Symptom Trajectories in the Electronic Health Record during the Transition to Maintenance Dialysis

Abstract

How symptoms recorded in the electronic health record (EHR) change during the transition to dialysis has not been fully explored. We used the Optum® de-identified Integrated Claims-Clinical Dataset to identify individuals with CKD stages 4 or 5 who transitioned to dialysis. We searched structured data elements from clinical notes, identified by natural language processing, for symptoms recorded across weekly intervals in the 6 months before and after dialysis initiation and estimated changes in the odds of a symptom being recorded with an interrupted time series analysis using segmented logistic regression. The cohort comprised 728 individuals (aged 67.7 ± 13.1 years, 44% women, 56% White, 30% Black). Prior to dialysis initiation, 83% were recorded as having pain, 68% fatigue/weakness, 66% shortness of breath, 61% nausea/vomiting, and 37% difficulty concentrating. Before dialysis initiation, odds of pain being recorded increased (slope: OR 1.02 per week, 95% CI 1.01 – 1.03); initiation was associated with a decrease (intercept change: OR 0.70, 95% CI 0.59 – 0.82). After initiation, odds of pain were unchanged (post-dialysis slope: OR 1.00 per week, 95% CI 0.99 – 1.01), although this represented an improved trajectory relative to the pre-dialysis period (change in slope: OR 0.98 per week, 95% CI 0.96 – 0.99). For fatigue/weakness, odds increased before initiation (OR 1.03 per week, 95% CI 1.02 – 1.04) but decreased upon initiation (OR 0.62, 95% CI 0.51 – 0.75) and thereafter (OR 0.98 per week, 95% 0.97 – 0.99), representing a reduction in slope (OR 0.95 per week, 95% CI 0.94 – 0.97). Patterns for shortness of breath, nausea/vomiting, and difficulty concentrating were similar to those of pain. Thus, the odds of five key symptoms being recorded in the EHR increased over time in the 6 months prior to dialysis initiation, decreased immediately upon initiation, and, generally, remained unchanged in the 6 months thereafter.