Cite this article: Yadla M (2017) Quality of Life Assessment using Sf-36 Questionnairre in Maintenance Hemodialysis Patients Supported by Government Funded Cashless Scheme. J Clin Nephrol Res 4(3): 1069.

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Journal of Clinical Nephrology and Research

*Corresponding authorManjusha Yadla, Gandhi Medical College, India, Tel: 040-23741265; Email:

Submitted: 26 May 2017

Accepted: 27 June 2017

Published: 29 June 2017

ISSN: 2379-0652

Copyright© 2017 Yadla

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Research Article

Quality of Life Assessment using Sf-36 Questionnairre in Maintenance Hemodialysis Patients Supported by Government Funded Cashless SchemeManjusha Yadla*Gandhi Medical College, India

Abstract

A cross sectional study was conducted to assess quality of life (QoL) in patients on maintenance hemodialysis at our centre. QoL was assessed using SF-36 questionnairre. Patients who completed 6 months of hemodialysis were included in the study. Various predictors of total score, physical score and mental score were analysed. Secondary outcomes like number of hospitalizations and deaths were also analysed with each score. Vintage of dialysis had statistical significance with total score. Mental score was significantly impaired in those with diabetes mellitus.

Keywords•Hemodialysis•Diabetes mellitus

INTRODUCTIONQoL is an important tool for measurement of outcomes of

interventions done in patients with chronic illnesses. QoL is compromised due to different factors like logistics, finances, emotional well being, physical dependence, nutrition etc. Various tools and questionnaires are available to assess QoL in patients on hemodialysis. SF-36 has been one of the time tested questionnaires for assessment of QoL. It was estimated that 55000 patients were on dialysis in India by 2013 and number was expected to increase by 10-20% annually [1]. This would imply that there may be 66000-77000 patients on hemodialysis. Cost constraints, lack of infrastructure and man power are the major limiting factors for patients to access dialysis care facilities. In this background, our state government has initiated a cashless scheme of hemodialysis to all the patients below poverty line. QoL of these patients, who are daily laborers or jobless or dependents, would be expected to be on lower side as finances play significant role in maintaining quality of life.

This study was done prospectively to assess the physical component status and mental component status using SF-36 questionnairre in patients on maintenance hemodialysis run by State government for free of cost.

PATIENTS AND METHODSThe study was done in our center, where patients are

supported by cashless government funded scheme, Aarogyasree,

a flagship card scheme for poor patients, below poverty line. Since the time of inception of the scheme in the year 2007 till date, a total of 184899 therapies (State wide) were given by the government free of cost to the poor.(Courtesy: Aarogyasree website).

Under this scheme, patients are given thrice weekly hemodialysis of 10-12 sessions per month. Hemodialysis is done using 4008 Fresenius machine, F6 polysulfone dialyser. Each session is given for 4 hours. Average reuse of dialyser in our unit is 8. Patients are given weekly Erythropoietin injections. Hemoglobin, Kt/V, S. creatinine, viral markers is assessed periodically. The study follow up period was of one year.

Inclusion criteria:

Age more than 18 years and less than 60 years

2. Duration of dialysis more than 6 months

Exclusion criteria:

1. Duration of dialysis less than 6months

2. Age less than 18years

3. Those who have not given consent

4. Patients who were critically ill or pregnant, recent hospitalization, trauma, malignancy and active infection

SF-36 measures the quality of life in multidimensional

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approach. SF 36 survey questionnaire (Medical Outcomes Study: 36-Item Short Form Survey) was assessed by department physicians in vernacular language Across eight domains of emotional and physical status: physical functioning; role limitations due to physical health; role limitations due to emotional problems; energy/fatigue; emotional well-being; social functioning; pain; general health, patients were asked to choose the best amongst the alternatives available. Data collected was compiled and the final score was given to each patient. Scoring was also assessed for PCS and MCS. Based on the total SF-36 score, depression was graded were graded.

Epidemiological data, vintage of dialysis, various comorbidities, dialysis data, vascular access and the laboratory parameters were studied. Based on total SF-36 score, patients were divided in to two groups. Secondary outcomes i.e. deaths, hospitalizations were also assessed.

STATISTICAL ANALYSISStatistical analysis was done using the SPSS package, version

20. Results were done by Chi-square test. Significance was considered for P < 0.05.Pearson correlation test and multiple logistic regression analysis were used to analyze the variables.

RESULTSOf 150 patients in our center, 130 patients satisfied inclusion

criteria and could answer the questionnaire.

Mean age of the group was 43.6 ± 11.9 years and 70% of them were men (92/130). Mean duration of dialysis was 29.48 ± 22.8 months (median duration: 24 months, range: 6months – 8 years). Moderate depression (SF score <50) was found in 48.4% (Table 1) and severe depression was not found in any of the patients. Severity of depression was assessed in different age groups, of which patients with mild- moderate depression were between 30-60 years (Figure 1).

Table (2) shows base line characteristics and the total SF-36 score. Based on total SF score, moderate – severe depression was observed in 48.4%. Of 130 study population, 50% had MCS score <50 and 39%had PCS score <50. Depression was found to be significant in those with vintage <24 months (p=0.015) and also in those with diabetes (p=0.008). A similar finding was noted with mental health status. A poor mental health was noted inpatients with diabetes (p=0.002)

Amongst the variables, depression was significant in those with longer vintage of dialysis (p<0.05). Other variables like diabetes, serum creatinine, weight loss and smoking were not found to be statistically significant. Age, gender, comorbities like diabetes, peripheral vascular disease, left ventricular dysfunction, serological status, hemoglobin, serum creatinine did

not differ between the two groups. Amongst the lab parameters, mean serum calcium score of the study group was 8.2 ± 1.2mg/dl and serum phosphorus was 2.5 ± 1.3mg/dl.

Analysis of individual scores of SF-36 shows that role limitation for physical health (RLPH) and emotional problems (RLEP) varied widely as 51 % of the group had low score of <25 and 41 -43% of them had score a good score of > 75 (Figure 2). Worst scores (<25) are also seen in physical health component and better scores (>75) are seen in social functioning, and bodily pain (Figure 2).

Both the physical and mental health scores were assessed independently. Various predictors of Physical health score (PH) are shown in Table (3). PH score was <50 in 39.23%. Low serum creatinine of <5mg/dl was found to be statistically significant with PH score. Though Odds ratio for diabetes, Kt/v, weight loss was found to be high, P value was not found to be significant.

Table (4) shows various predictors of mental health score. Diabetes was found to be statistically significant with the MH score (P =0.002).Other variables like vintage of dialysis, serum creatinine, smoking, intradialytic hypotension were found to have high odds ratio, but p value was not significant.

Secondary outcomes like deaths and hospitalizations were analysed. Correlation of secondary outcomes with total score, PH score and MH score was done (Table 5). Though P value for the

Table 1: Grading of depression and percentage distribution.

Score Grading N (%)

<25 Severe depression 0

25-50 Moderate depression 63(48.4%)

51-75 Mild depression 60(46%)

>75 Good health 7 (5.3%)

Figure 1 SF-36 score distribution between different age groups.

Figure 2 Distribution of all eight components of SF-36 score.

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Table 2: Baseline characteristics and total SF-36 score.

Variable StatusSF Score %

P Value OR<50 (63) (%) ≥50 (67) (%)

GenderF 14 (22.2) 24(35.8)

0.13 0.5(0.23-1.11)M 49 (77.8) 43 (64.2)

BMI18-25 38 (60.3) 42 (62.7)

0.90 0.9(0.44-1.83)<18 or>25 25 (39.7) 25 (37.3)

Duration< 24 m 35 (55.6) 23 (34.3)

0.02 2.3(1.17-4.85)≥ 24m 28 (44.4) 44 (65.7)

HTNY 39 (61.9) 43 (64.2)

0.93 0.9(0.44-1.84)N 24 (38.1) 24 (35.8)

DMY 32 (50.8) 27 (40.3)

0.30 1.52(0.76-3.06)N 31 (49.2) 40 (59.7)

LVDY 32 (50.8) 33 (49.3)

0.86 1.06(0.53-2.11)N 31 (49.2) 34 (50.7)

PVDY 28 (44.4) 32 (47.8)

0.83 0.87(0.43-1.74)N 35 (55.6) 35 (52.2)

CVAY 15 (23.8) 22 (32.8)

0.34 0.63(0.29-1.38)N 48 (76.2) 45 (67.2)

PTBY 5 (7.93) 3 (4.5)

0.64 1.83(0.42-8.03)N 58 (92.1) 64 (95.5)

HBVY 1 (1.6) 5 (7.5)

0.23 0.2(0.02-1.76)N 62 (98.4) 62 (92.5)

HCVY 10 (15.9) 11 (16.4)

0.87 0.96(0.37-2.44)N 53 (84.1) 56 (83.6)

S. CR>5mg 27 (42.9) 20 (29.9)

0.17 1.76(0.85-3.63)<5mg 36 (57.1) 47 (70.1)

Hb<10gm 41 (65.1) 52 (77.6)

0.16 0.53(0.24-1.16)>10gm 22 (34.9) 15 (22.4)

HD AccessAVF 49 (77.8) 59 (88.1)

0.18 0.47(0.18-1.22)IJV 14 (22.2) 8 (11.9)

Wt. LossY 42 (66.7) 34 (50.7)

0.09 1.94(0.96-3.94)N 21 (33.3) 33 (49.3)

SmokingY 31 (49.2) 26 (38.8)

0.30 1.52(0.76-3.06)N 32 (50.8) 41 (61.2)

Kt/v<1.2 40 (63.5) 40 (59.7)

0.79 1.17(0.57-2.38)>1.2 23 (36.5) 27 (40.3)

IDWG1-3kg 30 (47.6) 36 (53.7)

0.60 0.78(0.39-1.55)>3kg 33 (52.4) 31 (46.3)

ID HypoY 36 (57.1) 33 (49.3)

0.46 1.37(0.68-2.74)N 27 (42.9) 34 (50.7)

Table 3: Various predictors and PH score.

Variable StatusPH Score %

P Value OR<50 (51) ≥50 (79)

GenderF 13 (25.5) 25 (31.6)

0.57 0.73(0.33-1.62)M 38 (74.5) 54 (68.4)

BMI18-25 30 (58.8) 50 (63.3)

0.74 0.82(0.40-1.70)<18 or ≥25 21 (41.2) 29 (36.7)

Duration< 24 m 26 (51.0) 32 (40.5)

0.32 1.52(0.75-3.10)≥ 24m 25 (49.0) 47 (59.5)

HypertensionY 28 (54.9) 54 (68.4)

0.17 0.56(0.27-1.16)N 23 (45.1) 25 (31.6)

DMY 21 (41.2) 38 (48.1)

0.30 1.52(0.76-3.06)N 30 (58.8) 41 (51.9)

LVDY 22 (43.1) 43 (54.4)

0.28 0.63(0.31-1.29)N 29 (56.9) 36 (45.6)

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PVDY 22 (43.1) 38 (48.1)

0.70 0.81(0.40-1.66)N 29 (56.9) 41 (51.9)

CVAY 12 (23.5) 25 (31.6)

0.42 0.66(0.29-1.48)N 39 (76.5) 54 (68.4)

PTBY 3 (5.9) 5 (6.3)

0.18 0.92(0.21-4.05)N 48 (94.1) 74 (93.7)

HBVY 1 (2.0) 5 (6.3)

0.46 0.29(0.03-2.61)N 50 (98.0) 74 (93.7)

HCVY 6 (11.8) 15 (19.0)

0.39 0.56(0.20-1.57)N 45 (88.2) 64 (81.0)

S. Cr(mg/dl)>5 25 (49.0) 22 (27.8)

0.02 2.49 (1.19-5.20)<5 26 (51.0) 57 (72.2)

Hb(gm/dl)<10 33 (64.7) 60 (75.9)

0.23 0.58(0.26-1.25)>10 18 (35.3) 19 (24.1)

HD AccessAVF 42 (82.4) 67 (84.8)

0.89 0.83(0.32-2.15)IJV 9 (17.6) 12 (15.2)

Wt. LossY 32 (62.7) 44 (55.7)

0.53 1.33(0.65-2.75)N 19 (37.3) 35 (44.3)

SmokingY 21 (41.2) 36 (45.6)

0.75 0.83(0.41-1.70)N 30 (58.8) 43 (54.4)

Kt/v<1.2 35 (68.6) 45 (57.0)

0.25 1.65(0.78-3.46)>1.2 16 (31.4) 34 (43.0)

IDWG 1-3kg 27 (52.9) 39 (49.4)

0.82 1.15(0.57-2.33)3kg 24 (47.1) 40 (50.6)

ID HypoY 27 (52.9) 42 (53.2)

0.87 0.99(0.48-2.00)N 24 (47.1) 37 (46.8)

Table 4: Predictors and MH score.

Variable StatusMH Score %

P Value OR<50 (66) ≥50 (64)

GenderF 17 (25.8) 21 (32.8)

0.48 0.71(0.33-1.51)M 49 (74.2) 43 (67.2)

BMI18 -25 39 (59.1) 41 (64.1)

0.68 0.81(0.39-1.64)<18 or ≥25 27 (40.9) 23 (35.9)

Duration< 24 m 32 (48.5) 26 (40.6)

0.46 1.37(0.68-2.75)≥ 24m 34 (51.5) 38 (59.4)

HypertensionY 43 (65.2) 39 (60.9)

0.75 1.19(0.58-2.44)N 23 (34.8) 25 (39.1)

DMY 43 (65.2) 24 (37.5)

0.002 3.11(1.52-6.37)N 23 (34.8) 40 (62.5)

LVDY 34 (51.5) 31 (48.4)

0.86 1.13(0.56-2.25)N 32 (48.5) 33 (51.6)

PVDY 30 (45.5) 30 (46.9)

0.98 0.94(0.47-1.88)N 36 (54.5) 34 (53.1)

CVAY 15 (22.7) 22 (34.4)

0.20 0.56(0.25-1.21)N 51 (77.3) 42 (65.6)

PTBY 6 (9.1) 2 (3.1)

0.29 3.1(0.60-15.96)N 60 (90.9) 62 (96.9)

HBVY 2 (3.0) 4 (6.3)

0.64 0.46(0.08-2.65)N 64 (97.0) 60 (93.8)

HCVY 12 (18.2) 9 (14.1)

0.68 1.35(0.52-3.48)N 54 (81.8) 55 (85.9)

S. CR>5mg 28 (42.4) 19 (29.7)

0.18 1.79(0.84-3.60)<5mg 38 (57.6) 45 (70.3)

Hb<10g 46 (69.7) 47 (73.4)

0.78 0.83(0.38-1.78)>10g 20 (30.3) 17 (26.6)

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HD AccessAVF 52 (78.8) 56 (87.5)

0.27 0.53(0.20-1.36)IJV 14 (21.2) 8 (12.5)

Wt. LossY 41 (62.1) 35 (54.7)

0.49 1.35(0.67-2.73)N 25 (37.9) 29 (45.3)

SmokingY 34 (51.5) 23 (35.9)

0.10 1.89(0.93-3.82)N 32 (48.5) 41 (64.1)

Kt/v<1.2 42 (63.6) 38 (59.4)

0.74 1.19(0.59-2.42)>1.2 24 (36.4) 26 (40.6)

IDWG1-3kg 32 (48.5) 34 (53.1)

0.72 0.83(0.41-1.65)>3kg 34 (51.5) 30 (46.9)

ID HypoY 38 (57.6) 31 (48.4)

0.30 1.44(0.72-2.88)N 28 (42.4) 33 (51.6)

Table 5: Secondary outcomes with total score, PH score and MH scores.

Total score P value OR

No.of Hosp>3 43 (68.3) 48 (71.6)

0.81 0.85(0.40-1.80)(1-3) 20 (31.7) 19 (28.4)

Deaths Y 9(14.3) 10 (14.9) 0.88 0.95(0.35-2.51)

PH score

No.of Hosp>3 36 (70.6) 55 (69.6)

0.93 1.04(0.48-2.26)(1-3) 15 (29.4) 24 (30.4)

DeathsY 8 (15.7) 11 (13.9)

0.98 1.15(0.42-3.08)N 43 (84.3) 68 (86.1)

MH score

No.of Hosp>3 47 (71.2) 44 (68.8)

0.90 1.12(0.53-2.38)(1-3) 19 (28.8) 20 (31.3)

DeathsY 12 (18.2) 7 (10.9)

0.35 1.80(0.66-4.93)N 54 (81.8) 57 (89.1)

Abbreviations: IDWG: Interdialytic Weight Gain; IDH: Intradialytic Hypotension; LVD; Left Ventricular Dysfunction; PVD: Peripheral Vascular Disease; PTB: Pulmonary Tuberculosis; CVA: Cerebrovascular Accident; DM: Diabetes Mellitus; S.CR: Serum Creatinine; HBV: Hepatitis B; HCV: Hepatitis C; Hb: Hemoglobin; No. of Hosp: Number of Hospitalizations; PH: Physical Health; MH: Mental Health; RLEP: Role Limitation In Emotional Problems; RLPH: Role Limitation In Physical Health; EF: Energy Fatigue; BP: Bodily Pain; GH: General Health; EWB: Emotional Well Being; SF: Social Functioning

outcomes was not found to be significant with all the 3 scores, odds ratio was high with MH score on deaths.

DISCUSSIONAssessment of QoL is important in patients of chronic

illnesses placed on intervention modalities. QoL is shown to be one of the important factors influencing morbidity and mortality in those on renal replacement therapies. WHO has defined QoL as individual’s perception of their position in life in context of cultural and value systems in which they live in and in relation to their goals, expectations, standards and concerns [2].

SF-36 is a commonly used tool to assess the QoL of patients on MHD. QoL in these patients is affected not only by the quality and adequacy of dialysis but also by anemia correction, nutrition, availability of finances, emotional dependence. Assessment of physical health depends on the physical activities and assessment of mental health depends on extent of depression. Depression has been one of the most disabling morbidity in this group. Hence the score was categorized in to mild, moderate and severe depending on the SF score.

Limited studies are reported from India regarding QoL in

maintenance dialysis patients. Veerappan et al., studied QoL in 78 patients on dialysis [3-5]. Vettath et al., in a study of QoL in 60 patients on hemodialysis observed that depression was influenced by poverty, frequency of dialysis, erythropoietin usage [5]. Our group is different from the previous study in that though all the patients in our study are below poverty line, they are given 8-10 free hemodialysis sessions along with free erythropoietin.

Gender influence with females having worser scores was reported in both the studies. But we did not find gender influence in any of the scores.

In our study, we did not observe influence of various comorbidities like PVD, CVA, LVD, DM, PTB on total score, and physical score. But patients with diabetes were found to have low mental health score (P=0.002). This is in concordance with the study by Vettath et al.

A poor QoL was found to be associated with low serum albumin, low serum hemoglobin, low protein catabolic rate and severe degree of malnutrition [4-6]. In our group physical score was poor in those with serum creatinine less than 5mg/dl.

We could not find the significance of anemia with any of

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the scores though the incidence of anemia continued to be high (71%).This higher incidence and lack of statistical significance could be due to presence of equal number in both the groups and a higher cut off value of 10 gm/dl.

Dialysis parameters like Kt/V, IDWG, IDH did not show significance with the scores. In our study, we could not find the significance of scores on deaths or hospitalizations [7,8].

A poor QoL was correlated with severe malnutrition, low serum albumin, low serum creatinine and anemia (6,7,8).In our study, we could not assess serum albumin , protein catabolic rate, other serum parameters like serum iPTH, vitamin D status , CRP, regular liver function tests. Low PH scores were observed with low serum creatinine as physical health is significantly influenced by nutrition, indirectly by muscle mass and thus the creatinine.

In our study, we did not find the Physical score, mental score or the total score predicting deaths or hospitalizations unlike in many other studies, where mental scores and physical scores were significantly associated with mortality [9-15]. But we observed that presence of lower mental score has a slightly higher chance of mortality (OR=1.8).This could be due to small sample size of the study population.

CONCLUSIONS1. Moderate to severe depression was found in 48% despite

provision of free hemodialysis sessions in required number.

2. Duration of dialysis remains the statistically significant factor for poor SF-36 scores.

3. Diabetes mellitus and serum creatinine, are the statistically significant factors for mental health and physical health respectively.

LIMITATIONS 1. Small number of population study.

2. All the biochemical parameters could not be assessed as they are not funded by the government scheme.

ACKNOWLEDGEMENTWe acknowledge the immense help by Dr. Mahesh and Dr.

Raju for analysing the statistics of the study.

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Yadla M (2017) Quality of Life Assessment using Sf-36 Questionnairre in Maintenance Hemodialysis Patients Supported by Government Funded Cashless Scheme. J Clin Nephrol Res 4(3): 1069.

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