Home run-results of a chronic kidney disease Telemedicine Patient Education Study

The Use of a Novel Virtual Reality Training Tool for Peritoneal Dialysis: Qualitative Assessment Among Health Care Professionals

BACKGROUND

Effective peritoneal dialysis (PD) training is essential for performing dialysis at home and reducing the risk of peritonitis and other PD-related infections. Virtual reality (VR) is an innovative learning tool that is able to combine theoretical information, interactivity, and behavioral instructions while offering a playful learning environment. To improve patient training for PD, Fresenius Medical Care launched the stay•safe MyTraining VR, a novel educational program based on the use of a VR headset and a handheld controller.

OBJECTIVE

This qualitative assessment aims to investigate opinions toward the new tool among the health care professionals (HCPs) who were responsible for implementing the VR application.

METHODS

We recruited nursing staff and nephrologists who have gained practical experience with the stay•safe MyTraining VR within pilot dialysis centers. Predetermined open-ended questions were administered during individual and group video interviews.

RESULTS

We interviewed 7 HCPs who have 2 to 20 years of experience in PD training. The number of patients trained with the stay•safe MyTraining VR ranged from 2 to 5 for each professional. The stay•safe MyTraining VR was well accepted and perceived as a valuable supplementary tool for PD training. From the respondents' perspective, the technology improved patients' learning experience by facilitating the internalization of both medical information and procedural skills. HCPs highlighted that the opportunity offered by VR to reiterate training activities in a positive and safe learning environment, according to each patient's needs, can facilitate error correction and implement a standardized training curriculum. However, VR had limited use in the final phase of the patient PD training program, where learners need to get familiar with the handling of the materials. Moreover, the traditional PD training was still considered essential to manage the emotional and motivational aspects and address any patient-specific application-oriented questions. In addition to its use within PD training, VR was perceived as a useful tool to support the decision-making process of patients and train other HCPs. Moreover, VR introduction was associated with increased efficiency and productivity of HCPs because it enabled them to perform other activities while the patient was practicing with the device. As for patients' acceptance of the new tool, interviewees reported positive feedback, including that of older adults. Limited use with patients experiencing dementia or severe visual impairment or lacking sensomotoric competence was mentioned.

CONCLUSIONS

The stay•safe MyTraining VR is suggested to improve training efficiency and efficacy and thus could have a positive impact in the PD training scenario. Our study offers a process proposal that can serve as a guide to the implementation of a VR-based PD training program within other dialysis centers. Dedicated research is needed to assess the operational benefits and the consequences on patient management.

Development and Validation of KRT Knowledge Instrument

Key Points

KRT awareness is important for informed choice and use of dialysis modalities, but we lack validated instruments capable of measuring such awareness. We present a newly developed KRT Knowledge instrument, which can be used to evaluate the kidney failure and KRT awareness among patients with CKD. Our results show that KRT awareness is different and significantly lower than CKD awareness among patients with advanced CKD.

Background

Awareness of KRTs is associated with greater home dialysis use. However, validated instruments evaluating patient knowledge and awareness of various KRTs are currently lacking and are critical for informed decision making.

Methods

We developed a 24-item KRT knowledge instrument (Know-KRT) encompassing three domains of General, Technical, and Correlative information critical for informed dialysis decision making. We conducted a cross-sectional study among Veterans with advanced CKD to determine its reliability, dimensionality, and validity.

Results

The Know-KRT instrument dimensionality was acceptable with a root mean squared error of approximation of 0.095 for the conceptual three-domain model fit (χ2=824.6, P < 0.001). Corrected Item-Total Correlation indices were excellent (>0.4) for all individual items. Internal consistency was excellent for the full instrument, Cronbach's alpha, α =0.95, with α =0.86, 0.91, and 0.79 for the General, Technical, and Correlative domains, respectively. The Know-KRT score correlated strongly with the CKD knowledge score (r =0.68, P < 0.001). KRT awareness was low, with an ease index of 0.181 for the full instrument. The General, Technical, and Correlative domain scores demonstrated strong correlations with the Know-KRT total score (r =0.68, 0.61, and 0.48, respectively, P < 0.001) and CKD instrument score (r =0.95, 0.93, and 0.77, respectively, P < 0.001). KRT and CKD awareness correlated negatively with age and positively with health literacy, employment status, hypertension, and quality of nephrology care.

Conclusions

We report a newly developed Know-KRT instrument with three domains having acceptable internal consistency, reliability, and validity. We show that patients with advanced CKD have low awareness of KRTs, even for items related to basic descriptions of modalities, highlighting the need for targeted patient education efforts.

Clinical Trial registration number:

NCT04064086 .

Telehealth strategies in the care of people with chronic kidney disease: integrative review

OBJECTIVE

to evaluate the evidence about telehealth strategies in caring for people with chronic kidney disease.

METHOD

integrative literature review. The search for primary studies was carried out in six databases: PubMed/MEDLINE, Web of Science, EMBASE, CINAHL, LILACS, and Scopus. The sample consisted of 48 articles published between 2000 and 2021. The telehealth strategy was applied by a multidisciplinary team of doctors, nurses, pharmacists, nutritionis, and social workers. The type of study, country, strategy applied, setting, population, and professional were extracted from the articles. The studies were selected by reading the title and abstract (phase 1) and then reading them in full (phase 2), categorizing them by telehealth strategy. The results were summarized descriptively and the studies were classified according to their level of evidence.

RESULTS

the home was the most representative in dialysis and conservative treatment. Six categories of telehealth strategies were identified: remote monitoring devices, teleconsultation, digital platforms, apps, multimodality strategies, and telephone contact.

CONCLUSION

using these strategies for the care of people with chronic kidney disease presents different forms and implementations, being feasible for the renal population at any stage of the disease and applicable by different health professionals with an emphasis on the home environment. The evidence shows that telehealth favors lower cost, accessibility to remote locations, and better monitoring of dialysis with positive resul in symptom control, risk reduction, and patient training.

BACKGROUND

Telehealth in chronic kidney disease care is feasible and promising. (2) Telehealth is feasible for people at all stages of CKD. (3) Health promotion and monitoring were the most applied by telehealth. (4) Remote care can reduce costs, emergencies, and contac with the clinic. (5) Nurses mainly used telephone contact and teleconferencing.

Needs and Considerations for Standardization of Kidney Disease Education in Patients with Advanced CKD

Kidney health advocacy organizations and leaders in the nephrology community have repeatedly emphasized the need to increase home dialysis utilization in the United States. Limited awareness and understanding of options for the management of kidney failure among patients living with advanced CKD is a significant barrier to increasing the selection and use of home dialysis. Studies have shown that providing targeted comprehensive patient education before the onset of kidney failure can improve patients' awareness of kidney disease and substantially increase the informed utilization of home dialysis. Unfortunately, in the absence of validated evidence-based education protocols, outcomes associated with home dialysis use vary widely among published studies, potentially affecting the routine implementation and reporting of these services among patients with advanced CKD. This review provides pragmatic guidance on establishing effective patient-centered education programs to empower patients to make informed decisions about their KRT and, in turn, increase home dialysis use.

Electronic Phenotype for Advanced Chronic Kidney Disease in a Veteran Health Care System Clinical Database: Systems-Based Strategy for Model Development and Evaluation

BACKGROUND

Identifying advanced (stages 4 and 5) chronic kidney disease (CKD) cohorts in clinical databases is complicated and often unreliable. Accurately identifying these patients can allow targeting this population for their specialized clinical and research needs.

OBJECTIVE

This study was conducted as a system-based strategy to identify all prevalent Veterans with advanced CKD for subsequent enrollment in a clinical trial. We aimed to examine the prevalence and accuracy of conventionally used diagnosis codes and estimated glomerular filtration rate (eGFR)-based phenotypes for advanced CKD in an electronic health record (EHR) database. We sought to develop a pragmatic EHR phenotype capable of improving the real-time identification of advanced CKD cohorts in a regional Veterans health care system.

METHODS

Using the Veterans Affairs Informatics and Computing Infrastructure services, we extracted the source cohort of Veterans with advanced CKD based on a combination of the latest eGFR value ≤30 ml·min-1·1.73 m-2 or existing International Classification of Diseases (ICD)-10 diagnosis codes for advanced CKD (N18.4 and N18.5) in the last 12 months. We estimated the prevalence of advanced CKD using various prior published EHR phenotypes (ie, advanced CKD diagnosis codes, using the latest single eGFR <30 ml·min-1·1.73 m-2, utilizing two eGFR values) and our operational EHR phenotypes of a high-, intermediate-, and low-risk advanced CKD cohort. We evaluated the accuracy of these phenotypes by examining the likelihood of a sustained reduction of eGFR <30 ml·min-1·1.73 m-2 over a 6-month follow-up period.

RESULTS

Of the 133,756 active Veteran enrollees at North Florida/South Georgia Veterans Health System (NF/SG VHS), we identified a source cohort of 1759 Veterans with advanced nondialysis CKD. Among these, 1102 (62.9%) Veterans had diagnosis codes for advanced CKD; 1391(79.1%) had the index eGFR <30 ml·min-1·1.73 m-2; and 928 (52.7%), 480 (27.2%), and 315 (17.9%) Veterans had high-, intermediate-, and low-risk advanced CKD, respectively. The prevalence of advanced CKD among Veterans at NF/SG VHS varied between 1% and 1.5% depending on the EHR phenotype. At the 6-month follow-up, the probability of Veterans remaining in the advanced CKD stage was 65.3% in the group defined by the ICD-10 codes and 90% in the groups defined by eGFR values. Based on our phenotype, 94.2% of high-risk, 71% of intermediate-risk, and 16.1% of low-risk groups remained in the advanced CKD category.

CONCLUSIONS

While the prevalence of advanced CKD has limited variation between different EHR phenotypes, the accuracy can be improved by utilizing two eGFR values in a stratified manner. We report the development of a pragmatic EHR-based model to identify advanced CKD within a regional Veterans health care system in real time with a tiered approach that allows targeting the needs of the groups at risk of progression to end-stage kidney disease.

Feasibility and First Experiences from an Online Kidney School for Patients with Chronic Kidney Disease

Objectives: To examine patients' and relatives' experiences with participation in an online kidney school (OKS) and its influence on their choice of treatment modality; furthermore, to report on healthcare professionals' (HCPs) first experiences with OKS. Methods: A mixed-methods design with parallel data collection involving two questionnaires for participants, including patients and relatives and a focus group discussion (FGD) with HCPs. Results: The OKS was feasible, and overall, patients and relatives were satisfied. Participation in the OKS increased the percentage of those who felt ready to make a decision regarding treatment. One over-arching theme (evolvement of the online kidney school over time) and three sub-themes (concerns and perceived barriers, facilitators, and benefits and future possibilities) emerged from the FGD. Conclusions: The OKS proved feasible, was well-accepted, and increased participants' abilities to choose a preferred treatment modality. HCPs displayed initial concerns regarding the quality of the OKS and worried about the practicality of conducting the OKS. They experienced a feeling of something being lost. However, over time, HCPs developed strategies to tackle initial concerns and discovered that patients were more capable of participating than they had anticipated.

Supporting Shared Decision-Making and Home Dialysis in End-Stage Kidney Disease

It has been widely demonstrated that patient education and empowerment, especially involving shared treatment decisions, improve patient outcomes in chronic medical conditions, including chronic kidney disease requiring kidney replacement therapies. Accordingly, regulatory agencies in the US and worldwide recommend shared decision-making for finalizing one's choice of kidney replacement therapy. It is also recognized that the US needs to substantially increase home dialysis utilization to leverage its positive impacts on patient and healthcare cost-related outcomes. This perspective highlights how the routine clinical use of the recommended practice of shared decision-making can exist in synergy with the system's goal for increased home dialysis use. It introduces a pragmatic provider checklist, The Nephrologist's Shared Decision-Making Checklist, grounded in the relevant theories of shared decision-making, and, unlike some research assessments and extant tools, is easy to understand and implement in clinical practice. This qualitative Checklist can help providers ensure that they have co-constructed an SDM experience with the patient and involved caretakers, helping them benefit from the improved outcomes associated with SDM.

mHealth education for patients with chronic kidney disease: protocol for a scoping review

INTRODUCTION

More than 10% of the population worldwide is affected by chronic kidney disease (CKD). Despite many promising indications regarding the use of mHealth education for patients with CKD, there is still little evidence regarding the feasibility, effectiveness outcomes and outcome measures. Therefore, we will conduct a scoping review to examine the currently available evidence on mHealth education for patients with CKD and, thus, explore the existing evidence regarding feasibility, effectiveness outcomes and outcome measures, patient and/or provider perception and implementation challenges.

METHODS AND ANALYSIS

A scoping review will be conducted in accordance with Joanna Briggs Institute Manual for Evidence Synthesis chapter on scoping reviews.MEDLINE, Embase, CINAHL and PsycINFO will be searched. The search strategy will consist of blocks, which have been adopted and modified from former Cochrane reviews. Two independent reviewers will screen studies. Characteristics of the included studies, both quantitative and qualitative, will be reported using quantitative descriptive statistics. Quantitative results will be grouped by objectives (feasibility, effectiveness outcomes and outcome measures, patient perception and implementation challenges), types of intervention and characteristics of participants. Qualitative results will be organised into categories using an iterative process, as suggested by Pollock et al. ETHICS AND DISSEMINATION: As this scoping review does not involve primary data collection, ethical permission is unnecessary. Results of the scoping review will be published in an international peer-reviewed scientific journal.

TRIAL REGISTRATION NUMBER

Open Science Framework (https://osf.io/gxkeh/).

A randomized controlled trial to evaluate and assess the effect of comprehensive pre-end stage kidney disease education on home dialysis use in veterans, rationale and design

BACKGROUND

Informed dialysis selection and greater home dialysis use are the two long-desired, underachieved targets of advanced chronic kidney disease (CKD) care in the US healthcare system. Observational institutional studies have shown that comprehensive pre-kidney failure, conventionally referred to as end stage kidney disease education (CPE) can improve both these outcomes. However, lack of validated protocols, well-controlled studies, and systemic models have limited wide-spread adoption of CPE in the US. We hypothesized that a universal CPE and patient-centered initiation of kidney replacement therapy can improve multiple clinical, patient-centered and health service outcomes in advanced CKD and kidney failure requiring dialysis therapy.

METHODS

Trial to Evaluate and Assess the effects of CPE on Home dialysis in Veterans (TEACH-VET) is a multi-method randomized controlled trial aimed to evaluate the effects of a system-based approach for providing CPE to all Veterans with advanced CKD across a regional healthcare System. The study will randomize 544 Veterans with non-dialysis stage 4 and 5 CKD in a 1:1 allocation stratified by their annual family income and the stage of CKD to an intervention (CPE) arm or control arm. Intervention arm will receive a two-phase CPE in an intent-to-teach manner. Control arm will receive usual clinical care supplemented by resources for the freely-available kidney disease information. Participants will be followed after intervention/control for the duration of the study or until 90-days post-kidney failure, whichever occurs earlier.

RESULTS

The primary outcome will assess the proportion of Veterans using home dialysis at 90-days post-kidney failure, and secondary outcomes will include post-intervention/control CKD knowledge, confidence in dialysis decision and home dialysis selection. Qualitative arm of the study will use semi-structured interviews to in-depth assess Veterans' satisfaction with the intervention, preference for delivery, and barriers and facilitators to home dialysis selection and use. Several post-kidney failure clinical, patient-centered and health services outcomes will be assessed 90-days post-kidney failure as additional secondary outcomes.

CONCLUSION

The results will provide evidence regarding the need and efficacy of a system-based, patient-centered approach towards universal CPE for all patients with advanced CKD. If successful, this may provide a blueprint for developing such programs across the similar healthcare infrastructures throughout the country.

TRIAL REGISTRATION

NCT04064086 .

Home Blood Pressure and Telemedicine: A Modern Approach for Managing Hypertension During and After COVID-19 Pandemic

Hypertension is the most common cardiovascular risk factor for acute cardiovascular outcomes, including acute coronary disease, stroke, chronic kidney disease and congestive heart failure. Despite the fact that it represents the most prevalent risk factor in the general population, mostly in elderly individuals, its awareness is still relatively low, being about one third of patients living with undiagnosed hypertension and high risk of experiencing acute cardiovascular events. In addition, though recent improvement in pharmacological and non-pharmacological therapeutic options, hypertension is largely uncontrolled, with about 35-40% of treated hypertensive patients achieving the recommended therapeutic targets. Among different modern interventions proposed for improving blood pressure control in treated hypertensive patients, a systematic adoption of home BP monitoring has demonstrated to be one of the most effective. Indeed, it improves patients' awareness of the disease and adherence to prescribed medications and allows tailoring and personalizing BP lowering therapies. Home BP monitoring is particularly suitable for telemedicine and mobile-health solutions. Indeed, in specific conditions, when face-to-face interactions between patients and physicians are not allowed or even suspended, as in case of COVID-19 pandemic, telemedicine may ensure effective management of hypertension, as well as other cardiovascular and non-cardiovascular comorbidities. This review will summarize strengths and limitations of telemedicine in the clinical management of hypertension with a particular focus on the lessons learned during the COVID-19 pandemic.

The use of virtual physician mentoring to enhance home dialysis knowledge and uptake

Home dialysis therapies are flexible kidney replacement strategies with documented clinical benefits. While the incidence of end-stage kidney disease continues to increase globally, the use of home dialysis remains low in most developed countries. Multiple barriers to providing home dialysis have been noted in the published literature. Among known challenges, gaps in clinician knowledge are potentially addressable with a focused education strategy. Recent national surveys in the United States and Australia have highlighted the need for enhanced home dialysis knowledge especially among nephrologists who have recently completed training. Traditional in-person continuing professional educational programmes have had modest success in promoting home dialysis and are limited by scale and the present global COVID-19 pandemic. We hypothesize that the use of a 'Hub and Spoke' model of virtual home dialysis mentorship for nephrologists based on project ECHO would support home dialysis growth. We review the home dialysis literature, known educational gaps and plausible educational interventions to address current limitations in physician education.

Effect of multidisciplinary care of dialysis initiation for outpatients with chronic kidney disease

BACKGROUND

The aim of comprehensive multidisciplinary care (MDC) by the chronic kidney disease (CKD) team is not only to prevent worsening renal function, but also provide education on the selection of renal replacement therapy (RRT) by shared decision making (SDM). The purpose of this study was to examine the effects of MDC for predialysis outpatients on dialysis therapy, especially with regard to peritoneal dialysis (PD).

METHODS

This study evaluated 112 CKD patients who underwent dialysis at our hospital starting from 2012, with 53 outpatients receiving MDC from the CKD team and 59 outpatients not receiving MDC. Annual decreases in the estimated glomerular filtration rates (ΔeGFR), the duration from the time of intervention to dialysis initiation, the urgent dialysis rate using a temporary catheter, and the PD selection rate were compared and examined between the two groups. The ΔeGFR, the duration from intervention to PD initiation, and the PD retention rate were compared between 18 PD patients in the MDC group and 10 PD patients in the non-MDC group.

RESULTS

The MDC group had a significantly lower ΔeGFR, significantly longer duration, and a significantly lower urgent dialysis initiation rate versus the non-MDC group. Moreover, there was a significantly higher PD selection rate, significantly prolonged duration, and significantly higher PD retention rate.

CONCLUSIONS

Multidisciplinary CKD team care for outpatients is effective in delaying the progression of CKD and avoiding the initiation of urgent dialysis; contributing to improved PD selectivity and continuity by SDM.