Rescheduling hemodialysis treatments for next day linked to hospitalization
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Published findings suggest that, in addition to skipping a hemodialysis session entirely, rescheduling for the day following a missed treatment was associated with higher hospitalization rates and emergency department visits when compared with attending treatment.
“Given that missed in-center [hemodialysis] HD treatments are common, and their consequences severe, interventions that mitigate their effects have the potential to significantly improve patient outcomes,” Dena E. Cohen, PhD, of DaVita Clinical Research and DaVita Institute for Patient Safety, and colleagues wrote. “Rescheduling a missed treatment for the subsequent day represents a logical intervention from a physiological perspective. However, the degree to which rescheduling in this fashion can actually mitigate the effects of a missed treatment has not been examined.”
For the study, researchers included patients who were receiving in-center hemodialysis on a Monday/Wednesday/Friday schedule for at least 90 days (totaling 384,832 scheduled treatments). Hospital admissions, ED visits, mortality, blood pressure and anemia measures were considered during the 7- and 30-day periods following treatment attendance on either the scheduled or subsequent day. In addition, researchers matched patients who missed or rescheduled treatment to patients who attended treatment as scheduled.
Researchers found that, when compared with attending treatment, a missed treatment was associated with a 2.09-fold greater rate of hospitalization in the following 7 days, while a rescheduled treatment was associated with a 1.68-fold greater rate of hospitalization during this period. Furthermore, during the 30-day period, hospitalization rates were 1.39-fold greater among patients who missed a treatment and 1.28-fold greater for those who rescheduled.
Results were similar for ED visits with a missed treatment corresponding to a twofold greater incidence and a rescheduled treatment corresponding to a 1.33-fold greater incidence vs. attending treatment. In the 30-day period, a missed treatment was associated with a 1.37-fold greater rate of ED visits, while a rescheduled treatment was associated with a 1.13-fold greater rate.
No significant differences were observed regarding blood pressure, hemoglobin or mortality between patients who attended or rescheduled, leading researchers to argue that rescheduling may partially mitigate these risks since excess fluid and uremic toxins are able to be removed before the next scheduled treatment.
“This study demonstrates that attending a rescheduled treatment on the day following a missed treatment is associated with prognostic implications that are numerically less unfavorable than those of missing a treatment outright, both compared to attending treatment as scheduled,” they wrote. “Thus, while improving primary treatment adherence among in-center HD patients remains a priority, efforts to reschedule otherwise missed treatments may improve patient outcomes.” – by Melissa J. Webb
Disclosures: Cohen reports being an employee of DaVita Clinical Research. Please see the study for other authors’ relevant financial disclosures.
Perspective
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Kathy Aebel-Groesch, MSW, LCSW
In this study, Cohen and colleagues investigate the impact of missing scheduled in-center hemodialysis treatments on hospitalization risk, even when rescheduled.
“Researchers found that, when compared with attending treatment, a missed treatment was associated with a 2.09-fold greater rate of hospitalization in the following 7 days, while a rescheduled treatment was associated with a 1.68-fold greater rate of hospitalization during this period,” the authors wrote. “Furthermore, during the 30-day period, hospitalization rates were 1.39-fold greater among patients who missed a treatment and 1.28-fold greater for those who rescheduled.”
The results were similar for ED visits.
Addressing the root cause of missed treatments is complex. Patients skip treatments for a variety of psychosocial reasons, such as limited resources (lack of reliable and/or affordable transportation), caregiver obligations, mental health (ie, depression, anxiety, substance use disorder), health literacy and personal choice — at times, patients sometimes just don’t feel like coming.
Clearly, a rescheduled treatment is better than missing treatment altogether, but adhering to the prescribed schedule reduces risk of hospitalization. The medical team can show support for patients in several ways to reduce the likelihood of missed treatments:
- express empathy;
- avoid shaming;
- respect patients’ right to self-determination;
- understand social determinants of health to address barriers through resource navigation, psychoeducation, and engaging support systems; and
- involve patients in developing a plan of care that addresses their personal goals.
Social workers should provide counseling to address mental health needs. Treating the whole person and equipping them with coping skills will enhance patients’ self-management of ESKD.
DaVita Kidney Care
St. Louis
Nephrology News & Issues Editorial Board Member
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