The Influence of Symptoms, Functional Status, and Social Vulnerability on Healthcare Use Among Patients Receiving Dialysis

PROJECT ABSTRACT
For patients with end-stage renal disease, dialysis is a life-sustaining therapy unless they receive a kidney
transplant. Over half a million patients receiving dialysis in the U.S. experience multiple ongoing symptoms,
diminished functional status, and frequent emergency department (ED) visits and hospitalizations, which
negatively affect their quality of life and contribute to a costly burden on the healthcare system. While previous
research in this population has focused on clinical factors (e.g., fluid and electrolyte imbalances) as main
causes of healthcare use, other factors, such as symptom severity and functional status in the context of the
person’s social determinants of health (SDOH) remain understudied. This is a significant gap as most people
on dialysis are from disadvantaged communities (e.g., racial minority and lower socioeconomic status) and are
affected by multiple SDOH simultaneously. For these patients, understanding how social vulnerability of the
community where they live influences the relationships among symptom severity, functional status, and
healthcare use is crucial to improve health outcomes. The proposed secondary analysis using a longitudinal
dataset will examine the relationships among symptom severity, functional status, and healthcare use over
time in patients receiving dialysis and examine the role of social vulnerability as a moderator and/or mediator of
those relationships. The CDC’s Social Vulnerability Index (SVI) will be used as a collective measure of multiple
SDOH. The original study (R01NR013359: PI Song) recruited from dialysis centers in 7 counties in North
Carolina and examined the trajectories of multidimensional quality of life, including physical, emotional, and
cognitive symptoms and functional status, and collected healthcare use data monthly for 12 months (n=227; 13
data points). Guided by the Behavioral Model of Health Service Use and The Theory of Unpleasant Symptoms,
the proposed study will 1) determine whether symptom severity and functional status influence healthcare use
(measured by ED visits and hospital admissions) in patients receiving dialysis at baseline, 6 months, and 12
months; 2) examine whether symptom severity, functional status, and healthcare use vary by SVI levels of
patients receiving dialysis at baseline, 6 months, and 12 months; and 3) examine whether differences in SVI
influence the relationships among symptom severity, functional status, and healthcare use over time in patients
receiving dialysis using multilevel modeling. This study aligns with the NINR’s priorities to tackle today’s health
challenges by addressing the role of community-level SDOH in the relationships among symptom severity,
functional status, and healthcare use of patients on dialysis. The findings of this study will help identify
individuals whose healthcare use is most affected by symptoms and functional status and inform development
of future screening tools and interventions to support these individuals. With guidance from my mentors, the
proposed training plan will help me develop the necessary skills and expertise to complete the proposed study
and become an independent nurse scientist leading research involving patients on dialysis.