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American Journal of Kidney Diseases

Missed Hemodialysis Treatments: A Modifiable But Unequal Burden in the World

  • Steven Menez
    Affiliations
    Division of Nephrology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD

    Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
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  • Bernard G. Jaar
    Correspondence
    Address for Correspondence: Bernard G. Jaar, MD, MPH, 5601 Loch Raven Blvd, Ste 3 N, Baltimore, MD 21239.
    Affiliations
    Division of Nephrology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD

    Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD

    Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins University, Baltimore, MD

    Nephrology Center of Maryland, Baltimore, MD
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      Related Article, p. 634
      Of the approximately 2.5 million patients with end-stage renal disease (ESRD) on some form of renal replacement therapy worldwide, the vast majority (in most countries) receive in-center hemodialysis.
      • Robinson B.M.
      • Akizawa T.
      • Jager K.J.
      • Kerr P.G.
      • Saran R.
      • Pisoni R.L.
      Factors affecting outcomes in patients reaching end-stage kidney disease worldwide: differences in access to renal replacement therapy, modality use, and haemodialysis practices.
      In the United States, the frequency of missed hemodialysis treatments, barriers to better adherence with scheduled treatments, and consequences of missed dialysis treatments have been described.
      • Obialo C.I.
      • Hunt W.C.
      • Bashir K.
      • Zager P.G.
      Relationship of missed and shortened hemodialysis treatments to hospitalization and mortality: observations from a US dialysis network.
      • Chan K.E.
      • Thadhani R.I.
      • Maddux F.W.
      Adherence barriers to chronic dialysis in the United States.
      • Tohme F.
      • Mor M.K.
      • Pena-Polanco J.
      • et al.
      Predictors and outcomes of non-adherence in patients receiving maintenance hemodialysis.
      • Saran R.
      • Bragg-Gresham J.L.
      • Rayner H.C.
      • et al.
      Nonadherence in hemodialysis: associations with mortality, hospitalization, and practice patterns in the DOPPS.
      For instance, Chan et al
      • Chan K.E.
      • Thadhani R.I.
      • Maddux F.W.
      Adherence barriers to chronic dialysis in the United States.
      investigated potential reasons behind missed dialysis sessions in the United States over the course of 5 years using data from a large dialysis organization. These authors identified several factors, including day of the week (last session before the weekend), distance from home to the dialysis unit, and need for public transportation as important reasons for missed hemodialysis sessions. Patients who missed hemodialysis treatments were at increased risk for hospitalizations, emergency department visits, and intensive care unit admissions. In addition, the frequency of needing these services increased as the number of missed hemodialysis treatments increased.
      In this issue of AJKD, Al Salmi et al
      • Al Salmi I.
      • Larkina M.
      • Wang M.
      • et al.
      Missed hemodialysis treatments: international variation, predictors, and outcomes in the Dialysis Outcomes and Practice Patterns Study (DOPPS).
      have taken us one step further in our understanding of missed treatments on a more global stage. Using data from a well-established international prospective cohort of prevalent in-center hemodialysis patients, the Dialysis Outcomes and Practice Patterns Study (DOPPS), the authors evaluated the variation in, possible predictors of, and outcomes associated with missed hemodialysis treatments. Missed hemodialysis treatments (not due to inpatient stay) were assessed during a 4-month period in early 2012. Overall, the authors described a wide range of missed hemodialysis treatment frequency by country, ranging from < 1% in Italy and Japan to 24% in the United States. Patients with missed hemodialysis treatments were younger and had shorter hemodialysis vintage and hemodialysis treatment times, but longer commuting times (>1 hour) to the dialysis center. Further, these patients also had lower achieved Kt/V, worse metabolic profiles (anemia, hyperphosphatemia, and secondary hyperparathyroidism), and worse reported patient outcomes (depression symptoms, burden of kidney disease, and lower mental capacity score). The authors indicated that in countries with missed hemodialysis treatment risk > 5%, these missed treatments were independently associated with higher all-cause mortality, cardiovascular mortality, sudden cardiac death, and all-cause hospitalization.
      In their study, Al Salmi et al identified a number of potentially modifiable risk factors that may be contributing to this differential adherence to hemodialysis therapy, including logistical factors, sociocultural factors, and active medical issues. In addition, this study highlights the wide variation in adherence to in-center hemodialysis treatment on an international level and provides much better understanding of the scope of the burden of missed hemodialysis treatments by country. The authors also observed that within countries, the percentage of patients with missed treatments varied significantly across different facilities.
      • Al Salmi I.
      • Larkina M.
      • Wang M.
      • et al.
      Missed hemodialysis treatments: international variation, predictors, and outcomes in the Dialysis Outcomes and Practice Patterns Study (DOPPS).
      It is of paramount importance to better understand the reasons for the differences among diverse in-center hemodialysis facilities, as well as differences in the prevalence of missed treatments within countries. It is also essential to examine the different ways in which hemodialysis care is delivered and paid for across the globe to gain an understanding of how missed treatments can be reduced. As Chan et al
      • Chan K.E.
      • Thadhani R.I.
      • Maddux F.W.
      Adherence barriers to chronic dialysis in the United States.
      point out, various avenues exist to facilitate improved adherence to hemodialysis treatment, such as rescheduling hemodialysis before inclement weather and around holidays and increasing flexibility for known upcoming time conflicts such as scheduled elective surgery or a physician’s visit. Certainly, some hemodialysis facilities are better equipped to accommodate these changes than others. On a larger scale, comparison between for-profit and not-for-profit hemodialysis facilities, or hemodialysis facilities in affluent versus resource-limited areas, may prove useful for implementation of strategies to address missed hemodialysis treatments.
      Within the United States, demographic characteristics have been reported to vary greatly among 4 geographic regions (Northeast, South, Midwest, and West), and the prevalence of missed hemodialysis treatments varies significantly by region and by race/ethnicity.
      • Obialo C.
      • Zager P.G.
      • Myers O.B.
      • Hunt W.C.
      Relationships of clinic size, geographic region, and race/ethnicity to the frequency of missed/shortened dialysis treatments.
      In a study by Obialo et al,
      • Obialo C.
      • Zager P.G.
      • Myers O.B.
      • Hunt W.C.
      Relationships of clinic size, geographic region, and race/ethnicity to the frequency of missed/shortened dialysis treatments.
      the prevalence of missed or shortened hemodialysis treatments was lower in the Northeast region compared with the other regions and was higher in African Americans (21.5%), Hispanics (19.8%), and Native Americans (17.9%) compared with non-Hispanic whites (14.4%). Asians had the lowest prevalence of missed or shortened dialysis in this study at 9.8%. It is well established that dialysis patients in minority groups in the United States have a much higher prevalence of missed hemodialysis treatments; the reasons for this observation are complex and may be in part related to poor socioeconomic conditions, lower health literacy, and lack of trust in the health care system. Notably, in the same study, Obialo et al reported that patients at larger dialysis centers (>100 patients) had increased odds of missed or shortened dialysis treatments compared with those at centers with fewer than 50 patients.
      • Obialo C.
      • Zager P.G.
      • Myers O.B.
      • Hunt W.C.
      Relationships of clinic size, geographic region, and race/ethnicity to the frequency of missed/shortened dialysis treatments.
      Larger facilities may not have the resources needed (eg, extra staff and more social workers) to provide attention to patients at higher risk for nonadherence to hemodialysis treatment. Many studies have shown that younger age was also significantly associated with missed dialysis treatments; these patients typically have fewer comorbid conditions and overall feel healthier, which may lead them to believe erroneously that missing dialysis treatment has no health consequences.
      • Obialo C.I.
      • Hunt W.C.
      • Bashir K.
      • Zager P.G.
      Relationship of missed and shortened hemodialysis treatments to hospitalization and mortality: observations from a US dialysis network.
      • Tohme F.
      • Mor M.K.
      • Pena-Polanco J.
      • et al.
      Predictors and outcomes of non-adherence in patients receiving maintenance hemodialysis.
      Further, recent DOPPS data have also shown that the occurrence of missed hemodialysis treatments has significantly increased between 1996 to 2001 and 2012 to 2015.
      • Saran R.
      • Bragg-Gresham J.L.
      • Rayner H.C.
      • et al.
      Nonadherence in hemodialysis: associations with mortality, hospitalization, and practice patterns in the DOPPS.
      • Al Salmi I.
      • Larkina M.
      • Wang M.
      • et al.
      Missed hemodialysis treatments: international variation, predictors, and outcomes in the Dialysis Outcomes and Practice Patterns Study (DOPPS).
      The United States has one of the highest rates of missed hemodialysis treatments; however, missed hemodialysis treatment differences between the US geographical regions and internationally between countries are certainly difficult to explain. These differences are likely multifactorial and related to many factors, such as education, health literacy, health insurance coverage, access to care, location of the dialysis units, and transportation, to name a few. For example, missed hemodialysis treatments seem lower in the Northeast region of the United States, a region that is more urban and wealthier and in which patients travel shorter distances to their outpatient dialysis units.
      • Obialo C.
      • Zager P.G.
      • Myers O.B.
      • Hunt W.C.
      Relationships of clinic size, geographic region, and race/ethnicity to the frequency of missed/shortened dialysis treatments.
      Ultimately, identifying high-risk patient populations may help target interventions to improve adherence to hemodialysis treatments.
      Greater distance from dialysis centers may certainly play a role in missed hemodialysis treatments. Better location of dialysis centers in urban areas near public transport hubs (eg, metro stations and bus routes) or an increase in the number of dialysis centers in more rural areas could improve access to outpatient hemodialysis treatments and significantly reduce transportation time (and consequently increase adherence) to in-center hemodialysis treatments. An additional solution could be to increase the availability of free or discounted transportation services (eg, taxi vouchers) for patients with ESRD to and from their hemodialysis centers. Further, alternatives to in-center hemodialysis, namely home hemodialysis and peritoneal dialysis, should also be actively considered since the distance to dialysis facilities becomes much less of a concern.
      Al Salmi et al
      • Al Salmi I.
      • Larkina M.
      • Wang M.
      • et al.
      Missed hemodialysis treatments: international variation, predictors, and outcomes in the Dialysis Outcomes and Practice Patterns Study (DOPPS).
      propose that missed treatments serve as a marker for unmeasured indicators of poor health or sociocultural determinants of health. In surveys of 79 dialysis centers, transportation problems accounted for the majority (81.3%) of issues with hemodialysis adherence, whereas the second most-frequently cited reason was the perception that a few missed sessions would not affect health.
      • Brar A.
      • Babakhani A.
      • Salifu M.O.
      • Jindal R.M.
      Evaluation of non-adherence in patients undergoing dialysis and kidney transplantation: United States transplantation practice patterns survey.
      Hence, health literacy plays a significant role in adherence to dialysis treatments or the lack thereof. Predictably, this has resulted in worse health outcomes, with poor health literacy being associated with increased hospitalizations and mortality attributed to missed hemodialysis treatments.
      • Green J.A.
      • Mor M.K.
      • Shields A.M.
      • et al.
      Associations of health literacy with dialysis adherence and health resource utilization in patients receiving maintenance hemodialysis.
      Others have identified several barriers to successful hemodialysis treatment, such as appropriate staff training and experience and proper communication with patients. These issues were identified as some of the biggest concerns for patients on dialysis therapy.
      • Nobahar M.
      • Tamadon M.R.
      Barriers to and facilitators of care for hemodialysis patients; a qualitative study.
      Improving education of patients on dialysis therapy, whether through staff-led teaching or peer counseling, may be another promising avenue moving forward.
      • Russell C.L.
      • Cronk N.J.
      • Herron M.
      • et al.
      Motivational interviewing in dialysis adherence study (MIDAS).
      With access to more resources and staff training, dialysis centers may be able to offer greater patient counseling on the importance of dialysis adherence, adverse effects of missed dialysis treatments, and avenues for patient outreach for those who have missed dialysis treatments. Similar to the effects of improved health literacy, one might expect pre-ESRD education to improve patients’ outcomes, reduce anxiety, and potentially improve adherence to dialysis treatments.
      • Golper T.
      Patient education: can it maximize the success of therapy?.
      In patients with ESRD, depression is prevalent (20%-40%) and has been associated with poor outcomes.
      • Weisbord S.D.
      • Mor M.K.
      • Sevick M.A.
      • et al.
      Associations of depressive symptoms and pain with dialysis adherence, health resource utilization, and mortality in patients receiving chronic hemodialysis.
      Identification and treatment of depression in dialysis patients may improve treatment adherence and reduce missed dialysis sessions, with improvement in patient-centered outcomes. Similar benefits could be observed for treatment or counseling of other associated health conditions, such as substance abuse.
      • Weisbord S.D.
      • Mor M.K.
      • Sevick M.A.
      • et al.
      Associations of depressive symptoms and pain with dialysis adherence, health resource utilization, and mortality in patients receiving chronic hemodialysis.
      Though there are a number of barriers to adherence to dialysis treatments, many of these are modifiable by the interventions listed here and elsewhere.
      Ultimately, missed dialysis treatments have a significant impact on mortality, morbidity, and resource use, in part due to increased emergency department visits and hospitalizations (including intensive care unit admissions) for urgent but often preventable hemodialysis treatments. The true emotional, physical, and financial burden of missed dialysis treatments may be underestimated in many studies.
      Al Salmi et al undertook the daunting task of evaluating the prevalence and potential reasons for differences in the occurrence of missed hemodialysis treatments around the world. A variety of patient-level, provider-level, and health system–level factors likely affect adherence to in-center hemodialysis treatments. Multilevel interventions targeting individual patients, patient-provider relationship/communication, and the process of care delivery should help improve overall dialysis treatment adherence, particularly missed hemodialysis treatments (Box 1).
      Interventions That May Improve Adherence to In-Center Hemodialysis Treatments
      Tabled 1
      Patient Level

      Education:
      • Pre–end-stage renal disease education
      • Improve health literacy
      Social Support:
      • Peer mentoring program
      • Group support
      • Targeted interventions to at-risk groups (minority groups, younger patients)
      Health Conditions:
      • Screen and treat depression
      • Screen and treat alcohol abuse
      • Screen and treat substance abuse
      • Pain management
      • Quality-of-life assessment
      Provider Level

      Staff-Related Issues:
      • Improved staff skills
      • Staff-led teaching
      • Better staff to patient ratio
      Social Support:
      • Improve access to social workers
      • Improve access to available community resources
      • Patient counseling
      Communication:
      • Improve patient communication
      Health System Level

      Geography:
      • Better dialysis facility location
      • Increase no. of facilities in rural areas
      Transportation:
      • Place facilities close to transportation hubs
      • Free or discounted rates for public transportation
      Scheduling:
      • Flexible schedule
      • Opening hours (eg, offering early or late shifts)
      Offering Home Dialysis:
      • Home hemodialysis
      • Peritoneal dialysis
      Health Insurance:
      • Provide affordable health insurance

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