Characteristics and Effectiveness of Dedicated Care Programs for Patients Starting Dialysis: A Systematic Review

The experiences of people starting haemodialysis: A qualitative study

BACKGROUND AND OBJECTIVE

Starting dialysis is a life-changing transition for people living with kidney disease. People feel overwhelmed with diet changes, medications and surgical interventions, and often experience high levels of anxiety, depression and hospital admissions. The objective of this study was to explore and describe the experiences and perspectives of people starting dialysis.

STUDY DESIGN

Observational qualitative study using audio-recorded, individual, semi-structured interviews.

PARTICIPANTS

We conducted 20 semi-structured interviews with English-speaking adults who were within 90 days of starting in-centre haemodialysis at centres of a nonprofit dialysis provider in Northern California.

APPROACH

Trained qualitative researchers conducted interviews that were deidentified and transcribed verbatim before being inductively coded into codes, categories, and themes.

RESULTS

Three overarching themes emerged from the interviews. Being overwhelmed when starting dialysis, realises the emotional unpreparedness of patients starting dialysis and how the centre's environment (waiting and treatment areas) and staff behaviour impact the dialysis start experience. Making sense of it all, covers how the patient's symptoms, behaviour, and dialysis-related experiences impact the dialysis start. Moving forward, describes how education informed optimal decision-making, and can provide hope for a longer and better life.

LIMITATIONS

Predominantly college-educated participants were recruited from a single dialysis organisation which may limit the transferability of results.

CONCLUSION

Understanding the life-changing experiences that patients encounter when starting dialysis assist dialysis clinicians to help patients adjust and develop long-term coping strategies.

The Feasibility of a Transitional Care Unit for Patients Newly Started on In-Center Hemodialysis: A Research Letter

Background:

Patients with end-stage kidney disease face high mortality and morbidity after dialysis initiation. Transitional care units (TCUs) are typically 4- to 8-week structured multidisciplinary programs targeted toward patients starting hemodialysis during this high-risk time in their care. The goals of such programs are to provide psychosocial support, provide dialysis modality education, and reduce risks of complications. Despite apparent benefits, the TCU model may be challenging to implement, and the effect on patient outcomes is unclear.

Objective:

To assess a newly created multidisciplinary TCUs’ feasibility for patients newly started on hemodialysis.

Design:

Before-and-after study.

Setting:

Kingston Health Sciences Centre hemodialysis unit in Ontario, Canada.

Patients:

We considered all adult patients (age 18+) who initiated in-center maintenance hemodialysis eligible for the TCU program, although patients on infection control precautions and evening shifts were not able to receive TCU care due to staffing limitations.

Measurements:

We defined feasibility as eligible patients completing the TCU program in a timely fashion without additional need for space, no signal of harm, and without explicit concerns from TCU staff or patients at weekly meetings. Key outcomes at 6 months included mortality, proportion hospitalized, dialysis modality, vascular access, initiation of transplant workup, and code status.

Methods:

The TCU care consisted of 1:1 nursing and education until predefined clinical stability and dialysis decisions were satisfied. We compared outcomes among the pre-TCU cohort who initiated hemodialysis between June 2017 and May 2018, and TCU patients who initiated dialysis between June 2018 and March 2019. We summarized outcomes descriptively, along with unadjusted odds ratios (ORs) and 95% confidence intervals (CIs).

Results:

We included 115 pre-TCU patients and 109 post-TCU patients, of whom 49/109 (45%) entered and completed the TCU. The most common reasons for not participating in the TCU included evening hemodialysis shifts (18/60, 30%) or contact precautions (18/60, 30%). The TCU patients completed the program in a median of 35 (25-47) days. We observed no differences in mortality (9% vs 8%; OR = 0.93, 95% CI = 0.28-3.13) or proportion hospitalized (38% vs 39%; OR = 1.02, 95% CI = 0.51-2.03) between the pre-TCU cohort and TCU patients. There was also no difference in use of home dialysis (16% vs 10%; OR = 1.67, 95% CI = 0.64-4.39), non-catheter access (32% vs 25%; OR = 1.44, 95% CI = 0.69-2.98), initiation of transplant workup (14% vs 12%; OR 1.67; 95% CI = 0.64-4.39), and choosing “do not resuscitate” (DNR) orders (22% vs 19%; OR = 1.22, 95% CI = 0.54-2.77). There was no negative patient or staff feedback on the program.

Limitations:

Small sample size and potential for selection bias given inability to provide TCU care for patients on infection control precautions or evening shifts.

Conclusions:

The TCU accommodated a large number of patients, who completed the program in a timely fashion. The TCU model was determined to be feasible at our center. There was no difference in outcomes due to the small sample size. Future work at our center is required to expand the number of TCU dialysis chairs to evening shifts and evaluate the TCU model in prospective, controlled studies.

Assessing the impact of transitional care units on dialysis patient outcomes: A multicenter, propensity score-matched analysis

INTRODUCTION

Inadequate predialysis care and education impacts the selection of a dialysis modality and is associated with adverse clinical outcomes. Transitional care units (TCUs) aim to meet the unmet educational needs of incident dialysis patients, but their impact beyond increasing home dialysis utilization has been incompletely characterized.

METHODS

This retrospective study included adults initiating in-center hemodialysis at a TCU, matched to controls (1:4) with no TCU history initiating in-center hemodialysis. Patients were followed for up to 14 months. TCUs are dedicated spaces where staff provide personalized education and as-needed adjustments to dialysis prescriptions. For many patients, therapy was initiated with four to five weekly dialysis sessions, with at least some sessions delivered by home dialysis machines. Outcomes included survival, first hospitalization, transplant waiting-list status, post-TCU dialysis modality, and vascular access type.

FINDINGS

The study included 724 patients initiating dialysis across 48 TCUs, with 2892 well-matched controls. At the end of 14 months, patients initiating dialysis in a TCU were significantly more likely to be referred and/or wait-listed for a kidney transplant than controls (57% vs. 42%; p < 0.0001). Initiation of dialysis at a TCU was also associated with significantly lower rates of receiving in-center hemodialysis at 14 months (74% vs. 90%; p < 0.0001) and higher rates of arteriovenous access (70% vs. 63%; p = 0.003). Although not statistically significant, TCU patients were more likely to survive and less likely to be hospitalized during follow-up than controls.

DISCUSSION

Although TCUs are sometimes viewed as only a means for enhancing utilization of home dialysis, patients attending TCUs exhibited more favorable outcomes across all endpoints. In addition to being 2.5-fold more likely to receive home dialysis, TCU patients were 42% more likely to be referred for transplantation. Our results support expanding utilization of TCUs for patients with inadequate predialysis support.

Innovations to Increase Home Hemodialysis Utilization: The Transitional Care Unit

A large proportion of patients undergoing incident dialysis start in-center hemodialysis with suboptimal preparation and predialysis education. Transitional care units deliver a structured program by dedicated staff, with less patient-to-staff ratios than in regular in-center dialysis care, with the goals of supporting the emotional and physical well-being of patients while providing them with education and equipping them with the right tools to start their journey on dialysis. Key components of these programs include an emphasis on patient activation and self-management, educating and supporting patients to make informed modality choices, timely coordination of care, and an integrated approach to formation and use of the dialysis access. While data are still limited on best practices and on outcomes of these programs at a large scale, endorsing the model of transitional care units is a step in the right direction to fill the gap in our current care system.