Associations of Patient Activation with Outcomes among Patients on Chronic Hemodialysis: A Retrospective, Longitudinal, Observational Study

Key Points The study explores the potential utility of the Patient Activation Measure 13-item survey as a marker for identifying high-risk patients in the dialysis population. Patient activation had a significant association with mortality. However, no association was observed with hospital admission or markers of adherence. The findings emphasize the need for further studies to validate patient activation in patients on dialysis and its role in improving patient outcomes. Background Patient activation, defined as an individual's readiness, willingness, and ability to manage their own health and health care, is associated with healthy behaviors and improved outcomes. Patients undergoing in-center hemodialysis have low activation, but the association of patient activation with clinical outcomes among patients on dialysis is unclear. We investigated the association between patient activation and outcomes in patients on hemodialysis. Methods This cohort included 925 prevalent patients on in-center hemodialysis in ten facilities in a mid-size dialysis provider. All patients who completed the Patient Activation Measure 13-item (PAM-13) survey during a previous study were included, and their records were cross-referenced with data from the electronic heath system. Patients were followed for 180 days after completion of the survey for the primary outcomes of ( 1 ) time to death and ( 2 ) time to hospitalization. Markers of nonadherence during the months before and after completion of the PAM survey were examined as secondary outcomes, including ( 1 ) serum potassium >5.0 mEq/L; ( 2 ) serum phosphorus >5.5 mg/dl; ( 3 ) missed dialysis treatment because of absence (no hospitalization); and ( 4 ) interdialytic weight gain >4.0%. Univariate and adjusted regression models were fit to estimate associations of a three-point increment in PAM-13 score with the outcomes of interest; adjustment factors comprised age, sex, dialysis vintage, serum albumin, diabetes, and hospitalization history. Results A three-point increment in PAM score was associated with lower hazard of death (univariate hazard ratio [HR], 0.89; 95% confidence interval [CI], 0.84 to 0.94; adjusted HR, 0.90; 95% CI, 0.85 to 0.96), but not with hospitalization (univariate HR, 0.99; 95% CI, 0.96 to 1.02; adjusted HR, 0.99; 95% CI, 0.96 to 1.02). Higher scores were associated with increased odds of having high phosphorus levels in the unadjusted analysis, but this was attenuated and not significant in adjusted models. There were no significant relationships between a three-point increment in PAM score and any of the other secondary outcomes in univariate and adjusted analyses. Conclusions In a cohort of patients on prevalent, in-center hemodialysis, low activation was associated with mortality, but not with hospitalization or measures of nonadherence.