Patients' adherence to aspects of haemodialysis regimens in tropical north Queensland, Australia

Dialysis attendance patterns and health care utilisation of Aboriginal patients attending dialysis services in urban, rural and remote locations

Background

Aboriginal people in the Northern Territory (NT) suffer the heaviest burden of kidney failure in Australia with most living in remote areas at time of dialysis commencement. As there are few dialysis services in remote areas, many Aboriginal people are required to relocate often permanently, to access treatment. Missing dialysis treatments is not uncommon amongst Aboriginal patients but the relationship between location of dialysis service and dialysis attendance (and subsequent hospital use) has not been explored to date.

Aim

To examine the relationships between location of dialysis service, dialysis attendance patterns and downstream health service use (overnight hospital admissions, emergency department presentations) among Aboriginal patients in the NT.

Methods

Using linked hospital and dialysis registry datasets we analysed health service activity for 896 Aboriginal maintenance dialysis patients in the NT between 2008 and 2014. Multivariate linear regression and negative binomial regression analyses explored the associations between dialysis location, dialysis attendance and health service use.

Results

We found missing two or more dialysis treatments per month was more likely for Aboriginal people attending urban services and this was associated with a two-fold increase in the rate of hospital admissions and more than three-fold increase in ED presentations. However, we found higher dialysis attendance and lower health service utilisation for those receiving care in rural and remote settings. When adjusted for age, time on dialysis, region, comorbidities and residence pre-treatment, among Aboriginal people from remote areas, those dialysing in remote areas had lower rates of hospitalisations (IRR 0.56; P < 0.001) when compared to those who relocated and dialysed in urban areas.

Conclusion

There is a clear relationship between the provision and uptake of dialysis services in urban, rural and remote areas in the NT and subsequent broader health service utilisation. Our study suggests that the low dialysis attendance associated with relocation and care in urban models for Aboriginal people can potentially be ameliorated by access to rural and remote models and this warrants a rethinking of service delivery policy. If providers are to deliver effective and equitable services, the full range of intended and unintended consequences of a dialysis location should be incorporated into planning decisions.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-07628-9.

Non-adherence to hemodialysis regimens among patients on maintenance hemodialysis in sub-Saharan Africa: an example from Cameroon

Background

Non-adherence (NA) to hemodialysis regimens is one of the contributors to the high morbidity and mortality observed in patients with end-stage kidney disease (ESKD). We aimed to determine the prevalence and predictors of NA to hemodialysis (HD) regimens among patients on maintenance HD in Cameroon.

Methods

A cross-sectional study in two HD centers in Cameroon was conducted from January to February 2016. Consenting patients on HD for ≥3 months were included. NA to fluid restriction was defined as a mean interdialytic weight gain (IDWG) in the past month >5.7% of the dry weight, NA to dietary restriction as a pre dialysis serum phosphorus >5.5 mg/dl in a patient on phosphate binders and who is well-nourished, and NA to HD sessions as skipping at least one session in the past month. The study was approved by the institutional ethics board.

Results

A total of 170 (112 males) participants with a median age of 49 years (range 14–79) were included. The median dialysis vintage was 35 months (range 3–180 months). The prevalence of NA was 15.3% to fluid restriction, 26.9% to dietary restriction, and 21.2% to dialysis sessions. Age ≤49 years (p = .006, OR: 5.07, 95% CI: 1.59–16.20) and unmarried status (p = .041, OR: 2.63, 95% CI: 1.04–6.66) were independently associated with NA to fluid restrictions. No factor was associated with NA to dietary restrictions and HD sessions.

Conclusions

NA to HD regimens is common amongst patients in Cameroon. Younger age and being unmarried were the predictors of NA to fluid restriction.

Do remote dialysis services really cost more? An economic analysis of hospital and dialysis modality costs associated with dialysis services in urban, rural and remote settings

Background

Rates of end-stage kidney disease in Australia are highest in the Northern Territory (NT), with the burden of disease heaviest in remote areas. However, the high cost of delivering dialysis services in remote areas has resulted in centralisation, requiring many people to relocate for treatment. Patients argue that treatment closer to home improves health outcomes and reduces downstream healthcare use. Existing dialysis cost studies have not compared total health care costs associated with treatment in different locations.

Objective

To estimate and compare, from a payer perspective, the observed health service costs (all cause hospital admissions, emergency department presentations and maintenance dialysis) associated with different dialysis models in urban, rural and remote locations.

Methods

Using cost weights attributed to diagnostic codes in the NT Department of Health’s hospital admission data set (2008–2014), we calculated the mean (SD) total annual health service costs by dialysis model for 995 dialysis patients. Generalized linear modeling with bootstrapping tested the marginal cost differences between different explanatory variables to estimate ‘best casemix’/‘worst casemix’ cost scenarios.

Results

The mean annual patient hospital expenditure was highest for urban models at $97 928 (SD $21 261) and $43 440 (SD $5 048) and lowest for remote at $19 584 (SD $4 394). When combined with the observed maintenance dialysis costs, expenditure was the highest for urban models at $148 510 (SD $19 774). The incremental cost increase of dialysing in an urban area, compared with a rural area, for a relocated person from a remote area, was $5 648 more and increased further for those from remote and very remote areas to $10 785 and $15 118 respectively.

Conclusions

This study demonstrates that dialysis treatment in urban areas for relocated people has health and cost implications that maybe greater than the cost of remote service delivery. The study emphasises the importance of considering all health service costs and cost consequences of service delivery models.

Key points for decision makers

Relocation for dialysis treatment has serious health and economic consequences. Relocated people have low dialysis attendance and high hospital costs in urban areas. While remote dialysis service models are more expensive than urban models, the comparative cost differences are significantly reduced when all health service costs are included. The delivery of equitable and accessible dialysis service models requires a holistic approach that incorporates the needs of the patient; hence dialysis cost studies must consider the full range of cost impacts beyond the dialysis treatments alone.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-06612-z.

Most people requiring ongoing treatment for end-stage kidney disease in the Northern Territory (NT) identify as Aboriginal with the majority residing in areas classified as remote or very remote. Unlike other jurisdictions in Australia, haemodialysis in a satellite unit is the most common form of treatment. However, there is a geographic mismatch between demand and service provision, with services centralised in urban areas. Patients and communities have long advocated for services at or closer to home, maintaining that the consequences of relocation and dislocation have far reaching health, psychosocial and economic ramifications. We analysed retrospective hospital data for 995 maintenance dialysis patients, stratified by the model of care they received in urban, rural and remote locations. Using cost weights attributed to diagnosis codes, we costed hospital admissions, emergency department presentations and maintenance dialysis attendances, to provide a mean total health service cost/patient/year for each model of care. We found that urban services were associated with low observed maintenance dialysis and high hospital costs, but the inverse was true for remote and very remote models. Remote models had high maintenance dialysis costs (due to expense of remote service delivery and good dialysis attendance) but low hospital usage and costs. When adjusted for other variables such as age, dialysis vintage and comorbidities, lower total hospital costs were associated with rural and remote service provision. In an environment of escalating demand and constrained budgets, this study underlines the need for policy decisions to consider the full cost consequences of different dialysis service models.

Nurses' experience in improving adherence to fluid intake and diet in hemodialysis patients

The objective of study is to explore nurses' experiences in their role as educators in improving adherence to fluid and dietary restrictions in hemodialysis patients. This study used a qualitative phenomenological method with a purposive sampling method. Eight nurses were selected for in-depth interviews. Data analysis was conducted using the Colaizzi method. The study found five themes. (1) Intensive interaction with patients to optimize the role of nurses. (2) Various methods are used in delivering education. (3) Various obstacles are experienced in delivering education. (4) Nurses are required to improve their abilities and (5) Benefits for nurses. It is important for nurses to improve their role continuously. Hospitals and health facilities need to encourage nurses in their efforts to develop themselves and their clinical roles, so the quality of nursing care can be improved.

A Modified Version of the Greek Simplified Medication Adherence Questionnaire for Hemodialysis Patients

Non-adherence to the therapeutic regimen is an increasingly growing problem especially among patients undergoing hemodialysis. The aim of this study was to modify the Greek version of Simplified Medication Adherence Questionnaire (GR-SMAQ) for patients undergoing hemodialysis (GR-SMAQ-HD) and explore its validity and reliability. Between June 2016 and November 2016 a group of patients undergoing hemodialysis (N=107) completed the Greek version of SMAQ. The study was carried out in three Dialysis Units of Hospitals of Athens and Peloponnese region, Greece. The form of GR-SMAQ was modified specifically for renal patients while four additional items were added so as the tool study all aspects of adherence to hemodialysis regimen. Construct validity was checked through exploratory factor analysis with principal Component Analysis with the Equamax method. Test-retest reliability and internal consistency were tested. Statistical analysis was performed using the IBM SPSS Statistics version 21. The significance level was set up at 5%. The Greek version of SMAQ for patients undergoing hemodialysis includes eight questions. Three factors emerged from factor analysis. Cronbach’s a coefficient was 0.742 for the whole scale and for each subscale was for Medication Adherence 0.75, for Attendance at hemodialysis session 0.856 and for Diet/Fluid restriction was 0.717. The total mean score was 6.29 (±1.82). GR-SMAQ-HD is a reliable and valuable tool that can be used by hemodialysis nurses and students of nursing for detection of adherence levels in clinical practice.