PL3286: Lab in Health Psychology Quantitative Lab Report

Quality of Life of Incident and Prevalent ESRD patients

AY 2011/2012 Semester 2

Name: WAH LI TING Matriculation Number: A0069681R No. of Words: 2997 (excluding abstract, headings, tables and references)

Abstract Background: Patients with End-stage Renal Disease (ESRD) are required to follow strict treatment regimes which may affect their quality of life (QOL). Impaired QoL is often reported by ESRD patients and has shown to be a marker of poor outcome. Objective: The overarching aim of this study is to examine QoL status among patients undergoing chronic hemodialysis. After controlling for the differences in demographic variables between incident and prevalent groups, we will examine if QoL is significantly different between them. As QoL is associated to anxiety and depression levels, we will also examine if anxiety and depression levels differ between the two groups. Methods/Design: 301 ESRD Singaporean patients participated in this cross-sectional study. Demographic variables were collected. All patients were administered the Kidney Disease Short-Form (KDQoL-SF) and Hospital Anxiety and Depression Scale (HADS)

questionnaires to examine their QoL and emotional distress respectively. Results: After controlling for the different demographics, results demonstrated significant differences between incident patients (IP) and prevalent patients (PP) in six aspects of QoL namely: effects of kidney disease, burden of kidney disease, quality of social interaction, social support, mental health and transformed MCS. IP displayed higher anxiety levels than PP. Conclusion: The findings suggest that IP scored lower in the psychological aspects of QoL than PP. This difference proposes the existence of poorer psychological health in IP. Relevance to clinical practice: Based on this study, it is important for health practitioners to design and implement psychological interventions to improve the psychological health and increase the QoL status of patients in the incident group. Keywords: ESRD patients, Quality of life, Prevalent and Incident group

Background End-Stage Renal Disease (ESRD) is a chronic illness in which an individuals kidneys stop functioning. The prevalence of ESRD is rising worldwide and Singapore has the sixth highest incidence of ESRD (Singapore Renal Registry, 2011). In recent years, an average of 750 new people is diagnosed with ESRD each year (NKF, 2009). The number of ESRD patients is also expected to continue to rise with the growth of an ageing population in Singapore.

Generally, all ESRD patients have been associated with a compromised QoL (Griva et al., 2009). As long-term lifestyle changes are required, their daily life and interpersonal relationships may be affected (Merkus, 1997). The side-effects of treatment and the possibility of arising complications may further impair their quality of life. However, there is limited research comparing the QoL status between incident and prevalent groups of ESRD patients. Hence, this study aims to investigate if there is a difference in QoL status between the two groups of patients.

The definition of QoL has often been debated. The three main domains of QoL outlined by Kimmel (2006) are physical functioning, psychological aspects, and social aspects. Each of these domains can be further divided into subsidiary parameters. Physical functioning includes effects of kidney disease on daily life, sexual functioning and sleep. Psychological domains include burden of kidney disease, cognitive functioning and patients satisfaction. Social aspects include quality of social interaction, social support, and staff encouragement. Others contested that the psychological and social aspects are under the same domain instead.

Studies demonstrated that certain parameters of QoL are strongly correlated with morbidity and mortality of ESRD patients. Low QoL has shown to be a marker of poor outcome among dialysis patients (Mapes et al., 2003). Another study by Lopes et al. (2003) identified QoL as a strong predictor of hospitalizations and mortality in a large international sample of hemodialysis patients.

The study population for this study is the hemodialysis patients as hemodialysis is the most common treatment modality in Singapore (Raffles Medical Group, 2012). However, patients undergoing hemodialysis often report lower QoL. Evans et al. (1985) study
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documented that across the different treatment modalities, patients undergoing hemodialysis had the lowest QoL and the highest level of emotional distress. When the relationship between QoL and emotional distress was further explored in ESRD patients, results revealed that QoL was significantly negatively correlated with depression and anxiety. Similarly, Mapes (1991) study revealed that psychological distress explained 21% of the variance in the patients QoL. Hence, this study also investigates if the anxiety and depression levels differ between incident and prevalent patients.

Studies have shown certain demographic factors to be associated with quality of life According to Mahboob and Zohreh (2009), increased age and lower literacy levels are associated with a poorer QoL. The unemployed and the females are also observed to have a lower QoL. A significant correlation between marital status and QoL was also found, with the married ones having a higher QoL (Ibrahim, 2008). Hence, it is crucial to control for these different demographic variables when examining the QoL status between incident and prevalent groups to ensure that the two groups are comparable. In summary, ESRD has an adverse impact of patients QoL, especially those undergoing hemodialysis. QoL may affect their physical and psychological outcomes. Examining deeper into the QoL status of incident and prevalent groups can help to design interventions to improve their QoL to reduce negative outcomes in the future.

Study Aims Based on the existing literature, the aims of this cross-sectional study are: a) assess the QoL of patients undergoing chronic hemodialysis and identify any significant differences in QoL status between incident and prevalent groups, after controlling for the differences in demographic variables b) examine if anxiety and depression levels are significantly different between IP and PP.

Methods Participants 301 patients from National Kidney Foundation (NKF) participated in this crosssectional study after giving their informed consent.

Inclusion criteria are ESRD patients, 21 years old and above, undergoing hemodialysis. Exclusion criteria are patients who are unable to give informed consent, had a diagnosis of functional psychosis or organic brain disorder and impaired cognition.

Patients are divided into two groups. The incident group consists of 68 patients undergoing hemodialysis for less than 6 months. The prevalent group consists of 233 patients undergoing hemodialysis for more than 6 months.

Measures The following demographic information is collected: age, gender, highest education level, marital status, household income, previous and current employment status, and the number of other existing medical conditions.

Kidney Disease QoL Short Form - KDQoL-SF is used to assess QoL (Hays et al., 1997). This measure is adapted from the Short form 36 health survey questionnaire (SF-36). To reduce the burden of completion, SF-36 is replaced with the SF-12, which is a shorter validated version of SF36. SF-12 gathers information on eight health concepts: physical functioning, role functioning due to physical and emotional health, mental health, bodily pain, general health, vitality and social functioning. These items are scored using a normbased method providing a component summary scale score for both mental and physical health related QoL (Ware et al., 1994). The instrument has been proved reliable and valid (Joshi et al., 2010).

Scales targeted at particular concerns of individuals with kidney disease are added to SF-12. The specific scales are: symptoms, effects of kidney disease on daily life, burden of kidney disease, cognitive functioning, quality of social interaction, sexual functioning, sleep, social support, staff encouragement and patients satisfaction.

Anxiety and depression levels were assessed using the Hospital Anxiety and Depression Scale (HADS) (Zigmond & Snaith, 1983). This is a self-administered questionnaire, composed of two 7-item scales, one for anxiety and one for depression. This scale has been validated and proven to be reliable (Bjelland, 2002).

Procedures All the patients were given an explanation about the purpose of the study. Consent was obtained from those who agreed to participate. Patients filled in the demographic information and complete the two questionnaires: KDQoL and HADS themselves.

Statistical Methods Independent sample t-tests were conducted to test the differences in QoL status, depression and anxiety levels between the incident and prevalent group. Demographic variables were described using mean (M) and standard deviation (SD), or percentages (%). Independent sample t-test and chi-square test was carried out to test the differences in demographic profile of the two groups. One-way ANOVA was used to test the relationship between significant demographic variables and QoL scores. Post hoc analysis was conducted using Tukeys HSD criterion. Analyses of covariance (ANCOVA) were used to control for demographic variables, to examine if the differences in QoL status are still significant between incident and prevalent patients. The alpha level was set at .05 for all statistical tests.

Results Comparison of QoL status between groups The results of the independent-samples t-test comparing the mean scores of QoL status between incident and prevalent groups were shown in Table 1.

Results indicated that five aspects of KDQoL were significantly different between the two groups. A significant difference between means of effects of kidney disease (t(298)=2.18, p<.05) was found, with PP (M=61.17, SD=21.47) coping better than IP (M=57.81, SD=20.09). Significant difference between means of burden of kidney disease (t(148.22)=3.08, p<.01) was noted, with PP (M=31.65, SD=26.20) functioning better than IP (M=22.79, SD=19.07). PP (M=72.07, SD=21.68) had a significantly (t(299)=-2.14, p<.05) better cognitive functioning than IP (M=65.59, SD=23.00). There was a significant difference between means of quality of social interaction (t(299)=-3.13, p<.01), with PP (M=71.77, SD=20.07) having higher quality than IP (M=63.14, SD=19.87). A significant difference was also observed between means of social support (t(298)=2.42, p<.01), with IP (M=79.41, SD=21.76) having more social support than PP (M=70.76, SD=7.02).

PP cope slightly better with the symptoms, had poorer sexual functioning and sleep than IP. Although PP received more encouragement from staff than IP, they were less satisfied. However, the differences in means in these 5 aspects of KDQoL were not significant: a) symptom burden (t(299)=-1.32, p>.05), b) sexual functioning (t(124)=.06, p>.05), c) sleep (t(298)=.59, p>.05), d) staff encouragement (t(298)=-.95, p>.05) and e) satisfaction (t(296)=.84, p>.05). (Refer to Table 1 for M, SD and t).

SF-12 was divided into two main components: physical and mental, each with 5 subscales. PP had slightly better physical functioning, higher physical role functioning, experience lesser pain, better health in general than IP. PP had a higher transformed physical component score than IP. However, the differences in all the 5 subscales of physical components of SF-12 were not significant (p>.05) between the two groups (Refer to Table 1 for M, SD and t). There was no significant difference between the means of a) physical functioning (t(298)=-.40, p>.05), b) physical role functioning (t(297)=-1.13, p>.05), c) bodily pain (t(299)=-1.27, p>.05), d) general health (t(293)=-1.44, p>.05), and e) overall transformed physical component score (t(287)=-.43, p>.05).

Of the five subscales of the mental components, PP reported more vitality and higher social functioning than IP, but the difference between these two means not significant (p>.05) (Refer to Table 1 for M, SD and t). A significant difference was found between the means of emotional role functioning (t(298)=-1.96, p<.01), with PP (M=39.14, SD=11.14) functioning better than IP (M=36.10, SD=11.48). A significant difference was found between the means of mental health (t(299)=-2.67, p<.01), PP (M=46.73, SD=10.01) having better mental health than IP (M=43.03, SD=10.29). A significant difference was also found between the means of transformed mental component score (MCS) (t(287)=-2.72, p<.01), with PP (M=46.33, SD=10.49) having a higher score than IP (M=42.41, SD=10.03).

Overall, results showed that the incident patients scored lower for most aspects of QoL than prevalent patients. Some significant differences were observed in the mental components of SF-12, but not in the physical components.

Table 1. QoL scores of incident and prevalent patients Groups Components KDQoL Subscale Symptoms Incident 64.37 (19.55) Effects of kidney disease on daily life 57.81 (20.09) Burden of kidney disease 22.79 (19.07) Cognitive functioning 65.59 (23.00) Quality of social interaction 63.14 (19.87) Sexual functioning 64.38 (32.26) Sleep 60.51 (18.53) Social Support 79.41 (21.76) Staff encouragement 69.85 (21.41) Patients satisfaction 60.54 (18.19) Prevalent 67.99 (19.90) 64.17 (21.47) 31.65 (26.20) 72.07 (21.68) 71.77 (20.07) 63.92 (32.88) 58.99 (18.64) 70.76 (27.02) 72.84 (23.28) 58.04 (22.29) .84 296 -.95 298 2.42* 298 .59 298 .06 124 -3.13** 299 -2.14* 299 -3.08** 148.22 -2.18* 298 t -1.32 df 299

Physical components of SF-12

Physical functioning

37.27 (10.61)

37.88 (11.16) 40.11 (9.57) 40.82 (11.86) 35.39 (9.90) 37.55 (9.25) 45.54 (10.41) 43.26 (12.16) 39.14 (11.14) 46.73 (10.01) 46.33 (10.49)

-.40

298

Role functioning (physical)

38.61 (9.52)

-1.13

297

Bodily pain

38.71 (12.77)

-1.27

299

General health

33.45 (9.27)

-1.44

293

Transformed PCS

37.01 (8.48)

-.43

287

Mental components of SF-12

Vitality

44.43 (12.02)

-.74

297

Social functioning

40.53 (13.43)

-1.59

296

Role functioning (emotional)

36.10 (11.48)

-1.96*

298

Mental health

43.03 (10.29)

-2.67**

299

Transformed MCS

42.41 (10.03)

-2.72**

287

Note: * = p .05, ** = p . 01. Standard Deviations appear in parentheses below means

Study Population An independent sample t-test was carried out to compare the mean age of IP and PP. The mean age of the IP (M=56.22, SD=12.40) was slightly higher than PP (M=53.48, SD=10.49), but the difference was not significant (p>.05).

A chi-square test of independence was performed to examine the differences in demographic profile between the incident (N=68) and prevalent (N=233) groups and the results are summarized in Table 2.

As seen by the frequencies cross tabulated in Table 2, the two groups do not differ significantly (p>.05) in most of the demographic variables. No significant difference was observed in gender, 2(1,N=301)=0.268, p>.05; marital status, 2(5,N=301)=8.88, p>.05; income level, 2(5,N=301)=4.01, p>.05; current employment status, 2(7,N=301)=5.09, p>.05 and number of other existing illnesses, 2(5,N=301)=5.38, p>.05.

A significant difference in education level was noted between IP and PP, 2(4,N=301)=22.12, p<.01. Compared to the 3% of PP, 15% IP did not have any education qualifications. Another difference was observed in the post-secondary education (6% incident, 16% prevalent). There is also a significant difference in the past employment status between the two groups, 2(7,N=301)=20.22, p<.01). There were more retirees in IP (10%) than PP (3%).

Table 2. Demographic characteristics of study population Groups Incident Gender Highest Educational Level (%) None Primary School Secondary School Polytechnic/ITE/JC Tertiary Marital Status (%) 14.7 33.8 38.2 5.88 7.35 2.58 29.18 48.50 16.31 3.43 8.88 5 Prevalent 2 .268 22.12** df 1 4

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Married Divorced Widowed Single Living with partner Others Family Income $0-2000 $2001-$4000 $4001-$6000 $6001 and above Dont know Dont wish to answer Current Employment Status (%) Full time (FT) Part time (PT) Self-employed (SE) Unemployed (UE) Retired (R) Looking after family (L) Student (S) Others (O)

70.15 5.97 13.43 8.96 0.00 1.49

65.52 7.33 5.60 20.26 0.43 0.86 4.01 5

42.65 25.00 5.88 2.94 13.24 10.29

51.53 21.40 44.80 3.93 13.54 4.80 5.09 7

22.06 5.88 1.47 14.71 17.65 25.00 0.00 13.24

23.35 9.69 5.29 15.42 18.06 16.74 0.44 14.98

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Past Employment Status (%) Full time (FT) Part time (PT) Self-employed (SE) Unemployed (UE) Retired (R) Looking after family (L) Student (S) Others (O) Number of other illness 0 1 2 3 4 5 Note: * = p .05, ** = p . 01. Relationship between the QoL scores and demographic profile 50.00 27.90 19.10 1.50 1.50 0.00 54.50 18.90 17.60 6.40 1.70 0.90 44.1 10.3 5.9 2.9 10.3 23.5 0 2.9 64.1 4.8 10.4 1.7 2.6 13.0 1.7 1.7

20.22*

5.38

Table 1 and 2 respectively shows that eight aspects of QoL and two demographic parameters are significantly different between the two groups. A one-way ANOVA was used to investigate if these two demographic parameters are associated to the eight aspects of QoL.

Table 3 summarizes the ANOVA results of QoL scores and highest education level and Table 4 summarizes the post hoc analysis using Tukey HSD criterion for selective comparisons.

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Four aspects of KDQoL did not differ significantly across different education levels: a) effects of kidney disease, F(4,295)=1.51, p>.05; b) burden of kidney disease, F(4,296)=1.88, p>.05; c) cognitive functioning, F(4,296)=1.17, p>.05; d) quality of social interaction, F(4,296)=1.81, p>.05 (Refer to Table 3 for M, SD and t).

Table 3. Highest Education Level and QoL Scores Highest Education Level Quality of Life Component Effects of kidney disease Burden of kidney disease Cognitive functioning Quality of 67.29 social (22.19) interaction 83.33 Social support (17.22) Role 33.01 functioning (7.61) (emotional) 41.07 Mental health (9.79) (11.13) (9.50) (9.72) (9.45) 46.48 45.56 45.38 52.91 2.64* (12.39) (10.80) (10.35) (10.33) 40.73 37.61 36.51 44.47 3.39** (27.72) (24.00) (27.61) (27.35) 75.92 73.98 58.33 70.51 4.48** (20.10) (20.73) (20.04) (10.68) 71.32 69.18 65.87 82.05 1.81 55.47 (19.91) 25.78 (20.40) 65.00 (17.30) 65.51 (24.17) 31.80 (25.75) 70.22 (24.65) 61.00 (19.99) 27.70 (24.70) 69.62 (22.22) 62.86 (20.65) 27.98 (24.27) 73.97 (17.47) 70.43 1.51 (14.01) 45.67 1.88 (27.17) 80.00 1.17 (19.63) None Primary Secondary Post-Secondary University F

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Transformed MCS

39.38 (9.52)

46.82 (11.49)

44.96 (9.62)

44.41 (10.61)

51.22 2.93* (10.06)

Note. * = p .05, ** = p .01. Standard deviations appear in parentheses below means.

Social support differ significantly across different education levels, F(4,295)=4.48, p<.05. Post hoc analysis using Tukeys HSD criterion indicated that those reported postsecondary as their highest education level had lesser social support than the other groups. Post-secondary (M=58.33, SD=27.61) differ significantly from those without education (M=83.33, SD=17.22), primary (M=75.92, SD=27.72) and secondary (M=73.98, SD=24.00), but did not differ significantly from university (M=70.51, SD=27.35).

All aspects of SF-12 differ significantly. Emotional role functioning differ significantly across different education levels, F(4,295)=3.39, p<.05. Post hoc analysis using Tukeys HSD criterion indicated that those reported university as their highest education level had better emotional role functioning than other groups. University (M=44.47, SD=10.33) differ significantly from those without education (M=33.01, SD=7.61), but did not differ significantly from primary (M=40.71, SD=12.39), secondary (M=37.61, SD=10.80) and post-secondary (M=36.51, SD=10.35).

Mental health differ significantly across different education levels, F(4,296)=2.64, p<.05. Post hoc analysis using Tukeys HSD criterion indicated that without education had had poorer mental health than the other groups. Those without education (M=41.07, SD=9.79) differ significantly from university (M=52.91, SD=9.45), but did not differ significantly from primary (M=46.48, SD=11.13), secondary (M=45.56, SD=9.50) and postsecondary (M=45.38, SD=9.72).

Transformed

MCS

differ

significantly

across

different

education

levels,

F(4,284)=2.93, p<.05. Post hoc analysis using Tukeys HSD criterion indicated that without education had poorer transformed MCS than the other groups. Those without education (M=39.38, SD=9.52) differ significantly from university (M=51.22, SD=10.06), but did not differ significantly from primary (M=46.82, SD=11.49), secondary (M=44.96, SD=9.63) and post-secondary (M=44.41, SD=10.61).

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Table 4. Selective Comparisons between Highest Education Level and QoL Scores Quality of Life Components Comparisons None PostSocial support Secondary Secondary University None Emotional role University functioning Secondary Post-Secondary Primary Secondary Mental Health None Post-Secondary University Primary Transformed None MCS Post-Secondary University Note. * = p .05, ** = p .01. -5.02 -11.83* 3.07 3.87 -13.44 -22.45 3.39 -1.21 Secondary -4.31 -11.84** -7.44 -5.57 2.96 3.76 2.82 2.74 -12.43 -22.15 -15.18 -13.10 3.80 -1.53 .31 1.95 6.85 7.96 -5.41 -4.49 3.22 3.52 2.73 2.65 -1.98 -1.71 -12.90 -11.78 15.68 17.62 2.08 2.80 Primary -15.65** -12.18 11.45* 3.73 1.04 8.11 4.14 3.30 -28.00 -34.44 .08 -5.30 -3.30 10.08 22.82 12.77 Primary Mean Difference -25.00** -17.60** SE 7.51 4.77 95% CI Lower Bound Upper Bound -45.60 -30.70 -4.40 -4.48

Table 5 summarizes the ANOVA results of QoL scores and past employment status. Most aspects of KDQoL and SF12 did not differ significantly across different prior employment status: a) effects of kidney disease, F(7,290)=4.46, p>.05; b) burden of kidney disease, F(7,291)=1.65, p>.05. c) cognitive functioning, F(7,291)=1.94, p>.05; d) quality of

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social interaction, F(7,291)=1.54, p>.05; e) social support, F(7,290)=1.38, p>.05, f) mental health, F(7,291)=1.88, p>.05; g) quality of social interaction, F(7,280)=1.75, p>.05.

Emotional role functioning differ significantly across different employment status, F(7,290)=2.21, p<.05. However, post hoc analysis using Tukeys HSD criterion indicated no significant differences in emotional role-functioning between the FT (M=39.84, SD=10.99), PT (M=35.89, SD=12.45), SE (M=34.91, SD=12.11), UE (M=27.19, SD=11.41), retired (M=34.14, SD=12.80), looking after family (M=38.70, SD=9.74), student (M=42.10, SD=10.71) and others (M=41.17, SD=12.88).

Table 5. Prior employment status and Quality of Life Scores Quality of Life Measure Effects of kidney disease Burden of kidney disease Cognitive function Quality of 71.52 social (19.95) interaction 69.49 Social support (27.44) Role functioning 39.84 (10.99) (21.39) 35.89 (12.45) (27.73) 34.91 (12.11) (25.28) 27.19 (11.41) (21.35) 34.14 (12.80) (23.30) 38.70 (9.74) (25.00) 42.10 (10.71) (13.95) 41.17 2.21* (12.08) 77.77 70.23 75.00 80.77 80.79 79.16 75.00 1.38 (20.18) (22.30) (19.21) (24.64) (19.49) (16.33) (17.21) 59.26 65.36 56.67 70.51 71.01 66.67 75.56 1.54 FT 63.54 (20.90) 32.02 (25.79) 72.96 (20.81) PT 60.22 (27.31) 18.40 (20.28) 58.33 (27.01) Prior employment status before diagnosis SE 58.37 (18.14) 21.88 (18.12) 64.52 (25.34) UE 55.21 (17.97) 15.63 (18.85) 55.56 (17.72) R 66.24 (19.32) 29.81 (24.23) 69.74 (15.78) L 63.00 (22.03) 30.03 (25.33) 69.93 (24.19) S 56.25 (17.68) 20.31 (20.01) 78.33 (16.67) O 63.02 .446 (33.16) 39.58 1.65 (35.06) 75.56 1.94 (13.77) F

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(emotional) 46.76 Mental health (10.00) Transformed MCS 46.45 (10.30) (9.18) 46.48 (10.31) (10.79) 41.23 (10.45) (15.32) 35.31 (14.50) (8.90) 43.85 (9.50) (9.49) 45.40 (10.05) (6.30) 47.12 (12.38) (11.81) 43.14 1.75 (13.38) Note. * = p .05, ** = p .01. Standard deviations appear in parentheses below means. 46.93 41.03 38.53 45.03 46.20 52.35 46.66 1.88

Difference in QoL status in two groups after controlling for demographic variables A one-way analysis of covariance (ANCOVA) was conducted to test for the difference in QoL status between the two groups after controlling for highest education level

As seen in the summazied results in Table 6, no significant differences between the two groups was found for cognitive functioning, F(1,298)=3.63, p>.05, and emotional role functioning F(1,297)=3.79, p>.05.

The analysis shows that the differences in most aspects of QoL were still significant between the two groups after controlling for the highest education level. Burden of kidney disease, F(1, 298) = 6.31, p =.013 remains significantly different between the two groups. Effects of kidney disease, F(1, 297) = 4.46, p =.036 remains significantly different between the two groups. Quality of social interaction, F(1, 298) = 9.68, p =.002 remains significantly different between the two groups. Social support, F(1, 297) = 3.94, p =.048 remains significantly different between the two groups. Mental health, F(1, 298) = 6.00, p =.015 remains significantly different between the two groups. Transformed mental health

component, F(1, 286) = 6.61, p =.011 remains significantly different between the two groups.

Table 6. Difference in QoL status after controlling for highest educational level Aspects of QoL (DV) Source Sum of Squares df Mean Squared F p

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Burden of Kidney Disease

Education level Incident/Prevalent Group Error Total

69.81 38884.74 183585.02 187785.25 28.41 2004.19 133504.60 135656.91 1038.43 1745.49 1647400.00 146721.67 9.14 3896.23 119899.45 123834.99 5625.93 2580.04 194731.53 204292.69 .258 477.84 37499.26 37984.91

1 1 298 300 1 1 297 299 1 1 298 300 1 1 298 300 1 1 297 299 1 1 297 299

69.81 3884.74 616.06

.11 6.31

.737 .013*

Effects of Kidney Disease

Education level Incident/Prevalent Group Error Total

28.41 2004.19 499.51

.06 4.46

.802 .036*

Cognitive functioning

Education level Incident/Prevalent Group Error Total

1038.43 1745.49 481.44

2.16 3.63

.143 .058

Quality of Social interaction

Education level Incident/Prevalent Group Error Total

9.14 3896.23 402.35

.02 9.68

.880 .002**

Social Support

Education level Incident/Prevalent Group Error Total

5625.93 2580.04 655.66

8.58 3.94

.004 .048*

Role functioning (emotional)

Education level Incident/Prevalent Group Error Total

.258 477.84 126.26

.002 3.79

.964 .053

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Mental Health

Education level Incident/Prevalent Group Error Total

171.85 606.93 30156.99 31050.75 59.71 714.15 30899.20 31755.91

1 1 298 300 1 1 286 288

171.85 606.93

1.70 6.00

.194 .015*

Transformed MCS

Education level Incident/Prevalent Group Error Total

59.71 714.15 108.04

.55 6.61

.458 .011*

Note. * = p .05, ** = p .01.

Comparison of anxiety and depression levels between groups The results of the independent-samples t-test comparing the mean scores of anxiety and depression levels between incident and prevalent groups were shown in Table 7.

Table 7. Anxiety and depression levels of incident and prevalent patients Groups Subscale Anxiety Incident 8.46 (5.01) Depression 8.99 (4.64) Note. * = p .05, ** = p .01. IP reported higher depression level (M=8.99, SD=4.64) than PP (M=8.07, SD=4.01) but the difference was not significant (t(299)=1.60, p>.05). Besides a significant difference in QoL, the means of anxiety level was also observed to be significant (t(299)=2.84, p<.01). IP (M=8.46, SD=5.01) reported higher anxiety levels than the PP (M=6.70, SD=4.33). Prevalent 6.70 (4.33) 8.07 (4.01) t 2.84 ** 1.60 299 df 299

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Discussion QOL has become an important outcome measure after the initiation of dialysis treatments. Besides sustaining the lives of these ESRD patients, it is equally important to ensure these patients enjoy life to its fullest extent.

This study is the first to compare the QoL status between IP and PP undergoing hemodialysis. While it is often assumed that patients in both incident and prevalent groups have low QoL, the findings indicate that IP had significantly lower QoL than PP. It is also important to note that even after controlling for demographic variables, there were marked differences in QoL status between IP and PP in these six aspects namely: effects of kidney disease, burden of kidney disease, quality of social interaction, social support, mental health and transformed MCS.

IP received significantly more social support than PP (p=.05). This is supported by Patel (2005) study, which highlighted that the amount of social support patients received decreased over time. Support providers may be adversely affected by providing support and hence become less supportive over time. Many research studies documented that dialysis patients were most distressed during the initial weeks as they experienced high level of discomfort. IP may not be used to going to the dialysis centre thrice a week and follow the strict dietary and fluid intake. Hence, they may perceive the effects and burden of kidney disease to be more severe than PP. Due to the drastic changes in their lifestyles, IP may not be able to cope and hence, their mental health is compromised to a larger extent than PP.

Of the six aspects of QoL that were significantly different between IP and PP, it is worthwhile to note that all are psychological domains of QoL, except effects of kidney disease (Kimmel, 2006). This finding suggests psychological QoL differs to a larger extent between IP and PP than physical QoL. Furthermore, the anxiety levels of IP was also noted to be significantly higher than PP (p=.005). IP may not have adjusted to the process of hemodialysis and hence, they experience higher anxiety levels.

The results of this study show that IP have significantly lower QoL and higher anxiety levels than PP. This is congruent with previous studies showing the association between emotional distress and QoL, These findings propose that IP may have poorer psychological health than PP. This study shows the value and importance of having the healthcare
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professionals to design and implement psychological interventions to increase the QoL status of patients in the incident group.

There are several limitations related to the present study. This was cross-sectional study. However, QoL status of patients may change over time, hence future studies can replicate this study along with longitudinal designs. Future studies can also research deeper into the anxiety level and QoL status of incident patients undergoing hemodialysis in Singapore, exploring the relationship between these two variables and determine the directionality of this association.

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