Impact of Rescheduling a Missed Hemodialysis Treatment on Clinical Outcomes

Abstract

Rationale & objective: Among patients treated with in-center hemodialysis (HD), missed treatments are associated with higher subsequent rates of hospitalization and other adverse outcomes compared with attending treatment. The objective of this study was to determine whether and to what degree attending a rescheduled treatment on the day following a missed treatment ameliorates these risks.

Study design: Retrospective, observational.

Setting & participants: Included patients were those who were, as of any of 12 index dates during 2014, adult Medicare beneficiaries treated with in-center HD (vintage ≥ 90 days) on a Monday/Wednesday/Friday schedule.

Exposure: Treatment attendance on the index date and the subsequent day.

Outcomes: Hospital admissions, emergency department visits, mortality, blood pressure, and anemia measures, considered during the 7- and 30-day periods following exposure.

Analytical approach: In parallel analyses, patients who missed or rescheduled treatment were each matched (1:5) to patients who attended treatment on the index date on the basis of index day of week and propensity score. Within the matched cohorts, outcomes were compared across exposures using repeated-measures generalized linear models.

Results: Compared with attending treatment (N = 19,260), a missed treatment (N = 3,852) was associated with a 2.09-fold higher rate of hospitalization in the subsequent 7 days; a rescheduled treatment (N = 2,128) was associated with a 1.68-fold higher rate of hospitalization than attending (N = 10,640). Compared with attending treatment, hospitalization rates were 1.39- and 1.28-fold higher among patients who missed and rescheduled treatment, respectively, during the 30-day outcome period. Emergency department visits followed a similar pattern of associations as hospitalization. No statistically significant associations were observed with respect to mortality for either missed or rescheduled treatments compared with attending treatment.

Limitations: Possible influence of unmeasured confounding; unknown generalizability to patients with non-Medicare insurance.

Conclusions: Attending a rescheduled in-center HD treatment attenuates but does not fully mitigate the adverse effects of a missed treatment.

Keywords: adherence; hemodialysis; outcomes; treatment attendance.

Graphical abstract

Figure 1

Study schema. A schematic representation of the study is shown. In the 30 days before the index date, eligible patients were required to have Medicare parts A and B claims availability and no missed treatments for any reason. Eligible patients were ascribed an exposure status based on their pattern of treatment attendance on the index date and following day. Outcomes were considered over the 7- and 30-day periods following exposure assignment. Abbreviations: ED, emergency department; Tx, treatment.

Figure 2

Study flow diagram. Selection of scheduled treatments meeting study inclusion/exclusion criteria for the main and sensitivity analyses is shown. Abbreviation: ED, emergency department.

Figure 3

Primary outcomes by treatment attendance status. (A) Crude hospitalization rates per patient-year are plotted for the indicated outcome periods following an attended treatment (black bars), a missed treatment (white bars), or a rescheduled treatment (grey bars). Corresponding incidence rate ratios (95% confidence intervals) are shown above each pair of bars. (B) As for A but show the outcome of emergency department visits. (C) As for A but show mortality rate per 100 patient-years. Corresponding odds ratios (95% confidence intervals) are shown above each pair of bars.