Oral Medication and Self-Management in Hemodialysis Patients

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Oral Medication and Self-Management in
Hemodialysis Patients

• Source Browne T, Merighi JR. Barriers to adult
  hemodialysis patients self-management of oral
  medications. Am J Kid Dis. 201056(3)547557.

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Overview

• Hemodialysis patients, in order to manage their
  kidney disease and comorbid illnesses, are
  required to follow a multi-oral drug regimen on a
  daily basis.
• Most oral medications used daily by these
  patients are phosphorus binders.
• Findings from a study showed that hemodialysis
  patients have the highest pill burden among all
  chronically ill patients.
• The adherence to prescribed oral medication
  regimen is directly linked to several unit
  Quality Assessment and Performance Improvement
  (QAPI) goals and, more significantly to patient
  quality of life (QOL), morbidity, mortality and
  rate and length of hospitalizations.
• The perspective about a hemodialysis patient as a
  passive participant in care planning has changed
  to a fully collaborative member of the
  interdisciplinary team, following the new model
  of kidney disease care for dialysis units
  outlined in the 2008 US Centers for Medicare
  Medicaid Services conditions for coverage (CfC).

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Barriers to Self-Management of Oral Drug

• Above half of the hemodialysis patients may not
  comply with their oral medication regimens, due
  to burden of pills, demographic and socioeconomic
  reasons, psychosocial determinants, health
  literacy, patient satisfaction and health beliefs
  (see Fig. 1).

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Pill Burden

• The number, size and taste of drugs present as a
  challenge, and these are further complicated by
  strict daily fluid restrictions.
• According to the 2008 Medicare CfC, healthrelated
  QOL should be measured on an annual basis and
  addressed in dialysis unit-QAPI programs.
• Research suggests that the frequency of
  medication dosing is negatively associated with
  self-management of medication.
• Chronically ill patients may forget to take
  pills, or are not able to accurately recall all
  their medications or have difficulty in opening
  medication bottles.
• In addition, drugrelated adverse side-effects
  also account for poor oral medication
  self-management.

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Demographic and Socioeconomic Variables

• Socially disadvantaged chronically ill patients
  are at a greater risk of unsuccessful
  self-management of oral medications.
• Research indicates that patients with low income
  or limited formal education, those at a young
  age, without adequate prescription coverage and
  those faced with transportation challenges have
  less success with a selfmanaged oral medication
  regimen.
• The relation between sex and management of oral
  medication is inconclusive.

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Psychosocial Factors

• Patients with diabetes or kidney disease are at a
  higher risk of unsuccessful medication
  self-management due to depression.
• Patients habituated to smoking and drinking
  alcohol, or to other illicit substances may not
  follow the prescribed pattern of medication, as
  these substances have an impact on cognition,
  including, but not restricted to the ability to
  make proper judgments.
• Social support also plays an important role
  behind the successful medication regimen.
• Patients with very busy or erratic social lives
  may not comply with the requirement of
  self-management.
• Psychological distress and stressful life events
  are equally linked with the use of suboptimal
  oral medication in chronically ill patients.

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Health Literacy

• Health literacy is a vital predictor of
  self-management of medication, as it helps to
  describe the ability to read and understand
  health-related words and numbers as well as the
  capacity to successfully react on medical
  instructions.
• For hemodialysis patients, inadequate health
  literacy is related to adverse health outcomes
  and mortality.
• Health literacy has been associated with the
  adequate understanding of phosphorus control and
  the role of involved medications.

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Patient Satisfaction

• It has been observed that chronically ill
  patients, who are satisfied with the care service
  received, are more likely to be successful at
  self-managing oral medications.
• In addition, patients sharing a satisfactory
  relationship with their medical team and
  receiving a cooperative approach from care-team
  members can better manage oral medication.
• Based on the importance of patient satisfaction,
  the 2008 Medicare CfC recommends that every
  dialysis unit should measure each patients level
  of satisfaction on an annual basis.

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Health Beliefs

• Health belief, a model of health behavior, posits
  that patients are less susceptible to modify
  their behaviors when a condition is not thought
  to be as severe.
• About 6270 of hemodialysis patients demonstrate
  inadequate selfmanagement with phosphorus
  binders.
• The asymptomatic nature of many health conditions
  makes the self-management challenging due to the
  patients health beliefs.
• Cultural beliefs also may affect patient
  understanding of health data and self-management
  of health.
• Leventhals commonsense model of self-regulation
  posits the patients accurate linkage of symptoms
  to a health condition (identity), patients
  belief of the causes of the health condition,
  understanding of the consequence, controllability
  and belief about the timeline of the disease, and
  factors governing the self-regulation/
  self-management.

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Steps to Improve Self-Managed Oral Medication

• Dialysis teams should develop and practice a
  mutual association with patients and their team
  members.
• Every dialysis unit must have a proper medical
  team comprising of healthcare professionals, as
  this will help patients prevail over the
  obstructions to successful health outcomes.
• Dialysis units can employ QAPI programs to find
  out the barriers that lead to unsuccessful
  self-management of oral medication, and to devise
  strategies to prevent these barriers.
• Every patient should be examined individually and
  care plans should be able to cater to the
  customized need of each patient related to the
  unique lifestyle, barriers and resources.
• According to a study, a model for self-management
  training that includes the evaluation of patient
  beliefs, behavior and knowledge, collaborative
  goal setting, identifying patient barriers and
  supports, and developing an action plan tailored
  for each patient, could be implemented in
  dialysis units.

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• To reduce the pill burden, dialysis teams can
  customize medication dosing that complies with a
  patients schedule, and reduce the number and
  regularity of pills as possible.
• The visual ability and health literacy level of a
  patient should be considered when developing
  these tools and strategies.
• It is also essential to work with patients on
  plans, and evaluate the specific burdens posed by
  the phosphate binders.
• Further emphasis is required to identify the
  differences arising due to the race, age or sex
  factors among patients with kidney disease.
• Evaluating and engaging patients social network
  members are also important.
• Tools like test of functional health literacy in
  adults, drug regimen unassisted grading scale,
  beliefs about medication scale and beliefs about
  medicines questionnaire could be employed to
  evaluate the health literacy level.

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Conclusion

• Hemodialysis patients are subjected to a
  multi-oral drug regimen on a daily basis in order
  to manage the kidney disease and comorbid
  illnesses.
• Developing and following strategies to overcome
  barriers like the burden of pills, demographic
  and socioeconomic factors, psychosocial
  determinants, health literacy levels, patient
  satisfaction and health beliefs can help patients
  to comply with the self-managed oral medication
  regimens.
• Also, proper evaluation of the patients need and
  factors that build the relation between the care
  team and patient will also support the successful
  management of oral medication in hemodialysis
  patients.

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Comprehensive Basketin Anemia Management