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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. 2010;56(3):547557.
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
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).
Barriers to Self-Management of Oral
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).
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.
Demographic and Socioeconomic
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
The relation between sex and management of
oral medication is inconclusive.
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
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
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
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.
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
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.
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.
Steps to Improve Self-Managed Oral
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.
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
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.
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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