Psychosocial factors, behavioral compliance and survival in urban hemodialysis patients
Psychosocial factors, behavioral compliance and survival in urban hemodialysis patients
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DOI：
10.1046/j.1523-1755.1998.00989.x
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发表时间：
1998-07-01
影响因子：
19.6
通讯作者：
Veis, JH
中科院分区：
文献类型：
--
作者：
Kimmel, PL;Peterson, RA;Veis, JH
背景。与血液透析（HD）患者死亡率增加相关的医疗风险因素是众所周知的，但可能影响结果的社会心理因素尚未明确定义。心理社会因素可能通过与患者营养或透析处方依从性的相互作用影响死亡率。我们对城市HD患者进行了一项前瞻性、纵向、多中心研究，以确定依从性和社会心理因素对患者生存的贡献。采用社会支持、患者幸福感评估(包括疾病影响（IEQ）、生活满意度（SWLS）、贝克抑郁量表（BDI）、血清白蛋白浓度、Kt/V和蛋白质分解代谢率（PCR）等指标对患者进行评估。行为依从性以三种方式衡量：与规定时间相比，每次治疗实际透析时间的百分比（缩短行为）；参加会议的百分比（跳过行为）和总综合时间依从性（% TCOMP）。严重程度指数，以前被证明是死亡率的标志，被用来分级医疗合并症。记录了患者使用的透析器类型。采用Cox比例风险模型，控制年龄、医疗合并症、白蛋白浓度和透析器类型，评估心理因素和行为依从性变化的相对死亡风险。共有295名患者（60.8%）同意参与。我们人群的平均（+/- SD）年龄为54.6 +/- 14.1岁，平均PCR为1.06 +/- 0.27 g/kg/day，平均Kt/V为1.2 +/- 0.4，表明患者营养良好，透析充分。患者的平均BDI为11.4 +/- 8.1（轻度抑郁范围）。患者的SWLS与一组无慢性疾病的患者相似。在26个月的平均随访期后，在控制了患者年龄、疾病严重程度、血清白蛋白浓度和透析器类型变化的情况下，较高水平的感知社会支持、对疾病影响的感知改善和行为依从性增加与相对死亡风险降低显著相关（分别为0.8、0.77和0.79）。抑郁和Kt/V的变化不是观察期间死亡率的预测因子。较低的社会支持水平，对透析处方的行为依从性降低，以及对疾病影响的负面认知增加与HD治疗的ESRD患者死亡率增加独立相关。其影响与医疗风险因素具有相同的数量级。这种影响可能归因于患者对社会支持的感知与疾病和行为的影响之间的关系，以及其他因素，例如为拥有更大社会网络的患者提供更好的医疗服务。社会心理因素与透析依从性和生存之间关系的机制，以及干预措施在改善HD患者疾病认知、增加社会支持和透析依从性方面的作用有待研究。
Background. The medical risk factors associated with increased mortality in hemodialysis (HD) patients are well known, but the psychosocial factors that may affect outcome have not been clearly defined. Psychosocial factors could affect mortality through interaction with patients' nutrition or their compliance with the dialysis prescription. We conducted a prospective, longitudinal, multicenter study of urban HD patients to determine the contribution of compliance and psychosocial factors to patient survival.Methods. Patients were assessed using indices of social support, patient's assessments of their well-being, including illness effects (IEQ), and satisfaction with life (SWLS), the Beck Depression Inventory (BDI), serum albumin concentration, Kt/V and protein catabolic rate (PCR). Behavioral compliance was measured three ways: percent time actually dialyzed per treatment compared to prescribed time (shortening behavior); percent sessions attended (skipping behavior) and total integrated time compliance (% TCOMP). A severity index, previously demonstrated to be a mortality marker, was used to grade medical comorbidity. The type of dialyzer the patient was treated with was noted. A Cox proportional hazards model, controlling for age, medical comorbidity, albumin concentration and dialyzer type was used to assess relative mortality risk of variations in psychoscial factors and behavioral compliance.Results. A total of 295 patients (60.8% of those eligible) agreed to participate. The mean (+/- SD) age of our population was 54.6 +/- 14.1 year, mean PCR was 1.06 +/- 0.27 g/kg/day, and mean Kt/V 1.2 +/- 0.4, suggesting the patients were well nourished and adequately dialyzed. The patients' mean BDI was 11.4 +/- 8.1 tin the range of mild depression). Patients' SWLS was similar to that of a group of patients without chronic illness. After a 26 month mean follow-up period, higher levels of perceived social support, improved perception of the effects of illness and increased behavioral compliance were significantly associated with decreased relative mortality risk (0.8, 0.77, and 0.79, respectively), controlled for variations in patients' age, severity of illness, serum albumin concentration and dialyzer type. Variations in depression and Kt/V were not predictors of mortality during the observation period.Conclusions. Lower levels of social support, decreased behavioral compliance with the dialysis prescription, and increased negative perception of the effects of illness are independently associated with increased mortality in ESRD patients treated with HD. The effects are of the same order of magnitude as medical risk factors. Such effects may be attributable to a relationship between a patients' perception of social support and effects of illness and behavior, with other factors such as the provision of better medical care in patients with larger social networks. The mechanism underlying the relationship of psychosocial factors and compliance and survival, and the effect of interventions to improve perception of illness, and increase social support and compliance with the dialysis prescription in HD patients should be studied.