In‐center hemodialysis attendance: Patient perceptions of risks,barriers, and recommendations

Missed hemodialysis treatments lead to increased morbidity and mortality in the end‐stage renal disease population. Little is known about why patients have difficulty attending their scheduled in‐center dialysis treatments. Semistructured interviews with 15 adherent and 15 nonadherent hemodialysis patients were conducted to determine patients' attitudes about dialysis, health beliefs and risk perception regarding missed treatments, barriers and facilitators to hemodialysis attendance, and recommendations to improve the system to facilitate dialysis attendance. Average time on dialysis was 2.5 years for the nonadherent group and 7.3 years in the adherent group. In both groups, patients felt that dialysis is life‐saving and a necessity. A substantial number of patients in both groups understood that missing hemodialysis treatments is dangerous and several patients could clearly communicate the risk of skipping. The most common barriers to hemodialysis were inadequate or unreliable transportation (mentioned in both groups) and a lack of motivation to get to dialysis or that dialysis is not a priority (typically mentioned by the nonadherent group). Facilitators to hemodialysis attendance included explanations from the health care team regarding the risk of skipping and relationships with other dialysis patients. Patient recommendations to improve dialysis attendance included continued education about the risk of poor attendance and more accessible transportation. Patients did not feel that home dialysis would improve adherence. Hemodialysis patients must adhere to a complex and burdensome regimen. Through the elucidation of barriers and facilitators to hemodialysis attendance and through specific patient recommendations, at least three interventions may be further investigated to improve hemodialysis attendance: Improvement of the transportation system, education and supportive encouragement from the health care team, and peer support mentorship.     

Understanding barriers to home‐based and self‐care in‐center hemodialysis

Despite superior outcomes and lower associated costs, relatively few patients with end‐stage renal disease undergo self‐care or home hemodialysis. Few studies have examined patient‐ and physician‐specific barriers to self‐care and home hemodialysis in the modern era. The degree to which innovative technology might facilitate the adoption of these modalities is unknown. We surveyed 250 patients receiving in‐center hemodialysis and 51 board‐certified nephrologists to identify key barriers to adoption of self‐care and home hemodialysis. Overall, 172 (69%) patients reported that they were “likely” or “very likely” to consider self‐care hemodialysis if they were properly trained on a new hemodialysis system designed for self‐care or home use. Nephrologists believed that patients were capable of performing many dialysis‐relevant tasks, including: weighing themselves (98%), wiping down the chair and machine (84%), clearing alarms during treatment (53%), taking vital signs (46%), and cannulating vascular access (41%), but thought that patients would be willing to do the same in only 69%, 34%, 31%, 29%, and 16%, respectively. Reasons that nephrologists believe patients are hesitant to pursue self‐care or home hemodialysis do not correspond in parallel or by priority to reasons reported by patients. Self‐care and home hemodialysis offer several advantages to patients and dialysis providers. Overcoming real and perceived barriers with new technology, education and coordinated care will be required for these modalities to gain traction in the coming years.     

Is home hemodialysis a practical option for older people?

An increasing demand for in-center dialysis services has been largely driven by a rapid growth of the older population progressing to end-stage kidney disease. Since the onset of the COVID-19 pandemic, efforts to encourage home-based dialysis options have increased due to risks of infective transmission for patients receiving hemodialysis in center-based units. There are various practical and clinical advantages for patients receiving hemodialysis at home. However, the lack of caregiver support, cognitive and physical impairment, challenges of vascular access, and preparation and training for home hemodialysis (HHD) initiation may present as barriers to successful implementation of HHD in the older dialysis population. Assessment of an older patient's frailty status may help clinicians guide patients when making decisions about HHD. The development of an assisted HHD care delivery model and advancement of telehealth and technology in provision of HHD care may increase accessibility of HHD services for older patients. This review examines these factors and explores current unmet needs and barriers to increasing access, inclusion, and opportunities of HHD for the older dialysis population.     

Depressive symptom severity,contributing factors,and self‐management among chronic dialysis patients

Despite the high prevalence of depressive symptoms in patients receiving chronic dialysis, there has been inadequate attention to patient‐related barriers to management of depressive symptoms, such as factors identified by these patients as contributing to their symptoms, and how they responded to the symptoms. Participants (N = 210) in an ongoing longitudinal observational study of multidimensional quality of life in patients receiving chronic dialysis completed a battery of measures monthly for 12 months. For each patient at each measurement point, an event report was generated if he or she scored outside of the normal range on the depressive symptom scale (Center for Epidemiologic Studies Depression Scale‐Short Form [CESD‐SF] ≥10) or expressed suicidal ideation. Of the 210 participants, 100 (47.6%) had a CESD‐SF score ≥10 at least once resulting in 290 event reports. Of these 100 participants, 15 (15%) had also reported suicidal ideation in addition to having depressive symptoms. The most frequently stated contributing factors included “managing comorbid conditions and complications” (56 event reports, 19.3%), “being on dialysis” (50, 17.2%), “family or other personal issues” (37, 12.8%), and “financial difficulties” (31, 10.7%). On 11 event reports (3.8%) participants had been unaware of their depressive symptoms. On 119 event reports (41%) participants reported that they discussed these symptoms with their dialysis care providers or primary care providers, while on 171 event reports (59%) symptoms were not discussed with their health‐care providers. The prevalence of depressive symptoms is high and many patients lack knowledge about effective self‐management strategies.     

The perspectives of Aboriginal patients and their health care providers on improving the quality of hemodialysis services: A qualitative study

Chronic kidney disease has a higher prevalence in Indigenous populations globally. The incidence of end‐stage kidney disease in Australian Aboriginal people is eight times higher than non‐Aboriginal Australians. Providing services to rural and remote Aboriginal people with chronic disease is challenging because of access and cultural differences. This study aims to describe and analyze the perspectives of Aboriginal patients' and health care providers' experience of renal services, to inform service improvement for rural Aboriginal hemodialysis patients. We conducted a thematic analysis of interviews with Aboriginal patients (n = 18) receiving hemodialysis in rural Australia and health care providers involved in their care (n = 29). An overarching theme of avoiding the “costly” crisis encompassed four subthemes: (1) Engaging patients earlier (prevent late diagnosis, slow disease progression); (2) flexible family‐focused care (early engagement of family, flexibility to facilitate family and cultural obligations); (3) managing fear of mainstream services (originating in family dialysis experiences and previous racism when engaging with government organizations); (4) service provision shaped by culture (increased home dialysis, Aboriginal support and Aboriginal‐led cultural education). Patients and health care providers believe service redesign is required to meet the needs of Aboriginal hemodialysis patients. Participants identified early screening and improving the relationship of Aboriginal people with health systems would reduce crisis entry to hemodialysis. These strategies alongside improving the cultural competence of staff would reduce patients' fear of mainstream services, decrease the current emotional and family costs of care, and increase efficiency of health expenditure on a challenging and increasingly unsustainable treatment system.     

Costs of managing anemia with erythropoiesis‐stimulating agents during hemodialysis: A time and motion study

Use of erythropoiesis‐stimulating agents (ESAs) presents a significant time and cost burden in the management of anemia of chronic kidney disease (CKD). We conducted a prospective, observational, activity‐based costing study to estimate the health care personnel time and resulting direct medical costs associated with administering epoetin 3 times weekly to patients with end‐stage renal disease on dialysis. The study was conducted at 5 US hemodialysis centers. The personnel time and costs were derived from time and motion observations. Predicted time and cost savings were modeled for switching patients to once‐monthly ESA therapy. Patients also completed a survey questionnaire to assess their level of CKD knowledge and information needs. Total per‐patient‐per‐year (PPPY) time expended on anemia management with epoetin averaged 608 minutes (range 512–915 minutes), with an average PPPY cost of $548 (range $342–$651). Use of a once‐monthly ESA, compared with epoetin, could decrease average PPPY time expenditure by 79% (127 minutes [range 96–173 minutes]) and reduce PPPY costs by 81% ($104 [range $79–$136]). The patient questionnaire reported insufficient education on CKD. Use of a once‐monthly ESA to correct anemia in dialysis patients may provide substantial time, resource, and cost savings compared with current treatment practices.     

Late acceleration of glomerular filtration rate decline is a risk for hemodialysis catheter use in patients with established nephrology chronic kidney disease care

Chronic kidney disease (CKD) patients with established nephrology care have a high rate of tunneled dialysis catheters (TDC) as first vascular access when transitioning to hemodialysis (HD). We sought to identify factors associated with this problem. Patients who started HD and had prior CKD care within our renal clinic were categorized according to access type at incident HD. Clinical factors, all estimated glomerular filtration rates (eGFR), renal clinic attendance records, hospital admissions in the 6 months preceding HD start, and patient participation in predialysis education course were analyzed. Three hundred thirty‐eight patients initiated HD, 107 received pre‐HD CKD care within our clinics. Seventy patients started with a TDC. All groups started HD at similar eGFR values. The trajectory of eGFR decline in the 6 months prior to HD start was significantly more rapid in the TDC group. Patients in the TDC group had more acute health events in the prior 6 months. Multivariate modeling showed that failure to attend a predialysis education course and having a more rapid rate of eGFR decline in the 6 months prior to dialysis initiation were both associated with TDC use. Patients with CKD nephrology care who initiated HD with a TDC as first vascular access had a more rapid rate of decline in eGFR in the months preceding dialysis start and were less likely to have attended our predialysis education course. This appears to correspond with the observed increased number of emergency and hospital visits in the 6 months prior to end‐stage renal disease.     

Knowledge of Home Dialysis Among Inner‐City Satellite Hemodialysis Patients

There is limited use of home renal replacement therapies in the U.S.A. One percent of dialysis patients are on home hemodialysis (HHD) and only 9% undergo peritoneal dialysis (PD). In an effort to better understand this, 161 satellite hemodialysis patients in 6 units in Brooklyn were surveyed. Forty‐eight percent of patients were women, 86% were black, 5% white, 8% Hispanic, and 1% other. Mean age was 49.4 years (range 22 – 69 years). Etiology of renal disease was hypertension (41%), diabetes mellitus (31%), polycystic kidney disease (3%), systemic lupus erythematosus (4%), and other or unknown (21%). Patients were queried about knowledge of and attitudes toward home therapies. Seventy‐nine percent of patients knew of home dialysis. The source of this information was the nephrologist (59%), the social worker (14%), a nurse (8%), other patients (4%), and other sources (15%). Only 10% of patients had ever considered HHD. Fifty‐four percent were afraid to do self‐care at home and 35% were not interested. Surprisingly, only 3% felt they had no reliable helper and 8% felt that their housing was not suitable. Similarly, 78% of patients had been spoken to about PD, but only 11% had considered it. Forty‐one percent were afraid of doing self‐care on PD, and 45% were not interested. We conclude that, although the majority of patients in six inner‐city dialysis units had heard of home dialysis, only a small number ever considered it. As many patients were afraid of doing home therapy, better education about the risks and benefits needs to be disseminated.     

Pathways to improve nephrologist comfort in managing patients on in-center or home self-care dialysis

In end-stage kidney disease (ESKD), patient engagement and empowerment are associated with improved survival and complications. However, patients lack education and confidence to participate in self-care. The development of in center self-care hemodialysis can enable motivated patients to allocate autonomy, increase satisfaction and engagement, reduce human resource intensiveness, and cultivate a curiosity about home dialysis. In this review, we emphasize the role of education to overcome barriers to home dialysis, strategies of improving home dialysis utilization in the COVID 19 era, the significance of in-center self-care dialysis (e.g., cost containment and empowering patients), and implementation of an in-center self-care dialysis as a bridge to home hemodialysis (HHD).     

Patient experiences and preferences on short daily and nocturnal home hemodialysis

Quotidian/intensive hemodialysis (short daily and nocturnal) has variable effects on health‐related quality of life (HRQOL) as measured by standard HRQOL tools. We sought to understand the perceived benefits and limitations of quotidian dialysis by interviewing patients who had switched from conventional to home quotidian dialysis. We used a qualitative, phenomenological approach to explore the perceived benefits of quotidian dialysis from 10 patients using either short daily or nocturnal hemodialysis at a tertiary health care center in London, Canada. The patients varied in gender, age, employment status, home support, physical capacity, primary cause of kidney disease, previous forms of renal replacement therapy, and level of education. Four major themes emerged: (1) improvement in physical and mental well‐being including better blood pressure and concentration, (2) increased control over patient's own life including time availability, choosing when to dialyze, and dialyzing at home, (3) decreased perception of being sick including returning to regular employment and avoiding sicker patients who must have in‐center dialysis, and (4) identification of the competencies and supports required for quotidian dialysis including ability to provide self‐care, supportive family, and medical support. Our findings suggest when patients' willingness and physical ability to use quotidian dialysis are coupled with education and support systems to assist patients' and families' self‐directed care, patients qualitatively perceive benefits of both increased physical and mental health, both measures of health‐related quality of life.     

Multiple metastatic infections in a hemodialysis patient with untunneled internal jugular catheter

We present an end‐stage renal disease patient on dialysis with fever. The primary source was right internal jugular vein catheter which had metastatic infections in the body probably via an arteriovenous communication in a cavity in left lung. Patient had right psoas muscle abscess and a left kidney abscess. An ¹⁸F‐fluorodeoxyglucose‐positron emission spectroscopy scan was done to find out left kidney abscess. A search of literature did not reveal many patients of psoas abscess secondary to infection of hemodialysis access.     

Determinants of survival in patients receiving dialysis in Libya

Maintenance dialysis is associated with reduced survival when compared with the general population. In Libya, information about outcomes on dialysis is scarce. This study, therefore, aimed to provide the first comprehensive analysis of survival in Libyan dialysis patients. This prospective multicenter study included all patients in Libya who had been receiving dialysis for >90 days in June 2009. Sociodemographic and clinical data were collected upon enrolment and survival status after 1 year was determined. Two thousand two hundred seventy‐three patients in 38 dialysis centers were followed up for 1 year. The majority were receiving hemodialysis (98.8%). Sixty‐seven patients were censored due to renal transplantation, and 46 patients were lost to follow‐up. Thus, 2159 patients were followed up for 1 year. Four hundred fifty‐eight deaths occurred, (crude annual mortality rate of 21.2%). Of these, 31% were due to ischemic heart disease, 16% cerebrovascular accidents, and 16% due to infection. Annual mortality rate was 0% to 70% in different dialysis centers. Best survival was in age group 25 to 34 years. Binary logistic regression analysis identified age at onset of dialysis, physical dependency, diabetes, and predialysis urea as independent determinants of increased mortality. Patients receiving dialysis in Libya have a crude 1‐year mortality rate similar to most developed countries, but the mean age of the dialysis population is much lower, and this outcome is thus relatively poor. As in most countries, cardiovascular disease and infection were the most common causes of death. Variation in mortality rates between different centers suggests that survival could be improved by promoting standardization of best practice.     

Understanding patient willingness to recommend and return: a strategy for prioritizing improvement opportunities.

BACKGROUND: Beginning in April 1995, an ongoing, comprehensive measurement system has been developed and refined at BJC Health System, a regional integrated delivery and financing system serving the St Louis metropolitan area, mid-Missouri, and Southern Illinois, to assess patient satisfaction with inpatient treatment, outpatient treatment, outpatient surgery, and emergency care. This system has provided the mechanism for identifying opportunities, setting priorities, and monitoring the impact of improvement initiatives. METHODS: Satisfaction with key components of the care process among 23,361 patients (7,083 inpatients, 8,885 patients undergoing outpatient tests/procedures, 5,356 patients undergoing outpatient surgery, and 2,037 patients receiving emergency care) at 15 BJC Health System facilities was assessed through weekly surveys administered in April 1995 through December 1996. RESULTS: Structural equation models were developed to identify the key predictors of patient advocation-willingness to return for or recommend care. Across all venues of care the compassion provided to patients had the strongest relationship to patient advocation. Within each venue of care, however, a slightly different set of secondary factors emerged. The resulting models provided important information to help prioritize competing improvement opportunities in BJC Health System. In one hospital, a general medicine unit working for several years with little success to improve its patient satisfaction decided to focus on two primary factors predicting patient advocation: nursing care delivery and compassionate care. Root cause analysis was used to determine why two items-staff willingness to help with questions/concerns and clear explanation about tests and procedures-were rated low. On the basis of feedback from phone interviews with discharged patients, the care delivery process was changed to encourage patients to ask questions. Across the next two quarters, this unit experienced significant improvements in both targeted items. DISCUSSION: The significance of compassionate care and care delivery again speaks not only to the importance of the technical quality of clinical care but also to the customer-focused way in which this care was provided. After the primary predictors of patient advocation were identified, management was able to strategically focus improvement initiatives to maximize their impact. Across the organization, improvement teams scanned their data to find key factors where performance was lacking. Once these key opportunities were identified, the teams developed potential solutions and launched initiatives to improve their performance. SUMMARY AND CONCLUSIONS: Results suggest that some core issues are of extreme importance to patients regardless of whether they are receiving care in an inpatient, outpatient, or emergency setting. The compassion with which care is provided appears to be the most important factor in influencing patient intentions to recommend/return, regardless of the setting in which care is provided.     

Hemodialysis cost in Tehran,Iran

The purpose of this study was to assess the health service cost of hemodialysis (HD) delivered at hospitals in Iran as a developing country with a well‐defined program of renal replacement therapy. A cost analysis was performed from the viewpoint of the 2 hospitals, with 3 shifts and full chairs, on current practice for dialysis maintenance. Cost and patient data were collected in 2006 and from April 1 to May 31, 2007, respectively. A total of 22,464 HD sessions were performed and 247 patients were studied during the study period. The reference year for the value of USD for different mentioned costs was 2006. Health care sector costs associated with each HD session were estimated at US$78.87. Most of the total maintenance expenditure was made up of medical supplies (36.19%), with dialyzers as the major cost driver. Staff salaries represented 17% of the cost and fixed direct capital costs accounted for 21.4%. Of the family members, 32.4% accompanied their patients. The mean cost for transportation of patients and accompanied person was US$3.15 ± 2.83 and US$1.5 ± 0.29, respectively. These findings are important in the light of limited available resources coupled with the increasing prevalence of kidney failure. A major attempt should also be made to increase peritoneal dialysis coverage as in some centers we cannot keep all chairs full, especially in some vast areas. It is highly recommended to place initial focus on strategies and treatments that slow disease progression, to postpone renal replacement therapy to save resources.     

Cardioprotection in the ESRD Population: How Do We Get There?

Cardiovascular mortality for end‐stage renal disease (ESRD) patients is about 30 times the risk in the general population. About 30% of ESRD patients have hyperlipidemia. The 1998 National Kidney Foundation Task Force on Cardiovascular Disease recommends implementation of effective measures to prevent and treat cardiovascular disease in this population. Our intent was to evaluate the extent of use of cardioprotective drugs in ESRD patients through a quality improvement project. Twenty‐eight dialysis facilities throughout Ohio volunteered for this project. Data regarding use of angiotensin‐converting enzyme inhibitors (ACE‐I) and angiotensin receptor blockers (ARB) in heart failure, beta‐blockers in myocardial infarction (MI), aspirin in coronary artery disease, and 3‐hydroxy‐3‐methylglutaryl coenzyme A (HMG‐CoA) reductase inhibitors (statins) were collected using chart abstraction for the period March through May 2000. The results were compared to Ohio hospital discharges from July through September 2000. This latter population was comprised of non‐‐ESRD patients. Dialysis facilities were visited and interviews were conducted with staff members. Information was gathered regarding facility infrastructure, quality improvement process, and existing protocols. 27% of ESRD patients with a history of heart failure were on ACE‐I, compared to 75.7% of non‐ESRD patients. 34.8% of ESRD patients with a previous MI were taking beta‐blockers, compared with 68.0% of non‐ESRD patients with a prior MI. Aspirin use in ESRD patients with a previous MI was 52.8%, compared to 88% in non‐ESRD patients with a prior MI. 17.3% of ESRD patients were on statins. Hyperlipidemia is found in 30% to 50% of ESRD patients. The use of cardioprotective drugs in the Medicare ESRD patient is lower than in the Medicare non‐dialysis counterpart. Reasons for this are related to fragmentation of health care arising from communication and infrastructure issues. Until these issues are addressed and resolved, efforts at initiation of cardioprotective strategies will be slowed.     

What limits the expansion of self‐care dialysis at home?

Self-care dialysis at home, whether peritoneal dialysis or hemodialysis, is more cost-effective than in-center dialysis and treatment outcome is at least comparable. Still, both self-care modalities are considered underutilized and we wished to identify the perceived reasons for this underutilization among nephrology professionals. A questionnaire was distributed at 5 international nephrology meetings in 2006. Questions addressed the most important stakeholders and the most important issues for patients and nephrology professionals to enable the expansion of self-care dialysis and commonly mentioned barriers were given as alternative responses. The proportion of patients considered suitable for self-care was also investigated. Seven thousand responses were collected. The listed stakeholders, i.e., health care and reimbursement authorities, nurses and physicians, and finally patients and their families, are considered approximately equally important for the process. Nephrology professionals feel that patient motivation for choosing and performing self-care dialysis is the strongest driver. The need for dedicated resources for self-care is judged to be vital for the expansion of this modality of treatment. Thirty-two percent of incident patients are considered able to perform self-care dialysis at home. This international survey among 7000 nephrology professionals has identified patient motivation as one of the strongest drivers of self-care dialysis at home. The need for dedicated resources for the staff to devote time to developing such motivation is given as one of the major reasons for the slow adoption. Under ideal conditions, it is felt that one-third of all patients starting dialysis can be trained to perform self-care dialysis.     

The Glycemic Indices in Dialysis Evaluation (GIDE) study: Comparative measures of glycemic control in diabetic dialysis patients

The validity of hemoglobin A1c (HgbA1c) is undergoing increasing scrutiny in the advanced CKD/ESRD (chronic kidney disease/end‐stage renal disease) population, where it appears to be discordant from other glycemic indices. In the Glycemic Indices in Dialysis Evaluation (GIDE) Study, we sought to assess correlation of HgbA1c with casual glucose, glycated albumin, and serum fructosamine in a large group of diabetic patients on dialysis. From 26 dialysis facilities in the United States, 1758 diabetic patients (hemodialysis = 1476, peritoneal dialysis = 282) were enrolled in the first quarter of 2013. The distributions of HgbA1c and the other glycemic indices were analyzed. Intra‐patient coefficients of variation and correlations among the four glycemic indices were determined. Patients with low HgbA1c values were both on higher erythropoietin (ESA) doses and more anemic. Serum glucose exhibited the highest intra‐patient variability over a 3‐month period; variability was modest among the other glycemic indices, and least with HgbA1c. Statistical analyses inclusive of all glycemic markers indicated modest to strong correlations. HgbA1c was more likely to be in the target range than glycated albumin or serum fructosamine, suggesting factors which may or may not be directly related to glycemic control, including anemia, ESA management, and iron administration, in interpreting HgbA1c values. These initial results from the GIDE Study clarify laboratory correlations among glycemic indices and add to concerns about reliance on HgbA1c in patients with diabetes and advanced kidney disease.     

Utility of 18 F‐FDG PET/CT scan to diagnose the etiology of fever of unknown origin in patients on dialysis

Introduction: Studies on fever of unknown origin (FUO) in patients of chronic kidney disease and end stage renal disease patients on dialysis were not many. In this study, we used 18 F‐FDG PET/CT scan whole body survey for detection of hidden infection, in patients on dialysis, labelled as FUO. Methods: In this retrospective study, 20 patients of end stage renal disease on dialysis were investigated for the cause of FUO using 18F‐FDG PET/CT scan. All these patients satisfied the definition of FUO as defined by Petersdorf and Beeson. Any focal abnormal site of increased FDG concentration detected by PET/CT, either a solitary or multiple lesions was documented and at least one of the detected abnormal sites of radio tracer concentration was further examined for histopathology. Findings: All patients were on renal replacement therapy. Of these, 18 were on hemodialysis and two were on peritoneal dialysis. 18F‐FDG PET/CT scan showed metabolically active lesions in 15 patients and metabolically quiescent in five patients. After 18F‐FDG PET/CT scan all, but one patient had a change in treatment for fever. Anti‐tuberculous treatment was given in 15 patients, antibiotics in four patients and anti‐malaria treatment in one patient. Discussion: The present study is first study of 18F‐FDG PET/CT scan in patients of end stage renal disease on dialysis with FUO. The study showed that the 18 F FDG PET/CT scan may present an opportunity to attain the diagnosis in end stage renal disease patients on dialysis with FUO.     

The advanced practice nurse–nephrologist care model: Effect on patient outcomes and hemodialysis unit team satisfaction

The tertiary care nurse practitioner/clinical nurse specialist (NP/CNS) is an advanced practice nurse with a relatively new role within the health‐care system. It is stated that care provided by the NP/CNS is cost‐effective and of high quality but little research exists to document these outcomes in an acute‐care setting. The clinical coverage pattern by nephrologists and NP/CNS of a hemodialysis unit in a large academic center allowed such a study. Two NP/CNS plus a nephrologist followed two of three hemodialysis treatment shifts per day; only a nephrologist followed the third shift. The influence of this care pattern of patients was examined using a cross‐sectional review of outcomes such as adequacy of delivered dialysis, anemia management, phosphate control, hospitalizations, etc. In addition, the level of satisfaction of the dialysis team and perceptions of care delivered with the care models was assessed. The care model staff‐to‐patient‐number ratio was similar in both groups (1:27 for NP/CNS plus nephrologist; 1:29 for nephrologist alone). Patient demographics were similar in both groups but the NP/CNS–nephrologist group had patients with more comorbidities. No statistically significant (p < 0.05) differences existed between the groups in patient laboratory data, adherence to standards, medications, inter‐ and intradialytic blood pressure, achievement of target postdialysis weights, and hospitalizations or emergency room visits. Significantly more adjustments were made to target weights and medications and more investigations were ordered by the NP/CNS–nephrologist team. Team satisfaction and perceptions of care delivery were higher with the NP/CNS–nephrologist model. It is concluded that the NP/CNS–nephrologist care model may increase the efficiency of the care provided by nephrologists to chronic hemodialysis patients. The model may also be a solution to the problem of providing nephrologic care to an ever‐growing hemodialysis population.