Routine use of a patient questionnaire in clinical practice improves symptom assessment, but not symptom management for patients receiving hemodialysis (HD), a new pilot study suggests.

Studies in oncology have shown that feedback from patient-reported outcome measures (PROMs) can improve patient care and clinical outcomes.

Investigators tested the potential utility of the Edmonton Symptom Assessment System Revised: Renal (ESAS-r:Renal) questionnaire in 8 HD centers in Ontario, Canada. The patient questionnaire, administered every 4 to 6 weeks, gauged physical and psychosocial symptoms associated with living with end-stage kidney disease (ESKD), such as shortness of breath, anxiety, depression, fatigue, pain, and insomnia. A total of 1459 patients completed the ESAS-r:Renal and a subset provided feedback on providers’ ability to respond to complaints before and after implementation, respectively.

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Providers likewise rated their confidence to manage patient-reported symptoms and gauged interdisciplinary communication before and after implementation.

Of the 8 HD centers, 7 successfully implemented the standardized symptom screening process with response rates of more than 80%. But its clinical value was less certain.

The screening process improved patient and provider symptom awareness and empowered patients to raise issues with providers that they normally would not, Michael Walsh, MD, PhD, of Ontario Renal Network in Toronto, Ontario, Canada, and colleagues reported in the Clinical Journal of the American Society of Nephrology. “Yet, there were little, if any, measurable differences in symptom management, patient-provider communication, and interdisciplinary communication,” they reported.

Providers actually felt less confident in their teams’ abilities and resources to manage patient symptoms after the screening process was implemented. Two-thirds reported ESAS-r:Renal results helped them prioritize which symptoms to discuss with a particular patient, but nearly two-thirds also revealed that there were no standardized triggers for when and how to respond to these complaints.

Just over half (52%) of providers agreed or strongly agreed that ESAS-r:Renal improved interdisciplinary communication, and 53% and 57% were very or moderately confident managing depression and anxiety, respectively. With regard to barriers to using ESAS-r:Renal, 40% of providers cited difficulty in improving patients’ symptoms, 32% cited lack of awareness of relevant community-based services, and 32% cited the absence of standardized triggers for when and how to response to symptom score.

“This [study] is important because several groups are lobbying for the routine use of patient-reported outcomes in the care of patients undergoing hemodialysis, but there are very little data to guide their best use and demonstrate how they might improve care,” Dr Walsh stated in a press release from the American Society of Nephrology.

In an accompanying editorial, Jane O. Schell, MD, of the University of Pittsburgh Medical Center in Pittsburgh, Pennsylvania, and Dale Ellen Lupu, PhD, MPH, of George Washington University in Washington, DC, agreed that providers need more tools and resources: 

“Evans et al’s findings point in the direction of subsequent steps in the implementation chain needing further attention. For instance, they found that providers felt less confident to manage symptoms after the intervention despite the creation of education and training sessions. This suggests the need to bolster clinician capacity to evaluate and execute a symptom management plan.”

Dr Schell and Dr Lupu noted that the Kidney Health Initiative has created workgroups for addressing the most common symptoms, such as insomnia, muscle cramps, and fatigue.


Evans JM, Glazer A, Lum R, et al. 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. Published online August 25, 2020. doi:10.2215/CJN.01840220

Schell JO, Lupu DE. A step in the right direction: The promise of PROMs in routine hemodialysis care. Clin J Am Soc Nephrol. Published online August 25, 2020. doi:10.2215/CJN.12350720

Do patients undergoing hemodialysis benefit from routine assessments of their symptoms? [press release]. Washington DC; American Society of Nephrology; August 25, 2020.