Regular assessment of dialysis-related symptoms shows potential but more work needed
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Researchers who implemented a system to regularly assess symptoms of patients receiving hemodialysis found that while the program demonstrated feasibility and improved physician awareness, it did not lead to reductions in symptom burden.
“After the assessment was made part of usual care, patients and their health care providers completed surveys and interviews to help us understand how this approach helps and where it falls short,” Michael Walsh, MD, PhD, of McMaster University in Canada, said in a related press release. “This is important because several groups are lobbying for the routine use of patient-reported outcomes in the care of patients undergoing hemodialysis, but there are very little data to guide their best use and demonstrate how they might improve care.”
To further explore this area, Walsh and colleagues developed a patient-reported outcome measure (PROM) specifically designed to assess physical and psychosocial symptom burden. Health care providers at eight dialysis sites assessed patients every 4 weeks to 6 weeks for 1 year. Patients and providers were surveyed before, during and after PROM implementation. According to the researchers, the patient surveys were meant to examine changes in the perceptions of symptom management and patient-provider communication, while the provider surveys were developed to compare perceptions of interdisciplinary communication and confidence to manage symptoms pre- and post-implementation.
As seven of the eight sites had mean screening rates of more than 80%, and all sites had mean completion rates of more than 90%, Walsh and colleagues contended routinely using the PROM in clinical practice is feasible.
“Feasibility is further supported by the post-surveys, in which almost 80% of patients reported no problems completing the [Edmonton Symptom Assessment System Revised: Renal] ESAS-r: Renal, and less than a quarter of providers strongly agreed or agreed that the ESAS-r: Renal negatively affected clinic flow or that steps associated with the ESAS-r: Renal took too much time,” they elaborated.
The value and impact of PROM implementation, however, demonstrated mixed results, according to the researchers. They observed improved patient and provider symptom awareness, most notably for psychosocial symptoms, as well as increased empowerment for patients to raise issues with their providers. Despite this, they found “little” improvement in the metrics used to assess symptom management, patient-provider communication and interdisciplinary communication.
In the press release, Walsh explained further.
“The study found that although routinely assessing symptoms gave some patients a feeling of empowerment to discuss symptoms they otherwise would not have, their care providers need more support to help their patients,” he said. “Care providers found value in the process but felt that we administered it too frequently and that they needed better support to help them manage symptoms both in terms of training and education, but also in terms of ensuring the right resources are in place at the right time.”
In a related editorial, Jane Ogden Schell, MD, and Dale Ellen Lupu, PhD, contended that the study findings are “an important step in the right direction” for utilizing PROMs in routine hemodialysis care.
They suggested that although the study “joins many other PROMs studies that have affected care processes but failed to demonstrate an effect on care outcomes,” they still view PROMs as having potential to improve patient quality of life, recommending further work be done on how PROMs can most effectively be utilized.
“We urgently need a better arsenal of proven treatments for common symptoms in kidney disease,” Ogden Schell and Lupu added. “Recognizing the gap between symptom burden and effective treatments, the Kidney Health Initiative has created work groups for insomnia, muscle cramps and fatigue — common symptoms prioritized by patients with kidney disease. As future research provides better pharmacologic and nonpharmacologic strategies, we will be better positioned to demonstrate effectiveness in patient care through a model of implementation with steps that link PROMs to patient-centered outcomes.”
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