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Integrating a Medical Home in an Outpatient Dialysis Setting: Effects on Health-Related Quality of Life.

ABSTRACT: BACKGROUND:Integrating primary care has been proposed to reduce fragmented care delivery for patients with complex medical needs. Because of their high rates of morbidity, healthcare use, and mortality, patients with end-stage kidney disease (ESKD) may benefit from increased access to a primary care medical home. OBJECTIVE:To evaluate the effect of integrating a primary care medical home on health-related quality of life (HRQOL) for patients with ESKD receiving chronic hemodialysis. DESIGN:Before-after intervention trial with repeated measures at two Chicago dialysis centers. PARTICIPANTS:Patients receiving hemodialysis at either of the two centers. INTERVENTION:To the standard hemodialysis team (nephrologist, nurse, social worker, dietitian), we added a primary care physician, a pharmacist, a nurse coordinator, and a community health worker. The intervention took place from January 2015 through August 2016. MAIN MEASURES:Health-related quality of life, using the Kidney Disease Quality of Life (KDQOL) measures. KEY RESULTS:Of 247 eligible patients, 175 (71%) consented and participated; mean age was 54 years; 55% were men and 97% were African American or Hispanic. In regression analysis adjusted for individual visits with the medical home providers and other factors, there were significant improvements in four of five KDQOL domains: at 12 and 18 months, the Mental Component Score improved from baseline (adjusted mean 49.0) by 2.64 (p?=?0.01) and 2.96 (p?=?0.007) points, respectively. At 6 and 12 months, the Symptoms domain improved from baseline (adjusted mean?=?77.0) by 2.61 (p?=?0.02) and 2.35 points (p?=?0.05) respectively. The Kidney Disease Effects domain improved from baseline (adjusted mean?=?72.7), to 6, 12, and 18 months by 4.36 (p?=?0.003), 6.95 (p?

SUBMITTER: Hynes DM

PROVIDER: S-EPMC6816601 | biostudies-literature | 2019 Oct

REPOSITORIES: biostudies-literature

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Integrating a Medical Home in an Outpatient Dialysis Setting: Effects on Health-Related Quality of Life.

Hynes Denise M DM Fischer Michael M Fitzgibbon Marian M Porter Anna C AC Berbaum Michael M Schiffer Linda L Chukwudozie Ifeanyi B IB Nguyen Hai H Arruda Jose J

Journal of general internal medicine 20190724 10

<h4>Background</h4>Integrating primary care has been proposed to reduce fragmented care delivery for patients with complex medical needs. Because of their high rates of morbidity, healthcare use, and mortality, patients with end-stage kidney disease (ESKD) may benefit from increased access to a primary care medical home.<h4>Objective</h4>To evaluate the effect of integrating a primary care medical home on health-related quality of life (HRQOL) for patients with ESKD receiving chronic hemodialysi ...[more]

PMID: 31342329

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Project description:IntroductionDialysis patients are often prescribed a large number of medications to improve metabolic control and manage coexisting comorbidities. However, some studies suggest that a large number of medications could also detrimentally affect patients' health-related quality of life (HRQoL). Therefore, this study aims to provide insight in the association between the number of types of medications and HRQoL in dialysis patients.MethodsA multicentre cohort study was conducted among dialysis patients from Dutch dialysis centres 3 months after initiation of dialysis as part of the ongoing prospective DOMESTICO study. The number of types of medications, defined as the number of concomitantly prescribed types of drugs, was obtained from electronic patient records. Primary outcome was HRQoL measured with the Physical Component Summary (PCS) score and Mental Component Summary (MCS) score (range 0-100) of the Short Form 12. Secondary outcomes were number of symptoms (range 0-30) measured with the Dialysis Symptoms Index and self-rated health (range 0-100) measured with the EuroQol-5D-5L. Data were analysed using linear regression and adjusted for possible confounders, including comorbidity. Analyses for MCS and number of symptoms were performed after categorizing patients in tertiles according to their number of medications because assumptions of linearity were violated for these outcomes.ResultsA total of 162 patients were included. Mean age of patients was 58 ± 17 years, 35% were female, and 80% underwent haemodialysis. The mean number of medications was 12.2 ± 4.5. Mean PCS and MCS were 36.6 ± 10.2 and 46.8 ± 10.0, respectively. The mean number of symptoms was 12.3 ± 6.9 and the mean self-rated health 60.1 ± 20.6. In adjusted analyses, PCS was 0.6 point lower for each additional medication (95% confidence interval [95% CI]: -0.9 to -0.2; p = 0.002). MCS was 4.9 point lower (95% CI: -8.8 to -1.0; p = 0.01) and 1.0 point lower (95% CI: -5.1-3.1; p = 0.63) for the highest and middle tertiles of medications, respectively, than for the lowest tertile. Patients in the highest tertile of medications reported 4.1 more symptoms than in the lowest tertile (95% CI: 1.5-6.6; p = 0.002), but no significant difference in the number of symptoms was observed between the middle and lowest tertiles. Self-rated health was 1.5 point lower for each medication (95% CI: -2.2 to -0.7; p < 0.001).Discussion/conclusionAfter adjustment for comorbidity and other confounders, a higher number of medications were associated with a lower PCS, MCS, and self-rated health in dialysis patients and with more symptoms.

Project description:Rationale & objectiveDialysis patients judge health-related quality of life (HRQoL) as an essential outcome. Remarkably, little is known about HRQoL differences between home dialysis and in-center hemodialysis (HD) patients worldwide.Study designSystematic review and meta-analysis.Setting & study populationsSearch strategies were performed on the Cochrane Library, Pubmed, and EMBASE databases between 2007 and 2019. Home dialysis was defined as both peritoneal dialysis and home HD.Selection criteria for studiesRandomized controlled trials and observational studies that compared HRQoL in home dialysis patients versus in-center HD patients.Data extractionThe data extracted by 2 authors included HRQoL scores of different questionnaires, dialysis modality, and subcontinent.Analytical approachData were pooled using a random-effects model and results were expressed as standardized mean difference (SMD) with 95% CIs. Heterogeneity was explored using subgroup analyses.ResultsForty-six articles reporting on 41 study populations were identified. Most studies were cross-sectional in design (90%), conducted on peritoneal dialysis patients (95%), and used the 12-item or 36-item Short-Form Health Survey questionnaires (83%). More than half the studies showed moderate or high risk of bias. Pooled analysis of 4,158 home dialysis patients and 7,854 in-center HD patients showed marginally better physical HRQoL scores in home dialysis patients compared with in-center HD patients (SMD, 0.14; 95% CI, 0.04 to 0.24), although heterogeneity was high (I 2>80%). In a subgroup analysis, Western European home dialysis patients had higher physical HRQoL scores (SMD, 0.39; 95% CI, 0.17 to 0.61), while home dialysis patients from Latin America had lower physical scores (SMD, -0.20; 95% CI, -0.28 to -0.12). Mental HRQoL showed no difference in all analyses.LimitationsNo randomized controlled trials were found and high heterogeneity among studies existed.ConclusionsAlthough pooled data showed marginally better physical HRQoL for home dialysis patients, the quality of design of the included studies was poor. Large prospective studies with adequate adjustments for confounders are necessary to establish whether home dialysis results in better HRQoL.Trial registrationPROSPERO 95985.

Project description:BACKGROUND: Concerns are present on the limited value of renal function alone in defining the optimal moment to start dialysis. Disease-related symptoms and health-related quality of life (HRQOL) may have additional clinical value in defining this moment, but little is known about how these parameters change during pre-dialysis care. The aims of our study were to describe the course of symptoms and HRQOL during pre-dialysis care and to investigate their association with poor health outcomes. METHODS: In the prospective PREPARE-2 cohort, incident patients starting specialized pre-dialysis care were included when referred to one of the 25 participating Dutch outpatient clinics (2004-2011). In the present analysis, 436 patients with data available on symptoms and HRQOL were included. Clinical data, symptoms (revised illness perception questionnaire), and HRQOL (short form-36 questionnaire; physical and mental summary score) were collected every 6-month interval. A time-dependent Cox proportional hazard model was used to associate symptoms and HRQOL with the combined poor health outcome (i.e. starting dialysis, receiving a kidney transplant, and death). RESULTS: All symptoms increased, especially fatigue and loss of strength, and both the physical and mental summary score decreased over time, with the most pronounced change during the last 6-12 months of follow-up. Furthermore, each additional symptom (adjusted HR 1.04 (95% CI, 1.00-1.09)) and each 3-point lower physical and mental summary score (adjusted HR 1.04 (1.02-1.06) and 1.04 (1.02-1.06) respectively) were associated with a higher risk of reaching the combined poor health outcome within the subsequent 6 months. CONCLUSIONS: The number of symptoms increased and both the physical and mental HRQOL score decreased during pre-dialysis care and these changes were associated with starting dialysis, receiving a kidney transplant, and death. These results may indicate that symptoms and HRQOL are good markers for the medical condition and disease stage of pre-dialysis patients.

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Integrating a Medical Home in an Outpatient Dialysis Setting: Effects on Health-Related Quality of Life.

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Integrating a Medical Home in an Outpatient Dialysis Setting: Effects on Health-Related Quality of Life.

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