Study: The Impact of Missed Dialysis Treatments on Clinical Outcomes

Posted February 21, 2017 in Research and Innovation by Steven M. Brunelli, MD, MSCE.

A study conducted by DaVita Clinical Research worked to identify the prevalence of in-center hemodialysis absenteeism and its effects on clinical outcomes. It found that in-center hemodialysis patients miss treatments approximately 15 times per year; half of these are for non-medical reasons. One absence due to a non-medical reason is associated with a 40 percent greater risk of hospitalization and a more than double risk of mortality in the subsequent 30 days. Therefore, absenteeism creates a significant burden in terms of patient health and associated costs. It may be worthwhile to implement programs to reduce absenteeism to help improve outcomes among hemodialysis patients.

For more information, read the research poster here.

Comments

August 26, 2017 at 3:05 am

todd andersen

Dear Dr. Brunelli,

I receive Davita dialysis treatments and was given a handout based on “Missed Treatments: Causes and Effects Davita Clinical Research 25 May 2016”. I found the poster on the DaVita website. I have a number of questions about the study.

1. I am given to understand that the MWF schedule is more popular, thus represents more than half the total pool of patients. Why not use patients from both schedules?
2. It is not clear if “missed treatments” means the patient did not receive any treatment or did not receive treatment from the LDO (i.e. they did receive treatment in the hospital, or at a different treatment center?).
3. Per Figure 1, it appears that the lion’s share of missed treatments is attributable to 20 percent of the cohort. I find it hard to believe that a patient who misses very few sessions is at the same risk as the patient who misses the 15 or more sessions. Is the report saying the the doubling of risk is constant for all patients, or does the risk vary with number of missed treatments per year? Why wasn’t the risk of undesired outcomes presented by quintile or similar arrangement?
4. Without knowing what were the underlying risks for hospitalization or mortality the 40 percent and 118 percent figures are meaningless. I found many studies discussing mortality in dialysis patients with specific chronic conditions, but none for all dialysis patients. Please provide the citation(s) to the studies that underly the subject study’s conclusions.

Thank you for any response to these questions.

August 30, 2017 at 11:12 am

Steven M. Brunelli, MD, MSCE

Hi Todd,

Thank you for reaching out. Please see my answers to your questions below.

1. The choice to use only Monday/Wednesday/Friday patient data was a pragmatic one. It had to do with the sheer volume of data being analyzed. By analyzing Monday/Wednesday/Friday data only, we were able to limit the data to a more tractable scale. We anticipate that the effects of missed treatments would be no different based whether the patient dialyzed on the Monday/Wednesday/Friday schedule or on the Tuesday/Thursday/Saturday schedule.

2. Missed treatments as considered here applies to patients who did not attend outpatient dialysis. Patients who received care at a facility other than their own (eg, due to travel) were not considered to have missed. Given the complexities and implications of hospitalization, patients who were in the hospital were not included in the analysis. That is, they were neither considered as having missed nor as having attended their scheduled treatment.

3. I agree with your premise that likely there is a dose effect: ie, that missing more treatments has a greater impact than missing just one. We would very much have liked to have been able to explore this dose effect. Unfortunately, for a variety of technical reasons, it was not possible to study the dose effect without creating bias in the data. As such, we were limited to considering missed treatments as a dichotomous (ie, y/n) factor.

4. This is an excellent point. For hospitalization, the rates were 1.73 per patient-year among patients who missed a treatment and 1.23 per patient-year among patients who attended the treatment. For mortality, the rates were 11.48 per 100 patient-years among those who missed a treatment and 5.25 per 100 patient-years among those who attended the treatment.

If you’d like more details, the study has been published as a peer-reviewed manuscript that is publicly available at this link:
https://www.dovepress.com/in-center-hemodialysis-absenteeism-prevalence-and-association-with-out-peer-reviewed-fulltext-article-CEOR

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