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Among countries studied, US had highest rate of missed treatments among patients on dialysis
In a study on the impact of missed dialysis treatments in a global patient population, the United States had the highest percentage of missed treatments – 24% – compared to 1% in Italy and Japan.
In their study, Salmi and colleagues looked at the impact of missed hemodialysis treatments among patients treated in a variety of countries.
“Missing treatments is potentially modifiable and, if the rate of missed treatments were reduced, could lead to improved patient outcomes,” the researchers wrote.
To track missed treatments, data on patients who are part of phase 5 of the Dialysis Outcomes and Practice Patterns Study (DOPPS), that covered patients treated between 2012 and 2015, was reviewed. Of the 11,488 patients in phase 5 of the study treated at 439 facilities in 20 countries, 8,501 were selected who had consistently dialyzed three times a week with in-center hemodialysis for at least 120 days. Within that group, 4,493 patients from eight countries who had at baseline prior to the launch of the study had a missed treatment risk of less than 5%.
“The proportion of patients missing at least one treatment in the 4-month baseline period varied from 20% to 24% in the [Gulf Coast Cooperation Council] GCC and United States to less than 1% in Italy and Japan,” the researchers wrote. “Most of these patients missed one or more treatments during only 1 month in the 4-month period. In many countries, the percentage of patients who missed one or more treatments over 4 months varied greatly across facilities.”
Missed treatments were more likely seen in the study among patients who were younger, had less time (number of treatments) on dialysis therapy, shorter HD treatment time, lower Kt/V, longer travel time to HD centers and more symptoms of depression, the researchers wrote.
The resulting impact of the missed treatments included a greater cardiovascular mortality risk, including sudden death/cardiac arrest; greater risk of hospitalization; a serum phosphorus level of greater than 5.5 mg/dL; a parathyroid hormone level of greater than 300 pg/mL; a hemoglobin level of less than 10 g/dL; a greater kidney disease burden and worse general and mental health.
“[W]e observed on average 68% higher mortality for HD patients who missed vs. did not miss one or more HD treatments for 4 months. This raises the question of why mortality is so sensitive to missing even one HD treatment session,” they wrote.
Likewise, researchers wrote they were “disappointed” they could not explain the variation in missed treatments by country.
“Numerous factors have been shown to be related to missed treatments in HD patients, not all of which may be due to nonadherence per se, including logistic factors (eg, unreliable transportation or long travel time to HD unit, inclement weather and whether HD session was scheduled for Saturdays or holidays), effect of active medical issues (eg, gastrointestinal upset, vascular access dysfunction, alcohol/drug abuse, chronic pain and depression), or patient cultural, religious or demographic factors (eg, limited health literacy, age, race/ethnicity or marital support/status),” the authors wrote. “... Mean age of HD patients tended to be younger for the three countries with the highest percentage of missed treatments (GCC, Russia and United States), but some countries with considerably lower percentages of missed treatments (China and Turkey) had mean ages younger than U.S. patients.
“Reported alcohol and substance abuse were relatively low in each country and did not appear to explain the large variations in missed treatment across countries. Thus, the key factors explaining international missed treatment differences remain to be understood,” they wrote. “ ... It would be meaningful to understand the underlying reasons for these large international differences in missed treatments and encourage future data collection specifically designed for this purpose,” the researchers wrote.
Disclosures: The authors report no relevant financial disclosures.