Identifying Feasible Heart Failure Interventions Suitable for the Jordan Healthcare system: A Delphi Study

Interventions and strategies should align with the context and capacity of the health system. Identifying the most feasible and appropriate heart failure interventions in Jordan will improve heart failure management and clinical outcomes. Therefore, this study aimed to derive consensus from clinicians (using the Delphi method) regarding the most feasible and appropriate heart failure interventions in Jordan. A two-round Delphi study involving seven clinicians and policy makers were conducted. The Delphi results found consensus for the feasibility of the educational materials, follow up phone call, cardiac rehabilitation, group session, and training courses for staff. The components that were not feasible were: multidisciplinary team, individual session, and telemonitoring devices. The present study demonstrates the importance of utilizing interventions tailored to patients' characteristics and aligned with the capacity of healthcare system.

Systematic Review and Meta-analyses: Dietary Behavior Interventions in Non-dialysis Chronic Kidney Disease

Evidence of the effectiveness of dietary behavior interventions in patients with non-dialysis chronic kidney disease is limited. We aim to determine the benefits and barriers of dietary behavior interventions for this population. Eligible studies were obtained from databases including PubMed, Embase, the Cochrane Library, Web of Science, and CINAHL. Six studies including 432 participants were identified. Overall, dietary behavior interventions significant improved adherence to protein intake (2.64, 95% CI 1.33, 5.23, I2 = 0) and renal function (eGFR) (2.97, 95% CI 2.59, 3.35, I2 = 0). Moreover, dietary behavior interventions indicated a significant opportunity to promote adherence to sodium-restricted diets (SRD), blood pressure (BP), self-efficacy, and quality of life (QoL) in non-dialysis CKD patients. However, there is still need to determine dietary behavior intervention programs in large sample and amount of studies, develop reliable instruments to measure dietary adherence, and thereafter, provide more reliable results for clinical practice.

Effectiveness of educational or behavioral interventions on adherence to phosphate control in adults receiving hemodialysis: a systematic review

BACKGROUND

People with end-stage kidney disease (ESKD) develop impaired excretion of phosphate. Hyperphosphatemia develops in ESKD as a result of the kidney's reduced ability to excrete ingested phosphate load and is characterized by high bone turnover and increased musculoskeletal morbidity including bone pain and muscle weakness. Increased serum phosphate levels are also associated with cardiovascular disease and associated mortality. These effects are significant considering that cardiovascular disease is the leading cause of death in ESKD, making phosphate control a crucial treatment goal.

OBJECTIVES

To determine the effectiveness of education or behavioral interventions on adherence to phosphate control in adults with ESKD receiving hemodialysis (HD).

INCLUSION CRITERIA TYPES OF PARTICIPANTS

Adults aged over 18 years with ESKD undergoing HD, attending dialysis facilities regardless of frequency and duration of treatment sessions per week. Studies with participants receiving hemodiafiltration were excluded.

TYPES OF INTERVENTION(S)/PHENOMENA OF INTEREST

All types of educational and behavioral interventions aimed at improving adherence to dietary phosphate restriction, phosphate binder medication and HD.

TYPES OF STUDIES

Randomized controlled trials (RCTs), non-RCTs, before and after and cohort studies.

OUTCOMES

Outcome measures included serum phosphate levels, patient knowledge and adherence to phosphate control methods, chronic kidney disease (CKD) self-management behavior and perceived self-efficacy for CKD related to phosphate control.

SEARCH STRATEGY

A search was conducted in CINAHL, MEDLINE, The Cochrane Library, Embase, Web of Science, PsycINFO and ProQuest Dissertations and Theses Global to find published studies between January 2005 and December 2015.

METHODOLOGICAL QUALITY

Risk of bias was assessed by three reviewers prior to inclusion in the review using standardized critical appraisal instruments from the Joanna Briggs Institute Meta-Analysis of Statistics Assessment and Review Instrument (JBI-MAStARI).

DATA EXTRACTION

Data were extracted using the standardized data extraction tool from JBI-MAStARI.

DATA SYNTHESIS

Data were pooled using JBI software. Mean differences (95% confidence interval [CI]) and effect size estimates were calculated for continuous outcomes. Meta-analysis using a random-effects model was performed for serum phosphate levels, and where the findings could not be pooled using meta-analysis, results have been presented in a narrative form. Standard GRADE (Grading of Recommendations Assessment, Development and Evaluation) evidence assessment of outcomes has been reported.

RESULTS

A total of 18 studies were included in the review: seven studies focused on dietary phosphate, four studies focused on medications (phosphate binders) and six studies focused on dietary phosphate and medications. Only one study taught patients about diet, medications and HD to control phosphate. Sixteen studies showed significant improvements in phosphate levels. Meta-analysis of eight RCTs favored educational or behavioral interventions over standard care for serum phosphate control, with a weighted mean reduction of -0.23 mmol/l (95% CI -0.37, -0.08) in treatment groups.

CONCLUSION

Overall, educational or behavioral interventions increase adherence to phosphate control. Studies in this systematic review revealed improved outcomes on serum phosphate levels, patient knowledge and adherence to phosphate control methods, CKD self-management behavior and perceived self-efficacy for CKD related to phosphate control. However, there is a lack of sufficient data on how some of the studies implemented their interventions, suggesting that further research is required. Successful strategies that improve and optimize long-term adherence to phosphate control still need to be formulated.

What is the evidence for the effectiveness, appropriateness and feasibility of group clinics for patients with chronic conditions? A systematic review

Background

Group clinics are a form of delivering specialist-led care in groups rather than in individual consultations.

Objective

To examine the evidence for the use of group clinics for patients with chronic health conditions.

Design

A systematic review of evidence from randomised controlled trials (RCTs) supplemented by qualitative studies, cost studies and UK initiatives.

Data sources

We searched MEDLINE, EMBASE, The Cochrane Library, Web of Science and Cumulative Index to Nursing and Allied Health Literature from 1999 to 2014. Systematic reviews and RCTs were eligible for inclusion. Additional searches were performed to identify qualitative studies, studies reporting costs and evidence specific to UK settings.

Review methods

Data were extracted for all included systematic reviews, RCTs and qualitative studies using a standardised form. Quality assessment was performed for systematic reviews, RCTs and qualitative studies. UK studies were included regardless of the quality or level of reporting. Tabulation of the extracted data informed a narrative synthesis. We did not attempt to synthesise quantitative data through formal meta-analysis. However, given the predominance of studies of group clinics for diabetes, using common biomedical outcomes, this subset was subject to quantitative analysis.

Results

Thirteen systematic reviews and 22 RCT studies met the inclusion criteria. These were supplemented by 12 qualitative papers (10 studies), four surveys and eight papers examining costs. Thirteen papers reported on 12 UK initiatives. With 82 papers covering 69 different studies, this constituted the most comprehensive coverage of the evidence base to date. Disease-specific outcomes – the large majority of RCTs examined group clinic approaches to diabetes. Other conditions included hypertension/heart failure and neuromuscular conditions. The most commonly measured outcomes for diabetes were glycated haemoglobin A1c(HbA1c), blood pressure and cholesterol. Group clinic approaches improved HbA1cand improved systolic blood pressure but did not improve low-density lipoprotein cholesterol. A significant effect was found for disease-specific quality of life in a few studies. No other outcome measure showed a consistent effect in favour of group clinics. Recent RCTs largely confirm previous findings. Health services outcomes – the evidence on costs and feasibility was equivocal. No rigorous evaluation of group clinics has been conducted in a UK setting. A good-quality qualitative study from the UK highlighted factors such as the physical space and a flexible appointment system as being important to patients. The views and attitudes of those who dislike group clinic provision are poorly represented. Little attention has been directed at the needs of people from ethnic minorities. The review team identified significant weaknesses in the included research. Potential selection bias limits the generalisability of the results. Many patients who could potentially be included do not consent to the group approach. Attendance is often interpreted liberally.

Limitations

This telescoped review, conducted within half the time period of a conventional systematic review, sought breadth in covering feasibility, appropriateness and meaningfulness in addition to effectiveness and cost-effectiveness and utilised several rapid-review methods. It focused on the contribution of recently published evidence from RCTs to the existing evidence base. It did not reanalyse trials covered in previous reviews. Following rapid review methods, we did not perform independent double data extraction and quality assessment.

Conclusions

Although there is consistent and promising evidence for an effect of group clinics for some biomedical measures, this effect does not extend across all outcomes. Much of the evidence was derived from the USA. It is important to engage with UK stakeholders to identify NHS considerations relating to the implementation of group clinic approaches.

Future work

The review team identified three research priorities: (1) more UK-centred evaluations using rigorous research designs and economic models with robust components; (2) clearer delineation of individual components within different models of group clinic delivery; and (3) clarification of the circumstances under which group clinics present an appropriate alternative to an individual consultation.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Peer support and additional information in group medical consultations (GMCs) for BRCA1/2 mutation carriers: A randomized controlled trial

BACKGROUND

Group medical consultations (GMCs) provide individual medical visits in the presence of ≤ 7 peer- patients. This study evaluated the efficacy of GMCs in the yearly breast cancer surveillance of BRCA mutation carriers.

MATERIAL AND METHODS

This randomized controlled trial compared GMCs (intervention group, n = 63) with individual medical visits (control group, n = 59). Between-group differences on the primary outcomes distress and empowerment, were analyzed one week and three months after the visit. Feasibility is evaluated in terms of demand, acceptability and practicability.

RESULTS

No between-group differences were found on primary outcomes. More themes were discussed in GMCs. Seventy-five percent of GMC-participants experienced peer support. Carriers reported significantly higher satisfaction with individual visits. GMCs were less time-efficient.

CONCLUSION

This is the first GMC study which reports results in favor of individual visits. The hereditary nature of the condition differentiates our study population from earlier studied GMC groups. Even though most participants experienced peer support and received more information, the lower patient satisfaction may be explained by the lack of individual time with the clinician and disruption of normal surveillance routines. As the need for peer support and additional information is present in a substantial part of carriers, future research should study the process of peer support.