Applying the health belief model to the rational use of drugs for hemodialysis patients: A randomized controlled trial

BACKGROUND

Non-rational use of drugs is a common problem among people with chronic disease. The Health Belief Model (HBM) can develop beliefs and behaviors related to rational drug use.

OBJECTIVES

To investigate the effect of HBM-based training on the rational use of drugs in hemodialysis patients.

METHODS

This randomized controlled trial was conducted in 132 people receiving hemodialysis treatment. The data were collected using a Demographic Survey and the Rational Use of Drugs Scale (RUDS). Patients in the study groups were provided with HBM-based rational use of drugs training. The first training session took an average of 30-35 min for each patient, and the second (summary) took an average of 15-20 min RESULTS: The mean RUDS pretest score was 60.29 ± 10.17 in the intervention group and 62.85 ± 9.94 in the control group. The mean RUDS posttest scores were 78.80 ± 8.16 in the intervention group and 63.48 ± 9.77 in the control group. The difference between the pretest scores in these groups was not statistically significant (p > 0.05), whereas the difference between the posttest scores was found to be significant (p < 0.001).

CONCLUSION

It was observed that training based on the HBM increased the RUD scores. Thus, HBM may be recommended for use as a guide for rational drug use training, especially for patients undergoing hemodialysis.

PRACTICE IMPLICATIONS

The HBM can be an effective and cost-efficient strategy for standardized rational drug use training and supporting hemodialysis patients.

Incremental Initiation of Dialysis: One Center's Experience over a Two-Year Period

Objective

This pilot study describes our center's experience with peritoneal dialysis (PD) over the past 2 years using a “healthy start” dialysis protocol with an incremental approach to prescription management.

Design

Nonrandomized, prospective pilot study.

Setting

Single PD unit of a university teaching hospital.

Patients

Thirteen PD patients who initiated dialysis at our center from April 1997 to June 1999.

Methods

Patients initiating PD with residual renal Kt/V of 1.0 – 2.0/week were invited to participate. They were given an initial dialysis prescription so that total (residual renal + dialysis) weekly Kt/V exceeded 2.0. The dialysis prescription was “incrementally” increased as residual renal function (RRF) declined. Data collected for all patients included monthly serum chemistries, residual renal weekly Kt/V and creatinine clearance (CCr) at 1- to 2-month intervals, and peritoneal weekly Kt/V and CCr at 3-month intervals and 1 month after each prescription change.

Results

To date, we have followed 13 patients on our incremental PD protocol for a total of 159.3 patient-months. Mean serum albumin concentration and mean normalized protein equivalent of nitrogen appearance (nPNA) were stable throughout the study. Mean total Kt/V and CCr remained above the recommended targets of 2.0/wk and 60 L/wk, respectively. Residual renal function declined rather slowly in our PD patients. One patient died from complications of aortic valve surgery and a second died from pneumonia. A third patient died from peritonitis. One patient required a new Tenckhoff catheter after catheter migration. Three patients were temporarily switched to hemodialysis after a hernia repair, a pleural leak, and elective native/transplant nephrectomies, respectively. Two patients were permanently switched to hemodialysis: one after an episode of peritonitis, the second after accidentally damaging his PD catheter.

Conclusions

Providing incremental dialysis to maintain adequate total small solute clearance has been technically feasible in our patient population. However, a larger than expected number of complications was seen in our study. Fortunately, complications were easier to manage due to the presence of RRF. Because this study was not designed to compare outcome with that observed after traditional initiation of dialysis, further large-scale studies are needed.

Non-adherence in patients on peritoneal dialysis: a systematic review

BACKGROUND

It has been increasingly recognized that non-adherence is an important factor that determines the outcome of peritoneal dialysis (PD) therapy. There is therefore a need to establish the levels of non-adherence to different aspects of the PD regimen (dialysis procedures, medications, and dietary/fluid restrictions).

METHODS

A systematic review of peer-reviewed literature was performed in PubMed, PsycINFO and CINAHL databases using PRISMA guidelines in May 2013. Publications on non-adherence in PD were selected by two reviewers independently according to predefined inclusion and exclusion criteria. Relevant data on patient characteristics, measures, rates and factors associated with non-adherence were extracted. The quality of studies was also evaluated independently by two reviewers according to a revised version of the Effective Public Health Practice Project assessment tool.

RESULTS

The search retrieved 204 studies, of which a total of 25 studies met inclusion criteria. Reported rates of non-adherence varied across studies: 2.6-53% for dialysis exchanges, 3.9-85% for medication, and 14.4-67% for diet/fluid restrictions. Methodological differences in measurement and definition of non-adherence underlie the observed variation. Factors associated with non-adherence that showed a degree of consistency were mostly socio-demographical, such as age, employment status, ethnicity, sex, and time period on PD treatment.

CONCLUSION

Non-adherence to different dimensions of the dialysis regimen appears to be prevalent in PD patients. There is a need for further, high-quality research to explore these factors in more detail, with the aim of informing intervention designs to facilitate adherence in this patient population.

Adherence of pediatric patients to automated peritoneal dialysis

Little information is available on adherence to a home automated peritoneal dialysis (APD) prescription for children with end-stage renal disease. We have therefore retrospectively reviewed HomeChoice PRO Card data from patients <21 years of age who received home APD. Adherence was characterized as occurring ≥ 95%, 90-94%, or <90% of time by dividing the frequency of each of four measured prescription variables (sessions/month, duration of each session, number of cycles/session, volume of dialysate/session) by the prescribed frequency and multiplying by 100. The relationship between treatment adherence and patient age, gender, race and if the patient had received training, respectively, was assessed. Of the 51 patients (57% male), with a mean age at peritoneal dialysis (PD) onset of 11.8 ± 5.3 years, 28 (55%) were adherent for all variables. No difference in mean age or if patients were trained existed between the two groups. Males were more likely to be non-adherent (p = 0.026) as were African Americans (p = 0.048). The majority of patients were adherent to duration (96%) and number of cycles (92%), whereas non-adherence was more common with number of sessions (82%) and dialysate volume (78%). In conclusion, 45% of the pediatric patients in our study cohort exhibited some non-adherence to their prescribed APD regimen, emphasizing the value of closely monitoring the performance of home dialysis in children.

Ethical issues of compliance/adherence in the treatment of hypertension

The ethics of compliance suggests a conflict within the definition of compliance. Evidence-based medicine appears to provide clear pathways for clinical decisions, but, usually, the patient is not a part of the decision-making process. Physicians often develop a treatment plan and then attempt to make the therapy acceptable to the patient to achieve compliance. Interventions are tested to change patient behavior, but few are designed to consider the patient's point of view. Some suggest that the ideal patient is passive and obedient. However, few patients are either. The individual's perspective and goals most certainly affect adherence with a medical treatment and cannot be ignored. This article reviews the ethics of compliance/adherence issues. Future research of compliance might be improved if studies were designed to include patient preference in a partnership with physicians.

Response to inadequate dialysis in chronic peritoneal dialysis patients. Results from the 2000 Centers for Medicare and Medicaid (CMS) ESRD Peritoneal Dialysis Clinical Performance Measures (PD-CPM) Project

BACKGROUND

It is not known if patient prescriptions are being changed if patients are receiving an inadequate dose of peritoneal dialysis.

METHODS

Data from the 2000 Centers for Medicare and Medicaid were used to obtain data on dialysis adequacy and dialysis prescriptions.

RESULTS

A total of 359 of 1,268 (28%) adult peritoneal dialysis patients had a total weekly Kt/V urea (twKt/V) less than 2.0 and 436 of 1,245 (35%) patients had a total weekly creatinine clearance (twCrCl) less than 60 L/wk/1.73 m2, defined as "inadequate dialysis." Among chronic ambulatory peritoneal dialysis (CAPD) patients, 81 of 188 (43%) patients had inadequate dialysis and a change in the peritoneal dialysis prescription within 6 months of the initial adequacy value. Among cycler patients, 106 of 197 (54%) patients had inadequate dialysis and a change in the prescription. Thirty-six of 46 (78%) CAPD patients and 48 of 56 (86%) cycler patients had an improvement in twKt/V after the prescription was revised. Thirty-two of 42 (76%) CAPD patients and 45 of 57 (79%) cycler patients had an improvement in twCrCl after the prescription was changed. For these patients, twKt/V increased from 1.6 +/- 0.3 to 2.1 +/- 0.5, with an increase in the peritoneal Kt/V urea from 1.5 +/- 0.3 to 1.9 +/- 0.4. Similarly, twCrCl increased from 46.3 +/- 7.5 to 59.1 +/- 10.6 L/wk/1.73 m2 with an increase in the peritoneal CrCl dose from 42.0 +/- 9.1 to 52.7 +/- 9.9 L/wk/1.73 m2.

CONCLUSION

About half of peritoneal dialysis patients with inadequate dialysis did not have a prescription change and could benefit from modifications in their dialysis prescription.

Role of APD in compliance with therapy

Lack of compliance with prescribed treatment is an important cause of inadequate dialysis in patients on peritoneal dialysis (PD). The reported prevalence of noncompliance with treatment in PD varies from 5 to 38%. The predictors of noncompliance, its consequences, methods to identify and monitor compliance, differences in frequency between continuous ambulatory PD (CAPD) and automated PD (APD), and management are reviewed. The risk of noncompliance is greater in CAPD than in APD. Noncompliance should be managed by patient education and appropriate modification of therapy, including consideration of APD.

Improving compliance in dialysis patients: does anything work?

Noncompliance with prescribed therapy significantly impacts dialysis patient care and outcome. At least one-half of hemodialysis (HD) patients are likely to be noncompliant with some part of their treatment regimen, and one-third of peritoneal dialysis (PD) patients are believed to miss prescribed exchanges. Psychosocial issues, younger age, and smoking behavior have been linked with compliance problems in multiple studies. Few interventions have been rigorously tested, but patient education and/or individualized attention, supervision, encouragement, and support are widely advocated strategies to improve patient compliance. Areas in need of continued study include psychosocial determinants of compliance in PD as well as HD patients, compliance behavior patterns over time, and the parameters within which dialysis compliance can vary and still achieve specified treatment goals.

Adequacy of peritoneal dialysis

The National Kidney Foundation-Dialysis Outcomes Quality Initiatives guidelines have standardized many aspects of treating end-stage renal disease patients with peritoneal dialysis in an attempt to improve overall patient outcome. While recommending certain total solute clearance goals, the guidelines have also pointed out deficiencies in our knowledge base and precipitated many controversies. Some of these controversies have been resolved while others may have been interpreted wrongly, unnecessarily resulting in transfer of patients from peritoneal dialysis to hemodialysis due to "failure to meet adequacy targets" even when doing well clinically. This report reviews the rationale for the original guidelines and their subsequent modification. It also outlines a rational approach toward prescription modification based on peritoneal physiology. Specific solute clearance target goals discussed are the modifications for continuous ambulatory peritoneal dialysis (CAPD) and cycler peritoneal dialysis (CCPD), and a review of what solute clearance targets subsequent guidelines from other countries have used. Some examples are as follows: new guidelines suggest that solute clearance goals for creatine clearance should differ for low and low-average transporters than for high and high-average transporters (weekly clearance of 50 and 60 1/1.73 m(2), respectively) while Kt/V targets remain unchanged. Also discussed is the rationale for having the same target for patients on CCPD with a mid-day exchange as those for patients on CAPD. We are also reminded that solute clearance is only one aspect of "adequate" dialysis-blood pressure and volume control are equally important, and ways to maintain euvolemia and blood pressure control are discussed in the context of prescription management.

Pattern of noncompliance with dialysis exchanges in peritoneal dialysis patients

The purpose of the study is to evaluate the pattern of noncompliance in peritoneal dialysis (PD) patients using home visit supply inventories. Ninety-two patients were enrolled at the start of dialysis. Noncompliance, defined as performance of less than 90% of prescribed exchanges, was found in 30% of patients during the first 6 months of PD. Patients who were noncompliant with prescribed exchanges at the start of PD had greater rates of death (P = 0.03), transfer to hemodialysis secondary to uremia (P < 0.05), hospitalization (P < 0.001), and days hospitalized (P < 0.001) compared with compliant patients. Delivered Kt/V was 18% less in noncompliant compared with compliant patients (2.1 versus 2.57; P = 0.007). Serial evaluations of compliance in 53 patients showed that 72% were consistently compliant, 2% were consistently noncompliant, 15% were noncompliant at the beginning of PD but became compliant at follow-up, and 11% were intermittently noncompliant. The likelihood of future compliance in a patient compliant at the first home visit was 88%. Patients who were independent with their dialysis exchanges were more likely to be noncompliant (27%) than patients dependent on someone else to perform their dialysis (8%; P = 0.05). Serial 24 hour creatinine excretion was not a useful method to determine compliance. We recommend a home visit during the first 6 months of PD to determine compliance. Those found compliant probably do not need repeated evaluations, whereas noncompliant patients should be reevaluated in a few months. Involving another person in the dialysis might relieve some of the burden on patients who may be initially unable to cope with home dialysis. Identification of noncompliant patients and awareness of risk factors should reduce noncompliance and improve patient outcomes.