Family Consultation to Reduce Early Hospital Readmissions among Patients with End Stage Kidney Disease: A Randomized Controlled Trial

Factors associated with readmission in chronic kidney disease: Systematic review and meta-analysis

BACKGROUND

Risk factors associated with all-cause hospital readmission are poorly characterised in patients with chronic kidney disease.

OBJECTIVE

A systematic review and meta-analysis were conducted to identify risk factors and protectors of hospital readmission in chronic kidney disease.

DESIGN, PARTICIPANTS & MEASUREMENTS

Studies involving adult patients were identified from four databases from inception to 31/03/2020. Random-effects meta-analyses were conducted to determine factors associated with all-cause 30-day hospital readmission in general chronic kidney disease, in dialysis and in kidney transplant recipient groups.

RESULTS

Eighty relevant studies (chronic kidney disease, n = 14 studies; dialysis, n = 34 studies; and transplant, n = 32 studies) were identified. Meta-analysis revealed that in both chronic kidney disease and transplant groups, increasing age in years and days spent at the hospital during the initial stay were associated with a higher risk of 30-day readmission. Other risk factors identified included increasing body mass index (kg/m2 ) in the transplant group, and functional impairment and discharge destination in the dialysis group. Within the chronic kidney disease ​​​​group, having an outpatient follow-up appointment with a nephrologist within 14 days of discharge was protective against readmission but this was not protective if provided by a primary care provider or a cardiologist.

CONCLUSION

Risk-reduction interventions that can be implemented include a nephrologist appointment within 14 days of hospital discharge, rehabilitation programme for functional improvement in the dialysis group and meal plans in the transplant group. Future risk analysis should focus on modifiable factors to ensure that strategies can be tested and implemented in those who are more at risk.

Readmission outcomes following infectious hospitalization: same-care unit performed better than different-care unit

BACKGROUND

Previous studies showed that same-hospital readmission is associated with better outcomes than different-hospital readmission. However, little is known about whether readmission to the same care unit (same-care unit readmission) after infectious hospitalization performs better than readmission to a different care unit at the same hospital (different-care unit readmission).

METHODS

This retrospective study screened patients rehospitalized within 30 days following admission to two acute medical wards for infectious diseases from 2013 to 2015 and included only those readmitted for unplanned medical reasons. Outcomes of interest included hospital mortality and length of stay of readmitted patients.

RESULTS

Three hundred and fifteen patients were included; of those, 149(47%) and 166(53%) were classified as same-care unit and different-care unit readmissions, respectively. Same-care unit patients were more likely to be older(76 years vs. 70 years; P = 0.001), have comorbid chronic kidney disease(20% vs. 9%; P = 0.008), and have a shorter time to readmission(13 days vs. 16 days; P = 0.020) than different-care unit patients. Univariate analysis showed that same-care unit patients had a shorter length of stay than different-care unit patients(13 days vs. 18 days; P = 0.001), but had similar hospital mortality(20% vs. 24%; P = 0.385). The multivariable linear regression model indicated that same-care unit readmission was associated with a 5-day shorter hospital stay than different-care unit readmission(P = 0.002).

CONCLUSION

Among patients readmitted within 30 days after hospitalization for infectious diseases, same-care unit readmission was associated with a shorter length of hospital stay than different-care unit readmission. Whenever feasible, it is encouraged to allocate a readmitted patient to the same care unit in hope of pursuing continuity and quality of care.

Predictors of Self-Management Behaviors After Discharge Among Unplanned Dialysis Patients

BACKGROUND

Patients with unplanned dialysis must perform self-management behaviors to maintain their health in the community after discharge. Understanding the factors that predict the postdischarge self-management behaviors of patients with unplanned dialysis can assist nurses to implement appropriate discharge plans for this population.

PURPOSE

This study was designed to predict the effects of uncertainty in illness, self-care knowledge, and social-support-related needs during hospitalization on the self-management behaviors of patients with unplanned dialysis during their first 3 months after discharge from the hospital.

METHODS

One hundred sixty-nine patients with unplanned dialysis from the nephrology department of a medical center in Taiwan were enrolled in this prospective study using convenience sampling. At hospital admission, demographic, uncertainty in illness, self-care knowledge, and social support information was collected using a structured questionnaire. Information on self-management behavior was collected at 3 months postdischarge when the patients visited outpatient clinics.

RESULTS

Hierarchical multiple regression analyses showed that self-care knowledge, uncertainty in illness, and social support were important predictors of self-management behaviors at 3 months postdischarge, explaining 65.6% of the total variance in self-management behaviors. Social support increased the variance in self-management behaviors by 27.9%.

CONCLUSIONS/IMPLICATIONS FOR PRACTICE

Comprehensive discharge planning to improve the postdischarge self-management behaviors of patients with unplanned dialysis should involve interventions to improve self-care knowledge, reduce uncertainty in illness, and increase social support. Building social support should be given priority attention.

Interventions for improving health literacy in people with chronic kidney disease

BACKGROUND

Low health literacy affects 25% of people with chronic kidney disease (CKD) and is associated with increased morbidity and death. Improving health literacy is a recognised priority, but effective interventions are not clear.

OBJECTIVES

This review looked the benefits and harms of interventions for improving health literacy in people with CKD.

SEARCH METHODS

We searched the Cochrane Kidney and Transplant Register of Studies up to 12 July 2022 through contact with the Information Specialist using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Register (ICTRP) Search Portal and ClinicalTrials.gov. We also searched MEDLINE (OVID) and EMBASE (OVID) for non-randomised studies.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) and non-randomised studies that assessed interventions aimed at improving health literacy in people with CKD.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed studies for eligibility and performed risk of bias analysis. We classified studies as either interventions aimed at improving aspects of health literacy or interventions targeting a population of people with poor health literacy. The interventions were further sub-classified in terms of the type of intervention (educational, self-management training, or educational with self-management training). Results were expressed as mean difference (MD) or standardised mean difference (SMD) with 95% confidence intervals (CI) for continuous outcomes and risk ratios (RR) with 95% CI for dichotomous outcomes.

MAIN RESULTS

We identified 120 studies (21,149 participants) which aimed to improve health literacy. There were 107 RCTs and 13 non-randomised studies. No studies targeted low literacy populations. For the RCTs, selection bias was low or unclear in 94% of studies, performance bias was high in 86% of studies, detection bias was high in 86% of studies reporting subjective outcomes and low in 93% of studies reporting objective outcomes. Attrition and other biases were low or unclear in 86% and 78% of studies, respectively. Compared to usual care, low certainty evidence showed educational interventions may increase kidney-related knowledge (14 RCTs, 2632 participants: SMD 0.99, 95% CI 0.69 to 1.32; I² = 94%). Data for self-care, self-efficacy, quality of life (QoL), death, estimated glomerular filtration rate (eGFR) and hospitalisations could not be pooled or was not reported. Compared to usual care, low-certainty evidence showed self-management interventions may improve self-efficacy (5 RCTs, 417 participants: SMD 0.58, 95% CI 0.13 to 1.03; I² = 74%) and QoL physical component score (3 RCTs, 131 participants: MD 4.02, 95% CI 1.09 to 6.94; I² = 0%). There was moderate-certainty evidence that self-management interventions probably did not slow the decline in eGFR after one year (3 RCTs, 855 participants: MD 1.53 mL/min/1.73 m², 95% CI -1.41 to 4.46; I² = 33%). Data for knowledge, self-care behaviour, death and hospitalisations could not be pooled or was not reported. Compared to usual care, low-certainty evidence showed educational with self-management interventions may increase knowledge (15 RCTs, 2185 participants: SMD 0.65, 95% CI 0.36 to 0.93; I² = 90%), improve self-care behaviour scores (4 RCTs, 913 participants: SMD 0.91, 95% CI 0.00 to 1.82; I² =97%), self-efficacy (8 RCTs, 687 participants: SMD 0.50, 95% CI 0.10 to 0.89; I² = 82%), improve QoL physical component score (3 RCTs, 2771 participants: MD 2.56, 95% CI 1.73 to 3.38; I² = 0%) and may make little or no difference to slowing the decline of eGFR (4 RCTs, 618 participants: MD 4.28 mL/min/1.73 m², 95% CI -0.03 to 8.85; I² = 43%). Moderate-certainty evidence shows educational with self-management interventions probably decreases the risk of death (any cause) (4 RCTs, 2801 participants: RR 0.73, 95% CI 0.53 to 1.02; I² = 0%). Data for hospitalisation could not be pooled.

AUTHORS' CONCLUSIONS

Interventions to improve aspects of health literacy are a very broad category, including educational interventions, self-management interventions and educational with self-management interventions. Overall, this type of health literacy intervention is probably beneficial in this cohort however, due to methodological limitations and high heterogeneity in interventions and outcomes, the evidence is of low certainty.

Couple and family interventions for high mortality health conditions: A strategic review (2010-2019)

The earliest publications in the field of marriage and family therapy introduced interventions conducted with families experiencing complex health conditions. This strategic review captures an evaluation of efficacy for 87 couple and family interventions published between 2010 and 2019 with a focus on the leading causes of mortality in the United States. These health conditions include chromosomal anomalies and accidents with infants aged 0-4 years; accidents and cancer among children aged 5-14; accidents among adolescents aged 15-24; and heart disease, cancer, accidents, chronic lower respiratory diseases, stroke, Alzheimer's disease, diabetes, influenza/pneumonia, and nephritis/nephrosis among adults 25 and older. Results support the need for greater inclusion of couples and families in assessments and interventions. The greatest chasm in efficacy research was with minoritized couples and families. Implications include ways to initiate couple and family interventions in the context of health conditions with attention given to accessibility, recruitment, retention, and evaluation.

Interventions to Improve Communication at Hospital Discharge and Rates of Readmission: A Systematic Review and Meta-analysis

IMPORTANCE

Shortcomings in the education of patients at hospital discharge are associated with higher risks for treatment failure and hospital readmission. Whether improving communication at discharge through specific interventions has an association with patient-relevant outcomes remains unclear.

OBJECTIVE

To conduct a systematic review and meta-analysis on the association of communication interventions at hospital discharge with readmission rates and other patient-relevant outcomes.

DATA SOURCES

PubMed, EMBASE, PsycINFO, and CINAHL were systematically searched from the inception of each database to February 28, 2021.

STUDY SELECTION

Randomized clinical trials that randomized patients to receiving a discharge communication intervention or a control group were included.

DATA EXTRACTION AND SYNTHESIS

Two independent reviewers extracted data on outcomes and trial and patient characteristics. Risk of bias was assessed using the Cochrane Risk of Bias Tool. Data were pooled using a random-effects model, and risk ratios (RRs) with corresponding 95% CIs are reported. This study followed the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guideline.

MAIN OUTCOMES AND MEASURES

The primary outcome was hospital readmission, and secondary outcomes included adherence to treatment regimen, patient satisfaction, mortality, and emergency department reattendance 30 days after hospital discharge.

RESULTS

We included 60 randomized clinical trials with a total of 16 070 patients for the qualitative synthesis and 19 trials with a total of 3953 patients for the quantitative synthesis of the primary outcome. Of these, 11 trials had low risk of bias, 6 trials had high risk of bias, and 2 trials had unclear risk of bias. Communication interventions at discharge were significantly associated with lower readmission rates (179 of 1959 patients [9.1%] in intervention groups vs 270 of 1994 patients [13.5%] in control groups; RR, 0.69; 95% CI, 0.56-0.84), higher adherence to treatment regimen (1729 of 2009 patients [86.1%] in intervention groups vs 1599 of 2024 patients [79.0%] in control groups; RR, 1.24; 95% CI, 1.13-1.37), and higher patient satisfaction (1187 of 1949 patients [60.9%] in intervention groups vs 991 of 2002 patients [49.5%] in control groups; RR, 1.41; 95% CI, 1.20-1.66).

CONCLUSIONS AND RELEVANCE

These findings suggest that communication interventions at discharge are significantly associated with fewer hospital readmissions, higher treatment adherence, and higher patient satisfaction and thus are important to facilitate the transition of care.

Awareness, knowledge, and perception of chronic kidney disease patients at renal medicine outpatients' clinic

Chronic kidney disease (CKD) is a major cause of morbidity and mortality. Awareness and education of CKD patients positively influence its medical management and significantly diminish the economic burden on public health. We conducted a pretested, structured, questionnaire-based survey to assess the awareness, knowledge, and perception of CKD patients at Renal Medicine Outpatients' Clinic. The questionnaire was distributed to all CKD patients of at least one-year duration after their diagnosis. A total of 200 patients completed this study, mainly from the capital region. The mean age was 50 (17.1) years for males and 42.3 (16) years for females. The majority (74%) knew the reason for their referral to a nephrologist. Nearly 38% of the patients with CKD reported their shock and anger when informed about their kidney status by the nephrologist at the first encounter. Almost 64% of the patients reported having no knowledge of their CKD status and only 18% of the participants were aware that they were in CKD Stage 5, but according to the medical health computerized system, 44% were in CKD Stage 5. In addition, only 50% of them were aware of renal replacement therapy options. Patients and their family should receive enough information and education regarding the nature of kidney disease and the treatment options to allow them to make an informed decision about the management of their CKD. A well-informed decision-making in the treatment of CKD can provide health professionals with evidence on how to best deliver education programs for patients and their families. It may also enhance communication and improve the capacity of patient and family involvement in shared decision-making.