In-center hemodialysis absenteeism: prevalence and association with outcomes

Transportation Justice and Health

Policy Points The health care sector is increasingly investing in social conditions, including availability of safe, reliable, and adequate transportation, that contribute to improving health. In this paper, we suggest ways to advance the impact of transportation interventions and highlight the limitations of how health services researchers and practitioners currently conceptualize and use transportation. Incorporating a transportation justice framework offers an opportunity to address transportation and mobility needs more comprehensively and equitably within health care research, delivery, and policy.

Improving kidney care for people with severe mental health difficulties: a thematic analysis of twenty-two healthcare providers' perspectives

Introduction

People with severe mental health difficulties (SMHDs) and concurrent kidney disease have less access to quality kidney care and worse clinical outcomes. Our research investigates the barriers and facilitators to effective kidney care for people with SMHDs, and how care might be improved for this underserved population.

Methods

We conducted semi-structured interviews with twenty-two physical (n = 14) and mental (n = 8) healthcare professionals with experience working with people with SMHDs and concurrent kidney disease. Interview data were analysed and interpreted using reflexive thematic analysis.

Results

Four themes were generated from the data: 1. "It's about understanding their limitations and challenges, without limiting their rights" describes how some people with SMHDs need additional support when accessing kidney care due to challenges with their mental state, motivation, cognitive difficulties, or mistrust of the healthcare system. 2. "There are people falling through the cracks" describes how the separation of physical and mental healthcare, combined with under-resourcing and understaffing, results in poorer outcomes for people with SMHDs. 3. "Psychiatry is a black spot in our continuing medical education" describes how many renal healthcare providers have limited confidence in their understanding of mental health and their ability to provide care for people with SMHDs. 4. "When they present to a busy emergency department with a problem, the staff tend to go '…psych patient"" describes how stigma towards people with SMHDs can negatively impact quality of care.

Conclusion

Healthcare professionals accounts' describe how people with SMHDs and kidney disease can have favourable outcomes if they have appropriate hospital, community and social supports. Findings indicate that effective management of kidney disease for people with SMHDs requires integrated physical and mental health care, which takes an individualised "whole person" approach to addressing the interaction between kidney disease and mental health.

Association of the Comprehensive ESRD Care Model with Treatment Adherence

Background

Poor adherence to scheduled dialysis treatments is common and can cause adverse clinical and economic outcomes. In 2015, the Centers for Medicare and Medicaid Innovation launched the Comprehensive ESRD Care (CEC) Model, a novel modification of the Accountable Care Organization framework. Many model participants reported efforts to increase dialysis adherence and promptly reschedule missed treatments.

Methods

With Medicare databases covering 2014-2019, we used difference-in-differences models to compare treatment adherence among patients aligned to 1037 CEC facilities relative to those aligned to matched comparison facilities, while accounting for their differences at baseline. Using dates of service, we identified patients who typically received three weekly treatments and the days when treatments typically occurred. Skipped treatments were defined as days when the patient was not hospitalized but did not receive an expected treatment, and rescheduled treatments as days when a patient who had skipped their previous treatment received an additional treatment before their next expected treatment date.

Results

Patients in the CEC Model had higher odds of attending as-scheduled sessions relative to the comparison group, although the effect was only marginally significant (OR, 1.02; 95% CI, 1.00 to 1.04, P=0.08). Effects were stronger among females (OR, 1.03; 95% CI, 1.00 to 1.06, P=0.06) than males (OR, 1.01; 95% CI, 0.98 to 1.04, P=0.49), and among those aged <70 years (OR, 1.02; 95% CI, 1.00 to 1.05, P=0.04) than those aged ≥70 years (OR, 1.00; 95% CI, 0.96 to 1.04, P=0.96). The CEC was associated with higher odds of rescheduled sessions (OR, 1.09; 95% CI, 1.05 to 1.14, P<0.001). Effects were significant for both sexes, but were larger among males (OR, 1.11; 95% CI, 1.05 to 1.18, P<0.001) than females (OR, 1.07; 95% CI, 1.02 to 1.13, P=0.01), and effects were significant among those <70 years (OR, 1.12; 95% CI, 1.07 to 1.17, P<0.001), but not those ≥70 years (OR, 0.99; 95% CI, 0.92 to 1.07, P=0.80).

Conclusions

The CEC Model is intended to incentivize strategies to prevent costly interventions. Because poor dialysis adherence may precipitate hospitalizations or other adverse events, many CEC Model participants encouraged adherence and promptly rescheduled missed treatments as strategic priorities. This study suggests these efforts were a success, although the absolute magnitudes of the effects were modest.

How is the COVID-19 pandemic shaping transportation access to health care?

The Coronavirus disease 19 (COVID-19) pandemic has disrupted both transportation and health systems. While about 40% of Americans have delayed seeking medical care during the pandemic, it remains unclear to what extent transportation is contributing to missed care. To understand the relationship between transportation and unmet health care needs during the pandemic, this paper synthesizes existing knowledge on transportation patterns and barriers across five types of health care needs. While the literature is limited by the absence of detailed data for trips to health care, key themes emerged across populations and settings. We find that some patients, many of whom already experience transportation disadvantage, likely need extra support during the pandemic to overcome new travel barriers related to changes in public transit or the inability to rely on others for rides. Telemedicine is working as a partial substitute for some visits but cannot fulfill all health care needs, especially for vulnerable groups. Structural inequality during the pandemic has likely compounded health care access barriers for low-income individuals and people of color, who face not only disproportionate health risks, but also greater difficulty in transportation access and heightened economic hardship due to COVID-19. Partnerships between health and transportation systems hold promise for jointly addressing disparities in health- and transportation-related challenges but are largely limited to Medicaid-enrolled patients. Our findings suggest that transportation and health care providers should look for additional strategies to ensure that transportation access is not a reason for delayed medical care during and after the COVID-19 pandemic.

Redefining Medication Management in Dialysis: A Kidney Pharmacy Quality Pyramid

Patients with end-stage renal disease treated with dialysis are often prescribed complex medication regimens, placing them at risk for drug-drug interactions and other medication-related problems. Particularly in the context of a broader interest in more patient-centered value-based care, improving medication management is an increasingly important focus area. However, current medication management metrics, designed for the broader patient population, may not be well suited to the specific needs of patients with kidney disease, especially given the complexity of medication regimens used by dialysis patients. We propose a kidney pharmacy-focused quality pyramid that is intended to provide a framework to guide dialysis organizations, health care providers, and/or clinicians with respect to an optimal medication management approach for dialysis patients. Incorporation of core programs in medication management, including medication reconciliation, safety programs, and medication therapy management for patients at high risk for medication-related problems, may result in improved outcomes. Although a growing body of evidence supports the concept that active medication management can improve medication adherence and reduce medication-related problems, these strategies are viewed as costly and are not widely deployed. However, if done effectively, pharmacy-led medication management has the potential to be one of the more cost-effective disease management strategies and may greatly improve outcomes for these complex patients.

Impact of Rescheduling a Missed Hemodialysis Treatment on Clinical Outcomes

Rationale & Objective

Among patients treated with in-center hemodialysis (HD), missed treatments are associated with higher subsequent rates of hospitalization and other adverse outcomes compared with attending treatment. The objective of this study was to determine whether and to what degree attending a rescheduled treatment on the day following a missed treatment ameliorates these risks.

Study Design

Retrospective, observational.

Setting & Participants

Included patients were those who were, as of any of 12 index dates during 2014, adult Medicare beneficiaries treated with in-center HD (vintage ≥ 90 days) on a Monday/Wednesday/Friday schedule.

Exposure

Treatment attendance on the index date and the subsequent day.

Outcomes

Hospital admissions, emergency department visits, mortality, blood pressure, and anemia measures, considered during the 7- and 30-day periods following exposure.

Analytical Approach

In parallel analyses, patients who missed or rescheduled treatment were each matched (1:5) to patients who attended treatment on the index date on the basis of index day of week and propensity score. Within the matched cohorts, outcomes were compared across exposures using repeated-measures generalized linear models.

Results

Compared with attending treatment (N = 19,260), a missed treatment (N = 3,852) was associated with a 2.09-fold higher rate of hospitalization in the subsequent 7 days; a rescheduled treatment (N = 2,128) was associated with a 1.68-fold higher rate of hospitalization than attending (N = 10,640). Compared with attending treatment, hospitalization rates were 1.39- and 1.28-fold higher among patients who missed and rescheduled treatment, respectively, during the 30-day outcome period. Emergency department visits followed a similar pattern of associations as hospitalization. No statistically significant associations were observed with respect to mortality for either missed or rescheduled treatments compared with attending treatment.

Limitations

Possible influence of unmeasured confounding; unknown generalizability to patients with non-Medicare insurance.

Conclusions

Attending a rescheduled in-center HD treatment attenuates but does not fully mitigate the adverse effects of a missed treatment.

Theory-Based Interventions to Promote Fluid Intake Adherence Among Dialysis Patients: A Systematic Review

BACKGROUND AND PURPOSE

Dialysis involves a complex regimen including diet, fluid, medication, and treatment. Therapeutic regimen adherence determines the therapeutic success, quality of life, and survival of patients on dialysis. Complying with fluid management is the most difficult among the therapeutic regimen. Several theory-based interventions have been designed to promote fluid intake compliance in patients receiving dialysis. This review has two aims. One is to explore the effectiveness of theory-based interventions. The other is to examine the extent of the combination of theory and interventions in improving adherence to fluid intake among dialysis patients.

METHODS

A literature review was performed using PubMed, PsycINFO, Embase, Web of Science, and the Cochrane Library to acquire associated studies. Data were extracted independently by two researchers. The degree of theory application was accessed using a theory coding scheme (TCS).

RESULTS

Eight studies were identified as eligible for inclusion, and five theories were cited as basis (health belief model, social cognitive theory, self-regulation model, transtheoretical model). According to the TCS, adherence outcomes and the extent of theory use were not optimal.

IMPLICATIONS FOR PRACTICE

Combining theory with patient health education might be beneficial in improving fluid intake adherence of dialysis patients. The framework and TCS could be considered to guide theory utilization and promote nursing education in improving the quality of renal nursing care.

Effects of Oral Nutritional Supplements on Mortality, Missed Dialysis Treatments, and Nutritional Markers in Hemodialysis Patients

OBJECTIVE

Protein-energy wasting is common in end-stage renal disease patients undergoing dialysis and is strongly associated with mortality and adverse outcomes. Intradialytic oral nutritional supplements (ONS) reduce risk of mortality in these patients. Large studies characterizing the impact of ONS on other outcomes are lacking. We assessed the associations between administration of ONS and clinical and nutritional outcomes.

DESIGN

Retrospective evaluation of a pilot program providing ONS to patients at a large dialysis organization in the United States. The pilot program provided ONS to in-center hemodialysis patients with serum albumin ≤3.5 g/dL at 408 facilities.

SUBJECTS

ONS patients were compared to matched controls with serum albumin ≤3.5 g/dL, identified from facilities not participating in the ONS program (n = 3,374 per group).

INTERVENTION

Receipt of ONS.

MAIN OUTCOME MEASURES

Death, missed dialysis treatments, hospitalizations, serum albumin, normalized protein catabolic rate, and postdialysis body weight were abstracted from large dialysis organization electronic medical records.

RESULTS

There was a 69% reduction in deaths (hazard ratio = 0.31; 95% confidence interval = 0.25-0.39), and 33% fewer missed dialysis treatments (incidence rate ratio = 0.77; 95% confidence interval = 0.73-0.82) among ONS patients compared to controls (P < .001 for both). The effects of ONS on nutritional indices were mixed: serum albumin was lower, whereas normalized protein catabolic rate values, a surrogate for dietary protein intake, and postdialysis body weights were higher for ONS patients compared to controls during follow-up.

CONCLUSIONS

Our evaluation confirmed the beneficial effects of ONS in reducing mortality and improving some indices of nutritional status for hypoalbuminemic hemodialysis patients. We also report the novel finding that ONS can reduce the number of missed dialysis treatments. These results support the use of intradialytic ONS as an effective intervention to improve the outcomes in hemodialysis patients with low serum albumin.