Association of Patient-Reported Difficulty with Adherence with Achievement of Clinical Targets Among Hemodialysis Patients

Figures & data

Figure 1 Summary of exclusions of in-center hemodialysis patients in our study population.

Table 1 Adherence Questions Included on the Standardized Assessment of In-Center Hemodialysis Patients by Social Workers

Category	Question
Coming to dialysis	Over the past month, how easy or difficult has it been for you to come to each hemodialysis treatment?
Completing dialysis	Over the past month, how easy or difficult has it been for you to complete the full prescribed hemodialysis treatment time?
Fluid restrictions	Over the past month, how easy or difficult has it been for you to follow fluid restrictions?
Diet restrictions	Over the past month, how easy or difficult has it been for you to follow dietary restrictions?
Taking medications	Over the past month, how easy or difficult has it been for you to take medications as prescribed?

Table 2 Characteristics of In-Center Hemodialysis Patients Treated at Three Metropolitan Atlanta Dialysis Facilities, February 2010–October 2016

Characteristic	Overall (N=799)
Age (years), mean (SD)	57.1 (14.1)
Sex, % (N)
Male	54.8% (438)
Female	45.2% (361)
Race, % (N)^a
Black	95.3% (711)
Not black	4.7% (30)
Cause of ESRD, % (N)
Diabetes	19.3% (154)
Hypertension	57.3% (458)
Glomerulonephritis	5.3% (42)
Unknown/other	18.2% (145)
Depression/anxiety, % (N)^b
Yes	9.2% (72)
No	90.8% (711)
Memory impairment, % (N)^c
Yes	13.7% (107)
No	86.3% (677)
Employment status, % (N)^d
Employed	8.5% (53)
Unemployed disabled	56.7% (355)
Unemployed other	31.8% (199)
Other	3.0% (19)
Comorbid conditions, % (N)^e
Diabetes	10.3% (82)
Hypertension	74.8% (595)
Heart failure	5.2% (41)
Cancer	2.0% (16)
Pain	8.4% (67)
COPD	5.9% (47)
CVD	20.1% (160)
Vascular access, % (N)
Fistula	30.8% (246)
Graft	24.0% (192)
Catheter	45.2% (361)

Notes: ^aN=741; ^bN=783; ^cN=784; ^dN=626; ^eN=796.

Figure 2 Distribution of patient-reported ease of adherence, by category of adherence.

Table 3 Failure to Achieve Clinical Targets Among Metropolitan Atlanta In-Center Hemodialysis Patients, by Patient-Reported Difficulty with Adherence

Among Those with Reported Difficulty with:	% Actual Non-Adherence as Defined by:	P^a	% Agreement	Kappa (95% CI)
Coming to dialysis	Missing ≥3 sessions during study period
Yes	30.4	0.09	65.3%	0.06 (−0.01, 0.13)
No	24.2
Completing dialysis	Shortening sessions by ≥15 minin >3 sessions
Yes	41.2	0.6	52.9%	−0.02 (−0.08, 0.05)
No	43.3
Fluid restrictions	IDWG ≥3 kg
Yes	21.6	0.02	65.1%	0.07 (0.01, 0.14)
No	15.1
Diet restrictions	Serum potassium >5.0 mEq/L
Yes	15.8	0.7	61.1%	0.01 (−0.05, 0.07)
No	14.8
Diet restrictions and taking medications	Serum phosphate >5.5 mg/dL
Neither	33.9	0.4
Either	33.7		58.1%	−0.01 (−0.08, 0.05)
Both	40.2		62.2%	0.04 (−0.02, 0.10)

Note: ^aUsing chi-squared test.

Table 4 Associations Between Reported Difficulty with Adherence and Failure to Achieve Clinical Targets

OR (95% CI) for Failure to Achieve Clinical Targets by Adherence Recommendation
Reported Difficulty in:	Model 1^a	Model 2^b	Model 3^c
Coming to dialysis (yes vs no)	1.37 (0.95, 1.97)	1.40 (0.96, 2.03)	1.41 (0.96, 2.07)
Completing dialysis (yes vs no)	0.91 (0.66, 1.27)	1.00 (0.71, 1.41)	1.03 (0.73, 1.46)
Fluid restrictions (yes vs no)	1.55 (1.06, 2.27)	1.53 (1.03, 2.29)	1.62 (1.08, 2.43)
Diet restrictions (yes vs no)	1.08 (0.73, 1.62)	1.12 (0.74, 1.68)	1.13 (0.74, 1.72)
Taking medications/diet restrictions
Neither	Referent	Referent	Referent
Either	0.99 (0.69, 1.43)	0.98 (0.67, 1.43)	0.97 (0.66, 1.43)
Both	1.31 (0.87, 1.97)	1.28 (0.83, 1.96)	1.39 (0.89, 2.16)

Notes: ^aUnadjusted; ^bAdjusted for age, sex, and vascular access; ^cAdjusted for age, sex, vascular access, and depression/anxiety.

Table 5 Sensitivity Analysis

OR (95% CI) for Failure to Achieve Clinical Targets by Adherence Recommendation
Reported Difficulty in:	Fully Adjusted Model (from Table 4)	Neither Easy nor Difficult Placed in Not Difficult	Dialysis Vintage >1 Year Only (N=309)	Removing Exclusion for Not Answering All 5 Adherence Questions
Coming to dialysis (yes vs no)	1.41 (0.96, 2.07)	2.19 (1.37, 3.53)	1.70 (0.83, 3.49)	N=838 1.39 (0.96, 2.02)
Completing dialysis (yes vs no)	1.03 (0.73, 1.46)	1.67 (1.05, 2.67)	1.63 (0.97, 3.07)	N=835 1.03 (0.73, 1.44)
Fluid restrictions (yes vs no)	1.62 (1.08, 2.43)	2.20 (1.39, 3.48)	2.61 (1.46, 4.68)	N=819 1.62 (1.09, 2.42)
Diet restrictions (yes vs no)	1.13 (0.74, 1.72)	0.90 (0.30, 2.74)	0.50 (0.13, 1.82)	N= 823 1.14 (0.76, 1.73)
Taking medications/diet restrictions
Neither	Referent	Referent	Referent	Referent
Either	0.97 (0.66, 1.43)	0.90 (0.61, 1.33)	1.01 (0.54, 1.89)	1.02 (0.70, 1.50)
Both	1.39 (0.89, 2.16)	2.64 (0.96, 7.25)	1.34 (0.59, 3.03)	1.47 (0.95, 2.26)

Note: All models adjusted for age, sex, vascular access, and depression/anxiety.