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Americans Skip Dialysis; Swedes and Japanese Don't, Study Shows

American dialysis patients are far more likely to skip kidney dialysis treatments than patients in either Sweden or Japan, a Wake Forest University Baptist Medical Center physician reports in the April 7 issue of the Journal of the American Medical Association.

Anthony J. Bleyer, M.D., assistant professor of internal medicine (nephrology) said that Swedes and Japanese almost never miss a dialysis treatment. That''s not true in the United States, despite specific physician instructions.

"Even an occasional missed treatment places the patient as a much higher risk of life-threatening conditions," Bleyer said. "We have long seen a big difference in survival between the United States and other countries. A difference in compliance could contribute to this.

"There is a high rate of noncompliance for U.S. patients in general. We decided to study noncompliance in dialysis patients because it is likely to affect patient survival and could explain inferior U.S. dialysis patient survival compared to other countries."

In the first half of 1996, Bleyer and colleagues in Sweden and Japan compared a total of 415 patients at four southeastern United States dialysis centers with 84 patients at one Swedish center and 194 patients at four dialysis centers in Japan. Not one Swede or Japanese patient missed a single dialysis session, while 147 American patients missed at least one treatment, and seven missed at least 25 treatments. (All patients underwent a type of dialysis called hemodialysis.)

The difference in the initial observational study was so large that the investigators decided to conduct a cross-sectional survey of compliance, asking nurses and nephrologists in every state, as well as at 21 centers in Japan and 16 centers in Sweden.

In the United States, an average of 4 percent of patients in the cross-sectional study missed at least one treatment each month, compared with 0.1 percent in Sweden and 0 in Japan.

"The results of this study demonstrate a markedly increased incidence of skipping dialysis treatments in United States patients compared to patients from Sweden and Japan," Bleyer said. While data collection and health care delivery might vary among the countries, "the consistency of this finding, as well as the large magnitude of this difference, suggest there is a true international variation in patient compliance."

Why?

Bleyer and his colleagues suggested several reasons

:• "Differences in the way dialysis is prescribed in the United States may make treatments less comfortable for patients, resulting in ... increased absenteeism," they said. For instance, treatments are shorter, with higher blood flow, which may lead to cramping and very low blood pressure.

• U.S. dialysis patients are likely to be sicker than patients in other countries. Such sicknes leads to weakness and depression, which may increase noncompliance.

• Large differences exist between medical systems about who is eligible for dialysis. For example, a noncompliant patient addicted to illicit drugs may be more likely to be accepted on dialysis treatment in the United States than in other countries.

• Compliance for U.S. patients in general is likely to be low, due to increased independence, increased patient autonomy and increased suspicion of health care providers.

"Americans by nature are very independent and this may make them less likely to follow doctors'' instructions," he said. "These international differences in compliance could be responsible for international differences in infant morality and low vaccination rates."

Bleyer worked on the study with Britta Hylander, M.D. of the section on nephrology at Karolinska Hospital in Stockholm, Hiroshi Sudo, M.D., and Yasuo Nomoto M.D., of Tokai University School of Medicine in Isehara City, Japan, and three colleagues at Wake Forest — Ernesto de la Torre, M.D., Randolph A. Chen, M.D., and John M. Burkart, M.D.

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