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Sawhney S, Atherton I, Blakeman T, Black C, Cowan E, Croucher C, Fraser SDS, Hughes A, Nath M, Nitsch D, Scholes-Robertson N, Diaz MR. Individual and neighborhood-level social and deprivation factors impact kidney health in the GLOMMS-CORE study. Kidney Int 2024:S0085-2538(24)00545-3. [PMID: 39142564 DOI: 10.1016/j.kint.2024.07.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2024] [Revised: 06/14/2024] [Accepted: 07/11/2024] [Indexed: 08/16/2024]
Abstract
Prospective cohort studies of kidney equity are limited by a focus on advanced rather than early disease and selective recruitment. Whole population studies frequently rely on area-level measures of deprivation as opposed to individual measures of social disadvantage. Here, we linked kidney health and individual census records in the North of Scotland (Grampian area), 2011-2021 (GLOMMS-CORE) and identified incident kidney presentations at thresholds of estimated glomerular filtration rate (eGFR) under 60 (mild/early), under 45 (moderate), under 30 ml/min/1.73m2 (advanced), and acute kidney disease (AKD). Household and neighborhood socioeconomic measures, living circumstances, and long-term mortality were compared. Case-mix adjusted multivariable logistic regression (living circumstances), and Cox models (mortality) incorporating an interaction between the household and the neighborhood were used. Among census respondents, there were 48546, 29081, 16116, 28097 incident presentations of each respective eGFR cohort and AKD. Classifications of socioeconomic position by household and neighborhood were related but complex, and frequently did not match. Compared to households of professionals, people with early kidney disease in unskilled or unemployed households had increased mortality (adjusted hazard ratios: 95% confidence intervals) of (1.26: 1.19-1.32) and (1.77: 1.60-1.96), respectively with adjustment for neighborhood indices making little difference. Those within either a deprived household or deprived neighborhood experienced greater mortality, but those within both had the poorest outcomes. Unskilled and unemployed households frequently reported being limited by illness, adverse mental health, living alone, basic accommodation, lack of car ownership, language difficulties, and visual and hearing impairments. Thus, impacts of deprivation on kidney health are spread throughout society-complex, serious, and not confined to those living in deprived neighborhoods.
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Affiliation(s)
- Simon Sawhney
- Aberdeen Centre for Health Data Science, University of Aberdeen, Aberdeen, UK; Renal Unit, NHS Grampian, Aberdeen, Scotland, UK.
| | - Iain Atherton
- School of Health and Social Care, Edinburgh Napier University, Edinburgh, Scotland, UK; Scottish Centre for Administrative Data Research, Edinburgh, Scotland, UK
| | - Thomas Blakeman
- Centre for Primary Care, Institute of Population Health, University of Manchester, Manchester, England, UK
| | - Corri Black
- Aberdeen Centre for Health Data Science, University of Aberdeen, Aberdeen, UK; Renal Unit, NHS Grampian, Aberdeen, Scotland, UK
| | - Eilidh Cowan
- Aberdeen Centre for Health Data Science, University of Aberdeen, Aberdeen, UK
| | - Catherine Croucher
- Specialised Commissioning Team for London, London, England, UK; NHS England, London, England, UK
| | - Simon D S Fraser
- School of Primary Care, Population Sciences and Medical Education, University of Southampton, Southampton, England, UK
| | - Audrey Hughes
- Patient Partner, Grampian Kidney Patient Association, Aberdeen, Scotland, UK
| | - Mintu Nath
- Aberdeen Centre for Health Data Science, University of Aberdeen, Aberdeen, UK
| | - Dorothea Nitsch
- UK Kidney Association, Bristol, England, UK; Department of Non-Communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
| | | | - Magdalena Rzewuska Diaz
- Aberdeen Centre for Health Data Science, University of Aberdeen, Aberdeen, UK; Health Services Research Unit, University of Aberdeen, Aberdeen, Scotland, UK
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Band R, Ewings S, Cheetham-Blake T, Ellis J, Breheny K, Vassilev I, Portillo MC, Yardley L, Blickem C, Kandiyali R, Culliford D, Rogers A. Study protocol for 'The Project About Loneliness and Social networks (PALS)': a pragmatic, randomised trial comparing a facilitated social network intervention (Genie) with a wait-list control for lonely and socially isolated people. BMJ Open 2019; 9:e028718. [PMID: 31427326 PMCID: PMC6701612 DOI: 10.1136/bmjopen-2018-028718] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2018] [Revised: 03/13/2019] [Accepted: 06/17/2019] [Indexed: 12/27/2022] Open
Abstract
INTRODUCTION Loneliness and social isolation have been identified as significant public health concerns, but improving relationships and increasing social participation may improve health outcomes and quality of life. The aim of the Project About Loneliness and Social networks (PALS) study is to assess the effectiveness and cost-effectiveness of a guided social network intervention within a community setting among individuals experiencing loneliness and isolation and to understand implementation of Generating Engagement in Network Involvement (Genie) in the context of different organisations. METHODS AND ANALYSIS The PALS trial will be a pragmatic, randomised controlled trial comparing participants receiving the Genie intervention to a wait-list control group. Eligible participants will be recruited from organisations working within a community setting: any adult identified as socially isolated or at-risk of loneliness and living in the community will be eligible. Genie will be delivered by trained facilitators recruited from community organisations. The primary outcome will be the difference in the SF-12 Mental Health composite scale score at 6-month follow-up between the intervention and control group using a mixed effects model (accounting for clustering within facilitators and organisation). Secondary outcomes will be loneliness, social isolation, well-being, physical health and engagement with new activities. The economic evaluation will use a cost-utility approach, and adopt a public sector perspective to include health-related resource use and costs incurred by other public services. Exploratory analysis will use a societal perspective, and explore broader measures of benefit (capability well-being). A qualitative process evaluation will explore organisational and environmental arrangements, as well as stakeholder and participant experiences of the study to understand the factors likely to influence future sustainability, implementation and scalability of using a social network intervention within this context. ETHICS AND DISSEMINATION This study has received NHS ethical approval (REC reference: 18/SC/0245). The findings from PALS will be disseminated widely through peer-reviewed publications, conferences and workshops in collaboration with our community partners. TRIAL REGISTRATION NUMBER ISRCTN19193075.
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Affiliation(s)
- Rebecca Band
- Psychology, University of Southampton, Southampton, UK
- Health Sciences, University of Southampton, Southampton, UK
- NIHR Collaboration for Leadership in Applied Health Research and Care Wessex, NIHR, Wessex, UK
| | - Sean Ewings
- Health Sciences, University of Southampton, Southampton, UK
| | - Tara Cheetham-Blake
- Health Sciences, University of Southampton, Southampton, UK
- NIHR Collaboration for Leadership in Applied Health Research and Care Wessex, NIHR, Wessex, UK
| | - Jaimie Ellis
- Health Sciences, University of Southampton, Southampton, UK
- NIHR Collaboration for Leadership in Applied Health Research and Care Wessex, NIHR, Wessex, UK
| | - Katie Breheny
- Population Health Sciences, University of Bristol, Bristol, UK
| | - Ivaylo Vassilev
- Health Sciences, University of Southampton, Southampton, UK
- NIHR Collaboration for Leadership in Applied Health Research and Care Wessex, NIHR, Wessex, UK
| | - Mari Carmen Portillo
- Health Sciences, University of Southampton, Southampton, UK
- NIHR Collaboration for Leadership in Applied Health Research and Care Wessex, NIHR, Wessex, UK
| | - Lucy Yardley
- Academic Unit of Psychology, University of Southampton, Southampton, UK
- School of Psychological Science, University of Bristol, Bristol, UK
| | | | - Rebecca Kandiyali
- Centre for Child and Adolescent Health, University of Bristol School of Social and Community Medicine, Bristol, UK
| | - David Culliford
- NIHR Collaboration for Leadership in Applied Health Research and Care Wessex, NIHR, Wessex, UK
- Faculty of Medicine, University of Southampton, Southampton, UK
| | - Anne Rogers
- Health Sciences, University of Southampton, Southampton, UK
- NIHR Collaboration for Leadership in Applied Health Research and Care Wessex, NIHR, Wessex, UK
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Stevenson JK, Campbell ZC, Webster AC, Chow CK, Tong A, Craig JC, Campbell KL, Lee VWS. eHealth interventions for people with chronic kidney disease. Cochrane Database Syst Rev 2019; 8:CD012379. [PMID: 31425608 PMCID: PMC6699665 DOI: 10.1002/14651858.cd012379.pub2] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Chronic kidney disease (CKD) is associated with high morbidity and death, which increases as CKD progresses to end-stage kidney disease (ESKD). There has been increasing interest in developing innovative, effective and cost-efficient methods to engage with patient populations and improve health behaviours and outcomes. Worldwide there has been a tremendous increase in the use of technologies, with increasing interest in using eHealth interventions to improve patient access to relevant health information, enhance the quality of healthcare and encourage the adoption of healthy behaviours. OBJECTIVES This review aims to evaluate the benefits and harms of using eHealth interventions to change health behaviours in people with CKD. SEARCH METHODS We searched the Cochrane Kidney and Transplant Register of Studies up to 14 January 2019 through contact with the Information Specialist using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Register (ICTRP) Search Portal and ClinicalTrials.gov. SELECTION CRITERIA Randomised controlled trials (RCTs) and quasi-RCTs using an eHealth intervention to promote behaviour change in people with CKD were included. There were no restrictions on outcomes, language or publication type. DATA COLLECTION AND ANALYSIS Two authors independently assessed trial eligibility, extracted data and assessed the risk of bias. The certainty of the evidence was assessed using GRADE. MAIN RESULTS We included 43 studies with 6617 participants that evaluated the impact of an eHealth intervention in people with CKD. Included studies were heterogeneous in terms of eHealth modalities employed, type of intervention, CKD population studied and outcomes assessed. The majority of studies (39 studies) were conducted in an adult population, with 16 studies (37%) conducted in those on dialysis, 11 studies (26%) in the pre-dialysis population, 15 studies (35%) in transplant recipients and 1 studies (2%) in transplant candidates We identified six different eHealth modalities including: Telehealth; mobile or tablet application; text or email messages; electronic monitors; internet/websites; and video or DVD. Three studies used a combination of eHealth interventions. Interventions were categorised into six types: educational; reminder systems; self-monitoring; behavioural counselling; clinical decision-aid; and mixed intervention types. We identified 98 outcomes, which were categorised into nine domains: blood pressure (9 studies); biochemical parameters (6 studies); clinical end-points (16 studies); dietary intake (3 studies); quality of life (9 studies); medication adherence (10 studies); behaviour (7 studies); physical activity (1 study); and cost-effectiveness (7 studies).Only three outcomes could be meta-analysed as there was substantial heterogeneity with respect to study population and eHealth modalities utilised. There was found to be a reduction in interdialytic weight gain of 0.13kg (4 studies, 335 participants: MD -0.13, 95% CI -0.28 to 0.01; I2 = 0%) and a reduction in dietary sodium intake of 197 mg/day (2 studies, 181 participants: MD -197, 95% CI -540.7 to 146.8; I2 = 0%). Both dietary sodium and fluid management outcomes were graded as being of low evidence due to high or unclear risk of bias and indirectness (interdialytic weight gain) and high or unclear risk of bias and imprecision (dietary sodium intake). Three studies reported death (2799 participants, 146 events), with 45 deaths/1000 cases compared to standard care of 61 deaths/1000 cases (RR 0.74, CI 0.53 to 1.03; P = 0.08). We are uncertain whether using eHealth interventions, in addition to usual care, impact on the number of deaths as the certainty of this evidence was graded as low due to high or unclear risk of bias, indirectness and imprecision. AUTHORS' CONCLUSIONS eHealth interventions may improve the management of dietary sodium intake and fluid management. However, overall these data suggest that current evidence for the use of eHealth interventions in the CKD population is of low quality, with uncertain effects due to methodological limitations and heterogeneity of eHealth modalities and intervention types. Our review has highlighted the need for robust, high quality research that reports a core (minimum) data set to enable meaningful evaluation of the literature.
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Affiliation(s)
- Jessica K Stevenson
- The University of SydneyWestmead Clinical SchoolCentre for Kidney ResearchCnr Darcy Rd and Hawksbury RdWestmead, SydneyNSWAustralia2145
| | - Zoe C Campbell
- The University of SydneyDepartment of MedicineSydneyNSWAustralia2006
| | - Angela C Webster
- The University of Sydney at WestmeadCentre for Transplant and Renal Research, Westmead Millennium InstituteWestmeadNSWAustralia2145
- The Children's Hospital at WestmeadCochrane Kidney and Transplant, Centre for Kidney ResearchWestmeadNSWAustralia2145
- The University of SydneySydney School of Public HealthEdward Ford Building A27SydneyNSWAustralia2006
| | - Clara K Chow
- The George Institute for Global HealthCardiovascular DepartmentLevel 10, 83‐117 Missenden RoadCamperdownNSWAustralia2050
| | - Allison Tong
- The Children's Hospital at WestmeadCentre for Kidney ResearchLocked Bag 4001WestmeadNSWAustralia2145
| | - Jonathan C Craig
- The Children's Hospital at WestmeadCochrane Kidney and Transplant, Centre for Kidney ResearchWestmeadNSWAustralia2145
- Flinders UniversityCollege of Medicine and Public HealthAdelaideSAAustralia5001
| | - Katrina L Campbell
- Bond UniversityFaculty of Health Science and Medicine2 Promenthean WayRobinaQueenslandAustralia4226
| | - Vincent WS Lee
- Westmead & Blacktown HospitalsDepartment of Renal MedicineDarcy RdWestmeadNSWAustralia2145
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Valentijn PP, Biermann C, Bruijnzeels MA. Value-based integrated (renal) care: setting a development agenda for research and implementation strategies. BMC Health Serv Res 2016; 16:330. [PMID: 27481044 PMCID: PMC4970292 DOI: 10.1186/s12913-016-1586-0] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2015] [Accepted: 07/27/2016] [Indexed: 01/14/2023] Open
Abstract
BACKGROUND Integrated care services are considered a vital strategy for improving the Triple Aim values for people with chronic kidney disease. However, a solid scholarly explanation of how to develop, implement and evaluate such value-based integrated renal care services is limited. The aim of this study was to develop a framework to identify the strategies and outcomes for the implementation of value-based integrated renal care. METHODS First, the theoretical foundations of the Rainbow Model of Integrated Care and the Triple Aim were united into one overarching framework through an iterative process of key-informant consultations. Second, a rapid review approach was conducted to identify the published research on integrated renal care, and the Cochrane Library, Medline, Scopus, and Business Source Premier databases were searched for pertinent articles published between 2000 and 2015. Based on the framework, a coding schema was developed to synthesis the included articles. RESULTS The overarching framework distinguishes the integrated care domains: 1) type of integration, 2) enablers of integration and the interrelated outcome domains, 3) experience of care, 4) population health and 5) costs. The literature synthesis indicated that integrated renal care implementation strategies have particularly focused on micro clinical processes and physical outcomes, while little emphasis has been placed on meso organisational as well as macro system integration processes. In addition, evidence regarding patients' perceived outcomes and economic outcomes has been weak. CONCLUSION These results underscore that the future challenge for researchers is to explore which integrated care implementation strategies achieve better health and improved experience of care at a lower cost within a specific context. For this purpose, this study's framework and evidence synthesis have set a developmental agenda for both integrated renal care practice and research. Accordingly, we plan further work to develop an implementation model for value-based integrated renal services.
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Affiliation(s)
- Pim P Valentijn
- Department of Health Services Research, Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands. .,Department Integrated Care University, Essenburgh, Hierden, The Netherlands.
| | - Claus Biermann
- Faculty of Social Science, Ruhr University Bochum, Bochum, Germany
| | - Marc A Bruijnzeels
- Jan van Es Institute, Netherlands Expert Centre Integrated Primary Care, Almere, The Netherlands
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Lemos CF, Rodrigues MP, Veiga JRP. Family income is associated with quality of life in patients with chronic kidney disease in the pre-dialysis phase: a cross sectional study. Health Qual Life Outcomes 2015; 13:202. [PMID: 26690667 PMCID: PMC4687333 DOI: 10.1186/s12955-015-0390-6] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2015] [Accepted: 12/01/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Chronic kidney disease (CKD) is a condition of high prevalence in the general population mainly due to hypertension and diabetes mellitus. It is often associated with a high prevalence of complications and worse quality of life. The main objective of this study is to evaluate quality of life (QOL) using the generic instrument SF-36 in patients with CKD in pre-dialysis and identify the possible influence of the degree of renal function, hemoglobin level, age, gender, family income and level of education on QOL. METHODS A cross-sectional study was conducted and included 170 individuals (83 men) with a mean age of 57 ± 15 years who met the inclusion criteria and answered the SF-36. Laboratory tests and clinical and demographic data were obtained, and the glomerular filtration rate was estimated using the CKD-EPI formula. RESULTS The degree of renal function did not influence QOL. Women had lower scores in functional capacity, physical aspects, pain, and mental health. Patients younger than 47 years old showed better QOL in the functional capacity; however, their QOL was worse in terms of social aspects. Subjects with an income higher than 5.1 times the minimum wage had better QOL in the functional capacity, pain, social, physical and emotional roles, and mental health. Hemoglobin levels and education did not globally influence QOL. CONCLUSION Gender and age influenced QOL, but family income was the most important factor affecting QOL (6 out of 8 domains investigated by SF-36) in this sample of 170 individuals with CKD in pre-dialysis. These findings suggest that many efforts should be made to reduce the effect of these factors on quality of life in patients with CKD and reinforce the need for longitudinal studies and intervention.
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Affiliation(s)
- Camila Foresti Lemos
- University of Brasilia (UNB), Post-Graduate College of Medicine (UNB), Master (Msc) and Nurse Specialist in Nephrology, Campus Darcy Ribeiro, North Wing, Brasilia, 70910900, DF, Brazil.
| | - Marcelo Palmeira Rodrigues
- University of Brasilia (UNB), Laboratory of pneumology, Doctor (MD, PhD) and Adjunct professor, College of Medicine (UNB), Campus Darcy Ribeiro, North Wing, Brasília, DF, Brazil.
| | - Joel Russomano Paulo Veiga
- University of Brasilia, Laboratory of Nephrology, Doctor (MD, PhD) and Associate professor, College of Medicine (UNB), Campus Darcy Ribeiro, North Wing, Brasília, DF, Brazil.
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Non-disclosure of chronic kidney disease in primary care and the limits of instrumental rationality in chronic illness self-management. Soc Sci Med 2015; 131:31-9. [PMID: 25748112 DOI: 10.1016/j.socscimed.2015.02.035] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Early detection of long term conditions is predicated on assumptions that lifestyle changes and medications can be used to reduce or manage the risk of condition progression. However, ambiguity remains about the nature and place of diagnostic disclosure to people in newly recognised or asymptomatic 'pre' conditions such as early stage chronic kidney disease (CKD). The disclosure of a diagnosis is relevant to instigating strategies which rely on actively engaging patients as self-managers of their own care. Whilst primary care routinely records a diagnosis of early stage CKD, little is known about how patients learn about the fact that they have CKD or how they respond to this. This study aimed to explore patients' experiences of disclosure of CKD in primary care settings. A nested qualitative study of participants recruited to a trial of an intervention for CKD patients in Greater Manchester, UK was undertaken. A purposive sample of 26 patients, with a mean age of 72 years (range 59-89, median 71), were interviewed during 2012. Interview transcripts were analysed using constant comparative techniques. Narrative accounts reflected limited or partial disclosure of CKD; often cast in vague terms as "nothing to worry about". How patients described themselves in terms of participation and their tendencies towards 'active' or 'passive' involvement in consultations emerged as important components of narratives around disclosure. The findings illuminate the ways in which diagnosis is oriented in a context where it is possible to meet the requirements for remuneration under a pay for performance system of primary care, whilst apparently not disclosing a label or a diagnosis to patients. This challenges the presumptions inherent in wider health policy objectives that are increasingly built on the notion of responsible patients and the ethos of the active support of self-management for pre-conditions.
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Gaffney H, Blakeman T, Blickem C, Kennedy A, Reeves D, Dawson S, Mossabir R, Bower P, Gardner C, Lee V, Rogers A. Predictors of patient self-report of chronic kidney disease: baseline analysis of a randomised controlled trial. BMC FAMILY PRACTICE 2014; 15:196. [PMID: 25433525 PMCID: PMC4260196 DOI: 10.1186/s12875-014-0196-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/29/2013] [Accepted: 11/14/2014] [Indexed: 01/30/2023]
Abstract
Background Improving the quality of care for patients with vascular disease is a priority. Clinical guidance has emphasised the importance of early identification and active management of chronic kidney disease (CKD) in primary care in order to maintain vascular health. However, awareness of stage 3 CKD amongst patients remains limited. We aimed to identify predictors of patient self-report of CKD to inform tailoring of conversations around CKD in primary care for diverse patient populations. Methods We conducted a cross-sectional analysis of baseline data from 436 patients with stage 3 CKD from 24 GP practices taking part in a randomised controlled trial (RCT) evaluating a complex self-management intervention, which aimed to support the maintenance of vascular health in patients with stage 3 CKD. Potential predictors of patient self-report of CKD included demographics, stage of CKD, cardiovascular risk, self-reported co-morbidities, health status, self-management ability, and health service utilisation. Results Around half (52%, n = 227) of patients did not self-report CKD. Self-report rates did not appreciably differ by practice. Multivariate analysis revealed that female patients (p = 0.004), and patients with stage 3b CKD (p < 0.001), and with higher anxiety levels (p < 0.001), were more likely to self-report CKD. Conclusions Self-report of kidney problems by patients on CKD registers was variable and patterned by sociodemographic factors. Although it cannot be assumed that failure to self-report indicates a lack of awareness of CKD, our data do suggest the need for greater consistency in discussions around kidney health, with meaningful and relevant clinical dialogue that is aligned with existing clinical encounters to enable shared decision making and minimise anxiety. Electronic supplementary material The online version of this article (doi:10.1186/s12875-014-0196-3) contains supplementary material, which is available to authorized users.
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Blakeman T, Blickem C, Kennedy A, Reeves D, Bower P, Gaffney H, Gardner C, Lee V, Jariwala P, Dawson S, Mossabir R, Brooks H, Richardson G, Spackman E, Vassilev I, Chew-Graham C, Rogers A. Effect of information and telephone-guided access to community support for people with chronic kidney disease: randomised controlled trial. PLoS One 2014; 9:e109135. [PMID: 25330169 PMCID: PMC4199782 DOI: 10.1371/journal.pone.0109135] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2014] [Accepted: 09/02/2014] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Implementation of self-management support in traditional primary care settings has proved difficult, encouraging the development of alternative models which actively link to community resources. Chronic kidney disease (CKD) is a common condition usually diagnosed in the presence of other co-morbidities. This trial aimed to determine the effectiveness of an intervention to provide information and telephone-guided access to community support versus usual care for patients with stage 3 CKD. METHODS AND FINDINGS In a pragmatic, two-arm, patient level randomised controlled trial 436 patients with a diagnosis of stage 3 CKD were recruited from 24 general practices in Greater Manchester. Patients were randomised to intervention (215) or usual care (221). Primary outcome measures were health related quality of life (EQ-5D health questionnaire), blood pressure control, and positive and active engagement in life (heiQ) at 6 months. At 6 months, mean health related quality of life was significantly higher for the intervention group (adjusted mean difference = 0.05; 95% CI = 0.01, 0.08) and blood pressure was controlled for a significantly greater proportion of patients in the intervention group (adjusted odds-ratio = 1.85; 95% CI = 1.25, 2.72). Patients did not differ significantly in positive and active engagement in life. The intervention group reported a reduction in costs compared with control. CONCLUSIONS An intervention to provide tailored information and telephone-guided access to community resources was associated with modest but significant improvements in health related quality of life and better maintenance of blood pressure control for patients with stage 3 CKD compared with usual care. However, further research is required to identify the mechanisms of action of the intervention. TRIAL REGISTRATION Controlled-Trials.com ISRCTN45433299.
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Affiliation(s)
- Tom Blakeman
- NIHR Collaboration for Leadership in Applied Health Research (CLAHRC) Greater Manchester, Centre for Primary Care, Institute of Population Health, University of Manchester, Manchester, United Kingdom
| | - Christian Blickem
- NIHR Collaboration for Leadership in Applied Health Research (CLAHRC) Greater Manchester, Centre for Primary Care, Institute of Population Health, University of Manchester, Manchester, United Kingdom
| | - Anne Kennedy
- NIHR CLAHRC Wessex, Health Sciences, University of Southampton, Highfield Campus, Southampton, United Kingdom
| | - David Reeves
- NIHR Collaboration for Leadership in Applied Health Research (CLAHRC) Greater Manchester, Centre for Primary Care, Institute of Population Health, University of Manchester, Manchester, United Kingdom
| | - Peter Bower
- NIHR School for Primary Care Research, Centre for Primary Care, Institute of Population Health, University of Manchester, Manchester, United Kingdom
| | - Hannah Gaffney
- NIHR Collaboration for Leadership in Applied Health Research (CLAHRC) Greater Manchester, Centre for Primary Care, Institute of Population Health, University of Manchester, Manchester, United Kingdom
| | - Caroline Gardner
- NIHR School for Primary Care Research, Centre for Primary Care, Institute of Population Health, University of Manchester, Manchester, United Kingdom
| | - Victoria Lee
- NIHR School for Primary Care Research, Centre for Primary Care, Institute of Population Health, University of Manchester, Manchester, United Kingdom
| | - Praksha Jariwala
- NIHR Collaboration for Leadership in Applied Health Research (CLAHRC) Greater Manchester, Centre for Primary Care, Institute of Population Health, University of Manchester, Manchester, United Kingdom
| | - Shoba Dawson
- NIHR Collaboration for Leadership in Applied Health Research (CLAHRC) Greater Manchester, Centre for Primary Care, Institute of Population Health, University of Manchester, Manchester, United Kingdom
| | - Rahena Mossabir
- NIHR Collaboration for Leadership in Applied Health Research (CLAHRC) Greater Manchester, Centre for Primary Care, Institute of Population Health, University of Manchester, Manchester, United Kingdom
| | - Helen Brooks
- NIHR Collaboration for Leadership in Applied Health Research (CLAHRC) Greater Manchester, Centre for Primary Care, Institute of Population Health, University of Manchester, Manchester, United Kingdom
| | - Gerry Richardson
- Centre for Health Economics, University of York, Heslington, York, United Kingdom
| | - Eldon Spackman
- Centre for Health Economics, University of York, Heslington, York, United Kingdom
| | - Ivaylo Vassilev
- NIHR CLAHRC Wessex, Health Sciences, University of Southampton, Highfield Campus, Southampton, United Kingdom
| | - Carolyn Chew-Graham
- Primary Care & Health Services, University of Keele, Staffordshire, United Kingdom
| | - Anne Rogers
- NIHR CLAHRC Wessex, Health Sciences, University of Southampton, Highfield Campus, Southampton, United Kingdom
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Blickem C, Kennedy A, Jariwala P, Morris R, Bowen R, Vassilev I, Brooks H, Blakeman T, Rogers A. Aligning everyday life priorities with people's self-management support networks: an exploration of the work and implementation of a needs-led telephone support system. BMC Health Serv Res 2014; 14:262. [PMID: 24938492 PMCID: PMC4071856 DOI: 10.1186/1472-6963-14-262] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2013] [Accepted: 06/10/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Recent initiatives to target the personal, social and clinical needs of people with long-term health conditions have had limited impact within primary care. Evidence of the importance of social networks to support people with long-term conditions points to the need for self-management approaches which align personal circumstances with valued activities. The Patient-Led Assessment for Network Support (PLANS) intervention is a needs-led assessment for patients to prioritise their health and social needs and provide access to local community services and activities. Exploring the work and practices of patients and telephone workers are important for understanding and evaluating the workability and implementation of new interventions. METHODS Qualitative methods (interviews, focus group, observations) were used to explore the experience of PLANS from the perspectives of participants and the telephone support workers who delivered it (as part of an RCT) and the reasons why the intervention worked or not. Normalisation Process Theory (NPT) was used as a sensitising tool to evaluate: the relevance of PLANS to patients (coherence); the processes of engagement (cognitive participation); the work done for PLANS to happen (collective action); the perceived benefits and costs of PLANS (reflexive monitoring). 20 patients in the intervention arm of a clinical trial were interviewed and their telephone support calls were recorded and a focus group with 3 telephone support workers was conducted. RESULTS Analysis of the interviews, support calls and focus group identified three themes in relation to the delivery and experience of PLANS. These are: formulation of 'health' in the context of everyday life; trajectories and tipping points: disrupting everyday routines; precarious trust in networks. The relevance of these themes are considered using NPT constructs in terms of the work that is entailed in engaging with PLANS, taking action, and who is implicated this process. CONCLUSIONS PLANS gives scope to align long-term condition management to everyday life priorities and valued aspects of life. This approach can improve engagement with health-relevant practices by situating them within everyday contexts. This has potential to increase utilisation of local resources with potential cost-saving benefits for the NHS. TRIAL REGISTRATION ISRCTN45433299.
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Affiliation(s)
- Christian Blickem
- NIHR Collaboration for Leadership in Applied Health Research and Care (CLAHRC) Greater Manchester, Centre for Primary Care, Institute of Population Health, University of Manchester, Oxford Road, Manchester M13 9PL, UK.
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Kennedy A, Rogers A, Blickem C, Daker-White G, Bowen R. Developing cartoons for long-term condition self-management information. BMC Health Serv Res 2014; 14:60. [PMID: 24507692 PMCID: PMC3945740 DOI: 10.1186/1472-6963-14-60] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2013] [Accepted: 02/05/2014] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Advocating the need to adopt more self-management policies has brought with it an increasing demand for information about living with and making decisions about long-term conditions, with a significant potential for using cartoons. However, the purposeful use of cartoons is notably absent in many areas of health care as is evidence of their acceptability to patients and lay others. This paper outlines the process used to develop and evaluate cartoons and their acceptability for a series of self-management guidebooks for people with inflammatory bowel disease, irritable bowel syndrome, diabetes, chronic obstructive pulmonary disease and chronic kidney disease (CKD). METHODS Principles for a process to develop information and cartoons were developed. Cartoon topics were created using qualitative research methods to obtain lay views and experiences. The CKD guidebook was used to provide a detailed exemplar of the process. Focus group and trial participants were recruited from primary care CKD registers. The book was part of a trial intervention; selected participants evaluated the cartoons during in-depth interviews which incorporated think-aloud methods. RESULTS In general, the cartoons developed by this process depict patient experiences, common situations, daily management dilemmas, making decisions and choices and the uncertainties associated with conditions. CKD cartoons were developed following two focus groups around the themes of getting a diagnosis; understanding the problem; feeling that facts were being withheld; and setting priorities. Think-aloud interviews with 27 trial participants found the CKD cartoons invoked amusement, recognition and reflection but were sometimes difficult to interpret. CONCLUSION Humour is frequently utilised by people with long-term conditions to help adjustment and coping. Cartoons can help provide clarity and understanding and could address concerns related to health literacy. Using cartoons to engage and motivate people is a consideration untapped by conventional theories with the potential to improve information to support self-management.
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Affiliation(s)
- Anne Kennedy
- Faculty of Health Sciences, NIHR CLAHRC Wessex, University of Southampton, Southampton, UK
| | - Anne Rogers
- Faculty of Health Sciences, NIHR CLAHRC Wessex, University of Southampton, Southampton, UK
| | - Christian Blickem
- Centre for Primary Care, Institute of Population Health, University of Manchester, Manchester, UK
| | - Gavin Daker-White
- NIHR Greater Manchester Primary Care Patient Safety Translational Research Centre, University of Manchester, Manchester, UK
| | - Robert Bowen
- Centre for Primary Care, Institute of Population Health, University of Manchester, Manchester, UK
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Small N, Blickem C, Blakeman T, Panagioti M, Chew-Graham CA, Bower P. Telephone based self-management support by 'lay health workers' and 'peer support workers' to prevent and manage vascular diseases: a systematic review and meta-analysis. BMC Health Serv Res 2013; 13:533. [PMID: 24370214 PMCID: PMC3880982 DOI: 10.1186/1472-6963-13-533] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2013] [Accepted: 12/10/2013] [Indexed: 11/13/2022] Open
Abstract
Background Improved prevention and management of vascular disease is a global priority. Non-health care professionals (such as, ‘lay health workers’ and ‘peer support workers’) are increasingly being used to offer telephone support alongside that offered by conventional services, to reach disadvantaged populations and to provide more efficient delivery of care. However, questions remain over the impact of such interventions, particularly on a wider range of vascular related conditions (such as, chronic kidney disease), and it is unclear how different types of telephone support impact on outcome. This study assessed the evidence on the effectiveness and cost-effectiveness of telephone self-management interventions led by ‘lay health workers’ and ‘peer support workers’ for patients with vascular disease and long-term conditions associated with vascular disease. Methods Systematic review of randomised controlled trials. Three electronic databases were searched. Two authors independently extracted data according to the Cochrane risk of bias tool. Random effects meta-analysis was used to pool outcome measures. Results Ten studies were included, primarily based in community settings in the United States; with participants who had diabetes; and used ‘peer support workers’ that shared characteristics with patients. The included studies were generally rated at risk of bias, as many methodological criteria were rated as ‘unclear’ because of a lack of information. Overall, peer telephone support was associated with small but significant improvements in self-management behaviour (SMD = 0.19, 95% CI 0.05 to 0.33, I2 = 20.4%) and significant reductions in HbA1c level (SMD = -0.26, 95% CI −0.41 to −0.11, I2 = 47.6%). There was no significant effect on mental health quality of life (SMD = 0.03, 95% CI −0.12 to 0.18, I2 = 0%). Data on health care utilisation were very limited and no studies reported cost effectiveness analyses. Conclusions Positive effects were found for telephone self-management interventions via ‘lay workers’ and ‘peer support workers’ for patients on diabetes control and self-management outcomes, but the overall evidence base was limited in scope and quality. Well designed trials assessing non-healthcare professional delivered telephone support for the prevention and management of vascular disease are needed to identify the content of effective components on health outcomes, and to assess cost effectiveness, to determine if such interventions are potentially useful alternatives to professionally delivered care.
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Affiliation(s)
- Nicola Small
- Greater Manchester Collaboration for Leadership in Applied Health Research and Care, Centre for Primary Care, and Manchester Academic Health Science Centre, University of Manchester, Manchester, UK.
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Jha V, Garcia-Garcia G, Iseki K, Li Z, Naicker S, Plattner B, Saran R, Wang AYM, Yang CW. Chronic kidney disease: global dimension and perspectives. Lancet 2013; 382:260-72. [PMID: 23727169 DOI: 10.1016/s0140-6736(13)60687-x] [Citation(s) in RCA: 2662] [Impact Index Per Article: 242.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Chronic kidney disease is defined as a reduced glomerular filtration rate, increased urinary albumin excretion, or both, and is an increasing public health issue. Prevalence is estimated to be 8-16% worldwide. Complications include increased all-cause and cardiovascular mortality, kidney-disease progression, acute kidney injury, cognitive decline, anaemia, mineral and bone disorders, and fractures. Worldwide, diabetes mellitus is the most common cause of chronic kidney disease, but in some regions other causes, such as herbal and environmental toxins, are more common. The poorest populations are at the highest risk. Screening and intervention can prevent chronic kidney disease, and where management strategies have been implemented the incidence of end-stage kidney disease has been reduced. Awareness of the disorder, however, remains low in many communities and among many physicians. Strategies to reduce burden and costs related to chronic kidney disease need to be included in national programmes for non-communicable diseases.
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Affiliation(s)
- Vivekanand Jha
- Postgraduate Institute of Medical Education and Research, Chandigarh, India.
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