Health care providers' support of patients' autonomy, phosphate medication adherence, race and gender in end stage renal disease

African American Patients' Perspectives on Determinants of Hemodialysis Adherence and Use of Motivational Interviewing to Improve Hemodialysis Adherence

Key Points

African American patients have unique insights on hemodialysis adherence and use of motivational interviewing to promote adherence. Key themes were mental health issues; historical mistrust; social determinants of health; and importance of provider cultural competence. Themes led to a novel conceptual model, which will inform the design of a motivational interviewing-based protocol to improve adherence.

Background

Compared with White patients, African American (AA) patients have a four-fold higher prevalence of kidney failure and higher hemodialysis nonadherence. Adherence behaviors are influenced by psychosocial factors, including personal meaning of a behavior and self-confidence to enact it. We assessed perspectives of AA hemodialysis patients on unique factors affecting dialysis adherence, and use of motivational interviewing (MI), an evidence-based intervention, to improve these factors, dialysis adherence, and outcomes in AAs.

Methods

Self-identified AA hemodialysis patients (N =22) watched a brief video describing MI and then completed a semistructured interview or focus group session. Interview questions explored unique barriers and facilitators of hemodialysis adherence in AAs and perceived utility of MI to address these obstacles. Verbatim transcripts and an iterative inductive/deductive approach were used to develop a hierarchical coding system. Three experienced coders independently coded the same two transcripts. Coding was compared, and discrepancies were reconciled by a fourth coder or consensus. Transcripts, quotations, and codes were managed using Microsoft Excel 2016 and SPSS version 28.0.

Results

Themes and subthemes emerged and culminated in a novel conceptual model informed by three theoretical models of behavior change: Theory of Self-Care Management for Vulnerable Populations; Social Cognitive Theory; and Self Determination Theory. This conceptual model will inform the design of a culturally tailored, MI-based intervention to improve dialysis adherence in AAs.

Conclusions

Integrating AA hemodialysis patient perspectives is critical for enhancing dialysis care delivery and the design of effective interventions such as MI to improve dialysis adherence in AA and promote kidney health equity. AA hemodialysis patients view MI as a tool to clarify patient priorities, build trust, and promote patient-provider therapeutic alliance. Cultural tailoring of MI to address unique barriers of AAs with kidney failure will improve adherence and health outcomes in these vulnerable patients.

Hypertension management in chronic kidney disease: A guide for NPs

ABSTRACT

This article offers a guide for NPs for managing hypertension (HTN) in adults in the setting of chronic kidney disease (CKD). It outlines evidence-based strategies, including lifestyle modifications, pharmacologic interventions, and patient education measures, that can be used in patients with CKD to optimize BP control. Special considerations, such as comorbid mental health conditions and individualized treatment plans, are also addressed. NPs play a pivotal role in improving outcomes by fostering patient engagement and adherence. By embracing this holistic approach, NPs are poised to enhance the quality of care and well-being of patients with CKD and HTN.

Establishing the criterion validity of self-report measures of adherence in hemodialysis through associations with clinical biomarkers: A systematic review and meta-analysis

Accurate measurement of adherence is crucial to rigorously evaluate interventions aimed at improving this outcome in patients undergoing in-center hemodialysis. Previous research has shown great variability in non-adherence rates between studies, mainly due to the use of different direct (e.g., clinical biomarkers) and indirect (e.g., questionnaires) measures. Although self-reported adherence in hemodialysis has been widely explored, it is still unclear which is the most accurate questionnaire to assess this outcome; therefore, the question of how to optimize adherence measurement in research and clinical practice has emerged as a key issue that needs to be addressed. This systematic review and meta-analysis aimed to explore the criterion validity of self-report measures of adherence in hemodialysis established through the association between test scores and clinical biomarkers (the criterion measure). The protocol was registered in PROSPERO (2021 CRD42021267550). The last search was performed on March 29th, 2022, on Web of Science (all databases included), Scopus, CINHAL, APA PsycInfo, and MEDLINE/PubMed. Twenty-nine primary studies were included, and thirty-eight associations were analyzed. The Hunter-Schmidt's meta-analysis was computed for the associations with more than two studies (n = 20). The results showed that six associations were large (16%), 11 were medium (29%) and the remaining were of small strength. The test scores from the End-Stage Renal Disease Adherence Questionnaire (range: 0.212<rc <0.319) and the Dialysis Diet and Fluid Non-Adherence Questionnaire (range: 0.206<rc <0.359) had medium to large strength associations with interdialytic weight gain, serum phosphorus, and potassium levels, indicating that these questionnaires have reasonable concurrent criterion validity to measure fluid control and adherence to dietary restrictions in patients receiving hemodialysis. The available data did not allow exploring the criterion validity of the test scores in relation to hemodialysis attendance (skipping and/or shortening sessions). These results suggest that the decision to use one questionnaire over another must be made with caution, as researchers need to consider the characteristics of the sample and the objectives of the study. Given that direct and indirect methods have their advantages and disadvantages, the combination of adherence measures in hemodialysis is recommended to accurately assess this complex and multidimensional outcome.

Gender-specific differences in hemodialysis patients: a multicenter longitudinal study from Serbia

PURPOSE

The study was undertaken with the aim to determine gender-specific differences in incident hemodialysis (HD) patient and their changes over time.

METHODS

The retrospective longitudinal closed cohort study involved 441 incident patients starting HD in 2014 and followed for 1-59 (median 43, IQR 40) months. Demographic, clinical data, treatment characteristics, laboratory findings and outcome were abstracted from the patients' medical records.

RESULTS

The relative number of males on HD was about twice that of females throughout the five years investigated. At the beginning of the study, no significant differences were found in the main demographic and clinical characteristics except that diabetes was more often the underlying disease in men than in women. Systolic blood pressure decreased over time significantly more in females than in males. Throughout the study spKt/V was significantly higher in females than in males, but it increased in patients of both genders. There were no gender differences for comorbidities, vascular access and the majority of laboratory findings except for higher serum levels of creatinine and CRP in men than in women. Relatively more females were treated with erythropoiesis stimulating agents and phosphate binders than males. Age and malignancy were selected as significant predictors of mortality for both genders, and, in addition, polycystic kidney disease, serum level of albumin and CRP for men, but spKt/V for women.

CONCLUSION

Some significant gender differences were observed throughout, while others appeared during the study but none of them were due to gender inequalities in the applied treatment.

From the challenge of assessing autonomy to the instruments used in practice: A scoping review

Autonomy is one of the essential components to live a quality life. Monitoring this autonomy is, in effect, essential, to allow the nurses to conceive, implement and evaluate interventions aimed at its promotion or even maintenance. For this reason, this scoping review aims to map the evidence to identify and analyze the instruments used to assess the person's autonomy, which emerges from scientific production.

Methods

Scoping review based on the recommended principles by the Joanna Briggs Institute. The research was realized in the databases: Scopus (excluding MEDLINE), CINAHL complete (via EBSCO, Excluding MEDLINE), and MEDLINE (via PubMed). Two independent reviewers evaluated the articles' pertinence for the study's investigation, the extraction, and synthesis of articles.

Results

After the analysis, according to the inclusion criteria established, 34 articles were selected, allude to 7 different instruments to assess autonomy.

Conclusions

The need for further development at this level is highlighted, namely through the construction and validation of more comprehensive instruments, integrating the different components of the concept of autonomy.

Factors influencing poor medication adherence amongst patients with chronic disease in low-and-middle-income countries: A systematic scoping review

Background

Poor medication adherence among patients with Chronic Diseases is one of the significant health problems globally. Despite this, evidence on chronic medication adherence in low and middle-income countries is unclear.

Objective

This scoping review aimed to identify factors influencing poor medication adherence amongst patients with chronic diseases in low and middle-income countries.

Methods

We searched studies exploring factors influencing poor medication adherence amongst patients in low and middle-income countries across the following databases published between 2008 to 2018: Public or publisher Medline, Google scholar, Cumulated Index to Nursing and Allied Health Literature, Health Source, and Medline with full text via Elton B. Stephen's Company host. Methodological quality assessment of the primary studies was done as recommended by Levac, Colquhoun, and O'Brien (2010) review using a Mixed-Method Appraisal Tool 2018. We reported the results following the Preferred Reporting Item for Systematic reviews and Meta-Analyses extension for Scoping Review guidelines.

Results

From the initial 154 records screened, we identified six (6) eligible studies that presented evidence on factors influencing poor medication adherence amongst patients in low and middle-income countries. Studies included were from the following countries: Jordan, South Africa, Guatemala, Ethiopia, Indonesia, India, and Palestine. Kappa agreement of the full article screening shows that there was 76.92% agreement versus 58.12% expected by chance which constitutes a considerably good agreement between screeners (Kappa statistic = 0.45 and p-value <0.05). Of the six included studies that underwent methodological quality, five scored 100%, which is regarded as the highest score the remaining one scored between 50-75%, indicating a moderate to low risk bias overall. All included studies presented evidence on medication adherence as being in either knowledge of the diseases, attitudes towards medication taking, beliefs that a patient holds about the treatment or disease, and quality control amongst chronic diseases patients.

Conclusions

Our scoping review provides evidence that poor medication adherence in LMICs is influenced by a lack of knowledge, negative attitudes, and negative beliefs, leading to poor quality of life. There is limited research evidence on the effect of patients' beliefs and perceptions on medication adherence in low and middle-income countries. We call upon further research on beliefs, perceptions, and effectiveness of interventions towards chronic medication adherence in low and middle-income countries.

Interventions Incorporating Therapeutic Alliance to Improve Medication Adherence in Black Patients with Diabetes, Hypertension and Kidney Disease: A Systematic Review

BACKGROUND

Black Americans have a disproportionately increased risk of diabetes, hypertension, and kidney disease, and higher associated morbidity, mortality, and hospitalization rates than their White peers. Structural racism amplifies these disparities, and negatively impacts self-care including medication adherence, critical to chronic disease management. Systematic evidence of successful interventions to improve medication adherence in Black patients with diabetes, hypertension, and kidney disease is lacking. Knowledge of the impact of therapeutic alliance, ie, the unique relationship between patients and providers, which optimizes outcomes especially for minority populations, is unclear. The role and application of behavioral theories in successful development of medication adherence interventions specific to this context also remains unclear.

OBJECTIVE

To evaluate the existing evidence on the salience of a therapeutic alliance in effective interventions to improve medication adherence in Black patients with diabetes, hypertension, or kidney disease.

DATA SOURCES

Medline (via PubMed), EMBASE (OvidSP), Cumulative Index of Nursing and Allied Health Literature (CINAHL) (EBSCOhost), and PsycINFO (ProQuest) databases.

REVIEW METHODS

Only randomized clinical trials and pre/post intervention studies published in English between 2009 and 2022 with a proportion of Black patients greater than 25% were included. Narrative synthesis was done.

RESULTS

Eleven intervention studies met the study criteria and eight of those studies had all-Black samples. Medication adherence outcome measures were heterogenous. Five out of six studies which effectively improved medication adherence, incorporated therapeutic alliance. Seven studies informed by behavioral theories led to significant improvement in medication adherence.

DISCUSSION/CONCLUSION

Study findings suggest that therapeutic alliance-based interventions are effective in improving medication adherence in Black patients with diabetes and hypertension. Further research to test the efficacy of therapeutic alliance-based interventions to improve medication adherence in Black patients should ideally incorporate cultural adaptation, theoretical framework, face-to-face delivery mode, and convenient locations.

Feeling better on hemodialysis: user-centered design requirements for promoting patient involvement in the prevention of treatment complications

OBJECTIVE

Hemodialysis patients frequently experience dialysis therapy sessions complicated by intradialytic hypotension (IDH), a major patient safety concern. We investigate user-centered design requirements for a theory-informed, peer mentoring-based, informatics intervention to activate patients toward IDH prevention.

METHODS

We conducted observations (156 hours) and interviews (n = 28) with patients in 3 hemodialysis clinics, followed by 9 focus groups (including participatory design activities) with patients (n = 17). Inductive and deductive analyses resulted in themes and design principles linked to constructs from social, cognitive, and self-determination theories.

RESULTS

Hemodialysis patients want an informatics intervention for IDH prevention that collapses distance between patients, peers, and family; harnesses patients' strength of character and resolve in all parts of their life; respects and supports patients' individual needs, preferences, and choices; and links "feeling better on dialysis" to becoming more involved in IDH prevention. Related design principles included designing for: depth of interpersonal connections; positivity; individual choice and initiative; and comprehension of connections and possible actions.

DISCUSSION

Findings advance the design of informatics interventions by presenting design requirements for outpatient safety and addressing key design opportunities for informatics to support patient involvement; these include incorporation of behavior change theories. Results also demonstrate the meaning of design choices for hemodialysis patients in the context of their experiences; this may have applicability to other populations with serious illnesses.

CONCLUSION

The resulting patient-facing informatics intervention will be evaluated in a pragmatic cluster-randomized controlled trial in 28 hemodialysis facilities in 4 US regions.

Apolipoprotein L1 and mechanisms of kidney disease susceptibility

PURPOSE OF REVIEW

Allelic variants in the gene for apolipoprotein L1 (APOL1), found only in individuals of African ancestry, explain a majority of the excess risk of kidney disease in African Americans. However, a clear understanding how the disease-associated APOL1 variants cause kidney injury and the identity of environmental stressors that trigger the injury process have not been determined.

RECENT FINDINGS

Basic mechanistic studies of APOL1 biochemistry and cell biology, bolstered by new antibody reagents and inducible pluripotent stem cell-derived cell systems, have focused on the cytotoxic effect of the risk variants when APOL1 gene expression is induced. Since the APOL1 variants evolved to alter a key protein-protein interaction with the trypanosome serum resistance-associated protein, additional studies have begun to address differences in APOL1 interactions with other proteins expressed in podocytes, including new observations that APOL1 variants may alter podocyte cytoskeleton dynamics.

SUMMARY

A unified mechanism of pathogenesis for the various APOL1 nephropathies still remains unclear and controversial. As ongoing studies have consistently implicated the pathogenic gain-of-function effects of the variant proteins, novel therapeutic development inhibiting the synthesis or function of APOL1 proteins is moving toward clinical trials.

Provider Attitudes and Support of Patients' Autonomy for Phosphate Binder Medication Adherence in ESRD

This cross-sectional study of 56 dialysis providers from 3 dialysis clinics examined providers' attitudes and perception of autonomy support for patients' medication adherence behaviors. Respondents completed surveys assessing attitudes and perception of autonomy support. Compared to all other provider types, physicians and nurse practitioners (MD/NP) thought it was "less true" that phosphate binder medications are very important for dialysis patients (MD/NP vs others: 5.1 [1.4] vs 6.1 [1.1]; P = 0.02). More dialysis technicians (19%) offered the highest level of support. Attitudes and perception of autonomy support for medication adherence are suboptimal, vary by dialysis provider type, and are targets for quality improvement in dialysis care. This study addresses critical gap in existing knowledge about these two novel provider-based psychosocial factors and their potential impact on phosphate binder medication adherence.

Inequalities and outcomes: end stage kidney disease in ethnic minorities

Background

The international evidence about outcomes of End Stage Kidney Disease (ESKD) for ethnic minorities was reviewed to identify gaps and make recommendations for researchers and policy makers.

Methods

Nine databases were searched systematically with 112 studies from 14 different countries included and analysed to produce a thematic map of the literature.

Results

Reviews (n = 26) highlighted different mortality rates and specific causes between ethnic groups and by stage of kidney disease associated with individual, genetic, social and environmental factors. Primary studies focussing on uptake of treatment modalities (n = 19) found ethnic differences in access. Research evaluating intermediate outcomes and quality of care in different treatment phases (n = 35) e.g. dialysis adequacy, transplant evaluation and immunosuppression showed ethnic minorities were disadvantaged. This is despite a survival paradox for some ethnic minorities on dialysis seen in studies of longer term outcomes (n = 29) e.g. in survival time post-transplant and mortality. There were few studies which focussed on end of life care (n = 3) and ethnicity.

Gaps identified were: limited evidence from all stages of the ESKD pathway, particularly end of life care; a lack of system oriented studies with a reliance on national routine datasets which are limited in scope; a dearth of qualitative studies; and a lack studies from many countries with limited cross country comparison and learning.

Conclusions

Differences between ethnic groups occur at various points and in a variety of outcomes throughout the kidney care system. The combination of individual factors and system related variables affect ethnic groups differently indicating a need for culturally intelligent policy informed by research to prevent disadvantage.

Phosphate-control adherence in hemodialysis patients: current perspectives

OBJECTIVES

This review summarizes factors relevant for adherence to phosphate-control strategies in dialysis patients, and discusses interventions to overcome related challenges.

METHODS

A literature search including the terms "phosphorus", "phosphorus control", "hemo-dialysis", "phosphate binder medications", "phosphorus diet", "adherence", and "nonadherence" was undertaken using PubMed, PsycInfo, CINAHL, and Embase.

RESULTS

Hyperphosphatemia is associated with cardiovascular and all-cause mortality in dialysis patients. Management of hyperphosphatemia depends on phosphate binder medication therapy, a low-phosphorus diet, and dialysis. Phosphate binder therapy is associated with a survival benefit. Dietary restriction is complex because of the need to maintain adequate protein intake and, alone, is insufficient for phosphorus control. Similarly, conventional hemodialysis alone is insufficient for phosphorus control due to the kinetics of dialytic phosphorus removal. Thus, all three treatment approaches are important contributors, with dietary restriction and dialysis as adjuncts to the requisite phosphate binder therapy. Phosphate-control adherence rates are suboptimal and are influenced directly by patient, provider, and phosphorus-control strategy-related factors. Psychosocial factors have been implicated as influential "drivers" of adherence behaviors in dialysis patients, and factors based on self-motivation associate directly with adherence behavior. Higher-risk subgroups of nonadherent patients include younger dialysis patients and non-whites. Provider attitudes may be important - yet unaddressed - determinants of adherence behaviors of dialysis patients.

CONCLUSION

Adherence to phosphate binders, low-phosphorus diet, and dialysis prescription is suboptimal. Multicomponent strategies that concurrently address therapy-related factors such as side effects, patient factors targeting self-motivation, and provider factors to improve attitudes and delivery of culturally sensitive care show the most promise for long-term control of phosphorus levels. Moreover, it will be important to identify patients at highest risk for lack of control, and for programs to be ready to deliver flexible person-centered strategies through training and dedicated resources to align with the needs of all patients.

Treatment adherence and illness self-management: introduction to the special issue

The current issue is devoted broadly to research on treatment adherence and chronic illness self-management behavior. As the prevalence of chronic illness increases, the pervasive problem of treatment nonadherence is increasingly viewed as having a major impact on treatment outcomes, public health and healthcare costs, making this issue particularly timely. Sixteen articles spanning an array of topics are presented; articles include empirical studies, statistical simulations, systematic reviews, and theoretical commentaries. Studies conducted with diverse patient populations (e.g., chronic headache, diabetes, end-stage renal disease, HIV, hypertension, severe obesity), samples (e.g., adolescents, ethnic/racial minorities, low-income adults, parents, spousal dyads), and designs (e.g., cross-sectional, longitudinal assessment, randomized controlled trial), are represented. This issue highlights psychosocial factors associated with nonadherence, promising interventions to promote adherence, and state-of-the art methods for the study of illness self-management. We hope these articles engender even more high quality, methodologically rigorous research in this important subfield of behavioral medicine.