Volume 54, Issue 6, Pages 993-995 (December 2009)Can We Improve the Quality of Life for Dialysis Patients?
Alan S. Kliger, MDCorresponding Author Informationemail address, Fredric O. Finkelstein, MD
Refers to article:
Association Between Achievement of Hemodialysis Quality-of-Care Indicators and Quality-of-Life Scores , 27 September 2009
Eduardo Lacson, Jianglin Xu, Shu-Fang Lin, Sandie Guerra Dean, J. Michael Lazarus, Raymond Hakim
American Journal of Kidney Diseases
December 2009 (Vol. 54, Issue 6, Pages 1098-1107)
Abstract | Full Text | Full-Text PDF (428 KB)
Related Article, p. 1098
Quality of life (QoL), an individual's perception of his or her life and sense of well-being in relation to his or her goals, expectations, standards, and concerns,1 may be profoundly altered by chronic disease. A recent prospective evaluation of health-related QoL (HRQoL) in a cohort of patients with chronic kidney disease (CKD) showed decreasing scores with advancing CKD.2 Several studies of dialysis patients have shown that measures of HRQoL and depression are correlated with mortality and hospitalization.3, 4, 5, 6 For many dialysis patients, the quality of their lives is more important than hospitalization or mortality rates. Do our treatments with dialysis machines, medications, diet, and lifestyle counseling improve our patients' QoL? To answer this question, we need reliable tools to measure QoL and interventional studies to examine the effect of our treatments on these important outcomes.
The Centers for Medicare & Medicaid Services (CMS) has become increasingly aware of the importance of HRQoL, naming QoL measurement as 1 of 26 quality measures all end-stage renal disease facilities will be required to measure and submit for 100% of their patient population when its CROWNWeb database is operational.7 The new Conditions for Coverage governing dialysis facility operations require that a standardized mental and physical assessment tool be used to measure psychosocial status at regular intervals. Several tools have been used to assess QoL. The KDQoL-36 assessment survey is the tool endorsed by the National Quality Forum. This tool includes both kidney diseasespecific and generic questions derived from the Kidney Disease Quality of Life Short Form Questionnaire (KDQoL-SF) and has been widely accepted and used for dialysis patients. Although this measure and others have been used to assess QoL, no measure has achieved the scientific rigor of a gold standard. The Food and Drug Administration (FDA) reviewed published QoL measures used in assessing the efficacy of erythropoiesis-stimulating agents (ESAs) and found them wanting. On September 11, 2007, the Cardiovascular and Renal Drugs Advisory Committee of the FDA expressed concern about the methods used to examine the effect of ESAs on QoL in the published literature. The FDA then removed QoL claims in the previous labeling for ESAs used to treat patients with CKD.8 The FDA currently is devising final guidelines for the use of patient-reported outcomes as important QoL assessment tools. Still, we can learn about the relationship of our treatment to QoL using widely utilized measurement tools, such as the 36-Item Short Form Health Survey (SF-36) and the KDQoL.
In this issue of the American Journal of Kidney Diseases, Lacson et al9 show an association between achievement of quality goals for hemodialysis patients and QoL scores using the SF-36.9 Although previous studies have shown a relationship between achieving quality indicators and mortality, none has previously explored the relationship between these quality goals and patient-reported QoL. This large cross-sectional observational study shows that patients achieving serum albumin, hemodialysis adequacy, and catheter goals had higher Physical and Mental Component Summary scores on the SF-36 questionnaire. Patients who did not achieve targeted hemoglobin (Hb) and phosphorus levels also had lower Physical and Mental Component Summary scores. Incremental achievement of up to 5 goals was associated with progressively higher QoL scores. The reasons for this association deserve further exploration. One interpretation could be that when patients and their health team work together to achieve goals of care previously associated with better survival, they also achieve better patient-perceived QoL. Alternatively, it could be argued that patients with better QoL scores are less ill or more likely to adhere to their treatment regimen and thus more readily achieve targeted treatment goals. For example, patients with clinical depression adhere less to treatment regimens and have lower QoL scores.10
Some of the 5 goals tracked by Lacson et al9 have been relatively easy to achieve. Dialysis adequacy measured using Kt/Vurea and Hb levels increased progressively in the United States in the decade since they were monitored and publicly reported by the CMS.11 In 2008, 94% of US hemodialysis patients had single-pool Kt/Vurea ≥ 1.2 and only 5.9% had significant anemia with an Hb level < 10 g/dL.12 Recent studies have raised concerns that targeted Hb levels > 13 g/dL increase mortality for dialysis patients and those with earlier stages of CKD.13, 14 One of the major reasons to correct anemia has been to improve QoL. In the present study, most QoL domain scores continued to increase with Hb levels ≥ 13 g/dL, albeit not with statistical significance for patients with Hb levels > 13 g/dL. This finding may be particularly important as the ideal Hb goal is refined. Others have noted that the most dramatic changes in QoL measures occur as Hb levels are increased to the 11-12-g/dL range.15
Achieving other goals, such as albumin and phosphorus levels, are more challenging. Albumin is a marker of both nutrition and inflammation, and efforts to increase albumin levels using dietary counseling and supplements have been successful only infrequently.16, 17, 18 Phosphorus level control has remained problematic, with only 53% of US dialysis patients achieving phosphorus levels of 3.5-5.5 mg/dL.12 Efforts to improve phosphate control for hemodialysis patients include increasing the duration of dialysis19 and modifying education programs for patients concerning the importance of adherence to dietary and medication regimens. New educational programs for patients incorporating new techniques, such as motivational interviewing,20 may prove to be more successful to achieve these targets. Engaging patients in collaborative explorations of their behavior patterns using reflective listening, acknowledgement, and exploration may enhance patients' motivation to implement changes in their patterns and actively participate in the management of their complex medical regimens.
As Lacson et al9 note, their observational study only defines associations, but does not prove causation. Although many case-mix variables were accounted for in the analysis, socioeconomic, environmental, and geographic factors; comorbid conditions; patient lifestyle; and other factors were not examined in this study. Thus, future studies must prospectively examine not only the effect of achieving goals of treatment on HRQoL, but also the effect of QoL itself on achieving treatment goals. Despite the limitations of an observational study design, this study of a large hemodialysis patient population is an important step in our understanding of how we might improve QoL for dialysis patients.
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Financial Disclosure: None.
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Yale University School of Medicine, New Haven, Connecticut
Corresponding Author InformationAddress correspondence to Alan S. Kliger, MD, Department of Medicine, Hospital of Saint Raphael, New Haven, CT 06511