EFFECT OF PHARMACISTS’ MEDICATION RECONCILIATION AND COUNSELING IN

THE IMPROVEMENT OF QUALITY OF LIFE THE AMBULATORY DIALYSIS PATIENTS

Lynnette Joy B. Colonia

ABSTRACT
Chronic kidney disease (CKD) is currently considered a worldwide problem with 1 in 10
million or about 500 million prevalence worldwide (Davids, 2007). It has already resulted in
millions of deaths, years of life lost, years lived with disability and disability-adjusted life-years.
The failure to recognize CKD in patients who encounter the health-care system leaves them at risk
for medication errors that can intensify the severity of their illness, extend hospital stay,
potentially hasten disease progression (Fink & Chertow, 2009b) as well as increase the risk for
adverse drug effects and result to greater costs of care (Berns, 2015). Management of patients
with kidney diseases, in particular, those undergoing dialysis, poses many challenges to health
practitioners because they often have existing co-morbidities and are taking multiple medications
which predisposes them to a higher risk of adverse events (Patricia and Foote, 2016).
Pharmacists, through medication reconciliation and patient counseling, are in the best position to
improve the level of care and health related quality of life of kidney disease patients (Thomas D et
al., 2009). It is the interest of this study to explore pharmacists’ potential interventions in the
management of out-patient dialysis patients through medication reconciliation and counseling.
This study is a randomized quasi-experimental non-equivalent (pretest and posttest)
control group design exploring patient counseling among CKD patients undergoing dialysis. In
this design, the experimental Group A and control Group B were selected with random
assignment. Both groups took a pretest and posttest survey on health-related quality of life.
However, only the experimental group received patient counseling. Cross-sectional data
including self-perceived health status, knowledge, attitudes and practices among kidney disease
patients and level of medication adherence, were collected from July to August 2018.
Results showed that there were 108 identified errors identified through medication
reconciliation. Majority of these Level 0 (No Harm) errors were due to unspecified dosage
form (51.85%). There appears to be a significant change in the dialysis patients’ quality of
life after pharmacist’s patient counselling and medication reconciliation as shown by higher
scores in the post test. The results of the study strongly suggest that patient counselling
and medication reconciliation may help improve kidney patients’ quality of life.

Keywords: CKD, medication reconciliation, patient counseling, health-related quality of life

Introduction

Chronic kidney disease (CKD) is currently considered a worldwide problem with 1 in 10 million
or about 500 million prevalence worldwide (Davids, 2007). CKD has already resulted in millions of
deaths, years of life lost, years lived with disability and disability-adjusted life-years. The growing CKD
problem was believed to be a consequence of the lack of access of the world population to adequate
healthcare and incomplete understanding of the pathogenesis of CKD (Martín-Cleary & Ortiz, 2014) in a
population that is aging coupled with steep increases in the incidence of type 2 diabetes mellitus and
hypertension. (Xiwei Zheng, Cong Bi, Marissa Brooks, 2015).

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 Chronic Kidney Disease refers to a progressive and irreversible loss of renal function. It is a
pathophysiologic process with multiple etiologies, resulting in the inexorable attrition of nephron
number and function, and frequently leading to end stage renal disease (ESRD). It has been suggested
that late diagnosis and lack of predialysis care are associated with poor quality of life (QOL), and
increase in morbidity and mortality during dialysis treatment. (Sharma et al., 2013). Chronic kidney
disease requires early detection and treatment to delay progression. When CKD progresses to kidney
failure, patients are provided with two treatment options, either through transplantation with live or
deceased donor kidneys or through dialysis; hemodialysis or peritoneal dialysis.

To date, the best treatment option for ESRD is kidney transplant. This requires the patient to
have a kidney donor match, undergo a major surgery and take a lifetime regimen of immunosuppressive
prescriptions to prevent organ rejection exchange for a five-year survival rate of over 80 percent but the
shortage of organ donors because of the growing number of ESRD patients makes it difficult to match.
The transplantation of the kidney is another problem. Immunosuppressants can have numerous side
effects including infections and cancers. Challenging the patients’ immune system might be the biggest
obstacle for the success of the kidney transplant.

Therefore, the only resort other than transplantation is dialysis. Hemodialysis is the most
common type of dialysis. A process wherein the patients’ blood is pumped in through a machine
where the wastes are removed and the blood is pumped back to the body. It is repeated two to three
times a week for about 3-5 hours. While it is effective in the short term, the downsides of
hemodialysis is that it is limiting and inconvenient having patients trussed in a machine for several
hours and in two to three times per week. In addition, dialysis increases the fatigue, morbidity and
mortality with a 35% of patients enduring dialysis after 5 years of treatment.

The cost for dialysis differs in every country. The United States for example has Medicare
coverage extended to any person who requires dialysis or transplant to continue to live.
Hemodialysis can cost an average of $89,000 per patient per annum in the United States with a
total annual cost of $42 billion. The average cost of kidney transplant is $57,000 for the transplant
surgery and per year post-surgery to care for the patient to ensure the successful organ
transplant. Medicare shoulders part of these costs while the remaining are either covered by
Medicaid, other private insurance or paid out of pocket (United States Renal Data System, 2013)

CKD often goes unnoticed and is frequently associated with numerous comorbidities
and consequences, which permits the myriad of injurious events related to care delivered or
care omitted because of undetected or untreated CKD (Fink & Chertow, 2009a).

In recent years, the number of Filipinos afflicted with kidney diseases has increased and
continues to do so exponentially. The National Kidney and Transplant Institute (NKTI) reported in 2016
that twenty percent of Filipinos were diagnosed with chronic kidney disease, based on the glomerular
filtration rate (GFR). Currently, the Philippine Department of Health (DOH) ranks kidney diseases as one
of the top ten leading causes of mortality in the country. The Philippine Renal Disease Registry (PRDR)
Annual Report stated that in 2015, 18,603 new patients started dialysis. Data in December 2015 showed
that there is a total of 32,077 patients on dialysis all over the country. NKTI estimated that there is at
least one Filipino who develops chronic renal failure every hour or about 120 Filipinos per million
population per year (NKTI,n.d.) Thus, this increasing trend in the number of kidney disease patients is a
significant cause of concern for public health care providers. Financially speaking, chronic kidney
disease not only affects the patient, it becomes a family’s problem as well.

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The cost of treatment for dialysis in the Philippines may pose a huge financial burden even with private
insurances, Philhealth and out-of-pocket expenses. A typical hemodialysis session costs 4,000 to 7,000
pesos per treatment depending on the facility. Food and transportation allowance, a dose of Epoetin
after dialysis and maintenance medications is excluded. These expenses are multiplied in two to three
days per week. On the other hand, a kidney operation would range from 600,000 to 1 million pesos not
including the maintenance medications to prevent organ rejection. In 2012, Philhealth announced that it
will be subsidizing the full cost of kidney transplant up to 600,000 pesos for ESRD patients qualifying to
their Z Package criteria. Additionally, Philhealth will continue helping its members by subsidizing 90
sessions of dialysis from its previous 45 sessions annually.

The Research Problem

Management of patients with kidney diseases, in particular, those undergoing dialysis, poses
many challenges to health practitioners because they often have existing co-morbidities and are taking
multiple medications which predisposes them to a higher risk of adverse events (Patricia and Foote,
2016). In addition, they also receive care from multiple practitioners which can also place them at risk
for medication discrepancies (Wilson et al., n.d.). Renal injury is a well-known risk factor for ADEs, but it
often remains unrecognized by physicians and pharmacists (Joosten et al., 2013). Besides, the kidneys
play a key role in the disposition of drugs used in hospitalized patients. Most of the drugs available in
the market are cleared or metabolized by the kidney. This is of noteworthy importance as these drugs
can be potentially nephrotoxic. The failure to recognize CKD in patients who encounter the health-care
system leaves them at risk for medication errors that can intensify the severity of their illness, extend
hospital stay, potentially hasten disease progression (Fink & Chertow, 2009b) as well as increase the
risk for adverse drug effects and result to greater costs of care (Berns, 2015).

Pharmacists, through medication reconciliation and patient counseling, are in the best position
to improve the level of care and health related quality of life of kidney disease patients (Thomas D et al.,
2009). It is the interest of this study to explore pharmacists’ potential interventions in the management
of out-patient dialysis patients through medication reconciliation and counseling.

Objectives of the Research

This study aims to determine pharmacists’ interventions in the management of

out-patient dialysis patients through medication reconciliation and counseling.
Specifically,
1. Identify the socio-demographic characteristics of the respondents.
2. Determine the number of medication discrepancies and medication errors
in ambulatory dialysis patients identified by medication reconciliation;
3. Identify the potential level of harm associated with medication
discrepancies in ambulatory dialysis patients that can be identified
through medication reconciliation
4. Identify the patient-related factors (demographics, illness perception, knowledge,
attitudes and practices in kidney disease and level of medication adherence) that
may possibly affect health related quality of life in dialysis patients.
5. Determine the baseline quality of life of ambulatory dialysis
patients before and after patient counseling
6. Compare the quality of life in patients who received pharmacists’ interventions
with those in the control group who did not receive the interventions.

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Background of the Study

Management of patients with kidney diseases poses many challenges to health practitioners
because they often have existing co-morbidities and are taking multiple medications which predisposes
them to a higher risk of adverse events (Patricia, N. and Foote, E., 2016). Pharmacists, through
medication reconciliation and patient counseling, are in the best position to improve the level of care
and health related quality of life of kidney disease patients (Thomas, D et al., 2009)

Review of Related Literature

Chronic Kidney Disease

Chronic Kidney Disease (CKD) is a debilitating disease often undetected, undertreated
and ignored. It is now addressed as a public health threat that grows rapidly resulting to poor
health outcomes and increased financial burden globally. In the past, the only available and
simplest solution to this fast deteriorating health condition is renal replacement therapy that is
used to replace the normal function of the kidney when it is subjected to damage. This includes
dialysis; a process where toxins and excess water are removed from the body and electrolytes are
balanced to maintain bodily functions and kidney transplantation; where the damaged kidneys
function is ultimately replaced by a new kidney from a donor.

Causes of CKD
The two main causes of chronic kidney disease are diabetes and hypertension,
which are responsible for most of the cases. Other cases are caused by genetic disorders,
inflammation and infection, and the use of drugs or substances that are toxic to the kidneys.

Prevalence
Kidney disease ranks number 8 in the top 10 causes of death in the Philippines from
2011-2013 which accounts in 2.8% of death jumping with a 0.02% increase from 2012. From
the reported 14,954 deaths, 52.4% comes from Luzon, 22.0% from Visayas and 25.6% in
Mindanao according to the Philippine Statistics Authority (PSA) Vital Statistics Report.

Pharmacoeconomic Burden of Disease

When it comes to the economical burden, patients with Chronic Kidney Disease are
filling their generous share of expenses from medications, dialysis fees and hospitalization
costs. In one study, a patient typically maintains average of 11-12 medications to be taken
religiously to be able to live a life as normal as possible (Patricia & Foote, 2016b). Besides the
challenge of continuing a handful of maintenance medications, the patients also bear the burden
of paying the costs for the dialysis that he needs to endure for the rest of his life.

In the Philippines, the cost of treatment is simply ‘exorbitant,’ and even

with Philhealth coverage, there is often out-of-pocket expenses for the patient
(“Philippines struggles with renal disease,” n.d.).

The Philippine Health Insurance Corporation (PhilHealth) today announced that

coverage for hemodialysis is now expanded from 45 to 90 sessions per year in order to help
lessen the financial burden of its members undergoing the said treatment (PhilHealth, 2015).

The kidney specialist said that chronic kidney disease (CKD) is a burden worldwide,
with costs more than breast, colon and lung cancers combined (Magtubo, 2017).

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Quality of Life (QoL)
According to Cho, 2013, Quality of Life (QoL) is a patients distinct sense of well-
being and functional outcome in five life extent including ones’ 1) physical status and
functional abilities, 2) psychological status and well-being, 3) social interaction, 4)
economic and/or vocational status, and 5) religious and/or spiritual status.

Health Related Quality of Life (HRQoL)

While QoL is a notion that encompasses all facets of human life, Health Related
Quality of Life (HRQoL) emphasizes the effects of disease and precisely on the impact of
treatment on QoL. HRQoL is an individuals’ perception and reaction to their health status
which include health related factors such as physical, functional, emotional, and mental
well-being and nonhealth-related aspects of their lives like job, family, friends, and other
situations in life. HRQoL is a comprehensive evaluation covering all significant aspects of
QoL related to health in a wider and positive approach (Lin et al., 2013).

Dialysis is equally life sustaining and altering. It drastically limits a patient in physical,
mental, financial and social aspects. Patients also lose the capability to work because of dialysis
and its accompanying symptoms. The daily routine of a dialysis patient revolves to lifestyle
modifications, management of symptoms, a handful of medications and diet/fluid restrictions that
greatly change the perception of health-related quality of life. The HRQoL score is used as an
outcome and predictor of hospitalization and death among patients with CKD on dialysis (Dori,
Schatell; Witten, 2008). Studies suggests that patients with ESRD survive for 7-10 days following
dialysis discontinuation (O ’connor et al., 2013) and life expectancy is certainly reduced with
patients with lower levels of kidney function (Chowdhury Turin et al., 2012).

Kidney Disease Quality of Life (KDQoL)

The measurement of HRQoL can be demanding and exhaustive because of its subjectivity.
The patients’ satisfaction and sensitivity about their condition and treatment is described by the
HRQoL. An example of this is the Short Form-36 (SF-36) that is a generic evaluate HRQoL. On the
other hand, generic instruments cover and produce score for all domains of QoL and skips essential
details like chief complaints and symptoms. Disease-specific instruments have been developed to
assess the elements of HRQoL for a specific disease. These instruments explore the domains which
are inadequately assessed by generic measures and are focused on concerns pertinent to the disease
and its treatment. The instrument distinctly evaluates the HRQoL and are likely more useful in
identifying treatment effects and responsiveness to change.

Medication Discrepancies

A medication discrepancy was defined as any difference among the information sources used
to complete the BPMH. Drug omission was defined as the patient taking a medication that was not
listed on at least one of the sources. Discrepant dose was defined as a difference in dose between the
sources of information. Discrepant frequency was defined as a difference in dose frequency between
the sources of information. An incorrect drug was defined as a medication prescribed for the patient
but not being taken or a drug that the patient was taking but should not have been. The level of harm
used in this study follows the Harm Associated with Medication Error Classification (HAMEC) tool.
Gates et al., 2019 developed this new tool provides a harm classification
for use across clinical and research settings to further understand the impact of
medication errors and in order to promote patient safety.
The impact of medication reconciliation demands the evaluation of achieving the desired
therapeutic goals, monitoring for DRPs and overdose, provide rational and proper use of medicines,
assess self-management (patient adherence), evaluate completeness of medication chart, compare,

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review and select the best possible treatment regimens to be included or included in therapy
after hospital discharge. Medication reconciliation is a resource exhaustive and thorough
practice with the intention of maximizing benefits for patient safety (Babu et al., 2017).

Medication Reconciliation for Kidney Patients

A number of studies support the value of medication reconciliation for kidney patients. A
retrospective cohort study was conducted by Wilson et al., 2017 involved patients initiating
hemodialysis who received ambulatory medication reconciliation in a hospital renal program over
the period July 2014 to July 2016. Ambulatory medication reconciliation was conducted 296 times
for a total of 147 hemodialysis patients. The mean number of discrepancies identified by this
study per patient was 1.31 (standard deviation 2.00). Overall, 30% of these discrepancies were
deemed to have the potential to cause moderate to severe patient discomfort or clinical
deterioration. Survey results indicated that community practitioners found ambulatory medication
reconciliation valuable for providing quality care to dialysis patients.

Another study by Ledger & Choma, 2008 evaluated the potential impact of medication
reconciliation and optimization in the ambulatory care setting at the time of patient transfer from
an in-centre dialysis unit to a satellite dialysis unit. The study finds that overall, 15 patients
(78.8%) had at least one unintended medication variance. The majority of unintended variances
(56%) were caused by the physician/nurse practitioner (NP) omitting an order for medication that
the patient was taking. In this small study, authors concluded that medication reconciliation was
effective at identifying and rectifying medication errors and optimizing pharmacotherapy at the
time of transfer from an in-centre hemodialysis to a satellite dialysis unit.

Babu et al., 2014 also conducted a study to evaluate the role of medication reconciliation in
renal failure patients and to observe the effect of medication alert card and patient counseling in
medication reconciliation. In control, Drug Related Problems (DRPs) were identified only by chart
review. In test group, one arm containing patients with DRPs were identified using medication
reconciliation alone and in second arm, patient counseling and medication alert card was used in
addition to reconciliation. Patient data were recorded on a standard template obtained from The
Manitoba Renal Program (Canada). DRPs were recorded. Knowledge was assessed with a
questionnaire before and after counseling and it was quantified. The authors discovered that more
number of DRPs was identified by means of medication reconciliation. Patient counseling and
medication alert card had a significant role in medication reconciliation. The study was statistically
significant with P<0.05. Thus, this study demonstrated that medication reconciliation in renal failure
helps to identify more number of drug related problems. Based on the study, patient counseling and
medication alert card have effectively improved the effect of reconciliation in renal failure patients and
thus could improve clinical outcomes and quality of life.

Patient Counseling
Patient counseling is a process that assists the patients and ensures proper use of
medications by providing relevant information and advice pertaining to a drug. The
information and recommendation is given by the pharmacist directly to the patient or to the
patient’s representative and may well also comprise of information about the patient’s
condition and suggested lifestyle modifications. Usual counseling includes the name and
dose of the medication, the explanation why it has been prescribed, or how it works, how to
take the medication, (dosage and frequency), expected length of treatment, expected
benefits of therapy, possible adverse effects, possible drug or food interactions, advice on
missed dose, storage and special monitoring condition or requirements (Babu et al., 2017).

Patient Counseling in Kidney Disease Patients

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 Literature supports the role that pharmacists counselling kidney disease patients offer benefits
in improving outcomes. Ghimirey et al., 2013 evaluated a total of 64 patients with chronic kidney disease
through a prospective, pre–post study. The knowledge, attitude, and practice of patients regarding
chronic kidney disease were assessed and recorded via baseline questionnaire. Case group patients
were counseled regarding chronic kidney disease, their medication, diet, and lifestyle, and they were
also provided with informative leaflet, whereas in the control group patients, the pharmacist did not
intervene. After 1-month intervention, knowledge, attitude, and practice scores of patients of both
groups were measured using the same knowledge, attitude, and practice questionnaire. Effectiveness of
counseling on case group patients was evaluated by comparing the mean knowledge, attitude, and
practice scores before and after counseling by paired t-test. Results of this study showed that mean
knowledge, attitude, and practice scores before intervention were 8.16 ± 4.378, 38.19 ±
3.217, and 6.69 ± 0.896, respectively, and these scores were changed to 13.75 ± 3.510,
38.78 ± 3.035, and 6.91 ± 0.777, respectively, after the intervention (p < 0.05). The authors
concluded that pharmacist-provided counseling is effective in improving knowledge,
attitude, and practice of patients toward the disease management.
A review of available literature was conducted by Salgado et al., 2012 by accessing Medline,
International Pharmaceutical Abstracts, Pharmacy Abstracts and the Cochrane Library to search for
quantitative studies addressing the contribution of pharmacists’ interventions in patients with chronic
kidney disease. Quality of controlled studies was assessed using the Downs and Black scale. The
review identified 37 studies (38 articles), involving 4743 participants, eligible for inclusion. An
uncontrolled design corresponded with 80% of the studies. Twenty-one articles (55.3%) reported
outcome measures and process indicators, 4 (10.5%) reported only outcome measures and 13 (34.2%)
reported only process indicators. Pharmacists identified 2683 drug-related problems in 1209 patients.
The results from eight controlled studies (average quality score 0.57, SD = 0.10) demonstrated that
pharmacists’ interventions reduced all-cause hospitalisations [mean (SD) 1.8 (2.4) versus 3.1 (3.0), P
= 0.02] and cumulative time hospitalised [mean (SD) 9.7 (14.7) versus 15.5 (16.3) days, P = 0.06], reduced
the incidence of end-stage renal disease or death in patients with diabetic nephropathy (14.8 versus
28.2 per 100 patient-years, adjusted relative risk 60%, P < 0.001), improved management of anemia
(mean 69.8 versus 43.9%, P = 0.0001 and 64.8 versus 40.4%, P = 0.043 patients on goal hemoglobin and
transferrin saturation, respectively), blood pressure [systolic mean (SD) 145.3 (16.8) versus 175.8 (33.9)
mmHg, P = 0.029; diastolic mean (SD) 77.0 (10.2) versus 91.8 (12.0) mmHg, P = 0.020], calcium and
phosphate parameters [serum phosphate levels mean (SD) 1.81 (0.54) versus 2.07 (0.25) mmol/L, P =
0.03; calcium-phosphate product mean (SD) 4.43 (1.20) versus 4.80 (0.51) mmol 2 /L 2 , P = 0.04] and
lipid management [total cholesterol mean (SD) 4.4 (1.1) versus 5.0 (1.4) mmol/L, P = 0.06; low density
lipoprotein cholesterol mean (SD) 2.3 (0.9) versus 2.8 (1.0) mmol/L, P
= 0.013]. Results from uncontrolled studies revealed positive impact of pharmacists’ interventions on
reduced number of transplant rejections [mean (SD) 0.22 (0.42) versus 0.50 (0.51) episodes, P =
0.008] and adverse events (49 in 16.0% patients versus 73 in 21.3% patients, P < 0.05).
The review concluded that the evidence of pharmacists’ interventions in patients with
chronic kidney disease is sparse, of variable quality and with heterogeneous outcomes.
On the basis of best available evidence, pharmacists’ interventions may have a positive
impact on outcomes of patients with chronic kidney disease.
A study similar to the current undertaking by Shareef et al., 2014 was conducted on 60 patients
undergoing hemodialysis categorized into intervention and control groups by block randomization
method. Patients in the intervention group received counseling verbally along with the information
leaflet, whereas the control group received the counseling only after the end of the study. The QoL of
patients was assessed by using WHOQOL-BREF questionnaire at the baseline and at final follow-up.
The study showed that there was a statistically significant difference in the mean domain score was
found between the groups (P < 0.001) on the last follow-up but not at the baseline (P > 0.05). In the
study among the four domains, improvement was seen in both psychological (P <
0.01) and physical health (P < 0.05) domain. The researchers concluded that education and counseling
by clinical pharmacist in patients undergoing hemodialysis leads to clinically and statistically

7
significant improvement in the QoL of hemodialysis patients in the intervention
group as compared to that of control group.

Pharmacists Role in Medication Reconciliation and Counseling in CKD Patients

Patients with ESRD and enduring dialysis are imperiled to polypharmacy and unreasonably
expensive health care costs compared with the rest of the population. These patients in particularly are
part of a vulnerable population where they have to take a number of medications with a high risk of
exposing them to medication related problems (MRPs) or drug related problems (DRPs).

The provision of medication reconciliation and management is essential to avoid the

staggering expenditures of medication-related problems and hospitalizations. Medication
Reconciliation and counselling is different from the traditional role of dispensing and
compounding since it implicates a comprehensive review and management of disease states. The
dialysis facility is a reasonable epicenter for these services for the reason that patients stay in the
center long enough for survival. A committed and adequately trained pharmacist is necessary to
provide consistent, excellent medication management services. These services could reliably and
thoroughly recognize and resolve medication-related problems that could lead to better outcomes
in patients with CKD and decrease overwhelming health care costs. (Pai et al., 2013) In the
general population of hospitalized patients, interventions consisting of medication reconciliation
by a pharmacist in conjunction with patient counseling have reduced rates of adverse drug
reactions, serious complications and readmissions (Alicic et al., 2016).

To ensure successful disease management and uphold the quality of life of patients
undergoing dialysis, sustained support is a topmost priority. Clinicians such as doctors and
nurses are involved in the routine care for dialysis patients but the management of this condition
often appears simple but is unbelievably demanding, that’s why most are unavailable in providing
patient instructions. The clinical pharmacists are experts in pharmacotherapy with their broad
knowledge in the pharmacokinetic and pharmacodynamic properties of drugs are fitting to be
patient educators and counselors of patients with CKD on dialysis. Pharmacists are critical in
narrowing the gap and linking clinicians and the patients. Patient counseling is an inclusive
approach in improving the quality of life of the patient while considering different phases of
treatment (Nagappa et al., 2013). Pharmacists are ideal members of the healthcare team to address
education and communication gaps between patients, providers, and healthcare systems that
contribute to MRPs and suboptimal medication adherence. Because CKD patients have numerous
comorbid conditions requiring many medications, their risk for such problems is particularly high.
Nephrology clinical pharmacists can assist in educating their primary care and community
pharmacy colleagues to include CKD assessment and management as an integral part of
community-based MTM programs to aid in preventing and halting progression of CKD.

Research Methodology

Study Design
This study approach is a randomized quasi-experimental non-equivalent (pretest and
posttest) control group design exploring patient counseling among CKD patients
undergoing dialysis. This is the most appropriate research design for the purpose of
determining the effect of patient counselling in hemodialysis patients in this study. In this
design, the experimental Group A and control Group B was selected with random
assignment. Both groups took a pretest and posttest survey on health-related quality of life.
However, only the experimental group will receive patient counseling (Creswell, 2014).

For the medication reconciliation, all patients who agreed to take part in the
study were included for a comprehensive medication review of their charts.

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 This is an exploratory study since this is the first time that these pharmacy intervention
programs will be implemented in the study setting. Cross-sectional data was collected in the
course of six weeks from July to August 2019. Patients from NephroCare DLSU in De La Salle
University Medical Center undergoing hemodialysis were included in the study.

Study Setting
This study was conducted in NephroCare DLSU located at the 3 rd floor of the Medical Arts
Center of De La Salle University Medical Center in Dasmariñas. NephroCare is the service brand of
Fresenius Medical Care that provides outpatient services for hemodialysis. NephroCare DLSU has
been providing dialysis in cooperation with De La Salle University Medical Center for fifteen years.
It is composed of seven in-house supervising physician, thirty five highly skilled nurses, two
technicians and six administrative staff serving 250 patients monthly.

Data Collection
To ensure quality and consistency of data, the researcher trained three
pharmacists who were also employed in DLSUMC to assist in the administration of
the questionnaires and in medication reconciliation review.
Retrospective chart review was conducted to determine the number of medication
discrepancies and medication errors in ambulatory dialysis patients. Through medication
reconciliation, the researcher and the trained pharmacists identified the medication
discrepancies and categorized the type and level of potential harm of errors.
Patient demographics were obtained through the survey instrument to identify the patient-
related factors that may possibly affect health-related quality of life of the respondents.

To determine the patient-related factors that may affect health-related quality

of life, the Brief Illness perception questionnaire and the Knowledge, Attitudes and
Practices of patients with kidney diseases was administered.
To determine the baseline quality of life of the respondents, a standardized
questionnaire, the Kidney Disease and Quality of Life-36 (KDQOL-36) was adopted. Pilot
testing of the survey instrument was conducted on 20 patients who were not included
as respondents to determine the duration of administration and clarity of the questions.

Effects of Patient Counselling

The patient demographics on age, gender, occupation, religion, marital

status, level of education, socioeconomic status through average family monthly
income and duration of hemodialysis and other present medical history will be
determined. To test whether patient counselling affects the health-related quality of
life, the respondents were randomly assigned into two groups as follows:
Group A (intervention group) – received patient counselling by a
pharmacist using a structured standardized tool
Group B (control group) – did not receive patient counselling intervention by a pharmacist.
Both Group A and Group B answered the pretest and posttest survey on health-related quality
of life. This is an interviewer-assisted administration of the survey instrument to
further explain and answer clarifications that may be raised by the respondents.
Only completed questionnaires were considered eligible for data analysis.
Upon giving consent, the patient was asked to answer the health-related quality of life
questionnaire followed by a patient counselling session with a pharmacist. The patient counselling
intervention was conducted using the Indian Health Service (IHS) style counseling method that
measures the patients understanding of their medicine(s) with the use of three open-ended questions
regarding the purpose, dose/administration and outcomes (Volino & Das, 2014). The counseling
lasted for no more than 10 minutes. The post-test health related quality of life questionnaire was
administered to the respondents upon their visit on 5th to 6th week of the study period.

Profile of Pharmacists who conducted Patient Counselling

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 To ensure that a satisfactory, thorough, comprehensive and accurate patient counselling was
conducted, three senior hospital pharmacists were recruited to administer counselling to the patients.
One was a male pharmacist aged 24 years old who had been serving the hospital for three years and
had received previous training in patient counselling. The two others were both female, one was 24
years old, the other was 25 years old. Both had served in the hospital pharmacy rendering services to
chronic kidney disease patients for two and four years. They conducted the patient counseling after
duty hours beginning at 2:30 PM. The pharmacists used a counseling guide specific for chronic kidney
disease patients. This counselling guide is attached in Appendix K. Counselling was further validated
by the hospital senior pharmacist, CKD nurse and nephrologist who made random observations.
Feedback was also recorded and noted by the researcher.

Effects of Medication Reconciliation

For the medication reconciliation, both respondents in Group A and B were

included for a medication chart review. The medication reconciliation tool used was
adopted from the instrument of Wilson et al., 2017. Upon obtaining the BPMH, a
pharmacist classified the type of medication discrepancy and further categorized
by the potential level of harm or clinical impact described by the HAMEC Tool.

Study Participants
Inclusion
Registered out-patients in NephroCare Dialysis center in DLSU Medical Center Patients were
included in the study. They were considered eligible for inclusion if they meet the following criteria:

1. Filipino out-patients in NephroCare Dialysis center in DLSU Medical

Center who have been receiving hemodialysis from a minimum of three
months up to the study period of August 2019;
2. Male or female patients aged 18 and above;
3. Those diagnosed with Stage 3 to Stage 5 Chronic Kidney Disease (Stage
5 CKD or End Stage Renal Disease);
4. Able to communicate in written and verbal forms of communication

1. Have discontinued with hemodialysis;

2. Are diagnosed with HIV or hepatitis infections;
3. Have acute renal failure;

Sample Size Computation

Recent data (2017) showed that the dialysis center serves an average of 250 patients per
week. Given this population, a sample size of 131 respondents is computed based on a 5%
acceptable margin of error, 90% confidence level and approximate response distribution of 50%.
Sample size was computed using Raosoft sample size calculator. The equation is given by:

x = Z(c/100)2r(100-r)
Nx 2
n = /((N-1)E + x)

E =Sqrt[(N - n)x/n(N-1)]
Where n = sample size, E = margin of Error, N = population size, r=
fraction of responses, and Z (c/100) = critical value for confidence level.

10
Ethical Consideration
Ethical clearance was sought from the Ethics Review Board of the
Philippine Womens’ University.
To ensure protection of the subjects, the respondents were informed of their voluntary
participation at the start of the interview. They were also advised that they may wish to withdraw
their participation at any time. Upon the respondent’s expression of their willingness to
participate, they were asked to sign a formal written consent form. Each participant received a
copy of this consent form. The researcher and the interviewers briefed the subjects about the
objectives, purposes and procedures in the study. They were informed that all the information
which will be gathered in this study will be reported as group data and there would be no way to
individually identify them based on their answers in the interview questions. They were assured
that there were no right or wrong answers to the interview questions and that these questions
were formulated only to elicit data. They were notified that they may choose not to indicate their
names if they wish to maintain anonymity. Subjects were provided with the researcher’s contact
numbers so they can call or send messages if they had any further questions.

To further ensure confidentiality, all signed copies of the consent form and the
questionnaires were stored in a locked file in the researcher’s home. Raw data was
stored in an Excel file with a password protected data storage device. Data was coded
to further ensure confidentiality. Following the acceptance of the completed paper, the
raw data, transcripts, consent form and copies of the instrument will be shredded and
destroyed after three years to protect the participants’ identifications as recommended
by the protocol of Data Retention by the US Department of Health and Human Services.

Study Instruments
To determine the health-related quality of life of hemodialysis patients, the Kidney Disease and
Quality of Life-36 (KDQOL-36) was used. This instrument is a standardized questionnaire developed by
RAND and the University of Arizona. The Kidney Disease Quality of Life (KDQOL™) is a self-reported
questionnaire that combines the generic SF-36 Health Survey instrument and disease-specific
components for assessing the health-related quality of life of chronic kidney disease patients (Chow et
al., 2014). The KDQOL-36 is a 36-item health-related quality of life instrument adapted from the original
134-item KDQOL, an instrument principally developed to measure quality of life of dialysis patients. The
KDQOL-36™ combines generic domains with disease-specific domains. The disease-specific core has
24 items comprising three scales: Symptoms and Problems (12 items), Burden of Kidney Disease (4
items), and Effects of Kidney Disease (8 items). The items of the three subscales are embedded in the
KDQOL-SF™. The generic core is the 12-item Short Form Health Survey (SF-12). The results of the SF-12
instrument are summarized into the Physical Component Summary (PCS) score and the Mental
Component Summary (MCS) score. The raw scores were transformed linearly to a range of 0 to 100, with
higher scores indicating better HRQOL. The scale was adopted from RAND Corporation and was
translated to Filipino according to the basic guidelines and specifications on using forward and back
translation (see: [Link] (Chow et al., 2014).
This instrument was used and adopted for the study respondents. KDQOL-36 subscale scores ranged
from 0 to 100, and lower scores indicated worse self-reported quality of life. These subscale scores were
categorized into quintiles (first quintile = lowest scores, fifth quintile = highest scores).

To determine knowledge, attitudes, and practices associated with kidney disease, a translated
KAP Survey Instrument was used. In the first domain, items were constructed to test knowledge of the
etiology, diagnosis, symptoms and outcomes of kidney disease and were measured on a four-point
categorical response scale (‘Yes’, ‘No’, ‘Do Not Know’ and ‘Unsure’). In the second domain, items were
constructed to test attitudes related to kidney disease, and they were measured on a dichotomous
response scale (‘Yes’ and ‘No’). In the third domain, items were constructed to test hypothetical
practices associated with a diagnosis of kidney disease, and they were measured on a four-point Likert-
based scale (‘Very Unlikely’, ‘Unlikely’, ‘Likely’ and ‘Very Likely’). The relationship

11
between the items and their respective constructs (i.e. knowledge, attitudes or practices) was
represented by a casual indicator model because the items collectively determined the construct.
To determine adherence, the 4 – item Morisky Green Levine Medication Adherence Scale
was used. The original 4-item scale is referred to in literature as the "Medication Assessment
Questionnaire" (MGL MAQ) developed and applied in baseline and post-intervention interviews
with patients in the Johns Hopkins studies of hypertension control. The MGL MAQ is in the public
domain and is widely cited in peer-reviewed journals. Items in the scale address barriers to
medication-taking and permit the health care provider to reinforce positive adherence behaviors.
To ensure the reliability of the translated questionnaire, test for internal consistency was
conducted where a Cronbach alpha of 0.7 ≤ α < 0.8 is considered acceptable. Upon computation of the
Cronbach apha for the adopted and translated questionnaires, the following result was obtained:

Average interitem correlation: 0.0537

Number of items in the scale: 34
Scale reliability coefficient: 0.7587

Given the scale reliability coefficient of 0.7587, the internal consistency of

the questionnaire is acceptable.
Validity of the constructs used in the study was tested with three external validators
who were considered experts in the field. These experts were a sample patient not included
in the study, a nephrologist, a nurse in the dialysis center and a pharmacist. Their inputs
were triangulated and incorporated in the revision of the draft questionnaire.

Results

After conducting the study, the following results were obtained:

1. Among the 131 participants who completed the KDQOL-36 pre-test and
post-test, the mean age was 53 years, 70 were men (54.2%), 57 (43.5%)
were unemployed, 111 (84.7%) had Philhealth only as their insurance,
and 46 (35.1%) finished a college degree. Majority of the respondents
(37.4%) reported that high blood pressure is the cause of their kidney
disease. Diabetes is also one of the co-morbidities identified (34.4%).
2. Patient charts and prescriptions of enrolled respondents were
reviewed from July to August 2019. Upon medication
reconciliation, there were 108 identified errors. Majority of the
errors were due to unspecified dosage form (51.85%).
3. Using the Harm Associated Medication Errors Classification (HAMEC) tool,
98.15% of the enrolled patients showed Level 0-No harm associated with
medication error. There was no significant difference in the quality of life of
kidney patients in terms of the number of medications being taken, length of
patient admission in the hospital, number of days of clinic consultation, self-
perceived health status and level of medication adherence. But there was a
significant difference in the quality of life of kidney patients in terms of age.
4. The respondents believed that high blood pressure (79.4%) and diabetes
(87.0%) can cause kidney disease. Also, 98.5% reported that kidney disease can
only be diagnosed by a test at the hospital. Overall, participants are willing to
seek help from different sources for kidney disease. Majority responded that
they were very likely to seek care at a hospital or health clinic (98.5%) and were
very unlikely to have self-treatment at home (96.9%).
5. There appears to be a significant change in the dialysis patients’ quality of
life after pharmacist’s patient counselling as shown by higher scores in the
12
 posttest. This may indicate that patient counselling may help
improve kidney patients’ quality of life.
6. Lastly, there is a significant difference between the quality of life
of the patients who received pharmacists’ intervention through
medication counseling and those who have not.
Discussion

Demographics
Between July to September 2020, 131 patients were enrolled. Among the 131 participants
who completed the KDQOL-36 pre-test and post-test, the mean age was 53 years, 70 were men
(54.2%), 57 (43.5%) were unemployed, 111 (84.7%) had Philhealth only as their insurance, and 46
(35.1%) finished a college degree.

Majority of the respondents (37.4%) reported that high blood pressure is the
cause of their kidney disease. Diabetes is also one of the co-morbidities identified
(34.4%). Only 5.3% of the respondents did not know the etiology of their kidney disease.

Similar with the previous study of (Hecking et al., 2014), more men than women are
on dialysis. Employment was low among patients starting dialysis and some patients
stopped working during dialysis initiation (Erickson et al., 2018). Also, people who attained
lower education levels are vulnerable to chronic kidney disease (Thio et al., 2018).

Number and Type of Medication Discrepancies and Medication Errors Identified

by Medication Reconciliation

Patient charts and prescriptions of enrolled respondents were reviewed from July to
August 2019. Upon medication reconciliation, there were 108 identified errors. Majority of
the errors were due to unspecified dosage form (50.93%) which can be considered as
prescription errors. Two errors were associated with no dose specified (1.85%).

According to Velo and Minuz 2009, prescription errors are the most common problem
among medication errors. Although they are rarely fatal they can affect patients’ safety and
quality of healthcare. Prescription errors may be due to the use of traditional paper-based
prescription writing that relates to errors caused by illegible hand writing (Gharekhani et al., 2014)
since the process of drug prescription and administration most hospitals worldwide is still based
on handwritten medical chart entries (Hartel et al., 2011). Potentially harmful prescription errors
may arise due to the incompleteness and omission of units of the drug dosages (Kumar, 2015).

Potential Level of Harm Associated with Medication Discrepancies and Medication

Errors Identified by Medication Reconciliation

Using the Harm Associated Medication Errors Classification (HAMEC) tool, 98.15% of the
enrolled patients showed Level 0-No harm associated with medication error. However, there were
two patients’ charts showed Level 1-Minor Harm due to wrong dose (3.70%). One patient was
ordered with Clonidine 150 mg tablet instead of the appropriate dose of 150 mcg. However, the
order was not processed since there was no existing formulation for Clonidine 150 mg tablet. The
other patient was prescribed with an anti-hypertensive combination of Telmisartan+Amlodipine
40mg tablet instead of Telmisartan+Amlodipine 40mg/5mg tablet. The medication might be
mistaken for another common anti-hypertensive, Telmisartan. This might be confusing to the
pharmacists’ and drugstores personnels as there are several brands available.

Campbell and Karnon 2007 believes that medication error is a foremost

cause of avoidable harm suffered by patients. These errors are common and most
of it are deemed to have no potential to cause harm but some may cause moderate
or severe discomfort or clinical deterioration (Cornish et al., 2005).
13
Patient-related Factors Affecting Health-related Quality of Life in
Dialysis Patients Demographics

Patient-related factors including demographics, illness perception, knowledge,

attitudes and practices in kidney disease and levels of medication adherence were studied
to determine their relationship with the patients’ quality of life. For the demographics, a
survey instrument was utilized to determine the personal data of the patients. These data
were then tested for its association with the patients’ quality of life.

Results from the Pearson correlation showed inverse relationship between the
number of medications currently taken and the patients’ quality of life. Thus it appeared that
as the patients increase the number of medications they are currently taking, the lower will
their scores be in terms of quality of life. However, the results for both pre-test and post-test
showed that the inverse relationship is not statistically significant (p>0.05).

Montiel-Luque et al. 2017 suggests that using larger number of medications

can be associated with a worse quality of life. A recent cohort study concludes that
polypharmacy was connected with higher symptom burden and a poor quality of life
in adults with life-limiting illness (Schenker et al., 2019).

Results from the Pearson correlation showed direct relationship between the
patients’ number of days of admission in the hospital and the patients’ quality of
life. This indicates that the longer the patients stay in the hospital, the higher will
their scores be in terms of quality of life. However, the results for both pre-test and
post-test showed that the direct relationship is not statistically significant (p>0.05).

According to St. Peter 2010, dialysis patients are known to be frequently

hospitalized and on an average, a dialysis patient go through 4 transitions of care per
year, apart from visits made to the emergency room or skilled nursing facility stays. In a
study by Nafteux et al. 2013, there is a clear decline of the HRQL that can be seen in 3
months after the surgery for patients who had to stay in the hospital for >10 days.

Pearson’s correlation showed that lesser number of days for clinic consultation, the higher the
patients’ quality of life is. However, this relationship is not statistically significant (p>0.05)

In another study by Kim et al. 2014, lesser doctor visits is associated with higher life
satisfaction. Fischer et al. 2009 suggests that life satisfaction is positively associated with
health-related quality fo life. Kazemi karyani et al. 2019 also noted that there are strong
associations between chronic diseases, health related quality of life and life satisfaction.

Pearson’s correlation showed inverse relationship indicating that as age decreases,

the higher their quality of life is. This relationship is statistically significant (p>0.05).

These results support the study of Wu et al. 2013 where the researchers found out that
older people appear to have lower age-specific quality of life scores. This is in contrast with the
study of Zaninotto, Falaschetti, and Sacker 2009 which points out that quality of life at baseline
was poorer for older than younger respondents. QoL also declined more rapidly for older
individuals. Gender, education, depression, limiting long-standing illness, difficulty with ADL-s,
lack of wealth, non-employment, decreased number of friends and low positive support had a
negative impact on QoL. Another study by Cotts, Malviya, and Goldberg 2012 revealed a modest
negative correlation of some measures of QOL and health status with increasing age. According
to them, as age increases, so is the potential for worsening QOL and health status.

Self-perceived Health Status through the Brief Illness Perception Questionnaire

14
 From the conceptual framework of the study, it was identified that illness
perception, knowledge, attitudes and practices and level of medication adherence
among patients with kidney disease may affect health-related quality of life.

To determine the self-perceived health status of the patients, the standardized

Brief Illness Perception Questionnaire (BIPQ) was used and adopted for the study
setting. This questionnaire utilizes a 10-point scale in assessing the perception of the
severity of the disease where 0-no affect at all and 10-severely affect.

The brief illness perception questionnaire has 8 scales representing 1)

consequences, 2) timeline, 3) personal control, 4) treatment control, 5) identity, 6) concern,
7) understanding and 8) emotional response. From among these scales, respondents
ranked timeline as highest (mean=9.244), indicating that they felt that their condition will
continue for a long period of time. The identity scale ranked lowest (mean=5.084), indicating
the median scale in terms of the extent of symptoms they have experienced.

None of the eight scales in the BIPQ showed correlation with the respondents’ pre-and
post-test scores on the Quality of Life (p>0.05) as tested through Kruskal-Wallis rank test. This
may indicate that self-perceived health status is not correlated with the patient’s quality of life.

Pino et al. 2014, also associated activity status with self-perceived health status, but
not with QoL. In this study, activities for adults must be established in order to maintain and
improve their health. Sawatzky 2008, assessed that perceived mental and physical health
status and the dimensions of life satisfaction are factors contributing to global QOL.

Level of Adherence using Morisky – Green – Levine Medication Adherence Questionnaire

Morisky – Green – Levine Medicaition Adherence Questionnaire was used

to measure the level of adherence of the respondents. Patients from Group A had
higher adherence to therapy 94% compared to Group B who only had 24.6%.

A Spearman’s correlation was run to assess the relationship between the

level of adherence and quality of life. The correlation between level of adherence
and quality of life was not statistically significant, r s = 0.0315, p = .7209.

Numerous studies were made to determine the correlation between adherence

to medication and quality of life. Khayyat et al. 2019 found an association between
medication adherence and QoL in patients with diabetes and hypertension. A study by
Ahmad, Othaman, and Islahudin 2013, revealed that the willingness of epileptic
patients to adhere to medication therapy has a major impact on their quality of life.

The study results support the findings of Hamedi-Shahraki et al. 2019, where patient
adherence to treatment was also observed to improve the patients quality of life. The adherence of
dialysis patients suggests that the higher one’s compliance with treatment regimen, the greater
the quality of life (Rahdar et al. 2019). Another study by Maciel, Pimenta, and Caldeira 2016 relates
that there is a feeble connection between quality of life and medication adherence in hypertensive
patients. The authors emphasized the notion that quality of life maybe linked to other factors,
suggesting further research. Comparable with the findings of Kastien-Hilka et al. 2017, where
HRQol in TB patients is not only limited by adherence but also by other different factors affecting
HRQoL. Furthermore, a study with patients with COPD shows a similar finding with this study
where an association of adherence and HRQoL was not found Boland et al. 2016.

Knowledge, attitude and practices on Kidney Disease using KAP Survey

Knowledge
15
 The respondents believed that high blood pressure (79.4%) and diabetes
(87.0%) can cause kidney disease. Also, 98.5% reported that kidney disease can only
be diagnosed by a test at the hospital.
Knowledge on the disease remains a vital key in the progression of the disease. One
study by Gray et al. 2016 have shown that there is poor knowledge and understanding or kidney
disease. A limited participant understanding about CKD risk factors showed 38.8% of the
participants correctly identified hypertension as a risk factor for CKD (Gheewala et al. 2018). In
comparison to another study by Oluyombo et al. 2016, patients positively identified several risk
factors and their association to CKD like hypertension (43.6%), diabetes (38.3%) and family
history of CKD. In the Philippines, a study by Danguilan et al. 2013 found out that less 34%% of
the patients had no knowledge about kidney disease while 8% claimed that they are
knowledgeable about kidney disease when the perceived knowledge was measured. In the actual
measurement of knowledge of CKD, also revealed that 90% of the respondents scored <60%
while the respondents who claimed to be very knowledgeable about CKD had the same score.

Attitude
Participants showed a strong interest in learning more about kidney disease and are as well
concerned about their health, work and cost of therapy. Almost of the participants would like to learn
more about kidney disease. 79.4% were worried about their future. Less than a quarter worries about
their reputation in the community (15.3%) and 61.8% were troubled about their ability to work. 77.1 %
worries about their survival and everybody agrees that cost of kidney disease would be a problem.

The patients’ attitude toward their disease is also of notable importance. In a study by Yusoff et
al. 2016, patients are also eager to learn more information about kidney disease provided by doctors
and nurses. Hypertensive patients in a study identified that about 20% of the respondents were very
likely to develop CKD and 33% were very concerned about developing CKD (Boulware et al., 2009).

Meanwhile, the cost of therapy is another indispensable topic among patients undergoing
dialysis. Although there is limited knowledge about the cost of dialysis in low and middle-income
countries there is a clear indication that the costs are beyond the capability of the average individual to
pay for these services (Mushi, Marschall, and Fleβa 2015). In the Philippines, where the incidence of
ESRD and hemodialysis facilities have been thriving, RRT is categorized as a high-cost treatment for
ESRD. Most patients cannot afford access to the treatment (Teerawattananon et al., 2016).The
government health insurance recently included RRT in their benefit package, though in practice, there is
a limited coverage of 90 sessions annually (Garcia 2019).

Practices
Overall, participants are willing to seek help from different sources for kidney disease.
Majority responded that they were very likely to seek care at a hospital or health clinic (98.5%)
and were very unlikely to have self-treatment at home (96.9%). A small portion would still want
to seek care from traditional healers (3.8%) and use herbal or natural medications (6.1%).

In a similar study by Danguilan et al. 2013, the majority (91%) had previously consulted a
physician. Stanifer et al. 2016 suggested that participants are willing to seek help in hospitals
and clinics but still a few would seek consult from traditional healers and use herbal medicines.
Jha 2010 said that the use of herbal remedies is common in large parts of the developing world,
especially amongst the rural population. Jo et al. 2017 reported that patients with chronic
diseases had a marked preference for private and/ or traditional healers as first line of contact.

Kidney Disease Quality of Life (KDQoL) of Patients before and after Patient Counseling
The respondents for experimental Group A and control Group B were selected with
random assignment. Both groups completed a pretest and posttest survey on health-
related quality of life. However, only the experimental group received patient counseling.
16
Table 1. Summary of Scores for KDQoL

Mean
Mean N t df p-value
Difference

Quality of PreTest 65.162 131

Life -2.02 -2.35 130 .020
PostTest 67.183 131

The table shows the difference in the quality of life of ambulatory dialysis patients
before and after patient counseling. The average pre-test score is 65.162, while the average
post-test score is 67.183. With a p-value of 0.020, the average difference between pre-test
and post-test of -2.02 is significant. Thus there appears to be a significant change in the
dialysis patients’ quality of life after pharmacist’s patient counselling.

Other studies further validated the positive effects of patient counselling on patient
outcomes. Vigneshwaran 2013 suggested that among patients with HIV/AIDS, the provision of
patient education and counseling by pharmacists’ may help maintain and improve the quality of
life and medication adherence even if there is a limitation within the resources. In a related study
involving dialysis patients as respondents, Thomas D et al. 2009 also noted that there was a
notable impact of patient counseling for six months. In comparison of the declining or constant
QoL of the control group, the test group exhibited an improvement in their QoL.

Kidney Disease Quality of Life (KDQoL) of Patients with Pharmacists

Interventions and those Without Pharmacists Interventions

Table 2. Difference in the Quality of Life of Respondents with and without interventions

Mean Mann-
N p-value
Rank Whitney U

Quality of Life With interventions 66 78.81

1299.5 .000
Without
65 52.99
interventions

Table shows the difference in the quality of life of the respondents who have received
pharmacists’ intervention and those who have not received pharmacists’ intervention. The
mean score for the kidney disease quality of life for the group of patients with pharmacists’
interventions (78.81) is higher than those without interventions (52.99). Since the p-value is
less than the level of significance, 0.05, there is a significant difference between the quality
of life of the patients who received pharmacists’ intervention and those who have not.

The finding of this study is similar to the findings of another study that measured the
impact of pharmacists’ counseling on the quality of life of patients undergoing dialysis in a
tertiary hospital. Shareef, S, and Baikunje 2014 observed a clinically significant improvement in
the QoL among the patients who received pharmacist education and counseling versus the
control group. This has led to the recommendation of a regular and periodic counseling by a
clinical pharmacist to make a positive impact on improving the QoL.
17
Conclusion

The results of the study showed that patient counselling and pharmacists’
intervention through medication counseling may offer benefits to kidney patients
undergoing dialysis in terms of improvement of their health-related quality of life.

Recommendation and Future Works

In the light of the above findings and conclusions, the following

recommendations are hereby presented:

1. Given that the study was conducted only in a single setting, it is encouraged that
further follow-up studies be conducted in other clinical settings to support the
findings that pharmacists’ interventions like patient counseling and medication
reconciliation can help improve the quality of life of dialysis patients.
2. Given that participants are willing to seek help from different sources for kidney
disease, pharmacists involved in the care of dialysis patients must take a
proactive role in educating patients about their condition and medications.
3. This study showed that pharmacist’ interventions such as patient counseling and
medication reconciliation can significantly and positively improve dialysis
patients’ quality of life. Therefore, dialysis centers may consider including the
pharmacists in the patient care management team to improve patient outcomes.

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