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Reddy S, Scholes-Robertson N, Raj JM, Pais P. Catastrophic healthcare expenditure and caregiver burden in pediatric chronic kidney disease - a mixed methods study from a low resource setting. Pediatr Nephrol 2024; 39:3079-3093. [PMID: 38856776 DOI: 10.1007/s00467-024-06420-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Revised: 05/09/2024] [Accepted: 05/10/2024] [Indexed: 06/11/2024]
Abstract
BACKGROUND Caregivers of children with chronic kidney disease (CKD) in low resource settings must provide complex medical care at home while being burdened by treatment costs often paid out-of-pocket. We hypothesize that caregiver burden in our low resource setting is greater than reported from high income countries and is associated with frequent catastrophic healthcare expenditure (CHE). METHODS We conducted a mixed-methods study of primary caregivers of children with advanced CKD (stage 3b-5) in our private-sector referral hospital in a low resource setting. We assessed caregiver burden using the Pediatric Renal Caregiver Burden Scale (PRCBS) and measured financial burden by calculating the proportion of caregivers who experienced CHE (monthly out-of-pocket healthcare expenditure exceeding 10% of total household monthly expenditure). We performed a qualitative reflexive thematic analysis of caregiver interviews to explore sources of burden. RESULTS Of the 45 caregivers included, 35 (78%) had children on maintenance dialysis (25 PD, 10 HD). Mean caregiver burden score was 141 (± 17), greater than previously reported. On comparative analysis, PRCBS scores were higher among caregivers of children with kidney failure (p = 0.005), recent hospitalization (p = 0.03), non-earning caregivers (p = 0.02), caring for > 2 dependents (p = 0.009), and with high medical expenditure (p = 0.006). CHE occurred in 43 (96%) caregivers of whom 37 (82%) paid out-of-pocket. The main themes derived relating to caregiver burden were severe financial burden, mental stress and isolation, and perpetual burden of concern. CONCLUSION Parents of children with CKD experienced severe caregiver burden with frequent CHE and relentless financial stress indicating an imminent need for social support interventions.
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Affiliation(s)
- Soumya Reddy
- Department of Paediatric Nephrology, St Johns Medical College Hospital, St Johns National Academy of Health Sciences, Sarjapur Road, Bangalore, 560034, India
| | - Nicole Scholes-Robertson
- Rural and Remote Health, College of Medicine and Public Health, Flinders University, Bedford Park, Australia
| | - John Michael Raj
- Department of Biostatistics, St Johns Medical College, St Johns National Academy of Health Sciences, Bangalore, India
| | - Priya Pais
- Department of Paediatric Nephrology, St Johns Medical College Hospital, St Johns National Academy of Health Sciences, Sarjapur Road, Bangalore, 560034, India.
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Matthews M, McKeaveney C, Noble H, Reid J. Exploring the unmet needs and experiences of informal caregivers of patients with end-stage kidney disease (ESKD) receiving haemodialysis - a qualitative study. PLoS One 2024; 19:e0302525. [PMID: 38722989 PMCID: PMC11081335 DOI: 10.1371/journal.pone.0302525] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Accepted: 04/07/2024] [Indexed: 05/13/2024] Open
Abstract
BACKGROUND Patients with end stage kidney disease (ESKD) receiving haemodialysis experience multiple symptoms, which can present physical and emotional challenges for both patients and their informal caregivers. Caregivers can experience anxiety, depression, and social isolation negatively impacting their overall wellbeing and resulting in caregiver burden. The needs of this group of caregivers have been largely neglected, with little emphasis placed on supportive interventions that might assist and support them in their caring role. AIM The aim of this study Is to explore the unmet needs and experiences of caregivers of patients with ESKD receiving haemodialysis, and to determine the components of a supportive intervention. DESIGN A qualitative study using semi-structured interviews (n = 24) with informal caregivers. An interpretive qualitative framework was employed to generate a rich understanding of the unmet needs and experiences of caregivers. Data was analysed using thematic analysis. Interviews were transcribed verbatim and data management was assisted through NVIVO version 11. SETTING/PARTICIPANTS Twenty-four informal caregivers were purposively recruited from two haemodialysis settings within Northern Ireland. RESULTS Three themes were identified: (1) The negative impact of distress, anxiety, and isolation on caregivers due to their caregiving responsibilities (2) Inadequate information and knowledge about the complexities of renal care (3) The benefits of spiritual beliefs, stress management and peer support in relieving the caregiving burden. CONCLUSIONS Caregivers of patients with ESKD receiving haemodialysis are at increased risk of physical and psychological distress and burden arising from their caregiving role. The unpredictable nature of ESKD and haemodialysis treatment negatively impacts the caregiver experience and adds to the challenges of the role. The information needs of caregivers are not always adequately met and they subsequently lack appropriate knowledge, skills, and guidance to assist them in their caregiving role. Supportive interventions are essential for caregivers to enhance their capability to deliver effective care and improve their quality of life.
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Affiliation(s)
- Michael Matthews
- School of Nursing and Midwifery, Queen’s University Belfast, Belfast, United Kingdom
| | - Clare McKeaveney
- School of Nursing and Midwifery, Queen’s University Belfast, Belfast, United Kingdom
| | - Helen Noble
- School of Nursing and Midwifery, Queen’s University Belfast, Belfast, United Kingdom
| | - Joanne Reid
- School of Nursing and Midwifery, Queen’s University Belfast, Belfast, United Kingdom
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de Barbieri I, Strini V, Noble H, Carswell C, Rocchi MBL, Sisti D. Facilitators and Barriers to Receiving Palliative Care in People with Kidney Disease: Predictive Factors from an International Nursing Perspective. NURSING REPORTS 2024; 14:220-229. [PMID: 38391063 PMCID: PMC10885022 DOI: 10.3390/nursrep14010018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Revised: 12/26/2023] [Accepted: 01/18/2024] [Indexed: 02/24/2024] Open
Abstract
BACKGROUND Palliative care (PC) focuses on relieving pain and difficult symptoms rather than treating disease or delaying its progress. Palliative care views death as a natural process and allows patients to live the last phase of their existence in the best possible way, encouraging them to express their opinions and wishes for a good death. Interventions are advocated to control symptoms and distress and promote wellbeing and social functioning. A multidisciplinary approach to support patients receiving palliative care is encouraged. OBJECTIVE The aims of this study were to investigate the facilitators and barriers to PC in people with kidney disease from a nursing perspective and to explore predictive factors associated with nurse-perceived facilitators and barriers to PC in people with kidney disease. DESIGN This study is a survey that adopted a questionnaire created in 2021 with Delphi methology, which included 73 statements divided into 37 facilitators and 36 barriers to PC in patients with kidney disease, to be scored using a Likert scale. PARTICIPANTS AND MEASUREMENTS Participants were obtained through the membership database of the European Dialysis and Transplant Nurses Association/European Renal Care Association (EDTNA/ERCA) of 2020. Inclusion criteria included being registered as a nurse, an EDTNA/ERCA member and understanding of the English language. The questionnaire was sent via email. RESULTS Three profiles of respondents were found: the first group was characterized by the highest agreement percentages of facilitators and with an average value of 53.7% in barriers; the second was characterized by a lower endorsement of facilitators and similar agreement to the first group for barriers; the third group had a high probability (>80%) of items endorsing both barriers and facilitators. Predictive variables were significantly associated with "Years in nephrology" and "macro geographic area". CONCLUSIONS This study demonstrates variation in PC practice across Europe. Some professionals identified fewer barriers to PC and appeared more confident when dealing with difficult situations in a patient's care pathway, while others identified more barriers as obstacles to the implementation of adequate treatment. The number of years of nephrology experience and the geographical area of origin predicted how nurses would respond. This study was not registered.
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Affiliation(s)
- Ilaria de Barbieri
- Woman's and Child's Health Department, Padua University Hospital, 45128 Padova, Italy
| | - Veronica Strini
- Clinical Research Unit, Padua University Hospital, 45128 Padova, Italy
| | - Helen Noble
- School of Nursing and Midwifery, Queens University Belfast, Belfast BT9 7BL, UK
| | - Claire Carswell
- School of Nursing and Midwifery, Queens University Belfast, Belfast BT9 7BL, UK
| | - Marco Bruno Luigi Rocchi
- Department of Biomolecular Sciences, Service of Biostatistics, University of Urbino, 61029 Urbino, Italy
| | - Davide Sisti
- Department of Biomolecular Sciences, Service of Biostatistics, University of Urbino, 61029 Urbino, Italy
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Coumoundouros C, Farrand P, Sanderman R, von Essen L, Woodford J. "Systems seem to get in the way": a qualitative study exploring experiences of accessing and receiving support among informal caregivers of people living with chronic kidney disease. BMC Nephrol 2024; 25:7. [PMID: 38172754 PMCID: PMC10765659 DOI: 10.1186/s12882-023-03444-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2023] [Accepted: 12/19/2023] [Indexed: 01/05/2024] Open
Abstract
BACKGROUND The well-being of informal caregivers of people living with chronic kidney disease is influenced by their experiences with support, however, few studies have focused on exploring these experiences. This study aimed to explore informal caregivers' experiences accessing and receiving support while caring for someone living with chronic kidney disease. METHODS Informal caregivers of people living with chronic kidney disease (n = 13) in the United Kingdom were primarily recruited via community organisations and social media adverts to participate in semi-structured interviews. Interviews explored support needs, experiences of receiving support from different groups (e.g. healthcare professionals, family/friends), and barriers and facilitators to accessing support. Support was understood as including emotional, practical, and informational support. Data were analysed using reflexive thematic analysis. RESULTS Three themes were generated: (1) "Systems seem to get in the way" - challenges within support systems, illustrating the challenges informal caregivers encountered when navigating complex support systems; (2) Relying on yourself, describing how informal caregivers leveraged their existing skills and networks to access support independently, while recognising the limitations of having to rely on yourself to find support; and (3) Support systems can "take the pressure off", showing how support systems were able to help informal caregivers cope with the challenges they experienced if certain conditions were met. CONCLUSIONS In response to the challenges informal caregivers experienced when seeking support, improvements are needed to better consider informal caregiver needs within healthcare systems, and to develop interventions tailored to informal caregiver needs and context. Within the healthcare system, informal caregivers may benefit from system navigation support and better integration within healthcare teams to ensure their informational support needs are met. New interventions developed to support informal caregivers should fit within their existing support systems and incorporate the qualities of support, such as empathy, that were valued. Additionally, use of an equity framework and user-centered design approaches during intervention development could help ensure interventions are accessible and acceptable.
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Affiliation(s)
- Chelsea Coumoundouros
- Healthcare Sciences and e-Health, Department of Women's and Children's Health, Uppsala University, Dag Hammarskjölds väg 14B, Uppsala, 751 05, Sweden
- Clinical Education, Development and Research (CEDAR); Psychology, University of Exeter, Exeter, UK
| | - Paul Farrand
- Clinical Education, Development and Research (CEDAR); Psychology, University of Exeter, Exeter, UK
| | - Robbert Sanderman
- Department of Health Psychology, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Louise von Essen
- Healthcare Sciences and e-Health, Department of Women's and Children's Health, Uppsala University, Dag Hammarskjölds väg 14B, Uppsala, 751 05, Sweden
| | - Joanne Woodford
- Healthcare Sciences and e-Health, Department of Women's and Children's Health, Uppsala University, Dag Hammarskjölds väg 14B, Uppsala, 751 05, Sweden.
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Collins A, Hui D, Davison SN, Ducharlet K, Murtagh F, Chang YK, Philip J. Referral Criteria to Specialist Palliative Care for People with Advanced Chronic Kidney Disease: A Systematic Review. J Pain Symptom Manage 2023; 66:541-550.e1. [PMID: 37507095 DOI: 10.1016/j.jpainsymman.2023.07.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Revised: 07/17/2023] [Accepted: 07/21/2023] [Indexed: 07/30/2023]
Abstract
CONTEXT People with advanced chronic kidney disease (CKD) have significant morbidity, yet for many, access to palliative care occurs late, if at all. OBJECTIVES This study sought to examine criteria for referral to specialist palliative care for adults with advanced CKD with a view to improving use of these essential services. METHODS Systematic review of studies detailing referral criteria to palliative care in advanced CKD conducted and reported according to the Preferred Reporting Items for Systematic Reviews and Meta Analyses (PRISMA) guideline and registered (PROSPERO: CRD42021230751). DATA SOURCES Electronic databases (Ovid, MEDLINE, Ovid Embase, and PubMed) were used to identify potential studies, which were subjected to double review, data extraction, thematic coding, and descriptive analyses. RESULTS Searches yielded 650 unique titles ultimately resulting in 56 studies addressing referral criteria to specialist palliative care in advanced CKD. Of 10 categories of referral criteria, most commonly discussed were: Critical times of treatment decision making (n = 23, 41%); physical or emotional symptoms (n = 22, 39%); limited prognosis (n = 18, 32%); patient age and comorbidities (n = 18, 32%); category of CKD/ biochemical criteria (n = 13, 23%); functional decline (n = 13, 23); psychosocial needs (n = 9, 16%); future care planning (n = 9, 16%); anticipated decline in illness course (n = 8, 14%); and hospital use (n = 8, 14%). CONCLUSION Clinicians consider referral to specialist palliative care for a wide range of reasons, with many related to care needs. As palliative care continues to integrate with nephrology, our findings represent a key step towards developing consensus criteria to standardize referral for patients with chronic kidney diseases.
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Affiliation(s)
- Anna Collins
- Department of Medicine (A.C., K.D., J.P.), St Vincent's Hospital, University of Melbourne, Australia
| | - David Hui
- Department of Palliative Care (D.H., Y.K.C.), Rehabilitation and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Sara N Davison
- Division of Nephrology & Immunology (S.N.D.), Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Kathryn Ducharlet
- Department of Medicine (A.C., K.D., J.P.), St Vincent's Hospital, University of Melbourne, Australia; Department of Nephrology (K.D.), St Vincent's Hospital, Melbourne, Australia; Eastern Health Clinical School (K.D.), Monash University, Melbourne, Australia; Eastern Health Integrated Renal Services (K.D.), Melbourne, Australia
| | - Fliss Murtagh
- Wolfson Palliative Care Research Centre (F.M.), Hull York Medical School, University of Hull, UK
| | - Yuchieh Kathryn Chang
- Department of Palliative Care (D.H., Y.K.C.), Rehabilitation and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Jennifer Philip
- Department of Medicine (A.C., K.D., J.P.), St Vincent's Hospital, University of Melbourne, Australia; Palliative Care Service (J.P.), Royal Melbourne Hospital, Parkville, Australia; Palliative Care Service (J.P.), Peter MacCallum Cancer Centre, Melbourne, Australia.
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Gelfand SL. Conservative Kidney Management in the United States: What It Is and What It Could Be. Kidney Med 2023; 5:100740. [PMID: 37954191 PMCID: PMC10632098 DOI: 10.1016/j.xkme.2023.100740] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2023] Open
Affiliation(s)
- Samantha L. Gelfand
- Address for Correspondence: Samantha L. Gelfand, MD, 450 Brookline Avenue, JF8, Boston MA 02215.
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Mendoza K, Killeen K, Lakin JR, Leiter RE, Sciacca KR, Gelfand SL. Adding Pals to KidneyPal: Creating a Virtual Patient and Family Advisory Council for Kidney Palliative Care. J Palliat Med 2023; 26:1450-1452. [PMID: 37625026 DOI: 10.1089/jpm.2023.0108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/27/2023] Open
Abstract
Patient and family advisory councils (PFACs) represent one method of engaging patients and families in clinical program development and research, but existing practices too often exclude marginalized and minority voices. As a kidney palliative care team (KidneyPal) at a large academic medical center, we sought to create a PFAC that explicitly considered equity and inclusion in its approach to advisor recruitment. We developed two major innovations to reduce selection bias in our KidneyPal PFAC: adaptation to an entirely virtual process and alteration of the advisor recruitment and enrollment process. We eliminated several potential barriers to participation for our patients and their family members, a population with higher rates of advanced age, nonwhite ethnicity, and limited English proficiency than the local general population. We removed application requirements including lengthy online training modules, detailed employment history, a personal essay, and a criminal background check. The KidneyPal PFAC may act as a model for improving equity and inclusion in virtual patient advisory councils.
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Affiliation(s)
- Kimberly Mendoza
- Division of Palliative Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Kelsey Killeen
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Joshua R Lakin
- Division of Palliative Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Richard E Leiter
- Division of Palliative Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Kate R Sciacca
- Division of Palliative Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Samantha L Gelfand
- Division of Palliative Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
- Renal Division, Brigham and Women's Hospital, Boston, Massachusetts, USA
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Akbari R, Farsi Z, Sajadi SA. Relationship between fatigue and quality of life and related factors in family caregivers of patients on hemodialysis. BMC Psychiatry 2023; 23:430. [PMID: 37316855 DOI: 10.1186/s12888-023-04934-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Accepted: 06/07/2023] [Indexed: 06/16/2023] Open
Abstract
BACKGROUND The incessant and stressful nature of providing care to patients with chronic diseases can cause fatigue in caregivers. Caregivers' fatigue and reduced quality of life can reduce the patient's quality of care. Since it is important to pay attention to the mental health of family caregivers, this study investigated the relationship between fatigue and quality of life and their related factors in family caregivers of patients on hemodialysis. METHODS This cross-sectional descriptive-analytical study was performed in 2020-2021. One hundred seventy family caregivers were recruited by convenience sampling from two hemodialysis referral centers in the east of Mazandaran province, Iran. The data collection tools were the Family Caregiver Quality of Life questionnaire and Krupp's fatigue severity scale. RESULTS The majority (88%) of caregivers had moderate to severe fatigue. Caregivers' fatigue was a major factor influencing their quality of life. There was a significant fatigue difference between some categories of kinship and the caregiver's income level (P < 0.05). Caregivers with lower income and education levels, those who were the patient's spouse, and those who could not leave the patient alone had significantly worse quality of life than other caregivers (P < 0.05). Also, caregivers living with the patient in the same house had a worse quality of life than those living separately (P = 0.05). CONCLUSION Considering the high prevalence of fatigue among family caregivers of patients on hemodialysis and its adverse effect on their quality of life, it is recommended to perform routine screenings and implement fatigue alleviation interventions for these caregivers.
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Affiliation(s)
- Roghayeh Akbari
- Infectious Diseases and Tropical Medicine Research Center, Health Research Institute, Babol University of Medical Sciences, Babol, Iran
| | - Zahra Farsi
- Research and Community Health Departments, Nursing School, Aja University of Medical Sciences, Tehran, Iran
| | - Seyedeh Azam Sajadi
- Nursing Management Department, Nursing School, Aja University of Medical Sciences, Tehran, Iran.
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Coumoundouros C, Farrand P, Hamilton A, von Essen L, Sanderman R, Woodford J. Cognitive behavioural therapy self-help intervention preferences among informal caregivers of adults with chronic kidney disease: an online cross-sectional survey. BMC Nephrol 2023; 24:4. [PMID: 36600229 PMCID: PMC9812545 DOI: 10.1186/s12882-022-03052-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2022] [Accepted: 12/22/2022] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND Informal caregivers (i.e. family and friends) provide essential support to people with chronic kidney disease (CKD). Many informal caregivers experience mental health problems such as anxiety and depression due to the caregiving role, and commonly have unmet psychological support needs. One potential solution is cognitive behavioural therapy (CBT) self-help interventions that are less reliant on extensive involvement of healthcare professionals, which may increase access. Within the intervention development phase of the MRC framework, the study's primary objective was to examine informal caregivers' self-help intervention preferences (e.g. delivery format, content). Secondary objectives were to describe the informal caregiver's situation (e.g. type of care activities) and mental health (symptoms of depression, anxiety, and stress). METHODS An online cross-sectional survey conducted in the United Kingdom. Informal caregivers of adults living with CKD were recruited via social media, websites, newsletters, magazine articles, a podcast episode, and paid Facebook advertisements. The survey examined: informal caregiver characteristics; care recipient characteristics; self-help intervention preferences; and informal caregiver's mental health using the DASS-21. Data were analysed using descriptive statistics. RESULTS Sixty-five informal caregivers participated. The majority (85%) were female, caring for a male (77%) spouse/partner (74%). Responses indicated 58% of informal caregivers were experiencing at least mild depression. In total, 48% indicated they were likely to use a CBT self-help intervention, preferring an intervention provided via internet (e.g. website) (64%), workbook (56%), or individually in-person (54%). Regarding content, interventions should cover a wide range of topics including living with CKD, support services, informal caregiver's physical health, and diet. Overall, 48% reported a preference for a supported intervention, with support delivered in-person or via email by a trained professional at a community organisation. CONCLUSIONS Results suggest CBT self-help interventions may be an acceptable way to provide psychological support to informal caregivers, however the study is limited by the small sample size. A wide range of intervention preferences were identified indicating a need to tailor intervention content and delivery to enhance acceptability and engagement. Results will inform development of a CBT self-help intervention for informal caregivers of people with CKD.
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Affiliation(s)
- Chelsea Coumoundouros
- Department of Women's and Children's Health, Healthcare Sciences and E-Health, Uppsala University, Uppsala, Sweden.
- Clinical Education, Development and Research (CEDAR), Psychology, University of Exeter, Exeter, UK.
| | - Paul Farrand
- Clinical Education, Development and Research (CEDAR), Psychology, University of Exeter, Exeter, UK
| | - Alexander Hamilton
- Faculty of Health and Life Sciences, University of Exeter Medical School, University of Exeter, Exeter, UK
- Exeter Kidney Unit, Royal Devon University Healthcare NHS Foundation Trust, Exeter, UK
| | - Louise von Essen
- Department of Women's and Children's Health, Healthcare Sciences and E-Health, Uppsala University, Uppsala, Sweden
| | - Robbert Sanderman
- Department of Health Psychology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Joanne Woodford
- Department of Women's and Children's Health, Healthcare Sciences and E-Health, Uppsala University, Uppsala, Sweden
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10
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Bursic AE, Schell JO. Hospice Care in Conservative Kidney Management. Semin Nephrol 2023; 43:151398. [PMID: 37524007 DOI: 10.1016/j.semnephrol.2023.151398] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/02/2023]
Abstract
Hospice care offers multidisciplinary expertise to optimize symptom management and quality of life for patients with limited life expectancy and help ensure that patients receive care that reflects their personal goals and values. Many patients receiving conservative kidney management (CKM) and their loved ones can benefit from the additional support that hospice provides, particularly as symptom burdens and functional status worsen over the last few months of life. We provide an overview of hospice services and how they may benefit patients receiving CKM, describe the evolution of optimal CKM strategies and collaboration between nephrology and hospice clinicians over the course of disease progression, and explore challenges to effective hospice care delivery for patients with chronic kidney disease and how to address them.
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Affiliation(s)
- Alexandra E Bursic
- Renal-Electrolyte Division, University of Pittsburgh Medical Center, Pittsburgh, PA.
| | - Jane O Schell
- Renal-Electrolyte Division, University of Pittsburgh Medical Center, Pittsburgh, PA; Section of Palliative Care and Medical Ethics, Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
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11
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Wang X, Shi Q, Mo Y, Liu J, Yuan Y. Palliative care needs and symptom burden in younger and older patients with end-stage renal disease undergoing maintenance hemodialysis: A cross-sectional study. Int J Nurs Sci 2022; 9:422-429. [PMID: 36285085 PMCID: PMC9587393 DOI: 10.1016/j.ijnss.2022.09.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Revised: 09/15/2022] [Accepted: 09/17/2022] [Indexed: 11/06/2022] Open
Abstract
Objectives To investigate the current situation of palliative care needs and the symptom burden in patients with end-stage renal disease (ESRD) undergoing maintenance hemodialysis (MHD), and to explore whether there are differences between younger and older patients. Methods This cross-sectional study was conducted in the hemodialysis centers of two tertiary hospitals from November 2021 to June 2022. Participants were selected by convenience sampling. Socio-demographics, clinical characteristics, the Palliative Care Outcome Scale (POS), the Dialysis Symptom Index (DSI), and health-related quality of life (EQ-5D-3L) were used for evaluation. Descriptive statistics, between-group comparisons, and correlation analysis were used to analyze the data. Results A total of 236 patients were enrolled, including 118 younger and 118 older patients. The total median (P 25, P 75) POS score was 16.0 (12.0, 23.0), and the score was higher in older patients (P < 0.01). The mean total number of symptoms in MHD patients was 15.04 ± 5.06, and the overall median symptom severity score was 59.0 (52.0, 71.0); these scores were higher in the older group (P < 0.01). The most common symptom was dry mouth (91.5%), followed by itching (83.1%), and dry skin (82.2%). Additionally, palliative care needs were significantly associated with symptom burden and health-related quality of life (HRQOL). Conclusions The results showed that patients with ESRD undergoing MHD have a significant symptom burden and moderate palliative care needs, which are more severe in older patients. Therefore, interdisciplinary teams should be formed to actively manage patients' symptoms and meet the physical, psychological, social, and spiritual needs related to palliative care to improve patients' HRQOL.
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Affiliation(s)
- Xuefei Wang
- School of Nursing, Department of Medicine, Soochow University, Suzhou, Jiangsu, China
| | - Qiuyin Shi
- Zhongda Hospital Affiliated to Southeast University, Nanjing, Jiangsu, China
| | - Yongzhen Mo
- Jiangsu Province Official Hospital, Nanjing, Jiangsu, China
| | - Jing Liu
- Nanjing BenQ Medical Center, Nanjing, Jiangsu, China
| | - Yingying Yuan
- School of Nursing, Department of Medicine, Soochow University, Suzhou, Jiangsu, China
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12
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Ibrahim N, Chu SY, Siau CS, Amit N, Ismail R, Abdul Gafor AH. The effects of psychosocial and economic factors on the quality of life of patients with end-stage renal disease and their caregivers in Klang Valley, Malaysia: protocol for a mixed-methods study. BMJ Open 2022; 12:e059305. [PMID: 36691236 PMCID: PMC9171257 DOI: 10.1136/bmjopen-2021-059305] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Accepted: 05/12/2022] [Indexed: 01/27/2023] Open
Abstract
INTRODUCTION The number of patients in Malaysia requiring dialysis is expected to rise substantially in the future due to the ageing population and increasing prevalence of diabetes mellitus and hypertension. Hence, more individuals will be expected to adopt the role of caregivers in the future. The upward trend of end-stage renal disease (ESRD) and caregiving for dialysis patients has detrimental consequences for both patients and caregivers in terms of their psychological well-being and quality of life. Despite the current circumstances, there are very few studies in Malaysia that have explored the psychosocial factors, specifically on the economic impact of the management of ESRD. METHODS AND ANALYSIS This two-phase sequential explanatory mixed-methods design, incorporating a quantitative design (phase I) and a qualitative study (phase II), is to be conducted in 4 government hospitals and 10 other non-governmental organisations or private dialysis centres within Klang Valley, Malaysia. A cross-sectional survey (phase I) will include 236 patient-caregiver dyads, while focus group discussions (phase II) will include 30 participants. The participants for both phases will be recruited purposively. Descriptive statistics, independent sample t-tests and multiple regression analysis will be used for analyses in phase I, and thematic analysis will be used in phase II. ETHICS AND DISSEMINATION Approval for the study has been obtained from the National Medical Research and Ethics Committee (MREC) (NMRR-21-1012-59714) and the Research Ethics Committee of Hospital Canselor Tuanku Muhriz UKM (UKM PPI/111/8/JEP-2021-078) and University of Malaya Medical Centre (MREC ID NO: 2 02 178-10346). Informed consent of the participants will be obtained beforehand, and no personal identifiers will be obtained from the participants to protect their anonymity. The findings will be published in peer-reviewed scientific journals and presented at national or international conferences with minimal anonymised data.
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Affiliation(s)
- Norhayati Ibrahim
- Centre for Health Aging and Wellness (H-Care), Faculty of Health Sciences, Universiti Kebangsaan Malaysia, Kuala Lumpur, Federal Territory of Kuala Lumpur, Malaysia
- Institute of Islam Hadhari, Universiti Kebangsaan Malaysia, Kuala Lumpur, Federal Territory of Kuala Lumpur, Malaysia
| | - Sin Yee Chu
- Centre for Health Aging and Wellness (H-Care), Faculty of Health Sciences, Universiti Kebangsaan Malaysia, Kuala Lumpur, Federal Territory of Kuala Lumpur, Malaysia
| | - Ching Sin Siau
- Centre for Community Health Studies (ReaCH), Faculty of Health Sciences, Universiti Kebangsaan Malaysia, Kuala Lumpur, Federal Territory of Kuala Lumpur, Malaysia
| | - Noh Amit
- Centre for Community Health Studies (ReaCH), Faculty of Health Sciences, Universiti Kebangsaan Malaysia, Kuala Lumpur, Federal Territory of Kuala Lumpur, Malaysia
| | - Rozmi Ismail
- Centre for Research in Psychology and Human Well-being (PsiTra), Faculty of Social Sciences and Humanities, Universiti Kebangsaan Malaysia, Bangi, Selangor, Malaysia
| | - Abdul Halim Abdul Gafor
- Department of Medicine, Hospital Canselor Tuanku Muhriz UKM, Cheras, Federal Territory of Kuala Lumpur, Malaysia
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13
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Walavalkar A, Craswell A, Gray NA. Experiences of Caregivers of Patients With Conservatively Managed Kidney Failure: A Mixed Methods Systematic Review. Can J Kidney Health Dis 2022; 9:20543581221089080. [PMID: 35450152 PMCID: PMC9016578 DOI: 10.1177/20543581221089080] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Accepted: 02/07/2022] [Indexed: 11/24/2022] Open
Abstract
Background: Older people with kidney failure often choose conservative kidney care. The
experiences and quality of life (QOL) of caregivers who support them are
incompletely characterized. Objective: To determine the burden, QOL, and understand experiences of caregivers
supporting patients managed conservatively. Design: Systematic review of quantitative and qualitative studies. Sources of information: PubMed, Embase, PsycINFO, CINAHL, and MEDLINE electronic databases were
systematically searched for quantitative and qualitative studies published
between January 2000 and July 2020. Subjects: Caregivers of adults with kidney failure (estimated glomerular filtration
rate < 15 mL/min/1.73 m2) managed conservatively. Methods: Data were extracted by 2 independent reviewers using a prespecified
extraction tool. Study quality was assessed using the Critical Appraisal
Skills Program (CASP) tool. Measurements: Descriptive reports of demographics, measurement scales, and outcomes.
Thematic synthesis of qualitative data. Results: Six studies met inclusion criteria, including 3 quantitative and 3
descriptive qualitative studies. Caregivers of patients receiving
conservative kidney management (CKM) experienced significant caregiver
burden and similar impacts to their QOL as those caring for patients
receiving dialysis. Thematic synthesis revealed 5 themes: Understanding the
concept of CKM, Need for involvement in the decision for CKM, Identifying
available supports, Uncertainty about the future and negotiating
deteriorations and dying, and Burden of care impacting on QOL. Limitations: Low numbers of included studies, data collection and recruitment biases in
qualitative studies and small caregiver numbers in quantitative studies,
limit transferability of findings. Heterogeneity in study design and outcome
measures precluded meta-analysis. Conclusions: Caregivers of patients with conservatively managed kidney failure suffer
significant burden and experience QOL comparable with those caring for
patients on dialysis. Limited understanding and involvement in conservative
management decision making, and a fear of deterioration and dying, result in
anxiety in caregivers. Further research into the experiences of caregivers
will help support both caregivers and the patients who choose conservative
management. Registration: PROSPERO registration number CRD42021209811.
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Affiliation(s)
- Anisha Walavalkar
- Renal Unit, Department of Nephrology, Sunshine Coast University Hospital, Birtinya, Queensland, Australia
| | - Alison Craswell
- University of the Sunshine Coast, Sippy Downs, Queensland, Australia
- Sunshine Coast Health Institute, Birtinya, Queensland, Australia
| | - Nicholas A. Gray
- Renal Unit, Department of Nephrology, Sunshine Coast University Hospital, Birtinya, Queensland, Australia
- University of the Sunshine Coast, Sippy Downs, Queensland, Australia
- Sunshine Coast Health Institute, Birtinya, Queensland, Australia
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14
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Eneanya ND, Lakin JR, Paasche-Orlow MK, Lindvall C, Moseley ET, Henault L, Hanchate AD, Mandel EI, Wong SPY, Zupanc SN, Davis AD, El-Jawahri A, Quintiliani LM, Chang Y, Waikar SS, Bansal AD, Schell JO, Lundquist AL, Tamura MK, Yu MK, Unruh ML, Argyropoulos C, Germain MJ, Volandes A. Video Images about Decisions for Ethical Outcomes in Kidney Disease (VIDEO-KD): the study protocol for a multi-centre randomised controlled trial. BMJ Open 2022; 12:e059313. [PMID: 35396311 PMCID: PMC8996022 DOI: 10.1136/bmjopen-2021-059313] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
INTRODUCTION Older patients with advanced chronic kidney disease (CKD) often are inadequately prepared to make informed decisions about treatments including dialysis and cardiopulmonary resuscitation. Further, evidence shows that patients with advanced CKD do not commonly engage in advance care planning (ACP), may suffer from poor quality of life, and may be exposed to end-of-life care that is not concordant with their goals. We aim to study the effectiveness of a video intervention on ACP, treatment preferences and other patient-reported outcomes. METHODS AND ANALYSIS The Video Images about Decisions for Ethical Outcomes in Kidney Disease trial is a multi-centre randomised controlled trial that will test the effectiveness of an intervention that includes a CKD-related video decision aid followed by recording personal video declarations about goals of care and treatment preferences in older adults with advancing CKD. We aim to enrol 600 patients over 5 years at 10 sites. ETHICS AND DISSEMINATION Regulatory and ethical aspects of this trial include a single Institutional Review Board mechanism for approval, data use agreements among sites, and a Data Safety and Monitoring Board. We intend to disseminate findings at national meetings and publish our results. TRIAL REGISTRATION NUMBER NCT04347629.
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Affiliation(s)
- Nwamaka D Eneanya
- Renal-Electrolyte and Hypertension Division, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania, Philadelphia, PA, USA
| | - Joshua R Lakin
- Harvard Medical School, Boston, Massachusetts, USA
- Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Michael K Paasche-Orlow
- Boston University School of Medicine, Section of General Internal Medicine, Boston Medical Center, Boston, Massachusetts, USA
| | - Charlotta Lindvall
- Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Edward T Moseley
- Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Lori Henault
- Boston University School of Medicine, Section of General Internal Medicine, Boston Medical Center, Boston, Massachusetts, USA
| | - Amresh D Hanchate
- Department of Social Sciences and Health Policy, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Ernest I Mandel
- Harvard Medical School, Boston, Massachusetts, USA
- Division of Renal (Kidney) Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Susan P Y Wong
- University of Washington, Seattle, Washington State, USA
| | - Sophia N Zupanc
- Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | | | - Areej El-Jawahri
- Harvard Medical School, Boston, Massachusetts, USA
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Lisa M Quintiliani
- Boston University School of Medicine, Section of General Internal Medicine, Boston Medical Center, Boston, Massachusetts, USA
| | - Yuchiao Chang
- Harvard Medical School, Boston, Massachusetts, USA
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Sushrut S Waikar
- Section of Nephrology, Boston University School of Medicine and Boston Medical Center, Boston, Massachusetts, USA
| | - Amar D Bansal
- Section of Palliative Care and Medical Ethics, Department of General Medicine, Division of Renal-Electrolyte, University of Pittsburgh School of Medicine, UPMC Health System, Pittsburgh, Pennsylvania, USA
| | - Jane O Schell
- Section of Palliative Care and Medical Ethics, Department of General Medicine, Division of Renal-Electrolyte, University of Pittsburgh School of Medicine, UPMC Health System, Pittsburgh, Pennsylvania, USA
| | - Andrew L Lundquist
- Harvard Medical School, Boston, Massachusetts, USA
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Manjula Kurella Tamura
- Division of Nephrology, Stanford University School of Medicine; and Geriatric Research Education Clinical Center, VA Palo Alto Health Care System, Palo Alto, California, USA
| | - Margaret K Yu
- Division of Nephrology, Department of Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Mark L Unruh
- Department of Medicine, University of New Mexico, Albuquerque, New Mexico, USA
| | - Christos Argyropoulos
- Division of Nephrology, Department of Internal Medicine, University of New Mexico School of Medicine, Albuquerque, New Mexico, USA
| | - Michael J Germain
- Baystate Medical Center-University of Massachusetts Springfield, Springfield, Massachusetts, USA
| | - Angelo Volandes
- Harvard Medical School, Boston, Massachusetts, USA
- ACP Decisions Non-profit Foundation, Newton, Massachusetts, USA
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
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15
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Using an international online forum to explore perspectives of caregivers of patients with chronic kidney disease. J Nephrol 2022; 35:267-277. [PMID: 35000136 DOI: 10.1007/s40620-021-01216-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2021] [Accepted: 11/28/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND Caregivers of patients with chronic kidney disease (CKD) experience significant burden of care. Online forums provide an important platform for peer connection and expression of perspectives and concerns, but have not been used to capture consumer experiences in CKD research. Social support can improve caregivers' quality of life, with emerging research exploring online social support. METHOD This study employed qualitative content analysis to examine 159 posts on an online international forum: Caregivers of Patients with Kidney Disease to examine the experiences and concerns raised by caregivers of patients with CKD. Posts were coded using verbatim words and phrases, then arranged into three overarching themes, 12 categories and 71 sub-categories. RESULTS The overarching themes were Impact to Carer Wellbeing; Use of Online Social Support; Caregiver Knowledge. Online posts highlighted the psychological and physical challenges for caregivers of patients with CKD including social isolation, helplessness and the impact to paid employment. Participants used online social support to connect with peers and seek advice from the forum community on topics including: the patient's diet; clinical management; CKD symptoms; and how to support the patient to adhere to diet and medications. CONCLUSION This study provides valuable insight into gaps in caregiver knowledge and their need to seek online peer support. Caregiver forums can inform support strategies from healthcare professionals to increase caregiver involvement in treatment and education options, as well as tangible assistance to support caregivers' and patients' needs, such as transportation services for dialysis patients.
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16
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Matthews M, Reid J, McKeaveney C, Noble H. Knowledge Requirements and Unmet Needs of Informal Caregivers of Patients with End-Stage Kidney Disease (ESKD) Receiving Haemodialysis: A Narrative Review. Healthcare (Basel) 2021; 10:healthcare10010057. [PMID: 35052221 PMCID: PMC8775298 DOI: 10.3390/healthcare10010057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Revised: 12/20/2021] [Accepted: 12/26/2021] [Indexed: 11/30/2022] Open
Abstract
Background: Patients with end-stage kidney disease receiving haemodialysis rely heavily on informal caregivers to support them living at home. Informal caregiving may exact a toll on caregivers’ physical, emotional, and social well-being, impacting negatively on their overall quality of life. The aim of this narrative review is to report knowledge requirements and needs of informal caregivers of patients with end stage kidney disease (ESKD) receiving haemodialysis. Methods: The review followed the Preferred Reporting Items for Reporting Systematic Reviews and Meta-analyses (PRISMA). Five electronic databases were searched: Web of Science, PsycINFO, Embase, Medline, and CINAHL to identify the experiences and unmet needs of informal caregivers of patients with end stage kidney disease (ESKD) receiving haemodialysis. Results: Eighteen papers were included in the review and incorporated a range of methodological approaches. There are several gaps in the current literature around knowledge and informational needs and skills required by informal caregivers, such as signs and symptoms of potential complications, dietary requirements, and medication management. Although most research studies in this review illustrate the difficulties and challenges faced by informal caregivers, there is a paucity of information as to which support mechanisms would benefit caregivers. Conclusion: Informal caregivers provide invaluable assistance in supporting people with ESKD undergoing haemodialysis. These informal caregivers however experience multiple unmet needs which has a detrimental effect on their health and negatively influences the extent to which they can adequately care for patients. The development of supportive interventions is essential to ensure that informal caregivers have the requisite knowledge and skills to allow them to carry out their vital role.
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17
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Sajadi SA, Farsi Z, Akbari R, Sadeghi A, Akbarzadeh Pasha A. Investigating the relationship between quality of life and hope in family caregivers of hemodialysis patients and related factors. BMC Nephrol 2021; 22:383. [PMID: 34781888 PMCID: PMC8594219 DOI: 10.1186/s12882-021-02578-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Accepted: 10/26/2021] [Indexed: 11/16/2022] Open
Abstract
Background Family caregivers of hemodialysis patients are the first and most crucial source of care at home. They experience many problems in the care of hemodialysis patients, which can affect their quality of life and hope, affecting the quality of care provided to patients. This study aimed to determine the relationship between quality of life and hope in family caregivers of hemodialysis patients. Methods A cross-sectional (descriptive-analytical) study performed on 300 family caregivers in the east of Mazandaran province in Iran. Data were collected using the Family Caregiver Quality of Life (FQOL), SF8 and adult hope scale. Data analysis was performed in SPSS version 16, and a P-value of below 0.05 was considered statistically significant. Results The results showed that, there was a direct and significant relationship between hope and quality of life. However, the quality of life was significantly lower in suburban residents, the unemployed, spouses, people with lower education and income levels, caregivers who cannot leave their patients alone, those living with their patients in the same house, and those taking care of male patients, compared to other participants (P < 0.05). Suburban residents, the unemployed, people with an insufficient level of income, and those living with their patients in the same house had significantly lower hope, compared to other subjects. Conclusion Since an increase of hope and quality of life of caregivers can cause improved quality of patient care, it is recommended that hope-based educational programs and interventions be implemented for caregivers.
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Affiliation(s)
- Seyedeh Azam Sajadi
- Department of Nursing Management, Faculty of Nursing, Aja University of Medical Sciences, Tehran, Iran
| | - Zahra Farsi
- Medical-Surgical Nursing, Research and Community Health Departments, Faculty of Nursing, Aja University of Medical Sciences, Tehran, Iran
| | - Roghayeh Akbari
- Department of Nephrology, School of Medicine, Health Research Institute, Babol University of Medical Sciences, Babol, Iran.
| | - Atefeh Sadeghi
- Dialysis Ward, Shahid Beheshti Hospital, Babol University of Medical Sciences, Babol, Iran
| | - Abazar Akbarzadeh Pasha
- Clinical Research Development Center Shahid Beheshti Hospital, Babol University of Medical Sciences, Babol, IR, Iran
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