Health inequity associated with financial hardship among patients with kidney failure

Marques Shek Nam Ng; Dorothy Ngo Sheung Chan; Winnie Kwok Wei So

doi:10.1371/journal.pone.0287510

. 2023 Jun 23;18(6):e0287510. doi: 10.1371/journal.pone.0287510

Health inequity associated with financial hardship among patients with kidney failure

Marques Shek Nam Ng ^1,^*, Dorothy Ngo Sheung Chan ¹, Winnie Kwok Wei So ¹

Editor: Mohammad Meshbahur Rahman²

PMCID: PMC10289308 PMID: 37352190

Abstract

Financial hardship is a common challenge among patients with kidney failure and may have negative health consequences. Therefore, financial status is regarded as an important determinant of health, and its impact needs to be investigated. This cross-sectional study aimed to identify the differences in patient-reported and clinical outcomes among kidney failure patients with different financial status. A total of 354 patients with kidney failure were recruited from March to June 2017 at two hospitals in Hong Kong. The Dialysis Symptoms Index and Kidney Disease Quality of Life-36 were used to evaluate patient-reported outcomes. Clinical outcomes were retrieved from medical records and assessed using the Karnofsky Performance Scale (functional status) and Charlson Comorbidity Index (comorbidity level). Patients were stratified using two dichotomised variables, employment status and income level, and their outcomes were compared using independent sample t-tests and Mann-Whitney U-tests. In this sample, the employment rate was 17.8% and the poverty rate was 61.2%. Compared with other patients, increased distress of specific symptoms and higher healthcare utilization, in terms of more emergency room visits and longer hospital stays, were found in patients with poorer financial status. Low-income patients reported a decreased mental quality of life. Financially underprivileged patients experienced health inequity in terms of impaired outcomes. Attention needs to be paid to these patients by providing financial assessments and interventions. Additional research is warranted to confirm these findings and understand the experience of financial hardship and health equity.

Introduction

The global burden of kidney failure is increasing. More than 2 million patients have been diagnosed and treated with life-sustaining dialysis therapy worldwide [1]. In some countries, 2–3% of healthcare expenditures are used for managing kidney failure, and the demand for dialysis continues to surge [2]. At the individual level, patients often experience financial hardship associated with high treatment costs, unemployment, and reduced income. Although many countries provide reimbursement for dialysis therapy, patients are required to cover 12–71% of the costs out of pocket [3]. In addition, these patients have reduced productivity associated with disease-related disabilities. According to an international survey [4], less than 55% of haemodialysis (HD) and 68% of peritoneal dialysis (PD) patients are employed. Limited income due to decreased employment may amplify financial hardship among these patients [5].

Financial hardship is a profound and significant determinant of health. In fact, higher burdens associated with kidney failure are found in countries that are less socioeconomically developed [1]. From an individual perspective, patients utilize their personal resources to pay for their medical and other daily expenses, which may lead to the depletion of financial reserves or incurrence of debt [6]. Evidence suggests that impaired financial well-being is associated with poor physical and psychological health in patients with chronic illnesses [7, 8]. Negative health outcomes, including depression, anxiety, lower health-related quality of life (HRQoL), and higher mortality risk, have been reported in patients with kidney failure who are socioeconomically disadvantaged [9–11]. These outcomes may be seen as the consequences of health inequity caused by social determinants, especially financial factors.

Despite the impact of financial hardship on health, few studies have evaluated the relationships between this hardship and various health outcomes among patients with kidney failure [12]. A better understanding of these relationships may advance our understanding of health inequity among patients with kidney failure. Hence, in addition to financial aid, kidney care providers can proactively identify financially underprivileged patients and provide specific interventions that promote equal participation in daily life [13]. In Hong Kong, health consequences of financial hardship in patients with kidney failure have been rarely examined. Therefore, to explore directions for future research, the aim of this study was to identify the differences in patient-reported and clinical outcomes between kidney failure patients with high and low financial status.

This study was conducted in Hong Kong, one of the financial centres in the Chinese territory. While this city has a relatively high per capita gross domestic product of 49,801 USD in 2021 [14], it is famous for the large wealth gap. Its latest Gini coefficient in 2019 reached 51.8, which reflected fair inequality within this 700-million population [15]. In terms of the healthcare system, Hong Kong has a predominant public sector that provides over 90% of inpatient services and is largely subsidised by taxation [16]. Despite the availability of subsidised services, patients with kidney failure are required to use out-of-pocket expenses to cover costs of dialysis consumables and self-financed drugs.

Materials and methods

The cross-sectional data of 354 patients from a mixed-methods study were analysed [17]. This sample size was estimated to generate sufficient data for the latent class analysis in the original study. These patients were recruited at the dialysis clinics of Pamela Youde Nethersole Eastern Hospital and United Christian Hospital from March to June 2017. These hospitals were serving populations with highest and lowest household incomes in Hong Kong [18]. The inclusion criteria included: 1) adults diagnosed with kidney failure; 2) received any modality of dialysis therapy for three or more consecutive months; and 3) were willing to provide written consent. Those with active psychiatric disorders (e.g., schizophrenia, dementia) were excluded. Given that the complete patient lists could not be generated due to privacy issues, a convenience sampling method was used.

A research assistant approached patients in the clinics and screened for eligibility. After explaining the study and obtaining informed consent, the research assistant administered a questionnaire containing a demographic form (see S1 File) and the instruments. Then, electronic health records were reviewed at the dialysis clinics. This study was approved by the Joint CUHK-NTEC Clinical Research Ethics Committee (reference number: 2017.092), HKEC Research Ethics Committee (reference number: HKEC-2017-008), and KCC/KEC Research Ethics Committee (reference number: KC/KE-17-0016/ER-3) prior to data collection. Written consent was obtained from all participants.

Instruments

Symptoms and HRQoL were selected as the patient-reported outcomes. The Dialysis Symptoms Index (DSI) was used to assess the distress levels of 30 symptoms experienced in the past month [19]. A higher score indicates a higher level of distress. The Chinese version of the DSI demonstrated excellent content validity (0.99) and internal consistency (α = 0.87) [20]. The Kidney Disease Quality of Life-36 was used to evaluate the HRQoL of patients [21]. It consists of 24 disease-specific and 12 generic questions that can be divided into three subscales (symptom, burden, and effect of kidney disease) and two summary scores (physical and mental component summary). A higher score indicates better performance in the specific domain. Its Chinese version demonstrated good test-retest reliability (interclass correlation coefficient = 0.79–0.92) and acceptable internal consistency (α = 0.60–0.93) [22].

The clinical outcomes included the functional status, comorbidity level, healthcare service utilization, and biochemical parameters. The Karnofsky Performance Scale was used to evaluate functional status [23]. A higher score indicates higher ability to perform activities of daily living (range: 0–100). The Charlson Comorbidity Index was used to assess the comorbidity level [24]. Patients’ relative burden of comorbidity is evaluated based on the weighted sum of 14 conditions (range: 0–33). Other clinical data, including healthcare service utilization in past six months (such as number of emergency room [ER] attendance and days of hospital stay) and biochemical parameters (such as serum albumin concentration), were retrieved from the patients’ electronic health records. Glomerular filtration rate was estimated based on the Modification of Diet in Renal Disease (MDRD) equation [25]. These outcomes were analysed as continuous variables.

Analyses

Background characteristics and outcomes were summarised using appropriate descriptive statistics (e.g., percentage, mean, median) depending on the distributions of variables. Two dichotomized variables that reflected the patient’s financial status were created: employment status (unemployed vs. employed) and income level (below vs. above poverty line). In terms of income level, those earning a monthly household income of ≤ 10,000 HKD (approximately 1,290 USD) were regarded as below the poverty line, which is in line with the government’s definition [18]. After stratifying the patients by these variables, background characteristics were compared using chi-squared tests (sex, marital status, education level, dialysis modality, history of transplantation), independent sample t-tests and Mann-Whitney U-tests, as appropriate.

Unadjusted comparisons on patient-reported and clinical outcomes between groups of the financial status variables were made using independent sample t-tests and Mann-Whitney U-tests for normally and skewedly distributed variables, respectively. Then, multiple regression analyses were conducted to compare the outcomes between groups with adjustment for participants’ background characteristics (sex, marital status, education level, dialysis modality, history of transplantation, age, duration on dialysis). All analyses were conducted using SPSS version 25.0 (IBM Corp., Armonk, NY). A two-sided p-value of < 0.05 was considered as statistically significant.

Results

Of the 424 patients approached, 22 did not meet eligibility and 48 declined to participate. Among the consented patients, 58.5% were male. The patients had a mean age of 60.9 years (Table 1). Most of the patients received PD (69.9%) and had been on dialysis for a median of 36 months (inter-quartile range: 17–60). Overall, 17.8% of the patients were employed, and 61.2% were below the poverty line. The education level significantly differentiated patients regardless employment status and income level (p ≤ 0.001). Compared with other patients, a larger proportion of employed patients had received kidney transplants (9.5%; p = 0.035), and a larger proportion of patients above the poverty line were married (76.6%; p = 0.01).

Table 1. Background characteristics and comparison between different employment groups.

	Overall		Unemployed		Employed		Unadjusted analyses	Adjusted analyses^{^}
	(N = 354)		(n = 291; 82.2%)		(n = 63; 17.8%)		Unadjusted analyses	Adjusted analyses^{^}
Background characteristics							p	B	SE	p
Male (vs. Female)^ѱ	207	58.5%	164	56.4%	43	68.3%	0.082
Married (vs. Not married)^ѱ	243	68.6%	206	70.8%	37	58.7%	0.061
Secondary education (vs. Primary education or below)^ѱ	231	65.3%	177	60.8%	54	85.7%	<0.001^*
Peritoneal dialysis (vs. Haemodialysis)^ѱ	255	72.0%	212	72.9%	43	68.3%	0.461
History of transplantation (vs. No history of transplantation)^ѱ	16	4.5%	10	3.4%	6	9.5%	0.035^*
Age (years)	60.93	11.89	62.70	11.33	52.63	11.00	<0.001^*
Month on dialysis^#	36	17–60	36	18–60	30	11–60	0.309
Patient-reported outcomes
Dialysis Symptoms Index	34.16	23.03	36.07	22.03	31.32	24.73	0.163	-4.617	3.363	0.171
Constipation	1.09	1.60	1.15	1.65	0.78	1.35	0.057	-0.196	0.244	0.422
Chest pain	0.50	1.16	0.54	1.18	0.33	1.06	0.203	-0.301	0.177	0.090
Nausea	0.79	1.39	0.74	1.35	1.02	1.54	0.190	0.095	0.209	0.649
Vomiting	0.65	1.34	0.64	1.33	0.70	1.40	0.765	-0.109	0.205	0.596
Diarrhoea	0.71	1.34	0.70	1.36	0.73	1.30	0.876	-0.057	0.200	0.776
Decreased appetite	1.18	1.55	1.21	1.57	1.05	1.49	0.453	-0.040	0.236	0.867
Cramps	1.43	1.62	1.41	1.62	1.54	1.62	0.552	0.198	0.243	0.417
Oedema	0.97	1.36	0.93	1.35	1.14	1.40	0.271	0.215	0.207	0.299
Shortness of breath	1.07	1.49	1.09	1.51	1.00	1.45	0.668	-0.181	0.228	0.428
Dizziness	0.96	1.46	0.99	1.46	0.83	1.50	0.430	-0.120	0.224	0.593
Restless legs	0.60	1.32	0.64	1.36	0.43	1.10	0.243	-0.335	0.201	0.096
Limb numbness	1.04	1.53	1.08	1.55	0.87	1.44	0.342	-0.103	0.233	0.659
Tiredness	2.23	1.66	2.33	1.65	1.79	1.65	0.020^*	-0.543	0.250	0.031^*
Coughing	1.35	1.56	1.40	1.60	1.14	1.34	0.195	-0.223	0.239	0.651
Dry mouth	1.49	1.56	1.54	1.58	1.24	1.43	0.164	-0.158	0.235	0.501
Joint/bone pain	1.51	1.75	1.60	1.75	1.08	1.69	0.033^*	-0.527	0.267	0.049^*
Headache	0.73	1.29	0.76	1.30	0.60	1.28	0.352	-0.273	0.195	0.162
Muscle soreness	1.25	1.55	1.30	1.56	1.03	1.48	0.220	-0.251	0.235	0.286
Difficulty concentrating	1.05	1.50	1.08	1.54	0.89	1.35	0.355	-0.234	0.230	0.309
Dry skin	2.42	1.73	2.42	1.78	2.40	1.51	0.918	0.293	0.258	0.256
Itching	2.58	1.74	2.66	1.76	2.21	1.62	0.063	-0.212	0.264	0.422
Worrying	1.05	1.56	1.06	1.57	1.02	1.55	0.845	-0.015	0.233	0.950
Feeling nervous	0.88	1.46	0.90	1.48	0.79	1.45	0.592	-0.118	0.218	0.591
Trouble falling asleep	2.02	1.98	2.13	1.99	1.51	1.87	0.024^*	-0.455	0.299	0.129
Trouble staying asleep	1.92	1.88	2.00	1.89	1.54	1.76	0.080	-0.286	0.284	0.316
Feeling agitated	1.03	1.52	1.06	1.54	0.89	1.50	0.426	-0.163	0.228	0.475
Feeling sad	0.86	1.43	0.92	1.47	0.60	1.21	0.076	-0.232	0.213	0.278
Feeling anxious	0.78	1.35	0.79	1.35	0.75	1.38	0.828	-0.041	0.206	0.842
Decreased interest in sex	0.56	1.28	0.54	1.29	0.70	1.20	0.361	-0.178	0.186	0.339
Difficulty getting sexually aroused	0.53	1.27	0.48	1.25	0.73	1.33	0.164	-0.071	0.185	0.703
Kidney Disease Quality of Life 36
Symptom of kidney disease	78.20	15.02	77.90	14.68	46.60	16.55	0.417	1.308	2.263	0.564
Effect of kidney disease	71.73	19.45	72.52	19.53	68.11	18.84	0.103	-2.280	2.822	0.420
Burden of kidney disease	30.54	21.70	30.26	22.24	31.85	19.14	0.600	-0.441	3.300	0.894
Physical Component Summary	37.87	9.54	37.27	9.61	40.65	8.74	0.011^*	2.285	1.437	0.113
Mental Component Summary	48.54	10.84	48.80	11.05	47.36	9.86	0.340	-1.500	1.618	0.355
Clinical Outcomes
Karnofsky Performance Scale	88.59	13.43	87.56	14.07	93.33	8.61	<0.001^*	1.687	1.940	0.385
Charlson Comorbidity Index^#	2.	0–3	2	0–3	0	0–2	<0.001^*	-0.488	0.299	0.103
Clinical visits in 6 months^#	0	0–2	0	0–2	0	0–2	0.241	0.602	0.339	0.077
ER attendance in 6 months^#	0	0–1	0	0–1	0	0–0	0.002^*	-0.384	0.171	0.025^*
Days of hospital stay in 6 months^#	0	0–7	0	0–7	0	0–6	0.942	1.490	1.724	0.388
Glomerular filtration rate (mL/min/1.73m²)	5.45	2.26	5.50	2.32	5.21	1.95	0.359	-0.021	0.336	0.951
Serum albumin (g/L)	35.96	4.68	35.73	4.74	36.98	4.28	0.054	0.258	0.654	0.694
Serum calcium (mmol/L)	2.28	0.19	2.28	0.20	2.28	0.16	0.973	-0.020	0.029	0.490
Serum phosphate (mmol/L)	1.78	0.55	1.77	0.56	1.82	0.54	0.548	-0.132	0.081	0.103
Haemoglobin (g/dL)	10.27	2.79	10.31	2.98	10.12	1.67	0.631	-0.298	0.434	0.492

Open in a new tab

*p < 0.05

Data of variables marked with

^ѱ are presented as frequency and percentage

^# as median and inter-quartile range, and all others as mean and standard deviation.

^In the adjusted analyses, demographic factors adjusted included: Sex, marital status, education level, dialysis modality, history of transplantation, age, and duration on dialysis

Abbreviations: B = Regression coefficient of the dummy variable (Employment: 0 = Unemployed; 1 = Employed); SD = Standard deviation; SE = Standard error of the regression coefficient

Tables 1 and 2 present the differences in patient-reported and clinical outcomes between groups. Compared with employed patients, in unadjusted analyses, those who were unemployed reported higher levels of tiredness (mean: 2.33), joint or bone pain (mean: 1.60), and trouble falling asleep (mean: 2.13) (all p ≤ 0.05). Adjusted analyses showed that employed patients were associated with lower level of tiredness (Regression coefficient B = -0.543; standard error [SE] = 0.250; p = 0.031), and joint/bone pain (B = -0.527; SE = 0.267; p = 0.049) than those unemployed patients after adjusting for background characteristics. While no significant relationship was found between employment status and quality of life outcomes in the adjusted analyses, those employed reported a significantly lower mean number of ER attendance in the past six months (B = -0.384; SE = 0.171; p = 0.025) than their unemployed counterparts.

Table 2. Comparison between different income groups.

	Below Poverty Line		Above Poverty Line		Unadjusted analyses	Adjusted analyses^{^}
	(n = 217; 61.3%)		(n = 137; 38.7%)		Unadjusted analyses	Adjusted analyses^{^}
Background characteristics					p	B	SE	p
Male (vs. Female)^ѱ	128	59.0%	79	36.4%	0.806
Married (vs. Not married)^ѱ	138	63.6%	105	76.6%	0.010^*
Secondary education (vs. Primary education or below)^ѱ	127	58.5%	104	75.9%	0.001^*
Peritoneal dialysis (vs. Haemodialysis)^ѱ	158	72.8%	97	70.8%	0.682
History of transplantation (vs. No history of transplantation)^ѱ	10	4.6%	6	4.4%	0.920
Age (years)	63.36	11.51	57.10	11.51	<0.001^*
Month on dialysis^#	36	20–60	30	12–55	0.081
Patient-reported outcomes
Dialysis Symptoms Index	36.18	21.75	33.69	23.81	0.323	-3.615	2.660	0.175
Constipation	1.21	1.67	0.89	1.48	0.059	-0.164	0.193	0.396
Chest pain	0.53	1.21	0.46	1.09	0.070	-0.070	0.140	0.618
Nausea	0.72	1.34	0.89	1.47	0.282	-0.102	0.165	0.537
Vomiting	0.61	1.27	0.72	1.45	0.485	-0.086	0.163	0.599
Diarrhoea	0.76	1.43	0.61	1.20	0.283	-0.279	0.158	0.078
Decreased appetite	1.21	1.52	1.14	1.60	0.685	-0.067	0.187	0.722
Cramps	1.43	1.62	1.43	1.62	0.991	-0.035	0.193	0.855
Oedema	0.98	1.38	0.96	1.33	0.864	-0.174	0.164	0.289
Shortness of breath	1.06	1.51	1.09	1.48	0.888	0.016	0.180	0.931
Dizziness	0.97	1.45	0.94	1.49	0.870	-0.075	0.177	0.670
Restless legs	0.54	1.21	0.71	1.47	0.261	0.111	0.159	0.486
Limb numbness	1.06	1.53	1.00	1.54	0.700	0.140	0.184	0.446
Tiredness	2.21	1.64	2.28	1.70	0.700	0.136	0.198	0.492
Coughing	1.39	1.61	1.29	1.47	0.576	-0.086	0.189	0.651
Dry mouth	1.63	1.60	1.26	1.46	0.027^*	-0.385	0.186	0.039^*
Joint/bone pain	1.55	1.74	1.43	1.77	0.522	0.006	0.211	0.978
Headache	0.76	1.35	0.68	1.20	0.543	-0.108	0.154	0.483
Muscle soreness	1.27	1.53	1.22	1.57	0.775	-0.062	0.186	0.738
Difficulty concentrating	1.05	1.50	1.04	1.51	0.967	-0.040	0.182	0.828
Dry skin	2.68	1.68	1.99	1.73	<0.001^*	-0.826	0.204	<0.001^*
Itching	2.76	1.75	2.28	1.70	0.010^*	-0.536	0.209	0.011^*
Worrying	1.05	1.59	1.05	1.52	0.998	-0.108	0.184	0.558
Feeling nervous	0.89	1.51	0.88	1.42	0.933	-0.064	0.173	0.709
Trouble falling asleep	2.12	1.99	1.85	1.97	0.200	-0.149	0.237	0.530
Trouble staying asleep	2.07	1.86	1.66	1.88	0.045^*	-0.336	0.225	0.136
Feeling agitated	1.11	1.55	0.91	1.50	0.229	-0.246	0.181	0.175
Feeling sad	0.95	1.48	0.72	1.34	0.138	-0.258	0.168	0.127
Feeling anxious	0.81	1.36	0.74	1.35	0.640	-0.203	0.163	0.215
Decreased interest in sex	0.41	1.08	0.82	1.51	0.003^*	0.215	0.147	0.144
Difficulty getting sexually aroused	0.37	1.51	0.77	1.52	0.004^*	0.219	0.147	0.136
Kidney Disease Quality of Life 36
Symptom of kidney disease	77.84	15.07	78.77	14.99	0.571	1.556	1.790	0.385
Effect of kidney disease	71.79	19.13	71.65	20.03	0.947	4.210	2.232	0.060
Burden of kidney disease	29.46	22.07	32.25	21.06	0.239	2.379	2.611	0.363
Physical Component Summary	37.51	9.56	38.45	9.50	0.367	0.252	1.137	0.825
Mental Component Summary	47.88	10.98	49.58	10.59	0.151	2.725	1.280	0.034^*
Clinical Outcomes
Karnofsky Performance Scale	87.65	13.79	90.07	12.75	0.098	0.024	1.534	0.987
Charlson Comorbidity Index^#	2	0–3	1	0–2	0.001^*	-0.251	0.236	0.289
Clinical visits in 6 months^#	0	0–1	0	0–2	0.136	-0.017	0.268	0.949
ER attendance in 6 months^#	0	0–1	0	0–1	0.044^*	-0.233	0.136	0.088
Days of hospital stay in 6 months^#	0	0–11	0	0–5	0.062	-2.810	1.367	0.041^*
Glomerular filtration rate (mL/min/1.73m²)	5.53	2.25	5.32	2.27	0.397	-0.088	0.267	0.741
Serum albumin (g/L)	35.39	4.83	36.85	4.30	0.004^*	0.969	0.519	0.063
Serum calcium (mmol/L)	2.27	0.20	2.29	0.19	0.302	0.019	0.023	0.395
Serum phosphate (mmol/L)	1.74	0.55	1.84	0.56	0.113	0.048	0.064	0.453
Haemoglobin (g/dL)	10.29	1.68	10.24	3.94	0.878	-0.028	0.344	0.935

Open in a new tab

*p < 0.05

Data of variables marked with

^ѱ are presented as frequency and percentage

^# as median and inter-quartile range, and all others as mean and standard deviation.

^In the adjusted analyses, demographic factors adjusted included: Sex, marital status, education level, dialysis modality, history of transplantation, age, and duration on dialysis

Abbreviations: B = Regression coefficient of the dummy variable (Income: 0 = Below poverty line; 1 = Above poverty line); SD = Standard deviation; SE = Standard error of the regression coefficient

Patients below the poverty line reported higher levels of dry mouth (mean: 1.63), dry skin (mean: 2.68), itching (mean: 2.76), and trouble staying asleep (mean: 2.07) than those above the poverty line (all p ≤ 0.05). Interestingly, patients with lower income had less severe sexual symptoms (all p ≤ 0.05), namely a decreased interest in sex (mean: 0.41) and difficulty becoming sexually aroused (mean: 0.37). However, in the adjusted analyses, only dry mouth (B = -0.385; SE = 0.186; p = 0.039), dry skin (B = -0.826; SE = 0.204; p < 0.001), and itching (B = -0.536; SE = 0.209; p = 0.011) remain significantly different between the two income level groups. In addition, patients above poverty line had lower KDQOL-36 Mental Component Summary scale scores (B = 2.725; SE = 1.280; p = 0.034) and shorter hospital stays in the past six months (B = -2.810; SE = 1.367; p = 0.041) when compared with those who were below poverty line in the adjusted analyses.

In terms of clinical outcomes, patients with a poorer financial status had higher comorbidity levels (all p ≤ 0.05). Patients below the poverty line had a lower serum albumin concentration (p = 0.004) than patients with higher earnings. However, these results were not statistically significant after adjusting for background characteristics.

Discussion

The findings from this study suggest that patient-reported and clinical outcomes differ between patients with different financial statuses in terms of their employment and income level. Based on our preliminary findings, while no significant relationship was found between financial status and most patient-reported outcomes, patients who were unemployed or living below the poverty line reported higher distress associated with specific symptoms and more health care utilization than other patients. Consistent with existing evidence [8–10], the impact of financial hardship on health disparities among patients with kidney failure warrants additional attention.

Compared with the general population in Hong Kong, the employment rate in this study was halved and the poverty rate was three times higher (cf. employment rate: 34.9%; poverty rate: 21.4%) [18]. This finding is an alarming sign that in this city, which is well known for economic inequality, financial hardship is very common among patients with kidney failure. Our findings indicate the negative impact of such hardship within this group. Consistent with our previous studies [8, 26], financially underprivileged patients may experience a higher symptom burden in terms of tiredness, dry mouth, skin problems, and pain. There are some possible reasons for this relationship. As reported in one study [27], financially underprivileged patients may have fewer resources to pay for healthcare services, especially preventive care. They directly turn to the highly subsidized hospital care when they cannot tolerate their symptoms [28]. This may explain why patients with impaired financial well-being reported poorer outcomes, particularly a higher mean number of ER visits and length of hospital stay. Therefore, kidney care providers need to pay special attention to the financial needs of patients by incorporating appropriate assessments and interventions in routine care [12]. Nevertheless, there is a need to examine equity in the healthcare system to ensure that essential services are provided regardless of a person’s financial status. In addition, there may be a reciprocal relationship between financial hardship and outcomes. Symptoms and other outcomes may be signs of deteriorating health associated with financial hardship. However, patients with a poorer symptom status or poorer outcomes may also have a higher demand for healthcare services and a lower physical capacity for engaging actively in employment [29]. These consequences lead to increased medical expenditures and decreased income, which eventually intensify financial hardship [6]. A better understanding of the experience of financial hardship is warranted to explore the factors that modulate the relationship between financial hardship and health.

It is noteworthy that despite no significant relationship being found between financial status, quality of life outcomes, and biochemical parameters, the impact of financial hardship on health should not be underestimated. Associations between financial hardship and various symptoms, such as depression, fatigue, and pain, have been found in previous studies [8]. One reason for the lack of statistical significance is the limitations in evaluating financial status. As concluded in a systematic review [7], financial hardship consists of material, psychological, and behavioural changes in relation to financial status. In this study, financial hardship is indicated by unemployment and low income, which only reflect some aspects of the material change. In fact, some patients who are unemployed or with low income may be abundantly supported by families, personal savings, or other financial aids. Hence, the selected indicators may not be specific and sensitive enough to evaluate financial hardship and its impact.

Our preliminary evidence reveals the consequences of health inequity and suggests directions for researching issues associated with financial hardship among patients with kidney failure. However, several limitations warrant consideration. Although cross-sectional data were analysed and limited variables were evaluated, other factors that might confound the relationship between financial hardship and outcomes (e.g., financial aids, home ownership, personal savings, health spendings) were not assessed and controlled [8]. Given these methodological limitations, findings should be interpreted as markers of potential influences of financial status on patient outcomes. In addition, the causal relationships among financial statuses, kidney failure, incapacity for employment, and health outcomes need to be examined using a longitudinal design. Of note, as mentioned above, financial status was evaluated in terms of employment status and income level only, which might inadequately reflect the full picture of financial well-being. Therefore, the following suggestions are made: 1) factors influencing financial hardship should be identified and controlled in further analyses; 2) a longitudinal study should be conducted to evaluate changes in financial status and outcomes; and 3) a comprehensive conceptualization of financial hardship should be adopted.

Conclusion

Financial hardship is very common among patients with kidney failure, especially in Hong Kong, in terms of high percentages of unemployment and poverty. Our preliminary evidence suggests that this hardship may result in health inequity and manifest in impaired patient-reported and clinical outcomes. However, given the methodological limitations, additional research is warranted to confirm these findings and understand the experience of financial hardship and health equity.

Supporting information

S1 File. Demographic form.

This form was developed by the research team to collect demographic information of the participants.

(PDF)

Click here for additional data file.^{(263.1KB, pdf)}

Acknowledgments

The authors would like to express their gratitude to Dr Stephen Mo, Ms Eva Ho, Dr Sunny Wong, Ms Yun Ho Hui, and the staff members of the study sites for their assistance in data collection. Special thanks are given to Dr Kai Chow Choi for his professional statistical support.

Data Availability

Data cannot be shared publicly because of privacy issues. Confidential data are available from the CUHK Research Data Repository for researchers whose work has been approved by an institutional review board. Request may be sent together with the research proposal and ethical approval to the corresponding author or the Repository (website: https://researchdata.cuhk.edu.hk / email: data@cuhk.edu.hk).

Funding Statement

The authors received no specific funding for this work.

References

1.GBD Chronic Kidney Disease Collaboration. Global, regional, and national burden of chronic kidney disease, 1990–2017: a systematic analysis for the Global Burden of Disease Study 2017. Lancet 2020;395:709–33. doi: 10.1016/S0140-6736(20)30045-3 [DOI] [PMC free article] [PubMed] [Google Scholar]
2.Luyckx VA, Tonelli M, Stanifer JW. The global burden of kidney disease and the sustainable development goals. Bull World Health Organ 2018;96:414–22. doi: 10.2471/BLT.17.206441 [DOI] [PMC free article] [PubMed] [Google Scholar]
3.van der Tol A, Lameire N, Morton RL, Van Biesen W, Vanholder R. An international analysis of dialysis services reimbursement. Clin J Am Soc Nephrol 2019;14:84–93. doi: 10.2215/CJN.08150718 [DOI] [PMC free article] [PubMed] [Google Scholar]
4.Brown EA, Zhao J, McCullough K, Fuller DS, Figueiredo AE, Bieber B, et al. Burden of kidney disease, health-related quality of life, and employment among patients receiving peritoneal dialysis and in-center hemodialysis: findings from the DOPPS program. Am J Kidney Dis 2021;78:489–500. doi: 10.1053/j.ajkd.2021.02.327 [DOI] [PubMed] [Google Scholar]
5.Morton RL, Schlackow I, Gray A, Emberson J, Herrington W, Staplin N, et al. Impact of CKD on household income. Kidney Int Rep 2018;3:610–8. doi: 10.1016/j.ekir.2017.12.008 [DOI] [PMC free article] [PubMed] [Google Scholar]
6.Carrera PM, Kantarjian HM, Blinder VS. The financial burden and distress of patients with cancer: understanding and stepping-up action on the financial toxicity of cancer treatment. CA Cancer J Clin 2018;68:153–65. doi: 10.3322/caac.21443 [DOI] [PMC free article] [PubMed] [Google Scholar]
7.Altice CK, Banegas MP, Tucker-Seeley RD, Yabroff KR. Financial hardships experienced by cancer survivors: a systematic review. J Natl Cancer Inst 2017;109:djw205. doi: 10.1093/jnci/djw205 [DOI] [PMC free article] [PubMed] [Google Scholar]
8.Ng MSN, Chan DNS, Cheng Q, Miaskowski C, So WKW. Association between financial hardship and symptom burden in patients receiving maintenance dialysis: a systematic review. Int J Environ Res Public Health 2021;18:9541. doi: 10.3390/ijerph18189541 [DOI] [PMC free article] [PubMed] [Google Scholar]
9.Ikonomou M, Skapinakis P, Balafa O, Eleftheroudi M, Damigos D, Siamopoulos KC. The impact of socioeconomic factors on quality of life of patients with chronic kidney disease in Greece. J Renal Care 2015;41:239–46. doi: 10.1111/jorc.12132 [DOI] [PubMed] [Google Scholar]
10.Tao S, Zeng X, Liu J, Fu P. Socioeconomic status and mortality among dialysis patients: a systematic review and meta-analysis. Int Urol Nephrol 2019;51:509–18. doi: 10.1007/s11255-019-02078-5 [DOI] [PubMed] [Google Scholar]
11.Chen J, Liu L, Chen J, Ng MS, Lou VW, Wu B, et al. The cross-lagged association between depressive symptoms and health-related quality of life in patients receiving maintenance hemodialysis: a three-wave longitudinal study. Qual Life Res 2021;30:3463–3473. doi: 10.1007/s11136-021-02866-6 [DOI] [PubMed] [Google Scholar]
12.Krishnan M. The importance of considering total patient economics for hemodialysis. Kidney Int Rep 2019;4:365–6. [DOI] [PMC free article] [PubMed] [Google Scholar]
13.Kalantar-Zadeh K, Li PK, Tantisattamo E, Kumaraswami L, Liakopoulos V, Lui S, et al. Living well with kidney disease by patient and care-partner empowerment: kidney health for everyone everywhere. Clin Nephrol 2021;95:115–22. doi: 10.5414/CN110436 [DOI] [PubMed] [Google Scholar]
14.World Bank Group. GDP per capita (current US$)–Hong Kong SAR, China [Internet]. 2023. [Accessed 18 April 2023]. Available: https://data.worldbank.org/indicator/NY.GDP.PCAP.CD?locations=HK. [Google Scholar]
15.World Economics. Hong Kong’s Gini coefficient [Internet]. 2019. [Accessed 18 April 2023]. Available from: https://www.worldeconomics.com/Inequality/Gini-Coefficient/Hong%20Kong.aspx#. [Google Scholar]
16.Schoeb V. Healthcare service in Hong Kong and its challenges: the role of health professionals within a social model of health. China Perspect 2016;4:51–58. [Google Scholar]
17.Ng MSN, Miaskowski C, Cooper B, Hui YH, Ho EHS, Mo SKL, et al. Distinct symptom experience among subgroups of patients with ESRD receiving maintenance dialysis. J Pain Symptom Manage 2020;60:70–9. doi: 10.1016/j.jpainsymman.2020.01.004 [DOI] [PubMed] [Google Scholar]
18.Government of the HKSAR. Hong Kong poverty situation report 2019 [Internet]. 2019. [Accessed 30 March 2022]. Available from: https://www.povertyrelief.gov.hk/eng/pdf/Hong_Kong_Poverty_Situation_Report_2019.pdf. [Google Scholar]
19.Weisbord SD, Fried LF, Arnold RM, Rotondi AJ, Fine MJ, Levenson DJ, et al. Development of a symptom assessment instrument for chronic hemodialysis patients: the Dialysis Symptom Index. J Pain Symptom Manage 2004;27:226–240. doi: 10.1016/j.jpainsymman.2003.07.004 [DOI] [PubMed] [Google Scholar]
20.Ng MSN, So WKW, Wong CL, Hui YH, Ho EHS, Choi KC, et al. Stability and impact of symptom clusters in patients with end-stage renal disease undergoing dialysis. J Pain Symptom Manage 2020;59:67–76. [DOI] [PubMed] [Google Scholar]
21.Hays RD, Kallich JD, Mapes DL, Coons SJ, Amin N, Carter WB, et al. Kidney Disease Quality of Life Short Form (KDQOL-SFTM), version 1.3: a manual for use and scoring [Internet]. 1997. [Accessed 30 March 2022]. Available from: https://www.rand.org/health-care/surveys_tools/kdqol.html. [Google Scholar]
22.Chow SKY, Tam BML. Is the kidney disease quality of life-36 (KDQOL-36) a valid instrument for Chinese dialysis patients? BMC Nephrol 2014;15:1–7. [DOI] [PMC free article] [PubMed] [Google Scholar]
23.Péus D, Newcomb N, Hofer S. Appraisal of the Karnofsky performance status and proposal of a simple algorithmic system for its evaluation. BMC Med Inform Decis Mak 2013;13:1–7. [DOI] [PMC free article] [PubMed] [Google Scholar]
24.Hemmelgarn BR, Manns BJ, Quan H, Ghali WA. Adapting the Charlson Comorbidity Index for use in patients with ESRD. Am J Kidney Dis 2003;42:125–32. doi: 10.1016/s0272-6386(03)00415-3 [DOI] [PubMed] [Google Scholar]
25.Levey AS, Coresh J. Greene T, Stevens LA, Zhang Y, Hendriksen S, et al. Using standardized serum creatinine values in the modification of diet in renal disease study equation for estimating glomerular filtration rate. Ann Int Med 2006;145,247–54. doi: 10.7326/0003-4819-145-4-200608150-00004 [DOI] [PubMed] [Google Scholar]
26.Ng MSN, Wong CL, Choi KC, Hui YH, Ho EHS, Miaskowski C, et al. A mixed methods study of symptom experience in patients with end-stage renal disease. Nurs Res 2021;70:34–43. doi: 10.1097/NNR.0000000000000479 [DOI] [PubMed] [Google Scholar]
27.Essue BM, Wong G, Chapman J, Li Q, Jan S. How are patients managing with the costs of care for chronic kidney disease in Australia? A cross-sectional study. BMC Nephrol 2013;14:5. doi: 10.1186/1471-2369-14-5 [DOI] [PMC free article] [PubMed] [Google Scholar]
28.Ng MSN, Hui YH, Law BYS, Wong CL, So WKW. Challenges encountered by patients with end-stage kidney disease in accessing symptom management services: a narrative inquiry. J Adv Nurs 2021;77(3):1391–402. doi: 10.1111/jan.14678 [DOI] [PubMed] [Google Scholar]
29.Ng MSN, Wong CL, Ho EHS, Hui YH, Miaskowski C, So WKW. Burden of living with multiple concurrent symptoms in patients with end-stage renal disease. J Clin Nurs 2020;29:2589–601. doi: 10.1111/jocn.15282 [DOI] [PubMed] [Google Scholar]

PLoS One. doi: 10.1371/journal.pone.0287510.r001

Decision Letter 0

Jamie Males

22 Nov 2022

PONE-D-22-21227Health Inequity Associated with Financial Hardship Among Patients with

End-stage Kidney Disease: A Secondary AnalysisPLOS ONE

Dear Dr. Ng,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

Please note that we have only been able to secure a single reviewer to assess your manuscript. We are issuing a decision on your manuscript at this point to prevent further delays in the evaluation of your manuscript. Please be aware that the editor who handles your revised manuscript might find it necessary to invite additional reviewers to assess this work once the revised manuscript is submitted. However, we will aim to proceed on the basis of this single review if possible.

The reviewer has identified many aspects of your study design, methods and statistical analyses that require clarification and elaboration in order to demonstrate that your submission meets our third and fourth publication criteria (https://journals.plos.org/plosone/s/criteria-for-publication). Please respond carefully to all the points they have raised when preparing your revisions.

Please submit your revised manuscript by Jan 05 2023 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:

A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.
A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.
An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: https://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols. Additionally, PLOS ONE offers an option for publishing peer-reviewed Lab Protocol articles, which describe protocols hosted on protocols.io. Read more information on sharing protocols at https://plos.org/protocols?utm_medium=editorial-email&utm_source=authorletters&utm_campaign=protocols.

We look forward to receiving your revised manuscript.

Kind regards,

Jamie Males

Editorial Office

PLOS ONE

Journal Requirements:

When submitting your revision, we need you to address these additional requirements.

1. Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming. The PLOS ONE style templates can be found at

https://journals.plos.org/plosone/s/file?id=wjVg/PLOSOne_formatting_sample_main_body.pdf and

https://journals.plos.org/plosone/s/file?id=ba62/PLOSOne_formatting_sample_title_authors_affiliations.pdf

2. Your ethics statement should only appear in the Methods section of your manuscript. If your ethics statement is written in any section besides the Methods, please move it to the Methods section and delete it from any other section. Please ensure that your ethics statement is included in your manuscript, as the ethics statement entered into the online submission form will not be published alongside your manuscript.

[Note: HTML markup is below. Please do not edit.]

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: No

**********

2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: No

**********

3. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: No

**********

4. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

**********

5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: Thank you for the opportunity to review this interesting study on the relationship between financial hardship and patient-reported symptoms and clinical outcomes. In their study of patients with kidney failure on dialysis from two regional hospitals in Hong Kong, the authors find that unemployed patients and patients living below the poverty line experience worse clinical outcomes on composite measures and greater ER attendance relative to their employed peers and those living above the poverty line. They also note differences in certain symptoms; however, these differed by the measure of financial hardship.

This study is valuable and its contribution to the literature can be enhanced. I provide suggestions that I hope will improve the manuscript.

First, the setting of economic inequality in Hong Kong and the specific experience of healthcare-related financial hardship deserves greater attention. Hong Kong has enormous wealth disparity and housing segregation that may not be fully captured by employment and income. Further, the context of financial hardship as related to out-of-pocket healthcare costs requires further explanation given that public healthcare, as I understand, is free. It is important to understand both how this issue should be understood within the local context of Hong Kong and how it can be generalized to other global and health contexts. Second, the methodology and analysis are unclear. How were the instruments chosen? How was the subset of “patient-reported outcomes” reported in the table selected? Do they derive from the Dialysis Symptom Index, which includes a total of 30 items? This is not well explained. Also, how was the decision made to conduct so many t-tests? I am concerned that these multiple measures increase the likelihood of type I error. Third and finally, I believe the discussion overgeneralizes the interpretation of the results. The statements that “patient-reported and clinical outcomes differ between patients with different financial statuses in terms of their employment and income level” and financial “hardship may result in health inequity” do not appropriately account for the mixed results and study limitations.

I provide more detailed feedback below:

Title/Abstract

• Line 5/20: Recommend using “kidney failure” rather than “end-stage kidney disease” per guidelines advanced by Levey et al. (2020)

Levey AS, Eckardt KU, Dorman NM, Christiansen SL, Cheung M, Jadoul M, et al. Nomenclature for kidney function and disease: executive summary and glossary from a Kidney Disease: Improving Global Outcomes consensus conference*. Nephrology Dialysis Transplantation. 2020 Jul 1;35(7):1077–84.

Introduction

• Line 48: The authors state that patients may be required to cover 12-71% of dialysis costs out of pocket, but do not specify the nature of reimbursement at the hospitals in the study. This context would be especially helpful for understanding the impact of financial hardship on study participants. Also, I think it may be relevant to mention here that, as I understand it, public healthcare is virtually free and guaranteed in Hong Kong as this is not the case elsewhere.

• Lines 53-60: This section seems to emphasize the relationship between financial hardship and medical expenses, but I think the experience of economic oppression is more profound than that. I think the authors can do more to describe the local context of economic inequality in Hong Kong. I am not an expert in the region, though I think some relevant dynamics include issues of financialization, housing and spatial segregation, and immigration issues.

Materials and Methods

• Line 71: Are you able to add details about the hospitals from which these data were collected? They are described as “regional hospitals” but are they public? Private?

• Line 72: Please provide a citation where the inclusion and exclusion criteria are previously reported.

• Lines 93-100: I am not sure that the Methods adequately account for all four instruments and analyses. I also imagine chi-squared analyses were conducted to assess for differences in patient demographics, but these are not reported in the Methods. Looking at Table 1, I see composite scores for the Kidney Disease Quality of Life-36, the Karnofsky Performance Scale, and the Charlson Comorbidity Index, in addition to several individual patient-reported outcomes. Do the patient-reported outcomes derive from the Dialysis Symptoms Index? If so, how and why were only a subsample of the 30 symptoms selected for reporting?

Results

• The authors report significant results but do not describe results that are not significant, which is important.

Discussion

• Lines 126-128: I am not sure that this is the most accurate summary statement given that (1) your results differ based on employment status and poverty level, and (2) not all patient-reported outcomes were significantly different between your groups. I would revise this summary statement to provide a more cautious interpretation of your results.

• Lines 132-133: Consider rephrasing to situate the statistics of your study population relative to the general population (e.g., “In this study, roughly half as many people were employed and three times as many lived below the poverty line relative to the general population of Hong Kong”).

• Lines 137-142: Do you think that people experiencing economic oppression are at higher risk of developing kidney failure or that undergoing hemodialysis impedes employment opportunities, which then leads to financial hardship? Some literature on this might be helpful to include in the introduction. This might also be worth mentioning in the limitations with respect to the need for longitudinal analyses.

• Lines 159-160: Can you recommend additional factors affecting financial hardship (e.g., wealth, homeownership)?

Table 1

• The origin of the patient-reported outcomes is not clear to me. Are these from the DSI? If so, why are there not 30?

• What is the KDQOL-36 PCS vs. MCS?

• How did you choose serum albumin vs. urine microalbumin as a clinical outcome?

**********

6. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: Yes: Jessica P Cerdeña, PhD

**********

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step.

PLoS One. 2023 Jun 23;18(6):e0287510. doi: 10.1371/journal.pone.0287510.r002

Author response to Decision Letter 0

5 Jan 2023

We are pleased to re-submit the revised manuscript entitled ‘Health Inequity Associated with Financial Hardship Among Patients with Kidney Failure: A Secondary Analysis’ (Manuscript No.: PONE-D-22-21227). We would like to thank the Editor and Reviewer for their thoughtful comments on the manuscript. Our responses to each of the comments are provided below in italics. The suggested revisions have strengthened the report of preliminary evidence, which informs directions for future research in health equity and financial wellbeing of patients with kidney failure. Thank you for your attention and I look forward to hearing from you.

Title/Abstract

• Line 5/20: Recommend using “kidney failure” rather than “end-stage kidney disease” per guidelines advanced by Levey et al. (2020)

Response: We revised the wordings (e.g., kidney failure, kidney care) accordingly.

Introduction

Response: We added a description about Hong Kong’s healthcare system in the Introduction section (p.4 lines 72-79).

Response: Thanks for this very thoughtful comment. We added a description about Hong Kong’s economic inequity in the Introduction section (p.4 lines 72-79).

Materials and Methods

• Line 71: Are you able to add details about the hospitals from which these data were collected? They are described as “regional hospitals” but are they public? Private?

Response: We provided details about these hospitals in the Materials and Methods section (p.4 lines 82-84).

• Line 72: Please provide a citation where the inclusion and exclusion criteria are previously reported.

Response: Details of the original study can be found in the reference #16. We added the inclusion and exclusion criteria in the Methods section for better understanding of the study design (p.4 line 85-87).

Response: We supplemented detailed accounts and references for the four instruments used in the Methods section (p.5 lines 92-110). To provide a fair comparison, we presented the results of all symptoms in the Dialysis Symptoms Index and other instruments in Table 1.

Results

• The authors report significant results but do not describe results that are not significant, which is important.

Response: Thanks for pointing out this issue. We stated non-significant results in the Results and Discussion sections (p.6 lines 138-139; p.7 lines 148-149) and included the statistics in the Table 1.

Discussion

Response: We revised the summary to precisely capture both significant and non-significant results (p.7 lines 148-152).

Response: We revised the statements based on your suggestion (p.7 line 154).

Response: Thanks for your suggestion. We added this point about disparities in the Introduction section (p.3 lines 53-55). We also stressed the need for a longitudinal study to investigate the impact of financial hardship on the outcomes of patients with kidney failure (p.8 lines 181-183).

• Lines 159-160: Can you recommend additional factors affecting financial hardship (e.g., wealth, homeownership)?

Response: We made recommendations on additional factors based on our recent review (p.8 lines 180-181).

Table 1

• The origin of the patient-reported outcomes is not clear to me. Are these from the DSI? If so, why are there not 30?

Response: We substantially revised Table 1 to present all the results, regardless their statistical significance levels.

• What is the KDQOL-36 PCS vs. MCS?

Response: We are sorry about the confusion. We defined all the abbreviations in the legends and provided details of the instruments in the Methods section (p.5 lines 92-110).

• How did you choose serum albumin vs. urine microalbumin as a clinical outcome?

Response: Serum albumin was chosen as an indicator of nutritional status but not disease progression. The data were retrieved from the laboratory results in the medical records. We analysed glomerular filtration rate to evaluate disease progression but no significant result was found (Table 1).

Attachment

Submitted filename: PLOSO_Response_221220.docx

Click here for additional data file.^{(17.3KB, docx)}

PLoS One. doi: 10.1371/journal.pone.0287510.r003

Decision Letter 1

Ari Samaranayaka

27 Jan 2023

PONE-D-22-21227R1Health Inequity Associated with Financial Hardship Among Patients with Kidney Failure: A Secondary AnalysisPLOS ONE

Dear Dr. Ng,

Please submit your revised manuscript by Mar 13 2023 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:

A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.
A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.
An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

We look forward to receiving your revised manuscript.

Kind regards,

Ari Samaranayaka, PhD

Academic Editor

PLOS ONE

Additional Editor Comments (if provided):

Dear authors,

As the new academic editor, this is my first opportunity to read this manuscript, therefore it is likely to have points in my comments below that were not identified in the earlier review round.

1). Authors have used ttest to compare outcomes between two financial level groups. ttest does not account for confounders, therefore factors that authors identified should be interpreted only as markers not as those with independent effects. Therefore conclusions need to be cautious to be within that limitation.

2). Line 59/60. “Negative health outcomes, including depression, anxiety, lower health-related quality of life (HRQoL), and higher mortality risk, have been reported (9-11)”. Is this statement referring to those with lower financial levels or those with CKD in general?

3). Line 81. How were patients selected? All the patients who met inclusion/exclusion criteria in these 2 hospitals during the recruitment period were included or was there any selection? How representative the participants to non-participants if there was a selection? Was there any reason (like sample size estimation) for selecting specifically N=354 patients?

4). Line 87-88. “… research assistant administered a questionnaire…”. Please indicate what information were collected through this questionnaire. I assume this questionnaire was used to collect all patient-reported outcomes as opposed to assessing inclusion/exclusion criteria.

5). Line 82. “… patients were recruited from two public hospitals”. Could you name these hospitals?

6). Line 89/90. “… approved by the institutional research boards of the university and the involved hospitals”. Could you name these institutions?

7). Line 108-112. Please give references for weighted score version of Charlson Comorbidity Index and MDRD equation. Cited ref 23 not applicable for these measures.

8). Line 124. 58.5% were male. Different percentage in table1.

9). Line 131-141. This paragraph included results of comparing individual symptoms used to derive DSI score. This is a concern for multiple reasons. First, DSI index has been validated as a summative measure, not for individual symptoms, as reported in lines 92-110. Terefore how correct this comparison of individual items? Why validated summative DSI score not compared between groups? Second, ttest need outcome measures to be in continuous scale, patient-reported responses for these individual symptoms are in categorical scales (ie, likert scale coded to numeric) rather than in continuous scale, therefore not suitable for ttest. If authors need to retain these individual symptoms comparisons as results they need a justification with supporting reference(s) on why ttest is suitable. As at present ttest is not an appropriate statistical method. Otherwise comparison has to be done using a statistical method appropriate for the data. Same comment applicable to the corresponding results in table1.

10). Abstract line 32. “... increased distress associated with specific symptoms,…”. Methods section says dialysis symptom index (DSI) is derived from kidney symptoms, and higher DSI indicates higher distress. If so, above statement is obvious by definition, therefore I wonder why it is worth reporting as a result.

11). Table1. Please remove all asterisks and associated footnote because they are redundant.

12). Table1. Please check the correctness of the reported SD (0.11) for age for unemployed group.

13). Table1. Please mention Clinical visits and ER attendance are counted over what period. I could not find that in methods section. Please make sure method section includes how each of the reported measure was measured.

[Note: HTML markup is below. Please do not edit.]

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #1: (No Response)

**********

2. Is the manuscript technically sound, and do the data support the conclusions?

Reviewer #1: Yes

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

Reviewer #1: Yes

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

Reviewer #1: Yes

**********

6. Review Comments to the Author

Reviewer #1: Thank you for the opportunity to re-review this manuscript. I think this manuscript has improved significantly and I have just a few additional suggestions that I hope will strengthen it.

- It is not immediately clear to me why patients with active psychiatric disorders were excluded. Without going into too much detail, could the authors briefly explain this rationale? Also, the authors could also consider adding a flow diagram to demonstrate how they arrived at the final study population, unless this is included in previously published studies.

- I may misunderstand how the Dialysis Symptom Index should be used. I interpreted it as a summative instrument by which the positive response to more items indicates increased symptom burden. I am not sure what it means to interpret each symptom in isolation. For instance, what does it mean clinically that there is a significant difference in skin dryness and sleep maintenance between economically oppressed and advantaged people? I think it would be more meaningful to know whether there is a difference in symptom burden (or distress, as you write). This may be a null finding, which I think is understandable.

- I think your more meaningful finding is the significant difference in the Charleston Comorbidity Index. I think some of your discussion can be reframed to emphasize this specific finding—rather than the individual symptom differences—in addition to your other findings on healthcare utilization. For instance, I came across this older paper that looked into this question, and I imagine there are several more.

Droomers, Mariël, and Gert P. Westert. 2004. “Do Lower Socioeconomic Groups Use More Health Services, Because They Suffer from More Illnesses?” European Journal of Public Health 14 (3): 311–13. https://doi.org/10.1093/eurpub/14.3.311.

I recommend highlighting this finding as a key takeaway of the paper.

Again, thank you for the opportunity to review this paper and I look forward to seeing it published.

**********

7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: Yes: Jessica P. Cerdeña

**********

PLoS One. 2023 Jun 23;18(6):e0287510. doi: 10.1371/journal.pone.0287510.r004

Author response to Decision Letter 1

23 Feb 2023

Response: Thanks for this kindly advice. The limitation related to the statistical methods was highlighted in the Discussion section.

Response: The statement was revised to enhance clarity.

Response: Further details about recruitment were provided in the Methods and Results sections.

Response: The statement was revised to enhance clarity.

5). Line 82. “… patients were recruited from two public hospitals”. Could you name these hospitals?

Response: The names of the hospitals were provided.

6). Line 89/90. “… approved by the institutional research boards of the university and the involved hospitals”. Could you name these institutions?

Response: This statement which is redundant was removed. The names of the IRBs involved were provided together with the reference numbers in the following statement.

7). Line 108-112. Please give references for weighted score version of Charlson Comorbidity Index and MDRD equation. Cited ref 23 not applicable for these measures.

Response: References were updated for the captioned instruments.

8). Line 124. 58.5% were male. Different percentage in table1.

Response: Thanks for spotting out the inconsistency. The figure was checked against raw data and the numbers in Table 1 were revised.

9). Line 131-141. This paragraph included results of comparing individual symptoms used to derive DSI score. This is a concern for multiple reasons. First, DSI index has been validated as a summative measure, not for individual symptoms, as reported in lines 92-110. Therefore how correct this comparison of individual items? Why validated summative DSI score not compared between groups? Second, ttest need outcome measures to be in continuous scale, patient-reported responses for these individual symptoms are in categorical scales (ie, likert scale coded to numeric) rather than in continuous scale, therefore not suitable for ttest. If authors need to retain these individual symptoms comparisons as results they need a justification with supporting reference(s) on why ttest is suitable. As at present ttest is not an appropriate statistical method. Otherwise comparison has to be done using a statistical method appropriate for the data. Same comment applicable to the corresponding results in table1.

Response: Thanks for raising the statistical concerns. First, we added the comparison of DSI total scores in Table 1 for reference. The DSI not only generates a score to indicate the overall symptom burden, but it also provides a framework for assessing CKD-related symptoms, as demonstrated by good content validity and test-retest reliability of individual items in the original instrument (Weisbord et al., 2004). Of note, in a study by Weisbord et al. (2007), symptoms reported by patients and clinicians were compared based on the mean scores of individual symptoms. Second, it is implicitly assumed that the individual item scores of DSI are of interval scale data, otherwise it does not make sense to calculate a summative score for DSI. Indeed, it is common to report means and standard deviations of individual symptoms in previous studies (Almutary et al., 2016; de Rooji et al., 2022; Weisbord et al., 2007) and the item scores are not skewed. Therefore, we believe that t-test is appropriate to compare the severity levels of symptoms between groups.

References:

Almutary, H., Bonner, A., & Douglas, C. (2016). Which patients with chronic kidney disease have the greatest symptom burden? A comparative study of advanced CKD stage and dialysis modality. Journal of Renal Care, 42(2), 73-82.

de Rooij, E. N., Meuleman, Y., de Fijter, J. W., Jager, K. J., Chesnaye, N. C., Evans, M., ... & Hoogeveen, E. K. (2022). Symptom burden before and after dialysis initiation in older patients. Clinical Journal of the American Society of Nephrology, 17(12), 1719-1729.

Weisbord, S. D., Fried, L. F., Arnold, R. M., Rotondi, A. J., Fine, M. J., Levenson, D. J., & Switzer, G. E. (2004). Development of a symptom assessment instrument for chronic hemodialysis patients: The Dialysis Symptom Index. Journal of Pain and Symptom management, 27(3), 226-240.

Weisbord, S. D., Fried, L. F., Mor, M. K., Resnick, A. L., Unruh, M. L., Palevsky, P. M., ... & Arnold, R. M. (2007). Renal provider recognition of symptoms in patients on maintenance hemodialysis. Clinical Journal of the American Society of Nephrology, 2(5), 960-967.

Response: The meaning of the captioned phrase means distress ‘originated from specific symptoms.’ We did not imply a statistical association between distress and specific symptoms. The statement was revised to enhance clarity.

11). Table1. Please remove all asterisks and associated footnote because they are redundant.

Response: All asterisks and footnotes were removed accordingly.

12). Table1. Please check the correctness of the reported SD (0.11) for age for unemployed group.

Response: The figures were checked against raw data and the number in the Table 1 was revised.

Response: The duration of capturing clinical/ER visits and lengths of hospital stay were added in the Methods section and Table 1.

Attachment

Submitted filename: PLOSO_Response_230224.docx

Click here for additional data file.^{(17KB, docx)}

PLoS One. doi: 10.1371/journal.pone.0287510.r005

Decision Letter 2

Mohammad Meshbahur Rahman

14 Apr 2023

PONE-D-22-21227R2Health Inequity Associated with Financial Hardship Among Patients with Kidney Failure: A Secondary AnalysisPLOS ONE

Dear Dr. Ng,

Please submit your revised manuscript by May 29 2023 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:

A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.
A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.
An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

We look forward to receiving your revised manuscript.

Kind regards,

Mohammad Meshbahur Rahman, MS.

Academic Editor

PLOS ONE

Journal Requirements:

Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice.

[Note: HTML markup is below. Please do not edit.]

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

Reviewer #2: (No Response)

**********

2. Is the manuscript technically sound, and do the data support the conclusions?

Reviewer #2: Yes

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #2: No

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

Reviewer #2: No

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

Reviewer #2: Yes

**********

6. Review Comments to the Author

Reviewer #2: The study titled “Health Inequity Associated with Financial Hardship Among Patients with Kidney Failure: A Secondary Analysis” aims to identify the differences in patient-reported and clinical outcomes among patients with different financial status. This is a very timely article with the distinct merit of linking patients outcomes and financial status. However, I have some observations as follows:

My other comments are as follows:

Abstract:

1. Line 22: Please specify the terms “kidney failure patients” in this line “This cross-sectional study aimed to identify the differences in patient-reported and clinical outcomes among patients with different financial status”

2. Line 24: Please start with the word in this line “354 patients with end-stage kidney disease were recruited from 25 March to June 2017 at two regional hospitals in Hong Kong”

Introduction:

3. Line 66: it may be "aid" instead of "aids."

4. Line 68: Please add this line “In Hong Kong, not enough research is done to examine health consequences of financial status.”

5. Line 73-75: Can the author give more recent data?

Materials and Methods:

6. Line 92: “After explaining the study and obtaining informed consent, the research assistant administered a questionnaire containing a demographic form and the instruments.” Please share that form as a supplementary file.

7. Line 108: it maybe "It’s" instead of "Its"

8. Line 110-118: Please specify categories of all outcome (categorical) variables and also how they are categorized.

9. Line 127-128: Please add a few lines about how you measure the P-value for frequency or percentage information. Did the author check the chi-square test for the categorical variables? Please provide the relevant statistics.

10. Line 166: Why the author didn’t conduct any regression model? Any explanation?

Results

11. Line 131: Please provide this information “58.5% were male” either in a graph or in the table.

Discussion:

12. Line 173-175: Can the author justify this?

13. Line 179-182: Please clarify “While symptoms and other outcomes are signs of deteriorating health, patients with a poorer symptom status or poorer outcomes may have a higher demand for healthcare services and a lower physical capacity for engaging actively in employment.”

**********

7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #2: Yes: Mohammad Nayeem Hasan

**********

PLoS One. 2023 Jun 23;18(6):e0287510. doi: 10.1371/journal.pone.0287510.r006

Author response to Decision Letter 2

18 Apr 2023

Response: The sentence was revised accordingly.

2. Line 24: Please start with the word in this line “354 patients with end-stage kidney disease were recruited from 25 March to June 2017 at two regional hospitals in Hong Kong”

Response: The sentence was revised so that it begins with a word.

3. Line 66: it may be "aid" instead of "aids."

Response: The term was revised accordingly.

4. Line 68: Please add this line “In Hong Kong, not enough research is done to examine health consequences of financial status.”

Response: We inserted a statement based on this suggestion.

5. Line 73-75: Can the author give more recent data?

Response: We updated the latest available figures of per capita GDP and Gini coefficient in 2021 and 2019 (World Bank Group, 2023; World Economics, 2019), respectively.

References

World Bank Group. GDP per capita (current US$) – Hong Kong SAR, China [Internet]. 2023 [Accessed 18 April 2023]. Available: https://data.worldbank.org/indicator/NY.GDP.PCAP.CD?locations=HK.

World Economics. Hong Kong’s Gini coefficient [Internet]. 2019 [Accessed 18 April 2023]. Available from: https://www.worldeconomics.com/Inequality/Gini-Coefficient/Hong%20Kong.aspx#.

Response: We attached the demographic form as a supplementary material in the revised version.

7. Line 108: it maybe "It’s" instead of "Its"

Response: We checked with the editor and confirmed that the use of ‘its’ in this case is appropriate.

8. Line 110-118: Please specify categories of all outcome (categorical) variables and also how they are categorized.

Response: The outcomes (i.e., functional status, comorbidity level, healthcare service utilization, biochemical parameters) were analysed as continuous variables and their measurements were described in the paragraph. We have now specified all categories of the categorical variables (i.e., sex, marital status, education level, dialysis modality, history of transplantation) in Table 1.

Response: We added detailed description about comparing background characteristics of patients with different financial status. Specifically, categorical variables were compared between the financial status groups by using chi-squared test, while all patient-reported and clinical outcomes were compared by using independent sample t-test.

10. Line 166: Why the author didn’t conduct any regression model? Any explanation?

Response: This study analysed data from the original study on symptom experience of patients with kidney failure. Factors potentially influencing financial hardship (e.g., financial aids, home ownership, personal savings, health spendings) have not been accessed in the original study (Ng et al., 2020; 2021). It is therefore immature to conduct adjusted analysis, such as regression analysis. Exploratory univariate analyses were only conducted aiming to provide some insights into whether there are differences in patient-reported and clinical outcomes in terms of financial hardship.

References

Ng MSN, Miaskowski C, Cooper B, Hui YH, Ho EHS, Mo SKL, et al. Distinct symptom experience among subgroups of patients with ESRD receiving maintenance dialysis. J Pain Symptom Manage 2020;60:70-9.

Ng MSN, Chan DNS, Cheng Q, Miaskowski C, So WKW. Association between financial hardship and symptom burden in patients receiving maintenance dialysis: a systematic review. Int J Environ Res Public Health 2021;18:9541.

11. Line 131: Please provide this information “58.5% were male” either in a graph or in the table.

Response: This information was presented in Table 1 (Background characteristics – Overall).

12. Line 173-175: Can the author justify this?

Response: We added a sentence to clarify the relationship with the support of a relevant study.

Response: The sentence was revised to clarify the reciprocal relationship. While symptoms and other outcomes may be the consequences of financial hardship, they may also reflect a lower physical capacity for engaging in economic activities.

Attachment

Submitted filename: PLOSO_Response_230418.docx

Click here for additional data file.^{(18.4KB, docx)}

PLoS One. doi: 10.1371/journal.pone.0287510.r007

Decision Letter 3

Mohammad Meshbahur Rahman

29 May 2023

PONE-D-22-21227R3Health Inequity Associated with Financial Hardship Among Patients with Kidney Failure: A Secondary AnalysisPLOS ONE

Dear Dr. Ng,

Please submit your revised manuscript by Jul 13 2023 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:

A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.
A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.
An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

We look forward to receiving your revised manuscript.

Kind regards,

Mohammad Meshbahur Rahman, MS.

Academic Editor

PLOS ONE

[Note: HTML markup is below. Please do not edit.]

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

Reviewer #3: (No Response)

**********

2. Is the manuscript technically sound, and do the data support the conclusions?

Reviewer #3: Partly

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #3: No

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

Reviewer #3: Yes

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

Reviewer #3: Yes

**********

6. Review Comments to the Author

Reviewer #3: The authors studied an important issue in relation to chronic kidney disease (CKD) or kidney failure. Financial hardship and inability to pay often leads to kidney failure receiving inadequate or suboptimal care. However, the authors used two variables to indirectly read the financial hardship, namely, employment and monthly family income.

Based on the suggestions by the previous reviewers, authors have modified the manuscript and have properly answered the points except the question regarding why regression analysis was not carried out.

Although the authors tried to give an explanation, which is not quite satisfactory. I think a logistic or linear regression analysis was possible by dichotomizing the KPS scale scores or taking it as a continuous scale, where important factors age, sex, marital status, employment, education years, dialysis types, history of transplantation, days of hospital stay could have been taken as factor variables, in order to check the nature and magnitude of association of financial hardship and health when adjusted for other factors. Please note that if you find some patients unemployed but having good financial status, this could indirectly indicate that they are either receiving aid / or using personal savings. Similarly the health care service utilization and its relationship with various factors could checked in a similar way.

In addition, from the methods it seems clear that some information was collected directly from patients. Hence, the words “A secondary analysis” in the title does not seem appropriate.

The author should explore the said analyses, add additional tables and description and add necessary discussion.

**********

7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #3: No

**********

PLoS One. 2023 Jun 23;18(6):e0287510. doi: 10.1371/journal.pone.0287510.r008

Author response to Decision Letter 3

31 May 2023

We are pleased to re-submit the revised manuscript entitled ‘Health Inequity Associated with Financial Hardship Among Patients with Kidney Failure’ (Manuscript No.: PONE-D-22-21227). We would like to thank the Editor and Reviewer for their thoughtful comments on the manuscript. Our responses to each of the comments are provided below in italics. The suggested revisions have strengthened the report of preliminary evidence, which informs directions for future research in health equity and financial wellbeing of patients with kidney failure. Thank you for your attention and I look forward to hearing from you.

1. Although the authors tried to give an explanation, which is not quite satisfactory. I think a logistic or linear regression analysis was possible by dichotomizing the KPS scale scores or taking it as a continuous scale, where important factors age, sex, marital status, employment, education years, dialysis types, history of transplantation, days of hospital stay could have been taken as factor variables, in order to check the nature and magnitude of association of financial hardship and health when adjusted for other factors.

Response: We used multiple regression analyses to examine the associations between outcome variables, employment status, and income level adjusted for demographic factors (sex, marital status, education level, dialysis modality, history of transplantation, age, duration on dialysis). Findings were presented in Tables 1 and 2. The relevant contents in the Results, Discussion, and Abstract were amended accordingly.

2. In addition, from the methods it seems clear that some information was collected directly from patients. Hence, the words “A secondary analysis” in the title does not seem appropriate.

Response: We deleted the term ‘secondary analysis’ from the title and Methods.

3. The author should explore the said analyses, add additional tables and description and add necessary discussion.

Response: We conducted regression analyses, and their details and implications were added in the Methods, Results, and Discussions as appropriate.

Attachment

Submitted filename: PLOSO_Response_230530.docx

Click here for additional data file.^{(15.9KB, docx)}

PLoS One. doi: 10.1371/journal.pone.0287510.r009

Decision Letter 4

Mohammad Meshbahur Rahman

6 Jun 2023

PONE-D-22-21227R4Health Inequity Associated with Financial Hardship Among Patients with Kidney FailurePLOS ONE

Dear Dr. Ng,

==============================

Please submit your revised manuscript by Jul 21 2023 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:

A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.
A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.
An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

We look forward to receiving your revised manuscript.

Kind regards,

Mohammad Meshbahur Rahman, MS.

Academic Editor

PLOS ONE

Journal Requirements:

[Note: HTML markup is below. Please do not edit.]

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

Reviewer #3: All comments have been addressed

**********

2. Is the manuscript technically sound, and do the data support the conclusions?

Reviewer #3: Yes

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #3: Yes

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

Reviewer #3: Yes

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

Reviewer #3: Yes

**********

6. Review Comments to the Author

Reviewer #3: Thank you addressing the comments. The manuscript now looks complete. The recommended analyses has given some additional insights to the main findings.

Several minor corrections are recommended-

1. The following variables are not normally distributed in your data: Months on dialysis, CCI, clinical visits in 6 months, ER attendance in 6 months and days of hospital stay in 6 months. It is not justified to use t test for comparison of these variables across income and employment groups. Also, data should be expressed as 'median (IQR)' rather than as mean SD. So, for these variables in the tables do following things.

a. Use Wicoxon Rank Sum Test (Mann-Whiteny U test) for comparison

b. Express as Median (IQR) for all three columns

2. Instead of writing N % and Mean SD in the table rows, explain how data was presented in the footnotes. For example you can write- Data was presented as N %, Mean SD and Median IQR where appropriate.

3. Remove the column containing t values from the table. The p-values expressed in three decimal points are enough to display the student distribution of the differences.

4. Give the full forms of abbreviations used in the tables in table footnotes. (E.g. PCS, MCS, KPS, CCI etc).

**********

7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #3: Yes: Md. Abdullah Saeed Khan

**********

PLoS One. 2023 Jun 23;18(6):e0287510. doi: 10.1371/journal.pone.0287510.r010

Author response to Decision Letter 4

6 Jun 2023

a. Use Wicoxon Rank Sum Test (Mann-Whiteny U test) for comparison

b. Express as Median (IQR) for all three columns

Response: We appreciate these precise and constructive suggestions. We conducted the analyses as advised and revised the relevant parts in the manuscript (including Analyses, Results, and Tables).

Response: We added a footnote to indicate variables of which medians and inter-quartile ranges are presented.

3. Remove the column containing t values from the table. The p-values expressed in three decimal points are enough to display the student distribution of the differences.

Response: The column was deleted as advised.

4. Give the full forms of abbreviations used in the tables in table footnotes. (E.g. PCS, MCS, KPS, CCI etc).

Response: We provided the full names of the instruments in the Tables.

Attachment

Submitted filename: PLOSO_Response_230606.docx

Click here for additional data file.^{(16KB, docx)}

PLoS One. doi: 10.1371/journal.pone.0287510.r011

Decision Letter 5

Mohammad Meshbahur Rahman

7 Jun 2023

Health Inequity Associated with Financial Hardship Among Patients with Kidney Failure

PONE-D-22-21227R5

Dear Dr. Ng,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

An invoice for payment will follow shortly after the formal acceptance. To ensure an efficient process, please log into Editorial Manager at http://www.editorialmanager.com/pone/, click the 'Update My Information' link at the top of the page, and double check that your user information is up-to-date. If you have any billing related questions, please contact our Author Billing department directly at authorbilling@plos.org.

If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they’ll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org.

Kind regards,

Mohammad Meshbahur Rahman, MS.

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

Reviewer #3: All comments have been addressed

**********

2. Is the manuscript technically sound, and do the data support the conclusions?

Reviewer #3: Yes

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #3: Yes

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

Reviewer #3: Yes

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

Reviewer #3: Yes

**********

6. Review Comments to the Author

Reviewer #3: This a good study discovering impacts of socioeconomic inequity in the care of complicated chronic disease. Best wishes for you hard work.

**********

7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #3: Yes: Md. Abdullah Saeed Khan

**********

PLoS One. doi: 10.1371/journal.pone.0287510.r012

Acceptance letter

Mohammad Meshbahur Rahman

13 Jun 2023

PONE-D-22-21227R5

Health Inequity Associated with Financial Hardship Among Patients with Kidney Failure

Dear Dr. Ng:

I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department.

If your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information please contact onepress@plos.org.

If we can help with anything else, please email us at plosone@plos.org.

Thank you for submitting your work to PLOS ONE and supporting open access.

Kind regards,

PLOS ONE Editorial Office Staff

on behalf of

Mr. Mohammad Meshbahur Rahman

Academic Editor

PLOS ONE

Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Supplementary Materials

S1 File. Demographic form.

This form was developed by the research team to collect demographic information of the participants.

(PDF)

Click here for additional data file.^{(263.1KB, pdf)}

Attachment

Submitted filename: PLOSO_Response_221220.docx

Click here for additional data file.^{(17.3KB, docx)}

Attachment

Submitted filename: PLOSO_Response_230224.docx

Click here for additional data file.^{(17KB, docx)}

Attachment

Submitted filename: PLOSO_Response_230418.docx

Click here for additional data file.^{(18.4KB, docx)}

Attachment

Submitted filename: PLOSO_Response_230530.docx

Click here for additional data file.^{(15.9KB, docx)}

Attachment

Submitted filename: PLOSO_Response_230606.docx

Click here for additional data file.^{(16KB, docx)}

Data Availability Statement

[pone.0287510.ref001] 1.GBD Chronic Kidney Disease Collaboration. Global, regional, and national burden of chronic kidney disease, 1990–2017: a systematic analysis for the Global Burden of Disease Study 2017. Lancet 2020;395:709–33. doi: 10.1016/S0140-6736(20)30045-3 [DOI] [PMC free article] [PubMed] [Google Scholar]

[pone.0287510.ref002] 2.Luyckx VA, Tonelli M, Stanifer JW. The global burden of kidney disease and the sustainable development goals. Bull World Health Organ 2018;96:414–22. doi: 10.2471/BLT.17.206441 [DOI] [PMC free article] [PubMed] [Google Scholar]

[pone.0287510.ref003] 3.van der Tol A, Lameire N, Morton RL, Van Biesen W, Vanholder R. An international analysis of dialysis services reimbursement. Clin J Am Soc Nephrol 2019;14:84–93. doi: 10.2215/CJN.08150718 [DOI] [PMC free article] [PubMed] [Google Scholar]

[pone.0287510.ref004] 4.Brown EA, Zhao J, McCullough K, Fuller DS, Figueiredo AE, Bieber B, et al. Burden of kidney disease, health-related quality of life, and employment among patients receiving peritoneal dialysis and in-center hemodialysis: findings from the DOPPS program. Am J Kidney Dis 2021;78:489–500. doi: 10.1053/j.ajkd.2021.02.327 [DOI] [PubMed] [Google Scholar]

[pone.0287510.ref005] 5.Morton RL, Schlackow I, Gray A, Emberson J, Herrington W, Staplin N, et al. Impact of CKD on household income. Kidney Int Rep 2018;3:610–8. doi: 10.1016/j.ekir.2017.12.008 [DOI] [PMC free article] [PubMed] [Google Scholar]

[pone.0287510.ref006] 6.Carrera PM, Kantarjian HM, Blinder VS. The financial burden and distress of patients with cancer: understanding and stepping-up action on the financial toxicity of cancer treatment. CA Cancer J Clin 2018;68:153–65. doi: 10.3322/caac.21443 [DOI] [PMC free article] [PubMed] [Google Scholar]

[pone.0287510.ref007] 7.Altice CK, Banegas MP, Tucker-Seeley RD, Yabroff KR. Financial hardships experienced by cancer survivors: a systematic review. J Natl Cancer Inst 2017;109:djw205. doi: 10.1093/jnci/djw205 [DOI] [PMC free article] [PubMed] [Google Scholar]

[pone.0287510.ref008] 8.Ng MSN, Chan DNS, Cheng Q, Miaskowski C, So WKW. Association between financial hardship and symptom burden in patients receiving maintenance dialysis: a systematic review. Int J Environ Res Public Health 2021;18:9541. doi: 10.3390/ijerph18189541 [DOI] [PMC free article] [PubMed] [Google Scholar]

[pone.0287510.ref009] 9.Ikonomou M, Skapinakis P, Balafa O, Eleftheroudi M, Damigos D, Siamopoulos KC. The impact of socioeconomic factors on quality of life of patients with chronic kidney disease in Greece. J Renal Care 2015;41:239–46. doi: 10.1111/jorc.12132 [DOI] [PubMed] [Google Scholar]

[pone.0287510.ref010] 10.Tao S, Zeng X, Liu J, Fu P. Socioeconomic status and mortality among dialysis patients: a systematic review and meta-analysis. Int Urol Nephrol 2019;51:509–18. doi: 10.1007/s11255-019-02078-5 [DOI] [PubMed] [Google Scholar]

[pone.0287510.ref011] 11.Chen J, Liu L, Chen J, Ng MS, Lou VW, Wu B, et al. The cross-lagged association between depressive symptoms and health-related quality of life in patients receiving maintenance hemodialysis: a three-wave longitudinal study. Qual Life Res 2021;30:3463–3473. doi: 10.1007/s11136-021-02866-6 [DOI] [PubMed] [Google Scholar]

[pone.0287510.ref012] 12.Krishnan M. The importance of considering total patient economics for hemodialysis. Kidney Int Rep 2019;4:365–6. [DOI] [PMC free article] [PubMed] [Google Scholar]

[pone.0287510.ref013] 13.Kalantar-Zadeh K, Li PK, Tantisattamo E, Kumaraswami L, Liakopoulos V, Lui S, et al. Living well with kidney disease by patient and care-partner empowerment: kidney health for everyone everywhere. Clin Nephrol 2021;95:115–22. doi: 10.5414/CN110436 [DOI] [PubMed] [Google Scholar]

[pone.0287510.ref014] 14.World Bank Group. GDP per capita (current US$)–Hong Kong SAR, China [Internet]. 2023. [Accessed 18 April 2023]. Available: https://data.worldbank.org/indicator/NY.GDP.PCAP.CD?locations=HK. [Google Scholar]

[pone.0287510.ref015] 15.World Economics. Hong Kong’s Gini coefficient [Internet]. 2019. [Accessed 18 April 2023]. Available from: https://www.worldeconomics.com/Inequality/Gini-Coefficient/Hong%20Kong.aspx#. [Google Scholar]

[pone.0287510.ref016] 16.Schoeb V. Healthcare service in Hong Kong and its challenges: the role of health professionals within a social model of health. China Perspect 2016;4:51–58. [Google Scholar]

[pone.0287510.ref017] 17.Ng MSN, Miaskowski C, Cooper B, Hui YH, Ho EHS, Mo SKL, et al. Distinct symptom experience among subgroups of patients with ESRD receiving maintenance dialysis. J Pain Symptom Manage 2020;60:70–9. doi: 10.1016/j.jpainsymman.2020.01.004 [DOI] [PubMed] [Google Scholar]

[pone.0287510.ref018] 18.Government of the HKSAR. Hong Kong poverty situation report 2019 [Internet]. 2019. [Accessed 30 March 2022]. Available from: https://www.povertyrelief.gov.hk/eng/pdf/Hong_Kong_Poverty_Situation_Report_2019.pdf. [Google Scholar]

[pone.0287510.ref019] 19.Weisbord SD, Fried LF, Arnold RM, Rotondi AJ, Fine MJ, Levenson DJ, et al. Development of a symptom assessment instrument for chronic hemodialysis patients: the Dialysis Symptom Index. J Pain Symptom Manage 2004;27:226–240. doi: 10.1016/j.jpainsymman.2003.07.004 [DOI] [PubMed] [Google Scholar]

[pone.0287510.ref020] 20.Ng MSN, So WKW, Wong CL, Hui YH, Ho EHS, Choi KC, et al. Stability and impact of symptom clusters in patients with end-stage renal disease undergoing dialysis. J Pain Symptom Manage 2020;59:67–76. [DOI] [PubMed] [Google Scholar]

[pone.0287510.ref021] 21.Hays RD, Kallich JD, Mapes DL, Coons SJ, Amin N, Carter WB, et al. Kidney Disease Quality of Life Short Form (KDQOL-SFTM), version 1.3: a manual for use and scoring [Internet]. 1997. [Accessed 30 March 2022]. Available from: https://www.rand.org/health-care/surveys_tools/kdqol.html. [Google Scholar]

[pone.0287510.ref022] 22.Chow SKY, Tam BML. Is the kidney disease quality of life-36 (KDQOL-36) a valid instrument for Chinese dialysis patients? BMC Nephrol 2014;15:1–7. [DOI] [PMC free article] [PubMed] [Google Scholar]

[pone.0287510.ref023] 23.Péus D, Newcomb N, Hofer S. Appraisal of the Karnofsky performance status and proposal of a simple algorithmic system for its evaluation. BMC Med Inform Decis Mak 2013;13:1–7. [DOI] [PMC free article] [PubMed] [Google Scholar]

[pone.0287510.ref024] 24.Hemmelgarn BR, Manns BJ, Quan H, Ghali WA. Adapting the Charlson Comorbidity Index for use in patients with ESRD. Am J Kidney Dis 2003;42:125–32. doi: 10.1016/s0272-6386(03)00415-3 [DOI] [PubMed] [Google Scholar]

[pone.0287510.ref025] 25.Levey AS, Coresh J. Greene T, Stevens LA, Zhang Y, Hendriksen S, et al. Using standardized serum creatinine values in the modification of diet in renal disease study equation for estimating glomerular filtration rate. Ann Int Med 2006;145,247–54. doi: 10.7326/0003-4819-145-4-200608150-00004 [DOI] [PubMed] [Google Scholar]

[pone.0287510.ref026] 26.Ng MSN, Wong CL, Choi KC, Hui YH, Ho EHS, Miaskowski C, et al. A mixed methods study of symptom experience in patients with end-stage renal disease. Nurs Res 2021;70:34–43. doi: 10.1097/NNR.0000000000000479 [DOI] [PubMed] [Google Scholar]

[pone.0287510.ref027] 27.Essue BM, Wong G, Chapman J, Li Q, Jan S. How are patients managing with the costs of care for chronic kidney disease in Australia? A cross-sectional study. BMC Nephrol 2013;14:5. doi: 10.1186/1471-2369-14-5 [DOI] [PMC free article] [PubMed] [Google Scholar]

[pone.0287510.ref028] 28.Ng MSN, Hui YH, Law BYS, Wong CL, So WKW. Challenges encountered by patients with end-stage kidney disease in accessing symptom management services: a narrative inquiry. J Adv Nurs 2021;77(3):1391–402. doi: 10.1111/jan.14678 [DOI] [PubMed] [Google Scholar]

[pone.0287510.ref029] 29.Ng MSN, Wong CL, Ho EHS, Hui YH, Miaskowski C, So WKW. Burden of living with multiple concurrent symptoms in patients with end-stage renal disease. J Clin Nurs 2020;29:2589–601. doi: 10.1111/jocn.15282 [DOI] [PubMed] [Google Scholar]

PERMALINK

Health inequity associated with financial hardship among patients with kidney failure

Marques Shek Nam Ng

Dorothy Ngo Sheung Chan

Winnie Kwok Wei So

Roles

Abstract

Introduction

Materials and methods

Instruments

Analyses

Results

Table 1. Background characteristics and comparison between different employment groups.

Table 2. Comparison between different income groups.

Discussion

Conclusion

Supporting information

Acknowledgments

Data Availability

Funding Statement

References

Decision Letter 0

Jamie Males

Roles

Author response to Decision Letter 0

Decision Letter 1

Ari Samaranayaka

Roles

Author response to Decision Letter 1

Decision Letter 2

Mohammad Meshbahur Rahman

Roles

Author response to Decision Letter 2

Decision Letter 3

Mohammad Meshbahur Rahman

Roles

Author response to Decision Letter 3

Decision Letter 4

Mohammad Meshbahur Rahman

Roles

Author response to Decision Letter 4

Decision Letter 5

Mohammad Meshbahur Rahman

Roles

Acceptance letter

Mohammad Meshbahur Rahman

Roles

Associated Data

Supplementary Materials

Data Availability Statement

ACTIONS

PERMALINK

RESOURCES

Similar articles

Cited by other articles

Links to NCBI Databases