An integrated approach to care for patients with chronic kidney disease

Assessing the Delivery of Coordinated Care to Patients with Advanced Chronic Kidney Disease in Ontario, Canada: A Survey of Patients and Healthcare Professionals

Introduction:

Patients with advanced Chronic Kidney Disease (CKD) have complex health needs, and thus require care that is coordinated across professionals and organizations. This study aimed to describe the extent of coordinated care delivery for patients with advanced CKD from the perspectives of both patients and healthcare professionals.

Methods:

The Coordination Scale of the Patient Assessment of Chronic Illness Care (PACIC-26) survey was administered to a random sample of 14,257 patients on maintenance dialysis or receiving care in end-stage kidney disease preparation clinics in Ontario, Canada. A five-item survey was administered to 596 multidisciplinary nephrology professionals.

Results:

Among the 1,925 patient respondents, 67% reported they had been referred to an allied health professional; 19% had been encouraged to attend programs in the community; and 34% had been told how their visits with other types of doctors helped their treatment (% reporting “always” or “most of the time”). Patient responses were significantly different by treatment modality/setting, but not by gender or geographic location of treatment facility. Among the 276 professional respondents, 37% reported their patients’ care was well-coordinated across settings; 56% reported participating in interdisciplinary care planning discussions; and 53% reported they are aware of appropriate home and community services to support their patients (% reporting “always” or “most of the time”).

Conclusion:

The results suggest that care for patients with advanced CKD in Ontario is not consistently coordinated. Healthcare professionals may enhance patient perceptions of coordinated care through explicit communication with patients about how the professionals they see and treatments or services they receive influence their overall health and well-being. At a systems level, there is a need to improve professional awareness of and linkages to home- and community-based services.

The effect of a virtual reality exercise program on physical fitness, body composition, and fatigue in hemodialysis patients

[Purpose] The aim of the present study was to investigate the effects of a virtual reality exercise program (VREP) on physical fitness, body composition, and fatigue in hemodialysis (HD) patients with end-stage renal failure. [Subjects and Methods] A nonequivalent control group pretest-posttest design was used. Forty-six HD patients were divided into exercise (n=23) and control groups (n=23); while waiting for their dialyses, the exercise group followed a VREP, and the control group received only their usual care. The VREP was accomplished using Nintendo’s Wii Fit Plus for 40 minutes, 3 times a week for 8 weeks during the period of May 27 to July 19, 2013. Physical fitness (muscle strength, balance, flexibility), body composition (skeletal muscle mass, body fat rate, arm and leg muscle mass), and fatigue were measured at baseline and after the intervention. [Results] After the VREP, physical fitness and body composition significantly increased, and the level of fatigue significantly decreased in the exercise group. [Conclusion] These results suggest that a VREP improves physical fitness, body composition, and fatigue in HD patients. Based on the findings, VREPs should be used as a health promotion programs for HD patients.

Education of patients with chronic kidney disease at the interface of primary care providers and nephrologists

Patient education is promoted as an integral part of effective kidney disease management. Programs and tools are available for providers and patients to support patient CKD education in primary care and nephrology. Challenges to providing patient education across practice settings include patients' lack of awareness of CKD as a medical entity, physician perceptions of their own lack of skill and ability to educate patients, differences in how primary care and nephrology physicians perceive collaborative care, and shortage of staff and time to support educational efforts. In addition, there is little research available to guide evidence-based practices for implementing early patient CKD education interventions across medical disciplines. Development and testing of patient education programs using early CKD multidisciplinary care, educational websites, and phone-based applications are all areas of growing research. More work is needed to provide evidence and support that physicians and other health professionals need to ensure a seamless patient education experience across the continuum of care.

Quality of patient-physician discussions about CKD in primary care: a cross-sectional study

BACKGROUND

The quality of patient-physician discussions about chronic kidney disease (CKD) in primary care has not been studied previously.

STUDY DESIGN

Cross-sectional study.

SETTINGS & PARTICIPANTS

We audiotaped encounters between 236 patients with hypertension and their primary care physicians (n = 40).

PREDICTORS

Patient, physician, and encounter characteristics.

OUTCOMES & MEASUREMENTS

We described the occurrence and characteristics (content, use of technical terms, and physician assessment of patient comprehension of new concepts) of CKD discussions. We assessed patient and physician characteristics associated with CKD discussion occurrence.

RESULTS

Many patients (mean age, 59 years) had uncontrolled hypertension (51%), diabetes (44%), and/or 3 or more comorbid conditions (51%). Most primary care physicians practiced (52%) fewer than 10 years. CKD discussions occurred in few (26%; n = 61) encounters, with content focused on laboratory assessment (89%), risk-factor treatment (28%), and causes (26%) of CKD. In encounters that included a CKD discussion, physicians used technical terms (28%; n = 17) and rarely assessed patients' comprehension (2%; n = 1). CKD discussions were statistically significantly less common in visits of patients with some (vs no) college education (OR, 0.23; 95% CI, 0.09-0.56), with 3 or more (vs fewer) comorbid conditions (OR, 0.49; 95% CI, 0.25-0.96), and who saw physicians with more (vs fewer) than 10 years of practice experience (OR, 0.41; 95% CI, 0.21-0.80). CKD discussions were more common during longer encounters (OR, 1.31; 95% CI, 1.04-1.65) and encounters in which diabetes was (vs was not) discussed (OR, 2.87; 95% CI, 1.22-6.77).

LIMITATIONS

Generalizability of our findings may be limited.

CONCLUSIONS

Patient-physician discussions about CKD in high-risk primary care patients were infrequent. Physicians used technical terms and infrequently assessed patients' understanding of new CKD concepts. Efforts to improve the frequency and content of patient-physician CKD discussions in primary care could improve patients' clinical outcomes.