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Article Excerpt
Goal
To provide an overview of factors that affect the quality of life in persons on hemodialysis.
Objectives
1. Describe the quality of life in persons with end stage renal disease as found in this correlational, cross-sectional study.
2. List factors that have been determined to affect quality of life.
3. Explain how those factors may affect quality of life in persons on end stage renal disease.
More than 470,000 people live with end stage renal disease (ESRD), the final stage of chronic kidney disease, and each year, more than 100,000 additional people are diagnosed with ESRD (U.S. Renal Data System [USRDS], 2008). In 2006, Medicare costs for ESRD topped $23 billion (6.4% of the entire Medicare budget) (USRDS, 2008). Incidence of ESRD has dramatically increased over the past decade, increasing from 261.3 per million population in 1994 to 348.6 per million in 2004 (Centers for Disease Control and Prevention, 2007), placing a significant financial burden on the healthcare system.
Given these figures, it is imperative that persons with ESRD receive not only cost-effective care, but also care that contributes to an acceptable quality of life (QOL). However, the QOL for persons with ESRD has been shown to be lower than that of the general public (Cleary & Drennan, 2005; DeOreo, 1997; Ferrans & Powers, 1993; Frank, Auslander, & Weissgarten, 2003; Merkus et al., 1999), and in many dialysis centers, "life at any cost" is the unspoken rule (Russ, Shim, & Kaufman, 2007). The lower QOL associated with ESRD may be related to physical complications common in ESRD, such as fatigue, joint pain, and anorexia (Phillips, Davies, & White, 2001). More concerning is that persons with ESRD have a lower QOL than persons with other chronic illnesses (Loos, Briancon, Frimat, Hanesse, & Kessler, 2003), and that QOL is correlated with hospitalization and death in persons with ESRD (DeOreo, 1997). However, studies using QOL as an outcome are difficult to interpret and synthesize due to a lack of conceptual clarity regarding the meaning of QOL. The more specific term "health-related quality of life" is often interchanged with the more holistic term "quality of life." Health-related QOL is often defined and measured as "physical functioning," a narrower view than general QOL. Thus, very little research has been conducted on the broader concept of QOL in persons with ESRD and factors that contribute to it. This broad concept is best defined as a person's sense of well-being that stems from satisfaction or dissatisfaction with the areas of life that are important to him or her (Ferrans, Zerwic, Wilbur, & Larson, 2005).
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Purposes
The purposes of this study were to describe the QOL in persons with ESRD and examine factors which influence QOL.
Conceptual Framework
A revised version of Wilson and Cleary's (1995) model for QOL (Ferrans et al., 2005) was used to guide this study (see Figure 1). According to this model, there are four main determinants of overall QOL: biological function, symptoms, functional status, and general health perceptions. Characteristics of the individual and environment influence all determinants, as well as QOL.
Research Questions
The research questions were:
* What is the QOL in persons with ESRD?
* Do biological function (serum albumin and serum hemoglobin), symptoms (dialysis symptoms, anxiety, depression, and fatigue), functional status, and general health perception explain overall QOL in persons with ESRD?
* Do biological function (serum albumin and serum hemoglobin), symptoms (dialysis symptoms, anxiety, depression, and fatigue), functional status, general health perception, characteristics of the individual (age, gender, and race), and characteristics of the environment (marital status, socioeconomic status, and time on hemodialysis) explain overall QOL in persons with ESRD?
* When controlling for characteristics of the individual (age, gender, and race) and characteristics of the environment (marital status, socioeconomic status, and time on hemodialysis), do biological function (serum albumin and serum hemoglobin), symptoms (dialysis symptoms, anxiety, depression, and fatigue), functional status, and general health perception explain overall QOL in persons with ESRD?
Design
This non-experimental research study employed a cross-sectional, correlational design to determine factors affecting QOL in persons on hemodialysis. The data collection took place in a free-standing, outpatient dialysis clinic located in the southeastern United States. Convenience sampling was used to obtain participants from the outpatient dialysis clinic. Inclusion criteria consisted of actively undergoing incenter hemodialysis, on hemodialysis for at least three months, at least 18 years of age or older, and able to speak and understand the English language. Exclusion criteria consisted of a diagnosis of dementia or other condition that may impair the ability to answer questions and cognitive or medical changes occurring during the hemodialysis treatment that prevented the person from answering questions.
An a priori power analysis was conducted using nQuery Advisor[R] software to determine the needed sample size to answer the research questions. For multiple linear regression analysis, with a significance level of 0.05, 80% power, a total of 15 predictor variables, and an estimated moderate effect size ([R.sup.2] = 0.25), 70 subjects were needed. A conservative [R.sup.2] was estimated from a study using the Quality of Life Index--Dialysis version with persons on hemodialysis, in which the W was reported as 0.28 (Jablonski, 2007).
Protection of Human Subjects
The study was approved by the Institutional Review Board (IRB) of The University of North Carolina at Greensboro. In addition, permission to conduct the study at the dialysis clinic was obtained from the corporation's department of clinical studies.
All participants were approached by a nurse employee to briefly explain the study and ascertain interest. All those indicating interest were fully informed regarding the purpose of the study and expectations of participation. A written consent form was reviewed and signed by each participant prior to collecting data, and each participant received a copy. Confidentiality was maintained on all data collection forms by using codes to identify participants instead of names or any other personal identifiers. A master list of participant names was kept separate from the data collection forms. All data collection forms are kept in a locked file in the investigator's office separate from the master list.
Instruments
Dialysis Demographic Form
The Dialysis Demographic Form, an investigator-designed form, was used to collect information not captured on the other instruments. It included characteristics of the individual (age, gender, and race), characteristics of the environment (time on hemodialysis, marital status, and socioeconomic status), and most recent serum albumin and hemoglobin levels.
Dialysis Symptom Index
The Dialysis Symptom Index (DSI) is a comprehensive instrument that measures 30 common physical and emotional symptoms experienced by persons on hemodialysis and the severity/frequency of those symptoms (Weisbord et al., 2004). Each participant was asked if a symptom was experienced during the past week. If yes, the participant was asked to what degree the symptom was bothersome on a 5-point scale,...
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