By Peter Laird, MD
It is interesting to see the various responses from those within the dialysis community to the call for optimal dialysis. It is gratifying that many are supportive and active advocates for change to address America's poor CKD5 results, but there are others, and not a small group, that lay much of the blame for our poor results at the feet of noncompliant patients. Some go so far as to see noncompliant patients as the major cause for poor outcomes in our system. Certainly, I have had my share of patients that fit the noncompliant category during my medical career and there are reports of noncompliance in dialysis units as high as 50%. Yet, what does the medical evidence tell us about dialysis noncompliance and its causes? An interesting study is instrumental to understand some of the underlying causes:
Patient age and smoking were statistically significant effects in the model predicting skipping treatment; current smoking (P=0.04) and younger age (P=0.008) were significantly associated with skipping treatments.
In addition, three psychosocial variables were significantly associated with shortening of dialysis treatments: little or no perceived control over future health, depression, and perceived effects of kidney disease on daily life. Patients who had shortened treatments were more likely to feel little or no control over their future health (P=0.007), to be depressed (P=0.01), and to be bothered by the restrictions that kidney disease placed on their daily lives (P=0.006).
A less recognized psychological condition that may also be widely prevalent in dialysis patients is Post Traumatic Stress Disorder. We usually consider this as a diagnosis of soldiers returning from combat. Yet an interesting study came to the following conclusion:
Conclusions: PTSD is common in HD patients, but little work has been done to explore the variables associated with PTSD. Data suggest that PTSD is under diagnosed and under treated in HD patients. Interventions should target these patients with the goal to improve well-being and quality of life.
Many are doing just that, improving their patients well being and quality of life through self care without waiting for CMS to declare what is best practice, they understand already.
In our self-care dialysis facility, there are 46-50 patients who live in an inner-city environment and who have a mortality rate of approximately 2% per year. [Editor's note: This annual mortality rate is far below the 23% nationwide rate.] They also have a transplantation rate that is above the norm.
NxStage Reports Sustained Reduction in Clinical Depressive Symptoms for Daily Home Hemodialysis Patients After One Year
"Depression is a serious, often undiagnosed problem for ESRD patients. The 12-month study results are extremely encouraging because they indicate that for eligible patients, switching to daily home hemodialysis may provide lasting relief of depression symptoms, especially for patients in greatest need -- those with moderate to severe depression," says Dr. Finkelstein. "In turn, addressing the problem of depression in patients could translate into less hospitalizations and improved morbidity and mortality, helping to alleviate the physical and emotional burden on patients and their families, as well as the financial burden on the healthcare system."
I must now ask a simple question, noncompliance in dialysis patients, who is to blame? The many who use noncompliance as the major excuse for our American survival debacle at 24% annually will certainly lay 100% of the blame on the patients themselves. Yet by giving dialysis patients the opportunity for self care whether with inner city in center self care patients or those at home on the NxStage, depression which is one of the central causative factors of noncompliance is nearly completely eliminated with improved patient control and self care.
Let me add one more element to this discussion before I draw my own private opinion on this matter. The fact that depression and PTSD are highly associated with hemodialysis to the extent that they have been associated makes me wonder whether noncompliance could be the result of our poor American approach to dialysis instead of noncompliance being the cause of our poor results as we hear so often. I believe firmly that exploring the definition of a simple word holds part of that answer - Iatrogenic:
An iatrogenic disorder is a condition that is caused by medical personnel or procedures or that develops through exposure to the environment of a health care facility.
The definition specifically states that any condition that is caused by exposure to the environment of a health care facility is iatrogenic, or at the fault of that health care provider. I will not list the many ways that hemodialysis is traumatic. I will not list the many ways that dialysis patients lose their independence in dialysis centers. I will not list the many ways that life on dialysis is restricted.
Lastly, I will not declare whether noncompliance is iatrogenic or not. But I would compel all American dialysis professionals to self evaluate usual dialysis care and compare that just to the two examples above as well as the many examples discussed on DSEN over the last several months. I have my own private opinion on the blame game played out by so many that oppose our efforts to initiate optimal dialysis by citing the American failure is due to noncompliant patients. Or is noncompliance simply another symptom of how far wrong usual care dialysis is in America? I will leave that to every individual to answer for themselves.