In-Center Hemodialysis Patient Outcomes Negatively Impacted by Patient Care Technician Understaffing

Laura Plantinga, PhD

Credit: UCSF

Findings from a recent study are calling attention to a significant association between patient care technician (PCT) patient burden and patient outcomes, highlighting the negative impact of a higher patient-to-PTC ratio on patients receiving in-center hemodialysis.¹

Results published in JAMA Network Open detail greater rates of mortality and hospitalization in the first year of treatment as well as lower rates of waitlisting and transplantation among patients initiating hemodialysis in treatment facilities with the highest patient-to-PCT ratios.¹

As a treatment for failing kidneys, dialysis replicates kidney function by removing waste products and excess fluid from the blood. With hemodialysis, a machine removes blood from the body and filters it through a dialyzer in a 3- to 5-hour process that can be done at home or a dialysis center. Having trained staff on hand is widely considered to be a major advantage of in-center hemodialysis – however, widespread dialysis staffing issues have been speculated to lead to suboptimal care.^2,3

“There is sparse, inconsistent evidence regarding the association of PCT staffing with in-center HD patient outcomes,” Laura Plantinga, PhD, associate professor of medicine at the University of California San Francisco, and colleagues wrote.¹

To determine the association between facility-level dialysis PCT staffing and patient outcomes, investigators conducted a retrospective cohort study leveraging data for patients with end-stage kidney disease (ESKD) and their treatment facilities obtained from the US Renal Data System. Participants included patients 18-100 years of age initiating in-center hemodialysis between January 1, 2016, and December 31, 2018, who continued receiving in-center HD for ≥ 90 days and had data on PCT staffing at their initial treating facility. The hemodialysis patient census at the facility and the number of dialysis PCTs were obtained from the most recent prior Annual Facility Survey data.¹

The patient-to-PCT ratio was calculated by dividing the patient census by the number of dialysis PCT full-time equivalents. Investigators assigned ratios to patients according to their incident facility, identified using the US Renal Data System facility identification, and categorized them as quartiles, with the highest quartile representing the greatest number of patients per PCT:

• Quartile 1: ≤ 8.60
• Quartile 2: 8.61 - 10.20
• Quartile 3: 10.21 - 12.33
• Quartile 4: ≥ 12.34

Patient-level outcomes included 1-year patient mortality, hospitalization, and transplantation. For all outcomes, patients were followed up for up to 1 year from their first day of hemodialysis until death, transplant, dialysis modality switch, loss to follow-up, discontinuation of dialysis, or recovery of kidney function.¹

Among a cohort of 236,126 patients, the mean age was 63.1 (Standard deviation [SD], 14.4 years and the majority (57.6%) were male and had diabetes (61.9%). The overall median patient-to-PCT ratio was 10.2.¹

Investigators noted the cumulative incidence of mortality, all-cause hospitalization, and cause-specific hospitalizations were greatest in the fourth quartile compared to the third, second, and first quartiles, while the cumulative incidence of transplantation was lower in the fourth quartile versus the third, second, and first quartiles.¹

Upon analysis, the highest facility-level patient-to-PCT ratio was associated with a 7% greater rate of patient mortality (Incidence rate ratio [IRR], 1.07; 95% CI, 1.02-1.12), a 5% greater rate of hospitalization (IRR, 1.05; 95% CI, 1.02-1.08), an 8% lower rate of waitlisting (IRR, 0.92; 95% CI, 0.85-0.98), and a 20% lower rate of transplant (IRR, 0.80; 95% CI, 0.71-0.91) compared to the lowest patient-to-PCT ratio. Additionally, investigators also pointed out the highest ratio was associated with an 8% greater rate of sepsis-related hospitalization (IRR, 1.08; 95% CI, 1.03-1.14) and a 15% greater rate of vascular access–related hospitalization (IRR, 1.15; 95% CI, 1.03-1.28).¹

Investigators outlined several potential limitations to these findings, including potential misclassification in PCT staffing and/or workload, selection bias, residual confounding by unmeasured facility and patient factors, as well as weakened causal inference due to modest effect sizes and lack of a dose response for some outcomes.¹

Nonetheless, they concluded: “Our results suggest that dialysis PCTs may play a critical, often overlooked, role in the quality of care delivered to US patients receiving in-center HD and that higher PCT patient loads may be associated with worse patient outcomes”

References:

1. ^{Plantinga LC, Bender AA, Urbanski M, et al. Patient Care Technician Staffing and Outcomes Among US Patients Receiving In-Center Hemodialysis. JAMA Netw Open. 2024;7(3):e241722. doi:10.1001/jamanetworkopen.2024.1722}
2. ^{Cleveland Clinic. Dialysis. Treatments & Procedures. August 18, 2021. Accessed March 11, 2024. https://my.clevelandclinic.org/health/treatments/14618-dialysis}
3. ^{National Kidney Foundation. Understanding the pros and cons of hemodialysis. Accessed March 11, 2024. https://www.kidney.org/contents/understanding-pros-and-cons-hemodialysis}