Table 1.

Challenges in Developing and Implementing an Individualized PROM for Fatigue in Hemodialysis Patients and Recommendations for Resolution

Challenge	Recommendation
Imprecise definition of fatigue; various factors influence fatigue	Use of questions and clinical and/or laboratory assessments that help distinguish symptoms of fatigue related to comorbid conditions from those related to dialysis treatments
Heterogeneity of patient experiences of fatigue across dialysis treatment regimens	Development of fatigue PROMs that are specific for different dialysis treatment regimens
Difficulty for patients in interpreting the term “fatigue”	Creation of materials tailored to a 7th- or 8th-grade literacy level, using resources such as the CMS Toolkit for Making Writing Clear and Effective10,11
Within- and between-individual variation in experiences of fatigue over time	Repeated assessments of fatigue PROM that are consistent in relation to the dialysis treatment regimen
Difficulties with sustained uptake, repeated assessments, and implementation in an incenter hemodialysis unit	Use of computer adaptive testing for a fatigue PROM during a dialysis session12
Need to develop an action plan after fatigue-specific PROM collection	Multidisciplinary assessment and treatment approach: • Change in dialysis prescription (shorter duration, increased frequency, decreased fluid removal, etc) • Change in dialysis modality (switch to peritoneal dialysis, more frequent hemodialysis) • Trial of exercise regimen • ESA dosing to appropriate hemoglobin target • Antidepressant and/or cognitive behavioral therapy

Abbreviations: CMS, Centers for Medicare & Medicaid Services; ESA, erythropoiesis-stimulating agent; PROM, patient-reported outcome measure.