What is the clinical evidence from this study?

Study design: Observational. Population: Chronic hemodialysis (n=286). Intervention: Depressive symptoms and pain vs. Lower symptom scores. Primary outcome: Mortality (per 5-point increase in PHQ-9 score) (IRR 1.40, 95% CI 1.11 to 1.77).

August 1, 2014

Associations of Depressive Symptoms and Pain with Dialysis Adherence, Health Resource Utilization, and Mortality in Patients Receiving Chronic Hemodialysis

SWSteven D. WeisbordUniversity of Pittsburgh MMMaria K. MorVA Pittsburgh Healthcare System MSMary Ann SevickInstitute for Family Health

Key Result

Each 5-point increase in depressive symptom scores was independently associated with increased mortality (IRR 1.40), missed hemodialysis treatments, ED visits, and hospitalizations.

Study Design

Type

Observational (n=286)

Multicenter

Yes

Structured PICO

Are depressive symptoms and pain associated with dialysis adherence, health resource utilization, and mortality in patients receiving chronic hemodialysis?

Population

286 cognitively intact adults receiving chronic outpatient hemodialysis, followed for a median of 557 days to assess the longitudinal associations of depressive symptoms and pain with clinical outcomes.

Exposure

Depressive symptoms (assessed by Patient Health Questionnaire 9) and pain (assessed by Short-Form McGill Pain Questionnaire)

Outcome

Missed and abbreviated hemodialysis treatments, emergency department (ED) visits, hospitalizations, and mortalityhard clinical

Depressive symptoms and pain are independently associated with dialysis nonadherence, increased health services utilization, and mortality in chronic hemodialysis patients.

Main Result

Relative Risk: 1.4 (95% CI 1.11–1.77)

Limitations

Patients were participants in a clinical trial of symptom management interventions, which may have affected symptoms and outcomes
Conducted in a single geographic area, limiting generalizability
PHQ-9 is not considered the gold standard tool for the diagnosis of major depression
Observational design cannot establish causal associations
Assessment of ED visits relied on patient interviews and was potentially subject to recall bias
Median percentage of missed dialysis treatments was low and may not represent clinically significant nonadherence

Abstract

BACKGROUND AND OBJECTIVES: Depressive symptoms and pain are common in patients receiving chronic hemodialysis, yet their effect on dialysis adherence, health resource utilization, and mortality is not fully understood. This study sought to characterize the longitudinal associations of these symptoms with dialysis adherence, emergency department (ED) visits, hospitalizations, and mortality. DESIGN, SETTING, PARTICIPANTS, 95% confidence interval 95% CI, 1.10 to 1.33) and abbreviated (IRR, 1.08; 95% CI, 1.03 to 1.14) hemodialysis treatments, ED visits (IRR, 1.24; 95% CI, 1.12 to 1.37), hospitalizations (IRR, 1.19; 95% CI, 1.10 to 1.30), and mortality (IRR, 1.40; 95% CI, 1.11 to 1.77). Pain was independently associated with abbreviated hemodialysis treatments (IRR, 1.03; 95% CI, 1.01 to 1.06) and hospitalizations (IRR, 1.05; 95% CI, 1.00 to 1.10). Severe pain was independently associated with abbreviated hemodialysis treatments (IRR, 1.16; 95% CI, 1.06 to 1.28), ED visits (IRR, 1.58; 95% CI, 1.28 to 1.94), and hospitalizations (IRR, 1.22; 95% CI, 1.03 to 1.45), but not mortality (hazard ratio, 1.71; 95% CI, 0.81 to 2.96). CONCLUSIONS: Depressive symptoms and pain are independently associated with dialysis nonadherence and health services utilization. Depressive symptoms are also associated with mortality. Interventions to alleviate these symptoms have the potential to reduce costs and improve patient-centered outcomes.

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