title: Associations of depressive symptoms and pain with dialysis adherence, health resource utilization, and mortality in patients receiving chronic hemodialysis.
abstract: OBJECTIVE
  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.
  
  
  METHODS
  As part of a trial comparing symptom management strategies in patients receiving chronic hemodialysis, this study prospectively assessed depressive symptoms using the Patient Health Questionnaire 9, and pain using the Short-Form McGill Pain Questionnaire, monthly between 2009 and 2011. This study used negative binomial, Poisson, and proportional hazards regression to analyze the longitudinal associations of depressive symptoms and pain, scaled based on 5-point increments in symptom scores, with missed and abbreviated hemodialysis treatments, ED visits, hospitalizations, and mortality, respectively.
  
  
  RESULTS
  Among 286 patients, moderate-to-severe depressive symptoms were identified on 788 of 4452 (18%) assessments and pain was reported on 3537 of 4459 (79%) assessments. Depressive symptoms were independently associated with missed (incident rate ratio [IRR], 1.21; 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.
authors: Renal Section, Medicine Service Line, and Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania; Renal-Electrolyte Division, Department of Medicine, and weisbordsd@upmc.edu.
authors: Steven D
authors: SD
authors: Weisbord
authors: Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania; Department of Biostatistics, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania;
authors: Maria K
authors: MK
authors: Mor
authors: Department of Population Health, New York University School of Medicine, New York, New York; and.
authors: Mary Ann
authors: MA
authors: Sevick
authors: Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania;
authors: Anne Marie
authors: AM
authors: Shields
authors: Department of Population Health, New York University School of Medicine, New York, New York; and.
authors: Bruce L
authors: BL
authors: Rollman
authors: Renal Section, Medicine Service Line, and Renal-Electrolyte Division, Department of Medicine, and.
authors: Paul M
authors: PM
authors: Palevsky
authors: Divisions of General Internal Medicine and Palliative Care, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania;
authors: Robert M
authors: RM
authors: Arnold
authors: Nephrology Department, Geisinger Medical Center, Danville, Pennsylvania.
authors: Jamie A
authors: JA
authors: Green
authors: Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania; Divisions of General Internal Medicine and.
authors: Michael J
authors: MJ
authors: Fine
mesh_terms: D000368:Aged; D003863:Depression / Q000453:epidemiology*; D004636:Emergency Service, Hospital / Q000706:statistics & numerical data; D005260:Female; D006295:Health Resources / Q000706:statistics & numerical data*; D006760:Hospitalization / Q000706:statistics & numerical data; D006801:Humans; D008297:Male; D008875:Middle Aged; D010146:Pain / Q000453:epidemiology*; D010349:Patient Compliance / Q000706:statistics & numerical data*; D011446:Prospective Studies; D006435:Renal Dialysis
keywords: depression; mortality; outcomes