Hemodialysis in Stressor Patients_1

1. hemodialysis in stressor patients

Coping Strategies and Stressors in Patients With Hemodialysis

Shu-Chuan Jennifer Yeh, PhD and Hsueh-Chih Chou, RN, MBAFrom the Institute of Hospital and Health Care Administration (S.-C.J.Y.), National Yang-Ming University; Institute of Healthcare Management, College of Management, National Sun-Yat Sen University (S.-C.J.Y.), Kaohsiung, Taiwan; and the Department of Nursing, (H.-C.C.), Kaohsiung Veterans Hospital, Kaohsiung, Taiwan.Address correspondence and reprint requests to Shu-Chuan Jennifer Yeh, Institute of Hospital and Health Care Administration, National Yang-Ming University, No. 155, Sec. 2, Linong Street, Beitou District, Taipei, Taiwan, 112. E-mail: [email protected]: To investigate the stress related to undergoing hemodialysis (HD) and the relationship between these stresses and the coping strategies used by patients with end-stage renal disease.Methods: We used the Hemodialysis Stressor Scale and the Jalowiec Coping Scale to interview 2642 patients (mean age = 57 years; 53.5% female) receiving HD. The Hemodialysis Stressor Scale measures the level of stress related to stressor subscales: daily activity, physical condition, dependency on medical staff, fluid and food restriction, role ambiguity, blood vessel problems, and reproductive system functioning. The Jalowiec Coping Scale identifies the use of the following coping strategies: problem-oriented, emotion-oriented, support seeking, avoidance, and isolated thoughts. Data were analyzed using Hierarchical Linear Modeling.Results: Daily activity subscale scores were positively associated with using emotion-oriented, avoidance, and isolated thoughts as coping styles and negatively related to support seeking from professionals. The higher the perceived stress related to physical symptoms, dependency on medical staff, and blood vessel problems, the more the patients used emotion-oriented, support seeking, avoidance, and isolated thoughts to cope. Fluid and food restriction and role ambiguity subscales were found to be positively associated with emotion-oriented, avoidance, and isolated thoughts coping strategies. Reproductive system functioning was positively associated with emotion-oriented, avoidance, and isolated thoughts coping strategies. Patients on HD seldom use problem-oriented strategy to ease their stresses. Support seeking was another infrequently used coping strategy.Conclusions: The most commonly used coping strategies in our patients were emotion-oriented, avoidance, and isolated thoughts. The choice of coping strategy depended on the types of stressor.Key Words: stressor • coping • dialysis • end-stage renal disease

Abbreviations: ESRD = end-stage renal disease; HD = hemodialysis; HSS = Hemodialysis Stressor Scale; JCS = Jalowiec Coping Scale; OLS = ordinary least square.

http://www.psychosomaticmedicine.org/content/69/2/182.abstract

Coping Strategies and Stressors in Patients With Hemodialysis

Objectives: To investigate the stress related to undergoing hemodialysis (HD) and the relationship between these stresses and the coping strategies used by patients with end-stage renal disease. Methods: We used the Hemodialysis Stressor Scale and the Jalowiec Coping Scale to interview 2642 patients (mean age 57 years; 53.5% female) receiving HD. The Hemodialysis Stressor Scale measures the level of stress related to stressor subscales: daily activity, physical condition, dependency on medical staff, fluid and food restriction, role ambiguity, blood vessel problems, and reproductive system functioning. The Jalowiec Coping Scale identifies the use of the following coping strategies: problem-oriented, emotion-oriented, support seeking, avoidance, and isolated thoughts. Data were analyzed using Hierarchical Linear Modeling. Results: Daily activity subscale scores were positively associated with using emotion-oriented, avoidance, and isolated thoughts as coping styles and negatively related to support seeking from professionals. The higher the perceived stress related to physical symptoms, dependency on medical staff, and blood vessel problems, the more the patients used emotion-oriented, support seeking, avoidance, and isolated thoughts to cope. Fluid and food restriction and role ambiguity subscales were found to be positively associated with emotion-oriented, avoidance, and isolated thoughts coping strategies. Reproductive system functioning was positively associated with emotion-oriented, avoidance, and isolated thoughts coping strategies. Patients on HD seldom use problem-oriented strategy to ease their stresses. Support seeking was another infrequently used coping strategy. Conclusions: The most commonly used coping strategies in our patients were emotion-oriented, avoidance, and isolated thoughts. The choice of coping strategy depended on the types of stressor. Key words: stressor, coping, dialysis, end-stage renal disease.

INTRODUCTION

End-stage renal disease (ESRD) is a chronic, life-threatening condition. In 2003, 36,860 people received dialysis treatments in 333 facilities across Taiwan (1). The prevalence rate was 1630 per 1,000,000 people in our population (40% male, 60% female; 42%, age range 45– 64 years; 16% age range 65–74 years) (1). Patients with ESRD experience different levels of stress in response to various types of stressors. How stress is resolved is important to this population because it can contribute to greater

morbidity and even to earlier mortality (2,3). Many studies have examined the stressors of patients with ESRD. Stapleton (4) categorized stressors faced by patients with ESRD as being related to physiological need, psychological need, role disturbance, and daily activity. Mok and Tam (5) studied 50 patients with ESRD in Hong Kong to determine the stressors encountered and the coping methods used; they found fluid limitation to be the most frequently identified stressor, followed by food limitation, itching, fatigue, and cost. Moreover, Tsay and colleagues (6), using the Hemodialysis Stressor Scale (HSS) to assess 57 patients with ESRD in Taiwan, found the major stressors to be limitations on time and place related to employment, limitations on fluid intake, transportation difficulties, loss of bodily function, length of dialysis treatment, and limitation of physical activities. Other

studies concluded that physiological stressors were more troublesome than psychosocial stressors in patients receiving hemodialysis (HD) (7,8). Patients receiving HD use various strategies to cope with the stressors related to their disease and the treatment procedures. The kind of coping strategies they use also depends on their personal experience, social support system, individual beliefs, and availability of resources (5,9). Mok and Tam (5) reported that the most common coping methods used by patients with ESRD include “accepting the situation because very little could be done,” followed by “telling oneself not to worry because everything would work out fine” and “telling oneself that the problem was really not that important.” Some researchers categorized the coping strategies as problem-focused or emotion-focused (10 –13). Problem-focused coping is directed toward managing or changing a stressful situation (12), or it involves addressing the problem that causes distress (10), whereas emotion-focused coping involves explaining stress as inability to control one’s own circumstances (13) and its purpose is to ameliorate the negative emotions associated with the problem (10). Some researchers have found that patients with ESRD have both psychological and physiological stressors and that they use problem-focused coping strategies more often than emotion-focused coping strategies in response to those stressors (7,14,15); others have found that patients receiving HD use more evasive coping strategies (16) and emotion-focused coping strategies (17). In addition to identifying the coping mechanisms that patients with ESRD use when facing various stressors related to HD, research should also clarify the relationship between stress and coping strategies. Literature in this regard, particularly in patients receiving HD, is still limited and inconsistent. For example, Baldree et al. (18), in a survey of 32 patients receiving HD, did not find any significant relationship between stressors and coping scores, whereas Gurklis and Menke (7), in their survey of 68 patients on HD, reported a positive relationship between total stressor scores and total coping scores. More recently, Ersoy-Kart and Guldu (17), studying 55 patients receiving HD in Turkey, found that these patients had lower coping scores and were vulnerable to stress. Therefore, it is important to understand the extent of stress experienced by patients facing various stressors related to HD and the relationship between the patients’ coping strategies and the stress factors. In summary, most of the studies examining the relationship between stress and coping strategies for patients receiving HD are limited in sample size and seem to have inconsistent results. Thus, this study uses two scales, the HSS and the Jalowiec Coping Scale (JCS), in interviewing a large sample of patients with ESRD undergoing HD to determine if there is a positive relationship between coping strategy and level of stress in this population.

METHODS

Subjects

This study enrolled patients 15 years old who had been on dialysis for at least 3 months. Of the 333 hemodialysis centers in 2002, we randomly selected 33 (10%) and asked for permission to enroll patients in our study. Only 27 centers agreed to participate. A total of 2977 patients receiving HD from five medical centers, five regional hospitals, 10 community hospitals, and seven independent hemodialysis centers in 13 counties were interviewed.

A total of 208 patients who did not want to be interviewed and 127 patients who could not answer the questions were excluded, leaving us with 2642 patients and an effective response rate of 88.84%. Our patient sample had a mean age of 57 years (SD 14 years, range 15–95 years) (Table 1) and was composed of a few more women (53.5%) than men. About 78% were married. The patients had received HD for an average of 54 months (or 4.5 years) (range 3–249 months). The average number of comorbidities was 0.72. Most of the patients received HD three times a week.

Measures

We used a structured questionnaire consisting of three major sections. The first section covered demographic data (age, gender, marital status, education, occupation, and religion), as well as the characteristics of dialysis treatment (length of time receiving dialysis, major reasons for the dialysis, comorbidities, transportation, meal support, and frequency of dialysis). The second section was the HSS, a 29-item scale used for rating the incidence and severity of stressors associated with HD (18). In addition to the 29 questions, based on the suggestions from a panel of experts, we added three more questions about the operation for an arteriovenous fistula, puncture failure, and frequent dialysis staff change. The subjects rated the extent of being troubled by each of the 32 stressors using a 4-point scale (0 not at all,1 slightly, 2 moderately, and 3 a great deal). A subtotal stressor scale score was obtained by adding the ratings for items belonging to the same construct. The higher the score, the greater the stress. The internal consistency coefficient from previous studies was about 0.89, indicating good internal reliability. The instrument has an established test-retest reliability coefficient of r 0.71 (18). The third section contained questions for assessing the coping strategies used by patients receiving HD to handle the stressors experienced. We used the JCS developed by Jalowiec and Powers (19) and translated by Mok and Tam (5). This instrument covers 40 different coping behaviors, namely, 25 affective-orientated and 15 problem-orientated. A 4-point (0 –3) Likert scale is used (0 never used, 1 seldom used, 2 sometimes used, and 3 often used). Construct validity of the scale was tested by a panel from the Midwest Nursing Research Society, who were familiar with the stress and coping literature and thus yielded a high percentage of agreement (19). The reliability coefficient of the total scale is 0.86; 0.84 for the problem-orientated coping subscale, and 0.74 for the affective-orientated coping subscale from the study

by Gurklis and Menke (20). The test-retest reliability of the Chinese instrument, assessed in a pilot study with four patients receiving HD over a 2-week span, was found to be 0.87 (5).

http://www.psychosomaticmedicine.org/content/69/2/182.full.pdf

Preparing for hemodialysis: patient stressors and responses

In the United States (U.S.) the incidence and prevalence of kidney failure requiring dialysisis increasing (National Kidney Foundation [NKF], 2002). It is alarming that the prevalence of individuals who are in the early stages of chronic kidney disease (CKD)is even higher (NKF, 2002). In the U.S., approximately 8 million people have CKD stage III or higher (United States Renal Data System [USRDS], 2003) or an estimated glomerular filtration rate of less than 59 ml/min/1.73[m.sup.2] (NKF, 2002). In our renal program, over the past several years, the number of individuals requiring dialysis has increased at approximately 5% per annum.CKD, the continuum of kidney disease from early diagnosis to the time when dialysis starts, is emerging as a clinical and research area apart from dialysis. Emphasis is being placed on multi-disciplinary team interventions to delay the onset of dialysis and prepare patients for dialysis and/or transplantation. The NKF/DOOI (NKF, 2002) and the Canadian Society of Nephrology clinical practice guidelines (Churchill, Blake, Jindal, Toffelmire, & Goldstein, 1999) recommend that each center provide an established multi-disciplinary team for CKD care. To deliver adequate medical and psychosocial preparation, Churchill et al. (1999) recommended that patients undergo a minimum of 12 months of attendance in a multi-disciplinary CKD clinic prior to the initiation of dialysis.The "pre-dialysis" stage is a stressful one, with many adjustments required and much uncertainty. Our hypothesis for this study was that the stressors experienced in CKD are different than those experienced in individuals with end stage renal disease (ESRD) who are on either peritoneal or hemodialysis. Learning more about these stressors and the resulting patient responses is essential in order to design and deliver services that are effective and supportive for these individuals.Literature Review

Early referral to a nephrologist and CKD clinic has been shown to slow the rate of progression of kidney disease, allow for the management of anemia, provide for patient education to make decisions regarding modality choices, facilitate access placement, enable dietary education, provide early detection and treatment of secondary hyperparathyroidism, reduce cardiovascular risk factors, and offer supportive coping interventions (Bolton & Owen, 2002; Churchill et al., 1999; Crawford, 2005; Levin, 2000; Pereira, 2000). Several studies have demonstrated that early referral to a nephrologist/CKD clinic decreases morbidity, mortality, and health care costs (McLaughlin, Manns, Culleton, Donaldson, & Taub, 2001); improves long-term survival (Jungers et al., 2001); reduces the need for emergent dialysis (Schmidt, Domico, Sorkin, & Hobbs, 1998); extends the time to dialysis (Devins, Mendelssohn, Barre, & Binik, 2003); and improves health-related quality of life for 6 months after the start of dialysis (Korevaar et al., 2002). Patients who receive dialysis education have higher mood scores, less mobility problems, less functional disabilities, and a lower level of anxiety (Klang, Bjorvell, Berglund, Sundstedt, & Clyne, 1998), and are enabled to make decisions regarding modality type (Klang, Bjorvell, & Clyne, 1999). Less well understood are the actual stressors patients experience during the CKD stage of their illness.Baldree, Murphy, and Powers (1982) developed a hemodialysis stressors scale that was subsequently adapted to measure stressors in individuals on peritoneal dialysis (Jones, 1986). A similar scale was also developed and tested to measure stressors with renal transplant recipients (Hayward et al., 1989). Several studies followed, some using these instruments, to explore stressors (physiological, psychological, and total stressors) experienced by those on hemodialysis (Gurklis & Menke, 1995; Mok & Tam, 2001; Welch & Austin, 1999), peritoneal dialysis (Bihl, Ferrans, & Powers, 1988), renal transplantation

(White, Starr, Ketefian, & Voepel-Lewis, 1990) and with ESRD (Lindqvist, Carlsson, & Sjoden, 2000; Lok, 1996).One Scandinavian study (Klang, Bjorvell, & Cronqvist, 1996) examined coping strategies and sense of coherence (SOC) in patients with CKD and compared the results to patients on hemodialysis. The results of this study indicated that patients with CKD and patients on hemodialysis employed very different coping strategies. The group of patients with CKD had lower coping scores and used more emotive coping strategies. Although this study examined coping methods, it did not identify the stressors that these individuals experience.In a recent study, Mok, Lai, and Zhang (2004) interviewed 11 individuals with ESRD to explore coping methods. The individuals were asked to reflect on the course of their illness, beginning with questions related to the diagnosis of their renal failure. The participants described an emotional reaction when first faced with their illness. Although this qualitative study is rich with data regarding the patients' experiences, it is retrospective and does not specifically address stressors with CKD.Depression has also been shown to be a considerable problem for patients with CKD. In a sample of 60 patients with ESRD, 12 of the 17 patients who met the criteria for depression (as defined by the DSMIII) developed major depression before the initiation of renal replacement therapy (Hong, Smith, Robson, & Wetzel, 1987). In a study of 73 patients with renal disease (Sacks, Peterson, & Kimmel, 1990), the 16 patients with CKD reported a greater negative perception of illness and more depression than those already on dialysis. The authors suggested that depression was a reaction to potential loss and/or the fear of the unknown. In a more recent study, secondary data analysis done with 374 individuals admitted with congestive heart failure were screened for CKD and asked to complete measures for depression (Hedayati et al., 2004). Depression was more prevalent among the individuals with CKD than those without.The review of the related research with patients with CKD is largely quantitative and interventional.Many studies have been conducted with stressors associated with renal replacement therapy but not with CKD. This study fills a gap in present research by subjectively describing the stressors experienced by patients with CKD. Knowing what patients perceive as stressors in CKD is essential to understanding their experience, thus guiding future educational and supportive interventions.Purpose of the StudyThe purpose of this descriptive study was to explore the specific stressors patients with CKD who are on hemodialysis recalled experiencing as they approached dialysis. The research question that guided this study was: What stressors do patients with CKD experience and what activities do they engage in to prepare themselves for hemodialysis?For the purpose of this study, stress was defined as the relationship between the person and the environment, appraised by the person as taxing or exceeding his or her resources and endangering his or her well-being (Lazarus & Folkman, 1984).MethodologySettingThe London Heath Sciences Centre (LHSC) Renal Program has established a formal CKD education program for patients and family members. In addition to individual education/counseling, a series of three group education sessions are offered to all patients with a CKD diagnosis. Each of these multidisciplinary sessions is approximately 3 hours in length and is offered when the patient reaches specific milestones on the care pathway. The first session is offered soon after the CKD diagnosis. It provides general education about kidney disease, and the focus is on self-management interventions to

delay the progression of the disease. The second session reviews ESRD treatment options and ideally is offered approximately 6 to 12 months prior to the need for renal replacement therapy. This time frame gives the patient sufficient time to review options and to prepare for treatment. The third session is offered to those in the late CKD stage and up to 6 months after starting dialysis. This session focuses on lifestyle and coping issues. Patients also receive individual interventions in a multi-disciplinary clinic. Family members are encouraged to attend the three multi-disciplinary sessions. If the family is present during the clinic visit they are included in the one-to-one patient teaching provided during the visit.

http://findarticles.com/p/articles/mi_m0ICF/is_3_32/ai_n17209544/

Factors Associated with Treatment-Related Stressors in Hemodialysis Patients

Despite rapid technological advances in the treatment of patients on hemodialysis, most treatment-related stressors have not been eased by technology. Diet and fluid limitations, muscle cramps, fatigue, uncertainty about the future, activity limitations, itching, and lost time or activity as a result of dialysis continue to be very stressful for hemodialysis patients (Baldree, Murphy, & Powers, 1982; Bihl, Ferrans, & Powers, 1988; Gurklis & Menke, 1995, 1988; Iordanidis et al., 1993; Lok, 1996; Nichols & Springford, 1984). Although the literature on stressors in hemodialysis patients is extensive and highly stressful aspects of treatment have been identified, the studies have a number of limitations. First, they have not addressed who is most at risk for specific stressors. Second, because most studies have been cross-sectional, they have not looked at how stressors change over time. Third, samples have been predominantly Caucasian, which means that little is known about stressors in other races. Finally, patients who are new to dialysis usually have not been included in studies and, therefore, little is known about this important period. With over 200,000 patients receiving treatment for end stage renal disease (ESRD) in the United States, it is essential that strategies be developed for reducing stressors in this population. Before this can be done, however, the foregoing gaps in knowledge need to be corrected. The first step is to describe the specific stressors over time as they relate to specific personal and illness characteristics of dialysis patients.

Literature ReviewIn prior research, investigators have identified the most troublesome individual stressors. In these studies, however, stressors were grouped into physiological, psychosocial, or total stressor scores for data analysis (Baldree et al., 1982; Bihl et al., 1988; Gurklis & Menke, 1988; Lok, 1996). This strategy limited information on specific stressors. For example, in a small study of hemodialysis patients, Baldree and colleagues (1982) found that age was not related to the total stressor score, but did not report if age was related to any of the individual stressors. Identifying groups of people most at risk for specific problems should help in developing intervention strategies.Another limitation of past studies is the use of cross-sectional designs, which cannot address whether stressors persist over time or if they change with continuing treatment. Before interventions can be developed, it is important to know if and how these stressors change over time.Samples in previous research have included primarily Caucasians, although the population of ESRD patients

increasingly comprises minority patients. Because relatively more African Americans use hemodialysis as a treatment modality (Price & Owen, 1997), it is essential to investigate whether there are racial differences in stressors.

Lastly, although length of time on dialysis has been a variable in studies of stressors, findings have been equivocal. Baldree and associates (1982) reported that the greatest number of stressors was reported by persons who had been on dialysis for 13 to 16 months. Gurklis and Menke (1988), however, reported no significant relationship between stressors and length of time on dialysis. More recently, Lok (1996) reported that as length of time on dialysis increased, there was an increase in psychosocial stressors. None of these studies investigated individuals who were new to dialysis therapy.

Because patients on dialysis have extended periods of treatment, it is critical that research focus on reducing these stressors. Knowledge about likely concerns and problems would allow nephrology nurses to provide anticipatory guidance throughout the treatment regimen.

As part of a larger study (Welch, 1996), the purpose of this study was to describe the stressors of adults with ESRD on incenter hemodialysis. The specific research questions were:

1. What are the most troublesome treatment-related stressors identified by dialysis patients?2. What are the differences in individual treatment-related stressors associated with demographic (age, race, gender, marital status, and education) or illness variables (length of time on dialysis)?3. What are the changes over time in the individual treatment-related stressors associated with demographic (age, race, gender, marital status, and education) or illness variables (length of time on dialysis)?MethodsSample and setting. Following institutional review board approval and informed consent, a convenience sample of adults currently undergoing incenter hemodialysis was interviewed twice, 3 months apart. A total of 125 eligible persons were invited to participate and, of these, 103 subjects entered the study at Time 1. There were 86 consenting adults who completed the interview at both Time 1 and Time 2. To be included in the study the subjects must have been 18 years of age or older; alert and oriented to time, place, and person; able to speak English; able to respond to questions; have an absence of known psychiatric disorders, including major depression; and have a score on a modified Mini-Mental State (Folstein, Folstein, & McHugh, 1975) of 16 or greater (range 0-24). The presence of other medical disease did not cause exclusion from the study. Subjects were recruited from one hospital-based and one free-standing midwest inner-city dialysis clinic. Chi-square analyses indicated no significant differences in age, gender, or race between participants and nonparticipants. Subjects who continued the second interview were compared to those who dropped out of the study. Chi-square analyses indicated no significant differences between these two groups in terms of length of time on dialysis, gender, or race. As can be seen in Table 1, the sample was strong in terms of the demographic variables of particular interest.

hemodialysis in coping patients

Stress Reduction Techniques For Hemodialysis Patients

Undergoing dialysis can be very difficult and stressful for hemodialysis patients. There are a lot of factors

that can make this process difficult to cope with. Using coping strategies that best suit each individual can

make the process much easier.

One of the best methods of coping with the stress of dialysis is to perform some type of exercise, no matter

how small. Exercise increases the levels of neurotransmitters that make you feel happy, which is extremely

important if your dialysis therapy has you feeling depressed. One of the forms of exercise that can be

performed even if you are feeling exhausted is called isometrics. This is a resistance exercise that requires

barely any movement and can even be performed while sitting or lying down. In isometric exercise, you

exert some force against either an object that cannot be moved, or you tense the muscle in one position for

a certain amount of time. Flexing is a simple form of exercise, because you are tensing the muscle without

moving your joint at all.

Hemodialysis patients should always consult with your doctor before beginning any sort of exercise routine,

especially if you are undergoing dialysis, as this changes the demands on your body. The appropriate form

of exercise is a very healthy and natural way to take your mind off your condition and alleviate any feelings

of depression.

Another coping method for hemodialysis patients is spending time with other kidney patients on dialysis, or

people who have been on dialysis in the past. Talking and communicating with these people can help you

feel like there is a community that you are a part of. Many patients feel like they are alone in their treatment,

and that feeling of loneliness can be extremely hard to deal with. Talking with others who are under the

same stress can really help you get some of your feelings out in the open. It is always easier to deal with

something in the presence of others who understand your pain.

During the treatments themselves, take something to occupy yourself while you are in the clinic. Four hours

is a long time to lie in a hospital bed and do nothing, and boredom can be crippling sometimes. If you do not

feel like sleeping, you can always take a book of crossword puzzles or a sudoku book to take your mind off

the time. Bringing in a book or magazine is also a great way to while away the hours. Some people will even

bring a portable DVD player or a laptop into the session to provide distraction.

All of these methods are ways that can help you and other hemodialysis patients cope with dialysis

treatment. Everybody is different, so if you prefer to be alone, then reading would probably work best for

you, but if you are a very outgoing person then simply talking to another hemodialysis patient undergoing

treatment, as this can be a very effective way to get through the session and experience less stress about

the entire process.

Procedure Information For Hemodialysis Patients

From the 1960′s to the present, hemodialysis has been the method most commonly used in the treatment of

kidney failure. Kidney failure is a serious condition that leads to a build up of wastes in the blood, because

the kidneys are no long able to effectively filter waste products, excess minerals and excess fluids from the

blood. Even in cases of partial kidney damage, a person may experience high blood pressure and a sense

of fatigue and difficulty concentrating; these are some of the first warning signs of an impaired kidney. Once

kidney function reaches 15% the condition can become life threatening, prompting the use of special

treatments. For hemodialysis patients a special machine is utilized to filter the blood and do the work that the

failing kidneys are no longer able to do.

During the treatment, hemodialysis patients have a tube inserted into one of their major veins, usually in the

wrist, and the blood flows out and into the tube. It passes through an arterial pressure monitor that gauges

the pressure to ensure that it stays regular. From there it passes through a blood pump followed by a

heparin pump, which is important so that the blood does not begin to clot inside the tubes. The blood makes

its way down the line, through another monitor called the dialyzer inflow pressure monitor, which once again

ensures that the blood pressure is not fluctuating and it then passes into the dialyzer. Hemodialysis patients

can visually see most of this process happen before them, when they turn on the dialysis machine.

The dialyzer is essentially an artificial kidney for hemodialysis patients. It filters all the waste products, extra

minerals and fluids from the blood so that they can’t build up and become toxic. The clean blood exits the

dialyzer, passes through another pressure monitor and then flows through an air trap. The air trap is the last

step and is very important because it catches and removes any miniscule air bubbles that may be been

introduced in the dialyzer or in any of the pumps. Once the blood leaves the air trap it is returned to the body

to continue circulating. The entire hemodialysis system virtually replaces the kidneys and allows the body to

continue functioning.

One of the biggest issues that hemodialysis patients face with this treatment is the strict schedule necessary

to complete the procedure. A single session typically lasts between three to five hours and is usually

performed three times a week. Research is currently underway to determine if short day sessions or slightly

longer night sessions are more effective. The night sessions are performed while the patient is asleep.

A standard dialysis machine is roughly the size of a home dishwasher. Recently improvements in technology

have been made that may better facilitate home dialysis treatments. Smaller machines that require less

observation by trained staff could make the procedure much easier for hemodialysis patients who struggle

with the schedule of going to a dialysis clinic several times a week for long periods of time.

FAQs For Hemodialysis PatientsPosted on May 19, 2011 by admin

Q: How will my hemodialysis procedure be paid for?

A: This depends on your health plan coverage, and where you are located. If you have a health plan through

your doctor they may pay for the procedure, but you have to receive treatment from a hospital that is

specified in the health plan. Always request the most experienced doctor that the health plan will cover.

Billing will vary according to policy so it is necessary to access information before hemodialysis patients

begin treatment. If Medicare will be paying for the hemodialysis treatments, you should be sure to have the

access surgery the same month that you begin the hemodialysis treatment. You also need to start training

for home hemodialysis before the third month of dialysis begins. This helps the hospital bill Medicare for

everything at a similar time, which includes access surgery, the dialysis treatments and the home dialysis

training.

Q: Are there benefits to receiving hemodialysis more frequently?

A: Yes. Kidneys that function effectively will be processing and filtering your blood 24/7. Commonly,

hemodialysis, also known as intermittent dialysis, will be performed on at least three days out of the week,

and a single session will normally last between 3 and 5 hours. On the days between treatments,

hemodialysis patients may experience massive fluctuations in water retention, which will affect body weight,

waste accumulation and the balance of electrolytes. These fluctuations have been theorized to be the cause

of some of the side effects that are associated with hemodialysis, such as anemia, hypertension, and

malaise, which is a general feeling of illness. Increasing the frequency of treatments can negate most of the

fluctuations, or at least minimize the range of fluctuation, leading to a reduction in side effects. Frequent

dialysis sessions are much easier on the body and can provide more profound results.

Q: What is meant by nocturnal home hemodialysis for hemodialysis patients?

A: Nocturnal home hemodialysis, or NHHD, can be performed in the patient’s home at night while the patient

sleeps. For some hemodialysis patients this is performed every night of the week. It allows patients to

undergo more frequent hemodialysis sessions without the need for frequent visits to a dialysis clinic. The

session usually lasts for the same length of time that the patient is asleep, which is usually around eight

hours, although it can be as long as twelve hours. The home dialysis machine can be connected to a phone

line or an Internet connection, allowing staff at the hospital to monitor the condition of the machine. If any

problems occur, the machine will alert the hemodialysis patients, who have been trained to deal with minor

problems which normally only require resetting the machine. If the patient doesn’t respond to the alert after a

certain amount of time, the monitor at the hospital will call them via telephone.

Q: Does Medicare cover training for home hemodialysis?

A: Medicare pays the same rate for hemodialysis patients training that is pays for the normal dialysis

session, with an additional $20 per day to cover tests, training manual, supplies and staff time. Medicare will

cover the training for up to three months, although most of the time it will only take between 6 to 8 weeks for

full training.

Categories: Hemodialysis Patients | Tags: Anemia, Bill Medicare, Dialysis Treatments, FAQ’s, Fluctuation,Fluctuations, Frequent Dialysis, Health Plan Coverage, hemodialysis, Hemodialysis Patients,Hemodialysis Procedure, Hemodialysis Treatment, Home Dialysis, Home Hemodialysis, Hypertension,Kidneys, Least Three Days, Malaise, Medicare, nocturnal hemodialysis, Profound Results, Waste Accumulation, Water Retention | Leave a comment

Hemodialysis Patients – Kidney TransplantPosted on May 18, 2011 by admin

Advanced stages of kidney failure usually do not leave many options for hemodialysis patients. The most

common form of treatment is dialysis, although there is an alternative to dialysis. Kidney transplantation

involves receiving a kidney from a donor that is surgically placed into your body. A human being can live a

healthy, symptom free life with only one kidney, allowing you to continue with your life rather than

undergoing the hindrances that hemodialysis patients report from receiving dialysis.

Kidney transplant is a surgical procedure that involves opening your lower abdomen and placing the kidney

inside hemodialysis patients. A surgeon will anesthetize you and then make an incision directly over where

the kidney will go. They will connect the vein and the artery of the transplanted kidney to the corresponding

vein and artery in your own body. The kidney then performs exactly the same way as your original kidney

was intended to: blood flows into the kidney, which then filters out all waste products and excess fluids,

which are then sent to the bladder and excreted as urine. During transplant your own kidneys will be left in

your body, providing that they are not causing any sort of infection or danger to your body.

How to prepare for kidney transplantation

Some health conditions may cause a transplantation to fail, and it can also be considered dangerous in

certain situations for hemodialysis patients. The first thing you need to do is consult with your healthcare

provider to determine if your condition will allow you to receive a transplant.

The best option would be to receive a kidney from a living donor. Usually a family member or close friend

will provide the kidney, as long as their blood type is compatible. If this is not an option, you will be given a

place on a waiting list for a kidney from a recently deceased organ donor. The waiting process for

transplantation for hemodialysis patients can sometimes be very long. Depending on your own blood type,

this can take a long time, even up to several years. In this case, you will most likely be placed on dialysis

until a donor is found that matches your blood type.

The actual surgery will normally take approximately four hours to perform. After this, you will generally stay

in the hospital for around one week, and then regular follow up visits will need to be performed to ensure

that the kidney is functioning correctly. A transplant from a living donor will have a higher percentage of

success than one obtained from a deceased donor, although up to 90% of transplants from deceased

donors are successful.

Kidney transplantation is a much more attractive option than continued dialysis for hemodialysis patients,

because it is essentially a cure. Aside from the risk of rejection by the body, the transplant will completely

take over all the functions of your original kidneys. Of course it is essential to protect your new kidneys from

the damage that originally occurred to your own kidneys. To cut back on the rate of rejection, doctors often

prescribe immunosuppressant drugs, which will prevent your body from attacking the new kidney.

Categories: Hemodialysis Patients | Tags: Bladder, Blood Flows, Blood Type, Deceased Organ Donor,Dialysis, Excess Fluids, Family Member, Health Conditions, Healthcare Provider, Hemodialysis Patients,Hindrances, Incision, Kidney Donor, Kidney Health, Kidney Transplant, Kidney Transplantation, Kidneys,Lower Abdomen, Stages Of Kidney Failure, transplantation, Waiting List | Leave a comment

Stress Reduction Techniques For Hemodialysis PatientsPosted on April 19, 2011 by admin

Undergoing dialysis can be very difficult and stressful for hemodialysis patients. There are a lot of factors

that can make this process difficult to cope with. Using coping strategies that best suit each individual can

make the process much easier.

One of the best methods of coping with the stress of dialysis is to perform some type of exercise, no matter

how small. Exercise increases the levels of neurotransmitters that make you feel happy, which is extremely

important if your dialysis therapy has you feeling depressed. One of the forms of exercise that can be

performed even if you are feeling exhausted is called isometrics. This is a resistance exercise that requires

barely any movement and can even be performed while sitting or lying down. In isometric exercise, you

exert some force against either an object that cannot be moved, or you tense the muscle in one position for

a certain amount of time. Flexing is a simple form of exercise, because you are tensing the muscle without

moving your joint at all.

Hemodialysis patients should always consult with your doctor before beginning any sort of exercise routine,

especially if you are undergoing dialysis, as this changes the demands on your body. The appropriate form

of exercise is a very healthy and natural way to take your mind off your condition and alleviate any feelings

of depression.

Another coping method for hemodialysis patients is spending time with other kidney patients on dialysis, or

people who have been on dialysis in the past. Talking and communicating with these people can help you

feel like there is a community that you are a part of. Many patients feel like they are alone in their treatment,

and that feeling of loneliness can be extremely hard to deal with. Talking with others who are under the

same stress can really help you get some of your feelings out in the open. It is always easier to deal with

something in the presence of others who understand your pain.

During the treatments themselves, take something to occupy yourself while you are in the clinic. Four hours

is a long time to lie in a hospital bed and do nothing, and boredom can be crippling sometimes. If you do not

feel like sleeping, you can always take a book of crossword puzzles or a sudoku book to take your mind off

the time. Bringing in a book or magazine is also a great way to while away the hours. Some people will even

bring a portable DVD player or a laptop into the session to provide distraction.

All of these methods are ways that can help you and other hemodialysis patients cope with dialysis

treatment. Everybody is different, so if you prefer to be alone, then reading would probably work best for

you, but if you are a very outgoing person then simply talking to another hemodialysis patient undergoing

treatment, as this can be a very effective way to get through the session and experience less stress about

the entire process.

Coping strategies and styles of hemodialysis patients by gender

OBJECTIVE: The purpose of this study was to examine the relationship of gender to coping strategies of patients on hemodialysis. DESIGN: Nonexperimental, retrospective. SAMPLE/SETTING: A stratified random sample of 15 male and 15 female hemodialysis subjects was obtained from two privately owned outpatient hemodialysis centers in North Carolina. METHOD: All subjects completed a demographic data form and the Jalowiec coping Scale. A t-test was performed on the overall mean scores for the total coping scale. RESULTS: There was not a statistically significant difference between gender and coping strategies of patients on hemodialysis. However, the data suggest that male and female hemodialysis patients predominately used emotion-focused coping strategies. Patients on hemodialysis less than 8 years,

between the ages of 50 and 60, and who had an educational level less than twelfth grade, used more emotion-focused coping strategies. CONCLUSIONS: No significant difference was noted between the overall cooping scores for men and women. The variables of length of time on hemodialysis, age, and education could have an effect on the choice of coping strategies and coping scores for men and women.A severe chronic illness, such as end stage renal disease (ESRD) requiring hemodialysis, strains the coping capacities of patients and their families (Koller, 1991). As early as 1972, Kaplan De-Nour and Czaczkes hypothesized that there were important factors (physical condition, predialysis personality, factors of dialysis, family reactions, and reaction of the renal team) that affect a patient's ability to cope with dialysis. Kimmel, Weihs, and Peterson (1993) identified additional predictors such as age, gender, nutritional status, immunological competence, personality, family, and social and demographic parameters that affect coping and patient outcomes. Patients undergoing hemodialysis experience many physical, social, and psychological changes. The physical changes involve problems with all body organ systems. Social changes include interference with ability to work, a decreased earning capacity, the increased expense of hemodialysis, and dietary restrictions. Responses to the physical and social problems result in psychological changes.The psychological responses to these changes demand coping strategies. Coping ability must be considered when the goals of treatment for male and female patients receiving hemodialysis are addressed. The goals to be addressed include maintaining their present physiological health and preventing further complications. Even though gender has been cited as playing an important role in individuals' choice of coping strategies and coping styles (Ptacek, Smith, & Zanas, 1992), there has been little research on the affect of gender on the coping strategies of patients on hemodialysis. The identification of gender-based coping strategies for hemodialysis patients may be needed to guide the development of individualized nursing interventions to enhance coping and prevent major adjustment problems.Purpose StatementPsychosocial nursing care of renal patients may include helping them cope with hemodialysis. Therefore, nurses need an understanding of how gender affects coping strategies of hemodialysis patients. The purpose of this research was to investigate the relationship of gender to coping strategies of patients on hemodialysis. The research question was: What is the relationship of gender to coping strategies of patients on hemodialysis?Theoretical FrameworkThe Transactional Stress Model (Lazarus, 1991) provides the framework for this study. In Lazarus' model, stress is defined as a dynamic, ongoing relationship between the person and the environment that is appraised by the individual as exceeding his or her resources and as endangering well-being (Lazarus, 1966; 1991). The transaction refers to the interaction between the person and the situation or environment. This transactional model of stress and coping is an individualistic, process-oriented model that includes three types of appraisal.The three types of appraisal are: primary, secondary, and reappraisal. Primary appraisal is an assessment of a person-environment relationship. If the relationship is appraised as harmful, threatening, or challenging, a secondary appraisal is made. Secondary appraisal examines the availability of coping resources and possible options to resolve the transaction. Primary and secondary appraisal are viewed as interdependent and occurring simultaneously.

Quality of life of hemodialysis patients

Aspects of quality of life in hemodialysis patientsPL Kimmel, RA Peterson, KL Weihs, SJ Simmens, DH Boyle, I Cruz, WO Umana, S Alleyne and JH Veis Department of Medicine, George Washington University Medical Center, Washington, DC 20037, USA.

The proper means of measuring quality of life in chronically ill patients is unclear. Because different measures may assess varied aspects of patients' experience and because they may be interrelated in different ways, the relationship between several of these quality-of- life measures, including indices of psychological well-being, social support, and severity of illness in ESRD patients treated with hemodialysis (HD), was prospectively assessed. In addition, it was determined whether patients' assessment of quality of life, along any dimension, was related to patient compliance in three urban HD units, in a population largely composed of African-American patients. Severity of illness scores correlated with both attendance and compliance with the dialysis prescription. Karnofsky scores correlated inversely with age, depression, social environment, and level of severity of illness, as expected, but not with behavioral compliance

measures. Social support scores correlated with perception of illness, depression, satisfaction with life, and adjustment to illness scores, but not with behavioral or standard compliance measures. Perception of illness scores correlated with depression, social support, adjustment to illness, and satisfaction with life scores, but not with Karnofsky ratings, severity scores, or standard and/or behavioral compliance measures. Social environment scores correlated with almost all assessed variables, with the exception of anthropometric measurements, predialysis phosphorus levels, and behavioral compliance measures. Satisfaction with life scores (a global, subjective measure of quality of life) correlated with advancing age, level of social support, severity of illness, and the presence of a relationship, but were not correlated with Karnofsky scores. These data suggest that quality of life in patients treated with HD must be measured in several ways. The Psychological Adjustment to Illness Scale Social Environment score may be a useful, generalizable adjunct measure of quality of life in HD patients, in addition to the Satisfaction With Life Scale. Quality of life and perception of the effects of illness are not necessarily associated with functional ability in HD patients. These findings must be considered where making decisions about the discontinuation of HD treatment.http://jasn.asnjournals.org/content/6/5/1418.abstract

Quality of life of hemodialysis patients.Ferrans CE, Powers MJ.

AbstractThe purpose of this study was to assess the quality of life of hemodialysis patients. The sample (n = 349) was selected randomly from the adult, inunit hemodialysis patient population of 90% of the counties of Illinois, with the exception of those dialyzed by the Veterans Administration. The findings indicate that the patients in this study were satisfied with their lives in general. Nevertheless, the results also indicated that continued efforts are needed to improve the health and financial independence of hemodialysis patients.

http://www.ncbi.nlm.nih.gov/pubmed/8285799

Depression and Anxiety in Urban Hemodialysis Patients1. Daniel Cukor*, 2. Jeremy Coplan*, 3. Clinton Brown  †   , 4. Steven Friedman*,5. Allyson Cromwell-Smith*  ‡   , 6. Rolf A. Peterson  §   , 7. Paul L. Kimmel  ‖   ¶

+Author Affiliations1. Departments of *Psychiatry and Behavioral Sciences and †Medicine, SUNY Downstate Medical Center,

Brooklyn, and ‡Ferkauf Graduate School of Psychology, Yeshiva University, Bronx, New York; and Departments of §Psychology and ‖Medicine, George Washington University, and ¶American Society of Nephrology, Washington, DC

1. Address correspondence to:Dr. Daniel Cukor, Department of Psychiatry, SUNY Downstate Medical Center, 450 Clarkson Avenue, Box 1203, Brooklyn, NY 11203-2098. Phone: 718-270-2077; Fax: 718-270-3017; E-mail: [email protected] 

Next Section

Abstract

Depression is well established as a prevalent mental health problem for people with ESRD and is associated with morbidity and mortality. However, depression in this population remains difficult to assess and is undertreated. Current estimates suggest a 20 to 30% prevalence of depression that meets diagnostic criteria in this population. The extent of other psychopathology in patients with ESRD is largely

unknown. The aim of this study was to expand the research on psychiatric complications of ESRD and examine the prevalence of a broad range of psychopathology in an urban hemodialysis center and their impact on quality of life. With the use of a clinician-administered semistructured interview in this randomly selected sample of 70 predominately black patients, >70% were found to have a psychiatric diagnosis. Twenty-nine percent had a current depressive disorder: 20% had major depression, and 9% had a diagnosis of dysthymia or depression not otherwise specified. Twenty-seven percent had a current major anxiety disorder. A current substance abuse diagnosis was found in 19%, and 10% had a psychotic disorder. The mean Beck Depression Inventory score was 12.1 ± 9.8. Only 13% reported being in current treatment by a mental health provider, and only 5% reported being prescribed psychiatric medication by their physician. A total of 7.1% had compound depression or depression coexistent with another psychiatric disorder. The construct of depression was also disentangled from the somatic effects of poor medical health by demonstrating a unique relationship between depressive affect and depression diagnosis, independent of health status. This study also suggests the utility of cognitive variables as a meaningful way of understanding the differences between patients who have ESRD with clinical depression or other diagnoses and those who have no psychiatric comorbidity. The findings of both concurrent and isolated anxiety suggest that the prevalence of psychopathology in patients with ESRD might be higher than previously expected, and the disorders may need to be treated independently. In addition, the data suggest that cognitive behavioral therapeutic techniques may be especially advantageous in this population of patients who are treated with many medications.Previous studies established depression as the primary mental health problem of patients with ESRD (1–8). There are recent estimates of a 20 to 30% incidence of depressive disorders in hemodialysis populations (3,6–8). Depression is second only to hypertension in frequency as a comorbid diagnosis in patients with ESRD (9), yet it is understudied (4) and seldom identified or treated adequately in hemodialysis patients (5,7,8). Furthermore, depression has been associated with impaired recovery and increased mortality in many diseases (10,11) and specifically in ESRD (12,13). In addition, we and others have shown that depression is associated with diminished perception of quality of life (14,15).Despite this high rate of depression and the established complications of depression, there is little research on clinical interventions in this problem in patients with chronic kidney disease (16,17). One possible explanation for the lack of intervention trials is that there is still significant confusion regarding how to recognize and define “depression” in the ESRD population (1,4). There is strong overlap between uremic and depressive symptoms, and it can be difficult to identify psychiatric illness against the backdrop of the medical illness (1–4). For example, negative affect as a result of depression can be difficult to distinguish from the known uremic symptoms of irritability, cognitive dysfunction, and encephalopathy or from drug effects or inadequate dialysis. In addition, comorbid depression, or depression that coexists with another psychiatric or medical illness, may render depression relatively refractory to treatment (1–3,6,18,21). Although recent work has emphasized the place of pharmacotherapy for depression, nondrug therapies have also shown to have a place in its treatment (22–24). Kimmel et al. (6) showed that anxiety disorders were prevalent in the Medicare ESRD population, but no study to our knowledge has surveyed patients with ESRD for the presence of multiple psychiatric disorders.A possible way to differentiate between a psychiatric illness such as depression and medical illness involves delineating differences in thinking styles. Cognitive theory posits that people have cognitive conceptualizations of themselves and the world around them (25). When these core conceptualizations, or schemas, are maladaptive, psychopathology is created. Exploring a patient's cognitive schema could be an important tool in differentiating between the unhealthy schema that is associated with depression that stems from a maladaptive view of the world and the psychologically healthy schema of somatic depression that stems from medical illness, such as uremia. Specifically, for there to be meaning in the difference between people who score higher on measures of depressive affect or even a Diagnostic and Statistical Manual of Mental Disorders (DSM) diagnosis of depression and those with lower levels of depressive affect, there needs to be a difference in the quality and/or quantity of dysfunctional schema.Depression may be a salient problem for black patients with ESRD (26), and barriers to therapy may render treatment less available to this population (26,27). The existence of multiple psychiatric comorbid illnesses is an important public health problem in this vulnerable population, in an entitled program with total outlays exceeding $32.5 billion per year in the United States (5,26).We therefore wished to study the prevalence of the broad range of comorbid psychiatric illnesses in an inner-city hemodialysis population and to assess the interaction of medical and psychiatric diagnoses in association with patients’ perceptions of quality of life. We specifically wished to dissociate the symptoms of depression from those of uremia, using a novel approach based on the identification of depression-specific cognitive schema, and to differentiate between depression and anxiety.

Previous SectionNext Section

Materials and Methods

This study was approved by the institutional review board. Participants were randomly selected from the adult hemodialysis patients at a major urban dialysis center in central Brooklyn. All patients in each shift were assigned a number, and then a random list was developed to determine the order in which patients were approached. All selected patients were approached at the dialysis center, and informed consent was obtained. Patients were compensated $20 for their time upon the successful completion of all measures, which took an estimated 2 to 2.5 h. With a desired α of 0.05, an anticipated effect size of 0.15 (medium), and a desired power of 0.80, our estimated a priori sample size was 58 for the hierarchical regression and 17 patients for each of the four cells of our ANOVA. A sample size of 70 was selected to guarantee appropriate power for these analyses, and recruitment continued until 70 participants had completed the assessment. In total, 85 patients, of the possible 123 in the dialysis center, were approached with 73 agreeing to participate; 70 of these 73 completed the assessment. One of the randomly selected patients was unable to complete the informed consent because of her impaired consciousness, so she was not eligible for inclusion in the study. No data are available on the other 11 people who refused to participate. Two of the three who did not complete the assessment had been hospitalized. One stated that her husband wished that she not participate, so she withdrew. Interviews were audiotaped and then independently reviewed for diagnostic accuracy with an overall good level of agreement between raters (r = 0.94).

MeasuresThe Structured Clinical Interview for DSM-IV.

The Structured Clinical Interview for DSM-IV (SCID) (28) is a semistructured interview for making the major Axis I DSM-IV diagnoses. Using a decision tree approach, the SCID guides the clinician in testing diagnostic hypotheses as the interview is conducted. The output of the SCID is a record of the presence or absence of each of the disorders being considered, for current episode (past month). It has variable but acceptable reliability and validity and is accepted as the “gold standard” for deriving psychiatric diagnoses in research studies. It has been previously used in ESRD populations (8,29,30).

Beck Depression Inventory.The Beck Depression Inventory (BDI) (31) is a 21-item self-report instrument with high scores (range 0 to 63) reflecting the presence and the severity of depressed mood. It is a reliable and well-validated measure of depressive symptoms in both clinical and nonclinical samples (32). The BDI has been used extensively in ESRD populations (7,12,13,33,34). Kimmel's team has demonstrated its use in a black hemodialysis patient population (12,13,26). The standard cutoff for depression is a score of 10 or greater in the general population (32); however, in patients with ESRD, a score of 15 or greater has been suggested (35).

Kidney Disease Quality of Life Short Form.The Kidney Disease Quality of Life Short Form (KDQOL-SF) (36) assesses the quality of life of patients with kidney disease. This is accomplished with 43 disease-specific items, 36 generic (SF-36) items, and an overall health-ranking item. Items of the KDQOL-SF are arranged in these subscales: Kidney disease–specific items (symptom/problem list, effects of kidney disease, burden of kidney disease, work status, cognitive function, quality of social interaction, sexual function, sleep, social support, dialysis staff encouragement, patient satisfaction, and overall health rating), generic items (physical functioning, general health, pain, role-physical, emotional well-being, role-emotional, social function, energy/fatigue), and items regarding background information. The KDQOL has been used widely in ESRD populations (15,37,38).

Young's Schema Questionnaire–Short Form (39).The Young's Schema Questionnaire (YSQ) is a 75-item self-report inventory that was designed to measure 15 core beliefs or schemas organized into five domains. It is a relatively new instrument. Shah and Waller (40) published preliminary norms for a depressed group, and it has been used in depressed populations (41) as well as with people with an abuse history (42). Schmidt et al. (43) showed that its primary scales possess adequate test–retest reliability and internal consistency, with the majority of the proposed scales being replicated by factor analysis. The YSQ has also been found to possess convergent and discriminant validity with respect to measures of psychologic distress, self-esteem, cognitive vulnerability for depression, and personality disorder symptoms (43). A higher score reflects a more maladaptive, unhealthy core belief. The five domains with their subscales are displayed in the appendix.

View this table:

In this window 

In a new window

Table 1.

Demographic information

View this table:

In this window 

In a new window

Table 2.

Comparison of variables by psychopathology groupa

View this table:

In this window 

In a new window

Appendix 1.

YSQ domains, description, and included subscales

Statistical AnalysesAll data were analyzed using the computer-based statistical software package SPSS (version 13.0; SPSS, Chicago, IL). Descriptive statistics were calculated for the sample population, and the group differences were compared for continuous variables with an ANOVA, using Tukey least significant difference (LSD) for post hoc comparisons. Pearson correlations were derived, and tests of significance were set at 0.05. Patients were divided by type of psychopathology, and their quality of life, depressive affect, and cognitive schema were compared. For the ordinal comparisons, a cross-tabs with χ2 was used. For exploration of the effects of self-reported health status and depression on quality of life, a factorial ANOVA was undertaken, in which high and low scorers, determined by median split on the SF-36, and those with and without a depression diagnosis were compared on overall quality of life. Finally, for identification of the unique variance in depression diagnosis as a result of depressive affect once the common variance with health status had been controlled, a hierarchical logistic regression was used The SF-36 was entered into the model first and then BDI score to examine the unique effect of depression once the shared effects of health status were controlled.

Previous SectionNext Section

Results

Women composed 53% of the sample, and 50% of the people had been born in the United States (Table 1). The average age was 53.2 ± 15.0 yr. Eighty-nine percent identified themselves as black or Afro-Caribbean, 3% as Hispanic, 1% as white, and 7% as other. The average amount of education was 12.7 ± 3.7 yr. The sample was medically ill, averaging 1.9 ± 3.3 hospitalizations within the past year. The average duration for which patients were treated with dialysis was 61.0 ± 63.6 mo. Only 14% of the sample was working.

PsychopathologyIn the total sample of 70 patients with ESRD, 71.4% had a current DSM-IV Axis I diagnosis based on the SCID-I (Figure 1). Twenty-nine percent had a current depressive disorder: 20% had major depression, and 9% had a diagnosis of dysthymia or depression not otherwise specified. No patients had a diagnosis of bipolar disorder. Twenty-seven percent had a current major anxiety disorder (panic with or without agoraphobia, posttraumatic stress disorder, obsessive-compulsive disorder, social phobia, or generalized anxiety disorder). A current substance abuse diagnosis was found in 19%, and 10% had a current psychotic disorder. The group had a mean BDI score of 12.1 ± 9.8. Thirteen percent of the sample reported being in current treatment by a mental health provider, and an additional 5% reported being prescribed psychiatric medication by their physician. There were no differences between SCID groups regarding employment or place of birth. In a one-way ANOVA, there were no differences in the rates of psychopathology by age, length of time treated for ESRD, years of education, or number of medical hospitalizations in the past year.

View larger version:

In this page 

In a new window

Download as PowerPoint Slide

Figure 1.

Psychiatric diagnostic category.

Differences among Psychiatric Diagnostic GroupsPatients were divided into psychopathology groups on the basis of their SCID diagnoses to understand the interplay between psychiatric diagnosis and quality of life, depressive affect, and cognitive schema. There was significant overlap (60%) between psychotic diagnoses and substance abuse diagnoses, so these diagnostic groups were combined. Of the 70 patients, only seven had diagnoses from more than one diagnostic group. Two patients had both an anxiety and a depressive disorder; two patients had an anxiety and a substance/psychotic disorder; and three patients had an anxiety, a depression, and a substance/psychotic diagnosis. These patients were excluded from this analysis. Overall, there were significant differences in an ANOVA between psychopathology diagnoses and the BDI scores (F3,59 = 14.4, P < 0.001; Table 2). The depressed group had significantly higher mean BDI scores (21.9 ± 10.1) than the no psychopathology group (6.0 ± 4.3; Tukey HSD P < 0.01), the anxiety group (10.4 ± 8.3; Tukey HSD P < 0.01), and the other psychopathology group (10.1 ± 6.8; Tukey HSD P < 0.01). There were also significant differences on the KDQOL (F3,59= 16.9, P < 0.001), with the depressed group having significantly lower total quality of life than the no psychopathology group (51.1 ± 13.2 versus 75.4 ± 7.5; Tukey HSD P < 0.001), the anxiety group (65.6 ± 13.1; Tukey HSD P < 0.001), and the other psychopathology group (67.8 ± 5.6; Tukey HSD P < 0.001). The anxiety group demonstrated a lower perception of quality of life (KDQOL) than the no psychopathology group (65.6 ± 13.1 versus 75.4 ± 7.5; Tukey HSD P < 0.001). Age, gender, and length of time on dialysis were examined as possible covariates but did not significantly effect these relationships (P > 0.05).There were significant differences across psychopathology groups on the YSQ domains of disconnection and rejection (F3,59 = 6.8, P < 0.001) and impaired autonomy (F3,59 = 9.8, P < 0.001), with the depressed group showing higher values compared with the no psychopathology group (Tukey HSD P < 0.001) on both of these domains (Table 2). There were also differences on the other directedness YSQ domain (F3,59 = 5.3, P < 0.001), with people with psychotic or substance abuse diagnoses showing higher values when compared with the no psychopathology group (Tukey HSD P < 0.001).

Quality of LifeThe mean score for all patients on the KDQOL-SF was 65.8 ± 13.5, whereas the mean score on the SF-36 was 50.1 ± 70.3. It is interesting that there were no significant relationships between either perception of quality of life or self-reported health status and number of hospitalizations in the past year or length of time on dialysis (NS in all cases). For exploration of the effects of self-reported health status and depression on quality of life, a factorial ANOVA was undertaken. This analysis compared high and low scorers on the SF-36 with those with and without a depression diagnosis on KDQOL values. Both poor health status (F1,69 = 14.7, P < 0.001) and a positive depression diagnosis (F1,69 = 37.3,P < 0.001) were significantly associated with perception of lower quality of life. It is interesting that there was no interaction effect (F1,69 = .93, NS), indicating that both health status and depression diagnosis make unique contributions to the variance within quality-of-life scores.To highlight further the existence of depression independent of health status, we performed a hierarchical regression (entering SF-36 first and then BDI score) to predict SCID depression diagnosis. This method allowed for isolation of the unique variance in depression diagnosis as a result of depressive affect, once

the common variance with health status had been controlled. The BDI retained its significance in predicting depression diagnosis (Nagelkerke R2 = 0.515, P < 0.001), even when the shared variance with the SF-36 was held constant. The BDI step of the model correctly classified 82.6% of SCID depression cases correctly, indicating the presence of a unique construct of depression independent of health status.

Previous SectionNext Section

Discussion

This study sought to explore the range and the extent of psychopathology in urban patients who had ESRD and were treated with hemodialysis. Information on 70 randomly selected inner-city patients from the Hemodialysis Center was gathered. Overall, the population had a high rate of DSM-IV diagnoses (74%), as determined by the clinician-administered SCID. This is the first known report on the full spectrum of psychiatric disorders determined systematically in a hemodialysis population. Rates of depression were comparable to other studies in ESRD and other medically ill populations (1–3). We found that the rate of major depression (20%) and dysthymia (9%) in the current study were in good agreement with other ESRD studies. Watnick et al. (30) found SCID rates of depression of 26%, Hedayati et al. (8) reported a SCID depression prevalence of 27%, and Kimmelet al. (44) reported depression at 25% using a stringent cutoff of the BDI. The rate of anxiety disorders (27%) was somewhat higher than the expected rate (18%) on the basis of the National Comorbidity Survey (45). The rates of substance abuse disorders and psychotic disorders were higher than community averages, but that was anticipated because of the relationship between the cause of kidney disease and substance abuse (6,46,47) and the known prevalence of psychiatric disorders in patients who have ESRD and are treated with hemodialysis (6,48).More than 80% of patients with a psychotic disorder reported receiving mental health treatment, but only 12% of patients with a diagnosis of anxiety or depression were currently receiving treatment. This highlights how underrecognized depression and anxiety are and perhaps suggests a tolerance of depression and anxiety by physicians and staff, accepting them as part of the ESRD experience.The rate of comorbid depression and anxiety (7% for depression and a major anxiety disorder) was lower then expected. It is possible that the excess depression demonstrated in ESRD populations is causally linked, either biochemically or experientially, to ESRD, because there has been some research suggesting an causative link through inflammatory processes (3,49,50) and a psychodynamic literature (3,51) linking depression and dialysis. These pathways are specific for depression and do not include anxiety and therefore perhaps explain the relatively minor overlap between the diagnoses.Because of the strong overlap between uremic and depressive symptoms, it has been difficult to isolate the unique role that depression plays in ESRD. This study sought to explore the utility of the construct of depression by examining its relationship to quality of life and self-reported health status. In accordance with previous research, a strong negative relationship between quality of life and depression scores was demonstrated (1,2,4,33). The factorial ANOVA highlighted the independent contribution that a depression diagnosis has on quality of life for patients with both high and low health status. The hierarchical regression indicated that depressive affect accounts for depression diagnosis, independent of health status, suggesting that depression exists in ESRD populations independent of uremia. Both of these analyses support the conclusion that the construct of depression is meaningful in ESRD populations.This study also investigated the utility of using cognitive variables as another tool to understand effectively the meaningfulness of the construct of depression in this complex medically ill population. In this sample, the YSQ, specifically the disconnection and rejection domain and the impaired autonomy domain, effectively distinguished between those who had the diagnosis of depression and those who did not, granting validity to the notion of psychiatric depression in this patient population. In fact, patients with an anxiety disorder showed no elevations in their cognitive schema, lending validity to the YSQ as a sensitive measure of depressogenic schema. The elevation in the disconnection and rejection domain suggests that the depressed individuals have higher expectation that their needs for security, safety, acceptance, and respect will not be met in a predictable manner. In addition, the elevation in the impaired autonomy domain suggests that depressed individuals have increased expectations about themselves and the environment that interfere with their perceived ability to separate, survive, function independently, or perform successfully. These findings are in accordance with the primarily psychodynamic literature that discusses these themes of “aloneness” and “ineffectiveness” as hallmarks of the depressogenic changes that are associated with ESRD treatment (51).Methodologic limitations of this study include a lack of a community comparison group and the reliance on self-report measures of physical health without corroboration from health biomarkers. Despite these limitations, there were also methodologic strengths in that it used random selection within each dialysis shift and both self-report and clinician report measures of psychopathology. In addition, these data were collected from a population that was overenriched for black patients. This is an important subpopulation in the United States, composing 13% of the total population and 32% of patients in the US Renal Data

System (52). Although the data that were derived for this study may not be generalizable across the United States, these findings are largely comparable to units across the urban East Coast and Southeast of the United States, in which the overwhelming majority of patients are black (53). Our data need to be replicated in larger, multicenter studies that will yield populations that are more similar to the US Renal Data System.It is interesting to note the psychologic state of the patients without any psychiatric illness, because their overall depression (BDI) scores place them in the normal range and their overall quality-of-life scores placed them significantly higher than patients with an anxiety or depression diagnosis. It seems that despite all of the medical and psychologic challenges of living on dialysis, people without a comorbid psychiatric condition, particularly depression, can enjoy a much greater quality of life. These findings have strong implications for the need for treatment of depression in patients with ESRD, because now there is indication that treatment might not only decrease depression but also improve quality of life (5). The study provides preliminary evidence that anxiety exists independent of depression in this patient population, and further investigation is warranted to determine whether it is best treated with the depression or independently. In addition, this study contributes to the emerging intervention literature (33,54–56), suggesting more reason to suspect that interventions that are aimed at challenging distorted cognitive beliefs, perhaps using cognitive behavioral therapeutic techniques (54), will be particularly useful in this patient population, which is subject to treatment with so many medications.

http://cjasn.asnjournals.org/content/2/3/484.full

Renal Provider Recognition of Symptoms in Patients on Maintenance Hemodialysis

1. Steven D. Weisbord*  †   ‡   , 2. Linda F. Fried*  †   ‡   , 3. Maria K. Mor*  §   ,4. Abby L. Resnick*, 5. Mark L. Unruh  ‡   , 6. Paul M. Palevsky  †   ‡   ,7. David J. Levenson**, 8. Stephen H. Cooksey**, 9. Michael J. Fine*  ‖   ,10.Paul L. Kimmel  ¶   , 11.Robert M. Arnold  ‖

+Author Affiliations1. *Center for Health Equity Research and Promotion and †Renal Section, Medical

Specialty Service Line, VA Pittsburgh Healthcare System, ‡Renal-Electrolyte Division and ‖Division of General Internal Medicine and **Department of Medicine, University of Pittsburgh School of Medicine, and §Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania; and ¶Division of Renal Diseases and Hypertension, Department of Medicine, George Washington University Medical Center, Washington, DC

1. Address correspondence to:Dr. Steven D. Weisbord, VA Pittsburgh Healthcare System, Mailstop 111F-U, 7E Room 120, Pittsburgh, PA 15240. Phone: 412-688-6000, ext. 815911; Fax: 412-688-6908; E-mail: [email protected] 

Next Section

Abstract

Background and Objectives: Although several studies have found that the burden of symptoms in patients who are on maintenance hemodialysis is substantial, little is known about renal providers’ awareness of these symptoms. The aim of this study was to assess renal provider recognition of symptoms and their severity in hemodialysis patients.Design, Setting, Participants, & Measurements: The Dialysis Symptom Index, a 30-item measure of symptoms and their severity, was administered to patients during a routine hemodialysis session. Immediately after surveying patients, the renal provider who evaluated the patient completed the Dialysis Symptom Index to report the symptoms that he or she believed were present in that patient. Sensitivity, specificity, and positive and negative predictive values of provider reports of symptoms were calculated using patient reports as the reference standard. Patient–provider agreement on the presence and severity of symptoms was assessed using the κ statistic.Results: Surveys were completed by 75 patients and 18 providers. For 27 of 30 symptoms, the sensitivity of provider responses was <50%, and provider responses for 25 symptoms were characterized by positive predictive values of <75%. κ scores for 25 symptoms including those pertaining to pain, sexual dysfunction, sleep disturbance, and psychologic distress were <0.20, indicating poor provider recognition of these symptoms. Providers underestimated the severity of 19 of 30 symptoms.Conclusions: Renal providers are largely unaware of the presence and severity of symptoms in patients who are on maintenance hemodialysis. Implementation of a standardized symptom assessment process may improve provider recognition of symptoms and promote use of symptom-alleviating treatments.Patients who are on maintenance hemodialysis have impaired health-related quality of life (HRQoL) compared with the general population and patients with functioning renal transplants (1–5). Although multiple factors likely contribute to these impairment in HRQoL, growing evidence suggests that physical and emotional symptoms play an important role (6–13). Parfrey et al. (14–16) demonstrated nearly two decades ago that physical and emotional symptoms were both common and severe in patients who were on long-term hemodialysis. More recent studies confirmed this finding and have shown that symptom burden is highly correlated with impaired HRQoL in this patient population (7–9,11). Our group recently found that physical and emotional symptom burden is associated with reduced HRQoL and higher levels of depression (8).Despite the growing body of evidence that symptoms play an important role in the lives of patients who are on maintenance hemodialysis, there have been few efforts to examine the extent to which renal providers assess or effectively treat symptoms in these patients. Moreover, preliminary studies suggest that treatment of symptoms such as pain in patients with ESRD is suboptimal (17). Whether this is due to renal providers’ underrecognition of the presence of pain or their failure to implement effective therapeutic strategies for this symptom remains unknown. The success of interventions to ameliorate pain and other bothersome symptoms and ultimately improve the overall HRQoL of dialysis patients depends in large part on the answer to this question. The aim of our study was to assess renal provider recognition of the presence and severity of physical and emotional symptoms in maintenance hemodialysis patients.

Previous SectionNext Section

Materials and Methods

Study Participants

We conducted a cross-sectional, observational study of long-term hemodialysis patients and their renal providers from February 2006 to July 2006. Study patients and providers were recruited from three dialysis units in Pittsburgh, PA, including one university-affiliated and two community-based units. The university-affiliated unit provides care for a largely urban patient population and is staffed by academic nephrologists. One community-based unit serves an urban, predominantly black patient population, whereas the other services a largely suburban, white group of patients. Private practitioners treat patients at each of these community-based units. These three dialysis facilities were selected to recruit demographically diverse patients as well as a variety of renal providers from academic and community-based practice settings.

Provider and Patient Recruitment

At the initiation of the study, all physicians, physician assistants, and nurse practitioners caring for hemodialysis patients at each of the three participating dialysis units were approached and asked about their willingness to participate in a study of provider awareness of hemodialysis patients’ symptoms. We also approached nurse managers at one site in which patients were seen and evaluated by nurse managers before being evaluated by the renal providers. We included only providers who had experience treating dialysis patients for at least 3 mo and who routinely evaluated patients at the study dialysis units to help ensure the enrollment of clinicians who were familiar with the care of this patient population. Informed consent was obtained from providers who were willing to participate. Standard procedure at these three dialysis units was for the nephrologist to see patients once monthly and nurse practitioners/physician assistants to evaluate patients the alternate 3 wk.After the enrollment of all providers, patient recruitment commenced. Dialysis technicians approached patients to inquire about their willingness to participate in a study of dialysis-related symptoms during a routine hemodialysis session immediately after they had been seen by an enrolled study provider during dialysis rounds. Patients who expressed interest were approached by the study coordinator to explain the study in detail and to obtain written informed consent. To help ensure the recruitment of patients who were capable of providing reliable responses to the study survey, we administered the Mini-Cog, a combined three-word recall and clock-drawing test, and excluded patients with scores that were indicative of cognitive impairment (18,19). No data were collected from patients who did not consent to participate in the study.

Survey Administration and Data CollectionAfter patient enrollment, the study coordinator collected basic demographic data from the patient and administered the Dialysis Symptom Index (DSI) during the dialysis treatment. The DSI contains 30 items, each of which targets a specific physical or emotional symptom (20). Patients were asked to identify symptoms that had been present at some time during the previous 7 d by responding “yes” or “no” and to describe the severity of symptoms that had been present using a five-point Likert scale (1 = not bothersome to 5 = bothers very much). Immediately after the administration of the DSI to the patient, the same study investigator located the provider who had just examined the enrolled patient in the dialysis unit to have that provider complete the DSI and identify the symptoms that he or she believed were present in that patient during the previous 7 d and for symptoms that they believed were present, the corresponding severity. The DSI that providers were asked to complete was modified slightly to allow a response of “don't know” for

symptoms that he or she was not sure were present. For providers who were unable to complete the survey immediately after rounds, we requested that the survey be completed and returned within 24 h. This process helped ensure the temporal congruity between patient and provider completion of the DSI. Providers were not informed in advance regarding which patients would be approached for enrollment to limit the likelihood that they would alter their assessment of patients during dialysis rounds. Finally, the study investigator abstracted basic clinical and treatment-related data from the dialysis chart including hemoglobin, serum albumin, phosphorous, calcium, and intact parathyroid hormone concentrations and presence of the clinical conditions that comprise the Charlson Comorbidity Index.

Statistical AnalysesThe primary analyses were based on assessing provider recognition of symptoms in their patients. To examine the accuracy and predictive value of provider responses for identifying symptoms in their patients, we calculated sensitivity, specificity, and positive (PPV) and negative predictive values (NPV) of provider responses using patient reports as the gold standard and considering provider “don't know” responses as a “no” response. Sensitivity denotes the proportion of patients who have a symptom and are correctly identified by providers as having the symptom, whereas specificity represents the proportion of patients who do not have a symptom and are identified as such by providers. PPV represents the probability that a patient has a symptom if their provider indicates its presence, whereas NPV describes the probability that a patient does not have a symptom if their provider indicates its absence. To examine agreement between patients and providers on the presence/absence of individual symptoms on the DSI, we calculated κ scores. These scores were based on agreement between patient and provider on individual symptoms and do not reflect the total number of symptoms correctly identified by the provider. The κ statistic defines the level of agreement above what is attributable to chance alone. A κ score of 0 to 0.2 signifies poor agreement, 0.2 to 0.4 indicates fair agreement, and >0.4 denotes moderate to good agreement (21). Negative κ scores represent less agreement than would be expected purely by chance. Because the DSI that was administered to patients and providers differed slightly in that providers were allowed to record “don't know” responses for the presence of symptoms, we assessed patient–provider agreement on the presence of symptoms in three different ways. The first method of calculating κ scores, which we considered to be the most clinically informative, was based on considering provider “don't know” responses as disagreement. We also calculated κ scores by considering “don't know” responses as a “no” response for providers and, last, by excluding items for which providers’ responded “don't know” and using only items for which providers responded “yes” or “no” to the presence of a symptom. To assess patient–provider agreement on the severity of those symptoms that both the patient and provider indicated were present, we used weighted κ scores, which give partial credit for provider responses that were close to but not identical to patients’ severity rating.Multiple logistic regression was used to explore the effects of provider type, years of experience treating dialysis patients, and dialysis unit on the outcome variable of patient–provider agreement on the presence of symptoms (considering “don't know” responses as indicating disagreement). In these analyses, we accounted for clustering of responses by providers and controlled for type of symptom and provider age. We defined statistical significance using a two-tailed P = 0.05. All analyses were conducted using Stata 9 (Stata Corp., College Station, TX). All study procedures were approved by the University of Pittsburgh institutional review board.

Results

Study PopulationOverall, 18 of 19 providers and 75 of 79 patients were enrolled in the study; one patient did not pass the Mini-Cog test and was excluded. Ten (56%) providers were from the university-affiliated dialysis unit, and the remaining eight (44%) providers cared for patients at the community-based units. Nine providers were nephrologists, five were nurse practitioners or physician assistants, and four were nurse managers. The mean age of the providers was 41 ± 9 yr (range 27 to 56), and the mean number of years of experience treating dialysis patients was 9 ± 9 yr (range 1 to 27). The median number of surveys completed by providers was 3 (range 1 to 20). Sixteen providers were white, and two were Asian. Of the 75 patient participants, 33 (44%) were from the university-affiliated unit and the remaining 42 (56%) patients received dialysis at one of the two community-based clinics. None of the patients had been on dialysis for <6 mo. Table 1 illustrates the clinical characteristics of study patients.

View this table:

In this window 

In a new window

Table 1.

Baseline demographic and clinical characteristics of patients

Accuracy and Predictive Value of Provider ResponsesThe prevalence and severity of symptoms reported by patients and providers are depicted in Table 2. Providers underreported the presence of 29 (97%) of 30 individual symptoms and, compared with patient-reported severity, underestimated the severity of 19 (63%) of 30 symptoms (Table 2). The frequency of provider “don't know” responses ranged from 3% for “shortness of breath” to 76% for “difficulty becoming sexually aroused.” The sensitivity of provider responses for all symptoms other than “fatigue,” “nausea,” and “shortness of breath” was <50% (Table 3). The PPV of provider reports ranged from 0% for “chest pain” and “difficulty concentrating” to 100% for “dry mouth.” PPV were <75% for 25 individual symptoms (Table 3).

View this table:

In this window 

In a new window

Table 2.

Patient and provider reports of symptoms and their severity

View this table:

In this window 

In a new window

Table 3.

Accuracy and predictive value of provider responses

Patient–Provider Agreement on the Presence and Severity of SymptomsAgreement between patients and providers on the presence and severity of symptoms is displayed in Table 4. Overall, κ scores were lowest when provider “don't know” responses were considered a disagreement and slightly higher when “don't know” responses were considered as a “no” response or excluded. Considering the model in which “don't know” responses were counted as a disagreement, there was poor concordance (κ < 0.2) on the presence of 25 (83%) individual symptoms. Patient–provider agreement on the 12 symptoms that patients described as being most severe (mean severity >3.0) was universally poor (κ < 0.15). Agreement on the severity of individual symptoms was lowest for “feeling sad” (κ = −0.17) and “headache” (κ = −0.15) and highest for “dry mouth” (κ = 0.56). Weighted κ scores for the severity of five symptoms were less than zero, including those for “trouble falling asleep,” “feeling sad,” and “restless legs.”

View this table:

In this window 

In a new window

Table 4.

Patient–provider agreement on symptoms and their severitya

Associations of Provider Type, Years of Experience, and Dialysis Unit with Symptom RecognitionIn the multiple logistic regression model, nurse practitioners and physician assistants were less likely than nephrologists to agree with patients on the presence of symptoms (odds ratio [OR] 0.28; P < 0.001), and although not statistically significant, nurse managers tended to be more likely than nephrologists to agree with patients (OR 2.8; P = 0.21). Each year of providers’ experience was associated with a greater likelihood of agreeing with patients on the presence of symptoms (OR 1.1; P = 0.008). Relative to providers at the university-affiliated dialysis unit, providers at the two community-based clinics were less likely to agree with patients (OR 0.38 and 0.59 respectively; P = 0.01).

Previous SectionNext Section

Discussion

In this study, renal providers were largely unaware of the presence of physical and emotional symptoms in their patients who were on maintenance hemodialysis, including symptoms that patients described as most severe. When providers did correctly identify symptoms, the severity of those symptoms was commonly underestimated by providers. Although not unexpected, these observations are novel and have potential implications for the design of interventions to improve the treatment of symptoms in this patient population.Studies in other patient populations have also documented substantial underreporting of symptoms by providers. Using survey study techniques similar to ours, Justice et al. (22) compared patient- and provider-reported symptoms in a large cohort of HIV patients. The κ score for agreement on the presence of symptoms overall was 0.35 yet was found to be only 0.25 when comparing symptoms that patients had reported as at least moderately severe. These measured levels of agreement, although slightly higher than those seen in this study, were interpreted to signify considerable underrecognition of symptoms by providers. In a study of oncology patients, Grossman et al. (23) used a visual analog scale to compare patient and provider reports of the intensity of pain experienced by patients. In cases in which pain was reported as >4 on the 10-point analog scale, there was no statistically significant correlation between patient-described intensity of pain and the intensity reported by providers. Our findings closely mirror the results of these two studies.Especially noteworthy in this study is provider underrecognition of specific symptoms that are amenable to treatment and are correlated with impaired HRQoL. Provider awareness of “bone or joint pain,” which was one of the more common and most severe symptoms reported by patients, was characterized by a κ score of only 0.04 and sensitivity of 18%, whereas 35% of providers recorded a response of “don't know” for this symptom. Likewise, agreement on the presence of other pain-related symptoms, including “muscle cramps,” “muscle soreness,” and “chest pain,” were characterized by κ scores <0.05. A series of studies found that pain affects as many as 50% of hemodialysis patients, is frequently untreated or treated inadequately, and is associated with impaired quality of life (8,11,17,24). Moreover, a recent study by Barakzoy and Moss (25) demonstrated that implementation of the World Health Organization pain treatment algorithm effectively reduced the severity of pain in hemodialysis patients. The availability of effective therapy along with the high prevalence and clinical significance of pain in hemodialysis patients underscores the importance of our finding that renal providers seem largely unaware of the presence and severity of this symptom.A series of DSI items relate to patients’ sense of psychologic well-being and have been found in previous analyses to correlate closely with depression (8). Major depression is present in nearly one in five long-term hemodialysis patients and is associated with impaired HRQoL and adverse outcomes, including mortality (26–28). Our findings suggest that renal providers are also unaware of symptoms that may signify underlying psychologic distress, which would seem to compromise their capacity to identify and intervene on this problem. Likewise, 75% of renal providers reported not knowing whether symptoms pertaining to sexual dysfunction affected their patients. Dialysis patients may feel particularly uncomfortable discussing sexual dysfunction in the setting of a dialysis unit. However, problems with sexual function are common in hemodialysis patients, and the lack of awareness among providers of their presence and severity should serve as an impetus for the use of a standardized process of assessment of

such sensitive issues (29). Last, symptoms pertaining to sleep disturbance were among the most common and severe yet were largely unrecognized by providers. Behavioral therapy may be appropriate for dialysis patients who have trouble falling and staying asleep, yet implementation of such therapy hinges on the recognition of such symptoms by providers. Providers did recognize shortness of breath and swelling with reasonable accuracy. This is likely because these symptoms are often related to extracellular volume retention, which providers routinely assess in hemodialysis patients. Efforts to increase awareness of the symptoms that are less clinically apparent on physical examination may help to improve provider assessment and treatment of such symptoms.Our findings may be explained by the current framework for the treatment of dialysis patients in which quality of care is defined in large part by the attainment of target parameters of dialysis adequacy, anemia management, bone and mineral metabolism, and vascular access, rather than alleviation of symptoms or improvement in quality of life. In 2004, the Centers for Medicare and Medicaid Services changed reimbursement to nephrologists to increase the number of monthly patient evaluations and improve quality of care and outcomes. However, more frequent patient–provider interactions have not been shown to increase the proportion of patients who meet currently accepted quality metrics or improve overall quality of life or patient satisfaction with care, highlighting the need for alternative ways to improve the lives of hemodialysis patients (30). The Institute of Medicine has defined quality of care on the basis of six parameters, one of which is patient centeredness (31). Patient centeredness requires that care focus on issues that matter most to patients, including treatment of symptoms and improvement in quality of life. Our findings suggest that the current model of care for long-term hemodialysis patients is not adequately patient centered and that new systems of care that incorporate and emphasize patients’ symptoms, quality of life, and satisfaction with care should be considered.This study has important limitations. First, the sample size of patients and providers was small, which may limit the generalizability of our findings. However, our study patients were younger than the national average and seemed to have less cardiovascular comorbidity, suggesting that symptom burden may be even greater in a more ill patient group. Second, although all provider surveys were returned within 24 h of patient evaluations and all but two were returned immediately, lack of recall of symptoms may have contributed to provider responses. It is also possible that disagreement between patients and providers was due to the difficulty for providers to recall accurately which patient had a symptom, not whether they had the symptom. Third, we did not assess agreement considering provider “don't know” responses as a “yes” response. However, post hoc sensitivity analyses of this question did not result in different results (data not shown). Fourth, certain symptoms on the DSI may have no effective therapies, which may explain why providers are less aware of their presence. Providers did demonstrate greater awareness of symptoms such as shortness of breath and leg swelling, for which modification of the dialysis procedure might be therapeutic. This suggests that familiarity with treatment options influences providers’ assessment and awareness of symptoms. Fifth, the Mini-Cog may not have detected patients with mild cognitive impairment, which could have led to the underreporting of symptoms. Finally, we did not address whether certain symptoms were addressed by patients’ primary care providers, which might explain why renal providers did not accurately recognize them. Patients may not have reported certain symptoms to renal providers if they were only transiently present during the preceding 7 d, if they believed that the symptoms were being managed by nonrenal providers, or if they perceived the symptom as untreatable. However, even if other providers were administering treatment, given the severity of many symptoms, one would expect renal providers to note their presence and communicate potential undertreatment to the primary provider. We should also point out that standard practice at the university-based dialysis unit, from which nearly half of study patients and 56% of providers were recruited, is for the renal provider to assume the role of primary care provider.

Previous SectionNext Section

ConclusionsThe results of this study suggest that renal providers do not adequately recognize physical and emotional symptoms in patients who are on long-term hemodialysis and often underestimate the severity of the very symptoms that are most troubling to patients. These findings suggest that the development of a standard process of symptom assessment by renal providers, either during the dialysis procedure or apart from direct dialysis care, may be the first step toward the goal of improving recognition and treatment of symptoms in this population—processes that, in turn, could have a favorable impact on patients’ overall quality of life and satisfaction with care.

http://cjasn.asnjournals.org/content/2/5/960.full

Three barriers prevent better dialysis - Kidneys - hemodialysis treatment research - Brief Article - Statistical Data Included

A clinical trial at Case Western Reserve University School of Medicine, Cleveland, Ohio, demonstrates that identifying and overcoming three barriers--underprescription of dialysis by physicians, use of intravenous catheters to provide treatment, and shortening of treatment time by patients--greatly improves the quality of hemodialysis treatment, a finding that may help the 33,000 Americans receiving suboptimal doses. Hemodialysis is used to treat people with kidney failure. In the process, blood is removed from the body and pumped into a machine that filters out toxic substances from the blood and then returns the purified blood to the person. The randomized, controlled study showed that educating physicians and patients about these barriers resulted in a twofold increase in dialysis dose compared to conventional care.Virtually all dialysis treatment is paid for by Medicare, even for patients younger than 65. Despite Federal expenditures of $18,000,000,000 annually, the mortality rate among American hemodialysis patients is the highest in the industrialized world at 23% per year. (European and Japanese hemodialysis patient mortality rates run 10-15% annually.) One-sixth of the 200,000 Americans undergoing hemodialysis treatment do not receive an adequate dialysis dose, it was bund.The study, involving 169 patients from 29 hemodialysis facilities, identified and addressed each barrier separately. If dialysis prescriptions turned out to be too low, a study coordinator helped physicians improve them. If patients received treatment through a catheter, the coordinator assisted them in getting grafts or fistulas (surgically created connections between an artery and a vein that provide a better blood flow for dialysis) instead. If patients shortened treatment time by coming late or leaving early, the coordinator educated them about the importance of staying for the full amount of time."Dialysis is similar to drugs in that both must be given at an appropriate dose to be effective," Aswini Sehgal, associate professor of medicine, biomedical ethics, and epidemiology and biostatistics, points out. "Patients getting an inadequate dialysis dose die sooner and are hospitalized more often." Moreover, the Federal reimbursement system, which provides a fixed payment per treatment, may act as a financial disincentive to the providing of high-quality treatment. "Using higher-efficiency machines or increasing treatment time costs money, but facilities don't get paid more for these higher costs. I urge patients to stay for their full treatment time. I urge physicians and dialysis facilities to address the three barriers we identified. I urge policymakers to reexamine how we pay for dialysis treatment."

COPYRIGHT 2002 Society for the Advancement of Education

COPYRIGHT 2002 Gale Group

http://findarticles.com/p/articles/mi_m1272/is_2689_131/ai_92691055/