Perspectives on the new kidney disease education benefit: early awareness, race and kidney transplant access in a USRDS study.

Education services for Stage-IV chronic kidney disease patients were added in 2010 as a Part B covered benefit under the Medicare Improvements for Patients and Providers Act. Desired outcomes include early pursuit of kidney transplantation by more patients and reduction of racial disparities in access to transplantation. During 2005-2007, a United States Renal Data System (USRDS) special study surveyed 1123 patients in a national cohort who had recently started dialysis, identified themselves as black or white, and were reported by their physician as potentially eligible transplant candidates. Patients were asked if kidney transplantation had been discussed with them before they initiated renal replacement therapy, and survey responses were linked with subsequent wait listing and transplant events in USRDS registry files. Kaplan-Meier analyses showed a significant association between early transplant awareness and subsequent wait listing. Adjusted Cox models showed a significant race/early transplant awareness interaction, however, with the impact of early awareness on wait listing much stronger for whites. Ongoing support and education about kidney transplantation for patients after dialysis start could help to build on early education and foster greater quality improvement in patient outcomes.

Survival by time of day of hemodialysis in an elderly cohort.

CONTEXT: Patients with end-stage renal disease (ESRD) typically undergo hemodialysis (HD) during the morning or afternoon, with time of treatment generally based on space availability or patient preference. No studies have investigated variation in patient survival as a function of the time of day when they receive dialysis. OBJECTIVE: To investigate the association of elderly patients' HD treatment shift with their continued survival, controlling for well-established HD-related mortality risk factors. DESIGN, SETTING, AND PARTICIPANTS: An 11-year follow-up cohort study conducted among 242 ESRD patients aged 60 years or older who underwent HD at 58 dialysis facilities in Georgia either during a morning shift (n = 167) or an afternoon shift (n = 75) and who completed baseline (1988) [corrected] and follow-up (1991) interviews. MAIN OUTCOME MEASURE: Mortality from all causes occurring through July 7, 1999, as verified by death-certificate reviews, and compared by morning vs afternoon-shift HD. RESULTS: Morning-shift HD patients survived significantly longer than afternoon-shift patients (median survival, 941 days vs 470 days; P<.001). A Cox proportional hazards model indicated that the morning shift was protective (relative risk, 0.71; 95% confidence interval, 0.53-0.95) independent of age, race, sex, body mass index, functional status, diabetic ESRD, cardiovascular comorbidity, weekly hours of dialysis, and months of dialysis. CONCLUSIONS: Possible explanations for differential survival in association with morning vs afternoon dialysis include salutary effects of sleep in the morning or less efficient biochemical exchange during afternoon dialysis. Results from this cohort study may warrant prospective observational studies and randomized clinical trials that systematically alter the time of day at which HD is administered.

Improving compliance in dialysis patients: does anything work?

Noncompliance with prescribed therapy significantly impacts dialysis patient care and outcome. At least one-half of hemodialysis (HD) patients are likely to be noncompliant with some part of their treatment regimen, and one-third of peritoneal dialysis (PD) patients are believed to miss prescribed exchanges. Psychosocial issues, younger age, and smoking behavior have been linked with compliance problems in multiple studies. Few interventions have been rigorously tested, but patient education and/or individualized attention, supervision, encouragement, and support are widely advocated strategies to improve patient compliance. Areas in need of continued study include psychosocial determinants of compliance in PD as well as HD patients, compliance behavior patterns over time, and the parameters within which dialysis compliance can vary and still achieve specified treatment goals.

Body mass index as a predictor of continued survival in older chronic dialysis patients.

OBJECTIVE: To investigate the contribution of body mass index (BMI) to mortality over 11 years of follow-up in a prevalent sample of dialysis patients aged 60+. DESIGN: Multivariate Cox proportional hazards regression analysis. SETTING: Multicenter stratified random sample of black and white older chronic dialysis patients in a southeastern state. SUBJECTS: 316 patients on hemodialysis (HD) and peritoneal dialysis (PD). MAIN OUTCOME MEASURE: Continued survival from baseline interview in 1988 to June 1999. RESULTS: Adjusting for age, primary diagnosis of diabetes, cardiovascular comorbidity, HD/PD therapy, and patient-reported functional impairment, the interaction of baseline BMI with race and gender was associated with older patients' risk of mortality. Black females, black males, and white males with higher BMI had a reduced risk of mortality, while no protective effect of higher BMI was found for white females. Patients with cardiovascular comorbidity and greater functional impairment at baseline had increased mortality risk. BMI was not significantly correlated with serum albumin or functional impairment. CONCLUSION: BMI, a simple anthropometric measure that provides a marker of nutritional status, interacts with race and gender to predict long-term survival in older dialysis patients. The association of survival with dialysis adequacy, nutritional indicators, and cardiovascular status in black and white dialysis patients is an important area of study.

Structure of lifestyle disruptions in chronic disease: a confirmatory factor analysis of the Illness Intrusiveness Ratings Scale.

BACKGROUND: The Illness Intrusiveness Ratings Scale (IIRS) measures the extent to which disease or its treatment or both interfere with activities in important life domains. Before comparing IIRS scores within or across groups it is crucial to determine whether a common underlying factor structure exists across patient populations. OBJECTIVE: To investigate the factor structure underlying the IIRS and evaluate its stability across diagnoses. METHODS: IIRS responses from 5,671 respondents were pooled from 15 separate studies concerning quality of life in eight patient groups: rheumatoid arthritis; osteoarthritis; systemic lupus erythematosus; multiple sclerosis; end-stage renal disease (maintenance dialysis); renal transplantation; heart, liver, and lung transplantation; and insomnia. Data were gathered by different methods (eg, interview, self-administered, mail survey) and in diverse contexts (eg, individual vs. group). RESULTS: Exploratory maximum-likelihood factor analysis identified three underlying factors in a randomly selected subset of respondents (n = 400), corresponding to "Relationships and Personal Development," "Intimacy," and "Instrumental" life domains. Confirmatory factor analysis corroborated the stability of this structure in an independent subsample (n = 2100). Complementary goodness-of-fit indices confirmed the consistency of the three-factor solution, corroborating that IIRS scores are uniquely defined across patient populations. Coefficient alpha was high for total and subscale scores. CONCLUSIONS: IIRS scores can be compared meaningfully within and across patient groups. Both total and subscale scores can be used depending on research objectives.

Race and restless sleep complaint in older chronic dialysis patients and nondialysis community controls.

There is mixed evidence about the relation of race to risk of sleep disturbance. We explored the relation of race to restless sleep complaint in survey data from a cohort of 311 older patients undergoing chronic renal dialysis and a similarly aged cohort of 354 nondialysis controls. Older dialysis patients were significantly more likely to report restless sleep. Restless sleep complaint was related to comorbidity, depressed mood, use of sleep medications, and perceived health status in both groups. Black patients in the dialysis cohort had decreased odds of restless sleep, but Black and White controls did not differ significantly in reporting restless sleep. Compared with their more socially advantaged White counterparts, older Black dialysis patients may perceive the chronic dialysis care environment more favorably. The findings are consistent with the view that sleep quality in late life is likely to reflect a delicate balance between psychological as well as physical well-being.

Black/white differences in symptoms and health satisfaction reported by older hemodialysis patients.

Although Black end-stage renal disease (ESRD) patients on dialysis report better functioning and well-being than do White patients, little is known about the association of race with disease symptoms and treatment side effects. Interviews were conducted with 183 older Black and 125 older White in-center hemodialysis (HD) patients in Georgia. Patients were identified in a stratified (by race and sex) random sample of patients aged 60+ years selected from the ESRD Network census of all patients in that age category. Self-assessed disease symptoms and/or side effects of treatment, disability days, and health satisfaction were measured. Data were analyzed via logistic or linear regression, controlling for the effects of patients' gender, age, months on dialysis, primary diagnosis of diabetes, cardiovascular co-morbidity, HD treatment time, and usual interdialytic weight gain. Older Whites, compared to older Blacks, were at increased risk for reporting nausea, sexual dysfunction, recent bed disability days, fatigue, greater HD recovery time, and health dissatisfaction. The relation of these complaints to dialysis adequacy and patients' nutritional status merits continued study.

Functional decline among older adults: comparing a chronic disease cohort and controls when mortality rates are markedly different.

In studies of functional status decline in older persons, the strategy for handling deaths during follow-up may influence policy implications. We compared 301 older ESRD dialysis patients with 322 controls to determine whether functional decline over 3 years among dialysis patients exceeded that of "normal aging." We used two different statistical methods and, for each, compared results when deaths were excluded and then included in the analysis. Dialysis patients incurred a larger follow-up mortality rate and were more impaired at baseline. Findings based on functional transition over time, assessed by a nominal variable, were sensitive to whether or not deaths were included in the analysis. However, findings based on nonparametric methods for an ordinal scale (functional impairment) were not sensitive to whether or not deaths were included in the analysis. Analyzing data with and without deceased subjects may be the most comprehensive approach to comparing two cohorts over time.

Functional impairment, depression, and life satisfaction among older hemodialysis patients and age-matched controls: a prospective study.

OBJECTIVE: To compare change over time in functional impairment, depression, and life satisfaction among older dialysis patients and age-matched controls. DESIGN: Prospective cohort study over 3 years. SETTING: Urban and rural communities throughout Georgia. SUBJECTS: One hundred thirteen prevalent renal failure patients on in-center hemodialysis and 286 controls. MAIN OUTCOME MEASURES: Ordinal functional impairment index and life satisfaction rating, and Center for Epidemiologic Studies Depression Scale. RESULTS: Dialysis patients, compared with controls, reported significantly more functional impairment at baseline, and also at follow-up after adjusting for baseline impairment and covariates. Dialysis patients had higher depression scores at baseline, and also at follow-up after adjusting for baseline depression and covariates. In contrast, dialysis patients reported lower life satisfaction at baseline than did controls, but the two cohorts were not significantly different on reported life satisfaction at follow-up, after adjusting for baseline life satisfaction and race. In both cohorts, functional impairment and depression were significantly related. CONCLUSION: Older dialysis patients' life satisfaction at a 3-year follow-up, which was similar to life satisfaction among age-matched controls, indicates the value of delivered dialysis care; the value of this care would be increased by reducing excess functional impairment in these patients.

Patient-reported quality of life early in dialysis treatment: effects associated with usual exercise activity.

The purpose of this study was to investigate factors associated with quality of life (QoL) early in treatment in a cohort of incident (i.e. newly diagnosed) dialysis patients. This multicenter study investigated QoL reported by patients on chronic hemodialysis (HD) and peritoneal dialysis (PD) at approximately 60 days following the start of treatment. QoL was assessed by the Medical Outcomes Study Short-Form 36 (MOS-SF 36) and by disease-targeted scales from the Kidney Disease Quality of Life (KDQOL). Patient's QoL as measured by the SF-36 was substantially impaired compared to norms for the general population. In univariate analyses, patients' QoL scores were related to demographic variables (age, race, sex, educational level), clinical variables (predialysis BUN and serum creatinine, primary diagnosis of diabetes, cardiovascular comorbidity, average hematocrit and serum albumin in first months of treatment), dialysis variables (HD/PD modality, PD dialysis adequacy, facility patient-staff ratio) and patient's level of usual exercise activity. In multivariate analyses, the most important independent QoL predictor was patient's usual level of exercise activity. Exercise activity independently predicted two performance measures of physical functioning, maximal gait speed and repeated chair rises, as well as patient-perceived physical functioning. Continued study of patient outcomes in relation to adequacy of delivered dialysis, early versus late diagnosis of chronic renal failure (CRF), and patient's usual exercise activity is important because these variables can be the focus for intervention strategies to prevent early deterioration in dialysis patients' functional health status.

Improving physical functioning in the elderly dialysis patient: relevance of physical therapy.

Compromised physical functioning is characteristic of medically complicated patients on dialysis, but many of these deficits can be addressed by rehabilitation. This article describes the benefits and limitations of a 3-month physical therapy pilot program at an inner-city hemodialysis clinic. Program results indicate the difficulties in keeping patients participating in such a program, but, for those patients who did regularly participate, on-site physical therapy consultation was valuable in assisting staff to identify exercise regimens that were consistent with individual patients' needs and addressed their functional difficulties.

Reported pica behavior in a sample of incident dialysis patients.

In a prospective study, pica behavior was investigated during baseline interviews with a cohort of incident patients (n = 226) who began chronic dialysis therapy in metropolitan Atlanta, GA, during 1996 to 1997. Pica, defined as current pica behavior and/or reported history of pica behavior, was reported by 16% of the sample. Patients reporting pica were significantly more likely to be African American women and were significantly younger than the remainder of the sample. Approximately two thirds of patients who reported pica behaviors craved and excessively consumed ice; the remainder craved and consumed starch, dirt, flour, or aspirin. Among patients reporting pica, average serum albumin values were low and average phosphorus was increased. The average hematocrit of patients reporting ice pica was low. Over half of the hemodialysis patients reporting pica behavior had excessive usual interdialytic weight gain. Potential symptoms/problems affecting quality of life among patients practicing pica, eg, cramps, are shown in a case report. The data indicate the need for targeted education and support for dietitians' increased interaction with dialysis patients involved in pica behaviors.

A comparison of the quality of life reported by elderly whites and elderly blacks on dialysis.

OBJECTIVE: To compare indicators of quality of life reported by elderly whites and elderly blacks on chronic dialysis. DESIGN: Survey of surviving patients from a previously identified prevalent cohort. SETTING: 58 dialysis facilities located throughout the state of Georgia. SUBJECTS: 46 whites (mean age = 72) and 85 blacks (mean age = 70) on chronic dialysis > or = 3.5 years. MAIN OUTCOME MEASURES: Number of days in bed during past 3 months; number of nights hospitalized during past 6 months; score summarizing limitations in functional status; 10 dialysis symptoms/complaints; 9 indicators of subjective well-being. RESULTS: Elderly whites, more than elderly blacks, complained of nausea, fatigue, and longer time to recover following a hemodialysis treatment. Whites also were more likely than blacks to perceive kidney failure/dialysis as intrusive for their health and for their diet, to report health dissatisfaction, and to report life dissatisfaction. CONCLUSION: Although blacks were more likely than whites to have diabetes as a primary diagnosis and blacks' educational level was lower than that of whites, all the statistically significant quality of life differences identified in this elderly cohort showed better quality of life among black patients than among white patients.

Gender, self-reported depressive symptoms, and sleep disturbance among older community-dwelling persons. FICSIT group. Frailty and Injuries: Cooperative Studies of Intervention Techniques.

The purposes of this report are: (1) to investigate the association between sleep disturbances and depressive symptomatology in older adults; (2) to evaluate the degree to which gender serves to mediate this relationship; and (3) to determine whether several predefined covariates help to explain the association between sleep disturbance and depressive symptoms. This is a retrospective and cross-sectional analysis of baseline data from 485 elderly adults enrolled in three of the eight clinical sites participating in the Frailty and Injuries: Cooperative Studies of Intervention Techniques (FICSIT) trials. FICSIT was a linked series of randomized clinical trials which evaluated the impact of various exercise interventions on several measures of frailty in older adults. Women reported more depressive symptoms and more sleep disturbances than men. Sleep disturbances were independently associated with depressive symptoms, bodily pain, a history of falling, limited education, being married, and being female. Gender interactions suggest that, although women reported more depressive symptoms and more chronic health conditions than men, both may be more important predictors of sleep disturbance in men. By contrast, being married may be more predictive in women. Finally, the data suggest a stronger relationship between sleep disturbance and depressive symptoms in men than in women.

Self-report benefits of Tai Chi practice by older adults.

Older persons who are willing to begin exercise programs are often not willing to continue them. At the Atlanta FICSIT (Frailty and Injuries: Cooperative Studies of Intervention Techniques) site, individuals aged 70+ were randomized to Tai Chi (TC), individualized balance training (BT), and exercise control education (ED) groups for 15 weeks. In a follow-up assessment 4 months post-intervention, 130 subjects responded to exit interview questions asking about perceived benefits of participation. Both TC and BT subjects reported increased confidence in balance and movement, but only TC subjects reported that their daily activities and their overall life had been affected; many of these subjects had changed their normal physical activity to incorporate ongoing TC practice. The data suggest that when mental as well as physical control is perceived to be enhanced, with a generalized sense of improvement in overall well-being, older persons' motivation to continue exercising also increases.

Physical and psychosocial resource variables related to long-term survival in older dialysis patients.

The association of baseline characteristics with long-term survival (7 years past baseline interview) was investigated in a prevalent sample of 349 dialysis patients aged 60-87 at baseline. In primary diagnosis, treatment modality, and months on dialysis, the sample was representative of all patients aged 60+ living in the state of Georgia. There were 38 surviving patients at a 7-year follow-up. At their baseline assessment, long-term survivors were significantly younger and less likely to report cardiovascular comorbidity. With age and cardiovascular comorbidity controlled, long-term survivors were more likely at baseline to desire a transplant, and reported needing less time to "recover" from HD treatments. Survivors' physical functioning resources at baseline included less health limitation of activity, lower functional impairment, and more frequent activity/exercise. Psychosocial well-being resources included higher self-esteem, higher sense of mastery, and higher self-rated health status. Ongoing assessment of these resource variables, with targeted interventions, might contribute to improved survival as well as improved functioning and well-being for older patients.

Reducing frailty and falls in older persons: an investigation of Tai Chi and computerized balance training. Atlanta FICSIT Group. Frailty and Injuries: Cooperative Studies of Intervention Techniques.

OBJECTIVE: To evaluate the effects of two exercise approaches, Tai Chi (TC) and computerized balance training (BT), on specified primary outcomes (biomedical, functional, and psychosocial indicators of frailty) and secondary outcomes (occurrence of falls). DESIGN: The Atlanta FICSIT (Frailty and Injuries: Cooperative Studies of Intervention Techniques), a prospective, randomized, controlled clinical trial with three arms (TC, BT, and education [ED]. Intervention length was 15 weeks, with primary outcomes measured before and after intervention and at 4-month follow-up. Falls were monitored continuously throughout the study. SETTING: Persons aged 70 and older living in the community. PARTICIPANTS: A total of 200 participants, 162 women and 38 men; mean age was 76.2. MEASUREMENTS: Biomedical (strength, flexibility, cardiovascular endurance, body composition), functional (IADL), and psychosocial well-being (CES-D scale, fear of falling questionnaire, self-perception of present and future health, mastery index, perceived quality of sleep, and intrusiveness) variables. RESULTS: Grip strength declined in all groups, and lower extremity range of motion showed limited but statistically significant changes. Lowered blood pressure before and after a 12-minute walk was seen following TC participation. Fear of falling responses and intrusiveness responses were reduced after the TC intervention compared with the ED group (P = .046 and P = .058, respectively). After adjusting for fall risk factors, TC was found to reduce the risk of multiple falls by 47.5%. CONCLUSIONS: A moderate TC intervention can impact favorably on defined biomedical and psychosocial indices of frailty. This intervention can also have favorable effects upon the occurrence of falls. Tai Chi warrants further study as an exercise treatment to improve the health of older people.

Psychosocial issues in end-stage renal disease: aging.

Older end-stage renal disease (ESRD) patients presumably encounter multiple stressors: the need to undergo treatment for a chronic, life-threatening illness, age-related physical frailty and comorbidities, and exposure to psychosocial losses related to aging. However, most studies comparing older patients (typically patients aged 60 and older) with younger patients undergoing ESRD therapy indicate that the psychosocial well-being reported by older patients is at least as good as, and perhaps better than, the well-being reported by younger patients. These data reflect a health optimism generally characteristic of older persons, and ESRD patients' tendency to evaluate their functional status and their psychosocial well-being as largely independent domains. At the same time, availability of support from dialysis caregivers and from family members is acknowledged as a crucial variable affecting older patients' ability to successfully comply with treatment regimens and adjust to various ESRD therapies. Differential psychosocial outcomes related to older patients' sociodemographic characteristics are not well studied, but data from the United States show better perceived physical status and psychosocial well-being among older African-American patients than among older white patients on chronic dialysis. Suggestions are offered for methodological and conceptual refinements of research investigating the relation of age to psychosocial outcomes in ESRD.

Assessing end-stage renal disease patients' functioning and well-being: measurement approaches and implications for clinical practice.

Along with survival and other types of clinical outcome, the functioning and well-being that characterize end-stage renal disease patients are important indicators of the effectiveness of the medical care that they receive. In addition, maximizing functioning in chronically ill patients can be viewed as secondary prevention. Patient-reported functioning and well-being indicate how patients are doing in their daily lives and how they feel about their lives. Measurements used to assess patient functioning and well-being by health services researchers are applicable to health outcome assessment in the clinical setting. Disease- and treatment-specific outcome measurements are more sensitive to disease severity and treatment intervention effects, while generic outcome measurements provide generalizability across diseases or conditions. Specific measurements can provide data about clinically meaningful changes, and generic measurements help to indicate the significance of these outcomes in patients' daily lives. Using both types of patient-reported measurements, as well as performance-based assessments, will provide outcome-based data on end-stage renal disease patients' functional limitation and disability, and help to define relevant rehabilitation protocols for end-stage renal disease patients.