The impact of the Starting dialysis on Time, At home on the Right Therapy (START) project on the use of peritoneal dialysis

BACKGROUND

Peritoneal dialysis (PD) is actively promoted, but increasing PD utilisation is difficult. The objective of this study was to determine if the Starting dialysis on Time, At Home, on the Right Therapy (START) project was associated with an increase in the proportion of dialysis patients receiving PD within 6 months of starting therapy.

METHODS

Consecutive patients over age 18, with end-stage kidney failure, who started dialysis between 1 April 2015 and 31 March 2018 in the province of Alberta, Canada. Programmes were provided with high-quality data about the individual steps in the process of care that drive PD utilisation that were used to identify problem areas, design and implement interventions to address them, and then evaluate whether those interventions had impact. The primary outcome was the proportion of patients receiving PD within 6 months of starting dialysis. Secondary outcomes included hospitalisation, death or probability of transfer to haemodialysis (HD). Interrupted time series methodology was used to evaluate the impact of the quality improvement initiative on the primary and secondary outcomes.

RESULTS

A total of 1962 patients started dialysis during the study period. Twenty-seven per cent of incident patients received PD at baseline, and there was a 5.4% (95% confidence interval: 1.5-9.2) increase in the use of PD in the province immediately after implementation. There were no changes in the rates of hospitalisation, death or probability of transfer to HD after the introduction of START.

CONCLUSIONS

The approach used in the START project was associated with an increase in the use of PD in a setting with high baseline utilisation.

Electronic patient-reported outcomes in clinical kidney practice (ePRO Kidney): a process evaluation of educational support for clinicians

Background

Patient-reported outcomes (PROs) are increasingly mandated in kidney care to incorporate patients' perspectives.

Objectives

We assessed whether educational support for clinicians using electronic (e)PROs could enhance person-centered care.

Design

A process evaluation, using a mixed methods longitudinal comparative concurrent design was undertaken of educational support to clinicians on routine use of ePROs. In two urban home dialysis clinics in Alberta, Canada, patients completed ePROs. At the implementation site, clinicians were provided with ePROs and clinician-oriented education via voluntary workshops. At the non-implementation site, neither were provided. Person-centered care was measured using the Patient Assessment of Chronic Illness Care-20 (PACIC-20).

Methods

Longitudinal structural equation models (SEMs) compared change in overall PACIC scores. The interpretive description approach, using thematic analysis of qualitative data, further evaluated processes of implementation.

Results

Data were collected from questionnaires completed by 543 patients, 4 workshops, 15 focus groups, and 37 interviews. There was no overall difference in person-centered care throughout the study, including after delivery of workshops. The longitudinal SEMs revealed substantial individual-level variability in overall PACIC trajectories. However, there was no improvement at the implementation site and no difference between the sites during both the pre- and post-workshop periods. Similar results were obtained for each PACIC domain. Qualitative analysis provided insights into why there was no substantial difference between sites: (1) clinicians wanted to see kidney symptoms, not quality of life, (2) workshops were tailored to clinicians' educational needs, not patients' needs, and (3) variable use of ePRO data by clinicians.

Conclusion

Training clinicians on use of ePROs is complex and likely only part of what is required to enhance person-centered care.

Registration

NCT03149328. https://clinicaltrials.gov/ct2/show/NCT03149328.

Starting Dialysis on Time, At Home on the Right Therapy (START): Description of an Intervention to Increase the Safe and Effective Use of Peritoneal Dialysis

Background:

Most of the patients with end-stage kidney failure are treated with dialysis. Jurisdictions around the world are actively promoting peritoneal dialysis (PD) because it is equivalent to hemodialysis in terms of clinical outcomes, but is less costly. Unfortunately, PD penetration remains low.

Objectives:

The Starting dialysis on Time, At Home, on the Right Therapy (START) Project had 2 overarching goals: (1) to provide information that would help programs increase the safe and effective use of PD, and (2) to reduce inappropriate, early initiation of dialysis in patients with kidney failure. In this article, we focus on the first objective and describe the rationale for START and the methods employed.

Design:

The START Project was a comprehensive, province-wide quality improvement intervention.

Setting:

The START project was implemented in both Alberta Kidney Care (AKC)-South and AKC-North, including all 7 renal programs in the province.

Patients:

The project included all patients who commenced maintenance dialysis between October 1, 2015, and March 31, 2018, in Alberta, Canada who met our inclusion criteria.

Measurements:

We reported baseline characteristics of incident dialysis patients overall, and by site. Our key performance indicator was the proportion of patients who received PD for any period of time within 180 days of the first dialysis treatment. Reports also included detailed metrics pertaining to the 6 steps in the process of modality selection and we had the capacity to provide more granular data on an as-needed basis. To understand loss of PD patients, we reported the numbers of incident patients who recovered kidney function, experienced technique failure, received a transplant, were lost to follow-up, transferred to another program, or died.

Methods:

START provided dialysis programs with a conceptual framework for understanding the drivers of PD utilization. High-quality, detailed data were collected using a tool that was custom-built for this purpose, and were mapped to steps in the process of care that drove the outcomes of interest. This allowed sites to identify gaps in care, develop action plans, and implement local interventions to address them. The process was supported by an Innovation Learning Collaborative consisting of 3 learning sessions that brought frontline staff together from across the province to share strategies and learnings. Ongoing data collection allowed teams to determine whether their interventions were effective at each subsequent learning session, and to revisit their interventions if required (the “Plan-Do-Study-Act Cycle”).

Results:

Future work will report on the impact of the START project on incident PD utilization at a provincial and regional level.

Limitations:

The time required to design and implement interventions in practice, as well as the need for multiple PDSA (Plan-Do-Study-Act) cycles to see results, meant that the true potential may not be realized during a relatively short intervention period. Change required buy-in and support from local and provincial leadership and frontline staff. In the absence of accountability for local performance, we relied on the goodwill of participating programs to use the information and resources provided to effect change. Finally, the burden of documentation and data collection for frontline staff was high at baseline. We anticipated that adding supplemental data collection would be difficult.

Conclusions:

The START project was a comprehensive, province-wide initiative to maximize the safe and effective use of PD in Alberta, Canada. It standardized the management of incident dialysis patients, leveraged high-quality data to facilitate the reporting of metrics mapped to steps in the process of care that drove incident PD utilization, and helped programs to identify gaps in care and target them for improvement. Future work will report on the impact of the program on incident utilization at the provincial and regional level.

DNA methylation epi-signature is associated with two molecularly and phenotypically distinct clinical subtypes of Phelan-McDermid syndrome

Background

Phelan-McDermid syndrome is characterized by a range of neurodevelopmental phenotypes with incomplete penetrance and variable expressivity. It is caused by a variable size and breakpoint microdeletions in the distal long arm of chromosome 22, referred to as 22q13.3 deletion syndrome, including the SHANK3 gene. Genetic defects in a growing number of neurodevelopmental genes have been shown to cause genome-wide disruptions in epigenomic profiles referred to as epi-signatures in affected individuals.

Results

In this study we assessed genome-wide DNA methylation profiles in a cohort of 22 individuals with Phelan-McDermid syndrome, including 11 individuals with large (2 to 5.8 Mb) 22q13.3 deletions, 10 with small deletions (< 1 Mb) or intragenic variants in SHANK3 and one mosaic case. We describe a novel genome-wide DNA methylation epi-signature in a subset of individuals with Phelan-McDermid syndrome.

Conclusion

We identified the critical region including the BRD1 gene as responsible for the Phelan-McDermid syndrome epi-signature. Metabolomic profiles of individuals with the DNA methylation epi-signature showed significantly different metabolomic profiles indicating evidence of two molecularly and phenotypically distinct clinical subtypes of Phelan-McDermid syndrome.

Peritoneal Dialysis: A Scoping Review of Strategies to Maximize pd Utilization

The percentage of end-stage renal disease (ESRD) patients treated with peritoneal dialysis (PD) has declined in many countries since the mid-1990s. Barriers to PD have been reviewed extensively in the literature, but evidence about strategies to address these barriers and maximize the safe and effective use of PD is lacking. We therefore decided to conduct a scoping review identifying strategies to maximize PD use in adults with ESRD. Our search strategy included the following online databases: MEDLINE (OVID), EMBASE, PubMed, Cochrane Controlled Trials Register, Current Controlled Trials, and Cochrane Database of Systematic Reviews for articles published from 1974 to November 2013. Experts in the field were contacted for information about other ongoing or unpublished studies. A complementary search was conducted in the gray literature. Websites of national, provincial or regional agencies were searched for documents regarding policies surrounding the use of PD. Individual dialysis centers need to identify barriers to increasing PD in their program and direct targeted strategies to maximize PD utilization. Our review highlights some effective strategies that may be used. Our review also highlights the need for further research into strategies to maximize PD utilization.

Economic evaluation of frequent home nocturnal hemodialysis based on a randomized controlled trial

Provider and patient enthusiasm for frequent home nocturnal hemodialysis (FHNHD) has been renewed; however, the cost-effectiveness of this technique is unknown. We performed a cost-utility analysis of FHNHD compared with conventional hemodialysis (CvHD; 4 hours three times per week) from a health payer perspective over a lifetime horizon using patient information from the Alberta NHD randomized controlled trial. Costs, including training costs, were obtained using microcosting and administrative data (CAN$2012). We determined the incremental cost per quality-adjusted life year (QALY) gained. Robustness was assessed using scenario, sensitivity, and probabilistic sensitivity analyses. Compared with CvHD (61% in-center, 14% satellite, and 25% home dialysis), FHNHD led to incremental cost savings (-$6700) and an additional 0.38 QALYs. In sensitivity analyses, when the annual probability of technique failure with FHNHD increased from 7.6% (reference case) to ≥19%, FHNHD became unattractive (>$75,000/QALY). The cost/QALY gained became $13,000 if average training time for FHNHD increased from 3.7 to 6 weeks. In scenarios with alternate comparator modalities, FHNHD remained dominant compared with in-center CvHD; cost/QALYs gained were $18,500, $198,000, and $423,000 compared with satellite CvHD, home CvHD, and peritoneal dialysis, respectively. In summary, FHNHD is attractive compared with in-center CvHD in this cohort. However, the attractiveness of FHNHD varies by technique failure rate, training time, and dialysis modalities from which patients are drawn, and these variables should be considered when establishing FHNHD programs.

Using standardized patients as teachers: a concurrent controlled trial

PURPOSE

To compare two methods of teaching physical assessment, a traditional faculty-taught course and a course with components taught by specially trained standardized patients (SPs), with respect to students' performances and costs.

METHOD

Medical students in their second year and without preliminary course work in physical assessment were taught by faculty-led small groups. Students in their first year were taught by faculty-led lecture-demonstrations and exercises led by physical examination teaching associates (PETAs). Both groups of students were tested with a performance-based examination that involved six identical stations. The costs of both courses were calculated using faculty and SP salaries.

RESULTS

There was no difference in students' performances on two of the stations, those involving the eye and abdominal examinations. The class that had been taught by PETAs, however, demonstrated a statistically significant performance advantage on the remaining four stations. The cost saving from using the PETAs was conservatively estimated at $24,155.

CONCLUSION

Specially trained SPs can effectively teach the normal physical examination to medical students and are a less expensive alternative to traditional faculty small-group teaching methods.

Adenovirus-mediated gene transfer of the human tissue inhibitor of metalloproteinase-2 blocks vascular smooth muscle cell invasiveness in vitro and modulates neointimal development in vivo

BACKGROUND

Endovascular injury induced by balloon withdrawal leads to the increased activation of matrix metalloproteinases (MMPs) in the vascular wall, allowing smooth muscle cells (SMCs) to digest the surrounding extracellular matrix (ECM) and migrate from the media into the intima. The objective of this study was to examine the effects of a replication-deficient adenovirus carrying the cDNA for human tissue inhibitor of metalloproteinase-2 (AdCMV.hTIMP-2) on SMC function in vitro and neointimal development in the injured rat carotid artery.

METHODS AND RESULTS

Infection of cultured rat aortic SMCs at a multiplicity of infection of 100 with AdCMV.hTIMP-2 resulted in high-level expression of hTIMP-2 mRNA and protein secretion into the medium. Conditioned media (CM) from AdCMV. hTIMP-2-infected but not control virus (AdCMV.null or AdCMV. betagal)-infected SMCs inhibited MMP-2 activity on gelatin zymograms as well as the chemoattractant-directed migration of SMCs across reconstituted basement membrane proteins in the Boyden chamber assay. In contrast, AdCMV.hTIMP-2 CM had no effect on chemoattractant-directed migration of SMCs occurring in the absence of an ECM barrier or on the proliferation of cultured neointimal SMCs. Delivery of AdCMV.hTIMP-2 (2.5x10(9) pfu) to the carotid artery wall at the time of balloon withdrawal injury inhibited SMC migration into the intima by 36% (P<0.05) at 4 days and neointimal area by 53% (P<0.01) at 8 days and by 12% (P=NS) at 21 days after injury. AdCMV.hTIMP-2 had no effect on medial area.

CONCLUSIONS

Adenovirus-mediated hTIMP-2 gene transfer inhibits SMC invasiveness in vitro and in vivo and delays neointimal development after carotid injury.

The enteroinsular axis in dipeptidyl peptidase IV-negative rats

Evidence has accumulated that the incretins glucose-dependent insulinotropic polypeptide (GIP) and glucagon-like peptide-1 (GLP-1(7-36) amide) are degraded and rendered biologically inactive in plasma by the enzyme dipeptidyl peptidase IV (DPIV). A strain of Fischer rats lacking the DPIV enzyme were used in the current investigation as a model for examining the enteroinsular axis under conditions in which normal inactivation of GIP and GLP-1(7-36) does not occur. This was assessed by comparing GIP and GLP-1(7-36) responses following oral glucose in normal versus DPIV-deficient Fischer rats, and by comparing the insulinotropic potency of both peptides in the perfused pancreas of both groups. The insulin response to an oral glucose challenge was decreased slightly in DPIV-negative rats compared with control animals. Of the two incretins, the GIP response to oral glucose was reduced by 50% compared with controls, whereas GLP-1(7-36) release in response to glucose was unchanged. A decrease of 30% in the sensitivity of the perfused pancreas of DPIV-negative rats to GIP was observed, whereas the insulin response to GLP(7-36) was identical in both groups. Incubation of both peptides in plasma from DPIV-positive and -negative rats was performed to determine the effect of the presence or absence of DPIV on the insulinotropic activity of GLP-1(7-36) and GIP in the isolated perfused rat pancreas. Incubation in plasma from DPIV-positive rats resulted in a 65% decrease in insulinotropic activity of both incretins compared with incubation in plasma from DPIV-deficient rats. It was hypothesized that the reduced GIP response and decreased sensitivity of the pancreas to GIP are compensatory mechanisms that maintain insulin and glucose levels within a normal range despite abnormal degradation of GIP. An explanation of the lack of effect of the absence of DPIV on the GLP-1(7-36) response to oral glucose and insulinotropic action of this peptide must await further study.