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A Virtual Multidisciplinary Care Program for Management of Advanced Chronic Kidney Disease: Matched Cohort Study.

ABSTRACT: BACKGROUND:It is not well established whether a virtual multidisciplinary care program for persons with advanced chronic kidney disease (CKD) can improve their knowledge about their disease, increase their interest in home dialysis therapies, and result in more planned outpatient (versus inpatient) dialysis starts. OBJECTIVE:We aimed to evaluate the feasibility and preliminary associations of program participation with disease knowledge, home dialysis modality preference, and outpatient dialysis initiation among persons with advanced CKD in a community-based nephrology practice. METHODS:In a matched prospective cohort, we enrolled adults aged 18 to 85 years with at least two estimated glomerular filtration rates (eGFRs) of less than 30 mL/min/1.73 m2 into the Cricket Health program and compared them with controls receiving care at the same clinic, matched on age, gender, eGFR, and presence of heart failure and diabetes. The intervention included online education materials, a virtual multidisciplinary team (nurse, pharmacist, social worker, dietician), and patient mentors. Prespecified follow-up time was nine months with extended follow-up to allow adequate time to determine the dialysis start setting. CKD knowledge and dialysis modality choice were evaluated in a pre-post survey among intervention participants. RESULTS:Thirty-seven participants were matched to 61 controls by age (mean 67.2, SD 10.4 versus mean 68.8, SD 9.5), prevalence of diabetes (54%, 20/37 versus 57%, 35/61), congestive heart failure (22%, 8/37 versus 25%, 15/61), and baseline eGFR (mean 19, SD 6 versus mean 21, SD 5 mL/min/1.73 m2), respectively. At nine-month follow-up, five patients in each group started dialysis (P=.62). Among program participants, 80% (4/5) started dialysis as an outpatient compared with 20% (1/5) of controls (OR 6.28, 95% CI 0.69-57.22). In extended follow-up (median 15.7, range 11.7 to 18.1 months), 19 of 98 patients started dialysis; 80% (8/10) of the intervention group patients started dialysis in the outpatient setting versus 22% (2/9) of control patients (hazard ratio 6.89, 95% CI 1.46-32.66). Compared to before participation, patients who completed the program had higher disease knowledge levels (mean 52%, SD 29% versus mean 94%, SD 14% of questions correct on knowledge-based survey, P<.001) and were more likely to choose a home modality as their first dialysis choice (36%, 7/22 versus 68%, 15/22, P=.047) after program completion. CONCLUSIONS:The Cricket Health program can improve patient knowledge about CKD and increase interest in home dialysis modalities, and may increase the proportion of dialysis starts in the outpatient setting.

SUBMITTER: Kaiser P

PROVIDER: S-EPMC7055849 | biostudies-literature | 2020 Feb

REPOSITORIES: biostudies-literature

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A Virtual Multidisciplinary Care Program for Management of Advanced Chronic Kidney Disease: Matched Cohort Study.

Kaiser Paulina P Pipitone Olivia O Franklin Anthony A Jackson Dixie R DR Moore Elizabeth A EA Dubuque Christopher R CR Peralta Carmen A CA De Mory Anthony C AC

Journal of medical Internet research 20200212 2

<h4>Background</h4>It is not well established whether a virtual multidisciplinary care program for persons with advanced chronic kidney disease (CKD) can improve their knowledge about their disease, increase their interest in home dialysis therapies, and result in more planned outpatient (versus inpatient) dialysis starts.<h4>Objective</h4>We aimed to evaluate the feasibility and preliminary associations of program participation with disease knowledge, home dialysis modality preference, and outp ...[more]

PMID: 32049061

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Project description:IntroductionThe Renal Healthcare Program Uruguay (NRHP-UY) is a national, multidisciplinary program that provides care to chronic kidney disease (CKD) patients. In this study, we report the global results of CKD patient outcomes and a comparison between those treated at the NRHP-UY Units, with those patients who were initially included in the program but did not adhere to follow up.MethodsA cohort of not-on dialysis CKD patients included prospectively in the NRHP-UY between October 1st 2004 and September 30th 2017 was followed-up until September 30th 2019. Two groups were compared: a) Nephrocare Group: Patients who had at least one clinic visit during the first year on NRHP-UY (n = 11174) and b) Non-adherent Group: Patients who were informed and accepted to be included but had no subsequent data registered after admission (n = 3485). The study was approved by the Ethics Committee and all patients signed an informed consent. Outcomes were studied with Logistic and Cox´s regression analysis, Fine and Gray competitive risk and propensity-score matching tests.Results14659 patients were analyzed, median age 70 (60-77) years, 56.9% male. The Nephrocare Group showed improved achievement of therapeutic goals, ESKD was more frequent (HR 2.081, CI 95%1.722-2.514) as planned kidney replacement therapy (KRT) start (OR 2.494, CI95% 1.591-3.910), but mortality and the combined event (death and ESKD) were less frequent (HR 0.671, CI95% 0.628-0.717 and 0.777, CI95% 0.731-0.827) (p = 0.000) compared to the Non-adherent group. Results were similar in the propensity-matched group: ESKD (HR 2.041, CI95% 1.643-2.534); planned kidney replacement therapy (KRT) start (OR 2.191, CI95% 1.322-3.631) death (HR 0.692, CI95% 0.637-0.753); combined event (HR 0.801, CI95% 0.742-0.865) (p = 0.000).ConclusionMultidisciplinary care within the NRHP-UY is associated with timely initiation of KRT and lower mortality in single outcomes, combined analysis, and propensity-matched analysis.

Project description:BACKGROUND:Urological malignancy (UM) in patients with chronic kidney disease (CKD) is an added burden to their overall morbidity and mortality. UM is itself a common cause of CKD. Understanding the associations of UM with outcomes in advanced CKD can help in optimisation of the management of these patients. This study investigates the distribution and association of urological malignancy with outcomes (renal progression and mortality) in patients with advanced non-dialysis dependent CKD. METHODS:The study was conducted in 2637 of 3115 patients recruited in the Salford Kidney Study between the years 2002 and 2016. A comparative analysis was performed between 160 patients with UM (at baseline and incident) and 2477 patients with no malignancy. Cox-regression models and Kaplan-Meir estimates were used to explore the association between the presence of UM with mortality and renal outcome. Linear regression analysis was used to calculate the rate of progression of CKD in the groups. A 1:3 propensity score matched cohort of 640 patients was generated and utilised in the above analyses. RESULTS:4.4% had a history of UM at baseline with the annual incident rate being 0.37%. The site of malignancy was the kidney in 40% with comparable numbers for prostatic malignancy (39%). 70% (111/160) of UM patients had a medical cause as their primary diagnosis for CKD. Over a median follow up of 4?years, 34% (905) patients died. In the matched sample, the proportion of deaths was similar between the groups (UM 44% versus no malignancy 48%, p?=?0.36). 30% reached end-stage renal disease (ESRD) with no difference between the groups. In the Cox-regression model, UM did not prove to be a risk factor associated with either all-cause mortality (HR:1.03; CI: 0.79-1.35; p?=?0.81) or reaching ESRD (HR:1.12; CI: 0.80-1.58; p?=?0.49). The rate of decline in estimated glomerular filtration rate (eGFR) was similar between the groups (-?1.05 vs -?1.25?mL/min/1.73m2/year, p?=?0.31). CONCLUSIONS:There was no correlation observed between UM and all-cause mortality or ESRD. Medical causes of CKD have a significant influence on the outcomes in patients with UM, whereas the UM did not. Hence, a coordinated approach with early liaison between the urology and nephrology teams is needed in the management of UM patients with CKD.

Project description:BACKGROUND:Patient education regarding end-stage renal disease (ESRD) has the potential to reduce adverse outcomes and increase the use of in-home renal replacement therapies. OBJECTIVE:This study aimed to investigate whether an online, easily scalable education program can improve patient knowledge and facilitate decision making regarding renal replacement therapy options. METHODS:We developed a 4-week online, digital educational program that included written information, short videos, and social networking features. Topics included kidney transplant, conservative management, peritoneal dialysis, in-home hemodialysis, and in-center hemodialysis. We recruited patients with advanced chronic kidney disease (stage IV and V) to enroll in the online program, and we evaluated the feasibility and potential impact of the digital program by conducting pre- and postintervention surveys in areas of knowledge, self-efficacy, and choice of ESRD care. RESULTS:Of the 98 individuals found to be eligible for the study, 28 enrolled and signed the consent form and 25 completed the study. The average age of participants was 65 (SD 15) years, and the average estimated glomerular filtration rate was 21 (SD 6) ml/min/1.73 m2. Before the intervention, 32% of patients (8/25) were unable to make an ESRD treatment choice; after the intervention, all 25 participants made a choice. The proportion of persons who selected kidney transplant as the first choice increased from 48% (12/25) at intake to 84% (21/25) after program completion (P=.01). Among modality options, peritoneal dialysis increased as the first choice for 4/25 (16%) patients at intake to 13/25 (52%) after program completion (P=.004). We also observed significant increases in knowledge score (from 65 [SD 56] to 83 [SD 14]; P<.001) and self-efficacy score (from 3.7 [SD 0.7] to 4.3 [SD 0.5]; P<.001). CONCLUSIONS:Implementation of a digital ESRD education program is feasible and may facilitate patients' decisions about renal replacement therapies. Larger studies are necessary to understand whether the program affects clinical outcomes. TRIAL REGISTRATION:ClinicalTrials.gov NCT02976220; https://clinicaltrials.gov/ct2/show/NCT02976220.

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A Virtual Multidisciplinary Care Program for Management of Advanced Chronic Kidney Disease: Matched Cohort Study.

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A Virtual Multidisciplinary Care Program for Management of Advanced Chronic Kidney Disease: Matched Cohort Study.

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