Abstract
Background and objectivePrevious reports indicated that patients on thrice-weekly hemodialysis (HD) had higher mortality rates after the 3-day interdialytic interval. However, day-of-the-week patterns of emergency department (ED) visits and hospitalizations remain under-investigated.MethodsWe conducted a retrospective cohort study of HD patients on thrice-weekly dialysis, using 2013 data from the United States Renal Data System (USRDS). We estimated crude incidence rates of ED visits and hospitalizations by day of the week and dialysis schedule (Monday, Wednesday, Friday or Tuesday, Thursday, Saturday). Using Poisson regression, we estimated case-mix adjusted rate ratios of all-cause ED visits and hospitalizations, and adjusted rates of cause-specific ED visits and hospitalizations.ResultsWe identified 241,093 eligible HD patients in 2013, who had 514,773 ED visits and 301,674 hospitalizations that year. Three distinct but related patterns of outcome events were observed. Crude and adjusted incidence rates of all-cause, cardiovascular, and infection-related ED visits and hospitalizations, but not vascular-access-related events, were higher on all three HD treatment days (“dialysis-day effect”). Rates for ED visits and hospitalizations were lower on weekends than weekdays, rising appreciably from Sunday to Monday for both dialysis schedules (“post-weekend effect”); and rates were highest after the long 3-day interval between dialysis sessions for both dialysis schedules (“interdialytic-gap effect”). In contrast, rates of hospitalizations not preceded by an ED visit were nearly the same Monday through Friday and lower on weekends for both dialysis schedules.ConclusionsHigher rates of ED visits and hospitalizations on the days of HD sessions and early in the week are a public-health concern that should stimulate research to explain these patterns and reduce the excessive morbidity and associated costs among patients on thrice-weekly HD, while improving quality of care and patient experience with dialysis.
Highlights
Hemodialysis (HD) is the most common form of renal-replacement therapy in the United States (US)
A few investigators have found that all-cause mortality and cardiovascular disease (CVD) mortality were highest on the day following the 3-day interdialytic interval [2,3,4], with one reporting an approximately 40% higher mortality [3]
While a few studies have shown an increase in hospital admissions following the interdialytic interval for patients on thrice-weekly hemodialysis [2,4,5], the weekly patterns of emergency department (ED) visits with or without hospitalization have not received much attention, even though it is well-recognized that end-stage renal disease (ESRD) 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 [6]
Summary
Hemodialysis (HD) is the most common form of renal-replacement therapy in the United States (US). While a few studies have shown an increase in hospital admissions following the interdialytic interval for patients on thrice-weekly hemodialysis [2,4,5], the weekly patterns of emergency department (ED) visits with or without hospitalization have not received much attention, even though it is well-recognized that ESRD 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 [6]. The most prevalent renal replacement therapy among those with ESRD in the form of the unequivocally ‘non-physiological’ thrice-weekly HD [7,8,9], is likely insufficient to optimally correct fluid overload and often necessitates high ultrafiltration rates, predisposing patients to intradialytic hemodynamic instability [10,11].
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