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Volume 64, Number 3, 2012
Comparison of Utility Scores and Quality of Life Scores in Thai Patients between Twice and Thrice-Weekly Hemodialysis
Tanita Thaweethamcharoen, M.Pharm.,Somkiat Vasuvattakul, M.D.,Prapaporn Noparatayaporn, M.Pharm
Department of Pharmacy, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok 10700, Thailand.
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Abstract
Objective: To compare the utility scores and quality of life scores between patients who have twice and thrice-weekly hemodialysis.
Methods: This was a cross-sectional analytical study in 5 hemodialysis sites of the Nephrology Unit at Siriraj Hospital (the largest university hospital in Thailand), face-to-face interview using EuroQol questionnaire (EQ-5D), VAS, and KDQOL-36 (consists of 3 kidney disease subscales and SF-12) which was conducted between April 2011 and June 2011. One hundred and fifty three hemodialysis patients were recruited from the chronic hemodialysis clinic unit. This study compared the difference of hemodialysis times weekly to utility scores and quality of life scores of patients by using Independent Student’s t-test.
Results: SF-6D (derived from SF12), EQ-5D (UK and Thai preference weight), and VAS between the patients who received twice and thrice-weekly hemodialysis were not significantly different (p>0.05). This is also true for symptom/ problem list, effects of kidney disease, and burden of kidney disease scores. For SF-12, all physical and mental domains were not significantly different and similarly all utility and kidney disease specific scores were not significantly associated with hemodialysis times in weekly intervals (all, p>0.05).
Conclusion: These findings implied that thrice-weekly hemodialysis could not reflect the better quality of life more than twice-weekly hemodialysis. There was no significant difference in quality of life from the symptom/ problem list, effects of kidney disease, and burden of kidney disease between twice and thrice-weekly hemodialysis as well as the utility scores from SF-6D, EQ-5D and VAS. However, a further large cohort study of utility scores or cost effectiveness analysis between the difference of dialysis frequency at weekly intervals should be conducted.
Keywords: Utility, quality of life, twice-weekly, thrice-weekly, hemodialysis
Page: 94 - 97


MATERIALS AND METHODS

The study was a cross-sectional analytical study. If the patient gave informed consent, the investigator administered the study questionnaire as a face-to-face interview which included EQ-5D, VAS, and KDQOL-36 (consists of SF-12 and 3 subscales of kidney disease questionnaires), with sociodemographic and clinical data, together with a review of medical records, during April-June 2011 of 153 hemodialysis patients at the largest university hospital in Thailand (Siriraj Hospital), where the patients come from throughout Thailand. The study population was the patients who have hemodialyzed for at least 3 months but excluded the patients who are under 18 years old, changed the modality of dialysis, and those who could not answer the questionnaire or were not willing to participate in the study. The study was approved by the Siriraj Institutional Review Board (This study is a part of the topic “validity and reliability of modified KDQOL-SF v.1.3 in Thai kidney disease patients of Siriraj Hospital”. This study was approved by the Siriraj Institutional Review Board (EC Number 020/2554).

Analysis
All analyses were conducted using SPSS version 13 (SPSS Inc.). Independent Student’s t-test or Chi-Square test were used to compare the mean value and proportional differences of age, gender, marital status, underlying disease, hemodialysis duration, and family income, between twice-weekly and thrice-weekly hemodialysis patients who completed the KDQOL-36 (consists of SF-12 and kidney disease questionnaires) and EuroQol questionnaire.  The p-value <0.05 was accepted as statistically significant.

RESULTS

The mean (SD) age of the respondent sample was 55.53 (14.26) years of age, 47.70% were male, and more than half of the respondents had at least 1 underlying disease such as hypertension (80.90%). The duration of hemodialysis was 7.49 ± 5.57 years, and most of the respondents had Civil Servant medical Benefit scheme  (48.70%), Characteristics and clinical characteristics of the patients’ samples were classified by frequency of hemodialysis per week such as twice-weekly and thrice-weekly hemodialysis (Table 1).

The mean Hb for all patients were 10.30 g/dl. The mean Hb levels were 10.08 g/dl in the twice-weekly hemodialysis group and 10.49 g/dl in the thrice-weekly hemodialysis group   (p = 0.121) as shown in Table 2. Hemoglobin and creatinine levels were not different between the two groups, p-value = 0.121 and 0.607, respectively. The patients who received twice-weekly hemodialysis had higher Kt/V and blood urea nitrogen (BUN) than those who received thrice-weekly hemodialysis (p-value = 0.033 and 0.001, respectively), but the albumin of the twice-weekly hemodialysis was lower than the thrice-weekly hemodialysis (p=0.001) as shown in Table 2.

The mean and SD of utility scores from SF-6D, EQ-5D (UK, Thai algorithm), and VAS in the different hemodialysis weekly frequencies were not significantly differenct, (p-value = 0.709, 0.914, 0.888, and 0.654, respectively) as shown in Table 3. 

The score of 3 kidney disease specific subscales in the KDQOL-36 questionnaire were transformed onto 0 to 100 scale ranges as shown in Table 4. The better overall status patients are indicated with the higher score. The differences of weekly hemodialysis frequency were not significantly different in symptom/problem, effects of kidney disease, and burden of kidney disease scores (p-value = 0.486, 0.168, and 0.133, respectively). Other than the SF-12, items included physical functioning, role limitations due to physical health and mental health problems, general health perceptions, emotional well being, social functioning, and energy/fatigue or vitality. For the two groups of patients classified according to either twice-weekly hemodialysis or thrice-weekly hemodialysis, there were no significant differences in both SF-12 measures of physical health problems and SF-12 measures of mental health problems (p-value = 0.240 and 0.122, respectively).


Table 1. Characteristics of patients by frequency of hemodialysis per week.

Table 2. Clinical laboratory by frequency of hemodialysis per week (Mean ± SD).

Table 3. Mean±SD of utility scores and frequency of hemodialysis per week.

Table 4. Quality of Life scores and frequency of hemodialysis per week.
DISCUSSION
From 153 hemodialysis patients, more than half of the respondents had underlying disease (at least 1 disease) such as hypertension (80.90%). While 54.90% of patients hemodialyzed three times a week, 45.10% of patients hemodialyzed twice-weekly. Survival analysis revealed that patients dialyzed less than three times per week survived for a shorter period of time than patients receiving higher dialysis frequency, but their quality of life remained unclear.18 There was no significant difference in quality of life from the symptom/ problem list, effects of kidney disease, burden of kidney disease, PCS, and MCS scores between twice-weekly and thrice-weekly hemodialysis, as well as the utility scores from SF-6D, EQ-5D, and VAS. On the other hand, the previous study indicated that the difference of Hb levels was statistically significantly different in the effects of kidney disease, and MCS scores.19 Health schemes were different between the two groups of hemodialysis frequency (p<0.001). Most of the thrice-weekly hemodialysis patients were CSMBS (67.9%) because they were reimbursed for the hemodialysis expenditure while those using another scheme had to pay out of their own pocket. The thrice-weekly hemodialysis patients had higher family incomes than the twice-weekly hemiodialysis patients (p=0.034). From the answers of the respondents, we discovered the patients who hemodialyzed two times a week did so due to economic constraints, reimbursement policy or because the patients felt that hemodialysis interfered too much with their regular life. It was widely accepted that the higher frequency hemodialysis was associated with better survival of patients, but the patients felt that the thrice-weekly hemodialysis was not the best option for them because of the limit of the high expenditure and too much time consumed at the hospital. The higher frequency of hemodialysis led to the longer time because hemodilyzed patients had to go to the hemodialysis center and depend on  medical staffs for hemodialyis which interfered with their daily life.20-21 The limitation of this study was a non-randomized, unselected cohort study involving 153 hemodialysis patients in Siriraj Hospital which was different from other settings. A further large randomized multicenter study which studies the utility score or cost effectiveness between thrice-weekly and twice-weekly hemodialysis should be conducted.
CONCLUSION
Hemodialysis frequency between twice-weekly and thrice-weekly hemodialysis were dependent on financial support and reimbursement policy. Our results could summarize that quality of life score (SF-12 PCS and MCS functioning, burden of kidney disease subscale,  symptoms and problems subscale, effects of kidney disease on daily life subscale) and utility score (SF6D, EQ-5D, and VAS) of both the thrice-weekly and twice-weekly hemodialysis Thai patients at Siriraj Hospital indicated no significant differences. 
ACKNOWLEDGMENTS

The authors would especially like to acknowledge and thank hemodialysis patients for providing their valuable data, pharmacists, nurses and physicians for their assistance in collecting the data.

Sources of financial support
We appreciate grant support from the Routine to Research (R2R) of Siriraj Hospital, Mahidol University, Thailand.

Competing interests
The authors declare that they have no competing interests.

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