Adherence Barriers to Chronic Dialysis in the United States

Abstract

Hemodialysis patients often do not attend their scheduled treatment session. We investigated factors associated with missed appointments and whether such nonadherence poses significant harm to patients and increases overall health care utilization in an observational analysis of 44 million hemodialysis treatments for 182,536 patients with ESRD in the United States. We assessed the risk of hospitalization, emergency room visit, or intensive-coronary care unit (ICU-CCU) admission in the 2 days after a missed treatment relative to the risk for patients who received hemodialysis. Over the 5-year study period, the average missed treatment rate was 7.1 days per patient-year. In covariate adjusted logistic regression, the risk of hospitalization (odds ratio [OR], 3.98; 95% confidence interval [95% CI], 3.93 to 4.04), emergency room visit (OR, 2.00; 95% CI, 1.87 to 2.14), or ICU-CCU admission (OR, 3.89; 95% CI, 3.81 to 3.96) increased significantly after a missed treatment. Overall, 0.9 missed treatment days per year associated with suboptimal transportation to dialysis, inclement weather, holidays, psychiatric illness, pain, and gastrointestinal upset. These barriers also associated with excess hospitalization (5.6 more events per patient-year), emergency room visits (1.1 more visits), and ICU-CCU admissions (0.8 more admissions). In conclusion, poor adherence to hemodialysis treatments may be a substantial roadblock to achieving better patient outcomes. Addressing systemic and patient barriers that impede access to hemodialysis care may decrease missed appointments and reduce patient morbidity. Timely and unhindered access to preventative services and ambulatory care is an important component of sustaining healthy populations. Without access to these services, patients will experience more hospitalizations and deaths from preventable medical conditions. 1,2 Patients with ESRD who are on chronic hemodialysis typically require three outpatient treatments per week to prevent serious complications from their kidney failure. 2 Yet many patients with ESRD miss their hemodialysis treatment and place themselves at increased risk for hospitalization or mortality. 2 Why patients miss dialysis remains incompletely understood. Several small studies have associated depression, unreliable transportation, demographic factors, and lack of motivation with a missed dialysis treatment; however, a large comprehensive analysis of adherence barriers to dialysis care and their implication on patient outcomes currently remains elusive. [2][3][4] In this study, we identified missed hemodialysis appointments from a large ESRD cohort to quantify their effect on subsequent hospitalizations, emergency room(ER) visits,and intensive-coronarycareunit(ICU-CCU) admissions. We used these results to test which systemic and patient barriers potentially impede patients from getting to their dialysis facility for treatment. RESULTS Treatments Characteristics in the Study PopulationA total of 44,586,241 outpatient hemodialysis treatments from 182,53...

Depressive Affect and Hospitalization Risk in Incident Hemodialysis Patients

“…Furthermore, chemical brain alterations in depressed patients may affect cognitive dysfunction (which may manifest as poor adherence) (17), and cognitive dysfunction has been associated with depressive affect in HD patients (18). Poor adherence may also extend to missed HD treatments, which has been associated with greater risk for hospitalization from not just cardiovascular causes but all-causes as well (19,20). Poor adherence may also extend to medication adherence and dietary considerations (including anorexia) leading to malnutrition, both of which have been associated with increased hospitalization and mortality risk in this population (21)(22)(23)(24).…”

Eculizumab Dosing Intervals Longer than 17 Days May Be Associated with Greater Risk of Breakthrough Hemolysis in Patients with Paroxysmal Nocturnal Hemoglobinuria

“…6,7) However, rigorous adherence to the recommended dosing interval may be difficult to implement in reality due to many practical reasons. 11,12) To the best of our knowledge, it remains unclear whether inevitable prolongation of the dosing interval may increase the risk of breakthrough hemolysis. We retrospectively reviewed the medical records of 14 patients with PNH who received long-term eculizumab therapy in a single medical center.…”

Geographic disparities in mortality among the end stage renal disease patients: an analysis of the United States Renal Data System, 2007–08

“…The future studies should analyze data by zip codes and states to compare the impact of distances in urban areas in seeking healthcare with accessible versus not so accessible mass transit system. Prior work has indicated a relationship between a patient missing dialysis sessions and poor outcomes, such as an increased risk of hospitalization, intensive care, emergency visits, and early mortality [25]. We were unable to control for these missed sessions utilizing this data, as it does not capture the dialysis schedules of the individual patients.…”