Pediatr Nephrol DOI 10.1007/s00467-014-2780-0
ORIGINAL ARTICLE
Barriers to medication adherence and its relationship with outcomes in pediatric dialysis patients Douglas M. Silverstein & Angela Fletcher & Kathleen Moylan
Received: 5 August 2013 / Revised: 27 January 2014 / Accepted: 28 January 2014 # IPNA 2014
Abstract Background Medication adherence is a major factor determining outcome in children with chronic disease. Children with end-stage renal disease are challenged with requirements for renal replacement therapy in addition to complicated medication regimens. Methods We assessed barriers to medication adherence in 22 pediatric patients receiving chronic dialysis [63.6 % hemodialysis (HD), 36.4 % peritoneal dialysis (PD); age 15.9± 0.7 years, dialysis vintage 31.6±6.5 months]. Adherence was assessed by a 16-question survey with a maximum score (difficulty) of 64. Results The overall mean adherence score was 30.9±2.4 (range 16–49; median 27.5). There was a trend for lower adherence scores in patients on HD (27.5±2.9) compared to those on PD (36.8±3.7) (p=0.06). Compared to HD patients, the mean score/question was significantly higher in PD patients (1.7±0.2 vs. 2.4±0.2, respectively; p=0.006). Of the 16 questions, HD and PD patients gave a mean response of ≤1.2 for five and zero questions, respectively. Neither gender, age nor dialysis vintage was related to adherence scores. There was also a trend for adherence scores to be
D. M. Silverstein (*) Office of Device Evaluation, Renal Devices Branch (RNDB), United States Food and Drug Administration, 10903 New Hampshire Avenue, Silver Spring, MD 20903, USA e-mail: [email protected] A. Fletcher Children’s National/Sheikh Zayed Institute, Children’s National Medical Center, Washington, DC, USA K. Moylan DaVita Health Care Partners, Denver, CO, USA
higher in females (35.6±3.7) than in males (27.5±2.9) (p= 0.1), but this difference did not reach statistical significance. Markers of mineral bone disease were similar in HD and PD patients. Among all targets in HD and PD patients combined, there was no relationship between adherence scores and number of targets reached (r=−0.09, p=0.7). Conclusion There are many barriers to medication adherence in pediatric patients receiving dialysis. In our patient group the difficulties were more evident in patients receiving PD than in those receiving HD. Keywords Chronic disease . Peritoneal dialysis . Hemodialysis . Children
Introduction Medication adherence has always been a major factor influencing outcome in pediatric patients with chronic disease. However, a limitation in assessing a patient’s adherence is the difficulty in establishing standards and monitoring tools based on the various underlying demographics of individual patients. Adherence rates in children with chronic disease vary widely, but they are estimated to be approximately 50 % [1]. Factors that may potentially impact medication adherence in patients receiving dialysis can be categorized as patient level factors and system level factors. Patient level factors include type and severity of disease, age (being lowest in adolescence) [1], family dynamics [2, 3] psychosocial conditions [4, 5] and health literacy and beliefs [6–8]. System and treatment level factors include pill burden, dialysis modality and health beliefs of the patient [6–8]. Various methods have been utilized by clinicians to identify barriers to medication adherence in pediatric patients, each with various degrees of success, but not without significant
Pediatr Nephrol
limitations. Unfortunately, the most common method used to assess medication adherence remains self-reported feedback from parents and/or patients. One commonly used tool is to simultaneously invite reports from both the patient and their parent, even though there are potential discrepancies. That said, in a recent report of medication adherence in children with inflammatory bowel disease, Mackner et al. [9] showed that although self-reported adherence rates were low (48 % reported by children and 38 % reported by their parents), the concordance between the child and parent was very high. Moreover, these authors showed that factors which predict poor adherence include family dysfunction, as well as behavioral disorders and inadequate coping strategies among the children. Finally, another useful tool to assess medication adherence is the Medical Adherence Measure Medication Module (MAM). The MAM tool has been used to assess parental and adolescent reports on medication adherence in renal transplant patients over a 1-week period [10]. Despite these encouraging results, children with end-stage renal disease (ESRD) face unique challenges to successful outcomes. In addition to the multiple medications and complex medication schedules, these children require life-sustaining renal replacement therapy (RRT; dialysis or transplant). Currently, the two main dialysis modalities are in-center, thriceweekly hemodialysis (HD) and home peritoneal dialysis (PD). Outcome data vary tremendously among the dialysis programs. Our center has a comprehensive RRT program that includes all types of dialysis modalities and an advanced renal transplant program. In our dialysis program, we consistently assess standard laboratory tests but also offer comprehensive cardiovascular risk factor analysis. In addition, we are committed to global psychosocial support, mainly provided by intense and consistent support and intervention by a dedicated social worker and a psychologist. In the past few years, we have developed a comprehensive health-related quality of life program and most recently instituted an adherence assessment tool. This report includes our data on patient-reported barriers to medication adherence and the relationship between adherence and outcome variables in pediatric patients receiving maintenance HD or PD dialysis at Children’s National Medical Center (Washington D.C.).
Methods Patients This was a retrospective study performed on children receiving dialysis at Children’s National Medical Center, Washington D.C.. The inclusion criteria were: (1) age at the time of the study (1–22 years); (2) receiving either maintenance HD or PD for 2 consecutive months; (3) no change in modality at the time of the analysis; (4) able to read or fully understand the purpose of the survey and the questions. All patients aged ≥10 years (previous cutoff for the survey we used) were eligible to participate if
the parents consented. The study was approved by the Children’s National Medical Center Institutional Review Board. Adherence survey We used an adherence survey previously published by Simons et al. [11, 12] called the Adolescent Medication Barriers Scales (AMBS), designed to assess barriers to medication adherence in adolescent transplant recipients. In our study, one physician (DM Silverstein) first thoroughly explained the purpose of the survey to each patient, then explained how the survey should be taken. The patient reported if they understood the intent and procedure of the survey and was given as much time as he/she desired to complete the survey. The patient was permitted to ask any question while taking the survey. The survey comprised 16 questions. Each question required the respondent to assign an answer based on the reported frequency of a problem, from among the following choices: “Strongly Disagree,” “Disagree,” “Not Sure (Sometimes),” “Agree” and “Strongly Agree.” Each response had a value assigned to it, as follows: 0 for “Strongly Disagree,” 1 for “Disagree,” 2 for “Not Sure (Sometimes),” 3 for “Agree” and 4 for “Strongly Agree.” A lower response score (e.g. “Disagree”) for a question translated to fewer problems (barriers) for medication adherence, while a higher response score (e.g. “Strongly Agree”) for a question translated to fewer problems (barriers) for medication adherence. A total adherence score was tabulated among the 16 questions, and the combined value for all of the questions is referred to as the “Adherence Score.” The minimum score was 0 while the maximum score was 64. Thus, the lower the total adherence score, the fewer barriers to medication adherence experienced by the patient, while a higher overall score indicated more barriers. The AMBS survey included another parameter: “Sometimes it is hard to make it to the pharmacy to pick up the prescription before the medicine runs out.” Since the vast majority of our medications were obtained at the pharmacy by parents or, occasionally, delivered to the home, we believed that this question would provide little valuable information and may skew the data. Therefore, we decided to exclude this parameter from our analysis. Laboratory analysis Serum for measurement of iron, total iron binding capacity, ferritin, calcium, phosphorous and intact parathyroid hormone (iPTH) was obtained either before a routine, mid-week treatment (HD) or routine outpatient visit (PD). All values were recorded for three consecutive months (1 month before, the month during, and 1 month after the survey was completed), and the results represent averages over the 3 months. For patients receiving HD, interdialytic weight gain represents the percentage of weight gain/total body weight between dialysis treatments over a 1-month period of time. Targets The indices used to assess the types of clinical targets that are significantly affected by medication adherence were
Pediatr Nephrol
serum calcium, serum phosphorous, serum iPTH and interdialytic weight gain for HD patients and serum calcium, serum phosphorous, serum iPTH and transferrin saturation (TSAT) for PD patients. Medications All patients receiving HD were receiving an intravenous erythropoiesis stimulating agent (ESA), intravenous vitamin D (paricalcitol) and an oral phosphorous binder. All patients receiving PD were receiving a subcutaneous ESA, oral calcitriol and an oral phosphorous binder. Pill burden The total number of pills prescribed/day was tabulated. For patients receiving liquid medications, we equated 5 ml with one tablet.
Fig. 1 Total adherence scores among all patients and according to dialysis modality (HD hemodialysis, PD peritoneal dialysis). There was a trend for lower adherence scores in patients receiving HD than in those receiving PD
Statistics Comparison between two groups was achieved by Student’s t test. Correlation between variables was determined by linear regression analysis.
while the mean score per question was 1.9±0.1. There was a trend for lower adherence scores in patients receiving HD (27.5 ±2.9 compared to those receiving PD (36.8±3.7) (p=0.06), although this difference did not reach statistical significance.
Results Demographic data Twenty-two patients were eligible for inclusion. The majority (14/22, 63.6 %) were receiving HD. The mean age of the patients was 15.9±0.7 years and the time on dialysis (vintage) was 31.6±6.5 months. The majority (16/22, 72.7 %) were of African-American race (Table 1). Barriers to medication adherence As described by Simons et al. [12], we calculated a total adherence score by adding the individual scores for each patient. The lower the total adherence score, the fewer barriers to medication experienced by the patient, while a higher overall score indicated more barriers. The total scores among all patients and according to dialysis modality are given in Fig. 1. Among all patients, the mean total adherence score was 30.9±2.4 (range 16–49, median27.5) Table 1 Demographic data Parameter
Result
Dialysis modality
HD: 14/22 (63.6 %) PD: 8/22 (36.4 %) 15.9±0.7 years (range 10–21 years; median 16.5 years) Females: 9/22 (40.9 %); males: 13/22 (59.1 %) 31.6±6.5 months (range 2–103 months; median 19.0 months) African-American: 72.7 % Hispanic: 18.2 % Caucasian: 4.5 % Mixed: 4.5 %
Age Gender Dialysis vintage Ethnicity
HD, Hemodialysis; PD, peritoneal dialysis
Adherence scores according to modality Compared to patients HD, the mean score/question was significantly higher in PD patients (1.7±0.2 vs. 2.4±0.2, respectively; p=0.006). Mean responses of at least 2.0 (“Sometimes”) was observed for 12 questions for the PD patients compared to five for those receiving HD. Finally, A mean response of ≤1.2 was given by HD for five of the 16 questions and by PD patients for none of the questions (0/16). The most prominent barriers to medication adherence among all patients were the high pill number burden, poor taste, inability to remember the medication schedule and fatigue with taking medicines and having a medical condition. The barriers reported much more commonly in patients receiving PD compared to those on HD were inability to remember or unwillingness to take medications at school or home and concerns about the effect of medications on their appearance (Table 2). Potential factors influencing adherence scores The total number of pills prescribed per day was almost identical in HD and PD patients (21.6±1.7 vs. 23.5±3.7, respectively; p=0.6); pill burden had no relationship with adherence scores. In addition, neither gender, age nor dialysis vintage was related to adherence scores (Table 3). Finally, there was a trend for adherence scores to be higher in females than in males (35.6±3.7 vs. 27.5±2.9, respectively; p=0.1), but this difference did not reach statistical significance. Achievement of targets and relationship to adherence scores Among the markers of mineral bone disease, the mean values were very similar in HD and PD patients. Serum calcium [9.3±0.1 (HD) vs. 9.2±0.2 mg/dL (PD); p=0.5], serum phosphorous [5.9±0.3 (HD) vs. 5.9±0.5 mg/dL (PD); p=0.9] and iPTH [482.3±103.1 (HD) vs. 581.1±191.0 (PD) pg/mL; p=0.6] levels were similar in HD and PD patients. Interdialytic weight
Pediatr Nephrol Table 2 Barriers to medication adherence—results of the questionnairea Question
ALL (n=22)
HD (n=14)
Meds are hard to swallow Too many pills to take Don’t like taste Too many side effects
1.3 2.3 2.2 1.6
1.3 2.2 2.1 1.6
1.4 2.4 2.4 1.6
Don’t want to take at school Meds get in way of activities Forget to take meds each time Not organized about meds Don’t want others to see me take meds Don’t feel like taking meds Hard to stick to med schedule Don’t like what meds do to my appearance Tired of taking meds Tired of having a medical condition Don’t realize when I run out of meds
2 1.9 2 1.5 1.5 2.3 1.9 1.5
1.6 1.7 1.8 1 1.1 2 1.4 1.1
2.8 2.1 2.5 2.3 2.4 2.8 2.8 2.3
3 3.2 1.2
2.7 3.1 1
3.5 3.5 1.5
1 1.7±0.2
1.3 2.4±0.2*
Confused how to take meds (food, etc.) 1.1 Mean score/question 1.9±0.1 b Individual scores ≥2.0 5 Individual scores ≤1.2 2
5 5
PD (n=8)
12 0
*p=0.006 versus HD Numerical guide to responses: 0 = “Strongly Disagree”; 1 = “Disagree”; 2 = “Not Sure Sometimes”; 3 = “Agree”; 4 = “Strongly Agree.” Among all questions, the mean response for among patients was “Sometimes”. The mean value was higher in patients receiving PD than in those receiving HD
a
A mean response of ≥2.0 was observed in 12 questions for peritoneal dialysis (PD) patients compared to only 5 questions for hemodialysis (HD) patients
b
gain (as a % of total weight) was 4.8±0.5 in HD patients, while mean hemoglobin level was 10.9±0.7 g/dL and TSAT= 31.6±3.0 % in PD patients. Among all targets in HD and PD patients combined, there was no relationship between adherence scores and the number of targets reached (r= 0.06, p=0.8). Finally, to further assess the relationship between adherence scores and targets reached, we divided the patients into two groups: those with adherence scores of
ORIGINAL ARTICLE
Barriers to medication adherence and its relationship with outcomes in pediatric dialysis patients Douglas M. Silverstein & Angela Fletcher & Kathleen Moylan
Received: 5 August 2013 / Revised: 27 January 2014 / Accepted: 28 January 2014 # IPNA 2014
Abstract Background Medication adherence is a major factor determining outcome in children with chronic disease. Children with end-stage renal disease are challenged with requirements for renal replacement therapy in addition to complicated medication regimens. Methods We assessed barriers to medication adherence in 22 pediatric patients receiving chronic dialysis [63.6 % hemodialysis (HD), 36.4 % peritoneal dialysis (PD); age 15.9± 0.7 years, dialysis vintage 31.6±6.5 months]. Adherence was assessed by a 16-question survey with a maximum score (difficulty) of 64. Results The overall mean adherence score was 30.9±2.4 (range 16–49; median 27.5). There was a trend for lower adherence scores in patients on HD (27.5±2.9) compared to those on PD (36.8±3.7) (p=0.06). Compared to HD patients, the mean score/question was significantly higher in PD patients (1.7±0.2 vs. 2.4±0.2, respectively; p=0.006). Of the 16 questions, HD and PD patients gave a mean response of ≤1.2 for five and zero questions, respectively. Neither gender, age nor dialysis vintage was related to adherence scores. There was also a trend for adherence scores to be
D. M. Silverstein (*) Office of Device Evaluation, Renal Devices Branch (RNDB), United States Food and Drug Administration, 10903 New Hampshire Avenue, Silver Spring, MD 20903, USA e-mail: [email protected] A. Fletcher Children’s National/Sheikh Zayed Institute, Children’s National Medical Center, Washington, DC, USA K. Moylan DaVita Health Care Partners, Denver, CO, USA
higher in females (35.6±3.7) than in males (27.5±2.9) (p= 0.1), but this difference did not reach statistical significance. Markers of mineral bone disease were similar in HD and PD patients. Among all targets in HD and PD patients combined, there was no relationship between adherence scores and number of targets reached (r=−0.09, p=0.7). Conclusion There are many barriers to medication adherence in pediatric patients receiving dialysis. In our patient group the difficulties were more evident in patients receiving PD than in those receiving HD. Keywords Chronic disease . Peritoneal dialysis . Hemodialysis . Children
Introduction Medication adherence has always been a major factor influencing outcome in pediatric patients with chronic disease. However, a limitation in assessing a patient’s adherence is the difficulty in establishing standards and monitoring tools based on the various underlying demographics of individual patients. Adherence rates in children with chronic disease vary widely, but they are estimated to be approximately 50 % [1]. Factors that may potentially impact medication adherence in patients receiving dialysis can be categorized as patient level factors and system level factors. Patient level factors include type and severity of disease, age (being lowest in adolescence) [1], family dynamics [2, 3] psychosocial conditions [4, 5] and health literacy and beliefs [6–8]. System and treatment level factors include pill burden, dialysis modality and health beliefs of the patient [6–8]. Various methods have been utilized by clinicians to identify barriers to medication adherence in pediatric patients, each with various degrees of success, but not without significant
Pediatr Nephrol
limitations. Unfortunately, the most common method used to assess medication adherence remains self-reported feedback from parents and/or patients. One commonly used tool is to simultaneously invite reports from both the patient and their parent, even though there are potential discrepancies. That said, in a recent report of medication adherence in children with inflammatory bowel disease, Mackner et al. [9] showed that although self-reported adherence rates were low (48 % reported by children and 38 % reported by their parents), the concordance between the child and parent was very high. Moreover, these authors showed that factors which predict poor adherence include family dysfunction, as well as behavioral disorders and inadequate coping strategies among the children. Finally, another useful tool to assess medication adherence is the Medical Adherence Measure Medication Module (MAM). The MAM tool has been used to assess parental and adolescent reports on medication adherence in renal transplant patients over a 1-week period [10]. Despite these encouraging results, children with end-stage renal disease (ESRD) face unique challenges to successful outcomes. In addition to the multiple medications and complex medication schedules, these children require life-sustaining renal replacement therapy (RRT; dialysis or transplant). Currently, the two main dialysis modalities are in-center, thriceweekly hemodialysis (HD) and home peritoneal dialysis (PD). Outcome data vary tremendously among the dialysis programs. Our center has a comprehensive RRT program that includes all types of dialysis modalities and an advanced renal transplant program. In our dialysis program, we consistently assess standard laboratory tests but also offer comprehensive cardiovascular risk factor analysis. In addition, we are committed to global psychosocial support, mainly provided by intense and consistent support and intervention by a dedicated social worker and a psychologist. In the past few years, we have developed a comprehensive health-related quality of life program and most recently instituted an adherence assessment tool. This report includes our data on patient-reported barriers to medication adherence and the relationship between adherence and outcome variables in pediatric patients receiving maintenance HD or PD dialysis at Children’s National Medical Center (Washington D.C.).
Methods Patients This was a retrospective study performed on children receiving dialysis at Children’s National Medical Center, Washington D.C.. The inclusion criteria were: (1) age at the time of the study (1–22 years); (2) receiving either maintenance HD or PD for 2 consecutive months; (3) no change in modality at the time of the analysis; (4) able to read or fully understand the purpose of the survey and the questions. All patients aged ≥10 years (previous cutoff for the survey we used) were eligible to participate if
the parents consented. The study was approved by the Children’s National Medical Center Institutional Review Board. Adherence survey We used an adherence survey previously published by Simons et al. [11, 12] called the Adolescent Medication Barriers Scales (AMBS), designed to assess barriers to medication adherence in adolescent transplant recipients. In our study, one physician (DM Silverstein) first thoroughly explained the purpose of the survey to each patient, then explained how the survey should be taken. The patient reported if they understood the intent and procedure of the survey and was given as much time as he/she desired to complete the survey. The patient was permitted to ask any question while taking the survey. The survey comprised 16 questions. Each question required the respondent to assign an answer based on the reported frequency of a problem, from among the following choices: “Strongly Disagree,” “Disagree,” “Not Sure (Sometimes),” “Agree” and “Strongly Agree.” Each response had a value assigned to it, as follows: 0 for “Strongly Disagree,” 1 for “Disagree,” 2 for “Not Sure (Sometimes),” 3 for “Agree” and 4 for “Strongly Agree.” A lower response score (e.g. “Disagree”) for a question translated to fewer problems (barriers) for medication adherence, while a higher response score (e.g. “Strongly Agree”) for a question translated to fewer problems (barriers) for medication adherence. A total adherence score was tabulated among the 16 questions, and the combined value for all of the questions is referred to as the “Adherence Score.” The minimum score was 0 while the maximum score was 64. Thus, the lower the total adherence score, the fewer barriers to medication adherence experienced by the patient, while a higher overall score indicated more barriers. The AMBS survey included another parameter: “Sometimes it is hard to make it to the pharmacy to pick up the prescription before the medicine runs out.” Since the vast majority of our medications were obtained at the pharmacy by parents or, occasionally, delivered to the home, we believed that this question would provide little valuable information and may skew the data. Therefore, we decided to exclude this parameter from our analysis. Laboratory analysis Serum for measurement of iron, total iron binding capacity, ferritin, calcium, phosphorous and intact parathyroid hormone (iPTH) was obtained either before a routine, mid-week treatment (HD) or routine outpatient visit (PD). All values were recorded for three consecutive months (1 month before, the month during, and 1 month after the survey was completed), and the results represent averages over the 3 months. For patients receiving HD, interdialytic weight gain represents the percentage of weight gain/total body weight between dialysis treatments over a 1-month period of time. Targets The indices used to assess the types of clinical targets that are significantly affected by medication adherence were
Pediatr Nephrol
serum calcium, serum phosphorous, serum iPTH and interdialytic weight gain for HD patients and serum calcium, serum phosphorous, serum iPTH and transferrin saturation (TSAT) for PD patients. Medications All patients receiving HD were receiving an intravenous erythropoiesis stimulating agent (ESA), intravenous vitamin D (paricalcitol) and an oral phosphorous binder. All patients receiving PD were receiving a subcutaneous ESA, oral calcitriol and an oral phosphorous binder. Pill burden The total number of pills prescribed/day was tabulated. For patients receiving liquid medications, we equated 5 ml with one tablet.
Fig. 1 Total adherence scores among all patients and according to dialysis modality (HD hemodialysis, PD peritoneal dialysis). There was a trend for lower adherence scores in patients receiving HD than in those receiving PD
Statistics Comparison between two groups was achieved by Student’s t test. Correlation between variables was determined by linear regression analysis.
while the mean score per question was 1.9±0.1. There was a trend for lower adherence scores in patients receiving HD (27.5 ±2.9 compared to those receiving PD (36.8±3.7) (p=0.06), although this difference did not reach statistical significance.
Results Demographic data Twenty-two patients were eligible for inclusion. The majority (14/22, 63.6 %) were receiving HD. The mean age of the patients was 15.9±0.7 years and the time on dialysis (vintage) was 31.6±6.5 months. The majority (16/22, 72.7 %) were of African-American race (Table 1). Barriers to medication adherence As described by Simons et al. [12], we calculated a total adherence score by adding the individual scores for each patient. The lower the total adherence score, the fewer barriers to medication experienced by the patient, while a higher overall score indicated more barriers. The total scores among all patients and according to dialysis modality are given in Fig. 1. Among all patients, the mean total adherence score was 30.9±2.4 (range 16–49, median27.5) Table 1 Demographic data Parameter
Result
Dialysis modality
HD: 14/22 (63.6 %) PD: 8/22 (36.4 %) 15.9±0.7 years (range 10–21 years; median 16.5 years) Females: 9/22 (40.9 %); males: 13/22 (59.1 %) 31.6±6.5 months (range 2–103 months; median 19.0 months) African-American: 72.7 % Hispanic: 18.2 % Caucasian: 4.5 % Mixed: 4.5 %
Age Gender Dialysis vintage Ethnicity
HD, Hemodialysis; PD, peritoneal dialysis
Adherence scores according to modality Compared to patients HD, the mean score/question was significantly higher in PD patients (1.7±0.2 vs. 2.4±0.2, respectively; p=0.006). Mean responses of at least 2.0 (“Sometimes”) was observed for 12 questions for the PD patients compared to five for those receiving HD. Finally, A mean response of ≤1.2 was given by HD for five of the 16 questions and by PD patients for none of the questions (0/16). The most prominent barriers to medication adherence among all patients were the high pill number burden, poor taste, inability to remember the medication schedule and fatigue with taking medicines and having a medical condition. The barriers reported much more commonly in patients receiving PD compared to those on HD were inability to remember or unwillingness to take medications at school or home and concerns about the effect of medications on their appearance (Table 2). Potential factors influencing adherence scores The total number of pills prescribed per day was almost identical in HD and PD patients (21.6±1.7 vs. 23.5±3.7, respectively; p=0.6); pill burden had no relationship with adherence scores. In addition, neither gender, age nor dialysis vintage was related to adherence scores (Table 3). Finally, there was a trend for adherence scores to be higher in females than in males (35.6±3.7 vs. 27.5±2.9, respectively; p=0.1), but this difference did not reach statistical significance. Achievement of targets and relationship to adherence scores Among the markers of mineral bone disease, the mean values were very similar in HD and PD patients. Serum calcium [9.3±0.1 (HD) vs. 9.2±0.2 mg/dL (PD); p=0.5], serum phosphorous [5.9±0.3 (HD) vs. 5.9±0.5 mg/dL (PD); p=0.9] and iPTH [482.3±103.1 (HD) vs. 581.1±191.0 (PD) pg/mL; p=0.6] levels were similar in HD and PD patients. Interdialytic weight
Pediatr Nephrol Table 2 Barriers to medication adherence—results of the questionnairea Question
ALL (n=22)
HD (n=14)
Meds are hard to swallow Too many pills to take Don’t like taste Too many side effects
1.3 2.3 2.2 1.6
1.3 2.2 2.1 1.6
1.4 2.4 2.4 1.6
Don’t want to take at school Meds get in way of activities Forget to take meds each time Not organized about meds Don’t want others to see me take meds Don’t feel like taking meds Hard to stick to med schedule Don’t like what meds do to my appearance Tired of taking meds Tired of having a medical condition Don’t realize when I run out of meds
2 1.9 2 1.5 1.5 2.3 1.9 1.5
1.6 1.7 1.8 1 1.1 2 1.4 1.1
2.8 2.1 2.5 2.3 2.4 2.8 2.8 2.3
3 3.2 1.2
2.7 3.1 1
3.5 3.5 1.5
1 1.7±0.2
1.3 2.4±0.2*
Confused how to take meds (food, etc.) 1.1 Mean score/question 1.9±0.1 b Individual scores ≥2.0 5 Individual scores ≤1.2 2
5 5
PD (n=8)
12 0
*p=0.006 versus HD Numerical guide to responses: 0 = “Strongly Disagree”; 1 = “Disagree”; 2 = “Not Sure Sometimes”; 3 = “Agree”; 4 = “Strongly Agree.” Among all questions, the mean response for among patients was “Sometimes”. The mean value was higher in patients receiving PD than in those receiving HD
a
A mean response of ≥2.0 was observed in 12 questions for peritoneal dialysis (PD) patients compared to only 5 questions for hemodialysis (HD) patients
b
gain (as a % of total weight) was 4.8±0.5 in HD patients, while mean hemoglobin level was 10.9±0.7 g/dL and TSAT= 31.6±3.0 % in PD patients. Among all targets in HD and PD patients combined, there was no relationship between adherence scores and the number of targets reached (r= 0.06, p=0.8). Finally, to further assess the relationship between adherence scores and targets reached, we divided the patients into two groups: those with adherence scores of
