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Saudi Journal of Kidney Diseases and Transplantation
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Year : 2021  |  Volume : 32  |  Issue : 5  |  Page : 1382-1387
Impact of patient counseling on treatment adherence behavior and quality of life in maintenance hemodialysis patients

Department of Pharmacy Practice, Nirmala College of Pharmacy, Muvattupuzha, Kerala, India

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Date of Web Publication4-May-2022


Life in end-stage renal disease (ESRD) is miserable; food and fluid restrictions are mandatory due to impaired renal function. Patient involvement forms a key role in the management of ESRD. Hence, a direct impact of patient counseling on treatment adherence and quality of life (QOL) could be established, which forms the basis of this study. We conducted a prospective interventional study of 10 months, where the ESRD-Adherence Questionnaire and Kidney Disease QOL (KDQOL) data were used to study the effect of patient counseling. A total of 121 patients enrolled in the study with mean age of 62.14 ± 11.41 years. The adherence factors indicated that 97% were adherent to dialysis sessions, followed by 67.77% toward diet and 60.33% toward fluid. On assessing the influence of counseling on QOL and adherence to various factors affecting ESRD, a positive correlation could be observed, which indicates the impact of pharmacist intervention in improving the QOL and patient compliance, thus the need for periodic counseling was established as an effective way to improve health-related QOL and awareness in ESRD.

How to cite this article:
James M, Roy A, Antony E, George S. Impact of patient counseling on treatment adherence behavior and quality of life in maintenance hemodialysis patients. Saudi J Kidney Dis Transpl 2021;32:1382-7

How to cite this URL:
James M, Roy A, Antony E, George S. Impact of patient counseling on treatment adherence behavior and quality of life in maintenance hemodialysis patients. Saudi J Kidney Dis Transpl [serial online] 2021 [cited 2022 May 25];32:1382-7. Available from: https://www.sjkdt.org/text.asp?2021/32/5/1382/344758

   Introduction Top

Chronic kidney disease (CKD) is an irreversible progressive condition with high morbidity and mortality by means of an increase in incidence and prevalence, poor outcomes along with high cost. Lifelong treatment and lifestyle modifications are difficult to adapt, which significantly impairs treatment adherence and quality of life (QOL).[1] In India, about 100,000 patients suffer from end-stage renal disease (ESRD) each year and only 20,000 get treated. According to various studies, the cost of dialysis is between 600 and 2000 INR per session or 5500 and 20,000 INR per month and it is not affordable for an average patient.[2] The number of hemodialysis (HD) patients are increasing tremendously and ESRD is one of the major public health concerns in India.[3],[4]

ESRD patients are usually on complex drug regimens, with about 8–10 medications daily, many of which require multiple doses per day.[5] Due to polypharmacy, medically unstable nature of the disease and restricted lifestyle, dialysis patients are at increased risk of nonadherence and drug-related problems.[6],[7] As the diet and fluid restrictions should be strictly adhered to, thus ideally the diet should be salt-free, low in potassium and phosphorus content, and the protein uptake should be in accordance with the patient’s condition. Hence, the need for counseling on factors is necessary for patients to avoid further complications and morbidities. Education and counseling programs are mandatory in ESRD population for their better QOL and to improve the treatment adherence.[8] Apart from the counseling given by the doctor in the beginning of the dialysis treatment and guidance given by the duty staff during the dialysis schedules, the patients are not receiving enough education or counseling in a regular way that aids in the betterment of their life.[9]

ESRD pushes the patients into a situation where massive adjustments for sodium, potassium, calcium, pH, and serum levels turn out to be critical. The lack of time by physicians and nurses for detailing the doubts and condition of patient gives room for the provision of patient counseling. Thus, a clinical pharmacist can play an ideal role of counselor in educating patients, leading to increased QOL[8] which is the basis of this study.

   Patients and Methods Top

We conducted a prospective, longitudinal, observational, comparative, multicenter study for a period of 10 months. Patients diagnosed with ESRD with at least three-month history of HD aged between 20 and 80 years were included in the study and those patients who were not interested in counseling, patients with acute renal failure, psychiatric disorders, and infection with human immunodeficiency virus, hepatitis C were excluded from the study. The study proposal was approved by the Institutional Ethics Committee.

Outpatients visiting the nephrology department for HD were reviewed and those patients who met the study criteria were informed about the study procedure and enrolled into the study after obtaining their informed consent.

ESRD-Adherence Questionnaire (ESRD-AQ) and Kidney Disease QOL (KDQOL) questionnaire were used for assessing adherence and QOL, respectively, from patient or bystanders. Other relevant information was extracted from patient’s medical records. ESRD-AQ was used as a tool to assess the (1) degree of adherence and (2) perception and counseling of the patients toward HD treatment modalities. To measure the health-related QOL, KDQOL-SF™ version 1.3 was used in the study. It consists of generic and disease-related cores. The responses to the generic core were reported by two components – mental component summary and physical component summary. Disease targeted items consist of 11 subscales which make kidney disease component summary. The range of scores is from 0 to 100 and higher scores indicate better QOL.

After scoring of the ESRD-AQ and KDQOL, patients with poor adherence and QOL were selected and counseling was given to them. Counseling was provided to the patient one month after the baseline, with the support of patient information leaflet and a booklet prepared in local language (Malayalam), which was validated by the nephrologist. It was primarily focused on basic functions of kidney, causes and symptoms of CKD, complications, various treatment modalities, role of HD in human body, anemia and its treatment, importance of some laboratory tests, need for adherence to drug therapy, and dietary modifications. The well-being of the patient was inquired orally during every visit to the hospital for HD. The improvement of health outcome was assessed after one month of counseling using the same questionnaires. The data were summarized by using descriptive statistics and difference between pre- and post-scores after counseling was determined by paired t-test. Karl Pearson’s correlation coefficient was used to study the correlation between overall adherence with every domain of QOL. P <0.05 was considered statistically significant.

   Results Top

A total of 124 patients met the inclusion criteria and were recruited for the study, however, two patients passed away during the study period and one went for trans-plantation thus excluded. Therefore, a total of 121 patients were enrolled in the study. The mean age of the study population was 62.14 ± 11.41 years, with male patients dominating with 73%. On observing years on dialysis, it was observed that 62.8% of patients are doing dialysis in between one and five years and 74% of patients doing dialysis twice a week. The dominating comorbidity was hypertension (HTN) and diabetes (52.89%) followed by HTN (29.75%) and diabetes (9.09%) alone [Table 1].
Table 1: Sociodemographic and clinical characteristics of study population.

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Assessment of quality of life and treatment adherence

Adherence to the various treatment modalities including dialysis schedule, medications, fluid intake, and diet was assessed. Out of 121 patients, most of the patients showed high adherence to dialysis sessions – 97%, medications adherence was observed at 67.77%, followed by diet – 63.33%, and fluids – 60.33%. From this data, it was clear that adherence to the HD sessions was the highest with an average score of 293.80 ± 32.64 out of a maximum score of 300. The QOL was assessed in three components such as physical (26.32 ± 16.90), mental (36.69 ± 14.03), and kidney disease component (52.13 ± 17.79). It was found that the treatment adherence behavior and overall QOL of patients on HD were significantly impaired.

Overall adherence and quality of life

Overall adherence of each patient was assessed by the sum of all scores attained from the questionnaire which accounted for 974.38 ± 150.67. Out of 121 patients, a total of 68 (56.20%) had good adherence behavior, 45 (37.19%) had moderate adherence, and eight (6.61%) showed poor adherence. The correlation between the overall adherence behavior and QOL shows positive correlation with the adherence pattern [Table 2].
Table 2: Pearson correlation of overall adherence and quality of life.

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Patient counseling

The study revealed a remarkable difference in QOL and adherence behavior before and after counseling which was proved by paired t-test. It displayed that the adherence to each treatment option, i.e. diet, dialysis, medication, fluid, and each domain of QOL (physical, mental, and kidney disease component) was significantly improved (P <0.05) after giving a proper counseling to the patient [Table 3].
Table 3: Effect of counseling in treatment adherence and quality of life.

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Mean ± standard deviation of the scores of three components of KDQOL before and after the patient counseling indicates the statistical significance in all the three components [Table 3]. [Figure 1] revealed that the effect of patient counseling is highly influenced in the diet adherence by an increase in more than 50% uplift. Thus, patient counseling seemed to play an important role in improving the QOL and adherence behavior by providing proper awareness, changing their psychological thinking, emotional support, and initiating them toward spirituality.
Figure 1: Mean scores of treatment modalities before and after the patient counseling.

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   Discussion Top

The patient counseling in the ESRD population plays an enormous role in the overall treatment adherence and health-related QOL. Improvement in patient compliance and QOL has become the major treatment goal in CKD patients. Assessing patient satisfaction and improvement with therapy has become an integral parameter in the management of ESRD. In developed countries, several studies are documented related to nonadherence in patients with ESRD.[10],[11] All works done previously reported that 50% of the HD patients are showing nonadherence to fluid recommendations;[12],[13],[14] in this study, the nonadherence to the fluid recommendation is 39.67% well ahead of other studies. Failure to manage fluid intake, dietary habits compliance, and medication therapy has an impact on morbidity and mortality, Moreover, non-adherence will adversely affect the QOL of patients.[15] It is also evident that QoL of HD patients is highly impaired[16],[17] which is also represented in this study which indicates the same pattern of study results. The educational interventional studies are done, implicating that it is highly significant in the reduction of noncompliance rate in HD patients as shown by other studies also.[18],[19],[20]

The present study revealed a significant improvement in adherence to dialysis, medication, diet and fluid and every domains of QoL after educational intervention and counseling. The major reasons for the poor adherence to the medications were forgetfulness, inconvenience, medication cost, and misconception or lack of proper knowledge about importance of medications and poor adherence to the fluid and dietary restriction was patient’s inability to control the willingness toward fluid intake and their unawareness about the seriousness of recommendations. The pharmaceutical care provided by the health-care providers from variety of disciplines improves patient comprehension and can secure better compliance.[21] Various studies have also shown that patient education provides better health outcomes, improves compliance, and reduces health-care cost.[22],[23]

The major limitations of this study were the duration factor as the study period and follow-up period were only for an interval of 10 months and the other limitation was the interviewer interviewing the patient changed during the study period and was interviewed by three investigators which could have led to cases reporting biases and may have acted as confounding factor in our data.

Despite the limitations, the findings of the study and its output will definitely inspire other health-care providers to better understand the adherence pattern, physical, and emotional status of patients on HD and thus sparkle a strive for betterment in dialysis care delivery in all future cases.

   Conclusion Top

The study can be concluded by stating the impact of pharmacist intervention in improving the QoL and patient compliance. The current system of therapy only aims to improve the functional capacity of the patients for as long as possible, however, they were not bothered about the progression of HRQOL of the patients. It is imperative to improve education regarding various treatment modalities and misconceptions about disease conditions. The study suggests that periodic counseling by a clinical pharmacist at regular intervals has a significant positive impact on better QOL which can improve the patient’s medication outcome.

Conflict of interest: None declared.

   References Top

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Correspondence Address:
Shaji George
Department of Pharmacy Practice, Nirmala College of Pharmacy, Muvattupuzha, Kerala
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/1319-2442.344758

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  [Table 1], [Table 2], [Table 3]


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