Non-adherence to Dialysis and Utilization of the Emergency Department

Treatment in the emergency department (ED) accounts for nearly half of all hospital-associated care in the United States. Emergency departments treat more than 135 million patients annually. Interventions aimed at identifying patients at high risk for frequent, possibly preventable ED visits are designed to lower costs and ED crowding. Such patients include those on maintenance dialysis for the treatment of end-stage renal disease (ESRD).

The number of patients receiving dialysis for ESRD in the United States has risen substantially since 1980, as has the incidence of ED care for patients with ESRD, which is six to eight times greater than among the general population. Further, patients with ESRD experience up to twice the ED length-of-stay and significantly higher in-patient admission rates. Among patients who shorten or miss dialysis treatments, the risk of care in the ED further doubles and the risk of rehospitalization quadruples. There is an association between missed dialysis treatments and all-cause mortality and worse health.

According to Kamna S. Balhara, MA, MD, and colleagues, there are few available data assessing ED use following missed dialysis treatments. The researchers conducted an interdisciplinary pilot study designed to identify social determinants of heath associated with missing hemodialysis and presenting to the ED; the study also aimed to describe the resource utilization associated with those ED visits. Results of the study were reported online in BMC Nephrology [].

The prospective observational study included patients who had missed at least one hemodialysis session prior to a visit to the ED who were recruited in the ED of a large academic center (site 1), and a control group that included patients deemed adherent by their nephrologist who were recruited from a population of those regularly attending a large outpatient hemodialysis clinic (site 2).

Both sites are located in the same large urban city and serve communities in the same urban setting. Site 1 is an ED at an academic, tertiary care center with ~70,000 visits per year and a 22% admission rate; site 2 is a large outpatient hemodialysis center in the same city with nearly 300 chronic outpatient hemodialysis patients.

A total of 32 eligible cases were identified; of those, four declined participation and three were not reachable, resulting in a case cohort of 25. Of the 28 controls identified, three declined to participate and one was hospitalized during the recruitment period for a non-hemodialysis related cause, resulting in a control cohort of 24. There were no significant differences between the two groups in sex, age, diabetic status, and dialysis vintage. Most participants were African American with a dialysis vintage of <5 years, 44.9% were women, and 32.7% were diabetic.

In the case group, the most common reasons for missing dialysis were not feeling well or issues with transportation. Three of the seven patients who reported issues with transportation had problems related to the state mobility program. Of the 25 patients in the case group, 56% (n=14) had missed one session of hemodialysis prior to presentation at the ED, 20% (n=5) had missed two sessions, and 24% (n=6) had missed three or more sessions. On presentation to the ED, the most common complaint was shortness of breath (six patients). Six of the patients were acuity level 2 on the Emergency Severity Index (ESI) scale and the remainder were level 3. (ESI level 1 represents highest acuity, level 5 represents the lowest acuity.) Most patients arrived by private vehicle (48%) or ambulance (36%).

All patients who presented to the ED had laboratory studies drawn, at least one radiographic study, and at least one specialty consulting service. Intravenous medications were needed in 52% and 32% required intravenous access placed via ultrasound guidance by an ED physician. Median length of stay in the ED was 14 hours; 24% were directly discharged for the ED; 76% subsequently had an in-patient stay. Nearly half of the admitted patients were placed in monitored units (48%) and 16% required admission to the intensive care unit during the in-patient stay. Median in-patient length-of-stay was up to 6 days.

There were no significant differences between the two groups in comorbidity burden by Charlson Comorbidity Index score. Patients in the case group were significantly less likely to be fully mobile (P<.001), had greater reliance on mobility adjuncts (P=.015), and had poorer scores in the healthcare limitations scale of the Kidney Disease Quality of Life scale (P<.02). Higher levels of pain were reported by patients in the cases group than in the control group; 64% of patients in the case group reported severe or very severe bodily pain in the preceding 4 weeks. In the control group, most controls reported having no depression; rates of moderate, moderately severe, or severe depression were higher among patients in the case group. There were no differences between the two groups in alcohol or drug use; however, current participation in methadone or suboxone programs trended towards significance in the case group.

There were no differences between the groups in economic stability, educational attainment, health literacy, family support, or satisfaction with nephrology care. Cases were more dependent on public transport for dialysis (P=.03). There were no significant differences in distance traveled from home to outpatient hemodialysis center between the groups; a larger proportion of cases lived more than 5 miles from their outpatient HD center, but this difference did not reach statistical significance.

In citing limitations to the study findings, the researchers noted the small sample size, the  high proportion of African American participants, excluding risk factors such as tobacco use or marital status, and the possibility of recall and self-selection bias among the participants.

In conclusion, the researchers said, “ED visits after missed hemodialysis resulted in elevated length-of-stay and admission rates. Frequently cited social determinants of health such as health literacy did not confer significant risk for missing hemodialysis. However, pain, physical limitations, and depression were higher among cases. Community-specific collaborations between EDs and dialysis centers would be valuable in identifying risk factors specific to missed hemodialysis and ED use, to develop strategies to improve treatment adherence and reduce unnecessary ED utilization.”

Takeaway Points

  1. Utilization of the emergency department (ED) is twice as high among patients who miss dialysis treatments compared with adherent patients; researchers conducted a prospective observational study to identify social determinants of health associated with missing hemodialysis and presenting to the ED.
  2. Patients who missed at least one dialysis treatment (case group) had increased rates of hospital admission than patients who were adherent to their dialysis regimen (control group).
  3. Pain, physical limitations, and depression were higher among patients in the case group compared with the control group.