Through the Eye of Katrina:

Transcription

1 Through the Eye of Katrina: Lessons from the study of the New Orleans ESRD population Andrew J. Cohen, MD Chair, Nephrology

2 Mr. WM Mr. M is a 61 year-old retired fire chief with diabetic nephropathy, ESRD, and multiple medical problems including coronary and severe peripheral vascular disease (bilateral BKA.) He had been on peritoneal dialysis for two years. Following Hurricane Katrina and evacuation to Baton Rouge, his Tenckhoff catheter occluded. Attempts and replacement failed and he converted to hemodialysis,, with placement of a tunnelled catheter.

3 WM (continued) One month later, he returned to New Orleans but found his dialysis facility was closed and his nephrologist could not be reached. He transferred his care to Ochsner Medical Center and commenced hemodialysis after a one-week hiatus. During the course of his treatment, he has had poor urea clearance, marked hyperphosphatemia,, and progressive secondary hyperparathyroidism. One year following Hurricane Katrina, he lived in a FEMA trailer. He became profoundly depressed, withdrawn, and unable to attend to his needs for permanent vascular access placement and parathyroidectomy

4 WM: Monthly Kt/V

5 WM: Monthly PO 4

6 WM: Monthly PTH

7 Outline Immediate impact and aftermath effects Infrastructure Dialysis facilities and patients Longer term outcomes Dialysis facilities and patients Transplant programs Divisions of Nephrology Mortality Tulane-Ochsner Ochsner-USRDS Katrina Study Lessons Learned and Conclusions

8 Hurricane Katrina Saturday, 8/27/05

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10 Sunday 28 Sept 2005, in the Gulf of Mexico

11 Hurricane Katrina Timeline August 26 August 27 August 28 August 29 August 30 TS Katrina is upgraded to a Hurricane and crosses Florida peninsula New Orleans residents are warned of potential evacuation. Dialysis facilities anticipate closure and complete treatments. Mayor orders evacuation. ESRD patients are urged to evacuate. Katrina makes landfall. All electrical power is lost in metro New Orleans and conventional telecommunications fail Rupture of floodwalls and massive flooding in NOLA

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15 Ochsner Campus

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17 Hurricane Katrina-Immediate Aftermath: New Orleans infrastructure Electrical power Water Sewerage Telecommunications Transportation Public safety

18 Hurricane Katrina-Immediate Aftermath: Hemodialysis Almost all ESRD patients were displaced during the storm. All free-standing facilities closed. Dialysis facilities provided specific evacuation instructions including diet, medication supplies, and contact numbers. As part of the New Orleans diaspora, dialysis patients reported to centers in Baton Rouge, Houston, and Atlanta. Many had missed dialysis treatments for a week or more before resuming dialysis.

19 Hurricane Katrina - Immediate Aftermath: Gulf Coast Data (LA, MS, AL, FL) 65 dialysis facilities in affected areas 27 facilities closed (23 in Louisiana) 5849 dialysis patients in affected areas 95% of patients were located by CMS 148 deaths in the first 3 months

20 The Aftermath

21 The Aftermath

22 ili la ili la Geographic variations in adjusted incident rates (per million population), by HSA: 2003 Incident ESRD patients. By HSA; rates adjusted for age, gender, & race. Table 1. Age-adjusted incidence and prevalence rates of ESRD among adults 20 years of age in Louisiana and the United States Louisiana United States Incidence per 1,000,000 population Prevalence per 1,000,000 population 741 2, ,156

23 Obesity Trends* Among U.S. Adults BRFSS, 1991, 1996, 2004 (*BMI 30, or about 30 lbs overweight for 5 4 person) No Data <10% 10% 14% 15% 19% 20% 24% 25%

24 Hurricane Katrina - Immediate Aftermath: Dialysis Adequacy in a New Orleans Facility % of patients reaching goal URR Kt/V 50.0 June July August October 2005

25 Greater New Orleans Dialysis Facilities: by Parish TOTAL Orleans Jefferson St. Charles St. Bernard August, 2005 September, 2006

26 Kidney Transplants in Lousiana 400 New Orleans Transplant Programs Number Year

27 Divisions of Nephrology FTEs Tulane LSU Ochsner

28 Standardized Mortality of ESRD Patients in the Year Following Hurricane Katrina

29 Through the Eye of Katrina: Lessons Learned in the Aftermath Hurricane Katrina produced a near-total loss of municipal and healthcare infrastructure. Most ESRD patients evacuated and were distributed, within a few days to other cities throughout the diaspora diaspora. Preliminary data suggest that dialysis patients suffered from a host of problems including missed and inadequate dialysis treatments. Preliminary data suggest an excess mortality in the months immediately following the storm. Louisiana experienced a reduction in kidney transplant activity, presumably owing to the interruption of service during and after the storm

30 Tulane-Ochsner Ochsner-USRDS Katrina Study 392 of 458 eligible hemodialysis patients in 9 Greater New Orleans dialysis facilities Phase 1 Survey Domains Evacuation (including satisfaction with planning) PTSD (PCL-17 checklist) Coping self-efficacy efficacy Quality of Life (SF-12) Depression (Center for Epid.. Studies Depression Scale) Missed dialysis treatments Vascular access issues

31 Tulane-Ochsner Ochsner-USRDS Katrina Study Phase 2 Linkage with USRDS and LDO databases Hemodialysis biochemical parameters Morbidity and hospitalizations Mortality

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33 Distribution of Katrina-displaced dialysis patients during interviews New Orleans

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35 Table 2. Evacuation and displacement experiences of hemodialysis patients following Hurricane Katrina (% of study participants)

36 Table 2 (cont d.) Evacuation and displacement experiences of hemodialysis patients following Hurricane Katrina (% of study participants)

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38 Table 3. Percentage and adjusted prevalence ratios of post-traumatic stress disorder among hemodialysis patients.

39 Table 3 (contin d.) Percentage and adjusted prevalence ratios of post-traumatic stress disorder among hemodialysis patients.

40 Table 3 (contin d.) Percentage and adjusted prevalence ratios of post-traumatic stress disorder among hemodialysis patients.

41 Summary and Conclusions A high percentage of dialysis patients, almost one in four, suffered PTSD following Hurricane Katrina. Patients evacuation experiences were associated with PTSD Following the storm, nearly half of patients missed at least one dialysis treatment and 16.6% missed at least 3 treatments. These results indicate the need for better coordination of evacuation and placement of hemodialysis patients in the event of similar urban disasters. In addition, efforts to re-establish continuity of care, including dialysis treatments, should be part of postdisaster planning.

42 Missed dialysis sessions % of hemodialysis patients 60% 50% 40% 30% 20% 10% 0% 55.2% 16.6% missed 3 or more treatments 13.3% 13.6% 8.7% 4.6% 2.3% 1.0% Number of missed dialysis sessions

43 Factors contributing to missed treatments Age group, years Odds ratios of missing 1-2 sessions (95% CI) Odds ratios of missing 3+ sessions (95% CI) < to < Gender 2.86 ( ) 1.89 ( ) 1.00 (ref) 2.51 ( ) 2.47 ( ) 1.00 (ref) Men Women Race/ethnicity 1.00 (ref) 1.56 ( ) 1.00 (ref) 0.99 ( ) White Black Time since initiation of ESRD treatment 1.00 (ref) 0.96 ( ) 1.00 (ref) 2.01 ( ) 5+ years 2 to <5 years <2 years 1.00 (ref) 0.84 ( ) 0.75 ( ) 1.00 (ref) 0.62 ( ) 1.93 ( )

44 Odds ratios of missing 1-2 sessions (95% CI) Odds ratios of missing 3+ sessions (95% CI) Cohabitation before Hurricane Katrina Lived w/ spouse or partner Lived w/ family members Lived w/ roommate Lived alone Evacuated due to Hurricane Katrina 1.00 (ref) 1.59 ( ) 0.60 ( ) 1.69 ( ) 1.00 (ref) 1.83 ( ) 1.65 ( ) 4.56 ( ) Yes 1.00 (ref) 1.00 (ref) No 1.73 ( ) 2.18 ( ) Date of evacuation due to Hurricane Katrina * On/before August 27, 2005 August 28, (ref) 0.94 ( ) 1.00 (ref) 1.36 ( ) On/after August 29, ( ) 7.10 ( ) First evacuation location * Relative s house 1.00 (ref) 1.00 (ref) Friend s house 0.77 ( ) 2.33 ( ) Hotel 1.26 ( ) 1.87 ( ) Shelter 2.93 ( ) 4.99 ( )

45 Aware of dialysis clinic s evacuation plans Odds ratios of missing 1-2 sessions (95% CI) Odds ratios of missing 3+ sessions (95% CI) Yes 1.00 (ref) 1.00 (ref) No 1.81 ( ) 2.49 ( ) Followed dialysis clinic s evacuation plans Yes No 1.00 (ref) 1.21 ( ) 1.00 (ref) 2.30 ( )

46 Hospitalizations and missed treatments 40% 37.5% * 30% % Hospitalized 20% 19.1% 22.1% 10% 0% 0 1 or 2 3+ Number of missed dialysis sessions * P-value = 0.04 compared to missing 0 sessions.

47 Hemodialysis access complications among Katrina evacuees Any complication Infection Fistula Graft Catheter

48 Risk factors in catheter infections among Katrina evacuees Adjusted odds ratios (95% CI) of infections Adjusted odds ratios (95% CI) of any complications First evacuation location * Relative s house 4.94 ( ) 1.57 ( ) Friend s house 4.76 ( ) 3.15 ( ) Hotel 1.00 (ref) 1.00 (ref) Shelter 3.28 ( ) 2.27 ( ) Time since initiation of ESRD treatment <2 years 2 to <5 years 5+ years 3.72 ( ) 1.42 ( ) 1.00 (ref) 2.01 ( ) 1.11 ( ) 1.00 (ref)

49 Summary Patients who missed treatments were less likely to have made evacuation plans and more likely to have evacuated late. Patients who missed treatments were more likely to be hospitalized in the ensuing 6 months. Patients who suffered infectious and other vascular access complications were more likely to have been displaced to a shelter or other unfamiliar environment.

50 Through the Eye of Katrina: Additional Conclusions Hurricane Katrina produced the worst urban disaster in modern American history. The study of the New Orleans ESRD population provides a unique window on the impact of such a disaster on a socially vulnerable and chronically ill population. Lessons drawn from this study will be applicable to future urban catastrophes.

51 Storm Track: Hurricane of 1938

52 Hurricane of 1938 Connecticut River at Hartford, after the Hurricane of 1938

53 It can happen here! Providence, during the hurricane of City hall and Biltmore Hotel on the left, Dorrance Street on the right.

54 Thanks Collaborators Paul Muntner,, PhD Tulane School of Public Health Amanda Hyre,, MPH Tulane School of Public Health Nancy Kutner,, MD USRDS/Emory School of Medicine Arnold Alper,, MD Tulane School of Medicine Special Thanks Linda Duval, RN, BSN ESRD Network 13 Patricia Philliber,, Exec. Dir. ESRD Network 13 Post-Katrina Study is funded through an NIH sub-contract from the USRDS-Emory Special Studies Center