More emergency department visits on dialysis treatment days
Researchers observed three patterns related to when emergency department visits and hospitalizations were most likely for patients receiving hemodialysis.
“While a few studies have shown an increase in hospital admissions following the interdialytic interval for patients on thrice-weekly hemodialysis, the weekly patterns of emergency department visits with or without hospitalization have not received much attention, even though it is well-recognized that end-stage renal disease patients have ED utilization rates about six times the national average for US adults, and those rates are even higher among newly diagnosed ESRD patients,” Sai Zhang, MPH, of the kidney epidemiology and cost center at the school of public health at the University of Michigan, and colleagues wrote. “We hypothesized that given the high frequency of interdialytic complications, higher rates of ED visits and hospitalizations would not only occur early in the week (similar to mortality) but also on the days of hemodialysis sessions.”
Using 2013 data from the United States Renal Data System, researchers conducted a retrospective cohort study of 241,093 patients who received hemodialysis three times a week (schedule of either Monday/Wednesday/Friday [MWF] or Tuesday/Thursday/Saturday [TTS]). Incidence rates of ED visits and hospitalizations were determined by day of the week and dialysis schedule.
Researchers found MWF patients (n = 133,053) had a total of 279,602 ED visits and 164,900 hospital admissions, while those on the TTS schedule (n = 108,040) had 235,171 ED visits and 136,774 hospitalizations. For both groups, all-cause, cardiovascular and infection-related ED visits and hospitalizations were higher on all three hemodialysis treatment days. Researchers noted that ED visits and hospital admissions for vascular-access complications were lower in magnitude and less varied by day of the week.
In addition, rates for ED visits and hospitalizations were lower on weekends than weekdays — with increases seen from Sunday to Monday — and rates were highest after the interval between dialysis sessions (ie, Monday for MWF patients and Tuesday for TTS patients).
According to the researchers, the “dialysis-day effect,” which was especially strong for ED visits, is a new finding that can only partly be explained by the fact that patients are under greater medical supervision on days when dialysis is delivered. They suggest this result is also due to the large volume and electrolyte shifts that occur with dialysis, causing reduced circulatory and neuro-humoral adaptive responses.
“Consequently,” they wrote, “there is greater potential for hemodynamic instability and high incidence of intradialytic hypotension, predisposing to complications (eg, myocardial stunning, myocardial infarction, falls, etc.) that can result in the need for an ED visit of hospitalization.”
“Our study should serve to stimulate further research into the safety of dialysis sessions as currently practiced,” researchers concluded. “Additionally, there should be a serious reexamination of factors underlying both high mortality and morbidity after the weekend or long gap in dialysis. In particular, if the dialysis-day excess in ED visits and hospitalizations could be reduced in this high-risk patient population, it would go a long way to help improve both patient experience and health outcomes while reducing cost of care for dialysis patients in this country.” – by Melissa J. Webb
Disclosures: Zhang reports no relevant financial disclosures. Please see the study for all other authors’ relevant financial disclosures.