients with CKD and with preventable HAC was 1.24 (95% CI: 1.15 – 1.34). In the cohort with and without CKD the fully adjusted OR of mortality during index hospitalization in patients with CKD and no preventable HACs, patients without CKD and with preventable HACs, and patients with CKD and preventable HACs, were 2.22 (95%CI; 1.69 – 2.94), 5.26 (95%CI; 4.98 – 5.55), and 9.56 (95% CI; 7.23 – 12.56), respectively (referenced to patients without CKD or HAC). In fully adjusted models, the median incremental index hospitalization cost and in-hospital physician claims were $4,047 (95 %CI; 3,918 – 4,176) and $765 (95% CI; 738 – 792) in CKD patients with ≥ 1 preventable HACs, compared with those without. Post-discharge incremental costs in physician claim, ambulatory care, and readmission cost were $71 (95% CI; 54 – 89), $119 (95% CI; 74 – 164), and $1,429 (95% CI; 844 – 1,709), respectively. The incremental costs over 90 days from admission with ≥1 preventable HAC in patients with CKD was $7,522 (95% CI; 7,219 – 7,824). In patients without CKD but with a preventable HACs incremental costs within 90 days from hospital admission was $6,688 (95% CI: 6,612 – 6,723). Patients with CKD are at higher risk of preventable HACs. The presence of ≥ 1 preventable hospital acquired complication, including those are deemed to be preventable, was associated with greater risk of mortality, longer length of stay in hospital, readmission, and incremental healthcare cost in patients with CKD. In the cohort of patients with and without CKD (referenced to patients without CKD or HAC), negative clinical and economic outcomes increase with presence of CKD and preventable HACs. Further studies are proposed to examine the effect of evidence-based strategies on the risk of potentially preventable hospital acquired complications, with the goal of improving quality of care and associated with poor outcomes in patients with CKD.
This thesis is made available by the University of Alberta Libraries with permission of the copyright owner solely for the purpose of private, scholarly or scientific research. This thesis, or any portion thereof, may not otherwise be copied or reproduced without the written consent of the copyright owner, except to the extent permitted by Canadian copyright law.
Citation for previous publication
Bohlouli B, Tonelli M, Jackson T, Hemmelgam B, Klarenbach S. Risk of Hospital-Acquired Complications in Patients with Chronic Kidney Disease. Clin J Am Soc Nephrol 2016 June 12.

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