Decreasing hospitalizations in patients on hemodialysis: Time for a paradigm shift

Abstract

Hospitalizations drive up to 35% of the astronomical costs of care for patients on hemodialysis and are associated with poor outcomes. We describe outpatient care-sensitive categories of hospitalization risks in an effort to engage stakeholders and patients, as stakeholders, in mitigating hospitalizations. These categories include: (1) fluid (interdialytic weight gain (IDWG) and chronic volume status), (2) infection (vascular access and malnutrition/inflammation resilience), and c) psychosocial (poor social support, poor self-efficacy, and mood disorders) risks. Barriers to improving hospitalization outcomes, especially as they relate to above risk categories, exist at multiple stakeholder levels and include: (1) dialysis facilities (strict shift changes, personnel challenges), (2) nephrologists (static dialysis prescriptions and protocols based on dialysis facility metrics), and (3) patients (lack of engagement and self-efficacy). System-level elements, such as payment models, help to propagate these barriers. In this article, we seek to shift the care paradigm discussion to patient trajectories and long-term outcomes, and to active engagement of patients as self-managers, through which we hope to impact on high inpatient resource utilization. We will also focus attention on the complex interplay of practices that have become acceptable care structures, but that may be deleterious to outcomes. Only after thorough consideration of these topics can we hope to impact on this important problem.

Feasibility of a Peer Mentor Training Program for Patients Receiving Hemodialysis: An Educational Program Evaluation

“…In this way, the training aimed to empower and equip patients as coached by their mentors to coordinate a more efficient use of resources to avoid hospitalizations. 30 …”

Machine Learning Directed Interventions Associate with Decreased Hospitalization Rates in Hemodialysis Patients

“…A recent review article on the factors and barriers related to decreasing admission rates in dialysis patients proposed three key clinical categories driving hospitalization risk that are potentially actionable [22]. These categories include volume control, infection, and psychosocial risks.…”

Peer mentorship to improve outcomes in patients on hemodialysis (PEER-HD): a randomized controlled trial protocol

“…MHD specific patient knowledge, effective self-management behaviors and easy access to quality ambulatory healthcare have been identified as modifiable factors [ 5 – 7 ]. Barriers to adoption of effective self-management behaviors in patients receiving MHD include: 1)poor understanding of the rationale and metrics of estimated dry weight and the link between urea clearance, nutrition and uremic symptoms; and 2) under-utilization of healthcare resources available in the outpatient setting [ 8 – 11 ]. Low self-efficacy, frequently linked to poor social support, and its association with underutilization of available resources and non-adherence to hemodialysis treatments also contribute to hospitalization risk [ 5 , 6 ].…”