Pre-ESRD patient education: a review of the literature

Validity of a Standard Information Protocol Provided to End-Stage Renal Disease Patients and Its Effect on Treatment Selection

Objective

To evaluate the validity of a standard information package, comprising written and audiovisual aids, for end-stage renal disease (ESRD) patients in a pre-dialysis program.

Study Design

A multicenter study comprising patients entering a predialysis program. Three questionnaires were developed to gather data in this study: (1) a pre-information package questionnaire that evaluates the patient's initial knowledge of ESRD and the treatment options available (pre-informed patients); (2) a post-information package questionnaire that evaluates the patient's knowledge of ESRD and treatment options after being informed according to the protocol (post-informed patients); (3) a “start of the treatment” questionnaire that deals with the patient's choice of treatment at the time of starting dialysis, as well as the reasons leading to that choice. In all three questionnaires the patient's age, gender, level of creatinine clearance (Ccr), and hematocrit were recorded.

Inclusion Criteria

Any patient who was on a predialysis program in the participating centers.

Results

Three hundred and four patients were evaluated across 14 participating centers. Initial knowledge was assessed in 216 pre-informed patients (questionnaire 1). Patients were then guided through the information package. One hundred and fifty-eight patients answered the post-information package (questionnaire 2). During the course of the study, 174 patients (of the initial 304) started renal replacement therapy. Of these, 49.4% (86 patients) had received predialysis information according to our study protocol. All the patients who received the information throughout the trial improved their knowledge of ESRD and treatment options; this improvement was statistically significant.

Conclusions

The treatment options least well known at the start of the study were the peritoneal dialysis techniques. After receiving the information package, patients had an equal knowledge of all the different treatments, although hemodialysis was still the most familiar. This improvement in knowledge enabled patients who started a dialysis treatment to choose a therapy according to their own preferences. Their selections were as follows: 44% of the patients chose hemodialysis, 40% chose continuous ambulatory peritoneal dialysis, and 16% chose automated peritoneal dialysis. The standard information package, used as a patient education program, effectively resulted in patients having a significantly improved level of knowledge and understanding of ESRD and the different treatment options available.

Educational Interventions for Patients With CKD: A Systematic Review

BACKGROUND

Preventing progression from earlier stages of chronic kidney disease (CKD) to end-stage kidney disease and minimizing the risk for cardiovascular events and other complications is central to the management of CKD. Patients' active participation in their own care is critical, but may be limited by their lack of awareness and understanding of CKD. We aimed to evaluate educational interventions for primary and secondary prevention of CKD.

STUDY DESIGN

Systematic review. Electronic databases were searched to December 2015, with study quality assessed using the Cochrane Collaboration risk-of-bias tool.

SETTING & POPULATION

People with CKD stages 1 to 5 in community and hospital settings (studies with only patients with CKD stage 5, kidney transplant recipients irrespective of glomerular filtration rate, or patients receiving dialysis were excluded).

SELECTION CRITERIA FOR STUDIES

Randomized controlled trials and nonrandomized studies of educational interventions.

INTERVENTIONS

Educational strategies in people with CKD.

OUTCOMES

Knowledge, self-management, quality-of-life, and clinical end points.

RESULTS

26 studies (12 trials, 14 observational studies) involving 5,403 participants were included. Risk of bias was high in most studies. Interventions were multifaceted, including face-to-face teaching (26 studies), written information (20 studies), and telephone follow-up (13 studies). 20 studies involved 1-on-1 patient/educator interaction and 14 incorporated group sessions. 9 studies showed improved outcomes for quality of life, knowledge, and self-management; 9 had improved clinical end points; and 2 studies showed improvements in both patient-reported and clinical outcomes. Characteristics of effective interventions included teaching sessions that were interactive and workshops/practical skills (13/15 studies); integrated negotiated goal setting (10/13 studies); involved groups of patients (12/14 studies), their families (4/4 studies), and a multidisciplinary team (6/6 studies); and had frequent (weekly [4/5 studies] or monthly [7/7 studies]) participant/educator encounters.

LIMITATIONS

A meta-analysis was not possible due to heterogeneity of the interventions and outcomes measured.

CONCLUSIONS

Well-designed, interactive, frequent, and multifaceted educational interventions that include both individual and group participation may improve knowledge, self-management, and patient outcomes.

Stage-specific educational interventions for patients with end-stage renal disease: psychological and psychiatric considerations

To optimize the success of educational interventions for adults with end-stage renal disease, we developed a psychosocial framework of illness adjustment. Currently, no stage-specific guidelines are available for understanding the psychosocial concerns of patients with end-stage renal disease nor are there specific models of coping with the disease. The content and implementation of educational programs must correspond to a patient's stage of adjustment to the illness. Psychological or psychiatric concerns may also affect participation in and response to educational interventions. Recommendations for structuring and implementing educational interventions about renal replacement that are specific to the unique psychosocial tasks associated with adjusting to each stage of end-stage renal disease are presented. Increased information about this disease and the treatment options available can be instrumental in improving patients' quality of life.

Stage-Specific Educational Interventions for Patients with End-Stage Renal Disease: Psychological and Psychiatric Considerations

To optimize the success of educational interventions for adults with end-stage renal disease, we developed a psychosocial framework of illness adjustment. Currently, no stage-specific guidelines are available for understanding the psychosocial concerns of patients with end-stage renal disease nor are there specific models of coping with the disease. The content and implementation of educational programs must correspond to a patient's stage of adjustment to the illness. Psychological or psychiatric concerns may also affect participation in and response to educational interventions. Recommendations for structuring and implementing educational interventions about renal replacement that are specific to the unique psychosocial tasks associated with adjusting to each stage of end-stage renal disease are presented. Increased information about this disease and the treatment options available can be instrumental in improving patients' quality of life.

An integrated approach to care for patients with chronic kidney disease

Although the Kidney Disease Outcomes and Quality Initiative (K/DOQI) guidelines serve to integrate the multiple stages of chronic kidney disease (CKD), in practice, the treatment of kidney disease over its progressive course may be somewhat fragmented. Because the provision of integrated care across the stages of kidney disease, is likely to be advantageous for both patients and care providers, a conceptual framework which graphically depicts the complex and chronic nature of kidney disease may prove useful. The Life Options Rehabilitation Advisory Council (LORAC) proposes a cycle diagram to reflect the chronicity and complexity of kidney disease and to emphasize a holistic perception of kidney disease from its inception to the worst-case scenario outcome of kidney failure [corrected]. The kidney disease cycle conceptualization can serve as a patient teaching aid and as a reminder of the communication, collaboration, and cooperation that are required among primary care physicians and practitioners in each of the specialty areas that address the spectrum of kidney disease.

Optimizing medical management of patients with pre-end-stage renal disease

Patients with end-stage renal disease have reduced quality of life, high levels of morbidity, and an annual mortality of about 22%. Because the high morbidity and mortality of dialysis patients might be reduced substantially if patients were healthier at the time of initiating renal replacement therapy, this article will present treatment recommendations designed to retard the progression of chronic renal disease, to optimize the medical management of comorbid medical conditions, such as cardiovascular disease, diabetes, and lipid disorders, and to reduce the complications of renal insufficiency, including hypertension, anemia, hyperparathyroidism, and malnutrition. Given the lack of prospective clinical studies in this area, these recommendations are derived from consensus standards for managing dialysis patients or patients with cardiovascular disease, hypertension, diabetes, and lipid disorders, and from expert opinion derived from laboratory investigations of pathophysiology and relevant experimental disease models.

Patient education in the emergency department

The emergency department (ED) visit provides an opportunity for patient education. Many ED patients have poor access to regular health care, including patient education. Accreditation standards, legal considerations, and cost-efficiency concerns encourage the clinician to implement formal patient education in the ED. More importantly, published clinical studies evaluating patient education in both the ED and comparable settings support the hypothesis that ED-based patient education improves outcomes. The article discusses considerations for instructional material, highlights challenges to ED-based patient education, and suggests possibilities for future research.

Can we improve early mortality in patients receiving renal replacement therapy?

BACKGROUND

Approximately one in eight patients with end-stage renal disease (ESRD) die within the first three months of starting renal replacement therapy (RRT). We investigated which factors might improve this early mortality.

METHODS

We performed a prospective nationwide study of all patients commencing RRT for ESRD in Scotland over one year. Patients were classified according to how they presented to start RRT, their burden of comorbid diseases, access prepared for dialysis, and duration of care by a nephrologist prior to commencing RRT. Those factors most strongly associated with death within 90 days of commencing treatment were determined by logistic regression analysis.

RESULTS

Patients with an acute unexpected element to their presentation for RRT had early mortality rates between 6.0 and 8.9 times greater than those who commenced RRT electively after a period of care from a nephrologist. Patients in high and medium comorbidity risk groups had early mortality rates of 4.7 and 2.2 times greater than those in the low-risk group. Low serum albumin had a significant association with early death. Patients who progressed steadily to ESRD, who had a planned start to dialysis, and who had mature access were 3.6 times more likely to survive beyond three months than those with no access; they were, however, also younger with less comorbidity.

CONCLUSIONS

The factors principally associated with early mortality are nonelective presentation for RRT, comorbid illness, and low serum albumin. Patients cared for by a nephrologist before requiring RRT who have mature access have better short-term survival than those without access. They are also younger with less comorbidity. It may be possible to improve short-term survival in this "unplanned" group if referred early to facilitate reducing cardiovascular risk factors and preparation for RRT.

Predialysis education helps patients choose dialysis modality and increases disease-specific knowledge

The aims of this study were first, to evaluate the effects of a patient-education programme for a group of 28 uraemic patients (the Experimental (EG) group) with regard to their knowledge and perceived amount of information and to relate these effects to their sense of coherence and secondly, to study the patients' perception of their dialysis treatment. The results were compared with a comparison group (the Companion (CG) group, n = 28) which had received routine information only. The education programme seemed to have covered what the EG wanted to know. Significantly more patients in the EG group stated that they had acquired sufficient knowledge to enable them to participate in choosing dialysis modality compared with the CG group. The EG patients were significantly more informed in the post-educational evaluation compared with the pre-educational evaluation. In the EG, there was a significant relationship between the scores for knowledge and perceived amount of information. Men and younger patients perceived that they had received a greater amount of information than women and older patients. After having started dialysis treatment, there were no differences in the scores for knowledge and information between the EG and the CG. This indicates that other sources of knowledge and information were available to the CG patients. There was no significant correlation between the score of the Sense of Coherence (SOC) scale and the knowledge and information scores. Kidney transplantation, progression of renal failure, other patients' experiences of dialysis, dependence - independence, present and future wellbeing, how to cope with physical and psycho-social demands and continuity in their contacts with doctors and other health professionals were predominant concerns for the two groups of patients.

CONCLUSION

the predialysis group education programme enabled patients to choose dialysis modality to achieve an understanding of their illness and its treatment. It also provided the possibility of informal support by fellow patients and health professionals. The study emphasizes the special needs of elderly patients and we recommend that education programmes are tailored to their requirements.

Predialysis patient education: effects on functioning and well-being in uraemic patients

This study evaluated the effects of a predialysis patient education programme on functioning and well-being in 28 uraemic patients. The programme consisted of four group sessions with the following themes: renal disease and dietary restriction, active renal replacement therapy, physical exercise, and the impact of chronic renal failure on economy, family and social life. Three to 9 months after having started dialysis the patients were evaluated regarding symptoms, perceived health (Health Index), functional (SIP) and emotional (STAI) status. Twenty-eight patients already on dialysis treatment informed according to conventional routines constituted the comparison group. There were no significant differences between the groups regarding age, sex, educational or social background, duration of kidney disease, choice of dialysis treatment, cause of renal disease and laboratory tests except for s-urea. The patients who participated in the education programme scored significantly better mood, less mobility problems (HI), less functional disabilities (SIP) and lower levels of anxiety (STAI) compared to the comparison group. There were no significant differences between the two groups regarding symptoms and overall health. The differences between the groups prevailed during the first 6 months on dialysis treatment, after which the differences disappeared. In the comparison group age correlated significantly to anxiety and overall SIP, which was not the case in the experimental group. In conclusion, the experimental group that participated in a predialysis patient education programme, showed better functional and emotional well-being than the non-educated comparison group. The positive effects of participating in an education programme prevailed during the first 6 months of dialysis treatment. Moreover, the younger patients seemed especially to benefit from participation in a predialysis patient education programme. It is suggested that patient education should be ongoing for patients with end-stage renal failure initiated during the predialysis stage and continued after maintenance dialysis has been established.