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. 2019 Aug 15;14(8):e0220966.
doi: 10.1371/journal.pone.0220966. eCollection 2019.

Emergency department visits and hospitalizations among hemodialysis patients by day of the week and dialysis schedule in the United States

Sai Zhang  1   2 , Hal Morgenstern  2   3   4   5 , Patrick Albertus  1   6   7 , Brahmajee K Nallamothu  5   8   9 , Kevin He  1   2   10 , Rajiv Saran  1   2   5   6
Affiliations

Emergency department visits and hospitalizations among hemodialysis patients by day of the week and dialysis schedule in the United States

Sai Zhang et al. PLoS One. .

Abstract

Background and objective: Previous 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.

Methods: We 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.

Results: We 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.

Conclusions: Higher 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.

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Conflict of interest statement

We have read the journal's policy and the authors of this manuscript have the following competing interests: Dr. Morgenstern is a consultant to Arbor Research Collaborative for Health. All other authors declare no competing interests. This does not alter our adherence to PLOS ONE policies on sharing data and materials.

Figures

Fig 1
Fig 1
Adjusted incidence rate ratio (95% CI) of (A) total ED visits and (B) total hospital admissions among in-center HD patients in 2013, by dialysis schedule (MWF or TTS) and day of the week, compared with the MWF group in Sunday (reference group). Incidence rate ratios were adjusted for age, sex, race/ethnicity, the Charlson Comorbidity Index score, HD vintage, HD session length, Kt/V, IDWG, and BMI.
Fig 2
Fig 2
Adjusted incidences rate ratio (95% CI) of (A) ED visits not followed by a hospital admission, (B) ED visits followed by a hospital admission, and (C) hospital admissions not preceded by an ED visit among in-center HD patients in 2013, by dialysis schedule (MWF or TTS) and day of the week, compared with the MWF group on Sunday (reference group). Incidence rate ratios were adjusted for age, sex, race/ethnicity, the Charlson Comorbidity Index score, HD vintage, HD session length, Kt/V, IDWG, and BMI.
Fig 3
Fig 3
Adjusted incidence rates (per 100/year) of (A, B) cause-specific ED visits and (C, D) cause-specific hospital admissions for in-center HD patients in 2013, by dialysis schedule (MWF or TTS), day of the week, and primary diagnosis. Incidence rates were adjusted for age, sex, race/ethnicity, the Charlson Comorbidity Index score, HD vintage, HD session length, Kt/V, IDWG, and BMI.
Fig 4
Fig 4
Comparison of (A) findings from the main analysis of total ED visits in Fig 1A with (B) findings from the restricted sensitivity analysis of total ED visits. Each figure shows the adjusted incidence rate ratio (95% CI) of total ED visits, by dialysis schedule (MWF or TTS) and day of the week, compared with the MWF group on Sunday (reference group). Incidence rate ratios were adjusted for age, sex, race/ethnicity, the Charlson Comorbidity Index score, HD vintage, HD session length, Kt/V, IDWG, and BMI.
Fig 5
Fig 5
Comparison of (A) findings from the main analysis of total hospital admissions in Fig 1B with (B) findings from the restricted sensitivity analysis of total hospital admissions. Each figure shows the adjusted incidence rate ratio (95% CI) of total hospital admissions, by dialysis schedule (MWF or TTS) and day of the week, compared with the MWF group on Sunday (reference group). Incidence rate ratios were adjusted for age, sex, race/ethnicity, the Charlson Comorbidity Index, HD vintage, HD session length, Kt/V, IDWG, and BMI.
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