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Renal Provider Recognition of Symptoms in Patients on Maintenance Hemodialysis

Steven D. Weisbord^*,,, Linda F. Fried^*,,, Maria K. Mor^*,, Abby L. Resnick^*, Mark L. Unruh, Paul M. Palevsky^,, David J. Levenson^**, Stephen H. Cooksey^**, Michael J. Fine^*,||, Paul L. Kimmel^¶, and Robert M. Arnold^||

^* Center for Health Equity Research and Promotion and Renal Section, Medical Specialty Service Line, VA Pittsburgh Healthcare System, Renal-Electrolyte Division and ^|| Division of General Internal Medicine and ^** Department of Medicine, University of Pittsburgh School of Medicine, and Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania; and ^¶ Division of Renal Diseases and Hypertension, Department of Medicine, George Washington University Medical Center, Washington, DC

Address correspondence to: Dr. Steven D. Weisbord, VA Pittsburgh Healthcare System, Mailstop 111F-U, 7E Room 120, Pittsburgh, PA 15240. Phone: 412-688-6000, ext. 815911; Fax: 412-688-6908; E-mail: weisbordsd{at}upmc.edu

Background and Objectives: Although several studies have found that the burden of symptoms in patients who are on maintenance hemodialysis is substantial, little is known about renal providers’ awareness of these symptoms. The aim of this study was to assess renal provider recognition of symptoms and their severity in hemodialysis patients.

Design, Setting, Participants, & Measurements: The Dialysis Symptom Index, a 30-item measure of symptoms and their severity, was administered to patients during a routine hemodialysis session. Immediately after surveying patients, the renal provider who evaluated the patient completed the Dialysis Symptom Index to report the symptoms that he or she believed were present in that patient. Sensitivity, specificity, and positive and negative predictive values of provider reports of symptoms were calculated using patient reports as the reference standard. Patient–provider agreement on the presence and severity of symptoms was assessed using the statistic.

Results: Surveys were completed by 75 patients and 18 providers. For 27 of 30 symptoms, the sensitivity of provider responses was <50%, and provider responses for 25 symptoms were characterized by positive predictive values of <75%. scores for 25 symptoms including those pertaining to pain, sexual dysfunction, sleep disturbance, and psychologic distress were <0.20, indicating poor provider recognition of these symptoms. Providers underestimated the severity of 19 of 30 symptoms.

Conclusions: Renal providers are largely unaware of the presence and severity of symptoms in patients who are on maintenance hemodialysis. Implementation of a standardized symptom assessment process may improve provider recognition of symptoms and promote use of symptom-alleviating treatments.