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Review: multicomponent educational interventions improve some outcomes in predialysis and dialysis care

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J L Mason

Ms J L Mason, University Hospitals of Leicester NHS Trust, Leicester, UK; jo.l.mason{at}uhl-tr.nhs.uk

QUESTION

Are multicomponent educational interventions that include both informational and psychological components effective in patients with kidney disease?

REVIEW SCOPE

Studies selected compared structured educational interventions (including both informational and psychological components) with usual care in patients >18 years of age who had kidney disease (early stage chronic kidney disease [CKD], predialysis, and dialysis care). Studies of patients with kidney transplants were excluded. Outcomes included time to dialysis (in predialysis care), survival, self-efficacy, diet and fluid concordance, depression, anxiety, and quality of life.

REVIEW METHODS

Medline, CINAHL, EMBASE/Excerpta Medica, PsycINFO, Cochrane Controlled Trials Register, and reference lists were searched (all to Mar 2007) for randomised controlled trials (RCTs). 22 RCTs (n = 1967, age 19–82 y) met the selection criteria: 5 RCTs evaluated predialysis care, and 17 RCTs evaluated dialysis care. Jadad scores ranged from 1 to 3 out of 5, and follow-up ranged from 1 month to 20 years. Meta-analysis was not done because of study heterogeneity.

MAIN RESULTS

Multicomponent educational interventions increased time to dialysis in predialysis care, and improved self-efficacy and quality of life compared with usual care; groups did not differ for anxiety (table). Interventions had variable effects on diet and fluid concordance, and depression (table). In a single study, a predialysis intervention increased median survival at 20 years (relative risk 1.3, 95% CI 1.0 to 1.7). No studies evaluated patients with early-stage CKD.

Multicomponent educational interventions v usual care in kidney disease

CONCLUSION

Multicomponent educational interventions improve some outcomes in predialysis and dialysis care.

ABSTRACTED FROM

Mason J, Khunti K, Stone M, et al. Educational interventions in kidney disease care: a systematic review of randomized trials. Am J Kidney Dis 2008;51:933–51.

Clinical impact ratings: General/internal medicine 6/7; Nephrology 7/7

Commentary

Increasing competence and confidence in patients with chronic diseases optimises health and is the mainstay of self-management.1 In particular, many patients with CKD struggle to live successfully with their disease. For these reasons, a systematic evaluation of educational interventions for patients with CKD is a valuable addition to the literature. The systematic review by Mason et al noted that most RCTs lacked strong design methodology and theoretical frameworks to adequately evaluate educational interventions. There is also a paucity of disease-specific instruments. The authors provided detailed descriptions of the selection criteria and main outcomes of individual studies, with some interventions showing promising results despite the limited frequency and short duration of interventions.

In studies where physiological measures were used to evaluate effectiveness, 2 of 6 RCTs for fluid adherence and 3 of 7 RCTs for dietary adherence found significant changes in interdialytic weight gain, potassium, phosphorus, or calcium/phosphorus product. Although significant improvements in knowledge attainment were measured in 7 studies, it is difficult to relate the changes in knowledge directly to clinical or behavioural outcomes. Furthermore, 4 of 7 RCTs used self-developed questionnaires with unknown reliability and validity.

The ultimate educational goal of renal clinicians is to develop competent and confident patients who can optimise their health and improve quality of life. The review by Mason et al indicates that insufficient evidence exits to recommend specific clinical interventions to achieve this goal.

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Footnotes

  • Source of funding: Kidney Research UK (Edith Murphy Fellowship Programme).

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