Emergency Department Visits and Hospitalizations among Hemodialysis Patients by Day of the Week and Dialysis Schedule in the United States

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.