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Rationale for a home dialysis virtual ward: design and implementation.

ABSTRACT: Home-based renal replacement therapy (RRT) [peritoneal dialysis (PD) and home hemodialysis (HHD)] offers independent quality of life and clinical advantages compared to conventional in-center hemodialysis. However, follow-up may be less complete for home dialysis patients following a change in care settings such as post hospitalization. We aim to implement a Home Dialysis Virtual Ward (HDVW) strategy, which is targeted to minimize gaps of care.The HDVW Pilot Study will enroll consecutive PD and HHD patients who fulfilled any one of our inclusion criteria: 1. following discharge from hospital, 2. after interventional procedure(s), 3. prescription of anti-microbial agents, or 4. following completion of home dialysis training. Clinician-led telephone interviews are performed weekly for 2 weeks until VW discharge. Case-mix (modified Charlson Comorbidity Index), symptoms (the modified Edmonton Symptom Assessment Scale) and patient satisfaction are assessed serially. The number of VW interventions relating to eight pre-specified domains will be measured. Adverse events such as re-hospitalization and health-services utilization will be ascertained through telephone follow-up after discharge from the VW at 2, 4, 12 weeks. The VW re-hospitalization rate will be compared with a contemporary cohort (matched for age, gender, renal replacement therapy and co-morbidities). Our protocol has been approved by research ethics board (UHN: 12-5397-AE). Written informed consent for participation in the study will be obtained from participants.This report serves as a blueprint for the design and implementation of a novel health service delivery model for home dialysis patients. The major goal of the HDVW initiative is to provide appropriate and effective supports to medically complex patients in a targeted window of vulnerability.(NCT01912001).

SUBMITTER: Schachter ME

PROVIDER: S-EPMC3930556 | biostudies-literature | 2014 Feb

REPOSITORIES: biostudies-literature

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Rationale for a home dialysis virtual ward: design and implementation.

Schachter Michael E ME Bargman Joanne M JM Copland Michael M Hladunewich Michelle M Tennankore Karthik K KK Levin Adeera A Oliver Matthew M Pauly Robert P RP Perl Jeffrey J Zimmerman Deborah D Chan Christopher T CT

BMC nephrology 20140214

<h4>Background</h4>Home-based renal replacement therapy (RRT) [peritoneal dialysis (PD) and home hemodialysis (HHD)] offers independent quality of life and clinical advantages compared to conventional in-center hemodialysis. However, follow-up may be less complete for home dialysis patients following a change in care settings such as post hospitalization. We aim to implement a Home Dialysis Virtual Ward (HDVW) strategy, which is targeted to minimize gaps of care.<h4>Methods/design</h4>The HDVW P ...[more]

PMID: 24528505

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Project description:BACKGROUND: Many organizations rely on quality improvement collaboratives (QICs) to facilitate Patient-Centered Medical Home (PCMH) implementation, and there is a trend toward conducting QIC activities virtually to reduce costs and expand their reach. However, the evidence base for QICs is limited; questions remain about how QICs operate, why they succeed or fail, and how they are experienced by participants. OBJECTIVE: We surveyed participants in an innovative Virtual Collaborative (VC) designed to support PCMH implementation within one Veterans Integrated Service Network, to understand why and for whom the VC was more/less effective and identify opportunities for improvement. DESIGN: This anonymous online survey was designed to assess participants' views on the VC's usefulness, impact, and acceptability, and to explore variations by role, practice setting, prior training, and overall engagement in VC activities. PARTICIPANTS: Respondents were 353 primary care staff, including providers, nurses, and support staff. MEASURES/APPROACH: The survey comprised 32 structured and three free-response items. Structured items assessed participation in and perceived usefulness of VC activities; perceived acceptability of the training format; overall perceived impact; and basic demographics. Responses were dichotomized and compared using Chi-square tests. Free-response items inviting constructive criticism of the VC were coded and summarized to identify themes and illustrative quotes. RESULTS: The VC most benefited respondents with prior PCMH training and those who fully participated in VC activities. Respondents especially valued the opportunity to share experiences with other teams. Non-providers and those new to PCMH felt learning content did not meet their needs. Reported barriers to full participation included staffing constraints, insufficient and/or unprotected time, and inadequate leadership support. CONCLUSIONS: Our study offers practical lessons for others considering a virtual collaborative model for PCMH spread. Findings contribute to the evidence base for QICs overall and virtual QICs in particular, highlighting the value of seeking input from "the trenches."

Project description:BackgroundInformed dialysis selection and greater home dialysis use are the two long-desired, underachieved targets of advanced chronic kidney disease (CKD) care in the US healthcare system. Observational institutional studies have shown that comprehensive pre-kidney failure, conventionally referred to as end stage kidney disease education (CPE) can improve both these outcomes. However, lack of validated protocols, well-controlled studies, and systemic models have limited wide-spread adoption of CPE in the US. We hypothesized that a universal CPE and patient-centered initiation of kidney replacement therapy can improve multiple clinical, patient-centered and health service outcomes in advanced CKD and kidney failure requiring dialysis therapy.MethodsTrial to Evaluate and Assess the effects of CPE on Home dialysis in Veterans (TEACH-VET) is a multi-method randomized controlled trial aimed to evaluate the effects of a system-based approach for providing CPE to all Veterans with advanced CKD across a regional healthcare System. The study will randomize 544 Veterans with non-dialysis stage 4 and 5 CKD in a 1:1 allocation stratified by their annual family income and the stage of CKD to an intervention (CPE) arm or control arm. Intervention arm will receive a two-phase CPE in an intent-to-teach manner. Control arm will receive usual clinical care supplemented by resources for the freely-available kidney disease information. Participants will be followed after intervention/control for the duration of the study or until 90-days post-kidney failure, whichever occurs earlier.ResultsThe primary outcome will assess the proportion of Veterans using home dialysis at 90-days post-kidney failure, and secondary outcomes will include post-intervention/control CKD knowledge, confidence in dialysis decision and home dialysis selection. Qualitative arm of the study will use semi-structured interviews to in-depth assess Veterans' satisfaction with the intervention, preference for delivery, and barriers and facilitators to home dialysis selection and use. Several post-kidney failure clinical, patient-centered and health services outcomes will be assessed 90-days post-kidney failure as additional secondary outcomes.ConclusionThe results will provide evidence regarding the need and efficacy of a system-based, patient-centered approach towards universal CPE for all patients with advanced CKD. If successful, this may provide a blueprint for developing such programs across the similar healthcare infrastructures throughout the country.Trial registrationNCT04064086 .

Project description:BackgroundThe incidence and prevalence of older patients with kidney failure who are dependent on dialysis is increasing. However, observational studies showed limited or no benefit of dialysis on mortality in subgroups of these patients when compared to conservative care. As the focus is shifting towards health-related quality of life (HRQoL), current evidence of effects of conservative care or dialysis on HRQoL in older patients is both limited and biased. Dialysis comes with both high treatment burden for patients and high costs for society; better identification of patients who might not benefit from dialysis could result in significant cost savings. The aim of this prospective study is to compare HRQoL, clinical outcomes, and costs between conservative care and dialysis in older patients.MethodsThe DIALysis or not: Outcomes in older kidney patients with GerIatriC Assessment (DIALOGICA) study is a prospective, observational cohort study that started in February 2020. It aims to include 1500 patients from 25 Dutch and Belgian centres. Patients aged ≥70 years with an eGFR of 10-15 mL/min/1.73m2 are enrolled in the first stage of the study. When dialysis is initiated or eGFR drops to 10 mL/min/1.73m2 or lower, the second stage of the study commences. In both stages nephrogeriatric assessments will be performed annually, consisting of questionnaires and tests to assess most common geriatric domains, i.e. functional, psychological, somatic, and social status. The primary outcome is HRQoL, measured with the Twelve-item Short-Form Health Survey. Secondary outcomes are clinical outcomes (mortality, hospitalisation, functional status, cognitive functioning, frailty), cost-effectiveness, and decisional regret. All outcomes are (repeated) measures during the first year of the second stage. The total follow-up will be a maximum of 4 years with a minimum of 1 year in the second stage.DiscussionBy generating more insight in the effects of conservative care and dialysis on HRQoL, clinical outcomes, and costs, findings of this study will help patients and physicians make a shared decision on the best individual treatment option for kidney failure.Trial registrationThe study was registered in the Netherlands Trial Register ( NL-8352 ) on 5 February 2020.

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Rationale for a home dialysis virtual ward: design and implementation.

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Rationale for a home dialysis virtual ward: design and implementation.

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