Social determinants of health associated with hemodialysis non-adherence and emergency department utilization: a pilot observational study

Waitlist Time, Age, and Social Vulnerability: Impact on the Survival Benefit of Deceased Donor Kidney Transplantation Versus Long-term Dialysis Among Patients With End-stage Renal Disease

BACKGROUND

We sought to define the survival benefit of kidney transplantation versus long-term dialysis relative to waitlist time on dialysis, social vulnerability, and age among end-stage renal transplant candidates.

METHODS

End-stage renal disease patients who were candidates for their first deceased donor kidney transplantation between 2008 and 2020 were identified using the US Renal Data System. Survival probabilities for patient survival were compared using the restricted mean survival times (RMSTs) across different age and social vulnerability index (SVI) ranges.

RESULTS

Among 149 923 patients, 68 795 (45.9%) patients underwent a kidney transplant and 81 128 (54.1%) remained on dialysis. After propensity-score matching (n = 58 035 in each cohort), the 5-y RMST difference between kidney transplant and dialysis demonstrated an increasing trend in mean life-years gained within 5 y of follow-up relative to advancing age (<30 y: 0.40 y, 95% confidence interval, 0.36-0.44 y versus >70 y: 0.75 y, 95% confidence interval, 0.70-0.80 y). Conversely, disparities in 5-y RMSTs remained consistent relative to social vulnerability (median 5-y RMST difference: 0.62 y comparing low versus high SVI). When considering waitlist duration, stratified analyses demonstrated increasing trends across different age groups with the largest RMST differences observed among older patients aged ≥70 y. Notably, longer waitlist durations (>3 y) yielded more pronounced RMST differences compared with shorter durations (<1 y).

CONCLUSIONS

These data underscore the survival benefit associated with kidney transplantation over long-term dialysis across various age and SVI ranges. Transplantation demonstrated a greater advantage among older patients who had a longer waitlist duration.

Patients' Perspectives on Health-Related Social Needs and Recommendations for Interventions: A Qualitative Study

RATIONALE & OBJECTIVE

People with low socioeconomic status are disproportionately affected by kidney failure, and their adverse outcomes may stem from unmet health-related social needs. This study explored hemodialysis patient perspectives on health-related social needs and recommendations for intervention.

STUDY DESIGN

Qualitative study using semistructured interviews.

SETTINGS & PARTICIPANTS

Thirty-two people with low socioeconomic status receiving hemodialysis at 3 hemodialysis facilities in Austin, Texas.

ANALYTICAL APPROACH

Interviews were analyzed for themes and subthemes using the constant comparative method.

RESULTS

Seven themes and 21 subthemes (in parentheses) were identified: (1) kidney failure was unexpected (never thought it would happen to me; do not understand dialysis); (2) providers fail patients (doctors did not act; doctors do not care); (3) dialysis is detrimental (life is not the same; dialysis is all you do; dialysis causes emotional distress; dialysis makes you feel sick); (4) powerlessness (dependent on others; cannot do anything about my situation); (5) financial resource strain (dialysis makes you poor and keeps you poor; disability checks are not enough; food programs exist but are inconsistent; eat whatever food is available; not enough affordable housing; unstable housing affects health and well-being); (6) motivation to keep going (faith, support system, will to live); and (7) interventions should promote self-efficacy (navigation of community resources, support groups).

LIMITATIONS

Limited quantitative data such as on dialysis vintage, and limited geographic representation.

CONCLUSIONS

Dialysis exacerbates financial resource strain, and health-related social needs exacerbate dialysis-related stress. The participants made recommendations to address social needs with an emphasis on increasing support and community resources for this population.

PLAIN-LANGUAGE SUMMARY

People receiving dialysis often experience health-related social needs, such as food and housing needs, but little is known about how these impact patients' health and well-being or how to best address them. We interviewed people receiving dialysis about how health-related social needs affect them and what they think dialysis facilities can do to help them address those needs. The participants reported that they often lose their independence after starting dialysis and health-related social needs are common, exacerbate their stress and emotional distress, and reduce their sense of well-being. Dialysis facilities may be able to enhance the experience of these patients by facilitating connections with local resources and providing opportunities for patients to support one another.

High Prevalence of Adverse Social Determinants of Health in Dialysis Access Creation Patients in a Safety-Net Setting

BACKGROUND

Patients receiving dialysis access surgery are often exposed to adverse social determinants of health (SDH) that negatively impact their care. Our goal was to characterize these factors experienced by our arteriovenous dialysis access patients and identify differences in health outcomes based on their SDH.

METHODS

We performed a retrospective cohort study of all patients who underwent dialysis access creation (2017-2021) and were screened for SDH at a clinical visit (using THRIVE survey) implemented at an urban, safety-net hospital institution within 1 year of access creation. Demographics, procedural details, early postoperative outcomes, survey responses, and referral to our hospital's preventive food pantry were recorded. Univariable analysis and multivariable analyses were performed to assess for associations with key health outcomes.

RESULTS

There were 190 patients who responded to the survey within 1 year of their operation. At least 1 adverse SDH was identified in 42 (22%) patients. Normalized to number of respondents for each question, adverse SDH identified were difficulty obtaining transportation to medical appointments (18%), food insecurity (16%), difficulty affording utilities (13%), difficulty affording medication (12%), unemployed and seeking employment (9%), unstable housing (7%), difficulty caring for family/friends (6%), and desiring more education (5%). There were 71 (37%) patients who received food pantry referrals. Mean age was 60 years and 38% of patients were female and 64% were Black. More than half of patients (57%) had a tunneled dialysis catheter (TDC) at the time of access creation. Dialysis accesses created were brachiocephalic (39%), brachiobasilic (25%), radiocephalic fistulas (16%), and arteriovenous grafts (14%). Thirty-day emergency department (ED) visits, 30-day readmissions, and 90-day mortality occurred in 23%, 21%, and 2%, respectively. On univariable and multivariable analyses, any adverse SDH determined on survey and food pantry referral were not associated with preoperative dialysis through TDCs, receiving nonautogenous dialysis access, 30-day ED visits and readmissions, or 90-day mortality.

CONCLUSION

Nearly a quarter of dialysis access surgery patients at a safety-net hospital experienced adverse SDH and more than one-third received a food pantry referral. Most common difficulties experienced include difficulty obtaining transportation to medical appointments, food insecurity, and difficulty paying for utilities and medication. Although there were no differences in postoperative outcomes, the high prevalence of these adverse SDH warrants prioritization of resources in this population to ensure healthy equity and further investigation into their effects on health outcomes.

Real-World Data for Interdisciplinary Health Care Research: A Case Example

Real-word data (RWD) refer to data relating to patient health status and/or the delivery of health care routinely collected from a variety of sources, including electronic health records, medical claims data, and patient-generated data. Data sets that combine personal health data stored in different sources can provide a more complete picture of an individual's health and can be used to improve population health through research and practice. The 2-tiered aim of this article is to provide a brief introduction to using RWD in health care research and to present a case study that demonstrates data curation and data merge from different sources while highlighting the benefits and limitations of using RWD. The current digital health ecosystem and value-based care approach highlight the need to use RWD to catalyze the advancement of health care research and practice. This is an excellent field that nurse researchers can lead, as they have an innate understanding of such data and data sources.

The impact of neighborhood social disadvantage on presentation and management of first-time hemodialysis access surgery patients

OBJECTIVES

The impact of social determinants of health on the presentation, management, and outcomes of patients requiring hemodialysis (HD) arteriovenous (AV) access creation have not been well-characterized. The Area Deprivation Index (ADI) is a validated measure of aggregate community-level social determinants of health disparities experienced by members living within a community. Our goal was to examine the effect of ADI on health outcomes for first-time AV access patients.

METHODS

We identified patients who underwent first-time HD access surgery in the Vascular Quality Initiative between July 2011 to May 2022. Patient zip codes were correlated with an ADI quintile, defined as quintile 1 (Q1) to quintile 5 (Q5) from least to most disadvantaged. Patients without ADI were excluded. Preoperative, perioperative, and postoperative outcomes considering ADI were analyzed.

RESULTS

There were 43,292 patients analyzed. The average age was 63 years, 43% were female, 60% were of White race, 34% were of Black race, 10% were of Hispanic ethnicity, and 85% received autogenous AV access. Patient distribution by ADI quintile was as follows: Q1 (16%), Q2 (18%), Q3 (21%), Q4 (23%), and Q5 (22%). On multivariable analysis, the most disadvantaged quintile (Q5) was associated with lower rates of autogenous AV access creation (OR, 0.82; 95% confidence interval [CI], 0.74-0.90; P < .001), preoperative vein mapping (OR, 0.57; 95% CI, 0.45-0.71; P < .001), access maturation (OR, 0.82; 95% CI, 0.71-0.95; P = .007), and 1-year survival (OR, 0.81; 95% CI, 0.71-0.91; P = .001) compared with Q1. Q5 was associated with higher 1-year intervention rates than Q1 on univariable analysis, but not on multivariable analysis.

CONCLUSIONS

The patients undergoing AV access creation who were most socially disadvantaged (Q5) were more likely to experience lower rates of autogenous access creation, obtaining vein mapping, access maturation, and 1-year survival compared with the most socially advantaged (Q1). Improvement in preoperative planning and long-term follow-up may be an opportunity for advancing health equity in this population.

Social Determinants of Health in EMS Records: A Mixed-methods Analysis Using Natural Language Processing and Qualitative Content Analysis

Introduction: Social determinants of health (SDoH) are known to impact the health and well-being of patients. However, information regarding them is not always collected in healthcare interactions, and healthcare professionals are not always well-trained or equipped to address them. Emergency medical services (EMS) professionals are uniquely positioned to observe and attend to SDoH because of their presence in patients' environments; however, the transmission of that information may be lost during transitions of care. Documentation of SDoH in EMS records may be helpful in identifying and addressing patients' insecurities and improving their health outcomes. Our objective in this study was to determine the presence of SDoH information in adult EMS records and understand how such information is referenced, appraised, and linked to other determinants by EMS personnel. Methods: Using EMS records for adult patients in the 2019 ESO Data Collaborative public-use research dataset using a natural language processing (NLP) algorithm, we identified free-text narratives containing documentation of at least one SDoH from categories associated with food, housing, employment, insurance, financial, and social support insecurities. From the NLP corpus, we randomly selected 100 records from each of the SDoH categories for qualitative content analysis using grounded theory. Results: Of the 5,665,229 records analyzed by the NLP algorithm, 175,378 (3.1%) were identified as containing at least one reference to SDoH. References to those SDoH were centered around the social topics of accessibility, mental health, physical health, and substance use. There were infrequent explicit references to other SDoH in the EMS records, but some relationships between categories could be inferred from contexts. Appraisals of patients' employment, food, and housing insecurities were mostly negative. Narratives including social support and financial insecurities were less negatively appraised, while those regarding insurance insecurities were mostly neutral and related to EMS operations and procedures. Conclusion: The social determinants of health are infrequently documented in EMS records. When they are included, they are infrequently explicitly linked to other SDoH categories and are often negatively appraised by EMS professionals. Given their unique position to observe and share patients' SDoH information, EMS professionals should be trained to understand, document, and address SDoH in their practice.

Associations of health literacy with self-management behaviours and health outcomes in chronic kidney disease: a systematic review

INTRODUCTION

Low health literacy is widely reported in people with chronic kidney disease (CKD) and has been associated with reduced disease self-management, poor health outcomes, increased mortality and poorer quality of life. However, these associations are still not well understood.

METHODS

Electronic-based systematic searches were performed to identify studies examining associations between health literacy and self-management behaviours and/or health outcomes in patients with CKD. A tabular and narrative synthesis of the data was performed. Meta-analysis was not appropriate due to the heterogeneity of study designs and methods.

RESULTS

Searches identified 48 studies that met the inclusion criteria. A total of 41 published articles, six conference abstracts, and one thesis were included. Of the 48 studies, 11 were cohort and 37 were cross-sectional. In total there were 25,671 patients; 16,952 from cohort studies. Median study sample size was 159 (IQR 92-275). Study quality was high (5), moderate (24) and poor (19). Thirteen measures of health literacy were used. Despite the limitations of the available evidence, there appear to be consistent relationships between higher health literacy and favourable self-management behaviours for patients with CKD. Definitive relationships between health literacy and patient outcomes are far less clear and remain incompletely understood.

DISCUSSION

Conclusive evidence describing a causal link between health literacy and patient outcomes remains limited, but for many outcomes, a consistent association is described. In addition to associations with mortality, hospitalisation and clinical events, there were consistent associations between health literacy and favourable self-management behaviours which could support the development of patient education aimed at improving health literacy.

Predictors of Urgent Dialysis Following Ambulance Transport to the Emergency Department in Patients Treated With Maintenance Hemodialysis

Background

Patients receiving maintenance hemodialysis frequently require ambulance transport to the emergency department (ambulance-ED transport). Identifying predictors of outcomes after ambulance-ED transport, especially the need for timely dialysis, is important to health care providers.

Objective

The purpose of this study was to derive a risk-prediction model for urgent dialysis after ambulance-ED transport.

Design

Observational cohort study.

Setting and Patients

All ambulance-ED transports among incident and prevalent patients receiving maintenance hemodialysis affiliated with a regional dialysis program (catchment area of approximately 750 000 individuals) from 2014 to 2018.

Measurements

Patients' vital signs (systolic blood pressure, oxygen saturation, respiratory rate, and heart rate) at the time of paramedic transport and time since last dialysis were utilized as predictors for the outcome of interest. The primary outcome was urgent dialysis (defined as dialysis in a monitored setting within 24 hours of ED arrival or dialysis within 24 hours with the first ED patient blood potassium level >6.5 mmol/L) for an unscheduled indication. Secondary outcomes included, hospitalization, hospital length of stay, and in-hospital mortality.

Methods

A logistic regression model to predict outcomes of urgent dialysis. Discrimination and calibration were assessed using the C-statistic and Hosmer-Lemeshow test.

Results

Among 878 ED visits, 63 (7.2%) required urgent dialysis. Hypoxemia (odds ratio [OR]: 4.04, 95% confidence interval [CI]: 1.75-9.33) and time from last dialysis of 24 to 48 hours (OR: 3.43, 95% CI: 1.05-11.9) and >48 hours (OR: 9.22, 95% CI: 3.37-25.23) were strongly associated with urgent dialysis. A risk-prediction model incorporating patients' vital signs and time from last dialysis had good discrimination (C-statistic 0.8217) and calibration (Hosmer-Lemeshow goodness of fit P value .8899). Urgent dialysis patients were more likely to be hospitalized (63% vs 34%), but there were no differences in inpatient mortality or length of stay.

Limitations

Missing data, requires external validation.

Conclusion

We derived a risk-prediction model for urgent dialysis that may better guide appropriate transport and care for patients requiring ambulance-ED transport.

Systematic CKD Care Approaches: A Potential Solution for the Costly ESRD Program

Care of patients with advanced kidney disease includes dialysis, kidney transplant, vascular access, primary care, and other specialist care, which are often siloed among multiple physicians, dialysis clinics, vascular access centers, and health system or hospital-based transplant programs. Other than the patient themselves, no one provider has holistic patient visibility or responsibility. Given that hospitals often lose money on Medicare patients who require dialysis services, momentum from innovation in advanced kidney care management, new technology with the potential for reduced costs, expansion of Medicare Advantage, and Medicare incentives for home dialysis could be leveraged by health systems to ultimately reduce the nearly $50 billion annual Federal spending on patients with kidney failure in the United States. Health systems, which offer many primary and specialty care services, may be uniquely positioned to leverage the more favorable economics associated with these changes to move kidney care from siloed, provider-centric care to integrated, patient-centric care. With 60% of patients initiating dialysis through an unplanned hospitalization, a holistic health system approach that includes offerings of kidney care management and kidney replacement therapy could move financial incentives away from the interests of any single provider and toward better addressing the total needs and the goals of the patient.

Comparison of two self-report scales to assess anxiety and depressive symptoms in hemodialysis patients

INTRODUCTION

Psychiatric illness is prevalent among hemodialysis (HD) patients. This study compared the assessment of anxiety and depressive symptoms among HD patients using two self-administered scales; hospital anxiety and depression scale (HADS) and brief symptom inventory (BSI).

METHODS

A cross-sectional study was conducted among a convenience sample of HD patients (n = 352) from different dialysis centers in Jordan. Patients were interviewed in dialysis units, and demographics, clinical status, disease, and dialysis history data were collected. Symptoms of anxiety (HADS-A ≥ 8 and BSI-A ≥ 0.82) and depression (HADS-D ≥ 8 and BSI-D ≥ 0.82) were also measured.

RESULTS

The mean age of participants was 52.2 ± 15.6 years. The majority had been receiving HD three times daily and for >2 years. A significant moderate-strong correlation was observed between HADS-A and BSI-A (r = 0.753, p < 0.0001) as well as HADS-D and BSI-D (r = 0.588, p < 0.0001). Anxiety prevalence was 43.7 % using HADS-A ≥ 8 and 80.7 % using BSI-A ≥ 0.82, while depression prevalence was 53.1 % using HADS-D ≥ 8 and 51.7 % using BSI-D ≥ 0.82. When HADS was used as a standard, the operating characteristics reveal that a higher cut-off for BSI-A is recommended (≥1.58) for better anxiety screening.

DISCUSSION

Specific and suitable cut-off points need to be further explored and validated for HADS and BSI scales among patients undergoing dialysis.

The Prevalence and Severity of Chronic Pain in Patients With Chronic Kidney Disease: A Systematic Review and Meta-Analysis

Background:

Chronic pain is a common and distressing symptom reported by patients with chronic kidney disease (CKD). Clinical practice and research in this area do not appear to be advancing sufficiently to address the issue of chronic pain management in patients with CKD.

Objectives:

To determine the prevalence and severity of chronic pain in patients with CKD.

Design:

Systematic review and meta-analysis.

Setting:

Interventional and observational studies presenting data from 2000 or later. Exclusion criteria included acute kidney injury or studies that limited the study population to a specific cause, symptom, and/or comorbidity.

Patients:

Adults with glomerular filtration rate (GFR) category 3 to 5 CKD including dialysis patients and those managed conservatively without dialysis.

Measurements:

Data extracted included title, first author, design, country, year of data collection, publication year, mean age, stage of CKD, prevalence of pain, and severity of pain.

Methods:

Databases searched included MEDLINE, CINAHL, EMBASE, and Cochrane Library, last searched on February 3, 2020. Two reviewers independently screened all titles and abstracts, assessed potentially relevant articles, and extracted data. We estimated pooled prevalence of overall chronic pain, musculoskeletal pain, bone/joint pain, muscle pain/soreness, and neuropathic pain and the I² statistic was computed to measure heterogeneity. Random effects models were used to account for variations in study design and sample populations and a double arcsine transformation was used in the model calculations to account for potential overweighting of studies reporting either very high or very low prevalence measurements. Pain severity scores were calibrated to a score out of 10, to compare across studies. Weighted mean severity scores and 95% confidence intervals were reported.

Results:

Sixty-eight studies representing 16 558 patients from 26 countries were included. The mean prevalence of chronic pain in hemodialysis patients was 60.5%, and the mean prevalence of moderate or severe pain was 43.6%. Although limited, pain prevalence data for peritoneal dialysis patients (35.9%), those managed conservatively without dialysis (59.8%), those following withdrawal of dialysis (39.2%), and patients with earlier GFR category of CKD (61.2%) suggest similarly high prevalence rates.

Limitations:

Studies lacked a consistent approach to defining the chronicity and nature of pain. There was also variability in the measures used to determine pain severity, limiting the ability to compare findings across populations. Furthermore, most studies reported mean severity scores for the entire cohort, rather than reporting the prevalence (numerator and denominator) for each of the pain severity categories (mild, moderate, and severe). Mean severity scores for a population do not allow for “responder analyses” nor allow for an understanding of clinically relevant pain.

Conclusions:

Chronic pain is common and often severe across diverse CKD populations providing a strong imperative to establish chronic pain management as a clinical and research priority. Future research needs to move toward a better understanding of the determinants of chronic pain and to evaluating the effectiveness of pain management strategies with particular attention to the patient outcomes such as overall symptom burden, physical function, and quality of life. The current variability in the outcome measures used to assess pain limits the ability to pool data or make comparisons among studies, which will hinder future evaluations of the efficacy and effectiveness of treatments. Recommendations for measuring and reporting pain in future CKD studies are provided.

Trial registration:

PROSPERO Registration number CRD42020166965