Characteristics of facilities
Of the 4257 facilities surveyed, 1657 (39%) responded. The characteristics of the surveyed and responding facilities are shown in Table 2. There were no apparent differences between surveyed and responding facilities in terms of type of facility and patients on haemodialysis but the number of haemodialysis beds was larger in responded facilities than in surveyed facilities. Almost half of the responding facilities were hospitals. A total of 550 facilities, including 266 hospitals, 281 clinics, and three facilities with no given facility type, responded that they provide exercise instruction during haemodialysis treatment. This means that 33% of responding facilities and 13% of surveyed facilities provided this instruction. Facilities providing exercise instruction had fewer inpatient beds, more haemodialysis beds and more patients on haemodialysis than those not providing exercise instruction (Supplementary Table S2).
A total of 357 facilities (8% of surveyed facilities, 22% of responding facilities, and 65% of facilities providing exercise instruction) had already claimed the fees for exercise instruction during haemodialysis treatment. Insurance claims had been made by 66% of the clinics and 65% of the hospitals among the 545 facilities. The facilities claiming fees had more haemodialysis beds and patients on haemodialysis than those that had not claimed (Table 3).
Of the 550 facilities, 245 (55%) started providing exercise instruction in or after April 2022, the date from when insurance claims could be made. In facilities that started this provision after claims approval, 91% had actually claimed. However, only 45% of facilities that had provided this instruction before the change in the insurance regime had already claimed at the time of the survey.
Details of exercise instruction
In total, 85% of the 550 facilities providing exercise instruction used the JSRR clinical practice guideline for renal rehabilitation. Exercise therapy was provided to a median (IQR) of 8.5 (4, 17) patients, a median (IQR) percentage of 11% (4%, 26%) of the total patients on haemodialysis at the facility. Overall, 58% of facilities provided exercise therapy to 10 or fewer patients. Making a claim was not associated with the number of patients given instruction (claimed: 8 (4, 17), not claimed: 9 (4, 16), p = 0.96). Facilities with PTs tended to provide exercise instruction to more patients than those without PTs (with PTs: 10 (4, 20), without PTs: 7 (4, 15), p = 0.06).
The details of the instructors are shown in Table 4 and Fig. 1. Multiple responses were possible, but the instructors included physicians in 45% of facilities, nurses in 74%, and clinical engineers in 24%. In 266 facilities (48%), instruction was provided by PTs either alone or with someone else. Within the PTs category, the provision was by PTs at 253 (46%) facilities, OTs at 49 (9%), and health fitness programmers at five (0.1%). Some facilities had instruction provided by several other professions, including nutritionist, clinical laboratory technician, and radiological technologist, but these did not fall within the claims requirements. There were differences in claim rates by type of instructor, with higher claim rates for physicians (81%) and PTs (71%) than for nurses (67%) and clinical engineers (48%). Of the 25% of facilities where only nurses or clinical engineers were instructors, only 45% had claimed the fee, much fewer than facilities using other types of instructors.
Venn diagram of instructors providing exercise instruction during haemodialysis treatment. “Physical therapists” includes physical therapists, occupational therapists, and health fitness programmers.
Overall, 537 (98%) of the facilities provided exercise instruction during haemodialysis (Table 5), and 23% of the facilities also provided it before/after haemodialysis or on non-haemodialysis days. The frequency of the instruction was three times a week for 80%, twice a week for 9%, and once a week or less for 11% (Supplementary Table S3). The length of the instruction session was less than 20 min for 19%, between 20 and 30 min for 66%, and more than 30 min for 15%.
The details of the types of exercise instruction provided are shown in Table 6 and Fig. 2. The most frequently performed item was lower limb resistance training (81%), followed by aerobic exercise (62%, multiple answers possible). Nutritional instruction was provided at 24% of the facilities. The most common combination was training combining aerobic exercise and lower limb resistance training (48%). There were no differences in provision of exercise instruction by type of facility or presence of PTs.
Venn diagram of types of exercise instruction provided during haemodialysis treatment. RT, resistance training.
Evaluation of the effectiveness of the instruction was not a requirement for claims, but it was performed in 76% of the facilities (Fig. 3, Table 7). The most frequently evaluated item was change in muscle strength (49%), followed by change in ability to carry out activities of daily living and quality of life (ADL/QOL, 39%, multiple answers). Exercise tolerance was evaluated in 89 (21%) facilities, and included cardiopulmonary exercise testing (6%) and the 6-min walk test or incremental shuttle walk test (18%). Overall, 76% of the facilities evaluated either exercise tolerance or muscle strength. The evaluators tended to be PTs in hospitals and physicians and nurses in clinics (Supplementary Table S4). Clinical engineers provided evaluations in 17% of the facilities, mainly clinics. A total of 81% of facilities responded that they would continue exercise therapy after the 90-day claimable period had expired, and 84% responded that the exercise instruction was effective.
Venn diagram of items used to evaluate exercise instruction. ADL/QOL, activities of daily living and/or quality of life.
Adverse events associated with exercise therapy during haemodialysis
Overall, 39% (214) of the facilities had experienced adverse events associated with exercise instruction during haemodialysis. Most were minor and did not require any specific treatment (Table 8). However, 18 facilities reported moderate-to-severe adverse events, and a secondary survey was conducted to obtain more information. Eighteen adverse events were reported from 11 hospitals and seven clinics. They included 12 cases of cardiovascular problems (11 arrhythmias and one case of chest discomfort) and six cases of haemodialysis circuit problems. The period from the start of exercise instruction to the onset of the adverse events was 1 day for three cases, 2–28 days for six cases, 29–90 days for five cases, and 91 days or more for four cases. The type of exercise being performed at the time of the occurrence of the adverse event was lower limb resistance training in eight cases, aerobic training in 11 cases, and group exercises in one case. The 11 arrhythmias were all sinus tachycardia. One of the six cases of haemodialysis circuit problems required re-puncture because the haemodialysis needle had almost been removed. The remaining five cases showed increased venous pressure caused by flexion of the arm with arteriovenous fistula, which was improved by arm repositioning. None of the 18 people required hospitalization and there were no ongoing effects. In two cases, exercise instruction was discontinued after the event, but the others continued.
Other findings
Of the 1103 facilities that did not provide exercise instruction during haemodialysis treatment as of March 2023, 44% planned to start in the future. The main reasons for not providing exercise instruction were staff shortages (64%) and being unable to meet the requirements for claims (36%, Table 9).
Exercise therapy was provided for patients with non-dialysis CKD at 154 facilities (9% of responding facilities and 4% of those sent the survey). Of these, 118 (76%) were hospitals, and 59% had provided instruction to fewer than 10 people. The reasons for not providing exercise instruction were staff shortages (49%), because the additional fee cannot be claimed for non-dialysis CKD patients (25%), and absence of appropriate patients (22%) (Supplementary Table S5).
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- Source: https://www.nature.com/articles/s41598-024-59995-4