
==== Front
Kidney360
Kidney360
KIDNEY
Kidney360
Kidney360
2641-7650
American Society of Nephrology

38995698
K360-2024-000098
10.34067/KID.0000000000000505
00012
3
Clinical Research
Dialysis
The Patient's Perspective: Does It Align with Dialysis Adequacy?
Cohen-Hagai Keren 1 2
https://orcid.org/0009-0005-7868-8495
Kitani Angam 3
Benchetrit Sydney 1 2
Erez Daniel 2 4
Alon Antebi 5
https://orcid.org/0000-0002-8112-8721
Wilf-Miron Rachel 6 7
https://orcid.org/0000-0001-6869-0907
Saban Mor 8
1 Department of Nephrology and Hypertension, Meir Medical Center, Kefar Sava, Israel
2 Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
3 Healthcare System Management, School of Public Health, Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
4 Department of Internal Medicine D, Meir Medical Center, Kefar Sava, Israel
5 Fresenius Medical Care, Raanana, Israel
6 Department of Health Promotion, Faculty of Medicine, School of Public Health, Tel Aviv University, Tel Aviv, Israel
7 Center for Technology Assessment in Health Care, Sheba Medical Center, Gertner Institute for Epidemiology and Health Policy Research, Ramat Gan, Israel
8 Nursing Department, Faculty of Medical and Health Sciences, School of Health Professions, Tel Aviv University, Tel Aviv, Israel
Correspondence: Dr. Mor Saban, email: morsaban1@tauex.tau.ac.il
8 2024
12 7 2024
5 8 11371144
6 2 2024
3 7 2024
Copyright © 2024 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of the American Society of Nephrology
2024
https://creativecommons.org/licenses/by-nc-nd/4.0/ This is an open access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal.

Visual Abstract

Key Points

This study showed variation in satisfaction and quality of life between three dialysis centers, suggesting local factors influence outcomes.

One center linked better dialysis to less satisfaction, but fully grasping satisfaction differences between sites warrants additional study.

Background

The concept of patient-centered care puts the individual's health needs and desired health outcomes as the driving forces behind medical decision making and quality assessment in the health care system. Patients with ESKD treated by hemodialysis require frequent encounters with the dialysis facility to survive. Therefore, their satisfaction with care and perceived patient experience are important aspects that might affect their adherence to the care regimen. The aim of this study was to evaluate patient satisfaction and its association with perceived patient experience and objective clinical quality parameters, across three hemodialysis clinics.

Methods

A prospective cohort study analyzed the data of 126 patients with ESKD receiving chronic hemodialysis over 9 months in three different care facilities. Sociodemographic characteristics, medical history, treatment details, and dialysis adequacy (measures as STDKt/V) were collected. Perceived quality of care, patient satisfaction, and clinical outcomes were assessed.

Results

Patients differed significantly between sites by age, diabetes status, and biochemical parameters. Satisfaction scores varied significantly for 12/14 survey questions and at the site-level, with site 2 scoring the highest. Overall satisfaction did not correlate with Kt/V. At site 1, a moderate negative correlation was found between satisfaction and Kt/V. Kt/V correlated positively with age but inversely with satisfaction. Hospitalization rates were similar regardless of satisfaction. Mortality trended lower in the highest Kt/V quartile.

Conclusions

Achieving clinical quality while optimizing patient satisfaction requires multifactorial approaches tailored to the unique population of the hemodialysis facility. Further research is needed to fully understand factors influencing satisfaction and perceived quality.

dialysis
hemodialysis
hemodialysis adequacy
patient satisfaction
quality of life
OPEN-ACCESSTRUE
Read-alongYES
==== Body
pmcBackground

Hemodialysis is the most common RRT worldwide.1 A routine regimen of three 4-hour weekly sessions is required to provide appropriate RRT, although this may vary in frequency and duration with individual patient characteristics.2,3 In 2023, 6400 patients were treated by hemodialysis in 86 care facilities throughout Israel. Half of the patients were treated in 49 private facilities, while the other half were treated in public hospitals. The entire dialysis care in Israel is covered under the National Health Insurance Law for all Israeli citizens.4 Patient comorbidities, their cooperation with dietary limitations, satisfaction with care, and perceived quality of care are all important considerations that have an impact on patients' experience and adherence to the care protocol.5 Previous studies among dialysis patients have demonstrated that patient satisfaction is associated with better clinical outcomes, including hospitalization rates and survival.6

Clinical metrics, such as dialysis adequacy measures and laboratory results, have long been recognized as crucial indicators for evaluating the quality of care in hemodialysis treatment. These metrics provide objective data about the physiological outcomes of the treatment and help health care providers to assess the effectiveness of interventions. However, it has become evident that a comprehensive evaluation of care quality cannot rely solely on clinical metrics because they do not capture the patient's subjective experience and satisfaction with their hemodialysis care.7 This understanding has led health care systems to increasingly recognize the value of incorporating patient-centered perspectives into evidence-based dialysis care. While randomized trials remain crucial, engagement with individual experiences and priorities can also enhance outcomes by improving patient experience and adherence to treatment plans.8

The issue of patient satisfaction in health care is multifaceted, and as such, it serves as both a subjective and objective tool that holds great significance in the contemporary era of patient-centered medicine.5 Patient satisfaction, on the one hand, reflects the individual's personal experience and perception of the health care services they receive. This subjective aspect is crucial because it allows chronic patients to voice their feelings, concerns, and preferences, which, in turn, can lead to more patient-focused care. On the other hand, patient satisfaction can also be objectively measured using standardized assessment tools, surveys, and performance indicators, providing a quantitative evaluation of the quality of care. In the modern landscape of health care, where patient-centered medicine is a central tenet, the integration of both subjective and objective measures of satisfaction is essential.5,9

Patient satisfaction encompasses various aspects of dialysis care, including interactions with staff, the physical environment, and perceived symptom relief.10 Examining patient satisfaction drivers can therefore identify areas of improvement in various dialysis centers, including the social network and support provided by other dialysis patients.10

Despite growing recognition of patient satisfaction as a quality indicator, few studies have evaluated associations between perceived care quality and satisfaction among dialysis patients.11,12 Examining patient experience across multiple sites can identify common areas of dissatisfaction while accounting for potential center-level differences. This can ultimately inform patient-centered interventions to improve satisfaction and patient experience for those undergoing maintenance hemodialysis treatment.

This study aimed to evaluate patient experience and satisfaction with hemodialysis care across three dialysis centers. We hypothesized that higher levels of satisfaction would be associated with more positive perceptions of care quality as reported by patients. In addition, we hypothesized that satisfaction would correlate with key objective measures of clinical quality, such as dialysis adequacy and biochemical parameters. Exploring these associations could provide insights to enhance the patient-centeredness of hemodialysis services by identifying factors that influence satisfaction from the patient perspective.

Methods

A prospective cohort study was conducted between April 1, 2022, and December 31, 2022 (9 months of follow-up).

Participants

The study sample consisted of patients with ESKD treated with chronic hemodialysis (defined as dialysis treatments for a minimum of 3 months). Most of the patients were treated using conventional hemodialysis schedules (thrice weekly sessions, 4 hours each), with high-flux membranes. Small number of patients received shorter or more frequent hemodialysis sessions based on clinical need or tolerance. Dialysis time and frequency were determined by each patient's nephrologist and adjusted individually as needed.

The study was conducted at three outpatient hemodialysis facilities in central Israel, which varied in key characteristics. Site 1 is a private dialysis clinic with about 78 patients treated annually; site 2 is private dialysis clinic treating 62 patients annually; and site 3 is a large public academic medical center, treating 150 chronic hemodialysis patients. Site 1 and site 2 are located in smaller suburban municipalities, whereas site 3 has a large urban population served by its associated hospital. The inclusion criterion for participation in the study was chronic hemodialysis adult patients, irrespective of the cause of ESKD. Included in this study were patients who were able to sign informed consent and able to complete questioner (know read and write).

Exclusion criteria included patients treated by peritoneal dialysis; patients treated with hemodialysis for <3 months (including those with AKI) and those unable to sign informed consent.

Data Collection

All measures, excluding those related to patient satisfaction, were collected from the electronic medical records. Patients were deliberately selected for study inclusion on the basis of meeting certain criteria.

Independent Variables

Sociodemographic Characteristics

These included age, sex, marital status, religiousness, employment, and health fund mode of transportation to the dialysis facility.

Clinical Characteristics

Medical history was collected, including noncommunicable disease comorbidities, such as diabetes, hypertension, and ischemic heart disease. Laboratory blood tests included ferritin, phosphorus, transferrin, albumin, calcium, and hemoglobin levels.

Treatment Characteristics

Data that were collected included dialysis dose per week, dry weight measurement, type of vascular access, weekly treatment time, weekly number of dialysis sessions, and total treatment time calculated as the product of session time and frequency per week.

Hospitalizations

This was the number of hospitalization episodes in a general hospital for acute care during the study period. Repeat hospitalizations (within 30 days of discharge) were also included. Elective hospitalizations were not included.

Patient Satisfaction

This variable was calculated as the mean of each patient's answers on a satisfaction questionnaire consisting of three parts, as detailed below.

Dependent Variables

Mean Standardized Kt/Vurea (STDKt/V)

The STDKt/V is a theoretical calculation of dialysis adequacy per week on the basis of urea kinetics model and the single poole Kt/V. In these calculations, K represents urea clearance, meaning the volume of plasma cleared from urea per minute by the dialyzer (L/min), t represents time duration of treatment in minutes, and V represents volume of distribution of urea in liters. As described by Daugirdas et al., Kt/V is the hypothetical continuous clearance in patients treated with intermittent hemodialysis on the basis of the generation rate of urea nitrogen and the mean predialysis urea nitrogen.13 It is calculated using the serum total nitrogen levels before and after treatment, ultrafiltration and postdialysis weight, and the duration of dialysis. The product of this calculation is the spKt/V, which estimates the dialysis adequacy of a single hemodialysis session. On the basis of the calculation of spKt/V, duration of treatment and frequency of treatments per week, the STDKt/V can be also calculated. The mean STDKt/V was calculated over the study's 9-month follow-up.14

Dropout from Care

This was the number of patients who left the participating dialysis facility for reasons other than renal function recovery, kidney transplantation, or death.

Patient Mortality

This was the number of dialysis patients who died during the study period.

Patient Satisfaction with Care

The survey tool was adapted from the Kidney Disease Quality of Life–Short Form, a unique tool for assessing satisfaction in patients with ESKD developed by RAND Corporation.15 The Hebrew version was validated (α Cronbach for internal consistency=0.87) and then translated to Arabic and revalidated (for an English translation of the questionnaire).3 The questionnaire consists of three parts: (1) a subjective assessment of health status, with answers on a scale of 1–10 (1-very bad, 10-excellent); (2) questions assessing interaction with staff, physical conditions in the unit, accessibility, care continuity between the unit staff and community staff, and general satisfaction with the treatment unit, with answers on a Likert scale of 1–7 (1-not at all, 7-to a very high degree); and (3) an open question on patients' opinion for changes that should take place. In this study, we included in the analysis only parts (1) and (2) (close questions). Higher scores on the individual domains and composite scores indicate better health status and satisfaction. Following established guidelines, scores above the scale midpoint were interpreted as satisfactory, whereas those below the midpoint represented less satisfaction with care. For this study, domains scores >50 were considered satisfactory.16

The kidney disease quality of life survey was administered to all 126 participating patients from the three sites in their preferred language, either Hebrew or Arabic. Of the total, 74 patients (59%) completed the Hebrew version, and 52 patients (41%) completed the Arabic version.

Data Analysis

Data were collected using Excel software and analyzed using Python 3.0 software. Descriptive analysis of the variables was performed using descriptive statistics. Continuous variables were described using mean and SD and categorical variables using percentages and rates. In the second stage, the association between dialysis adequacy and continuous variables including patient satisfaction was examined using Pearson correlation; the association between dialysis adequacy and dichotomous variables including study dropout or mortality was performed using the independent t test. The association between treatment discontinuation and binary variables was tested using the chi-squared test.

For analyses involving questionnaires with incomplete data items (n=8), pairwise deletion was used to retain all available data points for each test.

Sample Size Calculation

Sample size calculation was performed using Win Pepi software17 at a significance level of 5% and 80% power using Pearson correlation (r=0.35). A minimum sample size of 62 patients was obtained. As mentioned above, the study included 126 patients.

Results

The cohort included 126 patients from three sites. Their sociodemographic and clinical characteristics are shown in Table 1. There were significant differences in the mean age between sites, with older patients treated at site 3. The prevalence of diabetes mellitus was higher in site 2 (80%) compared with sites 1 and 3 (80%, 36% and 65.4%, respectively) (P < 0.001). History of stroke was markedly higher in sites 1 and 2 than site 3.

Table 1 Comparison of sociodemographic and clinical characteristics between study sites

Site	1 (n=50)	2 (n=50)	3 (n=26)	P Value	
Demographic and general characteristics					
 Age, mean±SD	70.34±14.0	60.64±14.0	71.88±12.0	<0.001	
 Male, No. (%)	34 (68)	27 (54)	20 (77)	0.11	
 Female, No. (%)	16 (35)	23 (46)	6 (23)	
 Dry weight (kg), mean±SD	76.07±19.22	84.13±20.37	83.46±17.2	<0.001	
Comorbidities, No. (%)					
 Previous stroke	6 (12)	4 (8)	6 (23)	0.17	
 Diabetes mellitus	18 (36)	40 (80)	17 (65.4)	<0.001	
 Hypertension	38 (76)	43 (86)	25 (96)	0.07	
 Ischemic heart disease	25 (50)	32 (64)	9 (34.6)	0.05	
Baseline laboratory data, mean±SD					
 Hemoglobin (g/dl)	11.07±1.61	10.95±1.15	10.42±1.2	<0.001	
 Transferrin saturation index	23.76±20.13	26.81±16.28	23.27±10.18	<0.001	
 Ferritin (ng/ml)	847.57±640.2	695.07±628.71	575.81±523.4	<0.001	
 Albumin (g/dl)	3.72±0.33	3.76±0.38	3.59±0.36	<0.001	
 Calcium (mEq/L)	8.49±0.93	8.28±0.7	8.09±1.55	<0.001	
 Protein (g/dl)	4.89±1.31	4.93±1.13	5.06±1.12	<0.001	
Dialysis data, mean±SD					
 Treatment time (h)	3.85±0.3	3.78±0.4	3.85±0.3	<0.001	
 Frequency	3.0±0.5	3.0±0.6	2.92±0.4	<0.001	
 Dialysis dose weekly	11.74±1.09	12.06±0.82	13.44±1.0	<0.001	
 Dialysis vintage (yr)	4±3	4±2.56	3.53±1.7	<0.001	

There were statistically significant differences between the sites for various biochemical parameters including transferrin saturation index, albumin, calcium, ferritin, protein, hemoglobin, and weekly dialysis dose (all P < 0.001). Additional dialysis data are also shown in Table 1. A total of 15 patients withdrew from the study during the study period, with six withdrawing because of transferring to a different dialysis center and nine who died.

The mean score at the individual satisfaction question-level across all sites was 5.24±0.96. Statistically significant differences (P < 0.001) were observed between site means for 12 questions (1–3, 5–8, 10–13). Questions 4 and 9 also exhibited significant intersite variability (P < 0.001).

When averaging scores across all patient satisfaction questionnaire items, site 2 achieved the highest site-level mean of 5.39±1.02, followed by site 1 at 5.17±0.95 and site 3 at 5.11±0.95. A one-way ANOVA revealed these differences to be statistically significant (P < 0.001).

Overall, the mean across all questions across the three sites was 5.24±0.96. These findings provide strong evidence of site-dependent variability for the majority of individual questionnaire items and at the aggregate site and total levels, with most intergroup comparisons yielding P < 0.001 (Table 2).

Table 2 Comparison of satisfaction questionnaire scores between study sites

Questionnaire Item	Site 1	Site 2	Site 3	Total	P Value	
How would you rate your health in general?	6.18±2.21	6.38±2.38	5.22±2.21	6.06±2.32	<0.001	
How do you rate the warmth and interest expressed toward you as a person?	6.3±1.31	6.88±0.39	6.0±1.31	6.46±1.19	<0.001	
The dialysis team encourages me to be as independent as possible	4.92±2.66	6.36±1.86	4.15±2.66	5.32±2.54	<0.001	
Dialysis supports me in dealing with my kidney disease	5.8±1.97	6.62±1.1	5.74±1.97	6.11±1.75	<0.001	
How satisfied are you with the staff caring for the unit?	6.46±1.13	6.94±0.42	6.63±1.13	6.69±0.88	<0.001	
How satisfied are you with the physical conditions in the unit?	6.18±1.0	6.74±0.53	6.48±1.0	6.46±0.86	<0.001	
How satisfied are you with the meals served in the unit?	5.08±2.06	2.08±2.6	5.33±2.06	3.95±2.76	<0.001	
How satisfied are you with the accessibility to the unit? (elevator, parking)	6.28±1.2	4.82±2.34	5.96±1.2	5.64±1.91	<0.001	
How satisfied are you with the way to get to dialysis?	6.24±1.24	7.22±10.21	5.93±1.24	6.56±6.48	<0.001	
How satisfied are you with the unit's relationship with your family physician?	3.1±2.87	3.82±2.92	3.33±2.87	3.43±2.95	<0.001	
How satisfied are you with the unit's relationship with external parties? (Such as welfare, medical consultants, institutes, hospitalization)?	4.0±2.85	5.66±2.23	3.81±2.85	4.61±2.77	<0.001	
Would you recommend a friend who needs dialysis to be treated in this unit?	6.62±1.14	6.74±1.05	6.56±1.14	6.65±1.09	<0.001	
What is your overall satisfaction with the unit?	6.46±1.15	6.72±1.16	6.48±1.15	6.57±1.11	<0.001	
Mean of all questions	5.17±0.95	5.39±1.02	5.11±0.95	5.24±0.96	<0.001	

Overall, we did not observe significant correlation between mean individual satisfaction and STDKt/V (P = 0.23). STDKt/V was significantly positively correlated with patients age (correlation coefficient 0.19, P = 0.03). Age was inversely correlated with mean individual satisfaction (correlation coefficient −0.16, P = 0.07).

Figure 1 illustrates the associations between patient satisfaction (on a scale of 1–7, where higher scores correspond to a higher satisfaction) and the adequacy of hemodialysis treatment. Site 1 showed the highest STDKt/V (2.17) but the lowest mean satisfaction (5.16), with a moderate negative correlation was found between Kt/V and quality (correlation coefficient −0.33, P < 0.05). For sites 2 and 3, STDKt/V was 2.14 and 2.06, respectively, while site 2 achieved the highest reported satisfaction (5.39) among the three sites. Neither site 2 nor 3 showed a significant correlation between treatment adequacy and quality (Table 3).

Figure 1 Association between patient-reported quality of life measures (on a scale of 1–7, where higher scores correspond to a higher quality of life) and the adequacy of hemodialysis treatment.

Table 3 Linear regression model for predicting STDKt/V

Variable	Coefficient	STD Error	t	P>|t|	[0.025	0.975]	
Const	1.19	1.32	0.91	0.37	−1.42	3.81	
Site	−0.11	0.07	−1.67	0.10	−0.24	0.02	
Dialysis dose weekly	0.11	0.02	7.49	0.00	0.08	0.14	
Dry weight (g)	−0.01	0.00	−4.59	0.00	−0.01	0.00	
Weight gain (g)	0.00	0.00	2.23	0.03	0.00	0.00	
Diabetes mellitus	0.02	0.06	0.33	0.74	−0.10	0.14	
Hypertension	0.22	0.10	2.26	0.03	0.03	0.41	
Ischemic heart disease	−0.09	0.06	−1.62	0.11	−0.21	0.02	
s/p stroke	0.06	0.09	0.67	0.50	−0.12	0.23	
Vascular disease	−0.24	0.11	−2.10	0.04	−0.47	−0.01	
Hemoglobin (g/dl)	0.01	0.02	0.58	0.56	−0.03	0.05	
Ferritin (ng/ml)	0.00	0.00	0.54	0.59	0.00	0.00	
Transferrin saturation index	0.00	0.00	0.65	0.52	0.00	0.00	
Protein (g/dl)	0.01	0.02	0.23	0.82	−0.04	0.05	
Calcium (mEq/L)	0.02	0.03	0.66	0.51	−0.04	0.07	
Albumin (g/dl)	−0.01	0.08	−0.18	0.86	−0.17	0.15	
Age	0.00	0.00	1.54	0.13	0.00	0.01	
Sex	0.09	0.07	1.44	0.15	−0.04	0.22	
No. of hospitalizations	0.02	0.04	0.40	0.69	−0.06	0.09	
Satisfaction	0.02	0.05	0.47	0.64	−0.07	0.11	
Ended treatment (died/stopped treatment)	0.07	0.12	0.57	0.57	−0.17	0.30	
Treatment time (h)	−0.12	0.35	−0.35	0.73	−0.81	0.57	
Frequency	−0.23	0.45	−0.52	0.60	−1.12	0.65	
Total time (h)	0.06	0.12	0.47	0.64	−0.18	0.29	
Model Metrics	
Dependent Variable	Mean Quality STDKt/V	R2	0.601	
Model	Ordinary least squares	Adjusted R2	0.458	
Method	Least squares	F-statistic	4.195	
Date	Wednesday, October 11, 2023	Probability (F-statistic)	2.99E-08	
Time	17:35:05	Log-likelihood	12.901	
No. observations	126	Akaike information criterion	42.2	
df residuals	92	Bayesian information criterion	138.6	
df model	33			
Covariance type	Nonrobust			

Sixty patients were hospitalized during study (47.6%), and nine died (7.1%). We did not observe significant difference in mean individual satisfaction score between patients who required hospitalization during the study period. Regarding STDKt/V and mortality rate, lower quartile STDKt/V had a mortality rate of 11.1% versus 0% in the highest one (P = 0.19).

Discussion

Dialysis adequacy and patient experience important issues in chronic patients care such as maintenance hemodialysis patients. Several studies show that more efficient dialysis is associated with lower complications, morbidity, and mortality.18–20 Therefore, achieving the target levels of dialysis adequacy established in clinical practice guidelines is critically important for improving outcomes among hemodialysis patients.18,19

In our study, three different dialysis centers were included, with different case managers and different dialysis staff. Previous studies suggest that patient satisfaction can vary between different health care institutions,21,22 and it is often influenced by several factors, including the characteristics of the patient population and the specific practices and policies of each institution. Patient profiles, encompassing demographics, cultural backgrounds, and health conditions, can significantly affect individual expectations and perceptions of care.

However, in the current study, the type of site was not found to be a statistically significant predictor of patient satisfaction.

Overall, we did not observe a significant correlation between mean individual satisfaction and STDKt/V across facilities. At one site, there was a moderate negative correlation between satisfaction scores and STDKt/V levels. However, our study was not designed to make determinations about potential underlying reasons for this finding.

Some previous research has speculated that longer duration of dialysis treatment, which can correlate with higher adequacy measures over time, may also relate to patient satisfaction.1,23 However, our data did not include treatment duration and so we cannot substantiate such a hypothesized relationship in this cohort. By tailoring care strategies to the specific patient profiles and preferences at each institution, health care providers can better meet the needs and expectations of their diverse patient populations, ultimately leading to higher patient satisfaction and better health care outcomes.

Previous studies have found that very intensive hemodialysis schedules with longer treatment times can reduce patients' sense of independence, flexibility, and satisfaction. The heavy time commitment conflicts with priorities like family, work, and social activities. This is supported by the moderate negative correlation observed at site 1. Meanwhile, sites 2 and 3 achieved comparable clinical adequacy without statistically significant impacts on satisfaction, suggesting their approaches balanced targets appropriately.5

A variety of patient-reported experience measures (PREMs) have been developed and used in research to assess the perspectives of dialysis patients on aspects of their care. Our study employs a quantitative survey instrument, although PREMs can also incorporate qualitative methods like interviews to generate a richer understanding of themes influencing well-being. Different instruments may measure broader or more focused constructs, with multidimensional tools capturing experience across clinical, technical, engagement, and satisfaction domains. Standardized national and international PREMs datasets now facilitate benchmarking and quality improvement initiatives. However, challenges remain in disentangling disease, treatment, and health system determinants of reported experience. Future work should explore use of complementary PREMs in heterogeneous settings to obtain comprehensive insights into care priorities and optimization opportunities from the patient viewpoint.

Assessing patient satisfaction has significant clinical implications in the era of patient-centered medicine.5 First, their feedback provides valuable insights into areas for improvement make necessary adjustments, thus resulting in quality improvement. Second, it promotes better communication between health care providers and patients. Understanding patients' needs, preferences, and concerns allows clinicians to tailor care plans and offer more personalized guidance. Third, active participation of patients and shared decision making is encouraged in a patient-centered approach because patients who feel engaged in their health care decisions have better treatment adherence and health outcomes.8,24

Notably, an inverse correlation between dialysis dose and patient-reported satisfaction at one site raises policy considerations. While adequate solute clearance is paramount, improving patient-centered experience may help mitigate risks of diminished satisfaction or compliance for some.25,26 Furthermore, individualized dosing algorithms incorporating both clinical and humanistic factors deserve exploration.

Patient satisfaction plays an important role in clinical outcomes and quality of life for those living with chronic conditions such as ESKD on dialysis. Dialysis care encompasses various aspects of daily life and health status management. This study found significant differences in certain comorbidities such as diabetes mellitus and history of stroke between the study sites. While this may reflect underlying population characteristics, the potential influence of such clinical factors on patient experience was beyond the scope of our analysis. Our data did not directly examine how individual health conditions might affect satisfaction ratings.

A growing body of literature has associated satisfaction with outcomes like hospitalizations and mortality among dialysis patients. However, further research is needed to elucidate the complex interrelationships between comorbidity burden, treatment experiences, and reported perspectives on care quality for this medically complex patient group. Large, longitudinal studies are better equipped than cross-sectional designs to disentangle such influences. The heterogenic nature of morbidity and mortality among dialysis patients limits the consequences that can be concluded from our relatively small cohort.

Limitations

In this small prospective study, we assessed patients' satisfaction and evaluated possible association to dialysis adequacy. We observe high variability in patients' satisfaction and in its association to dialysis adequacy. This highlights the need for examine this hypothesis in larger cohort. However, we believe the use of heterogenic chronic hemodialysis patients from three different dialysis clinics is an important strength of this study.

Patients' candidacy for kidney transplant and their waiting times for kidney transplant may vary between patients and centers and may have potential bias on patient satisfaction. However, individual transplant status and duration on the waitlist were not documented as part of this study. Future work should control for potential impacts of differential transplant opportunities when comparing outcomes across site.

This preliminary study provides insights into the relationship between hemodialysis adequacy and patients' perspectives. Significant associations between higher STDKt/V and lower satisfaction were observed at one facility, challenging existing assumptions. However, considerable variability between sites underscores the need for larger, more robust investigations to clarify this relationship while accounting for potential confounding factors.

The impact of facility-level differences on outcomes also warrants deeper exploration. While achieving adequate dialysis is important, individualizing treatment regimens based on both clinical targets and patient priorities may optimize care. Further research incorporating nuanced risk adjustment is needed to develop a well-rounded understanding of how to balance adequacy with independence and quality of life.

Overall, this initial exploration generated fresh perspectives and questions worth pursuing in larger cohort studies. Continued exploration of patient-centered factors has potential to personalize hemodialysis care and outcome.

Disclosures

Disclosure forms, as provided by each author, are available with the online version of the article at http://links.lww.com/KN9/A565.

Funding

None.

Statement of Ethics

The study was conducted after receiving the approval of the ethics committee of Tel Aviv University (0003063-3) and the Institutional Human Subjects Ethics Committee (0247-21-MMC). All data were collected anonymously. All methods were carried out in accordance with the relevant guidelines and regulations. Informed consent was obtained from all subjects prior to their participation in this study.

Author Contributions

Conceptualization: Antebi Alon, Sydney Benchetrit.

Data curation: Angam Kitani.

Investigation: Daniel Erez, Rachel Wilf-Miron.

Methodology: Keren Cohen-Hagai, Angam Kitani, Mor Saban.

Project administration: Antebi Alon, Sydney Benchetrit, Keren Cohen-Hagai, Mor Saban, Rachel Wilf-Miron.

Software: Daniel Erez.

Supervision: Keren Cohen-Hagai.

Validation: Sydney Benchetrit, Keren Cohen-Hagai.

Writing – original draft: Keren Cohen-Hagai, Mor Saban.

Writing – review & editing: Antebi Alon, Sydney Benchetrit, Keren Cohen-Hagai, Daniel Erez, Angam Kitani, Mor Saban, Rachel Wilf-Miron.

Data Sharing Statement

The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available because of privacy or ethical restrictions.
==== Refs
References

1. Aghsaeifard Z Zendehdel A Alizadeh R Salehnasab A . Chronic hemodialysis: evaluation of dialysis adequacy and mortality. Ann Med Surg. 2022;76 :103541. doi:10.1016/J.AMSU.2022.103541
2. Gerasimoula K Lefkothea L Maria L Victoria A Paraskevi T Maria P . Quality of life in hemodialysis patients. Mater Sociomed. 2015;27 (5 ):305–309. doi:10.5455/MSM.2015.27.305-309 26622195
3. Hagai KC Goldman S Victor RW , . Delivering dialysis during wartime: the Israeli experience. Kidney360. 2024;5 (4 ):615–617. doi:10.34067/KID.0000000000000385 38317277
4. Ministry of Health. The National Registry of Renal Replacement Therapy (Dialysis and Renal Transplants), Renal Replacement Therapy in Israel 1990-2010. Israel Ministry of Health and the Israeli Society of Nephrology and Hypertension, ICDC Publication No. 324, Jerusalem, Israel.
5. Al Nuairi A Bermamet H Abdulla H Simsekler MCE Anwar S Lentine KL . Identifying patient satisfaction determinants in hemodialysis settings: a systematic review. Risk Manag Healthc Policy. 2022;15 :1843–1857. doi:10.2147/RMHP.S372094 36203651
6. Palmer SC De Berardis G Craig JC , . Patient satisfaction with in-centre haemodialysis care: an international survey. BMJ Open. 2014;4 (5 ):e005020. doi:10.1136/BMJOPEN-2014-005020
7. Evans JM Glazer A Lum R , . Implementing a patient-reported outcome measure for hemodialysis patients in routine clinical care perspectives of patients and providers on esas-r:Renal. Clin J Am Soc Nephrol. 2020;15 (9 ):1299–1309. doi:10.2215/CJN.01840220 32843371
8. Masakane I Ito M Tanida H Nawano T . Patient-centered care could improve quality of life and survival of dialysis patients: dialysis prescription and daily practice. Blood Purif. 2023;52 (suppl 1 ):1–12. doi:10.1159/000526995
9. Iqbal MS Iqbal Q Iqbal S Ashraf S . Hemodialysis as long term treatment: patients satisfaction and its impact on quality of life. Pak J Med Sci. 2021;37 (2 ):398–402. doi:10.12669/PJMS.37.2.2747 33679921
10. Nair D Wilson FP . Patient-reported outcome measures for adults with kidney disease: current measures, ongoing initiatives, and future opportunities for incorporation into patient-centered kidney care. Am J Kidney Dis. 2019;74 (6 ):791–802. doi:10.1053/J.AJKD.2019.05.025 31492487
11. Aydemir E Sahin Y . Evaluation of healthcare service quality factors using grey relational analysis in a dialysis center. Grey Syst Theor Appl. 2019;9 (4 ):432–448. doi:10.1108/gs-01-2019-0001
12. Cirillo L Toccafondi A Cutruzzulà R , . Association between satisfaction with dialysis treatment and quality of life: a cross-sectional study. Blood Purif. 2021;50 (2 ):188–195. doi:10.1159/000509787 32846414
13. Daugirdas JT Depner TA Greene T Levin NW Chertow GM Rocco MV .; Frequent Hemodialysis Network Trial Group. Standard Kt/Vurea: a method of calculation that includes effects of fluid removal and residual kidney clearance. Kidney Int. 2010;77 (7 ):637–644. doi:10.1038/KI.2009.525 20107428
14. Rivara MB Ravel V Streja E , . Weekly standard Kt/Vurea and clinical outcomes in home and in-center hemodialysis. Clin J Am Soc Nephrol. 2018;13 (3 ):445–455. doi:10.2215/CJN.05680517 29326306
15. Hays RD Kallich JD Mapes DL Coons SJ Carter WB . Development of the kidney disease quality of life (KDQOL) instrument. Qual Life Res. 1994;3 (5 ):329–338. doi:10.1007/BF00451725 7841967
16. Al-Jumaih A Al-Onazi K Binsalih S Hejaili F Al-Sayyari A . A study of quality of life and its determinants among hemodialysis patients using the KDQOL-SF instrument in one center in Saudi Arabia. Arab J Nephrol Transplant. 2011;4 (3 ):125–130. doi:10.4314/ajnt.v4i3.71024 22026335
17. Abramson JH . WINPEPI updated: computer programs for epidemiologists, and their teaching potential. Epidemiol Perspect Innov. 2011;8 (1 ):1. doi:10.1186/1742-5573-8-1 21288353
18. Hong WP Lee YJ . The association of dialysis adequacy, body mass index, and mortality among hemodialysis patients. BMC Nephrol. 2019;20 (1 ):382. doi:10.1186/s12882-019-1570-0 31640580
19. Locatelli F Buoncristiani U Canaud B Köhler H Petitclerc T Zucchelli P . Dialysis dose and frequency. Nephrol Dial Transplant. 2005;20 (2 ):285–296. doi:10.1093/ndt/gfh550 15598667
20. Liu SX Wang ZH Zhang S , . The association between dose of hemodialysis and patients mortality in a prospective cohort study. Sci Rep. 2022;12 (1 ):13708. doi:10.1038/s41598-022-17943-0 35962178
21. Brady BM Zhao B Niu J , . Patient-reported experiences of dialysis care within a national pay-for-performance system. JAMA Intern Med. 2018;178 (10 ):1358–1367. doi:10.1001/JAMAINTERNMED.2018.3756 30208398
22. Gander JC Zhang X Ross K , . Association between dialysis facility ownership and access to kidney transplantation. JAMA. 2019;322 (10 ):957–973. doi:10.1001/JAMA.2019.12803 31503308
23. El-Sheikh M El-Ghazaly G . Assessment of hemodialysis adequacy in patients with chronic kidney disease in the hemodialysis unit at Tanta University Hospital in Egypt. Indian J Nephrol. 2016;26 (6 ):398–404. doi:10.4103/0971-4065.168141 27942169
24. Hussein WF Bennett PN Abra G Watson E Schiller B . Integrating patient activation into dialysis care. Am J Kidney Dis. 2022;79 (1 ):105–112. doi:10.1053/j.ajkd.2021.07.015 34461165
25. Lin CC Hwang SJ . Patient-centered self-management in patients with chronic kidney disease: challenges and implications. Int J Environ Res Public Health. 2020;17 (24 ):9443. doi:10.3390/IJERPH17249443 33339300
26. O’Hare AM . Patient-centered care in renal medicine: five strategies to meet the challenge. Am J Kidney Dis. 2018;71 (5 ):732–736. doi:10.1053/J.AJKD.2017.11.022 29433828
