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Ludden R, Ring D, Jayakumar P. What Is the Association Between Agency and Levels of Capability and Comfort in Musculoskeletal Care? A Systematic Review. Clin Orthop Relat Res 2024; 482:1770-1776. [PMID: 38446424 PMCID: PMC11419470 DOI: 10.1097/corr.0000000000003027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2023] [Accepted: 02/07/2024] [Indexed: 03/07/2024]
Abstract
BACKGROUND People who take active responsibility for their health demonstrate agency. Agency in the context of chronic illness management with disease-modifying treatments is commonly linked to adherence and confidence in care seeking. In musculoskeletal health, agency is commonly observed in the accommodation of conditions related to aging and reflected in studies of people not seeking care. The development of agency measures originates from the realm of medical management of chronic illness rather than that of musculoskeletal disease, which is often optional or discretionary. With growing interest in the universal adoption of agency as a performance measure for quality payment programs, there is a need to better understand how agency is measured across musculoskeletal conditions, and how agency may be a modifiable correlate of capability, comfort, mindset, and circumstances. QUESTIONS/PURPOSES We systematically reviewed the evidence regarding agency among people seeking musculoskeletal specialty care and asked: (1) Are greater levels of agency associated with greater levels of comfort and capability? (2) Are greater levels of agency associated with better mental and social health? METHODS Following the PRISMA guidelines, we performed searches on May 22, 2023, with searches spanning September 1988 (in PubMed and Web of Science) and September 1946 (in Ovid Medline) to May 2023. We included original clinical studies addressing the relationship between agency and levels of comfort, capability, mindset, and circumstances (by utilizing patient-reported agency measures [PRAMs], patient-reported outcome measures [PROMs], and mental and social health measures) involving adult patients 18 years or older receiving specialist care for musculoskeletal conditions. We identified 11 studies involving 3537 patients that addressed the primary research question and three studies involving 822 patients that addressed the secondary question. We conducted an evidence quality assessment using the Methodological Index for Non-Randomized Studies (MINORS) and found the overall evidence quality to be relatively high, with loss to follow-up and lack of reporting of sample size calculation the most consistent study shortcomings. The measures of capability varied by anatomical region. The Patient Activation Measure (a validated 10- or 13-item survey originally designed to assess a patient's level of understanding and confidence in managing their health and ability to engage in healthcare related to chronic medical illness) was used as a measure of agency in 10 studies (one of which also used the Effective Consumer Scale) and attitudes regarding one's management of musculoskeletal disorders in one study. We registered this systematic review on PROSPERO (Reg CRD42023426893). RESULTS In general, the relationships between PRAMs and PROMs are weak to moderate in strength using the Cohen criteria, with 10 of 11 studies demonstrating an association between levels of agency and levels of comfort and capability. The three studies addressing mental health found a weak correlation (where reported) between levels of agency and levels of symptoms of depression and anxiety. CONCLUSION The finding that agency in patients seeking care for musculoskeletal conditions is associated with greater comfort, capability, and mental health supports the prioritization of agency modification during musculoskeletal specialty care. This might include behavioral health and cognitive debiasing strategies along with strategies and services promoting self-management. Our work also points to an opportunity to develop agency measures better suited for discretionary care that more directly assess the cultivation of healthy mindsets, behaviors, and accommodative attitudes toward the discomfort and incapability experienced during aging. LEVEL OF EVIDENCE Level II, prognostic study.
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Affiliation(s)
- Rebecca Ludden
- Department of Surgery and Perioperative Care, Dell Medical School, The University of Texas at Austin, Austin, TX, USA
| | - David Ring
- Department of Surgery and Perioperative Care, Dell Medical School, The University of Texas at Austin, Austin, TX, USA
| | - Prakash Jayakumar
- Department of Surgery and Perioperative Care, Dell Medical School, The University of Texas at Austin, Austin, TX, USA
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Nair D, Schildcrout JS, Prigmore HL, Greevy R, Trochez RJ, Bachmann JM, Umeukeje EM, Fissell RB, Taylor WD, Kripalani S, Cavanaugh KL. Health Competence Is a Determinant of Exercise Frequency in Older Adults With CKD. Kidney Int Rep 2024; 9:2567-2570. [PMID: 39156163 PMCID: PMC11328564 DOI: 10.1016/j.ekir.2024.05.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Revised: 05/14/2024] [Accepted: 05/20/2024] [Indexed: 08/20/2024] Open
Affiliation(s)
- Devika Nair
- Division of Nephrology and Hypertension, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Vanderbilt Center for Health Services Research, Nashville, Tennessee, USA
- Veterans Affairs Tennessee Valley Health System, Nashville, Tennessee, USA
| | - Jonathan S. Schildcrout
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Heather L. Prigmore
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Robert Greevy
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Ricardo J. Trochez
- Vanderbilt Center for Health Services Research, Nashville, Tennessee, USA
| | - Justin M. Bachmann
- Division of Cardiovascular Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Ebele M. Umeukeje
- Division of Nephrology and Hypertension, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Vanderbilt Center for Health Services Research, Nashville, Tennessee, USA
| | - Rachel B. Fissell
- Division of Nephrology and Hypertension, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Vanderbilt Center for Health Services Research, Nashville, Tennessee, USA
| | - Warren D. Taylor
- Department of Psychiatry and Behavioral Sciences, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Geriatric Research, Education, and Clinical Center, Veterans Affairs Tennessee Valley Health System, Nashville, Tennessee, USA
| | - Sunil Kripalani
- Vanderbilt Center for Health Services Research, Nashville, Tennessee, USA
- Division of General Internal Medicine and Public Health, Section of Hospital Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Kerri L. Cavanaugh
- Vanderbilt Center for Health Services Research, Nashville, Tennessee, USA
- Veterans Affairs Tennessee Valley Health System, Nashville, Tennessee, USA
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Gonzales KM, Koch-Weser S, Kennefick K, Lynch M, Porteny T, Tighiouart H, Wong JB, Isakova T, Rifkin DE, Gordon EJ, Rossi A, Weiner DE, Ladin K. Decision-Making Engagement Preferences among Older Adults with CKD. J Am Soc Nephrol 2024; 35:772-781. [PMID: 38517479 PMCID: PMC11164120 DOI: 10.1681/asn.0000000000000341] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Accepted: 03/18/2024] [Indexed: 03/23/2024] Open
Abstract
Key Points Clinicians’ uncertainty about the degree to which older patients prefer to engage in decision making remains a key barrier to shared decision making. Most older adults with advanced CKD preferred a collaborative or active role in decision making. Background Older adults with kidney failure face preference-sensitive decisions regarding dialysis initiation. Despite recommendations, few older patients with kidney failure experience shared decision making. Clinician uncertainty about the degree to which older patients prefer to engage in decision making remains a key barrier. Methods This study follows a mixed-methods explanatory, longitudinal, sequential design at four diverse US centers with patients (English-fluent, aged ≥70 years, CKD stages 4–5, nondialysis) from 2018 to 2020. Patient preferences for engagement in decision making were assessed using the Control Preferences Scale, reflecting the degree to which patients want to be involved in their decision making: active (the patient prefers to make the final decision), collaborative (the patient wants to share decision making with the clinician), or passive (the patient wants the clinician to make the final decision) roles. Semistructured interviews about engagement and decision making were conducted in two waves (2019, 2020) with purposively sampled patients and clinicians. Descriptive statistics and ANOVA were used for quantitative analyses; thematic and narrative analyses were used for qualitative data. Results Among 363 patient participants, mean age was 78±6 years, 42% were female, and 21% had a high school education or less. Control Preferences Scale responses reflected that patients preferred to engage actively (48%) or collaboratively (43%) versus passively (8%). Preferred roles remained stable at 3-month follow-up. Seventy-six participants completed interviews (45 patients, 31 clinicians). Four themes emerged: control preference roles reflect levels of decisional engagement; clinicians control information flow, especially about prognosis; adapting a clinical approach to patient preferred roles; and clinicians' responsiveness to patient preferred roles supports patients' satisfaction with shared decision making. Conclusions Most older adults with advanced CKD preferred a collaborative or active role in decision making. Appropriately matched information flow with patient preferences was critical for satisfaction with shared decision making. Clinical Trial registry name and registration number: Decision Aid for Renal Therapy (DART), NCT03522740 .
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Affiliation(s)
- Kristina M. Gonzales
- Department of Community Health, Tufts University, Medford, Massachusetts
- Research on Ethics, Aging, and Community Health (REACH Lab), Medford, Massachusetts
| | - Susan Koch-Weser
- Department of Public Health and Community Medicine, Tufts University School of Medicine, Boston, Massachusetts
| | - Kristen Kennefick
- Research on Ethics, Aging, and Community Health (REACH Lab), Medford, Massachusetts
| | - Mary Lynch
- Research on Ethics, Aging, and Community Health (REACH Lab), Medford, Massachusetts
| | - Thalia Porteny
- Mailman School of Public Health, Columbia University, New York, New York
| | - Hocine Tighiouart
- Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, Massachusetts
- Tufts Clinical and Translational Science Institute, Tufts University, Boston, Massachusetts
| | - John B. Wong
- Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, Massachusetts
- Tufts Clinical and Translational Science Institute, Tufts University, Boston, Massachusetts
| | - Tamara Isakova
- Center for Translational Metabolism and Health, Institute for Public Health and Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Dena E. Rifkin
- Division of Nephrology, Veterans' Affairs Healthcare System, University of California, San Diego, San Diego, California
| | - Elisa J. Gordon
- Department of Surgery, Center for Biomedical Ethics and Society, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Ana Rossi
- Piedmont Transplant Institute, Atlanta, Georgia
| | - Daniel E. Weiner
- Division of Nephrology, Tufts Medical Center, Boston, Massachusetts
| | - Keren Ladin
- Department of Community Health, Tufts University, Medford, Massachusetts
- Research on Ethics, Aging, and Community Health (REACH Lab), Medford, Massachusetts
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Lo CT, Sheshadri A, Edmonson L, Nair D. Patient-Reported Outcomes to Achieve Person-Centered Care for Aging People With Kidney Disease. Semin Nephrol 2024; 44:151548. [PMID: 39181804 PMCID: PMC11456389 DOI: 10.1016/j.semnephrol.2024.151548] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/27/2024]
Abstract
Person-centered care is a system of care delivery that supports effective patient-clinician communication and empowers patients to partner with their clinical providers to develop goal-concordant treatment plans. Models of person-centered care often involve the implementation of patient-reported outcomes (PROs) to measure patients' symptoms and quality of life as they navigate complex chronic health conditions. Models of person-centered care have been particularly effective in improving the quality of care delivery for older adults as well as younger adults with aging-associated conditions such as physical function decline. Though PROs have been developed and validated in kidney disease, they are not routinely implemented in clinical practice. Most individuals with kidney disease are 65 and older, but many younger individuals with kidney disease also experience aging-associated conditions earlier than in the general population. Thus, PROs represent an important tool for achieving person-centered care in groups with kidney disease who are the most vulnerable to adverse health outcomes and excess health care utilization. In this article, we aim to move toward more routine implementation of PROs in kidney care for aging adults. To identify the most clinically relevant PROs for this group and understand the ideal mode and context in which to implement PROs, we will (1) provide an evidence-based summary of PROs with the greatest prognostic significance in the general population and in kidney disease, including those specific to older adults; (2) describe barriers to the implementation of PROs in kidney care with a special focus on the needs of older adults and younger adults with aging-associated conditions; and (3) conclude with our evidence-based recommendations for the content, time, and context in which PROs should be implemented to achieve person-centered kidney care for aging adults.
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Affiliation(s)
- Claire T Lo
- Division of Internal Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Anoop Sheshadri
- Division of Nephrology, University of California, San Francisco, San Francisco, CA
| | - Larry Edmonson
- Person With Chronic Kidney Disease, Vanderbilt University Medical Center, Nashville, TN
| | - Devika Nair
- Division of Nephrology and Hypertension, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN; Center for Health Services Research, Vanderbilt University Medical Center, Nashville, TN; Tennessee Valley Veterans Affairs Health System, Nashville, TN.
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Martinez A, Warner A, Powe NR, Fernandez A, Tuot DS. Association between English Proficiency and Kidney Disease Knowledge and Communication Quality among Patients with ESKD. KIDNEY360 2024; 5:560-568. [PMID: 38356152 PMCID: PMC11093550 DOI: 10.34067/kid.0000000000000398] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/12/2023] [Accepted: 02/08/2024] [Indexed: 02/16/2024]
Abstract
Key Points In one hospital-based safety-net dialysis unit, only one half of patients with ESKD knew their cause of kidney failure, which did not differ by English proficiency status. Patients with limited English proficiency (versus English-proficient patients) reported poorer communication with the dialysis care team (less listening, fewer clear explanations, less time spent). We highlight the need for tailored, patient-centered communication between limited English-proficient patients and dialysis care team members. Background ESKD is a chronic health condition for which communication between health care teams and patients is important to guide patient self-management activities. Yet, little is known about the quality of communication among patients with ESKD and their care team members. We examined the influence of patient's limited English proficiency (LEP) status on communication experiences at one dialysis center. Methods A survey was administered to adults receiving ESKD care at a dialysis unit within a public health care delivery system between July 2022 and February 2023, to ascertain kidney disease knowledge and perceptions of communication quality with the dialysis care team. Multivariable logistic and ordinal logistic regression models adjusted for age and sex were used to determine associations between LEP status and CKD knowledge. Results Among 93 eligible patients, 88.2% (n =82) completed the survey. Approximately 37.8% (n =31) had LEP, mean age was 58.8 years, 68.3% were men, mean dialysis vintage was 3.9 years, and 25% had a positive depression screen (LEP 30%; English-proficient 22%). A higher proportion of English-proficient patients screened positive for limited health literacy compared to those with LEP (74.5% versus 38.7%, P = 0.002). Overall, knowledge of assigned cause of ESKD (53.4%) and CKD/transplant knowledge (57.3%) was suboptimal. After adjustment, LEP status was not significantly associated with knowing the correct cause of kidney failure (odds ratio, 0.49; 95% confidence interval, 0.19 to 1.27) but was significantly associated with having a higher score on a CKD/transplant knowledge scale (odds ratio, 3.99; 95% confidence interval, 1.66 to 9.58). Patients with LEP reported poorer communication quality with dialysis providers and staff (less listening, fewer clear explanations, less time spent with patients) compared with English-proficient patients, although differences were not statistically significant. Conclusions Overall communication between patients with ESKD and members of the dialysis care team was suboptimal, regardless of English proficiency. Interventions to enhance communication for ESKD patients are needed.
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Affiliation(s)
- Ashley Martinez
- Division of Nephrology, Stanford University School of Medicine, Stanford, California
| | - Austin Warner
- Loyola University Chicago Stritch School of Medicine, Maywood, Illinois
| | - Neil R. Powe
- Department of Medicine, San Francisco School of Medicine, University of California, San Francisco, San Francisco, California
- Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, California
- Center for Vulnerable Populations, San Francisco School of Medicine, University of California, San Francisco, San Francisco, California
| | - Alicia Fernandez
- Department of Medicine, San Francisco School of Medicine, University of California, San Francisco, San Francisco, California
- Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, California
- Center for Vulnerable Populations, San Francisco School of Medicine, University of California, San Francisco, San Francisco, California
| | - Delphine S. Tuot
- Department of Medicine, San Francisco School of Medicine, University of California, San Francisco, San Francisco, California
- Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, California
- Center for Vulnerable Populations, San Francisco School of Medicine, University of California, San Francisco, San Francisco, California
- Division of Nephrology, University of California, San Francisco, San Francisco, California
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6
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Greenwood SA, Young HML, Briggs J, Castle EM, Walklin C, Haggis L, Balkin C, Asgari E, Bhandari S, Burton JO, Billany RE, Bishop NC, Bramham K, Campbell J, Chilcot J, Cooper NJ, Deelchand V, Graham-Brown MPM, Hamilton A, Jesky M, Kalra PA, Koufaki P, McCafferty K, Nixon AC, Noble H, Saynor Z, Taal MW, Tollit J, Wheeler DC, Wilkinson TJ, Worboys H, Macdonald JH. Evaluating the effect of a digital health intervention to enhance physical activity in people with chronic kidney disease (Kidney BEAM): a multicentre, randomised controlled trial in the UK. Lancet Digit Health 2024; 6:e23-e32. [PMID: 37968170 DOI: 10.1016/s2589-7500(23)00204-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Revised: 09/04/2023] [Accepted: 09/27/2023] [Indexed: 11/17/2023]
Abstract
BACKGROUND Remote digital health interventions to enhance physical activity provide a potential solution to improve the sedentary behaviour, physical inactivity, and poor health-related quality of life that are typical of chronic conditions, particularly for people with chronic kidney disease. However, there is a need for high-quality evidence to support implementation in clinical practice. The Kidney BEAM trial evaluated the clinical effect of a 12-week physical activity digital health intervention on health-related quality of life. METHODS In a single-blind, randomised controlled trial conducted at 11 centres in the UK, adult participants (aged ≥18 years) with chronic kidney disease were recruited and randomly assigned (1:1) to the Kidney BEAM physical activity digital health intervention or a waiting list control group. Randomisation was performed with a web-based system, in randomly permuted blocks of six. Outcome assessors were masked to treatment allocation. The primary outcome was the difference in the Kidney Disease Quality of Life Short Form version 1.3 Mental Component Summary (KDQoL-SF1.3 MCS) between baseline and 12 weeks. The trial was powered to detect a clinically meaningful difference of 3 arbitrary units (AU) in KDQoL-SF1.3 MCS. Outcomes were analysed by an intention-to-treat approach using an analysis of covariance model, with baseline measures and age as covariates. The trial was registered with ClinicalTrials.gov, NCT04872933. FINDINGS Between May 6, 2021, and Oct 30, 2022, 1102 individuals were assessed for eligibility, of whom 340 participants were enrolled and randomly assigned to the Kidney BEAM intervention group (n=173) or the waiting list control group (n=167). 268 participants completed the trial (112 in the Kidney BEAM group and 156 in the waiting list control group). All 340 randomly assigned participants were included in the intention-to treat population. At 12 weeks, there was a significant improvement in KDQoL-SF.13 MCS score in the Kidney BEAM group (from mean 44·6 AU [SD 10·8] at baseline to 47·0 AU [10·6] at 12 weeks) compared with the waiting list control group (from 46·1 AU [10·5] to 45·0 AU [10·1]; between-group difference of 3·1 AU [95% CI 1·8-4·4]; p<0·0001). INTERPRETATION The Kidney BEAM physical activity platform is an efficacious digital health intervention to improve mental health-related quality of life in patients with chronic kidney disease. These findings could facilitate the incorporation of remote digital health interventions into clinical practice and offer a potential intervention worthy of investigation in other chronic conditions. FUNDING Kidney Research UK.
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Affiliation(s)
- Sharlene A Greenwood
- Department of Renal Medicine, King's College Hospital NHS Trust, London, UK; Renal Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK.
| | - Hannah M L Young
- NIHR Leicester Biomedical Research Centre, Leicester, UK; Leicester Diabetes Centre, University of Leicester, Leicester, UK; Physiotherapy Department, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Juliet Briggs
- Department of Renal Medicine, King's College Hospital NHS Trust, London, UK
| | - Ellen M Castle
- School of Physiotherapy, Department of Health Sciences, Brunel University, London, UK
| | - Christy Walklin
- Department of Renal Medicine, King's College Hospital NHS Trust, London, UK
| | - Lynda Haggis
- Department of Renal Medicine, King's College Hospital NHS Trust, London, UK
| | - Caitlin Balkin
- Department of Renal Medicine, King's College Hospital NHS Trust, London, UK
| | - Elham Asgari
- Department of Renal Medicine, Guy's and St Thomas' NHS Trust, London, UK
| | - Sunil Bhandari
- Department of Renal Medicine, Hull University Teaching Hospitals NHS Trust, Hull, UK
| | - James O Burton
- NIHR Leicester Biomedical Research Centre, Leicester, UK; Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
| | - Roseanne E Billany
- NIHR Leicester Biomedical Research Centre, Leicester, UK; Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
| | - Nicolette C Bishop
- School of Sport Exercise and Health Sciences, Loughborough University, Loughborough, UK
| | - Kate Bramham
- Women's Health, King's College London, London, UK
| | - Jackie Campbell
- Faculty of Health, Education and Society, University of Northampton, Northampton, UK
| | - Joseph Chilcot
- Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | - Nicola J Cooper
- Department of Population Health Sciences, University of Leicester, Leicester, UK
| | | | - Matthew P M Graham-Brown
- NIHR Leicester Biomedical Research Centre, Leicester, UK; Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
| | | | - Mark Jesky
- Department of Renal Medicine, Nottingham NHS Trust, Nottingham, UK
| | - Philip A Kalra
- Salford Royal Hospital, Northern Care Alliance NHS Foundation Trust, Salford, UK
| | - Pelagia Koufaki
- Department of Renal Medicine, Queen Margaret University, Edinburgh, UK
| | | | - Andrew C Nixon
- Department of Renal Medicine, Lancashire Teaching Hospitals NHS Foundation Trust, Preston, UK; Division of Cardiovascular Sciences, University of Manchester, Manchester, UK
| | - Helen Noble
- School of Nursing and Midwifery, Queen's University, Belfast, UK
| | - Zoe Saynor
- School of Sport, Health and Exercise Science, University of Portsmouth, Portsmouth, UK
| | - Maarten W Taal
- Centre for Kidney Research and Innovation, School of Medicine, University of Nottingham, Nottingham, UK
| | - James Tollit
- Salford Royal Hospital, Northern Care Alliance NHS Foundation Trust, Salford, UK
| | - David C Wheeler
- Department of Renal Medicine, University College London, London, UK
| | - Thomas J Wilkinson
- NIHR Leicester Biomedical Research Centre, Leicester, UK; Leicester Diabetes Centre, University of Leicester, Leicester, UK
| | - Hannah Worboys
- Department of Population Health Sciences, University of Leicester, Leicester, UK
| | - Jamie H Macdonald
- Institute for Applied Human Physiology, Bangor University, Bangor, UK
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Berman ME, Lowentritt JE. Chronic kidney disease and value-based care: Lessons from innovation, iteration, and ideation in primary care. Hemodial Int 2024; 28:6-16. [PMID: 37936554 DOI: 10.1111/hdi.13126] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Revised: 10/15/2023] [Accepted: 10/16/2023] [Indexed: 11/09/2023]
Abstract
Value-based primary care has reduced health care costs, improved the quality of rendered care, and enhanced the patient experience. Value-based care emphasizes prevention, outreach, follow-up, patient engagement, and comprehensive, whole-person health. Primary care Accountable Care Organizations have leveraged technology-enabled workflows, practice transformation, and cutting-edge data and analytics to achieve success. These efforts are increasingly aided by predictive modeling used in the context of patient identification and prioritization algorithms. Value-based kidney care programs can glean salient takeaways from successful value-based primary care methods and models. The kidney care community is experiencing unprecedented transformation as novel payer programs and financial models burgeon. The authors contend these efforts can be accelerated by the adoption of techniques honed in value-based primary care. To optimize value-based kidney care, though, nephrology thought leaders must transcend the archetype of value-based primary care. To do so, the nephrology community must: (1) impel behavioral change among fee-for-service adherents; (2) harness emerging policy, guidelines, and quality measures; (3) adopt innovative tools, technologies, and therapies. In aggregating lessons from value-based primary care-and leveraging novel methodologies and approaches-the kidney care community will be better equipped to achieve the quadruple aim for kidney care.
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Fowler KJ. The Untapped Power of Patient Engagement in Kidney Diseases. ADVANCES IN KIDNEY DISEASE AND HEALTH 2024; 31:2-4. [PMID: 38403389 DOI: 10.1053/j.akdh.2024.01.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/27/2024]
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O'Brien T, Rose K, Focht B, Al Kahlout N, Jensen T, Heareth K, Nori U, Daloul R. The feasibility of Technology, Application, Self-Management for Kidney (TASK) intervention in post-kidney transplant recipients using a pre/posttest design. Pilot Feasibility Stud 2023; 9:190. [PMID: 37993961 PMCID: PMC10664655 DOI: 10.1186/s40814-023-01417-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Accepted: 11/08/2023] [Indexed: 11/24/2023] Open
Abstract
BACKGROUND Weight gain after a kidney transplant remains a major problem that can lead to adverse effects on morbidity and mortality. The posttransplant phase provides a window of opportunity to improve the engagement of self-management of care for lifestyle modifications for diet and physical activity. The purpose of our study was to (1) test the feasibility of recruitment, retention, and adherence for using the Technology, Application, Self-Management for Kidney (TASK) intervention in post-kidney transplant recipients (≥ 18 years of age) at baseline, 4, 8, and 12 weeks; and (2) estimate the preliminary effects of the TASK intervention in producing change over time for blood pressure (BP), weight, fruits/vegetable intake, fiber intake, sodium intake, self-efficacy to exercise, and perceived stress. METHODS This study used a 12-week pre/posttest design using to test the feasibility of the TASK intervention. We applied paired t-tests and McNemar's test to compare the outcomes at weeks 4, 8, and 12. RESULTS We met our recruitment goal (N = 20) and found a 15% attrition rate (n = 3) at Week 12. Adherence rate among the study completers for recording daily food intake was 83-94% over the 12 weeks and for recording daily physical activity was 17-33% over the 12 weeks. We observed improvements over time for BP, weight, fruits/vegetable intake, fiber intake, and sodium intake; these differences were non-significant, although clinically important. We did find a significant difference from baseline to 12 weeks in weight reduction (p = 0.02), self-efficacy to exercise (p = 0.003), and perceived stress (p = 0.04). CONCLUSIONS The data suggest the TASK intervention was feasible for kidney recipients to use and resulted in weight control, increased self-efficacy to exercise, and decreased perceived stress. TRIAL REGISTRATION ClinicalTrials.gov #:NCT05151445.
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Affiliation(s)
- Tara O'Brien
- The Ohio State University College of Nursing, Newton Hall, 1585 Neil Ave, Columbus, OH, 43210 , USA.
| | - Karen Rose
- The Ohio State University College of Nursing, Newton Hall, 1585 Neil Ave, Columbus, OH, 43210 , USA
| | - Brian Focht
- The Ohio State University College of Education and Human Ecology, 152 PAES, 305 Annie and John Glenn Ave, Columbus, OH, 43210, USA
| | - Noor Al Kahlout
- The Ohio State University College of Nursing, Newton Hall, 1585 Neil Ave, Columbus, OH, 43210 , USA
| | - Tad Jensen
- The Ohio State University College of Nursing, Newton Hall, 1585 Neil Ave, Columbus, OH, 43210 , USA
| | - Kenzie Heareth
- The Ohio State University College of Nursing, Newton Hall, 1585 Neil Ave, Columbus, OH, 43210 , USA
| | - Uday Nori
- The Ohio State University College of Medicine, 300 West 10Th Avenue Suite 1150, Columbus, OH, 43210, USA
| | - Reem Daloul
- Division of Nephrology, Kidney and Pancreas Transplant Program, Allegheny General Hospital, Erie, PA, 16505, USA
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10
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Skeens R, Cavanaugh KL, Cronin R, Chen Q, Liu Y, Huth H, Jackson GP. Parent Activation in the Neonatal Intensive Care Unit. Am J Perinatol 2023; 40:1413-1420. [PMID: 34638138 DOI: 10.1055/s-0041-1736294] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
OBJECTIVE Patient activation is the knowledge, skills, and confidence to manage one's health; parent activation is a comparable concept related to a parent's ability to manage a child's health. Activation in adults is a modifiable risk factor and associated with clinical outcomes and health care utilization. We examined activation in parents of hospitalized newborns observing temporal trends and associations with sociodemographic characteristics, neonate characteristics, and outcomes. STUDY DESIGN Participants included adult parents of neonates admitted to a level-IV neonatal intensive care unit in an academic medical center. Activation was measured with the 10-item Parent version of the Patient Activation Measure (P-PAM) at admission, discharge, and 30 days after discharge. Associations with sociodemographic variables, health literacy, clinical variables, and health care utilization were evaluated. RESULTS A total of 96 adults of 64 neonates were enrolled. The overall mean P-PAM score on admission was 81.8 (standard deviation [SD] = 18), 88.8 (SD = 13) at discharge, and 86.8 (SD = 16) at 30-day follow-up. Using linear mixed regression model, P-PAM score was significantly associated with timing of measurement. Higher P-PAM scores were associated with higher health literacy (p = 0.002) and higher in mothers compared to fathers (p = 0.040). There were no significant associations of admission P-PAM scores with sociodemographic characteristics. Parents of neonates who had a surgical diagnosis had a statistically significant (p = 0.003) lower score than those who did not. There were no associations between discharge P-PAM scores and neonates' lengths of stay or other indicators of illness severity. CONCLUSION Parental activation in the NICU setting was higher than reported in the adult and limited pediatric literature; scores increased from admission to discharge and 30-day postdischarge. Activation was higher in mothers and parents with higher health literacy. Additional larger scale studies are needed to determine whether parental activation is associated with long-term health care outcomes as seen in adults. KEY POINTS · Little is known about activation in parents of neonates.. · Activation plays a role in health outcomes in adults.. · Larger studies are needed to explore parent activation..
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Affiliation(s)
- Ryan Skeens
- Division of Neonatology, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Kerri L Cavanaugh
- Division of Nephrology and Hypertension, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
- Vanderbilt Center for Effective Health Communication, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Robert Cronin
- Department of Medicine and Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - QinGxia Chen
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee
- Department of Ophthalmology and Visual Sciences, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Yuhan Liu
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Hannah Huth
- College of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Gretchen P Jackson
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee
- Department of Pediatric Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
- IBM Watson Health, Cambridge, Massachusetts
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11
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Lightfoot CJ, Wilkinson TJ, Yates T, Davies MJ, Smith AC. 'Self-Management Intervention through Lifestyle Education for Kidney health' (the SMILE-K study): protocol for a single-blind longitudinal randomised controlled trial with nested pilot study. BMJ Open 2022; 12:e064916. [PMID: 36385018 PMCID: PMC9670928 DOI: 10.1136/bmjopen-2022-064916] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Accepted: 10/17/2022] [Indexed: 01/25/2023] Open
Abstract
INTRODUCTION Many people living with chronic kidney disease (CKD) are expected to self-manage their condition. Patient activation is the term given to describe the knowledge, skills and confidence a person has in managing their own health and is closely related to the engagement in preventive health behaviours. Self-management interventions have the potential to improve remote disease management and health outcomes. We are testing an evidence-based and theory-based digital self-management structured 10-week programme developed for peoples with CKD called 'My Kidneys & Me'. The primary aim of the study (Self-Management Intervention through Lifestyle Education for Kidney health (SMILE-K)) is to assess the effect on patient activation levels. METHODS AND ANALYSIS A single-blind randomised controlled trial (RCT) with a nested pilot study will assess the feasibility of the intervention and study design before continuation to a full RCT. Individuals aged 18 years or older, with established CKD stage 3-4 (eGFR of 15-59 mL/min/1.73 m2) will be recruited through both primary and secondary care pathways. Participants will be randomised into two groups: intervention group (receive My Kidneys & Me in addition to usual care) and control group (usual care). The primary outcome of the nested pilot study is feasibility and the primary outcome of the full RCT is the Patient Activation Measu (PAM-13). The full RCT will assess the effect of the programme on online self-reported outcomes which will be assessed at baseline, after 10 weeks, and then after 20 weeks in both groups. A total sample size of N=432 participants are required based on a 2:1 randomisation. A substudy will measure physiological changes (eg, muscle mass, physical function) and patient experience (qualitative semi-structured interviews). ETHICS AND DISSEMINATION This study was fully approved by the Research Ethics Committee-Leicester South on the 19 November 2020 (reference: 17/EM/0357). All participants are required to provide informed consent obtained online. The results are expected to be published in scientific journals and presented at clinical research conferences. This is protocol version 1.0 dated 27 January 2021. TRIAL REGISTRATION NUMBER ISRCTN18314195.
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Affiliation(s)
- Courtney J Lightfoot
- Department of Health Sciences, University of Leicester, Leicester, UK
- Leicester NIHR Biomedical Research Centre, Leicester General Hospital, Leicester, UK
| | - Thomas J Wilkinson
- NIHR Applied Research Collaboration East Midlands, Leicester Diabetes Centre, Leicester, UK
| | - Thomas Yates
- Leicester NIHR Biomedical Research Centre, Leicester General Hospital, Leicester, UK
- Diabetes Reseach Centre, Leicester General Hospital, Leicester, UK
| | - Melanie J Davies
- Leicester NIHR Biomedical Research Centre, Leicester General Hospital, Leicester, UK
- Diabetes Reseach Centre, Leicester General Hospital, Leicester, UK
| | - Alice C Smith
- Department of Health Sciences, University of Leicester, Leicester, UK
- Leicester NIHR Biomedical Research Centre, Leicester General Hospital, Leicester, UK
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12
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van der Horst D, van Uden-Kraan C, Parent E, Bart J, Waverijn G, Verberk-Jonkers I, van den Dorpel M, Pieterse A, Bos W. Optimizing the use of patients’ individual outcome information – development and usability tests of a Chronic Kidney Disease dashboard. Int J Med Inform 2022; 166:104838. [DOI: 10.1016/j.ijmedinf.2022.104838] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2022] [Revised: 07/18/2022] [Accepted: 07/19/2022] [Indexed: 11/24/2022]
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13
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Memory KE, Wilkinson TJ, Smith AC, Lightfoot CJ. A qualitative exploration of the facilitators and barriers to self-management in kidney transplant recipients. J Nephrol 2022; 35:1863-1872. [PMID: 35467326 PMCID: PMC9035973 DOI: 10.1007/s40620-022-01325-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Accepted: 03/27/2022] [Indexed: 11/26/2022]
Abstract
Background Understanding the behaviours that facilitate or impede one’s ability to self-manage is important to improve health-related outcomes in kidney transplant recipients (KTRs). Previous studies exploring the self-management experiences of KTRs have focused on specific tasks (e.g., medication adherence), age groups (e.g., adolescent or older recipients), or have been conducted outside of the UK where transferability of findings is unknown. Our study aimed to explore the perceptions and experiences of self-management in UK KTRs to identify facilitators and barriers associated with self-management tasks. Methods Semi-structured interviews were conducted with eleven KTRs. Topics explored included experiences of self-management tasks (diet, exercise, medications, stress management), perceived healthcare role, and future interventional approaches. Thematic analysis was used to identify and report themes. Results Eight themes were identified which were mapped onto the three self-management tasks described by Corbin and Strauss: medical, role and emotional management. Perceived facilitators to self-management were: gathering health-related knowledge, building relationships with healthcare professionals, creating routines within daily life, setting goals and identifying motivators, establishing support networks, and support from family and friends. Complexity of required treatment and adjusting to a new health status were perceived barriers to self-management. Conclusions Participants described the importance of collaborative consultations and continuity of care. Tailored interventions should identify individualised goals and motivators for participating in self-management. Education on effective strategies to manage symptoms and comorbidities could help alleviate KTRs’ perceived treatment burden. Family and peer support could emotionally support KTRs; however, managing the emotional burden of transplantation warrants more attention. Graphic abstract ![]()
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Affiliation(s)
- Katherine E Memory
- Leicester Medical School, University of Leicester, Leicester, UK
- Leicester Kidney Lifestyle Team, Department of Health Sciences, University of Leicester, Leicester, UK
| | - Thomas J Wilkinson
- Leicester Kidney Lifestyle Team, Department of Health Sciences, University of Leicester, Leicester, UK
| | - Alice C Smith
- Leicester Kidney Lifestyle Team, Department of Health Sciences, University of Leicester, Leicester, UK
| | - Courtney J Lightfoot
- Leicester Kidney Lifestyle Team, Department of Health Sciences, University of Leicester, Leicester, UK.
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14
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Hussein WF, Bennett PN, Carrasco A, Sun S, Reiterman M, Watson E, Schiller B. Changes in patient activation in people starting dialysis: A prospective longitudinal, observational study. Hemodial Int 2022; 26:435-448. [PMID: 35441410 PMCID: PMC9546050 DOI: 10.1111/hdi.13013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Revised: 03/06/2022] [Accepted: 03/24/2022] [Indexed: 11/29/2022]
Abstract
Introduction Increased patient activation is associated with improved health outcomes; however, little is known about patient activation in people with end‐stage kidney disease at the start of their dialysis journey. This study aimed to measure activation status changes over the first 4 months of dialysis. Methods Prospective, longitudinal, and observational study. Incident patients initiating dialysis at 25 in‐center hemodialysis and 17 home dialysis programs across three US states managed by the same dialysis provider completed the 13‐item Patient Activation Measure (PAM‐13) survey at baseline (month 1 after commencement of dialysis) and follow‐up (month 4). The survey yields a score (0–100) that corresponds to four levels (1–4), with higher scores or levels indicating higher activation. Findings One hundred eighty‐two participants (139 center, 43 home) completed both baseline and follow‐up surveys. Mean age was 60 ± 15 years, 40% female. Mean PAM‐13 scores were 65.1 ± 16.8 and 64.8 ± 17.8 at baseline and follow‐up, respectively; mean intraindividual change: −0.3 ± 17.3. The proportions of patients at levels 1–4 at baseline were 11%, 23%, 35%, and 31% respectively. At follow‐up, 50%, 64%, 52%, and 37% of participants at levels 1–4, respectively, changed to a different PAM level (Spearman correlation = 0.47; p < 0.001). Home dialysis was associated with higher PAM scores when compared to in‐center hemodialysis in multivariable analyses, adjusted for sociodemographic variables, comorbidities, and predialysis nephrology care (β = 5.74, 95% confidence intervals [CI]: 0.11–11.37 and 9.02, 95% CI: 3.03–15.02, at baseline and follow–up, respectively). Discussion Although aggregated group scores and levels remained stable, intra‐individual patient activation changed significantly during the first 4 months of dialysis. This novel finding is foundational to future projects aiming to design interventions to improve patient activation.
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Affiliation(s)
- Wael F Hussein
- Satellite Healthcare, San Jose, California, USA.,Department of Medicine, Division of Nephrology, Stanford University School of Medicine, Palo Alto, California, USA
| | - Paul N Bennett
- Satellite Healthcare, San Jose, California, USA.,Clinical & Health Sciences, University of South Australia, Adelaide, South Australia, Australia
| | | | - Sumi Sun
- Satellite Healthcare, San Jose, California, USA
| | | | | | - Brigitte Schiller
- Satellite Healthcare, San Jose, California, USA.,Department of Medicine, Division of Nephrology, Stanford University School of Medicine, Palo Alto, California, USA
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15
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Waterman AD, Nair D, Purnajo I, Cavanaugh KL, Mittman BS, Peipert JD. The Knowledge Assessment of Renal Transplantation (KART) 2.0: Development and Validation of CKD and Transplant Knowledge Scales. Clin J Am Soc Nephrol 2022; 17:555-564. [PMID: 35332061 PMCID: PMC8993477 DOI: 10.2215/cjn.11490821] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Accepted: 02/18/2022] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND OBJECTIVES Many individuals with kidney disease, particularly those belonging to racial and ethnic minority groups and whose primary language is not English, lack knowledge related to kidney disease symptoms, physiologic functions of the kidney, and benefits and risks of kidney transplantation. Valid instruments to assess patients' knowledge of CKD and kidney transplantation are needed. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS Using a sample of 977 patients with stages 3-5 CKD in the Kaiser Permanente health system, we developed the Knowledge Assessment of Renal Transplantation (KART) 2.0 instrument. We conducted cognitive interviews followed by item response theory (IRT) to reduce 48 candidate items. Construct validity was tested by examining differences in scores between patients who spent <1 and ≥1 hour receiving CKD and transplant education. RESULTS Cognitive interviews modified four items and omitted 11. IRT analyses resulted in two scales: the KART 2.0-Transplant Knowledge Scale (16 items; Cronbach's α=0.8) and the KART 2.0-CKD Knowledge Scale (nine items; Cronbach's α=0.79). Differential item functioning showed that the scales were unbiased to capture knowledge across self-identified race, primary language, CKD stage, and sex. Both scales distinguished patients who had spent <1 and ≥1 hour speaking with health professionals (effect size [ES]=0.33 [transplant], 0.54 [CKD]; P<0.001 for both), reading about kidney disease (ES=0.45 [transplant], 0.62 [CKD]; P<0.001), reading about kidney transplantation (ES=0.67 [transplant], 0.69 [CKD]; P<0.001), and reading about living donor kidney transplant (ES=0.76 [transplant], 0.62 [CKD]; P<0.001). CONCLUSIONS The KART 2.0 is a valid tool to assess patients' knowledge of CKD and kidney transplantation.
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Affiliation(s)
- Amy D Waterman
- Department of Surgery and J.C. Walter Jr. Transplant Center, Houston Methodist Hospital, Houston, Texas
| | - Devika Nair
- Division of Nephrology and Hypertension, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
- Vanderbilt O'Brien Center for Kidney Disease, Nashville, Tennessee
| | | | - Kerri L Cavanaugh
- Division of Nephrology and Hypertension, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
- Vanderbilt O'Brien Center for Kidney Disease, Nashville, Tennessee
- Center for Effective Health Communication, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Brian S Mittman
- Health Services Research and Implementation Science, Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, California
| | - John Devin Peipert
- Department of Medical Social Sciences, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
- Northwestern University Transplant Outcomes Research Collaborative, Comprehensive Transplant Center, Feinberg School of Medicine, Chicago, Illinois
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16
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Lightfoot CJ, Nair D, Bennett PN, Smith AC, Griffin AD, Warren M, Wilkinson TJ. Patient Activation: The Cornerstone of Effective Self-Management in Chronic Kidney Disease? KIDNEY AND DIALYSIS 2022; 2:91-105. [PMID: 37101653 PMCID: PMC10127536 DOI: 10.3390/kidneydial2010012] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 04/28/2023]
Abstract
The importance of patient activation (i.e., the knowledge, skills, and confidence one has in managing one's own healthcare) in people with long-term conditions, including kidney disease, is growing. Enabling and empowering patients to take a more active role in their health and healthcare is the focus of person-centred care. Patient activation is recognised as a key construct of self-management, as to effectively self-manage a long-term condition, it is required to enable individuals to actively participate in treatment decisions, prevent complications, and manage risk factors. Identifying an individual's level of activation can help guide and tailor care, and interventions aimed at increasing patient activation may improve patient engagement and health outcomes. In this review, we explore the concepts of patient activation and self-management, the relationship between patient activation and self-management, interventions aimed at improving these, and what these mean to people living with kidney disease.
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Affiliation(s)
- Courtney J. Lightfoot
- Leicester Kidney Lifestyle Team, Department of Health Sciences, University of Leicester,Leicester LE1 7RH, UK
- Leicester NIHR Biomedical Research Centre, Leicester LE5 4PW, UK
| | - Devika Nair
- Division of Nephrology and Hypertension, Vanderbilt University Medical Center, Nashville, TN 37232, USA
- Vanderbilt Center for Kidney Disease, Nashville, TN 37232, USA
| | - Paul N. Bennett
- Clinical & Health Sciences, University of South Australia, Adelaide, SA 5000, Australia
| | - Alice C. Smith
- Leicester Kidney Lifestyle Team, Department of Health Sciences, University of Leicester,Leicester LE1 7RH, UK
- Leicester NIHR Biomedical Research Centre, Leicester LE5 4PW, UK
| | - Anthony D. Griffin
- Leicester Kidney Lifestyle Team, Leicester General Hospital, Leicester LE5 4PW, UK
| | - Madeleine Warren
- Leicester Kidney Lifestyle Team, Leicester General Hospital, Leicester LE5 4PW, UK
| | - Thomas J. Wilkinson
- NIHR Applied Research Collaboration East Midlands (ARC-EM), Leicester Diabetes Centre, Leicester LE5 4PW, UK
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17
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Magadi W, Lightfoot CJ, Memory KE, Santhakumaran S, van der Veer SN, Thomas N, Gair R, Smith AC. Patient activation and its association with symptom burden and quality of life across the spectrum of chronic kidney disease stages in England. BMC Nephrol 2022; 23:45. [PMID: 35081904 PMCID: PMC8793272 DOI: 10.1186/s12882-022-02679-w] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Accepted: 01/13/2022] [Indexed: 12/11/2022] Open
Abstract
Background The knowledge, skills, and confidence to manage one’s own health is termed patient activation and can be assessed using the Patient Activation Measure (PAM). This measure is increasingly recommended for use in chronic kidney disease (CKD), but there is a need to better understand patient activation within this population. This work aimed to explore the association of PAM with patient-reported outcomes, namely symptom burden and health-related quality of life (HRQoL), to understand the relationship between patient activation and outcomes which are of importance to people with CKD. Methods Non-dialysis, dialysis, and kidney transplant patients from 14 renal units across England completed a survey comprising questionnaires assessing patient activation, symptom burden, and HRQoL. Latent class analysis (LCA) was used to determine HRQoL and symptom burden subgroups in the data. Multinomial logistic regression analyses were performed to investigate the associations between patient activation and symptom burden and HRQoL classes separately, adjusting for age, gender, ethnicity, deprivation and treatment modality. Results Three thousand thirteen participants (mean age 61.5 years, 61.8% males, and 47% haemodialysis) were included in the analysis. Patient activation was strongly associated with both the HRQoL and symptom burden classes identified, with highly activated patients more likely to report higher HRQoL (P = < 0.0001; OR 29.2, 95% CI 19.5–43.9) and fewer symptoms (P = < 0.0001; OR 25.9, 95% CI 16.8–40.2). Conclusion Lower activation levels are associated with a higher symptom burden and reduced HRQoL across the trajectory of CKD stages and treatment modalities. Therefore, targeted and holistic self-management support focussing on improving activation may have the potential to improve aspects of health experience which are valued by individuals living with kidney disease. Supplementary Information The online version contains supplementary material available at 10.1186/s12882-022-02679-w.
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Affiliation(s)
- Winnie Magadi
- UK Renal Registry, Brandon House Building 20A1, Southmead Road, Bristol, BS34 7RR, UK.
| | - Courtney J Lightfoot
- Leicester Kidney Lifestyle Team, Department of Health Sciences, University of Leicester, Leicester, UK
| | - Katherine E Memory
- Leicester Kidney Lifestyle Team, Department of Health Sciences, University of Leicester, Leicester, UK
| | - Shalini Santhakumaran
- UK Renal Registry, Brandon House Building 20A1, Southmead Road, Bristol, BS34 7RR, UK
| | - Sabine N van der Veer
- Centre for Health Informatics, Division of Informatics, Imaging and Data Sciences, Manchester Academic Health Science Centre, The University of Manchester, Manchester, UK
| | - Nicola Thomas
- School of Health and Social Care, London South Bank University, London, UK
| | - Rachel Gair
- UK Renal Registry, Brandon House Building 20A1, Southmead Road, Bristol, BS34 7RR, UK
| | - Alice C Smith
- Leicester Kidney Lifestyle Team, Department of Health Sciences, University of Leicester, Leicester, UK
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18
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Nair D, Cukor D, Taylor WD, Cavanaugh KL. Applying A Biopsychosocial Framework to Achieve Durable Behavior Change in Kidney Disease. Semin Nephrol 2022; 41:487-504. [PMID: 34973694 DOI: 10.1016/j.semnephrol.2021.10.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Chronic disease self-management is the establishment and maintenance of behaviors needed to be an active participant in one's health care and experience the best health outcomes. Kidney disease self-management behaviors to slow disease progression include engaging in exercise or physical activity; adhering to a diet low in sodium, potassium, and phosphorus; monitoring laboratory parameters; managing complex medication regimens; coping with disease-related emotional distress; and communicating effectively with providers. Durable behavior change has been difficult to achieve in kidney disease, in part because of an incomplete understanding of the multilevel factors determining chronic disease self-management in this patient group. The biopsychosocial model of chronic illness care posits that an individual's health outcomes result from biological, psychological, social, and environmental factors as part of a multilevel systems hierarchy. Although this theoretical model has been used to comprehensively identify factors driving self-management in other chronic conditions, it has been applied infrequently to behavioral interventions in kidney disease. In this scoping review, we apply the biopsychosocial model of health to identify individual, interpersonal, and systems-level drivers of kidney disease self-management behaviors. We further highlight factors that may serve as novel, impactful targets of theory-based behavioral interventions to understand and sustain behavior change in kidney disease.
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Affiliation(s)
- Devika Nair
- Division of Nephrology and Hypertension, Vanderbilt University Medical Center, Nashville, TN; Vanderbilt O'Brien Center for Kidney Disease, Nashville, TN.
| | - Daniel Cukor
- Behavioral Health Program, The Rogosin Institute, New York, NY
| | - Warren D Taylor
- Division of Geriatric Psychiatry, Vanderbilt University Medical Center, Nashville, TN
| | - Kerri L Cavanaugh
- Division of Nephrology and Hypertension, Vanderbilt University Medical Center, Nashville, TN; Vanderbilt O'Brien Center for Kidney Disease, Nashville, TN; Center for Effective Health Communication, Vanderbilt University Medical Center, Nashville, TN
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19
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Giullian J, Becker B, Ketchersid T. The Large Kidney Care Organizations' Experience With the New Kidney Models. Adv Chronic Kidney Dis 2022; 29:40-44. [PMID: 35690402 DOI: 10.1053/j.ackd.2022.02.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Three years ago, the Advancing American Kidney Health executive order launched a substantial effort with the goals of delaying the progression of kidney disease while also increasing kidney transplantation and the utilization of home dialysis. Included among the initiatives created by this executive order are two new payment models under the supervision of the Centers for Medicare & Medicaid Services Innovation Center. The End Stage Renal Disease Treatment Choices model is a mandatory payment model impacting nephrologists and dialysis providers in many regions across the country. The Kidney Care Choices model offers nephrologists four voluntary options for participation in value-based care. The early experience of two large kidney care organizations highlights the improvements these payment models have demonstrated over prior kidney care payment models while also suggesting additional opportunities for improvement. These models offer nephrologists the opportunity to partner with other providers and deliver patient-centered care across the kidney care continuum. The models represent another step toward value-based care and, if successful, should yield great benefits for patients with kidney disease.
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Affiliation(s)
| | | | - Terry Ketchersid
- Chief Medical Officer, Integrated Care Group, Fresenius Medical Care North America, Co Chief Medical Officer, InterWell Health, Waltham, MA.
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20
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Hussein WF, Bennett PN, Sun SJ, Reiterman M, Watson E, Farwell IM, Schiller B. Patient Activation Among Prevalent Hemodialysis Patients: An Observational Cross-Sectional Study. J Patient Exp 2022; 9:23743735221112220. [PMID: 35924026 PMCID: PMC9340399 DOI: 10.1177/23743735221112220] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Patient activation is the product of knowledge, skills, and confidence that
enables a person to manage their own healthcare. It is associated with healthy
behaviors and improved patient outcomes. We surveyed prevalent hemodialysis (HD)
patients at 10 centers using the Patient Activation Measure 13-item instrument
(PAM-13). Activation was reported as scores (0-100) and corresponding levels
(1-4). Of 1149 eligible patients, surveys were completed by 925 patients (92%
response rate). Mean age was 62 ± 14 years, 40% were female, median vintage was
41 (IQR 19-77) months, and 66% had diabetes. Mean PAM score was 56 ± 13, with
14%, 50%, 25%, and 10% in levels 1 to 4, respectively. In adjusted analysis,
older age and having diabetes were associated with lower activation, whereas
higher educational levels and female gender were associated with higher scores.
Significant variation in activation was observed among participants from
different centers even after adjustment for other variables. In conclusion, low
activation is common among prevalent HD patients.
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Affiliation(s)
- Wael F Hussein
- Satellite Healthcare, San Jose, CA, USA
- Department of Medicine, Division of Nephrology, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Paul N Bennett
- Satellite Healthcare, San Jose, CA, USA
- Clinical and Health Sciences, University of South Australia, Adelaide, Australia
| | | | | | | | | | - Brigitte Schiller
- Satellite Healthcare, San Jose, CA, USA
- Department of Medicine, Division of Nephrology, Stanford University School of Medicine, Palo Alto, CA, USA
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21
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Grandinetti A, Waktola A, Nair D. Qualitative Analyses to Amplify Patient and Care Partner Needs for Self-Management in Glomerular Disease. Kidney Int Rep 2022; 7:13-14. [PMID: 35005309 PMCID: PMC8720811 DOI: 10.1016/j.ekir.2021.11.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Affiliation(s)
| | - Abebech Waktola
- Division of Nephrology and Hypertension, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Devika Nair
- Division of Nephrology and Hypertension, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Vanderbilt O’Brien Center for Kidney Disease, Nashville, Tennessee, USA
- Vanderbilt Center for Health Services Research, Nashville, Tennessee, USA
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22
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Lunardi LE, Bennett PN, Hill K, Eckert M, Corsini N. Effect of patient activation interventions on health-related behavioral outcomes in adults with chronic kidney disease: a systematic review protocol. JBI Evid Synth 2021; 19:3394-3401. [PMID: 34387282 DOI: 10.11124/jbies-20-00387] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
OBJECTIVE This review aims to examine the effect of patient activation interventions compared with usual care on health-related behavioral outcomes in adults with chronic kidney disease stages 3-5. INTRODUCTION Chronic kidney disease is a global health problem associated with a high mortality, reduction of health-related quality of life, and high health care costs. The chronic nature requires active involvement and self-management of the person with chronic kidney disease. Patient activation is a self-management approach that refers to the knowledge, confidence, and skills of people to enable them to manage their own health needs. However, the effectiveness of patient activation interventions on health-related behavioral outcomes in this population have not yet been systematically evaluated. INCLUSION CRITERIA This systematic review will include primary research studies measuring the effect of behavioral change interventions addressing beliefs, knowledge, confidence, and/or skills to optimize self-management in adult patients with chronic kidney disease stages 3-5 who are not receiving dialysis. Studies included in this review will be randomized controlled trials. METHODS Published studies will be searched in MEDLINE, Embase, Emcare, and PsycINFO. Unpublished studies and gray literature sources will also be searched. Titles and abstracts of search results published in English from 2005 onward will be screened, and the full text of potentially relevant studies will be assessed in detail. Studies selected for inclusion will undergo critical appraisal. Data extracted will include specific details about population, study methods, interventions, and outcomes. Studies will be pooled in statistical meta-analysis, if possible. SYSTEMATIC REVIEW REGISTRATION NUMBER PROSPERO CRD42020205084.
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Affiliation(s)
- Laura E Lunardi
- University of South Australia, Clinical Health Science, SA, Australia.,Central Northern Adelaide Renal and Transplantation Service (CNARTS), Adelaide, SA, Australia.,Clinical and Health Sciences, Rosemary Bryant AO Research Centre, University of South Australia, SA, Australia
| | - Paul N Bennett
- University of South Australia, Clinical Health Science, SA, Australia.,Medical and Clinical Affairs, Satellite Healthcare, San Jose, SA, USA
| | - Kathy Hill
- University of South Australia, Clinical Health Science, SA, Australia.,Clinical and Health Sciences, Rosemary Bryant AO Research Centre, University of South Australia, SA, Australia
| | - Marion Eckert
- Clinical and Health Sciences, Rosemary Bryant AO Research Centre, University of South Australia, SA, Australia
| | - Nadia Corsini
- Clinical and Health Sciences, Rosemary Bryant AO Research Centre, University of South Australia, SA, Australia
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Leone DRR, Pereira GA, Silva ACDP, Aguiar ASD. Fatores associados à ativação de pacientes em hemodiálise. AVANCES EN ENFERMERÍA 2021. [DOI: 10.15446/av.enferm.v40n1.90046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Objetivo: mensurar a ativação de pacientes em hemodiálise e determinar os fatores associados à ativação dessa população.
Materiais e método: estudo exploratório, de caráter descritivo e corte transversal com 162 pacientes em tratamento hemodialítico no interior de Minas Gerais, Brasil. Os dados foram coletados de janeiro a abril de 2019, com instrumentos para avaliação sociodemográfica, socioeconômica e clínica e da escala Patient Activation Measure de 13 itens. A análise de dados foi realizada por estatística descritiva e regressão de Poisson com variância robusta.
Resultados: a medida de ativação dos pacientes em hemodiálise variou de 39,4 a 90,7 pontos, em que a média é 60,85 + 15,57 pontos e a mediana 53,2 (IC: 58,4-63,3) pontos. Dos participantes, 52,5 % (n = 85) apresentavam baixa ativação, sendo que o menor quantitativo de pessoas (18,5 %, n = 30) se encontrava no nível 3. Foi associado à maior prevalência de alta ativação o fato de apresentar o nível superior de ensino e não necessitar de cuidador.
Conclusões: embora as variáveis associadas à alta ativação não sejam modificadas pelos profissionais de saúde, conhecê-las permite inferir qual o perfil de pacientes em hemodiálise que necessitam de intervenções direcionadas ao aumento dos níveis de ativação.
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Ferreira da Silva P, Talson MD, Finlay J, Rossum K, Soroka KV, McCormick M, Desjarlais A, Vorster H, Fontaine G, Sass R, James M, Sood MM, Tong A, Pannu N, Tennankore K, Thompson S, Tonelli M, Bohm C. Patient, Caregiver, and Provider Perspectives on Improving Information Delivery in Hemodialysis: A Qualitative Study. Can J Kidney Health Dis 2021; 8:20543581211046078. [PMID: 34721884 PMCID: PMC8552378 DOI: 10.1177/20543581211046078] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Accepted: 07/21/2021] [Indexed: 12/14/2022] Open
Abstract
Background Patients with kidney failure are exposed to a surfeit of new information about their disease and treatment, often resulting in ineffective communication between patients and providers. Improving the amount, timing, and individualization of information received has been identified as a priority in in-center hemodialysis care. Objective To describe and explicate patient, caregiver, and health care provider perspectives regarding challenges and solutions to information transfer in clinical hemodialysis care. Design In this multicenter qualitative study, we gathered perspectives of patients, their caregivers, and health care providers conducted through focus groups and interviews. Setting Five Canadian hemodialysis centers: Calgary, Edmonton, Winnipeg, Ottawa, and Halifax. Participants English-speaking adults receiving in-center hemodialysis for longer than 6 months, their caregivers, and hemodialysis health care providers. Methods Between May 24, 2017, and August 16, 2018, data collected through focus groups and interviews with hemodialysis patients and their caregivers subsequently informed semi-structured interviews with health care providers. For this secondary analysis, data were analyzed through an inductive thematic analysis using grounded theory, to examine the data more deeply for overarching themes. Results Among 82 patients/caregivers and 31 healthcare providers, 6 main themes emerged. Themes identified from patients/caregivers were (1) overwhelmed at initiation of hemodialysis care, (2) need for peer support, and (3) improving comprehension of hemodialysis processes. Themes identified from providers were (1) time constraints with patients, (2) relevance of information provided, and (3) technological innovations to improve patient engagement. Limitations Findings were limited to Canadian context, English speakers, and individuals receiving hemodialysis in urban centers. Conclusions Participants identified challenges and potential solutions to improve the amount, timing, and individualization of information provided regarding in-center hemodialysis care, which included peer support, technological innovations, and improved knowledge translation activities. Findings may inform the development of interventions and strategies aimed at improving information delivery to facilitate patient-centered hemodialysis care.
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Affiliation(s)
| | - Melanie D Talson
- Max Rady College of Medicine, University of Manitoba, Winnipeg, Canada
| | - Juli Finlay
- Cumming School of Medicine, University of Calgary, AB, Canada
| | - Krista Rossum
- Max Rady College of Medicine, University of Manitoba, Winnipeg, Canada
| | | | | | - Arlene Desjarlais
- Can-SOLVE CKD Network Patient Council, Canada.,Can-SOLVE CKD Network Indigenous Peoples' Engagement and Research Council, Winnipeg, MB, Canada
| | | | - George Fontaine
- Can-SOLVE CKD Network Patient Council, Canada.,Can-SOLVE CKD Network Indigenous Peoples' Engagement and Research Council, Winnipeg, MB, Canada
| | - Rachelle Sass
- Max Rady College of Medicine, University of Manitoba, Winnipeg, Canada
| | - Matthew James
- Cumming School of Medicine, University of Calgary, AB, Canada
| | - Manish M Sood
- Department of Medicine, Ottawa Hospital Research Institute, University of Ottawa, ON, Canada
| | - Allison Tong
- Sydney School of Public Health, The University of Sydney, NSW, Australia
| | - Neesh Pannu
- Department of Medicine, University of Alberta, Edmonton, Canada
| | | | | | | | - Clara Bohm
- Max Rady College of Medicine, University of Manitoba, Winnipeg, Canada.,Chronic Disease Innovation Centre, Seven Oaks General Hospital, Winnipeg, MB, Canada
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25
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Cozzi E, Schneeberger S, Bellini MI, Berglund E, Böhmig G, Fowler K, Hoogduijn M, Jochmans I, Marckmann G, Marson L, Neuberger J, Oberbauer R, Pierson RN, Reichart B, Scobie L, White C, Naesens M. Organ transplants of the future: planning for innovations including xenotransplantation. Transpl Int 2021; 34:2006-2018. [PMID: 34459040 DOI: 10.1111/tri.14031] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Revised: 08/10/2021] [Accepted: 08/24/2021] [Indexed: 12/15/2022]
Abstract
The future clinical application of animal-to-human transplantation (xenotransplantation) is of importance to society as a whole. Favourable preclinical data relevant to cell, tissue and solid organ xenotransplants have been obtained from many animal models utilizing genetic engineering and protocols of pathogen-free husbandry. Findings have reached a tipping point, and xenotransplantation of solid organs is approaching clinical evaluation, the process of which now requires close deliberation. Such discussions include considering when there is sufficient evidence from preclinical animal studies to start first-in-human xenotransplantation trials. The present article is based on evidence and opinions formulated by members of the European Society for Organ Transplantation who are involved in the Transplantation Learning Journey project. The article includes a brief overview of preclinical concepts and biology of solid organ xenotransplantation, discusses the selection of candidates for first-in-human studies and considers requirements for study design and conduct. In addition, the paper emphasizes the need for a regulatory framework for xenotransplantation of solid organs and the essential requirement for input from public and patient stakeholders.
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Affiliation(s)
- Emanuele Cozzi
- Department of Cardiac, Thoracic and Vascular Sciences and Public Health, Transplant Immunology Unit, Padua University Hospital, Padua, Italy
| | - Stefan Schneeberger
- Department of Visceral, Transplant and Thoracic Surgery, Innsbruck Medical University, Innsbruck, Austria
| | - Maria Irene Bellini
- Department of Surgical Sciences, Sapienza University of Rome, Rome, Italy
- Department of Emergency Medicine and Surgery, Azienda Ospedaliera San Camillo Forlanini, Rome, Italy
| | - Erik Berglund
- Department of Clinical Science, Intervention and Technology (CLINTEC), Division of Transplantation Surgery, Karolinska Institute and ITB-MED, Stockholm, Sweden
| | - Georg Böhmig
- Division of Nephrology and Dialysis, Medical University Vienna, Vienna, Austria
| | - Kevin Fowler
- The Voice of the Patient, Inc., Chicago, IL, USA
| | - Martin Hoogduijn
- Department of Internal Medicine, Erasmus MC Transplant Institute, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Ina Jochmans
- Transplantation Research Group, Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium
| | - Georg Marckmann
- Institute of Ethics, History and Theory of Medicine, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Lorna Marson
- The Edinburgh Transplant Centre, Royal Infirmary of Edinburgh, Edinburgh, UK
| | | | | | - Richard N Pierson
- Center for Transplantation Sciences, Department of Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Bruno Reichart
- Walter Brendel Center for Experimental Medicine, LMU Munich, Munich, Germany
| | - Linda Scobie
- Department of Biological and Biomedical Sciences, Glasgow Caledonian University, Glasgow, UK
| | | | - Maarten Naesens
- Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium
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Hussein WF, Bennett PN, Abra G, Watson E, Schiller B. Integrating Patient Activation Into Dialysis Care. Am J Kidney Dis 2021; 79:105-112. [PMID: 34461165 DOI: 10.1053/j.ajkd.2021.07.015] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Accepted: 07/17/2021] [Indexed: 11/11/2022]
Abstract
Patient activation, the measure of patients' readiness and willingness to manage their own health care, is low among people receiving in-center hemodialysis, which is exacerbated because such centers are commonly set up for patients to passively receive care. In our pursuit of person-centered care and value-based medicine, enabling patients to take a more active role in their care can lead to healthy behaviors, with subsequent reductions in individual burden and costs to the health care system. To improve patient activation, we need to embrace a patient-first approach and combine it with ways to equip patients to thrive with self-management. This requires changes in the training of the health care team as well as changes in care delivery models, promoting interventions such as health coaching and peer mentoring, while leveraging technology to enable self-access to records, self-monitoring, and communication with providers. We also need health care policies that encourage a focus on patient-identified goals, including more attention to patient-reported outcomes. In this article, we review the current status of patient activation in dialysis patients, outline some of the available interventions, and propose steps to change the dynamics of the current system to move toward a more active role for patients in their care.
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Affiliation(s)
- Wael F Hussein
- Satellite Healthcare, San Jose, California; Department of Medicine, Division of Nephrology, Stanford University School of Medicine, Palo Alto, California.
| | - Paul N Bennett
- Satellite Healthcare, San Jose, California; Clinical & Health Sciences, University of South Australia, Adelaide, SA, Australia
| | - Graham Abra
- Satellite Healthcare, San Jose, California; Department of Medicine, Division of Nephrology, Stanford University School of Medicine, Palo Alto, California
| | | | - Brigitte Schiller
- Satellite Healthcare, San Jose, California; Department of Medicine, Division of Nephrology, Stanford University School of Medicine, Palo Alto, California
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27
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Jain G, Weiner DE. Value-Based Care in Nephrology: The Kidney Care Choices Model and Other Reforms. KIDNEY360 2021; 2:1677-1683. [PMID: 35372980 PMCID: PMC8785791 DOI: 10.34067/kid.0004552021] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Accepted: 08/13/2021] [Indexed: 02/04/2023]
Abstract
The Advancing American Kidney Health (AAKH) initiative has reinvigorated the focus on improving the care of patients with advanced CKD. Multiple interventions have been planned, focusing on education campaigns for both clinicians and patients, delaying the progression of kidney disease and improving utilization of home dialysis modalities and kidney transplantation. Value-based care models for patients with advanced kidney disease are being rolled out, with the ESKD treatment choices model starting in January 2021, and the Kidney Care Choices model planned to start in January 2022. There is increasing emphasis on the role of the nephrologist as the "captain of the ship," leading efforts in care coordination as physician leaders. The transplant reforms have focused on changes to organ procurement organizations aiming to increase availability of organs, and transplants performed, both deceased and living donor, and removing financial disincentives from live organ donation. The American Society of Nephrology (ASN) and the National Kidney Foundation (NKF) are partnering with the Department of Health and Human Services to develop educational material for clinicians and patients. In this review, we discuss these reforms, potential challenges that have arisen, and potential solutions, with emphasis on the Kidney Care Choices model.
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Affiliation(s)
- Gaurav Jain
- Division of Nephrology, Department of Medicine, University of Alabama in Birmingham, Birmingham, Alabama
| | - Daniel E. Weiner
- Department of Nephrology, Tufts Medical Center, Boston, Massachusetts
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28
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Fotheringham J, Barnes T, Dunn L, Lee S, Ariss S, Young T, Walters SJ, Laboi P, Henwood A, Gair R, Wilkie M. A breakthrough series collaborative to increase patient participation with hemodialysis tasks: A stepped wedge cluster randomised controlled trial. PLoS One 2021; 16:e0253966. [PMID: 34283851 PMCID: PMC8291659 DOI: 10.1371/journal.pone.0253966] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2021] [Accepted: 06/14/2021] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Compared to in-centre, home hemodialysis is associated with superior outcomes. The impact on patient experience and clinical outcomes of consistently providing the choice and training to undertake hemodialysis-related treatment tasks in the in-centre setting is unknown. METHODS A stepped-wedge cluster randomised trial in 12 UK renal centres recruited prevalent in-centre hemodialysis patients with sites randomised into early and late participation in a 12-month breakthrough series collaborative that included data collection, learning events, Plan-Study-Do-Act cycles, and teleconferences repeated every 6 weeks, underpinned by a faculty, co-production, materials and a nursing course. The primary outcome was the proportion of patients undertaking five or more hemodialysis-related tasks or home hemodialysis. Secondary outcomes included independent hemodialysis, quality of life, symptoms, patient activation and hospitalisation. ISRCTN Registration Number 93999549. RESULTS 586 hemodialysis patients were recruited. The proportion performing 5 or more tasks or home hemodialysis increased from 45.6% to 52.3% (205 to 244/449, difference 6.2%, 95% CI 1.4 to 11%), however after analysis by step the adjusted odds ratio for the intervention was 1.63 (95% CI 0.94 to 2.81, P = 0.08). 28.3% of patients doing less than 5 tasks at baseline performed 5 or more at the end of the study (69/244, 95% CI 22.2-34.3%, adjusted odds ratio 3.71, 95% CI 1.66-8.31). Independent or home hemodialysis increased from 7.5% to 11.6% (32 to 49/423, difference 4.0%, 95% CI 1.0-7.0), but the remaining secondary endpoints were unaffected. CONCLUSIONS Our intervention did not increase dialysis related tasks being performed by a prevalent population of centre based patients, but there was an increase in home hemodialysis as well as an increase in tasks among patients who were doing fewer than 5 at baseline. Further studies are required that examine interventions to engage people who dialyse at centres in their own care.
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Affiliation(s)
- James Fotheringham
- Sheffield Kidney Institute, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, England
| | - Tania Barnes
- Sheffield Kidney Institute, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, England
| | - Louese Dunn
- Sheffield Kidney Institute, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, England
| | - Sonia Lee
- Sheffield Kidney Institute, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, England
| | - Steven Ariss
- School of Health and Related Research, University of Sheffield, Sheffield, England
| | - Tracey Young
- School of Health and Related Research, University of Sheffield, Sheffield, England
| | - Stephen J. Walters
- School of Health and Related Research, University of Sheffield, Sheffield, England
| | - Paul Laboi
- Renal Department, York Teaching Hospital NHS Foundation Trust, York, England
| | - Andy Henwood
- Renal Department, York Teaching Hospital NHS Foundation Trust, York, England
| | - Rachel Gair
- Think Kidneys, UK Renal Registry, Bristol, England
| | - Martin Wilkie
- Sheffield Kidney Institute, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, England
- * E-mail:
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29
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Nair D, Cavanaugh KL. Sincere Integration of Patients' Perspectives into Kidney Care: Affirming and Adopting Patient Activation. Clin J Am Soc Nephrol 2021; 16:840-842. [PMID: 34117076 PMCID: PMC8216604 DOI: 10.2215/cjn.05050421] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Revised: 04/27/2021] [Accepted: 04/27/2021] [Indexed: 02/04/2023]
Affiliation(s)
- Devika Nair
- Division of Nephrology and Hypertension, Vanderbilt University Medical Center, Nashville, Tennessee
- Vanderbilt O’Brien Center for Kidney Disease, Nashville, Tennessee
| | - Kerri L. Cavanaugh
- Division of Nephrology and Hypertension, Vanderbilt University Medical Center, Nashville, Tennessee
- Vanderbilt O’Brien Center for Kidney Disease, Nashville, Tennessee
- Center for Effective Health Communication, Vanderbilt University Medical Center, Nashville, Tennessee
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30
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Lightfoot CJ, Wilkinson TJ, Memory KE, Palmer J, Smith AC. Reliability and Validity of the Patient Activation Measure in Kidney Disease: Results of Rasch Analysis. Clin J Am Soc Nephrol 2021; 16:880-888. [PMID: 34117081 PMCID: PMC8216620 DOI: 10.2215/cjn.19611220] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Accepted: 03/22/2021] [Indexed: 02/04/2023]
Abstract
BACKGROUND AND OBJECTIVES Despite the increasing prioritization of the promotion of patient activation in nephrology, its applicability to people with CKD is not well established. Before the Patient Activation Measure is universally adopted for use in CKD, it is important to critically evaluate this measure. The aim of this study was to describe the psychometric properties of the Patient Activation Measure in CKD. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS A survey containing the 13-item Patient Activation Measure was completed by 942 patients with CKD, not treated with dialysis. Data quality was assessed by mean, item response, missing values, floor and ceiling effects, internal consistency (Cronbach's alpha and average interitem correlation), and item-rest correlations. Rasch modeling was used to assess item performance and scaling (item statistics, person and item reliability, rating scale diagnostics, factorial test of residuals, and differential item functioning). RESULTS The item response was high, with a small number of missing values (<1%). Floor effect was small (range 1%-5%), but the ceiling effect was above 15% for nine items (range 15%-38%). The Patient Activation Measure demonstrated good internal consistency overall (Cronbach α=0.925, and average interitem correlation 0.502). The difficulty of the Patient Activation Measure items ranged from -0.90 to 0.86. Differential item functioning was found for disease type (item 3) and age (item 12). The person separation index was 9.48 and item separation index was 3.21. CONCLUSIONS The 13-item Patient Activation Measure appears to be a suitably reliable and valid instrument for assessing patient activation in CKD. In the absence of a kidney-specific instrument, our results support the 13-item Patient Activation Measure as a promising measure to assess activation in those with CKD, although consideration for several items is warranted. The high ceiling effect may be a problem when using the 13-item Patient Activation Measure to measure changes over time.
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Affiliation(s)
- Courtney J Lightfoot
- Department of Health Sciences, University of Leicester, Leicester, United Kingdom
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31
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Ladin K, Neckermann I, D’Arcangelo N, Koch-Weser S, Wong JB, Gordon EJ, Rossi A, Rifkin D, Isakova T, Weiner DE. Advance Care Planning in Older Adults with CKD: Patient, Care Partner, and Clinician Perspectives. J Am Soc Nephrol 2021; 32:1527-1535. [PMID: 33827902 PMCID: PMC8259659 DOI: 10.1681/asn.2020091298] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Accepted: 02/09/2021] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Older patients with advanced CKD are at high risk for serious complications and death, yet few discuss advance care planning (ACP) with their kidney clinicians. Examining barriers and facilitators to ACP among such patients might help identify patient-centered opportunities for improvement. METHODS In semistructured interviews in March through August 2019 with purposively sampled patients (aged ≥70 years, CKD stages 4-5, nondialysis), care partners, and clinicians at clinics in across the United States, participants described discussions, factors contributing to ACP completion or avoidance, and perceived value of ACP. We used thematic analysis to analyze data. RESULTS We conducted 68 semistructured interviews with 23 patients, 19 care partners, and 26 clinicians. Only seven of 26 (27%) clinicians routinely discussed ACP. About half of the patients had documented ACP, mostly outside the health care system. We found divergent ACP definitions and perspectives; kidney clinicians largely defined ACP as completion of formal documentation, whereas patients viewed it more holistically, wanting discussions about goals, prognosis, and disease trajectory. Clinicians avoided ACP with patients from minority groups, perceiving cultural or religious barriers. Four themes and subthemes informing variation in decisions to discuss ACP and approaches emerged: (1) role ambiguity and responsibility for ACP, (2) questioning the value of ACP, (3) confronting institutional barriers (time, training, reimbursement, and the electronic medical record, EMR), and (4) consequences of avoiding ACP (disparities in ACP access and overconfidence that patients' wishes are known). CONCLUSIONS Patients, care partners, and clinicians hold discordant views about the responsibility for discussing ACP and the scope for it. This presents critical barriers to the process, leaving ACP insufficiently discussed with older adults with advanced CKD.
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Affiliation(s)
- Keren Ladin
- Research on Ethics, Aging, and Community Health, Medford, Massachusetts,Departments of Occupational Therapy and Community Health, Tufts University, Medford, Massachusetts
| | - Isabel Neckermann
- Research on Ethics, Aging, and Community Health, Medford, Massachusetts
| | - Noah D’Arcangelo
- Research on Ethics, Aging, and Community Health, Medford, Massachusetts
| | - Susan Koch-Weser
- Department of Public Health and Community Medicine, Tufts University School of Medicine, Boston, Massachusetts
| | - John B. Wong
- Division of Clinical Decision Making, Tufts Medical Center, Boston, Massachusetts
| | - Elisa J. Gordon
- Center for Health Services and Outcomes Research, Center for Bioethics and Medical Humanities, Division of Transplantation, Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Ana Rossi
- Piedmont Transplant Institute, Atlanta, Georgia
| | - Dena Rifkin
- Division of Nephrology-Hypertension, University of California San Diego, San Diego, California,Nephrology Section, Veterans Affairs San Diego Healthcare System, San Diego, California
| | - Tamara Isakova
- Division of Nephrology and Hypertension, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois,Center for Translational Metabolism and Health, Institute for Public Health and Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Daniel E. Weiner
- William B Schwartz MD Division of Nephrology, Tufts Medical Center, Boston, Massachusetts
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Wilkinson TJ, Memory K, Lightfoot CJ, Palmer J, Smith AC. Determinants of patient activation and its association with cardiovascular disease risk in chronic kidney disease: A cross-sectional study. Health Expect 2021; 24:843-852. [PMID: 33835670 PMCID: PMC8235879 DOI: 10.1111/hex.13225] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Revised: 01/06/2021] [Accepted: 02/10/2021] [Indexed: 12/16/2022] Open
Abstract
Background Patient activation describes the knowledge, skills and confidence in managing one's own health. Promoting patient activation is being prioritized to reduce costs and adverse outcomes such as cardiovascular disease (CVD). The increasing prevalence of chronic kidney disease (CKD) presents a need to understand the characteristics that influence patient activation and the effect on health outcomes. Design Cross‐sectional study. Setting and participants Patients with non‐dialysis CKD recruited from 14 sites (general nephrology and primary care) in England, UK. Outcome measures Patient activation was measured using the PAM‐13. Demographic and health‐related variables, self‐reported symptom burden, health‐related quality of life (HRQOL), socioeconomic status (SES), were assessed as determinants of patient activation. Major CVD risk factors included hypertension, dyslipidaemia, obesity and hyperkalaemia. Results 743 patients were included (eGFR: 32.3 (SD17.1) mL/min/1.73 m2, age 67.8 (SD13.9) years, 68% male). The mean PAM score was 55.1 (SD14.4)/100. Most patients (60%) had low activation. Those with low activation were older (P<.001), had lower eGFR (P = .004), greater number of comorbidities (P = .026) and lower haemoglobin (P = .025). Patients with low activation had a 17% greater number of CVD risk factors (P < .001). Risk factors in those with low activation were being older (P < .001) and having diabetes (P < .001). Conclusion This study showed that only a minority of CKD patients are activated for self‐management. Our findings help better understand the level of activation in these patients, particularly older individuals with multimorbidity, and further the knowledge regarding the characteristics that influence activation. Patient or Public Contribution Patients were involved in the design of main study.
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Affiliation(s)
- Thomas J Wilkinson
- Leicester Kidney Lifestyle Team, Department of Health Sciences, University of Leicester, Leicester, UK
| | - Katherine Memory
- Leicester Kidney Lifestyle Team, Department of Health Sciences, University of Leicester, Leicester, UK
| | - Courtney J Lightfoot
- Leicester Kidney Lifestyle Team, Department of Health Sciences, University of Leicester, Leicester, UK
| | - Jared Palmer
- Leicester Kidney Lifestyle Team, Department of Health Sciences, University of Leicester, Leicester, UK
| | - Alice C Smith
- Leicester Kidney Lifestyle Team, Department of Health Sciences, University of Leicester, Leicester, UK
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Bristol AA, Chaudhry S, Assis D, Wright R, Moriyama D, Harwood K, Brody AA, Charytan DM, Chodosh J, Scherer JS. An Exploratory Qualitative Study of Patient and Caregiver Perspectives of Ambulatory Kidney Palliative Care. Am J Hosp Palliat Care 2021; 38:1242-1249. [PMID: 33438435 DOI: 10.1177/1049909120986121] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
OBJECTIVES The ideal clinical model to deliver palliative care to patients with advanced kidney disease is currently unknown. Internationally, ambulatory kidney palliative care clinics have emerged with positive outcomes, yet there is limited data from the United States (US). In this exploratory study we report perceptions of a US-based ambulatory kidney palliative care clinic from the perspective of patient and caregiver attendees. The objective of this study was to inform further improvement of our clinical program. METHODS Semi-structured interviews were conducted to elicit the patient and caregiver experience. Eleven interviews (8 patients with chronic kidney disease stage IV or V and 3 caregivers) were analyzed using qualitative description design. RESULTS We identified 2 themes: "Communication addressing the emotional and physical aspects of disease" and "Filling gaps in care"; Subthemes include perceived value in symptom management, assistance with coping with disease, engagement in advance care planning, program satisfaction and patient activation. SIGNIFICANCE OF RESULTS Qualitative analysis showed that attendees of an ambulatory kidney palliative care clinic found the clinic enhanced the management of their kidney disease and provided services that filled current gaps in their care. Shared experiences highlight the significant challenges of life with kidney disease and the possible benefits of palliative care for this population. Further study to determine the optimal model of care for kidney palliative care is needed. Inclusion of the patient and caregiver perspective will be essential in this development.
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Affiliation(s)
- Alycia A Bristol
- 16177University of Utah College of Nursing, Salt Lake City, UT, USA
| | | | - Dana Assis
- 1940Yale New Haven Health, New Haven, CT, USA
| | | | - Derek Moriyama
- 12223Keck School of Medicine of University of Southern California, CA, USA
| | - Katherine Harwood
- Columbia University-Morgan Stanley Children's Hospital, New York, NY, USA
| | - Abraham A Brody
- Hartford Institute for Geriatric Nursing, NYU Rory Meyers College of Nursing, New York, NY, USA.,Division of Geriatrics and Palliative Care, Department of Internal Medicine, NYU School of Medicine, New York, NY, USA
| | - David M Charytan
- Division of Nephrology, Department of Internal Medicine, NYU School of Medicine, New York, NY, USA
| | - Joshua Chodosh
- Division of Geriatrics and Palliative Care, Department of Internal Medicine, NYU School of Medicine, New York, NY, USA
| | - Jennifer S Scherer
- Division of Geriatrics and Palliative Care, Department of Internal Medicine, NYU School of Medicine, New York, NY, USA.,Division of Nephrology, Department of Internal Medicine, NYU School of Medicine, New York, NY, USA
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Inkeroinen S, Koskinen J, Karlsson M, Kilpi T, Leino-Kilpi H, Puukka P, Taponen RM, Tuominen R, Virtanen H. Sufficiency of Knowledge Processed in Patient Education in Dialysis Care. Patient Prefer Adherence 2021; 15:1165-1175. [PMID: 34079237 PMCID: PMC8166350 DOI: 10.2147/ppa.s304530] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Accepted: 04/21/2021] [Indexed: 11/25/2022] Open
Abstract
PURPOSE Patient education improves health and treatment adherence of patients with chronic kidney disease. However, evidence about the sufficiency of patients' knowledge processed in patient education is limited. The purpose of this study was to evaluate subjective and objective sufficiency of knowledge processed in patient education in dialysis care and treatment. PATIENTS AND METHODS A cross-sectional study design was used. The sample (n=162) comprised patients in predialysis or home dialysis. All eligible patients during the data collection timeframe (2016-2017) in two university hospital districts in Finland were invited to participate. Subjective sufficiency was evaluated with a structured questionnaire having 34 items divided into six dimensions of empowering knowledge (bio-physiological, functional, social, experiential, ethical, and financial) on a Likert scale (1=not sufficient at all, 4=very sufficient). Objective sufficiency was evaluated with a structured knowledge test with 10 items (score range 0-10, correct=1, wrong/no knowledge=0) based on the multidimensional content of patient education emphasizing bio-physiological dimension. RESULTS In subjective sufficiency of knowledge, the mean was 3.27 (SD 0.54). The bio-physiological dimension of empowering knowledge was the most sufficient (mean 3.52, SD 0.49) and the experiential the least (mean 2.8, SD 0.88). In objective sufficiency, the means ranged 5.15-5.97 (SD 2.37-2.68) among patients in different modalities of dialysis care and treatment. The least sufficient objective scores were bio-physiological and functional knowledge. The subjective and objective sufficiency did not correlate with each other. CONCLUSION Patients' knowledge, either subjective or objective, does not seem to be sufficient. Hence, attention should be paid to supporting patients with more personalized knowledge. Furthermore, the relationship between subjective and objective sufficiency needs future consideration, as their non-correspondence was a new discovery.
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Affiliation(s)
- Saija Inkeroinen
- Department of Nursing Science, University of Turku, Turku, Finland
- Correspondence: Saija Inkeroinen Department of Nursing Science, University of Turku, Turku, 20014, FinlandTel +358400760698 Email
| | - Jenni Koskinen
- Department of Nursing Science, University of Turku, Turku, Finland
- Hematology and Stem Cell Transplantation Unit, Turku University Hospital, Turku, Finland
| | - Mia Karlsson
- Kidney Center, Department of Medicine, Turku University Hospital, Turku, Finland
| | - Taina Kilpi
- Turku City Welfare, City of Turku, Turku, Finland
| | - Helena Leino-Kilpi
- Department of Nursing Science, University of Turku, Turku, Finland
- Turku University Hospital, Turku, Finland
| | - Pauli Puukka
- Department of Nursing Science, University of Turku, Turku, Finland
| | - Ros-Marie Taponen
- Abdominal Center Dialysis Unit, Hospital District of Helsinki and Uusimaa, Helsinki, Finland
| | | | - Heli Virtanen
- Department of Nursing Science, University of Turku, Turku, Finland
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