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CUAJ – Original Research Bos et al Patient compliance with stone practices Compliance of the recurrent renal stone former with current best practice guidelines

Introduction: Patient compliance to best practice guidelines is a significant factor in preventing renal stone recurrence. While patient compliance has been historically poor, there remains a paucity of data in the renal stone setting. We evaluated compliance of the recurrent renal stone former with current Canadian Urological Association (CUA) best practice guidelines. Methods: A prospective, cross-sectional study design was used to evaluate patient compliance. Recurrent renal stone former patients were consecutively recruited from McMaster’s Institute of Urology and completed a one-time questionnaire developed in accordance with CUA best practice guidelines. Questionnaire sections included: 1) demographics; 2) interaction(s) and satisfaction with their healthcare provider; and 3) knowledge, attitudes, and compliance with best practices. Results: A total of 300 patients were enrolled in the study; 55.3% were men, 69.5% had a history of stone surgery, while 23.7% had a positive family history. Participants perceived satisfactory education from their urologist and primary care physician 82.7% and 59.7% of the time, respectively (p<0.05). Nearly a quarter of patients (22.8%) perceived their stone disease to be severe and 67.1% of patients believed in the efficacy of preventative stone measures. Overall, 45.8% of patients were compliant with CUA best practice guidelines. The majority of patients (72.6%) complied with high fluid intake, the most critical stone preventative practice. Conclusions: Consistent with previous studies, compliance to dietary recommendations in this evaluation of recurrent stone formers was low. Study findings may be attributed to insufficient knowledge translation, lack of perceived disease severity, and/or patient uncertainty in the importance of preventative stone practices. CUAJ – Original Research Bos et al Patient compliance with stone practices Introduction The increasing prevalence of nephrolithiasis is well recognized worldwide. Renal stone recurrence occurs in up to 50% of patients within the first five years following initial stone development. Moreover, relapses occur more frequently and the time interval between each recurrence is shortened. Fortunately, stone clinics have shown that patients can reduce their five-year recurrence rate by as much as 60% with changes in lifestyle and dietary habits alone. Similar to many chronic medical conditions, these preventative practices are dependent on patient self-awareness, motivation, and ultimately, compliance. The recurrent nature of the disease often results in significant patient morbidity and burdensome healthcare expenditures. In the United States alone, the total cost associated with nephrolithiasis has been estimated to be as high as $5.3 billion. This estimation not only includes the treatment of acute consequences of nephrolithiasis, such as pain, surgery, and hospitalization, but also the indirect costs such as loss of employment. Economic considerations related to stone disease are known to have a considerable impact on overall healthcare expenses. Patient compliance has often been a challenge in the prevention and treatment of any chronic disease. It is estimated that as many as 75% of patients consistently fail to follow their clinicians’ recommendations when it pertains to preventative health practices. Compliance rates across disease processes vary considerably, and have even shown to be poor for treatments that are deemed highly effective. Currently, there is a paucity of literature defining patient compliance to conservative treatment measures within the recurrent renal stone former population. Our study aimed to address this knowledge gap in the urological literature. The study objective was to evaluate the recurrent stone formers’ compliance with current Canadian Urological Association (CUA) best practice guidelines, while gaining insight into patients’ understanding of preventative practices and the education they receive from healthcare providers. Methods In a single-group, prospective cross-sectional survey study, renal stone patients seen at the McMaster Institute of Urology located in Hamilton, ON, Canada, were enrolled from August 2015 to September 2016. Potential participants were identified and recruited during their scheduled clinic visit. Eligible participants were known renal stone formers (defined by two or more documented stone occurrences during his/her lifetime) and at least 18 years of age. A research assistant obtained informed consent from all eligible participants and distributed the questionnaire in the clinic waiting room. To limit bias, all surveys were completed prior to the patient-urologist interaction, and all participants were instructed that involvement in the study would not influence their care. Basic survey methodology was used in questionnaire development (e.g., anchored Likert CUAJ – Original Research Bos et al Patient compliance with stone practices scales, multiple-choice, dichotomous, and short answer questions). The 21 survey questions were designed based on the current CUA best practice guidelines on stone preventative measures (see Appendix). The questionnaire consisted of three domains. The first included demographics, comorbidities, and previous stone management. The second domain covered previous clinician encounters due to kidney stones and patient satisfaction, while the third consisted of questions directed at patient knowledge, attitudes, and guideline compliance. Research ethics board approval was obtained prior to commencing the study. The primary outcome measure was compliance of the recurrent renal stone former to the CUA best practice guidelines. Secondary outcome measures included the evaluation of participant characteristics that may influence compliance, including knowledge, education, frequency, and subjective quality of preventative education, perceived severity of their disease, prior stone interventions, and, if applicable, attitudes regarding efficacy of stone-related conservative treatments. All participants were assigned an identification number to ensure anonymity, and consent forms were stored separately from the surveys. All quantitative data was analyzed via descriptive statistics using IBM SPSS Statistics 22 (IBM Corp, Armonk, NY, USA). Correlations were explored for variables within and between survey domains using the Chi-square test for categorical data and t-tests for ordinal data. All tests were two-sided, with a p-value of <0.05 defining statistical significance.