与血液透析不依从和急诊就诊相关的健康社会决定因素：一项试点观察性研究。
Social determinants of health associated with hemodialysis non-adherence and emergency department utilization: a pilot observational study.
机构信息
The Johns Hopkins University School of Medicine, Baltimore, MD, USA.
University of the West Indies, Mona, Jamaica.
出版信息
BMC Nephrol. 2020 Jan 6;21(1):4. doi: 10.1186/s12882-019-1673-7.
BACKGROUND
Dialysis patients who miss treatments are twice as likely to visit emergency departments (EDs) compared to adherent patients; however, prospective studies assessing ED use after missed treatments are limited. This interdisciplinary pilot study aimed to identify social determinants of health (SDOH) associated with missing hemodialysis (HD) and presenting to the ED, and describe resource utilization associated with such visits.
METHODS
We conducted a prospective observational study with a convenience sample of patients presenting to the ED after missing HD (cases); patients at local dialysis centers identified as HD-compliant by their nephrologists served as matched controls. Patients were interviewed with validated instruments capturing associated risk factors, including SDOH. ED resource utilization by cases was determined by chart review. Chi-square tests and ANOVA were used to detect statistically significant group differences.
RESULTS
All cases visiting the ED had laboratory and radiographic studies; 40% needed physician-performed procedures. Mean ED length of stay (LOS) for cases was 17 h; 76% of patients were admitted with average LOS of 6 days. Comparing 25 cases and 24 controls, we found no difference in economic stability, educational attainment, health literacy, family support, or satisfaction with nephrology care. However, cases were more dependent on public transport for dialysis (p = 0.03). Despite comparable comorbidity burdens, cases were more likely to have impaired mobility, physical limitations, and higher severity of pain and depression. (p < 0.05).
CONCLUSIONS
ED visits after missed HD resulted in elevated LOS and admission rates. Frequently-cited SDOH such as health literacy did not confer significant risk for missing HD. However, pain, physical limitations, and depression were higher among cases. Community-specific collaborations between EDs and dialysis centers would be valuable in identifying risk factors specific to missed HD and ED use, to develop strategies to improve treatment adherence and reduce unnecessary ED utilization.
背景
与依从性患者相比，错过治疗的透析患者前往急诊部（ED）的可能性是其两倍; 然而，评估错过治疗后 ED 使用情况的前瞻性研究有限。这项跨学科的试点研究旨在确定与错过血液透析（HD）和前往 ED 就诊相关的健康社会决定因素（SDOH），并描述与这些就诊相关的资源利用情况。
方法
我们对因错过 HD 而前往 ED 的患者（病例）进行了一项前瞻性观察性研究，采用便利抽样法，对当地透析中心的患者进行了研究，他们的肾脏科医生认为他们是 HD 依从性患者，作为匹配的对照组。患者通过验证的仪器进行采访，以获取相关风险因素，包括 SDOH。通过病历审查确定病例的 ED 资源利用情况。使用卡方检验和 ANOVA 检测统计学上的组间差异。
结果
所有因错过 HD 而前往 ED 的患者均进行了实验室和影像学检查；40%的患者需要医生进行的操作。病例的 ED 平均停留时间（LOS）为 17 小时；76%的患者住院，平均 LOS 为 6 天。将 25 例病例和 24 例对照组进行比较，我们发现经济稳定性、教育程度、健康素养、家庭支持或对肾脏科护理的满意度没有差异。然而，病例更依赖公共交通进行透析（p=0.03）。尽管合并症负担相当，但病例更有可能存在行动不便、身体受限，以及更高的疼痛和抑郁严重程度（p<0.05）。
结论
因错过 HD 而前往 ED 就诊会导致 ED 停留时间和住院率增加。经常被引用的 SDOH，如健康素养，并未显著增加错过 HD 的风险。然而，病例的疼痛、身体受限和抑郁程度更高。ED 和透析中心之间的社区特定合作将有助于确定与错过 HD 和 ED 使用相关的特定风险因素，制定提高治疗依从性和减少不必要 ED 利用的策略。
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