ORIGINAL RESEARCH
THE IMPACT OF SOCIOECONOMIC FACTORS ON QUALITY OF LIFE OF PATIENTS WITH CHRONIC KIDNEY DISEASE IN GREECE Margarita Ikonomou1,2, Petros Skapinakis2,3, Olga Balafa1,2, Marianna Eleftheroudi4, Dimitrios Damigos2,3, Kostas C. Siamopoulos1,2 1 Department of Nephrology, School of Medicine, University of Ioannina, Ioannina, Greece 2 Psychonephrology Unit, Department of Nephrology, School of Medicine, University of Ioannina, Ioannina, Greece 3 Department of Psychiatry, School of Medicine, University of Ioannina, Ioannina, Greece 4 Department of Nephrology, “Papageorgiou” General Hospital, Thessaloniki, Greece
Ikonomou M., Skapinakis P., Balafa O., Eleftheroudi M., Damigos D., Siamopoulos K.C. (2015). The impact of socioeconomic factors on quality of life of patients with chronic kidney disease in Greece. Journal of Renal Care 41(4), 239–246.
SUMMARY Background: Quality of Life (QoL) is often poor in people undergoing dialysis and this sometimes contributes to the high rate of morbidity and mortality. The aim of our study is to assess the QoL of patients on haemodialysis in Greece and discuss the socio-demographic factors that affect QoL in this period of financial crisis. Design/Patients: Patients with CKD not on dialysis, plus those undergoing Haemodialysis (HD) and Peritoneal Dialysis (PD) were invited to complete the SF-36 questionnaire electronically, supervised by a trained nurse. Patients were asked about their marital status, education level and monthly household income. Additionally, patients were requested to comment on their subjective financial difficulties. Results: A total of 172 patients were enrolled in the study, 39 of them were undergoing PD, 90 on HD and 43 had CKD. Among those with CKD, on HD and PD, 9.3%, 17.8% and 23.1%, respectively, had ‘some/a lot’ difficulties in copying with financial problems. The physical component summary score was significant lower in HD, while the summary score of the mental component showed no differences between the groups. In multiple linear regression analysis, age and dialysis had significantly negative correlations with physical functioning scores. Those who were divorced or widowed tended to perform worse in physical scores compared with those who were married. Mental scores were affected only by coping with financial difficulties. Conclusions: In general terms, people with CKD patients present with a poor QoL. Apart from the burden of the renal disease per se, social and economic factors (divorce, financial difficulties) seem to aggravate their status, especially in this period of financial crisis.
K E Y W O R D S CKD Haemodialysis Peritoneal Dialysis SF-36 BIODATA Margarita Ikonomou is the head nurse of the Peritoneal Dialysis Unit at the University Hospital of Ioannina, Greece. She has worked with patients with chronic kidney disease since 1995. In this time she has completed her PhD on “The detection of mental disorders in patients with chronic kidney disease”. She has been involved in the organisation of the Psychonephrology Unit of the Nephrology Department and her main interests include training programmes and psychological support for patients on dialysis. CORRESPONDENCE
Margarita Ikonomou, Department of Nephrology, University Hospital of Ioannina, St. Niarchos Ave, 45500 Ioannina, Greece Tel.: þ30 2651 099 648 Fax: þ30 2651 099 395 Email: [email protected]
BACKGROUND Quality of Life (QoL) assessment has become increasingly important in clinical research for people with Chronic Kidney Disease (CKD) stages 1–4 and patients undergoing dialysis (Finkelstein et al. 2012), with the impact of the illness on QoL being considerable. (Cleary & Drennan, 2005) found that patients with end-stage kidney disease (ESKD) had lower QoL than the general population, while (Loos et al. 2003) identified that patients with ESKD had poorer QoL compared to patients with other chronic diseases. It is now widely accepted that lower scores of QoL are associated with higher risk of death and hospitalisation in those on dialysis (Mapes et al. 2003). In addition, QoL is not only a research outcome in CKD and dialysis population studies, but a strong tool for evaluating the impact of intervention’s effectiveness (Kalantar-Zadeh & Unruh 2005; Mujais et al. 2009). Fukuhara et al. (2007) have suggested that nephrologists should be
© 2015 European Dialysis and Transplant Nurses Association/European Renal Care Association
Journal of Renal Care 2015
239
Ikonomou et al.
focused not only on biological outcomes but more importantly a patient’s perceptions of their QoL. Therefore, periodical assessment of QoL is mandatory in dialysis centers in the USA.
the initial assessment/diagnosis of CKD had been made. The protocol was approved by the scientific committees and Ethics Boards of the three Hospitals on February of 2011.
Many studies have explored differences in QoL among patients undergoing Haemodialysis (HD) and Peritoneal Dialysis (PD) (Gokal et al. 1999; Avramovic & Stefanovic, 2012; Wu et al. 2013) Those patients treated with PD and home HD showed better results than those patients on centre HD (Liem et al. 2008; Mau et al. 2008). The impairment of QoL of patients with CKD (stage 1–4), not on dialysis, has also recently been evaluated (Perlman et al. 2005; Finkelstein et al. 2009; Mujais et al. 2009). Mujais et al. (2009) in a cross-sectional analysis have shown a progressive decline of various QoL measures as CKD progresses. (Perlman et al. 2005) found higher SF-36 scores in the CKD cohort compared with patients undergoing HD, but lower than in healthy controls.
STUDY MEASURES
However, factors related with QoL in patients with CKD vary between studies and countries. Race, sex, co-morbidities, haematocrit level, educational and socioeconomic status are the most common among these factors (Valderrabano et al. 2001; Sesso et al. 2003; Crews et al. 2010). In Greece a number of studies have explored QoL and possible relevant factors in dialysis and transplantation patients (Kontodimopoulos et al. 2009; Theofilou 2012), but none in the CKD population to date. The aim of our study was to assess the QoL in Greek patients with CKD and in patients undergoing PD and HD, and investigate possible differences between the groups/treatment modalities. Moreover, we examined a variety of socio-demographic and clinical factors that may contribute to this status, especially during a period which coincides with a crucial time in the history of modern Greece, the deep socioeconomic crisis.
METHOD STUDY DESIGN AND PARTICIPANTS The study was conducted during 2011 at the Departments of Nephrology of three Hospitals in Greece; the University Hospital of Ioannina, the University Hospital of Patra and the General Hospital Papageorgiou in Thessaloniki. Patients with severe infection, malignancy and severe cardiovascular disease were excluded. Patients who received PD or HD for at least 3 months were recruited into the study. The patients with CKD were those who attended the outpatient clinic for a second time after
240
Journal of Renal Care 2015
ASSESSMENT OF QUALITY OF LIFE Assessment of QoL was performed using the 36-item ShortForm Survey (SF-36) (Ware & Sherbourne 1992), a generic instrument which has been validated in a Greek general population (Pappa et al. 2005) and has been previously used in patients undergoing long-term dialysis (Kontodimopoulos et al. 2009). Generic instruments have a major advantage over the use of disease-specific instruments, in that they allow direct comparisons with the general population and other chronic conditions. The measurement of SF-36 was accomplished electronically in an interview form, supported by the same trained local nurse for all patients. For patients with CKD, measurements were completed in the outpatient clinic after the scheduled visit, while patients on PD completed the measurements during their routine monthly clinic visit. The patients undergoing HD completed the SF-36 before their routine haemodialysis session. The SF-36 is evaluated in eight domains: physical functioning (PF), role-physical (RP), bodily pain (BP), general health (GH), vitality (VT), social functioning (SF), role-emotional (RE), and mental health (MH). These eight domain scores are aggregated into the physical and mental component summary (PCS and MCS) scores. Scores of the SF-36 domains range from 0 to 100. Higher scores indicate better quality of life. SOCIO-DEMOGRAPHIC AND CLINICAL DATA MEASUREMENTS Socio-demographic and clinical data of the patients were collected at the time of the interview. Patients were asked about their marital status (married, unmarried, divorced, widowed), education level (primary, secondary, higher) and monthly household income (less than or equal to 1,000 euro, 1000–2000 euro, 2000–3000 euro or more. In 2011, in Greece basic mean pension was about 1000 euro, while mean salary was almost 2000 euro. Monthly houselold 2000-3000 (or more) euro is considered high income). Additionally, patients were requested to comment on their subjective financial difficulties by answering the question ‘how do you/ does your family cope with the financial difficulties’? The four possible answers were: a) no financial difficulties b) few
© 2015 European Dialysis and Transplant Nurses Association/European Renal Care Association
QUALITY OF LIFE IN GREEK PATIENTS WITH CKD
difficulties (We copy with our expenses but our standards of living get worse) c) some difficulties (We can copy with most of the expenses but no money left every month) d) a lot (We cannot copy with all the expenses, we borrow money), but we merged these answers into two categories, of ‘no/few’ or ‘some/a lot’ difficulties for easier interpretation. Regarding patients with CKD estimated GFR was calculated based on MDRD equation.
STATISTICAL ANALYSIS Statistical analyses were performed using Stata (version 12.0). All data were described as means and standard deviations (SD) for continuous variables, and as frequencies and proportions for categorical variables. We used the Kruskal–Wallis test to determine if there were differences in quality of life between the different stages of chronic kidney disease. We also carried out post hoc pairwise tests, comparing patients with CKD with patients on either haemodialysis or peritoneal dialysis, using the ‘dunntest’ command in Stata with Sidak correction for multiple comparisons (available from: http://www.doyenne.com/stata/ dunntest.txt). Multiple linear regression was further performed for investigating differences in QoL associated with different disease categories, while adjusting for the effects of socio-demographic variables.
Age (years) Sex (Male %) Marital status Married (%) Unmarried (%) Divorced (%) Widowed (%) Educational status Primary level (%) Secondary level (%) High level (%) Monthly income Low income (%) (1,000 euro/month) Median income (%) (2,000 euro/month) High income (%) (3,000 euro/month) Financial difficulties Some/a lot (%) Albumin (g/dl) Haemoglobin (g/dl)
RESULTS DEMOGRAPHIC AND CLINICAL CHARACTERISTICS OF PATIENTS A total of 172 patients (109 males) were enrolled in the study, 39 of them were patients undergoing PD, 90 were undergoing HD and 43 were patients with CKD. The age range was 17–83 years. However, the group of CKD patients was significant older compared with the other two groups (p 0.05). The mean value of estimated GFR of patients with CKD was 31.6 19 ml/min/1.73 m2. There were no significant differences between the three groups on gender, marital status, education, and income (Table 1). Moreover 9.3%, 17.8% and 23.1% of the CKD, HD and PD patients respectively had ‘some/a lot’ difficulties in copying with financial problems, however, this difference was not significant (p ¼ 0.237). COMPARISON OF QOL BETWEEN CKD, HD AND PD PATIENTS The scores of physical functioning were significant lower in patients on HD (p ¼ 0.014) with a tendency to be lower in patients on PD (p ¼ 0.067) compared with patients with CKD. Patients on PD scored lower scores in general health compared with patients not on dialysis (p ¼ 0.058), while patients on HD scored less in vitality compared with the other groups (p ¼ 0.011). These differences exist even though patients not
CKD (n ¼ 43)
HD (n ¼ 90)
PD (n ¼ 39)
P
64.8 (11.2) 72
57.9 (13.8) 56
58.0 (16) 69
0.024 0.155 0.247
86 4.65 4.65 4.65
76 8.89 6.67 7.78
87 12.82 0.00 0.00
55.8 25.58 18.6
49.5 42.53 8.05
43.6 51.28 5.13
18.6 65.12 16.28
27.8 41.11 31.11
28.2 48.72 23.08
9.3 4.13 (0.56) 12.49 (1.68)
17.8 3.68 (0.28) 11.66 (1.17)
23.1 3.72 (0.34) 11.84 (1.37)
0.071
0.128
0.237
THE IMPACT OF SOCIOECONOMIC FACTORS ON QUALITY OF LIFE OF PATIENTS WITH CHRONIC KIDNEY DISEASE IN GREECE Margarita Ikonomou1,2, Petros Skapinakis2,3, Olga Balafa1,2, Marianna Eleftheroudi4, Dimitrios Damigos2,3, Kostas C. Siamopoulos1,2 1 Department of Nephrology, School of Medicine, University of Ioannina, Ioannina, Greece 2 Psychonephrology Unit, Department of Nephrology, School of Medicine, University of Ioannina, Ioannina, Greece 3 Department of Psychiatry, School of Medicine, University of Ioannina, Ioannina, Greece 4 Department of Nephrology, “Papageorgiou” General Hospital, Thessaloniki, Greece
Ikonomou M., Skapinakis P., Balafa O., Eleftheroudi M., Damigos D., Siamopoulos K.C. (2015). The impact of socioeconomic factors on quality of life of patients with chronic kidney disease in Greece. Journal of Renal Care 41(4), 239–246.
SUMMARY Background: Quality of Life (QoL) is often poor in people undergoing dialysis and this sometimes contributes to the high rate of morbidity and mortality. The aim of our study is to assess the QoL of patients on haemodialysis in Greece and discuss the socio-demographic factors that affect QoL in this period of financial crisis. Design/Patients: Patients with CKD not on dialysis, plus those undergoing Haemodialysis (HD) and Peritoneal Dialysis (PD) were invited to complete the SF-36 questionnaire electronically, supervised by a trained nurse. Patients were asked about their marital status, education level and monthly household income. Additionally, patients were requested to comment on their subjective financial difficulties. Results: A total of 172 patients were enrolled in the study, 39 of them were undergoing PD, 90 on HD and 43 had CKD. Among those with CKD, on HD and PD, 9.3%, 17.8% and 23.1%, respectively, had ‘some/a lot’ difficulties in copying with financial problems. The physical component summary score was significant lower in HD, while the summary score of the mental component showed no differences between the groups. In multiple linear regression analysis, age and dialysis had significantly negative correlations with physical functioning scores. Those who were divorced or widowed tended to perform worse in physical scores compared with those who were married. Mental scores were affected only by coping with financial difficulties. Conclusions: In general terms, people with CKD patients present with a poor QoL. Apart from the burden of the renal disease per se, social and economic factors (divorce, financial difficulties) seem to aggravate their status, especially in this period of financial crisis.
K E Y W O R D S CKD Haemodialysis Peritoneal Dialysis SF-36 BIODATA Margarita Ikonomou is the head nurse of the Peritoneal Dialysis Unit at the University Hospital of Ioannina, Greece. She has worked with patients with chronic kidney disease since 1995. In this time she has completed her PhD on “The detection of mental disorders in patients with chronic kidney disease”. She has been involved in the organisation of the Psychonephrology Unit of the Nephrology Department and her main interests include training programmes and psychological support for patients on dialysis. CORRESPONDENCE
Margarita Ikonomou, Department of Nephrology, University Hospital of Ioannina, St. Niarchos Ave, 45500 Ioannina, Greece Tel.: þ30 2651 099 648 Fax: þ30 2651 099 395 Email: [email protected]
BACKGROUND Quality of Life (QoL) assessment has become increasingly important in clinical research for people with Chronic Kidney Disease (CKD) stages 1–4 and patients undergoing dialysis (Finkelstein et al. 2012), with the impact of the illness on QoL being considerable. (Cleary & Drennan, 2005) found that patients with end-stage kidney disease (ESKD) had lower QoL than the general population, while (Loos et al. 2003) identified that patients with ESKD had poorer QoL compared to patients with other chronic diseases. It is now widely accepted that lower scores of QoL are associated with higher risk of death and hospitalisation in those on dialysis (Mapes et al. 2003). In addition, QoL is not only a research outcome in CKD and dialysis population studies, but a strong tool for evaluating the impact of intervention’s effectiveness (Kalantar-Zadeh & Unruh 2005; Mujais et al. 2009). Fukuhara et al. (2007) have suggested that nephrologists should be
© 2015 European Dialysis and Transplant Nurses Association/European Renal Care Association
Journal of Renal Care 2015
239
Ikonomou et al.
focused not only on biological outcomes but more importantly a patient’s perceptions of their QoL. Therefore, periodical assessment of QoL is mandatory in dialysis centers in the USA.
the initial assessment/diagnosis of CKD had been made. The protocol was approved by the scientific committees and Ethics Boards of the three Hospitals on February of 2011.
Many studies have explored differences in QoL among patients undergoing Haemodialysis (HD) and Peritoneal Dialysis (PD) (Gokal et al. 1999; Avramovic & Stefanovic, 2012; Wu et al. 2013) Those patients treated with PD and home HD showed better results than those patients on centre HD (Liem et al. 2008; Mau et al. 2008). The impairment of QoL of patients with CKD (stage 1–4), not on dialysis, has also recently been evaluated (Perlman et al. 2005; Finkelstein et al. 2009; Mujais et al. 2009). Mujais et al. (2009) in a cross-sectional analysis have shown a progressive decline of various QoL measures as CKD progresses. (Perlman et al. 2005) found higher SF-36 scores in the CKD cohort compared with patients undergoing HD, but lower than in healthy controls.
STUDY MEASURES
However, factors related with QoL in patients with CKD vary between studies and countries. Race, sex, co-morbidities, haematocrit level, educational and socioeconomic status are the most common among these factors (Valderrabano et al. 2001; Sesso et al. 2003; Crews et al. 2010). In Greece a number of studies have explored QoL and possible relevant factors in dialysis and transplantation patients (Kontodimopoulos et al. 2009; Theofilou 2012), but none in the CKD population to date. The aim of our study was to assess the QoL in Greek patients with CKD and in patients undergoing PD and HD, and investigate possible differences between the groups/treatment modalities. Moreover, we examined a variety of socio-demographic and clinical factors that may contribute to this status, especially during a period which coincides with a crucial time in the history of modern Greece, the deep socioeconomic crisis.
METHOD STUDY DESIGN AND PARTICIPANTS The study was conducted during 2011 at the Departments of Nephrology of three Hospitals in Greece; the University Hospital of Ioannina, the University Hospital of Patra and the General Hospital Papageorgiou in Thessaloniki. Patients with severe infection, malignancy and severe cardiovascular disease were excluded. Patients who received PD or HD for at least 3 months were recruited into the study. The patients with CKD were those who attended the outpatient clinic for a second time after
240
Journal of Renal Care 2015
ASSESSMENT OF QUALITY OF LIFE Assessment of QoL was performed using the 36-item ShortForm Survey (SF-36) (Ware & Sherbourne 1992), a generic instrument which has been validated in a Greek general population (Pappa et al. 2005) and has been previously used in patients undergoing long-term dialysis (Kontodimopoulos et al. 2009). Generic instruments have a major advantage over the use of disease-specific instruments, in that they allow direct comparisons with the general population and other chronic conditions. The measurement of SF-36 was accomplished electronically in an interview form, supported by the same trained local nurse for all patients. For patients with CKD, measurements were completed in the outpatient clinic after the scheduled visit, while patients on PD completed the measurements during their routine monthly clinic visit. The patients undergoing HD completed the SF-36 before their routine haemodialysis session. The SF-36 is evaluated in eight domains: physical functioning (PF), role-physical (RP), bodily pain (BP), general health (GH), vitality (VT), social functioning (SF), role-emotional (RE), and mental health (MH). These eight domain scores are aggregated into the physical and mental component summary (PCS and MCS) scores. Scores of the SF-36 domains range from 0 to 100. Higher scores indicate better quality of life. SOCIO-DEMOGRAPHIC AND CLINICAL DATA MEASUREMENTS Socio-demographic and clinical data of the patients were collected at the time of the interview. Patients were asked about their marital status (married, unmarried, divorced, widowed), education level (primary, secondary, higher) and monthly household income (less than or equal to 1,000 euro, 1000–2000 euro, 2000–3000 euro or more. In 2011, in Greece basic mean pension was about 1000 euro, while mean salary was almost 2000 euro. Monthly houselold 2000-3000 (or more) euro is considered high income). Additionally, patients were requested to comment on their subjective financial difficulties by answering the question ‘how do you/ does your family cope with the financial difficulties’? The four possible answers were: a) no financial difficulties b) few
© 2015 European Dialysis and Transplant Nurses Association/European Renal Care Association
QUALITY OF LIFE IN GREEK PATIENTS WITH CKD
difficulties (We copy with our expenses but our standards of living get worse) c) some difficulties (We can copy with most of the expenses but no money left every month) d) a lot (We cannot copy with all the expenses, we borrow money), but we merged these answers into two categories, of ‘no/few’ or ‘some/a lot’ difficulties for easier interpretation. Regarding patients with CKD estimated GFR was calculated based on MDRD equation.
STATISTICAL ANALYSIS Statistical analyses were performed using Stata (version 12.0). All data were described as means and standard deviations (SD) for continuous variables, and as frequencies and proportions for categorical variables. We used the Kruskal–Wallis test to determine if there were differences in quality of life between the different stages of chronic kidney disease. We also carried out post hoc pairwise tests, comparing patients with CKD with patients on either haemodialysis or peritoneal dialysis, using the ‘dunntest’ command in Stata with Sidak correction for multiple comparisons (available from: http://www.doyenne.com/stata/ dunntest.txt). Multiple linear regression was further performed for investigating differences in QoL associated with different disease categories, while adjusting for the effects of socio-demographic variables.
Age (years) Sex (Male %) Marital status Married (%) Unmarried (%) Divorced (%) Widowed (%) Educational status Primary level (%) Secondary level (%) High level (%) Monthly income Low income (%) (1,000 euro/month) Median income (%) (2,000 euro/month) High income (%) (3,000 euro/month) Financial difficulties Some/a lot (%) Albumin (g/dl) Haemoglobin (g/dl)
RESULTS DEMOGRAPHIC AND CLINICAL CHARACTERISTICS OF PATIENTS A total of 172 patients (109 males) were enrolled in the study, 39 of them were patients undergoing PD, 90 were undergoing HD and 43 were patients with CKD. The age range was 17–83 years. However, the group of CKD patients was significant older compared with the other two groups (p 0.05). The mean value of estimated GFR of patients with CKD was 31.6 19 ml/min/1.73 m2. There were no significant differences between the three groups on gender, marital status, education, and income (Table 1). Moreover 9.3%, 17.8% and 23.1% of the CKD, HD and PD patients respectively had ‘some/a lot’ difficulties in copying with financial problems, however, this difference was not significant (p ¼ 0.237). COMPARISON OF QOL BETWEEN CKD, HD AND PD PATIENTS The scores of physical functioning were significant lower in patients on HD (p ¼ 0.014) with a tendency to be lower in patients on PD (p ¼ 0.067) compared with patients with CKD. Patients on PD scored lower scores in general health compared with patients not on dialysis (p ¼ 0.058), while patients on HD scored less in vitality compared with the other groups (p ¼ 0.011). These differences exist even though patients not
CKD (n ¼ 43)
HD (n ¼ 90)
PD (n ¼ 39)
P
64.8 (11.2) 72
57.9 (13.8) 56
58.0 (16) 69
0.024 0.155 0.247
86 4.65 4.65 4.65
76 8.89 6.67 7.78
87 12.82 0.00 0.00
55.8 25.58 18.6
49.5 42.53 8.05
43.6 51.28 5.13
18.6 65.12 16.28
27.8 41.11 31.11
28.2 48.72 23.08
9.3 4.13 (0.56) 12.49 (1.68)
17.8 3.68 (0.28) 11.66 (1.17)
23.1 3.72 (0.34) 11.84 (1.37)
0.071
0.128
0.237
