Understanding the causative factors, outcomes and costs associated with missed dialysis to develop a model of care to reduce Emergency Department pressures

The Northern Territory (NT) has the highest rates of kidney disease in Australia, with the heaviest burden in First Nations Territorians. The majority of people requiring renal replacement therapy in the NT receive haemodialysis in a satellite facility. Haemodialysis is prescribed three times a week for the majority of patients to maintain optimal health.

Missing treatments, even infrequently, can lead to poorer health outcomes, increased hospital presentations and more complicated admissions, and decreased life expectancy. International research has demonstrated that missing one or more dialysis sessions per month increased mortality risk by 30%. In the NT, research has shown that nearly half of all dialysis patients miss one or more sessions per month, which was associated with a tripling in the rate of Emergency Department (ED) presentations.

This mixed methods project commenced with a baseline analysis consisting of a retrospective quantitative analysis of dialysis attendance and ED presentations for patients who, for a multitude of reasons, have had lower rates of dialysis attendance in the previous 12 months.

A qualitative component includes informal interviews (yarning) with patients who have lower dialysis attendance to understand the range and complexity of reasons that contribute to patients missing dialysis. These yarning circles are facilitated by the Project Manager with support from First Nations Research Officers and Consumer Engagement Officers. Yarning circles are undertaken in Alice Springs, and Darwin to capture the experiences and perspectives of different patient cohorts. Qualitative, semi-structured interviews are also being conducted with clinicians and other stakeholders that provide care to patients on dialysis to understand the impact of lower dialysis attendance on health outcomes and identify other factors that may facilitate or make it difficult for patients to attend treatment.

In the next phase, the information will be collated and interpreted with the larger established consumer advocacy and reference groups in the Top End and Central Australian regions. Through this feedback and validation process with patients who have lower dialysis attendance, we will gain a better understanding of the root causes leading to missed treatments and potential strategies/opportunities to intervene. Working in collaboration with stakeholders (patient preceptors, patient reference groups, clinicians, community representatives and community services), and exploring strategies previously implemented, we will co-design a model of care to address and pre-empt situations leading to missed treatments.

Our implementation strategy will include a process evaluation to identify the strengths and weaknesses of the model and make adjustments as necessary. Our evaluation strategy will be based on a Realist Evaluation Framework allowing us to determine the strategies appropriate to the different social and cultural contexts of each region and assess the effectiveness of the strategies: that is, ‘what worked, for whom, in what circumstances and why.’

Project aims:
  1. Identify the modifiable drivers of lower dialysis attendance through an analysis of health service attendance data and interviews/workshops with patients and stakeholders;
  2. Co-design models of care with stakeholders to contribute to addressing the modifiable drivers of lower dialysis attendance;
  3. Evaluate the co-design process and the effectiveness of models of care to address the drivers of lower dialysis attendance; and
  4. Undertake a comparative analysis of health service costs associated with lower dialysis attendance before and after the development of the co-designed models of care (i.e. opportunity costs of doing nothing compared to intervention).

Key staff:

Gillian Gorham
Trudi Sieland