An International Study of Patient Compliance With Hemodialysis

Anthony J. Bleyer; Britta Hylander; Hiroshi Sudo; et al.

Online article and related content current as of June 9, 2010. JAMA. 1999;281(13):1211-1213 (doi:10.1001/jama.281.13.1211) http://jama.ama-assn.org/cgi/content/full/281/13/1211

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April 7, 1999
JAMA. 1999;281(13):1239.

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BRIEF REPORT

An International Study of Patient Compliance With Hemodialysis

Anthony J. Bleyer, MD Britta Hylander, MD Hiroshi Sudo, MD Yasuo Nomoto, MD Ernesto de la Torre, MD Randolph A. Chen, BS John M. Burkart, MD
Context International differences in compliance of patients undergoing hemodialysis are poorly characterized and could contribute to international survival differences. Objective To compare international differences in patient compliance with hemodialysis treatments. Design A prospective observational study of patients undergoing hemodialysis in 1995 and a cross-sectional survey of health care professionals caring for hemodialyzed patients in 1996. Setting and Patients Four dialysis centers in the southeastern United States with 415 patients undergoing hemodialysis, 1 center in Sweden with 84 patients, and 4 centers in Japan with 194 patients participated in the prospective observational study. In the cross-sectional survey, nurses and nephrologists from the United States (n = 49), Japan (n = 21), and Sweden (n = 16) responded to questions regarding the compliance of their patients undergoing hemodialysis. Main Outcome Measures Percentage of patients who miss a dialysis treatment and number of missed dialysis treatments. Results Of 415 US patients, 147 missed 699 treatments over a 6-month period (28.1 missed treatments per 100 patient-months or 2.3% of all prescribed treatments). During a 3-month period, there were 0 missed treatments per 100 patient-months for patients from Japan and 0 missed treatments per 100 patient-months for patients from Sweden (P .001). In the cross-sectional survey, the mean (SD) estimated percentage of patients missing a treatment per month was 4% (3%) for the United States, 0% for Japan, and 0.1% (3%) for Sweden (P .001). Conclusions Noncompliance is much more common in US patients undergoing hemodialysis than Swedish and Japanese patients. The implications of these results for international differences in survival deserve further study.
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is measured by how well a patient adheres to a prescribed medical regimen, including compliance with appointments, medications, and diet. International differences in patient compliance have not been well characterized but could greatly alter the efficacy of various therapies and potentially explain differences in patient outcomes between countries.1,2 Differences in compliance could be partly responsible for inferior gross survival of patients undergoing dialysis in the United States compared with that of other developed nations.3 For this reason, an international comparison of patient compliance with hemodialysis regimens was undertaken. METHODS In 1995, an international comparison of hemodialysis populations and therapy was begun with a comparison of demographics and dialysis dosage among 4 dialysis centers in the southeastern United States, 4 centers in Japan, and 1 in Stockholm, Sweden. In early 1996, a comparison of compliance was undertaken. Between January and June 1996, information was prospectively collected on US patients regarding missed treatments that met

OR THE PHYSICIAN, COMPLIANCE

the following criteria: (1) the patient spontaneously and voluntarily did not show up for a scheduled treatment; (2) no prior arrangements for missing the dialysis treatment were made; and (3) missed treatment was not due to absolute lack of transportation (eg, severe weather disturbances) or hospitalization. Similarly, information was obtained on missed treatments between February and April 1996 for patients from Japan and Sweden. Almost all US patients were eligible to receive free van transportation from local government support. In Sweden, free taxi service was provided, and in Japan, patients relied on public transportation or in some

cases received a partially subsidized rate for taxi service. To determine whether the findings of the prospective study were representative, a cross-sectional survey was carried out in each country, with nurses or nephrologists asked to determine the number of missed treatments in an average
Author Affiliations: Sections on Nephrology, Wake Forest University School of Medicine, WinstonSalem, NC (Drs Bleyer, de la Torre, and Burkart and Mr Chen), and Karolinska Hospital, Stockholm, Sweden (Dr Hylander); and Tokai University School of Medicine, Isehara City, Japan (Drs Sudo and Nomoto). Corresponding Author and Reprints: Anthony J. Bleyer, MD, Wake Forest University School of Medicine, Section on Nephrology, Medical Center Boulevard, Winston-Salem, NC 27157-1054 (e-mail: ableyer@wfubmc.edu). JAMA, April 7, 1999Vol 281, No. 13 1211

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INTERNATIONAL HEMODIALYSIS COMPLIANCE STUDY

month in their dialysis centers. In the United States, a dialysis center from each continental state and the District of Columbia were randomly identified from a list of dialysis providers.4 In Sweden, 16 centers were randomly sampled from a registry of dialysis providers, and in Japan a survey of 21 nephrologists at a national meeting was performed. Collected data were analyzed using SAS statistical software (Cary, NC, version 6.12). Results are expressed as the number of missed treatments per 100 patient-monthsanalagous to how many treatments would be missed in 1 month in a dialysis center of 100 patients. A general linear model was used to compare the number of missed treatments per 100 patient-months in each country relative to the United States.
Figure. Frequency of Missed Hemodialysis Treatments for US Patients Who Missed at Least 1 Treatment
50 45 40 35 30 25 20 15 10 5 0

No. of Patients

RESULTS Over a 3-month period, there were 0 missed treatments per 100 patientmonths for 84 patients in Sweden and 0 missed treatments per 100 patientmonths for 194 patients in Japan. Over a 6-month period there were 699 missed treatments for 415 US patients (28.1 treatments per 100 patient-months or 2.3% of all treatments) (P .001). One hundred forty-seven US patients (35.4%) missed at least 1 treatment. The FIGURE shows the frequency of missed treatments for US patients who missed at least 1 treatment. Most patients who missed treatments missed fewer than 3 (4.2% of treatments); 7 patients missed at least 20 (27.8% of treatments). TABLE 1 shows the characteristics of patients who missed no treatments, missed between 1 and 3 treatments, and those who missed more than 3 treatments. While there was some difference in race and age in these categories, missing treatments was common for patients of all ages and races. Results from the cross-sectional survey confirmed the marked difference in compliance between US patients and patients from Japan and Sweden (TABLE 2). COMMENT The results of this study demonstrate a markedly increased incidence of skip-

7-19

20

No. of Missed Treatments

Table 1. Characteristics of US Patients Missing Dialysis Treatments Over a 6-Month Period

No. of Treatments Missed Characteristic* Age, y Time on dialysis, y White patients Men 0 58.6 (14.6) 3.76 (3.16) 47.4 51.8 1-3 56.4 (14.6) 3.96 (3.81) 33.3 45.3 3 50.1 (13.8) 4.12 (3.25) 23.6 44.4

*Age and time on dialysis are given as mean (SD); race and sex, as a percentage. P .05 for difference compared with patients who missed no treatments. P .001 for difference compared with patients who missed no treatments.

Table 2. Characteristics of Dialysis Centers Participating in the Cross-sectional Survey

Region Japan Sweden United States
ellipses indicate not applicable.

No. of Centers 21 16 49

Patients Missing 1 Treatment* 0 0.1 (3.0) 4 (3.0)

P .001 .001 ...

*Data are given as estimated percentage (SD) in an average month; P values are for comparison with the US centers;

ping dialysis treatments in US patients compared with patients from Sweden and Japan. While there are potential international differences in health care delivery and data collection that could lead to bias, the consistency of this finding by 2 methods as well as the magnitude of this difference suggest that there is a true international variation in patient compliance. Importantly, the outcome measure chosen was a direct measurement of compliance. Other indirect measures of compliancefor example, blood pressure controlmay be affected by how aggressively the patients physician treats these conditions and may also be affected by the underlying health of the patient. However, showing up for dialysis treatment is mainly dependent on the patients compliance, especially when transportation is available. In the prospective study, noncompliance was present in all US patient groups, regardless of race, age, or duration of dialysis. Other prospective studies of compliance have noted similar findings.5,6 An estimated 4% of patients missed treatments in the cross-sectional study, while the percentage of patients who missed treatments in the US centers ranged from 12.5% to 16.5% for each month studied. There are several potential reasons for this difference. First, poor compliance at the US centers may, in part, have stimulated the development of this study. Another potential reason is the underestimation of compliance by health care personnel. A national prospective population-based survey of dialysis centers noted an incidence of 9% of patients missing treatments per month,7 while another crosssectional survey of 860 patients with end-stage renal disease in New Jersey, Puerto Rico, and the Virgin Islands revealed that between 5.1% and 7.6% of patients missed at least 1 treatment each month.5 What are the potential reasons for the increased rates of noncompliance among US patients undergoing dialysis? First, differences in the way dialysis is prescribed in the United States may make

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INTERNATIONAL HEMODIALYSIS COMPLIANCE STUDY

treatments less comfortable for patients, resulting in an increased apprehension of treatment and therefore increased absenteeism. In general, US patients receive a shorter treatment with higher blood flows, which may lead to increased incidences of cramping and hypotension.8 In earlier work with the same centers involvedintheprospectivestudy,wefound higher blood flow rates and shorter dialysis times for US patients.9 Another important factor is differences between countries in patient autonomy. In the United States, patient autonomy has become increasingly emphasized in the health care profession,10-12 in lay publications, and most importantly on television. One result of this increased auREFERENCES 1. DERI Mortality Study Group. International analysis of insulin-dependent diabetes mellitus mortality: a preventable mortality perspective: the Diabetes Epidemiology Research International (DERI) Study. Am J Epidemiol. 1995;142:612-618. 2. Anderson GF. In search of value: an international comparison of cost, access, and outcomes. Health Aff (Millwood). 1997;16:163-171. 3. US Renal Data Systems. XI: International comparisons of ESRD therapy. AM J Kidney Dis. 1996;28 (suppl 2):S146-S151. 4. The List. Dial Transplantation. 1997;26:L6-L71. 5. Sherman RA, Cody RP, Matera JJ, Rogers ME, So-

tonomy is the inability of the physician to influence poor decision making by the patient, which may result in noncompliance. Finally, large international differences in the selection process of patients for dialysis13 may contribute to compliance differences. For example, a noncompliant patient using illicit drugs may be more likely to be accepted for dialysis treatment in the United States than other countries. The patients noncompliant behavior is likely to continue while undergoing dialysis treatment. Differences in compliance are important and could contribute to differences in death rates between countries. Even an occasional missed treatment places the patient at a much higher risk
lanchick JC. Deficiencies in delivered hemodialysis therapy due to missed and shortened treatments. Am J Kidney Dis. 1994;24:921-923. 6. Kimmel PL, Peterson RA, Weihs KL, et al. Behavioral compliance with dialysis prescription in hemodialysis patients. J Am Soc Nephrol. 1995;5:1826-1834. 7. Leggat JE, Orzol SM, Hulbert-Shearon TE, et al. Noncompliance in hemodialysis: predictors and survival analysis. Am J Kidney Dis. 1998;32:139-145. 8. Bleyer AJ. An international comparison of dialysis prescriptions. Nephrol News Issues. 1996; 10:33-35. 9. Bleyer AJ, Disney AP, Hylander B, et al. The mul-

of life-threatening conditions such as volume overload and hyperkalemia. Attempts to improve patient compliance through education and improved patient comfort during treatment could help improve the survival of US patients undergoing hemodialysis. It is unlikely that international compliance differences are limited to patients undergoing hemodialysis. International compliance differences in other areas must also be studied to identify if they contribute significantly to differences in outcome.
Acknowledgment: We would like to acknowledge contributions to this article by Paulina Niculescu, MD, who died prior to its publication.

tinational study of dialysis therapy: dialysis dose. J Am Soc Nephrol. 1995;6:593. 10. Gaylin W. Worshiping autonomy. Hastings Cent Rep. 1996;26(6):43-45. 11. Scarr S. Individuality and community: the contrasting role of the state in family life in the United States and Sweden. Scand J Psych. 1996;37:93-102. 12. Tsukamoto Y. Patients autonomy vs. doctors professional integrity. Med Law. 1996;15:195-199. 13. US Renal Data System. USRDS 1996 Annual Data Report. Bethesda, Md: National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases; April 1996:144.

I am imbued with two deep impressions; the first, that science knows no country; the second, which seems to contradict the first, although it is in reality a direct consequence of it, that science is the highest personification of the nation. Science knows no country because knowledge belongs to humanity, and is the torch which illuminates the world. Science is the highest personification of the nation because that nation will remain the first which carries the furthest the works of thought and intelligence.
Louis Pasteur (1822-1895)

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