Emergency Department Utilization Among Maintenance Hemodialysis Patients: A Systematic Review

Rationale & Objective: To evaluate predictors of emergency department (ED) utilization by adult patients receiving hemodialysis (HD) and interventions to reduce ED utilization by HD patients. Study Design: We searched Ovid MEDLINE, Ovid Embase, and the Cochrane Library for randomized controlled trials and observational studies published until April 2020. Setting & Participants: We included studies that investigated predictors of ED utilization and/or interventions to reduce ED utilization in HD patients. We extracted data regarding the study design and study population and results regarding ED utilization from 38 studies using Excel software. Analytical Approach: We performed a narrative synthesis to group articles that investigated similar themes. Results: 1,060 titles and abstracts were screened, of which 98 were selected for full-text review. In total, 38 studies met the inclusion criteria and underwent data extraction. Quality was high according to the Downs and Black tool, with 11 studies rated as good, 22 as fair, and 5 as poor. 34 studies described predictors of ED utilization, whereas 4 studies investigated interventions in which ED utilization was studied. Our narrative synthesis produced 8 concept subgroups in the core concepts of access to care, comorbid condition burden, and new health care models. Poor access to care and a high comorbid condition burden are associated with increased ED use. No ED-based interventions designed to reduce ED utilization were identified, but recent changes in health care systems, like the formation of End-Stage Renal Disease Seamless Care Organizations and greater involvement of palliative care services, are associated with improved outcomes. Limitations: Clinical heterogeneity and variability in the included studies precluded a meta-analysis. Conclusions: HD patients' high ED use is multifactorial. Further research is required to understand and predict ED utilization in this vulnerable population, which will facilitate the development of interventions to reduce avoidable ED use.