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Perl J, Dember LM, Bargman JM, Browne T, Charytan DM, Flythe JE, Hickson LJ, Hung AM, Jadoul M, Lee TC, Meyer KB, Moradi H, Shafi T, Teitelbaum I, Wong LP, Chan CT. The Use of a Multidimensional Measure of Dialysis Adequacy-Moving beyond Small Solute Kinetics. Clin J Am Soc Nephrol 2017; 12:839-847. [PMID: 28314806 PMCID: PMC5477210 DOI: 10.2215/cjn.08460816] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Urea removal has become a key measure of the intensity of dialysis treatment for kidney failure. Small solute removal, exemplified by Kt/Vurea, has been broadly applied as a means to quantify the dose of thrice weekly hemodialysis. Yet, the reliance on small solute clearances alone as a measure of dialysis adequacy fails fully to quantify the intended clinical effects of dialysis therapy. This review aims to (1) understand the strengths and limitations of small solute kinetics as a surrogate marker of dialysis dose, and (2) present the prospect of a more comprehensive construct for dialysis dose, one that considers more broadly the goals of ESRD care to maximize both quality of life and survival. On behalf of the American Society of Nephrology Dialysis Advisory Group, we propose the need to ascertain the validity and utility of a multidimensional measure that moves beyond small solute kinetics alone to quantify optimal dialysis derived from both patient-reported and comprehensive clinical and dialysis-related measures.
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Affiliation(s)
- Jeffrey Perl
- Due to the number of contributing authors, the affiliations are provided in the Supplemental Material
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Walker RC, Howard K, Morton RL. Home hemodialysis: a comprehensive review of patient-centered and economic considerations. CLINICOECONOMICS AND OUTCOMES RESEARCH 2017; 9:149-161. [PMID: 28243134 PMCID: PMC5317253 DOI: 10.2147/ceor.s69340] [Citation(s) in RCA: 55] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Internationally, the number of patients requiring treatment for end-stage kidney disease (ESKD) continues to increase, placing substantial burden on health systems and patients. Home hemodialysis (HD) has fluctuated in its popularity, and the rates of home HD vary considerably between and within countries although there is evidence suggesting a number of clinical, survival, economic, and quality of life (QoL) advantages associated with this treatment. International guidelines encourage shared decision making between patients and clinicians for the type of dialysis, with an emphasis on a treatment that aligned to the patients’ lifestyle. This is a comprehensive literature review of patient-centered and economic impacts of home HD with the studies published between January 2000 and July 2016. Data from the primary studies representing both efficiency and equity of home HD were presented as a narrative synthesis under the following topics: advantages to patients, barriers to patients, economic factors influencing patients, cost-effectiveness of home HD, and inequities in home HD delivery. There were a number of advantages for patients on home HD including improved survival and QoL and flexibility and potential for employment, compared to hospital HD. Similarly, there were several barriers to patients preferring or maintaining home HD, and the strategies to overcome these barriers were frequently reported. Good evidence reported that indigenous, low-income, and other socially disadvantaged individuals had reduced access to home HD compared to other forms of dialysis and that this situation compounds already-poor health outcomes on renal replacement therapy. Government policies that minimize barriers to home HD include reimbursement for dialysis-related out-of-pocket costs and employment-retention interventions for home HD patients and their family members. This review argues that home HD is a cost-effective treatment, and increasing the proportion of patients on this form of dialysis compared to hospital HD will result in a more equitable distribution of good health outcomes for individuals with ESKD.
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Affiliation(s)
- Rachael C Walker
- School of Public Health, Sydney Medical School, University of Sydney, Sydney, Australia; Hawke's Bay District Health Board, Hastings, New Zealand
| | - Kirsten Howard
- School of Public Health, Sydney Medical School, University of Sydney, Sydney, Australia
| | - Rachael L Morton
- NHMRC Clinical Trials Centre, Sydney Medical School, University of Sydney, Sydney, Australia
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Raj R, Ahuja KDK, Frandsen M, Jose M. Older patient considering treatment for advanced renal disease: protocol for a scoping review of the information available for shared decision-making. BMJ Open 2016; 6:e013755. [PMID: 27932341 PMCID: PMC5168622 DOI: 10.1136/bmjopen-2016-013755] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2016] [Revised: 10/22/2016] [Accepted: 11/15/2016] [Indexed: 11/03/2022] Open
Abstract
INTRODUCTION Older adults constitute the largest group of patients on dialysis in most parts of the world. Management of advanced renal disease in the older adult is complex; treatment outcomes and prognosis can be markedly different from younger patients. Clinical teams caring for such patients are often called on to provide information regarding prognosis and outcomes with treatment-particularly, the comparison between having dialysis treatment versus not having dialysis. These discussions can be difficult for clinicians because they have to contend with incomplete or nascent data regarding prognosis and outcomes in this age group. We aim to summarise the currently available information regarding the prognosis and outcomes of advanced renal disease in the older adult by means of a scoping review of the literature. This article discusses our protocol. METHODS This scoping review will be undertaken in accordance with the Joanna Briggs Institute's methodology for scoping reviews. A directed search will look for relevant articles in English (within electronic databases and the grey literature), written between 2000 and 2016, which have studied older patients with advanced renal disease (estimated glomerular filtration rate <30 mL/min/1.73 m2). After screening by two independent reviewers, selected articles will be analysed using a data charting tool. Reporting will include descriptions, analysis of themes using qualitative software and display of information using charts. ETHICS AND DISSEMINATION This scoping review will analyse previously collected data, and so does not require ethical approval. Results will be disseminated through academic journals, conferences and seminars. We anticipate that our summary of the currently available knowledge regarding the older adult with advanced renal disease will be a repository of information for clinicians in the field. We expect to identify areas of study that are suited to systematic reviews. Our findings can also be expected to influence guidelines and clinical practice recommendations in the future.
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Affiliation(s)
- Rajesh Raj
- School of Medicine, University of Tasmania, Launceston, Tasmania, Australia
| | - Kiran D K Ahuja
- School of Health Sciences, University of Tasmania, Launceston, Tasmania, Australia
| | - Mai Frandsen
- School of Health Sciences, University of Tasmania, Launceston, Tasmania, Australia
| | - Matthew Jose
- School of Medicine, University of Tasmania, Launceston, Tasmania, Australia
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Winterbottom A, Bekker H, Mooney A. Dialysis modality selection: physician guided or patient led? Clin Kidney J 2016; 9:823-825. [PMID: 27994862 PMCID: PMC5162419 DOI: 10.1093/ckj/sfw109] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2016] [Accepted: 09/27/2016] [Indexed: 11/14/2022] Open
Abstract
The process of choosing dialysis modality for patients is complex and requires input from the expert renal team. Although it is commonplace for nephrologists to recommend dialysis modalities to patients, this might not always lead to the patient receiving treatment which they regard as most suitable. Nephrologists should consider whether it is appropriate for pre-dialysis education to be directive, or whether the choice between treatment options should be led by the patient.
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Affiliation(s)
| | - Hilary Bekker
- Leeds Institute of Health Sciences, Faculty of Medicine and Health, University of Leeds, Leeds, UK
| | - Andrew Mooney
- Renal Unit, St James's University Hospital, Leeds, UK
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Abstract
Technical innovations in peritoneal dialysis (PD), now used widely for the long-term treatment of ESRD, have significantly reduced therapy-related complications, allowing patients to be maintained on PD for longer periods. Indeed, the survival rate for patients treated with PD is now equivalent to that with in-center hemodialysis. In parallel, changes in public policy have spurred an unprecedented expansion in the use of PD in many parts of the world. Meanwhile, our improved understanding of the molecular mechanisms involved in solute and water transport across the peritoneum and of the pathobiology of structural and functional changes in the peritoneum with long-term PD has provided new targets for improving efficiency and for intervention. As with hemodialysis, almost half of all deaths on PD occur because of cardiovascular events, and there is great interest in identifying modality-specific factors contributing to these events. Notably, tremendous progress has been made in developing interventions that substantially reduce the risk of PD-related peritonitis. Yet the gains have been unequal among individual centers, primarily because of unequal clinical application of knowledge gained from research. The work to date has further highlighted the areas in need of innovation as we continue to strive to improve the health and outcomes of patients treated with PD.
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Affiliation(s)
- Rajnish Mehrotra
- Kidney Research Institute and
- Harborview Medical Center, Division of Nephrology, Department of Medicine, University of Washington, Seattle, Washington
| | - Olivier Devuyst
- Institute of Physiology, University of Zurich, Zurich, Switzerland
- Division of Nephrology, Université Catholique de Louvain Medical School, Brussels, Belgium
| | - Simon J Davies
- Department of Nephrology, Keele University, Staffordshire, United Kingdom; and
| | - David W Johnson
- Department of Nephrology, Division of Medicine, Princess Alexandra Hospital, University of Queensland, Brisbane, Australia
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56
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Berns JS. Honoring Patient Preferences: The 2016 National Kidney Foundation Presidential Address. Am J Kidney Dis 2016; 68:661-664. [PMID: 27555104 DOI: 10.1053/j.ajkd.2016.07.018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2016] [Accepted: 07/20/2016] [Indexed: 11/11/2022]
Affiliation(s)
- Jeffrey S Berns
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania.
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57
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Walker RC, Howard K, Tong A, Palmer SC, Marshall MR, Morton RL. The economic considerations of patients and caregivers in choice of dialysis modality. Hemodial Int 2016; 20:634-642. [PMID: 27196634 PMCID: PMC5324572 DOI: 10.1111/hdi.12424] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Introduction Broader adoption of home dialysis could lead to considerable cost savings for health services. Globally, however, uptake remains low. The aim of this study was to describe patient and caregiver perspectives of the economic considerations that influence dialysis modality choice, and elicit policy-relevant recommendations. Methods Semistructured interviews with predialysis or dialysis patients and their caregivers, at three hospitals in New Zealand. Interview transcripts were analyzed thematically. Findings 43 patients and 9 caregivers (total n = 52) participated. The three themes related to economic considerations were: (i) productivity losses associated with changes in employment; (ii) the need for personal subsidization of home dialysis expenses; and (iii) the role of socio-economic disadvantage as a barrier to home dialysis. Patients weighed the flexibility of home dialysis which allowed them to remain employed, against time required for training and out-of-pocket costs. Patients saw the lack of reimbursement of home dialysis costs as unjust and suggested that reimbursement would incentivize home dialysis uptake. Social disadvantage was a barrier to home dialysis as patients' housing was often unsuitable; they could not afford the additional treatment costs. Home hemodialysis was considered to have the highest out-of-pocket costs and was sometimes avoided for this reason. Discussion Our data suggests that economic considerations underpin the choices patients make about dialysis treatments, however these are rarely reported. To promote home dialysis, strategies to improve employment retention and housing, and to minimize out-of-pocket costs, need to be addressed directly by healthcare providers and payers.
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Affiliation(s)
- Rachael C Walker
- Sydney School of Public Health, University of Sydney, Sydney, New South Wales, 2006, Australia.
- Hawke's Bay District Health Board, Hawke's Bay, New Zealand.
| | - Kirsten Howard
- Sydney School of Public Health, University of Sydney, Sydney, New South Wales, 2006, Australia
| | - Allison Tong
- Sydney School of Public Health, University of Sydney, Sydney, New South Wales, 2006, Australia
- Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, New South Wales, 2145, Australia
| | - Suetonia C Palmer
- Department of Medicine, University of Otago, Christchurch, 8140, New Zealand
| | | | - Rachael L Morton
- NHMRC Clinical Trials Centre, University of Sydney, Sydney, New South Wales, 2006, Australia
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59
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Reid C, Seymour J, Jones C. A Thematic Synthesis of the Experiences of Adults Living with Hemodialysis. Clin J Am Soc Nephrol 2016; 11:1206-1218. [PMID: 27246010 PMCID: PMC4934845 DOI: 10.2215/cjn.10561015] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2015] [Accepted: 03/16/2016] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND OBJECTIVES Patients on in-center dialysis spend significant amounts of time in the dialysis unit; additionally, managing ESRD affects many aspects of life outside the dialysis unit. To improve the care provided to patients requiring hemodialysis, their experiences and beliefs regarding treatment must be understood. This systematic review aimed to synthesize the experiences of patients receiving in-center hemodialysis. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS We searched Embase, MEDLINE, CINAHL, PsychINFO, Google Scholar, and reference lists for primary qualitative studies published from 1995 to 2015 that explored the experiences of adult patients receiving treatment with in-center hemodialysis. A thematic synthesis was conducted. RESULTS Seventeen studies involving 576 patients were included in the synthesis. Four analytic themes were developed. The first theme (a new dialysis-dependent self) describes the changes in identity and perceptions of self that could result from dialysis dependence. The second theme (a restricted life) describes the physical and emotional constraints that patients described as a consequence of their dependence. Some patients reported strategies that allowed them to regain a sense of optimism and influence over the future, and these contributed to the third theme (regaining control). The first three themes describe a potential for change through acceptance, adaption, and regaining a sense of control. The final theme (relationships with health professionals) describes the importance of these relationships for in-center patients and their influence on perceptions of power and support. These relationships are seen to influence the other three themes through information sharing, continuity, and personalized support. CONCLUSIONS Our synthesis has resulted in a framework that can be used to consider interventions to improve patients' experiences of in-center hemodialysis care. Focusing on interventions that are incorporated into the established relationships that patients have with their health care professionals may enable patients to progress toward a sense of control and improve satisfaction with care.
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Affiliation(s)
- Claire Reid
- Supportive Care, Early Diagnosis and Advanced Disease Research Group, Hull York Medical School, University of York, York, United Kingdom; and
| | - Julie Seymour
- Supportive Care, Early Diagnosis and Advanced Disease Research Group, Hull York Medical School, University of York, York, United Kingdom; and
| | - Colin Jones
- York Hospitals National Health Service Trust
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60
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Dahlerus C, Quinn M, Messersmith E, Lachance L, Subramanian L, Perry E, Cole J, Zhao J, Lee C, McCall M, Paulson L, Tentori F. Patient Perspectives on the Choice of Dialysis Modality: Results From the Empowering Patients on Choices for Renal Replacement Therapy (EPOCH-RRT) Study. Am J Kidney Dis 2016; 68:901-910. [PMID: 27337991 DOI: 10.1053/j.ajkd.2016.05.010] [Citation(s) in RCA: 101] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2015] [Accepted: 05/08/2016] [Indexed: 11/11/2022]
Abstract
BACKGROUND Little is known about factors that are important to patients with advanced kidney disease and their perspectives at the time they choose a dialysis modality. EPOCH-RRT, a study supported in part by the Patient-Centered Outcomes Research Institute (PCORI), was designed to assist patients with this choice by identifying such factors and effectively provide relevant information. STUDY DESIGN Cross-sectional study, designed and conducted in collaboration with a multistakeholder advisory panel that included patients, caregivers, and health care professionals. SETTING & PARTICIPANTS 180 patients with advanced chronic kidney disease (CKD; estimated glomerular filtration rate < 25mL/min/1.73m2), either non-dialysis-dependent (NDD-CKD; n=65) or on dialysis therapy (hemodialysis [HD], n=77; or peritoneal dialysis, n=38), recruited across the United States through social media and in-person contacts. METHODOLOGY Semistructured telephone interviews including open- and closed-ended questions. ANALYTICAL APPROACH Mixed methods, integrating quantitative and qualitative approaches; themes identified through content analysis of interview transcripts by 2 independent coders. RESULTS Themes most often reported as important were keeping as much independence as possible, quality and quantity of life, and flexibility in daily schedule. Other factors (eg, concern about the way they look) differed across patient subgroups based on age, sex, and NDD-CKD/dialysis modality. Among patients who had initiated dialysis therapy, almost half (47%) the HD patients believed that the decision to be treated by HD had largely not been their choice; this was only reported by 3% of peritoneal dialysis patients. LIMITATIONS Recruitment through social media and willingness to participate in lengthy telephone interviews resulted in a select sample that may not be representative of the broader advanced CKD population; therefore, generalizability of findings cannot be determined. CONCLUSIONS Incorporation of patient priorities in care improves health outcomes. Given the perceived limited role in the choice of dialysis treatment, our findings support the need for interventions to improve shared decision making on dialysis treatment options, targeting both patients and clinicians.
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Affiliation(s)
| | - Martha Quinn
- The Center for Managing Chronic Disease, University of Michigan, Ann Arbor, MI
| | | | - Laurie Lachance
- The Center for Managing Chronic Disease, University of Michigan, Ann Arbor, MI
| | | | - Erica Perry
- University of Michigan Health System, Ann Arbor, MI; EPOCH-RRT Advisory Panel, Bingham Farms, MI
| | - Jill Cole
- EPOCH-RRT Advisory Panel, Bingham Farms, MI; Greenfield Health Systems, Bingham Farms, MI
| | - Junhui Zhao
- Arbor Research Collaborative for Health, Ann Arbor, MI
| | | | | | - Leslie Paulson
- University of Michigan at the Michigan Institute for Clinical & Health Research, Ann Arbor, MI
| | - Francesca Tentori
- Arbor Research Collaborative for Health, Ann Arbor, MI; Vanderbilt University Medical Center, Nashville, TN.
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61
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Abstract
In light of the recent emphasis on patient-centered outcomes and quality of life for patients with kidney disease, we contend that the nephrology community should no longer fund, perform, or publish studies that compare survival by dialysis modality. These studies have become redundant; they are methodologically limited, unhelpful in practice, and therefore a waste of resources. More than two decades of these publications show similar survival between patients undergoing peritoneal dialysis and those receiving thrice-weekly conventional hemodialysis, with differences only for specific subgroups. In clinical practice, modality choice should be individualized with the aim of maximizing quality of life, patient-reported outcomes, and achieving patient-centered goals. Expected survival is often irrelevant to modality choice. Even for the younger and fitter home hemodialysis population, quality of life, not just duration of survival, is a major priority. On the other hand, increasing evidence suggests that patients with ESRD continue to experience poor quality of life because of high symptom burden, unsolved clinical problems, and unmet needs. Patients care more about how they will live instead of how long. It is our responsibility to align our research with their needs. Only by doing so can we meet the challenges of ESRD patient care in the coming decades.
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Affiliation(s)
- Martin B. Lee
- Division of Nephrology, University Medicine Cluster, National University Health System, Singapore; and
| | - Joanne M. Bargman
- Division of Nephrology, University Health Network, Toronto, Ontario, Canada
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62
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Gura V, Rivara MB, Bieber S, Munshi R, Smith NC, Linke L, Kundzins J, Beizai M, Ezon C, Kessler L, Himmelfarb J. A wearable artificial kidney for patients with end-stage renal disease. JCI Insight 2016; 1:86397. [PMID: 27398407 DOI: 10.1172/jci.insight.86397] [Citation(s) in RCA: 79] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND Stationary hemodialysis machines hinder mobility and limit activities of daily life during dialysis treatments. New hemodialysis technologies are needed to improve patient autonomy and enhance quality of life. METHODS We conducted a FDA-approved human trial of a wearable artificial kidney, a miniaturized, wearable hemodialysis machine, based on dialysate-regenerating sorbent technology. We aimed to determine the efficacy of the wearable artificial kidney in achieving solute, electrolyte, and volume homeostasis in up to 10 subjects over 24 hours. RESULTS During the study, all subjects remained hemodynamically stable, and there were no serious adverse events. Serum electrolytes and hemoglobin remained stable over the treatment period for all subjects. Fluid removal was consistent with prescribed ultrafiltration rates. Mean blood flow was 42 ± 24 ml/min, and mean dialysate flow was 43 ± 20 ml/min. Mean urea, creatinine, and phosphorus clearances over 24 hours were 17 ± 10, 16 ± 8, and 15 ± 9 ml/min, respectively. Mean β2-microglobulin clearance was 5 ± 4 ml/min. Of 7 enrolled subjects, 5 completed the planned 24 hours of study treatment. The trial was stopped after the seventh subject due to device-related technical problems, including excessive carbon dioxide bubbles in the dialysate circuit and variable blood and dialysate flows. CONCLUSION Treatment with the wearable artificial kidney was well tolerated and resulted in effective uremic solute clearance and maintenance of electrolyte and fluid homeostasis. These results serve as proof of concept that, after redesign to overcome observed technical problems, a wearable artificial kidney can be developed as a viable novel alternative dialysis technology. TRIAL REGISTRATION ClinicalTrials.gov NCT02280005. FUNDING The Wearable Artificial Kidney Foundation and Blood Purification Technologies Inc.
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Affiliation(s)
- Victor Gura
- Cedars-Sinai Medical Center, Los Angeles, California, USA.,David Geffen School of Medicine at UCLA, UCLA, Los Angeles, California, USA
| | - Matthew B Rivara
- Kidney Research Institute, Division of Nephrology, University of Washington, Seattle, Washington, USA
| | - Scott Bieber
- Kidney Research Institute, Division of Nephrology, University of Washington, Seattle, Washington, USA
| | - Raj Munshi
- Kidney Research Institute, Division of Nephrology, University of Washington, Seattle, Washington, USA.,Division of Nephrology, Department of Pediatrics, Seattle Children's Hospital and University of Washington, Seattle, Washington, USA
| | - Nancy Colobong Smith
- Kidney Research Institute, Division of Nephrology, University of Washington, Seattle, Washington, USA.,University of Washington Medical Center, Seattle, Washington, USA
| | - Lori Linke
- Kidney Research Institute, Division of Nephrology, University of Washington, Seattle, Washington, USA
| | - John Kundzins
- Kidney Research Institute, Division of Nephrology, University of Washington, Seattle, Washington, USA
| | - Masoud Beizai
- Blood Purification Technologies Inc., Beverly Hills, California, USA
| | - Carlos Ezon
- Blood Purification Technologies Inc., Beverly Hills, California, USA
| | - Larry Kessler
- Kidney Research Institute, Division of Nephrology, University of Washington, Seattle, Washington, USA.,Department of Health Services, School of Public Health, University of Washington, Seattle, Washington, USA
| | - Jonathan Himmelfarb
- Kidney Research Institute, Division of Nephrology, University of Washington, Seattle, Washington, USA
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63
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Hauber AB, González JM, Groothuis-Oudshoorn CGM, Prior T, Marshall DA, Cunningham C, IJzerman MJ, Bridges JFP. Statistical Methods for the Analysis of Discrete Choice Experiments: A Report of the ISPOR Conjoint Analysis Good Research Practices Task Force. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2016; 19:300-15. [PMID: 27325321 DOI: 10.1016/j.jval.2016.04.004] [Citation(s) in RCA: 700] [Impact Index Per Article: 87.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/25/2016] [Accepted: 04/03/2016] [Indexed: 05/09/2023]
Abstract
Conjoint analysis is a stated-preference survey method that can be used to elicit responses that reveal preferences, priorities, and the relative importance of individual features associated with health care interventions or services. Conjoint analysis methods, particularly discrete choice experiments (DCEs), have been increasingly used to quantify preferences of patients, caregivers, physicians, and other stakeholders. Recent consensus-based guidance on good research practices, including two recent task force reports from the International Society for Pharmacoeconomics and Outcomes Research, has aided in improving the quality of conjoint analyses and DCEs in outcomes research. Nevertheless, uncertainty regarding good research practices for the statistical analysis of data from DCEs persists. There are multiple methods for analyzing DCE data. Understanding the characteristics and appropriate use of different analysis methods is critical to conducting a well-designed DCE study. This report will assist researchers in evaluating and selecting among alternative approaches to conducting statistical analysis of DCE data. We first present a simplistic DCE example and a simple method for using the resulting data. We then present a pedagogical example of a DCE and one of the most common approaches to analyzing data from such a question format-conditional logit. We then describe some common alternative methods for analyzing these data and the strengths and weaknesses of each alternative. We present the ESTIMATE checklist, which includes a list of questions to consider when justifying the choice of analysis method, describing the analysis, and interpreting the results.
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Affiliation(s)
| | | | | | - Thomas Prior
- Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Deborah A Marshall
- Department of Community Health Sciences, Faculty of Medicine, University of Calgary and O'Brien Institute for Public Health, Calgary, Alberta, Canada
| | - Charles Cunningham
- Department of Psychiatry and Behavioural Neuroscience, Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Maarten J IJzerman
- Department of Health Technology and Services Research, University of Twente, Enschede, The Netherlands
| | - John F P Bridges
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
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64
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Sims J, Bennett PN, Ockerby C, Ludlow M, Fairbairn J, Wilson A, Kerr PG. The effect of holiday haemodialysis treatments on patient mood, adverse symptoms and subjective wellbeing using the Big Red Kidney Bus. Nephrology (Carlton) 2016; 22:107-113. [PMID: 27161902 DOI: 10.1111/nep.12811] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2016] [Revised: 05/02/2016] [Accepted: 05/05/2016] [Indexed: 11/27/2022]
Abstract
BACKGROUND AND AIMS People with end-stage kidney disease receiving haemodialysis are restricted to holidays where dialysis services are readily available. Holiday dialysis in regional, rural and remote areas is particularly challenging. The aims of this study were to evaluate the wellbeing of those who received dialysis in a holiday haemodialysis bus and to measure patient well-being with that of a comparable cohort of haemodialysis patients. METHODS A three machine haemodialysis bus, the Big Red Kidney Bus, was built to enable people, their families and carers to take holidays across a range of tourist destinations in Victoria, Australia. Measures included pre-post subjective well-being, dialysis symptoms and mood questionnaires complemented by post semi-structured telephone interviews. RESULTS Participating holidaymakers were positive about the haemodialysis bus service and the standard of care experienced. They reported decreased dialysis side effects of fatigue, muscle cramp and dry skin. The overall number of reported symptoms decreased, and the perceived level of bother associated with symptoms also decreased. No changes in subjective well-being and mood were detected. Mean Personal Wellbeing Index scores were significantly higher than in a comparative haemodialysis sample. CONCLUSION The Big Red Kidney Bus provided a safe and feasible holiday dialysis service. Holidaymakers' well-being was reflected by the decreased dialysis patient side effects.
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Affiliation(s)
- Jane Sims
- School of Primary Care, Monash University, Melbourne, Victoria, Australia.,Jane Sims and Associates, Melbourne, Victoria, Australia
| | - Paul N Bennett
- School of Nursing and Midwifery, Deakin University, Geelong, Australia.,Stanford University, Palo Alto, California, USA
| | - Cherene Ockerby
- School of Nursing and Midwifery, Deakin University, Geelong, Australia.,Centre for Nursing Research-Deakin University & Monash Health Partnership, Monash Health, Melbourne, Victoria, Australia
| | - Marie Ludlow
- Kidney Health Australia, Melbourne, Victoria, Australia
| | - Jo Fairbairn
- Kidney Health Australia, Melbourne, Victoria, Australia
| | - Anne Wilson
- Kidney Health Australia, Melbourne, Victoria, Australia
| | - Peter G Kerr
- Department of Nephrology, Monash Health and Monash University, Melbourne, Victoria, Australia
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65
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Tam-Tham H, Thomas CM. Does the Evidence Support Conservative Management as an Alternative to Dialysis for Older Patients with Advanced Kidney Disease? Clin J Am Soc Nephrol 2016; 11:552-4. [PMID: 26988749 DOI: 10.2215/cjn.01910216] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Affiliation(s)
| | - Chandra M Thomas
- Department of Medicine, Division of Nephrology, University of Calgary, Calgary, Alberta, Canada
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66
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Johnson DS, Kapoian T, Taylor R, Meyer KB. Going Upstream: Coordination to Improve CKD Care. Semin Dial 2016; 29:125-34. [PMID: 26765792 DOI: 10.1111/sdi.12461] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Care coordination for patients with chronic kidney disease has been shown to be effective in improving outcomes and reducing costs. However, few patients with CKD benefit from this systematic management of their kidney disease and other medical conditions. As a result, outcomes for patients with kidney disease are not optimal, and their cost of care is increased. For those patients who transition to kidney failure treatment in the United States, the transition does not go as well as it could. The effectiveness of treatments to delay progression of kidney disease in contemporary clinical practice does not match the efficacy of these treatments in clinical trials. Conservative care for kidney disease, which should be an option for patients who are very old and very sick, is not considered often enough or seriously enough. Opportunities for early and even pre-emptive transplantation are missed, as are opportunities for home dialysis. The process of dialysis access creation is rarely optimal. The consequence is care which is not as good as it could be, and much more expensive than it should be. We describe our initial efforts to implement care coordination for chronic kidney disease in routine clinical care and attempt to project some of the benefits to patients and the cost savings.
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Affiliation(s)
| | - Toros Kapoian
- Rutgers-Robert Wood Johnson Medical School, New Brunswick, New Jersey.,Dialysis Clinic, Inc., North Brunswick, New Jersey
| | - Robert Taylor
- Dialysis Clinic, Inc., Nashville, Tennessee.,Nephrology Associates, Nashville, Tennessee
| | - Klemens B Meyer
- Division of Nephrology, Tufts Medical Center, Boston, Massachusetts
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Prieto-Velasco M, Quiros P, Remon C. The Concordance between Patients' Renal Replacement Therapy Choice and Definitive Modality: Is It a Utopia? PLoS One 2015; 10:e0138811. [PMID: 26466387 PMCID: PMC4605797 DOI: 10.1371/journal.pone.0138811] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2015] [Accepted: 09/03/2015] [Indexed: 11/18/2022] Open
Abstract
INTRODUCTION It is desirable for patients to play active roles in the choice of renal replacement therapy (RRT). Patient decision aid tools (PDAs) have been developed to allow the patients to choose the option best suited to their individual needs. MATERIAL AND METHODS An observational, prospective registry was conducted in 26 Spanish hospitals between September 2010 and May 2012. The results of the patients' choice and the definitive RRT modality were registered through the progressive implementation of an Education Process (EP) with PDAs designed to help Chronic Kidney Disease (CKD) patients choose RRT. RESULTS Patients included in this study: 1044. Of these, 569 patients used PDAs and had made a definitive choice by the end of registration. A total of 88.4% of patients chose dialysis [43% hemodialysis (HD) and 45% peritoneal dialysis (PD)] 3.2% preemptive living-donor transplant (TX), and 8.4% conservative treatment (CT). A total of 399 patients began RRT during this period. The distribution was 93.4% dialysis (53.6% HD; 40% PD), 1.3% preemptive TX and 5.3% CT. The patients who followed the EP changed their mind significantly less often [kappa value of 0.91 (95% CI, 0.86-0.95)] than those who did not follow it, despite starting unplanned treatment [kappa value of 0.85 (95% CI, 0.75-0.95]. A higher agreement between the final choice and a definitive treatment was achieved by the EP and planned patients [kappa value of 0.93 (95% CI, 0.89-0.98)]. Those who did not go through the EP had a much lower index of choosing PD and changed their decision more frequently when starting definitive treatment [kappa value of 0.73 (95% CI, 0.55-0.91)]. CONCLUSIONS Free choice, assisted by PDAs, leads to a 50/50 distribution of PD and HD choice and an increase in TX choice. The use of PDAs, even with an unplanned start, achieved a high level of concordance between the chosen and definitive modality.
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Affiliation(s)
- Mario Prieto-Velasco
- Department of Nephrology, Complejo Asistencial Universitario de León, León, Spain
- * E-mail:
| | - Pedro Quiros
- Department of Nephrology, Hospital Universitario de Puerto Real, Puerto Real, Spain
| | - Cesar Remon
- Department of Nephrology, Hospital Universitario de Puerto Real, Puerto Real, Spain
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Kasza J, Polkinghorne KR, Marshall MR, McDonald SP, Wolfe R. Clustering and Residual Confounding in the Application of Marginal Structural Models: Dialysis Modality, Vascular Access, and Mortality. Am J Epidemiol 2015; 182:535-43. [PMID: 26316597 DOI: 10.1093/aje/kwv090] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2014] [Accepted: 03/30/2015] [Indexed: 11/13/2022] Open
Abstract
In the application of marginal structural models to compare time-varying treatments, it is rare that the hierarchical structure of a data set is accounted for or that the impact of unmeasured confounding on estimates is assessed. These issues often arise when analyzing data sets drawn from clinical registries, where patients may be clustered within health-care providers, and the amount of data collected from each patient may be limited by design (e.g., to reduce costs or encourage provider participation). We compared the survival of patients undergoing treatment with various dialysis types, where some patients switched dialysis modality during the course of their treatment, by estimating a marginal structural model using data from the Australia and New Zealand Dialysis and Transplant Registry, 2003-2011. The number of variables recorded by the registry is limited, and patients are clustered within the dialysis centers responsible for their treatment, so we assessed the impact of accounting for unmeasured confounding or clustering on estimated treatment effects. Accounting for clustering had limited impact, and only unreasonable levels of unmeasured confounding would have changed conclusions about treatment comparisons. Our analysis serves as a case study in assessing the impact of unmeasured confounding and clustering in the application of marginal structural models.
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Tong A, Manns B, Hemmelgarn B, Wheeler DC, Tugwell P, Winkelmayer WC, van Biesen W, Crowe S, Kerr PG, Polkinghorne KR, Howard K, Pollock C, Hawley CM, Johnson DW, McDonald SP, Gallagher MP, Urquhart-Secord R, Craig JC. Standardised outcomes in nephrology - Haemodialysis (SONG-HD): study protocol for establishing a core outcome set in haemodialysis. Trials 2015; 16:364. [PMID: 26285819 PMCID: PMC4543451 DOI: 10.1186/s13063-015-0895-7] [Citation(s) in RCA: 58] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2015] [Accepted: 08/03/2015] [Indexed: 11/19/2022] Open
Abstract
Background Chronic kidney disease is a significant contributor to mortality and morbidity worldwide, and the number of people who require dialysis or transplantation continues to increase. People on dialysis are 15 times more likely to die than the general population. Dialysis is also costly, intrusive, and time-consuming and imposes an enormous burden on patients and their families. This escalating problem has spurred a proliferation of trials in dialysis, yet health and quality of life remain poor. The reasons for this are complex and varied but are attributable in part to problems in the design and reporting of studies, particularly outcome selection. Problems related to outcomes include use of unvalidated surrogates, outcomes of little or no relevance to patients, highly variable outcome selection limiting comparability across studies, and bias in reporting outcomes. The aim of the Standardised Outcomes in Nephrology-Haemodialysis (SONG-HD) study is to establish a core outcome set for haemodialysis trials, to improve the quality of reporting, and the relevance of trials conducted in people on haemodialysis. Methods/design SONG-HD is a five-phase project that includes the following: a systematic review to identify outcomes that have been reported in haemodialysis systematic reviews and trials; nominal group technique with patients and caregivers to identify, rank, and describe reasons for their choices; qualitative stakeholder interviews with patients, caregivers, clinicians, researchers, and policy makers to elicit individual values and perspectives on outcomes for haemodialysis trials; a three-round Delphi survey with stakeholder groups to distil and generate a prioritised list of core outcomes; and a consensus workshop to establish a core outcome set for haemodialysis trials. Discussion Establishing a core outcome set to be consistently measured and reported in haemodialysis trials will improve the integrity, transparency, usability, and contribution of research relevant to patients requiring haemodialysis; ensure that outcomes of relevance to all stakeholders are consistently reported across trials; and mitigate against outcome reporting bias. Ultimately, patients will be more protected from potential harm, patients and clinicians will be better able to make informed decisions about treatment, and researchers and policy makers will be more able to maximise the value of research to the public
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Affiliation(s)
- Allison Tong
- Sydney School of Public Health, The University of Sydney, Sydney, Australia. .,Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, Sydney, Australia.
| | - Braden Manns
- Departments of Medicine and Community Health Sciences, Libin Cardiovascular Institute and O'Brien Institute of Public Health, University of Calgary, Calgary, Canada.
| | - Brenda Hemmelgarn
- Departments of Medicine and Community Health Sciences, Libin Cardiovascular Institute and O'Brien Institute of Public Health, University of Calgary, Calgary, Canada.
| | - David C Wheeler
- Centre for Nephrology, University College London, London, United Kingdom.
| | - Peter Tugwell
- Department of Medicine, University of Ottawa, Ottawa, Canada.
| | | | - Wim van Biesen
- Renal Division, Ghent University Hospital, Ghent, Belgium.
| | - Sally Crowe
- Crowe Associates, Ltd, Oxon, United Kingdom.
| | - Peter G Kerr
- Monash Medical Centre and Monash University, Clayton, Australia.
| | - Kevan R Polkinghorne
- Monash Medical Centre and Monash University, Clayton, Australia. .,Department of Epidemiology and Preventative Medicine, Monash University, Melbourne, VIC, Australia.
| | - Kirsten Howard
- The Institute for Choice, University of South Australia, Sydney, Australia.
| | - Carol Pollock
- Renal Division, Kolling Institute, Sydney, New South Wales, Australia.
| | - Carmel M Hawley
- Queesland School of Medicine, University of Queensland at Princess Alexandra Hospital, Brisbane, Australia. .,Translational Research Institute, Brisbane, Australia. .,Metro South and Ipswich Nephrology and Transplant Services (MINTS), Brisbane, Australia.
| | - David W Johnson
- Queesland School of Medicine, University of Queensland at Princess Alexandra Hospital, Brisbane, Australia. .,Translational Research Institute, Brisbane, Australia. .,Metro South and Ipswich Nephrology and Transplant Services (MINTS), Brisbane, Australia.
| | - Stephen P McDonald
- Central Northern Adelaide Renal and Transplantation Service, Royal Adelaide Hospital, Adelaide, Australia. .,Faculty of Health Science, University of Adelaide, Adelaide, Australia.
| | - Martin P Gallagher
- Concord Clinical School, University of Sydney, Sydney, Australia. .,Renal and Metabolic Division, The George Institute, Sydney, Australia.
| | - Rachel Urquhart-Secord
- Sydney School of Public Health, The University of Sydney, Sydney, Australia. .,Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, Sydney, Australia.
| | - Jonathan C Craig
- Sydney School of Public Health, The University of Sydney, Sydney, Australia. .,Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, Sydney, Australia.
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Liu FX, Gao X, Inglese G, Chuengsaman P, Pecoits-Filho R, Yu A. A Global Overview of the Impact of Peritoneal Dialysis First or Favored Policies: An Opinion. Perit Dial Int 2015; 35:406-20. [PMID: 25082840 PMCID: PMC4520723 DOI: 10.3747/pdi.2013.00204] [Citation(s) in RCA: 89] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2013] [Accepted: 02/25/2014] [Indexed: 01/03/2023] Open
Abstract
Given the ever-increasing burden of end-stage renal disease (ESRD) in a global milieu of limited financial and health resources, interested parties continue to search for ways to optimize dialysis access. Government and payer initiatives to increase access to renal replacement therapies (RRTs), particularly peritoneal dialysis (PD) and hemodialysis (HD), may have meaningful impacts from clinical and health-economic perspectives; and despite similar clinical and humanistic outcomes between the two dialysis modalities, PD may be the more convenient and resource-conscious option. This review assessed country-specific PD-First/Favored policies and their associated background, implementation, and outcomes. It was found that barriers to policy-implementation are broadly associated with government policy, economics, provider or healthcare professional education, modality-related factors, and patient-related factors. Notably, the success of a given country's PD-Favored policy was inversely associated with the extent of HD infrastructure. It is hoped that this review will provide a foundation across countries to share lessons learned during the development and implementation of PD-First/Favored policies.
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Affiliation(s)
| | - Xin Gao
- Pharmerit International, Bethesda, MD, USA
| | | | | | - Roberto Pecoits-Filho
- Pontificia Universidade Católica do Paraná, School of Medicine, Curitiba, Parana, Brazil
| | - Alex Yu
- Hong Kong Baptist Hospital, Hong Kong, China
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71
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Janssen IM, Gerhardus A, von Gersdorff GD, Baldamus CA, Schaller M, Barth C, Scheibler F. Preferences of patients undergoing hemodialysis - results from a questionnaire-based study with 4,518 patients. Patient Prefer Adherence 2015; 9:847-55. [PMID: 26170634 PMCID: PMC4492657 DOI: 10.2147/ppa.s79559] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Chronic kidney disease is an increasing health problem worldwide and in its final stage (stage V) can only be treated by renal replacement therapy, mostly hemodialysis. Hemodialysis has a major influence on the everyday life of patients and many patients report dissatisfaction with treatment. Little is known about which aspects of treatment are considered important by hemodialysis patients. The objective of this study was to rate the relative importance of different outcomes for hemodialysis patients and to analyze whether the relative importance differed among subgroups of patients. PATIENTS AND METHODS Within the framework of a yearly questionnaire which is distributed among patients receiving hemodialysis by the largest hemodialysis provider in Germany, we assessed the relative importance of 23 outcomes as rated on a discrete visual analog scale. Descriptive statistics were used to rank the outcomes. Subgroup analyses were performed using Mann-Whitney U or Kruskal-Wallis tests. RESULTS Questionnaires of 4,518 hemodialysis patients were included in the analysis. The three most important outcomes were safety of treatment, health-related quality of life, and satisfaction with care. Further important outcomes were hospital stays, accompanying symptoms, hemodialysis duration, and the improvement or preservation of a good emotional state. Age, profession, and education had the strongest influence on relevant differences of preferences for outcomes; no relevant influence of sex or comorbidity was observed. CONCLUSION Outcomes concerning the delivery or provision of care and aspects influencing quality of life are rated by patients to be at least as important as clinical outcomes. Many of the outcomes judged to be important by the patients are not regularly considered in research, evaluation studies, or quality programs.
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Affiliation(s)
- Inger Miriam Janssen
- Department of Epidemiology and International Public Health, Bielefeld University, Bielefeld, Germany
| | - Ansgar Gerhardus
- Department for Health Services Research, University of Bremen, Bremen, Germany
- Health Sciences Bremen, University of Bremen, Bremen, Germany
| | - Gero D von Gersdorff
- Department of Internal Medicine II, University Hospital of Cologne, Cologne, Germany
| | | | - Mathias Schaller
- Department of Internal Medicine II, University Hospital of Cologne, Cologne, Germany
| | - Claudia Barth
- KfH Kuratorium fuer Dialyse und Nierentransplantation e.V., NeuIsenburg, Germany
| | - Fueloep Scheibler
- Department of Non-Drug Interventions, Institute for Quality and Efficiency in Health Care, Cologne, Germany
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72
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Wells SA. Occupational Deprivation or Occupational Adaptation of Mexican Americans on Renal Dialysis. Occup Ther Int 2015; 22:174-82. [DOI: 10.1002/oti.1394] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2014] [Revised: 05/07/2015] [Accepted: 05/07/2015] [Indexed: 11/11/2022] Open
Affiliation(s)
- Shirley A. Wells
- Occupational Therapy Department; The University of Texas-Pan American; Edinburg Texas USA
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73
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MacPhail A, Ibrahim JE, Fetherstonhaugh D, Levidiotis V. The Overuse, Underuse, and Misuse of Dialysis in ESKD Patients with Dementia. Semin Dial 2015; 28:490-6. [PMID: 25997680 DOI: 10.1111/sdi.12392] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
The profile of patients on chronic dialysis has shifted. There is a growing group of older patients with comorbid dementia and ESKD, who are at risk of overuse, underuse, and misuse of dialysis. Policy is lacking to help guide treatment decisions in this group. This paper explores clinical considerations specific to patients with comorbid ESKD and dementia. These include: the impact of comorbid dementia on dialysis effectiveness and feasibility; burden of care issues that are specific to patients with dementia; and capacity, autonomy, and consent. A better understanding of these issues may help guide discussions and decision making about treatment. For some older patients with multiple comorbidities including dementia, dialysis does not provide survival or quality of life benefit compared to medical management. These patients also experience additional treatment burden due to a 'dementia unfriendly' environment. However, exceptions may include patients who are younger, more independent, and have fewer comorbidities. Patients with dementia are often inappropriately assumed to lack capacity to participate in treatment decision making, and are at risk of having their preferences overlooked. Many patients with mild-to-moderate dementia remain capable of reporting their preferences and quality of life, and should always be involved in treatment discussions where possible.
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Affiliation(s)
| | - Joseph E Ibrahim
- Ballarat Health Services, Ballarat, Victoria, Australia.,Victorian Institute for Forensic Medicine, Department of Forensic Medicine, Monash University, Southbank, Victoria, Australia
| | - Deirdre Fetherstonhaugh
- Australian Centre for Evidence Based Aged Care, La Trobe University, Melbourne, Victoria, Australia.,Centre for Palliative Care, St Vincent's Health, Fitzroy, Victoria, Australia
| | - Vicki Levidiotis
- University of Melbourne, Parkville, Victoria, Australia.,Western Health, Footscray Hospital, Footscray, Victoria, Australia
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Walker RC, Morton RL, Tong A, Marshall MR, Palmer S, Howard K. Patient and caregiver preferences for home dialysis-the home first study: a protocol for qualitative interviews and discrete choice experiments. BMJ Open 2015; 5:e007405. [PMID: 25877279 PMCID: PMC4401852 DOI: 10.1136/bmjopen-2014-007405] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
INTRODUCTION The number of patients requiring dialysis continues to increase worldwide imposing a substantial social and economic burden on patients, their families and healthcare systems. Compared with facility-based dialysis, dialysis performed by the patient at home is associated with higher quality of life, freedom, survival and reduced healthcare costs. International guidelines recommend suitable patients are offered a choice of dialysis modality, including home-based dialysis. Predialysis education and offering patients choice increase home dialysis uptake, yet the factors that patients and families are willing to trade off in making decisions about dialysis location are not well understood. The Home First study will explore patients' and caregivers' beliefs, attitudes and preferences regarding dialysis education and decision-making with regards to dialysis options; to identify key attributes which influence their decision-making, and to quantify the relative value of these attributes. METHODS AND ANALYSIS This study will use a mixed-methods approach to describe patient and caregiver preferences and views about the factors that influence their choice of home or facility-based dialysis. Face-to-face, semistructured interviews will be conducted with 30-40 patients and 10-15 caregivers. Thematic analysis of interview transcripts will be conducted. Additional to providing information on the perspectives and experiences of patients and caregivers, these analyses will also inform the design of discrete choice experiments (DCEs). We will undertake DCEs with approximately 150 patients and 150 caregivers to quantify preferences for home and facility dialysis. ETHICS AND DISSEMINATION The Hawke's Bay, Counties Manukau, and Capital Coast District Health Board Research Ethics Committees approved the study. Findings will be presented in national/international conferences and peer-reviewed journals. Dissemination to patients will take the form of presentations, newsletters and reports to support and community groups. Reports will be disseminated to funders and participating renal units and to the New Zealand Ministry of Health. TRIAL REGISTRATION NUMBER ACTRN12615000314527.
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Affiliation(s)
- Rachael C Walker
- Renal Department, Hawke's Bay District Health Board, Hastings, New Zealand
- Sydney School of Public Health, School of Medicine, The University of Sydney, Sydney, New South Wales, Australia
| | - Rachael L Morton
- Sydney School of Public Health, School of Medicine, The University of Sydney, Sydney, New South Wales, Australia
- Nuffield Department of Population Health, Health Economics Research Centre, The University of Oxford, Oxford, UK
| | - Allison Tong
- Sydney School of Public Health, School of Medicine, The University of Sydney, Sydney, New South Wales, Australia
- Centre for Kidney Research, The Children's Hospital at Westmead, Sydney, New South Wales, Australia
| | - Mark R Marshall
- Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
- Department of Renal Medicine, Counties Manukau District Health Board, Auckland, New Zealand
- Baxter Healthcare (Asia-Pacific), Shanghai, China
| | - Suetonia Palmer
- Department of Medicine, University of Otago Christchurch, Christchurch, New Zealand
| | - Kirsten Howard
- Sydney School of Public Health, School of Medicine, The University of Sydney, Sydney, New South Wales, Australia
- Institute for Choice, UniSA Buisness School, Sydney, New South Wales, Australia
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75
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Prakash S, McGrail A, Lewis SA, Schold J, Lawless ME, Sehgal AR, Perzynski AT. Behavioral stage of change and dialysis decision-making. Clin J Am Soc Nephrol 2015; 10:197-204. [PMID: 25591499 DOI: 10.2215/cjn.05560614] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND OBJECTIVES Behavioral stage of change (SoC) algorithms classify patients' readiness for medical treatment decision-making. In the precontemplation stage, patients have no intention to take action within 6 months. In the contemplation stage, action is intended within 6 months. In the preparation stage, patients intend to take action within 30 days. In the action stage, the change has been made. This study examines the influence of SoC on dialysis modality decision-making. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS SoC and relevant covariates were measured, and associations with dialysis decision-making were determined. In-depth interviews were conducted with 16 patients on dialysis to elicit experiences. Qualitative interview data informed the survey design. Surveys were administered to adults with CKD (eGFR≤25 ml/min/1.73 m(2)) from August, 2012 to June, 2013. Multivariable logistic regression modeled dialysis decision-making with predictors: SoC, provider connection, and dialysis knowledge score. RESULTS Fifty-five patients completed the survey (71% women, 39% white, and 59% black), and median annual income was $17,500. In total, 65% of patients were in the precontemplation/contemplation (thinking) and 35% of patients were in the preparation/maintenance (acting) SoC; 62% of patients had made dialysis modality decisions. Doctors explaining modality options, higher dialysis knowledge scores, and fewer lifestyle barriers were associated with acting versus thinking SoC (all P<0.02). Patients making modality decisions had doctors who explained dialysis options (76% versus 43%), were in the acting versus the thinking SoC (50% versus 10%), had higher dialysis knowledge scores (1.4 versus 0.5), and had lower eGFR (13.9 versus 16.8 ml/min/1.73 m(2); all P<0.05). In adjusted analyses, dialysis knowledge was significantly associated with decision-making (odds ratio, 4.2; 95% confidence interval, 1.4 to 12.9; P=0.01), and SoC was of borderline significance (odds ratio, 5.8; 95% confidence interval, 1.0 to 32.6; P=0.05). The model C statistic was 0.87. CONCLUSIONS Dialysis decision-making was associated with SoC, dialysis knowledge, and physicians discussing treatment options. Future studies determining ways to assist patients with CKD in making satisfying modality decisions are warranted.
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Affiliation(s)
- Suma Prakash
- Division of Nephrology, Department of Medicine, MetroHealth Medical Center, Cleveland, Ohio; Division of Nephrology, Department of Medicine, Case Western Reserve University, Cleveland, Ohio;
| | - Anna McGrail
- Research Institute, MetroHealth Medical Center, Cleveland, Ohio
| | - Steven A Lewis
- Center of Health Care Research and Policy, MetroHealth Medical Center, Cleveland, Ohio; Department of Medicine, MetroHealth Medical Center, Cleveland, Ohio
| | - Jesse Schold
- Department of Quantitative Health Sciences, Cleveland Clinic Foundation, Cleveland, Ohio; and
| | - Mary Ellen Lawless
- Department of Medicine, MetroHealth Medical Center, Cleveland, Ohio; Department of Medicine, Case Western Reserve University, Cleveland, Ohio
| | - Ashwini R Sehgal
- Division of Nephrology, Department of Medicine, MetroHealth Medical Center, Cleveland, Ohio; Division of Nephrology, Department of Medicine, Case Western Reserve University, Cleveland, Ohio
| | - Adam T Perzynski
- Department of Medicine, MetroHealth Medical Center, Cleveland, Ohio; Department of Medicine, Case Western Reserve University, Cleveland, Ohio
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Lewicki MC, Polkinghorne KR, Kerr PG. Debate: Should dialysis at home be mandatory for all suitable ESRD patients?: home-based dialysis therapies are the second choice after transplantation. Semin Dial 2014; 28:147-54. [PMID: 25481976 DOI: 10.1111/sdi.12322] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Since their inception in the 1960s, home-based dialysis therapies have been viable alternatives to conventional thrice weekly in center hemodialysis. In spite of this, uptake of these therapies has been steadily declining over past decades with utilization varying globally; dependent on training support, funding models, and prevailing Nephrologist beliefs. In the Australian context, home dialysis (predominantly peritoneal dialysis and extended hours nocturnal hemodialysis) is now again increasing in popularity--with enthusiasm driven not only by evidence of an array of physiological and psychological patient benefit but also significant economic advantage: critical in the current climate where dialysis therapies in Australia take approximately $1 billion dollars per year from the healthcare budget. When assessing the significant advantages of home-based therapies, it is important to consider not only the increasing body of evidence around improved survival but also that for dramatically better health-related quality of life, decreased economic burden and the overall benefits of undertaking treatment in the home. With patient-centered care an increasingly important aspect of our decision making paradigm, home-based dialysis should be considered as the default option in all patients transitioning to renal replacement therapy.
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Affiliation(s)
- Michelle C Lewicki
- Department of Nephrology, Monash Medical Centre, Clayton, Victoria, Australia; Department of Medicine, Monash University, Clayton, Victoria, Australia
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Clark MD, Determann D, Petrou S, Moro D, de Bekker-Grob EW. Discrete choice experiments in health economics: a review of the literature. PHARMACOECONOMICS 2014; 32:883-902. [PMID: 25005924 DOI: 10.1007/s40273-014-0170-x] [Citation(s) in RCA: 512] [Impact Index Per Article: 51.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/03/2023]
Abstract
BACKGROUND Discrete choice experiments (DCEs) are increasingly used in health economics to address a wide range of health policy-related concerns. OBJECTIVE Broadly adopting the methodology of an earlier systematic review of health-related DCEs, which covered the period 2001-2008, we report whether earlier trends continued during 2009-2012. METHODS This paper systematically reviews health-related DCEs published between 2009 and 2012, using the same database as the earlier published review (PubMed) to obtain citations, and the same range of search terms. RESULTS A total of 179 health-related DCEs for 2009-2012 met the inclusion criteria for the review. We found a continuing trend towards conducting DCEs across a broader range of countries. However, the trend towards including fewer attributes was reversed, whilst the trend towards interview-based DCEs reversed because of increased computer administration. The trend towards using more flexible econometric models, including mixed logit and latent class, has also continued. Reporting of monetary values has fallen compared with earlier periods, but the proportion of studies estimating trade-offs between health outcomes and experience factors, or valuing outcomes in terms of utility scores, has increased, although use of odds ratios and probabilities has declined. The reassuring trend towards the use of more flexible and appropriate DCE designs and econometric methods has been reinforced by the increased use of qualitative methods to inform DCE processes and results. However, qualitative research methods are being used less often to inform attribute selection, which may make DCEs more susceptible to omitted variable bias if the decision framework is not known prior to the research project. CONCLUSIONS The use of DCEs in healthcare continues to grow dramatically, as does the scope of applications across an expanding range of countries. There is increasing evidence that more sophisticated approaches to DCE design and analytical techniques are improving the quality of final outputs. That said, recent evidence that the use of qualitative methods to inform attribute selection has declined is of concern.
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Affiliation(s)
- Michael D Clark
- Department of Economics, University of Warwick, Coventry, CV4 7AL, UK,
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Patients' perceptions of information and education for renal replacement therapy: an independent survey by the European Kidney Patients' Federation on information and support on renal replacement therapy. PLoS One 2014; 9:e103914. [PMID: 25079071 PMCID: PMC4117591 DOI: 10.1371/journal.pone.0103914] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2014] [Accepted: 07/03/2014] [Indexed: 11/29/2022] Open
Abstract
Background Selection of an appropriate renal replacement modality is of utmost importance for patients with end stage renal disease. Previous studies showed provision of information to and free modality choice by patients to be suboptimal. Therefore, the European Kidney Patients’ Federation (CEAPIR) explored European patients’ perceptions regarding information, education and involvement on the modality selection process. Methods CEAPIR developed a survey, which was disseminated by the national kidney patient organisations in Europe. Results In total, 3867 patients from 36 countries completed the survey. Respondents were either on in-centre haemodialysis (53%) or had a functioning graft (38%) at the time of survey. The majority (78%) evaluated the general information about kidney disease and treatment as helpful, but 39% did not recall being told about alternative treatment options than their current one. Respondents were more often satisfied with information provided on in-centre haemodialysis (90%) and transplantation (87%) than with information provided on peritoneal dialysis (79%) or home haemodialysis (61%), and were more satisfied with information from health care professionals vs other sources such as social media. Most (75%) felt they had been involved in treatment selection, 29% perceived they had no free choice. Involvement in modality selection was associated with enhanced satisfaction with treatment (OR 3.13; 95% CI 2.72–3.60). Many respondents (64%) could not remember receiving education on how to manage their kidney disease in daily life. Perceptions on information seem to differ between countries. Conclusions Kidney patients reported to be overall satisfied with the information they received on their disease and treatment, although information seemed mostly to have been focused on one modality. Patients involved in modality selection were more satisfied with their treatment. However, in the perception of the patients, the freedom to choose an alternative modality showed room for improvement.
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Walker R, Marshall MR, Morton RL, McFarlane P, Howard K. The cost-effectiveness of contemporary home haemodialysis modalities compared with facility haemodialysis: A systematic review of full economic evaluations. Nephrology (Carlton) 2014; 19:459-70. [DOI: 10.1111/nep.12269] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/14/2014] [Indexed: 11/30/2022]
Affiliation(s)
- Rachael Walker
- Renal Department; Hawkes Bay District Health Board; Hastings New Zealand
- Sydney School of Public Health; University of Sydney; Sydney New South Wales Australia
| | - Mark R Marshall
- Faculty of Medical and Health Sciences; University of Auckland; Auckland New Zealand
- Department of Renal Medicine; Counties Manukau District Health Board; Auckland New Zealand
- Australia and New Zealand Dialysis and Transplant Registry (ANZDATA); The Royal Adelaide Hospital; Adelaide South Australia Australia
| | - Rachael L Morton
- Sydney School of Public Health; University of Sydney; Sydney New South Wales Australia
- Health Economics Research Centre; Nuffield Department of Population Health; University of Oxford; Oxford UK
| | - Philip McFarlane
- Division of Nephrology; St Michael's Hospital; Toronto Ontario Canada
- Department of Medicine; University of Toronto; Toronto Ontario Canada
| | - Kirsten Howard
- Sydney School of Public Health; University of Sydney; Sydney New South Wales Australia
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80
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Schell JO, Cohen RA. A communication framework for dialysis decision-making for frail elderly patients. Clin J Am Soc Nephrol 2014; 9:2014-21. [PMID: 24970868 DOI: 10.2215/cjn.02190314] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Frail elderly patients with advanced kidney disease experience many of the burdens associated with dialysis. Although these patients constitute the fastest-growing population starting dialysis, they often suffer loss of functional status, impaired quality of life, and increased mortality after dialysis initiation. Nephrology clinicians face the challenges of helping patients decide if the potential benefits of dialysis outweigh the risks and preparing such patients for future setbacks. A communication framework for dialysis decision-making that aligns treatment choices with patient goals and values is presented. The role of uncertainty is highlighted, and the concept of a goal-directed care plan is introduced. This plan incorporates a time-limited trial that promotes frequent opportunities for reassessment. Using the communication skills presented, the clinician can prepare and guide patients for the dialysis trajectory as it unfolds.
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Affiliation(s)
- Jane O Schell
- Section of Palliative Care and Medical Ethics and Renal-Electrolyte Division, University of Pittsburgh School of Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania; and
| | - Robert A Cohen
- Department of Medicine, Nephrology Division, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts
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81
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Palmer SC, de Berardis G, Craig JC, Tong A, Tonelli M, Pellegrini F, Ruospo M, Hegbrant J, Wollheim C, Celia E, Gelfman R, Ferrari JN, Törok M, Murgo M, Leal M, Bednarek-Skublewska A, Dulawa J, Strippoli GFM. Patient satisfaction with in-centre haemodialysis care: an international survey. BMJ Open 2014; 4:e005020. [PMID: 24840250 PMCID: PMC4039823 DOI: 10.1136/bmjopen-2014-005020] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
OBJECTIVES To evaluate patient experiences of specific aspects of haemodialysis care across several countries. DESIGN Cross-sectional survey using the Choices for Healthy Outcomes in Caring for End-Stage Renal Disease (CHOICE) questionnaire. SETTING Haemodialysis clinics within a single provider in Europe and South America. PARTICIPANTS 2748 adults treated in haemodialysis. PRIMARY AND SECONDARY OUTCOMES The primary outcome was patient satisfaction with overall care. Secondary outcomes included patient experiences of individual aspects of dialysis care. RESULTS 2145 (78.1%) adults responded to the questionnaire. Fewer than half (46.5% (95% CI 44.5% to 48.6%)) rated their overall care as excellent. Global perceptions of care were uninfluenced by most respondent characteristics except age and depressive symptoms; older respondents were less critical of their care (adjusted OR for excellent rating 1.44 (1.01 to 2.04)) and those with depressive symptoms were less satisfied (0.56 (0.44 to 0.71)). Aspects of care that respondents most frequently ranked as excellent were staff attention to dialysis vascular access (54% (52% to 56%)); caring of nurses (53% (51% to 55%)); staff responsiveness to pain or discomfort (51% (49% to 53%)); caring, helpfulness and sensitivity of dialysis staff (50% (48% to 52%)); and ease of reaching dialysis staff by telephone (48% (46% to 50%)). The aspects of care least frequently ranked as excellent were information provided when choosing a dialysis modality (23% (21% to 25%)), ease of seeing a social worker (28% (24% to 32%)), information provided about dialysis (34% (32% to 36%)), accuracy of information from nephrologist (eg, about prognosis or likelihood of a kidney transplant; 37% (35% to 39%)) and accuracy of nephrologists' instructions (39% (36% to 41%)). CONCLUSIONS Haemodialysis patients are least satisfied with the complex aspects of care. Patients' expectations for accurate information, prognosis, the likelihood of kidney transplantation and their options when choosing dialysis treatment need to be considered when planning healthcare research and practices.
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Affiliation(s)
- Suetonia C Palmer
- Department of Medicine, University of Otago Christchurch, Christchurch, New Zealand
| | | | - Jonathan C Craig
- School of Public Health, University of Sydney, Sydney, New South Wales, Australia
| | - Allison Tong
- School of Public Health, University of Sydney, Sydney, New South Wales, Australia
| | - Marcello Tonelli
- Division of Nephrology and Immunology, University of Alberta, Edmonton, Canada
| | - Fabio Pellegrini
- Consorzio Mario Negri Sud, S. Maria Imbaro, Italy
- Scientific Institute Casa Sollievo della Sofferenza, Italy
| | | | | | | | | | | | | | | | - Marco Murgo
- Diaverum Scientific Medical Office, Lund, Sweden
| | - Miguel Leal
- Diaverum Scientific Medical Office, Lund, Sweden
| | | | - Jan Dulawa
- Diaverum Scientific Medical Office, Lund, Sweden
| | - Giovanni F M Strippoli
- Consorzio Mario Negri Sud, S. Maria Imbaro, Italy
- School of Public Health, University of Sydney, Sydney, New South Wales, Australia
- Diaverum Scientific Medical Office, Lund, Sweden
- Department of Emergency and Organ Transplantation, University of Bari, Bari, Italy
- Division of Nephrology and Transplantation, Department of Translational Medicine,Amedeo Avogadro University of Eastern Piedmont, Novara, Italy
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82
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Tong A, Winkelmayer WC, Craig JC. Qualitative research in CKD: an overview of methods and applications. Am J Kidney Dis 2014; 64:338-46. [PMID: 24768353 DOI: 10.1053/j.ajkd.2014.02.026] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2013] [Accepted: 02/25/2014] [Indexed: 11/11/2022]
Abstract
There recently has been a paradigm shift in health care policies and research toward greater patient centeredness. A core tenet of patient-centered care is that patients' needs, values, and preferences are respected in clinical decision making. Qualitative research methods are designed to generate insights about patients' priorities, values, and beliefs. However, in the past 5 years (2008-2013), only 23 (0.4%) of the 6,043 original articles published in the top 5 nephrology journals (assessed by impact factor) were qualitative studies. Given this observation, it seems important to promote awareness and better understanding within the nephrology community about qualitative research and how the findings can contribute to improving the quality and outcomes of care for patients with chronic kidney disease. This article outlines examples of how qualitative research can generate insight into the values and preferences of patients with chronic kidney disease, provides an overview of qualitative health research methods, and discusses practical applications for research, practice, and policy.
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Affiliation(s)
- Allison Tong
- Sydney School of Public Health, The University of Sydney, Sydney, NSW, Australia; Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, NSW, Australia.
| | | | - Jonathan C Craig
- Sydney School of Public Health, The University of Sydney, Sydney, NSW, Australia; Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, NSW, Australia
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83
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Ulutas O, Farragher J, Chiu E, Cook WL, Jassal SV. Functional Disability in Older Adults Maintained on Peritoneal Dialysis Therapy. Perit Dial Int 2014; 36:71-8. [PMID: 24711642 DOI: 10.3747/pdi.2013.00293] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2014] [Accepted: 02/22/2014] [Indexed: 01/17/2023] Open
Abstract
UNLABELLED ♦ BACKGROUND Older in-center hemodialysis patients have a high burden of functional disability. However, little is known about patients on home chronic peritoneal dialysis (PD). As patients opting for home dialysis are expected to play a greater role in their own dialysis care, we hypothesized that a relatively low number of PD patients would require help with basic self-care tasks (ADL) and instrumental activities of daily living (IADL). ♦ METHODS We used a cross-sectional study design to measure the proportion of patients aged 65 years and older undergoing outpatient PD who needed help with day-to-day activities. Patients living in nursing homes were excluded from the study. Functional dependence in ADL and IADL tasks were measured by the Barthel and Lawton Scales. Physical performance measures used included the timed up-and-go (TUG) test, chair stands and Folstein mini-mental score (MMSE). ♦ RESULTS A total of 74 of 76 (97%) eligible PD patients participated. Patients had a mean age of 76.2 ± 7.5 years. Thirty-six percent had impaired MMSE scores, 69% were unable to stand from a chair without the use of their arms and 51% had abnormal TUG scores. Only 8 patients (11%) were fully independent for both ADL and IADL activities. Dependence in one or more ADL activity was reported by 64% of participants, while 89% reported dependence in one or more IADL. ♦ CONCLUSIONS Impaired physical and functional performance is common in older patients maintained on PD. Collaborative geriatric-renal programs may be beneficial within the dialysis community.
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Affiliation(s)
- Ozkan Ulutas
- Division of Nephrology, University Health Network, Toronto Division of Nephrology, Faculty of Medicine, Inonu University, Malatya, Turkey
| | | | - Ernest Chiu
- Division of Nephrology, University Health Network, Toronto
| | - Wendy L Cook
- Division of Geriatric Medicine, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
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84
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Manns B, Barrett B, Evans M, Garg A, Hemmelgarn B, Kappel J, Klarenbach S, Madore F, Parfrey P, Samuel S, Soroka S, Suri R, Tonelli M, Wald R, Walsh M, Zappitelli M. Establishing a national knowledge translation and generation network in kidney disease: the CAnadian KidNey KNowledge TraNslation and GEneration NeTwork. Can J Kidney Health Dis 2014; 1:2. [PMID: 25780597 PMCID: PMC4346238 DOI: 10.1186/2054-3581-1-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2013] [Accepted: 02/14/2014] [Indexed: 11/21/2022] Open
Abstract
Patients with chronic kidney disease (CKD) do not always receive care consistent with guidelines, in part due to complexities in CKD management, lack of randomized trial data to inform care, and a failure to disseminate best practice. At a 2007 conference of key Canadian stakeholders in kidney disease, attendees noted that the impact of Canadian Society of Nephrology (CSN) guidelines was attenuated given limited formal linkages between the CSN Clinical Practice Guidelines Group, kidney researchers, decision makers and knowledge users, and that further knowledge was required to guide care in patients with kidney disease. The idea for the Canadian Kidney Knowledge Translation and Generation Network (CANN-NET) developed from this meeting. CANN-NET is a pan-Canadian network established in partnership with CSN, the Kidney Foundation of Canada and other professional societies to improve the care and outcomes of patients with and at risk for kidney disease. The initial priority areas for knowledge translation include improving optimal timing of dialysis initiation, and increasing the appropriate use of home dialysis. Given the urgent need for new knowledge, CANN-NET has also brought together a national group of experienced Canadian researchers to address knowledge gaps by encouraging and supporting multicentre randomized trials in priority areas, including management of cardiovascular disease in patients with kidney failure.
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Affiliation(s)
- Braden Manns
- Department of Medicine, University of Calgary, Calgary, Alberta Canada ; Department of Community Health Sciences, University of Calgary, Calgary, Alberta Canada ; Libin Cardiovascular Institute and Institute for Population Health, University of Calgary, Kragujevac, Alberta Canada
| | - Brendan Barrett
- Department of Medicine, Memorial Medical School, St John's, NL Canada
| | - Michael Evans
- Family Medicine and Public Health, University of Toronto, Toronto, Canada
| | - Amit Garg
- Division of Nephrology, Department of Medicine, University of Western Ontario, London, ON Canada
| | - Brenda Hemmelgarn
- Department of Medicine, University of Calgary, Calgary, Alberta Canada ; Department of Community Health Sciences, University of Calgary, Calgary, Alberta Canada ; Libin Cardiovascular Institute and Institute for Population Health, University of Calgary, Kragujevac, Alberta Canada
| | - Joanne Kappel
- Department of Medicine, University of Saskatchewan, Saskatoon, SK Canada
| | - Scott Klarenbach
- Department of Medicine, University of Alberta, Edmonton, Alberta Canada
| | - Francois Madore
- Department of Medicine, University of Montreal, Montreal, Quebec Canada
| | - Patrick Parfrey
- Department of Medicine, Memorial Medical School, St John's, NL Canada
| | - Susan Samuel
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta Canada ; Division of Pediatric Nephrology, Department of Pediatrics, Faculty of Medicine, University of Calgary, Calgary, Alberta Canada ; Alberta Children's Hospital Research Institute for Child and Maternal Health, Calgary, Alberta Canada
| | - Steven Soroka
- Department of Medicine, Dalhousie University, Halifax, Nova Scotia Canada
| | - Rita Suri
- Division of Nephrology, Department of Medicine, University of Western Ontario, London, ON Canada ; Medicine, Centre de Recherche du Centre Hospitalier de l`Université de Montréal, Montréal, QC Canada
| | - Marcello Tonelli
- Department of Medicine, University of Alberta, Edmonton, Alberta Canada
| | - Ron Wald
- Division of Nephrology, St. Michael's Hospital and the University of Toronto, Toronto, ON Canada ; Li Ka Shing Knowledge Institute of St. Michael's Hospital, Toronto, ON Canada
| | - Michael Walsh
- Division of Nephrology, McMaster University, Hamilton, Ontario Canada
| | - Michael Zappitelli
- Department of Pediatrics, McGill University Health Centre, Montreal, QC Canada
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85
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Malavade T, Sokwala A, Jassal SV. Dialysis therapies in older patients with end-stage renal disease. Clin Geriatr Med 2014; 29:625-39. [PMID: 23849012 DOI: 10.1016/j.cger.2013.05.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Each year a large number of older individuals with advanced renal disease are started on chronic dialysis therapy. Life expectancy is estimated at between 2 and 4 years depending on age, comorbidity, and intensity of medical care required in the weeks around the dialysis start time. Survivors remain at high risk of ongoing morbidity. Regarding quality of life, many older patients express regret over having opted for chronic dialysis therapy and subsequently choose to withdraw from treatment, whereas many others maintain a quality of life similar to that of age-matched peers. Early assessment and ongoing comprehensive geriatric assessment is recommended.
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Affiliation(s)
- Tuschar Malavade
- Division of Nephrology, Department of Medicine, University of Toronto, University Health Network, 200 Elizabeth Street, 8N857, Toronto, Ontario M5G 2K8, Canada
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86
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Blake PG, Quinn RR, Oliver MJ. Peritoneal dialysis and the process of modality selection. Perit Dial Int 2014; 33:233-41. [PMID: 23660605 DOI: 10.3747/pdi.2012.00119] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
The process of modality selection and how it works is a critical determinant of peritoneal dialysis (PD) utilization. This very complex process has not been well analyzed. Here, we break it down into 6 steps and point out how problems at each step can significantly reduce the proportion of endstage renal disease patients initiating PD. It is important that any program wishing it to grow its use of PD understand the steps and the points at which problems may be arising. Examples are presented.
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Affiliation(s)
- Peter G Blake
- Division of Nephrology, Department of Medicine, Western University, London, Ontario, Canada.
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87
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Tennankore K, Nadeau-Fredette AC, Chan CT. Intensified home hemodialysis: clinical benefits, risks and target populations. Nephrol Dial Transplant 2013; 29:1342-9. [DOI: 10.1093/ndt/gft383] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
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88
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Kane PM, Vinen K, Murtagh FEM. Palliative care for advanced renal disease: a summary of the evidence and future direction. Palliat Med 2013; 27:817-21. [PMID: 23765187 DOI: 10.1177/0269216313491796] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Patients with end-stage kidney disease can have a significant symptom burden with complex co-morbidities. Compounding this is the choice between dialysis and conservative management. NEED FOR SUPPORTIVE AND PALLIATIVE CARE: For individuals with end-stage kidney disease, palliative care can provide support with symptom management, advance care planning and psychological support and education for both patients and their families. Optimum management may be achieved through collaboration between renal and palliative care professionals, combining their different skills in addressing symptom and medication management. Palliative and supportive care must be patient-centred to be effective. Multidisciplinary cross-organisational input is central to address the complex care needs of these patients, particularly for those in the community. WHAT IS KNOWN/WHAT IS NOT KNOWN: There is growing awareness of the need for research into the palliative care needs of those with end-stage kidney disease. Research has shown that patients receiving dialysis may prioritise quality of life over survival time, partly due to the constraints that they feel dialysis imposes on them. Systematic study of those opting for a conservative management pathway rather than dialysis is beginning to happen. RESEARCH IMPLICATIONS Research is required into what underpins the preferences and priorities of patients with end-stage kidney disease to provide them with the best palliative and supportive care. POLICY AND PRACTICE: As more patients opt to follow the conservative pathway for their advanced renal disease, a change in service provision is required, with greater regular inclusion of palliative and supportive needs to address the gap in the care provision for this growing group.
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Affiliation(s)
- Pauline M Kane
- King's College London, Department of Palliative Care, Policy and Rehabilitation, Cicely Saunders Institute, London, UK
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89
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Tennankore KK, Hingwala J, Watson D, Bargman JM, Chan CT. Attitudes and perceptions of nephrology nurses towards dialysis modality selection: a survey study. BMC Nephrol 2013; 14:192. [PMID: 24020978 PMCID: PMC3847622 DOI: 10.1186/1471-2369-14-192] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2013] [Accepted: 09/04/2013] [Indexed: 12/02/2022] Open
Abstract
Background There is a paucity of information about the views of dialysis nurses towards dialysis modality selection, yet nurses often have the most direct contact time with patients. We conducted a survey to better understand nurses’ attitudes and perceptions, and hypothesized that nurses with different areas of expertise would have differences in opinions. Methods We administered an electronic survey to all dialysis/predialysis nurses (n = 129) at a large, tertiary care center. The survey included questions about preferred therapy - in-center hemodialysis (CHD), versus home dialysis (home hemodialysis and peritoneal dialysis) and ideal modality mix. Responses were compared between nurses with home dialysis and CHD experience. Results The survey response rate was 69%. Both nursing groups ranked patient caregivers and dialysis nurses as having the least impact on patient modality selection. For most patient characteristics (including age > 70 years and presence of multiple chronic illnesses), CHD nurses felt that CHD was somewhat or strongly preferred, while home dialysis nurses preferred a home modality (p < 0.001 for all characteristics studied). Similar differences in responses were noted for patient/system factors such as patient survival, cost to patients and nursing job security. Compared to CHD nurses, a higher proportion of home dialysis nurses felt that CHD was over-utilized (85% versus 58%, p = 0.024). Conclusion Dialysis nurses have prevailing views about modality selection that are strongly determined by their area of experience and expertise.
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Affiliation(s)
- Karthik K Tennankore
- From the Division of Nephrology, Dalhousie University, 5070 Dickson Building 5820 University Avenue, Halifax, NS, Canada.
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Abstract
PURPOSE OF REVIEW Elderly patients comprise the fastest growing population initiating dialysis and also experience the worst outcomes, including increased mortality, loss of functional status, and impaired quality of life. Nephrologists are often challenged with how best to engage in dialysis decision-making discussions within this population. Prognostication tools can assist nephrologists in engaging in these discussions, especially in patients for whom survival benefits may be outweighed by the burdens of treatment. RECENT FINDINGS This review includes the latest research in the survival of elderly patients with and without dialysis; prognostic factors associated with renal progression and survival; and integrative prognostic models to predict both short-term and long-term prognosis. The concept of kidney illness disease trajectory is defined with important outcomes including survival, health-related quality of life, and symptoms with and without dialysis. This prognostic information will then be integrated into an individualized approach to shared decision-making regarding treatment decision-making.(Figure is included in full-text article.) SUMMARY Treatment decision-making for elderly patients with advanced kidney disease necessitates an active process between nephrologist and patient, incorporating medical information as well as patient preferences. Prognostic information and observational data can facilitate nephrologists' ability to foresee and foretell the illness trajectory both with and without dialysis, further guiding these conversations.
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91
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Laplante S, Krepel H, Simons B, Nijhoff A, van Liere R, Simons M. Offering assisted peritoneal dialysis is a cost-effective alternative to the current care pathway in frail elderly Dutch patients. INTERNATIONAL JOURNAL OF HEALTHCARE MANAGEMENT 2013; 6:27-36. [PMID: 24791197 PMCID: PMC3991312 DOI: 10.1179/2047971912y.0000000028] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Background With the Dutch population aging, the number of individuals 75 years old or more needing dialysis is growing. This analysis assessed the cost-effectiveness of adding nurse-assisted peritoneal dialysis (aPD) to the usual care pathway in frail Dutch end-stage renal disease (ESRD) patients. Methods The current Dutch treatment pathway (conservative management, CM: 40% and PD in nursing home, nhPD: 60%) was compared in a decision-tree model with a new approach where the proportion of patients on dialysis would increase to 80% (i.e. CM: 20%; nhPD: 20%; and aPD: 60%). In-center hemodialysis was added in a secondary analysis. Inputs included survival (from literature), utility (from literature), and costs (2009 official tariffs). A healthcare payer's perspective was used with a 5-year horizon. Results The new approach was almost cost neutral in the primary analysis (despite more patients on dialysis) and dominant (more effective and less expensive) in the secondary analysis. The incremental cost-effectiveness ratio was only €52/QALY. In the sensitivity analyses (primary and secondary analyses), the new approach was either dominant or cost-effective in approximately 75% of the simulations. Conclusions Despite the investment required, offering aPD to frail elderly ESRD patients is a cost-effective alternative to the current pathway for Dutch healthcare payers.
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Affiliation(s)
- Suzanne Laplante
- EMEA Health Outcomes, Baxter Healthcare Corporation, Brussels, Belgium
| | - Harmen Krepel
- Sint Franciscus Ziekenhuis, Roosendaal, the Netherlands
| | - Bregje Simons
- Sint Franciscus Ziekenhuis, Roosendaal, the Netherlands
| | - Aafke Nijhoff
- Baxter Healthcare Corporation, Utrecht, the Netherlands
| | - Rens van Liere
- Healthcare Management School, Amersfoort, the Netherlands
| | - Michel Simons
- Baxter Healthcare Corporation, Utrecht, the Netherlands
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92
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Castledine CI, Gilg JA, Rogers C, Ben-Shlomo Y, Caskey FJ. Renal centre characteristics and physician practice patterns associated with home dialysis use. Nephrol Dial Transplant 2013; 28:2169-80. [PMID: 23737483 DOI: 10.1093/ndt/gft196] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND There is a wide variation in home dialysis use (peritoneal dialysis and home haemodialysis) between renal centres. This study identifies which centre characteristics and practice patterns are associated with home dialysis use. METHODS An observational study of all UK patients starting renal replacement therapy (RRT) in 2007-2008 using patient characteristics from the UK Renal Registry (UKRR) and renal centre characteristics ascertained from a national survey. Multilevel logistic regression was used to examine the association between patient and centre characteristics and home dialysis uptake. RESULTS Twenty-six per cent of 11 913 patients used home dialysis and survey responses were available from every renal centre. After taking into account patient factors, several centre factors were associated with a higher probability of home dialysis: physicians aspiring to a higher 'ideal' peritoneal dialysis rate (odds ratio, OR 1.21, 95% CI 1.06-1.37, P = 0.003 per 10% increase in 'ideal' percentage), early use of peritoneal dialysis (PD, OR 1.52, 95% CI 1.18-1.95, P < 0.001), use of home visits to educate patients pre-dialysis (OR 1.39, 95% CI 1.05-1.83, P = 0.02) and to provide trouble-shooting advice for existing home dialysis patients (OR 1.63, 95% CI 1.11-2.42, P = 0.01). Using videos/DVDs as part of the pre-dialysis education programme was associated with a lower probability of home dialysis, but this was correlated with lower levels of physician enthusiasm (r = -0.48, P < 0.001). After adjustment for this, the association disappeared (OR 0.77, 95% CI 0.55-1.07, P = 0.1). CONCLUSIONS Home dialysis use is associated with modifiable centre factors as well as individual patient characteristics.
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93
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Tong A, Palmer S, Manns B, Craig JC, Ruospo M, Gargano L, Johnson DW, Hegbrant J, Olsson M, Fishbane S, Strippoli GFM. The beliefs and expectations of patients and caregivers about home haemodialysis: an interview study. BMJ Open 2013; 3:bmjopen-2012-002148. [PMID: 23355670 PMCID: PMC3563121 DOI: 10.1136/bmjopen-2012-002148] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
OBJECTIVES To explore the beliefs and expectations of patients and their caregivers about home haemodialysis in Italy where the prevalence of home haemodialysis is low. DESIGN Semistructured, qualitative interview study with purposive sampling and thematic analysis. SETTING Four dialysis centres in Italy without home haemodialysis services (Bari, Marsala, Nissoria and Taranto). PARTICIPANTS 22 patients receiving in-centre haemodialysis and 20 of their identified caregivers. RESULTS We identified seven major themes that were central to patient and caregiver perceptions of home haemodialysis in regions without established services. Three positive themes were: flexibility and freedom (increased autonomy, minimised wasted time, liberation from strict dialysis schedules and gaining self-worth); comfort in familiar surroundings (family presence and support, avoiding the need for dialysis in hospital) and altruistic motivation to do home haemodialysis as an exemplar for other patients and families. Four negative themes were: disrupting sense of normality; family burden (an onerous responsibility, caregiver uncertainty and panic and visually confronting); housing constraints; healthcare by 'professionals' not 'amateurs' (relinquishing security and satisfaction with in-centre services) and isolation from peer support. CONCLUSIONS Patients without direct experience or previous education about home haemodialysis and their caregivers recognise the autonomy of home haemodialysis but are very concerned about the potential burden and personal sacrifice home haemodialysis will impose on caregivers and feel apprehensive about accepting the medical responsibilities of dialysis. To promote acceptance and uptake of home haemodialysis among patients and caregivers who have no experience of home dialysis, effective strategies are needed that provide information about home haemodialysis to patients and their caregivers, assure access to caregiver respite, provide continuous availability of medical and technical advice and facilitate peer patient support.
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Affiliation(s)
- Allison Tong
- Centre for Kidney Research, The Children's Hospital at Westmead, Sydney, New South Wales, Australia
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Williams ME. Tough Choices: Dialysis, Palliative Care, or a Third Option for Elderly ESRD. Semin Dial 2012; 25:633-9. [DOI: 10.1111/sdi.12018] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
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Gabbay E, Meyer KB. Kidney Failure Treatment: The Freedom to Choose. Am J Kidney Dis 2012; 60:5-7. [DOI: 10.1053/j.ajkd.2012.04.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2012] [Accepted: 04/10/2012] [Indexed: 11/11/2022]
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