Hemodialysis is a critical lifeline for individuals with kidney failure, preventing severe and life-threatening health issues. Consistent dialysis treatments are essential, and studies have consistently shown that missed sessions significantly increase the risk of emergency room visits, hospitalizations, and even death.1,2 Therefore, any barriers that prevent patients from attending their dialysis appointments are a major concern. We often ask, “what’s the weather like today?” in casual conversation, but for hemodialysis patients, the answer to this simple question can have profound implications for their health. Recently, Remigio and colleagues3 published insightful research in CJASN exploring the connection between adverse weather conditions and the likelihood of missed hemodialysis treatments in the Northeastern United States. Their findings shed light on a critical, often overlooked, environmental factor impacting patient care.
This comprehensive study analyzed data from 60,135 adult patients undergoing in-center hemodialysis across 99 Fresenius Kidney Care facilities between 2001 and 2019. Utilizing a case-crossover study design, the researchers discovered a clear link between various forms of inclement weather and a heightened risk of missed dialysis appointments on those days. Rainfall, sustained high winds, wind gusts, snowfall, and hurricane or tropical storm events all correlated with an increased probability of patients missing their scheduled hemodialysis. Interestingly, the duration of this risk varied depending on the weather type. The risk of missing dialysis persisted for up to seven days following snowfall and two days after sustained wind advisories, but only for a single day with rainfall. Contrary to initial expectations, the immediate risk wasn’t prolonged during hurricanes and tropical storms. However, when considering cumulative exposure over seven days to hurricanes/tropical storms, sustained wind advisories, and wind gusts, there was a statistically significant increased risk of missing hemodialysis treatments by 55%, 29%, and 34%, respectively.3
A dialysis machine in a clinic setting, highlighting the technology that provides life-sustaining treatment for patients with kidney failure.
The study’s strengths are notable, beginning with its innovative approach to a previously underexplored question. The large and diverse patient population, combined with the detailed data available from electronic health records, allowed for precise identification of unexcused missed dialysis sessions specifically on days with inclement weather. Crucially, the study distinguished between missed sessions due to weather and excused absences like planned travel or hospitalization. While previous research has linked severe weather events like hurricanes to increased mortality within 30 days, these studies often lacked specific data on missed treatment circumstances or the frequency of prescribed dialysis.4 Furthermore, this study expands upon existing literature by examining a broader spectrum of weather conditions beyond just snow and hurricanes,1,4 including the impact of rain on dialysis attendance. However, the study did not include high-temperature conditions, leaving the question of whether extreme heat also increases the risk of missed dialysis treatments unanswered.
While many studies have concentrated on patient-specific barriers to dialysis attendance, Remigio and colleagues effectively highlight the environment as an additional layer of challenges, both anticipated and unexpected. Their work underscores the importance of considering a patient’s geographical location and their frequency of exposure to inclement weather as significant risk factors for missing crucial treatments. For healthcare providers and policymakers, understanding “what’s the weather like today?” becomes more than just small talk; it becomes a factor in patient access and health outcomes.
A snowy road scene, illustrating the type of inclement weather that can create barriers to transportation and healthcare access, particularly for vulnerable populations like dialysis patients.
However, certain limitations of the study warrant consideration. The data originated from the Northeastern United States, a region with specific weather patterns and frequencies that may not be representative of other geographical areas. In regions with more severe weather, patient diversion to backup dialysis units might be more readily managed in the Northeast due to facility density compared to more rural areas with fewer centers. Notably, the Northeast also has the shortest average driving distance to a dialysis center in the US (6 miles).5 This suggests that the correlation between inclement weather and missed hemodialysis treatments could be different, and potentially more pronounced, in areas with longer average patient travel distances. Future research exploring whether patient distance to facilities or rurality influences the observed effect would be valuable.
The study reported an average of 94 visits per patient per year, which, assuming thrice-weekly dialysis, suggests a somewhat modest overall attendance rate, albeit with a wide standard deviation. It remains unclear if specific patient subgroups are more susceptible to missing appointments across all weather types. Crucially, the study didn’t directly link missed dialysis treatments to immediate clinical outcomes like emergency department visits, hospitalizations, or mortality within this dataset. Gathering such data would be particularly relevant for frequently occurring weather events like rain, which, despite their frequency, haven’t been consistently linked to adverse clinical outcomes in prior studies.
Proactive measures, such as providing early dialysis treatments when severe weather is anticipated, could potentially mitigate missed dialysis sessions and the subsequent adverse outcomes, as demonstrated during Hurricane Sandy. A retrospective study of 13,264 in-center dialysis patients in Hurricane Sandy-affected areas revealed elevated post-hurricane risks of emergency department visits, hospitalizations, and 30-day mortality.6 Leading up to Sandy’s landfall, health officials strongly recommended early dialysis treatments, and emergency response systems were activated to coordinate dialysis care and transportation.6 Consequently, 59% of the study group received early dialysis before the hurricane. Similarly, a study on mortality after Hurricane Maria in Puerto Rico found no increased mortality among dialysis patients, potentially attributed to adherence to disaster preparedness guidelines and swift government and care delivery responses.7 While Remigio and colleagues suggest that early in-center hemodialysis before anticipated hurricanes and tropical storms may explain the lack of sustained lagged risk in their study, the frequency of early dialysis wasn’t reported, and it’s unclear which facilities or patients received this intervention. Furthermore, temporal trends in the relationship between weather and missed dialysis appointments were not explored, even though improvements in emergency preparedness over the last two decades might have lessened the impact of inclement weather over time.
The challenges of accessing medical care during inclement weather extend beyond dialysis. In oncology, for instance, patients with gynecological cancer in Puerto Rico experienced disruptions to their care and communication with providers following Hurricanes Irma and Maria in 2017.8 The findings of Remigio et al. underscore the broader need for further research into the specific relationships between various weather subtypes and their impact on treatment access for individuals with chronic conditions. In-center hemodialysis is particularly vulnerable due to its reliance on consistent healthcare personnel and infrastructure. Missing multiple treatments can lead to life-threatening complications such as electrolyte imbalances, hypertensive emergencies, and pulmonary edema. Emergency preparedness strategies should include readily available potassium binders and point-of-care laboratory testing equipment to prioritize patients needing urgent treatment when outpatient lab services are disrupted. Comprehensive patient education on emergency procedures, robust staffing plans (including staff safety and evacuation), and reliable patient communication strategies for situations where phone and internet services are unreliable are also crucial.
Current initiatives like the Kidney Community Emergency Response and resources from the Department of Health and Human Services, along with state and local operations, offer valuable guidance and mechanisms to improve hemodialysis access during natural disasters. Dialysis facilities must prioritize securing backup power and alternative water sources, establishing communication methods for when phone lines are down, and preparing for the deployment of personnel and equipment to affected areas or patient diversion to unaffected regions to minimize adverse clinical outcomes. This study serves as a crucial reminder of the urgent need for strong policies, robust preparedness plans, and a clear recognition of the link between weather conditions and in-center hemodialysis attendance, especially for vulnerable patient populations facing transportation challenges and evacuation barriers. Ensuring equitable access to hemodialysis in the face of inclement weather demands ongoing, collaborative resilience from patients, dialysis facilities, healthcare providers, and communities.
References
1 (Original article reference 1)
2 (Original article reference 2)
3 Remigio, et al. CJASN. (Original article reference 3)
4 (Original article reference 4)
5 (Original article reference 5)
6 (Original article reference 6)
7 (Original article reference 7)
8 (Original article reference 8)
