A nurse-led disease management programme for chronic kidney disease improves outcomes such as adherence to diet and continuous ambulatory peritoneal dialysis
- Correspondence to Helen Goodman
Royal Brompton Hospital, Sydney Street, London SW3 6NP, UK;
Wong and colleagues address a very important area of adherence to treatment in end-stage renal failure. They have developed a disease management programme of weekly telephone contacts for 6 weeks to improve adherence to diet, fluid and medication regimes. The first and last contacts are with specialist nurses and the intervening ones with trained general nurses who used standardised pro formas and questionnaires. They also discuss health goals and reinforce positive health behaviour.
The programme has been evaluated using a randomised controlled trial involving all patients attending the follow-up clinics at two centres in Hong Kong. The sample size was achieved, and the study was blinded as far as possible.
The outcome measures were a combination of physical and psychological parameters as well as adherence to the programme. The results were significant between groups for degree of diet change and within groups for diet, degree of change to fluid intake and adherence to medication regime, though the changes were small. The authors conclude that the programme is effective for this group of patients. However, while this is encouraging, no CIs were given, and the within group improvement might suggest that patients' increasing awareness of their condition led them to increase compliance. The quality of life measures showed small between group differences in just 2 of the 20 measures (‘sleep’ and ‘symptom’) and within group improvements in ‘staff encouragement’, suggesting that both groups felt supported, and also general health perception, which suggests that their understanding of their illness increased. The latter is interesting as there is no mention of addressing health perception in the management plan.
Widening the approach
The study was an innovative piece of research in this area. The outcome measures were comprehensive, but it is interesting to have an economic perspective of the costs of the programme.
Many of the previous case management studies used to set up the programme were the authors own work, and it may have been helpful to look more widely at other approaches encouraging behavioural change such as motivational interviewing,1 used by other interventions for renal patients,2 or exploring health beliefs, to understand why patients did or did not comply,3 or their locus of control, to see if certain types of patient are more likely to comply, as Williams and colleagues did with exercise programmes for patients with renal failure.4 In the Background section, concerns such as continuing symptoms and stress are mentioned, and it would be interesting to know if the patients' understanding of the causes of these were explored in the consultations.
It is also not clear whether the training for the general nurses was followed up to ensure that the intervention was given as intended. Jolly and colleagues evaluated a mixed approach of specialists and community nurses and found that their health education for cardiac patients was not effective; the nurses assessed the patients but did not necessarily help them follow through on actions.5 The use of skill mix is an excellent one as long as staffs are supported and suitably equipped for the role.
Results may be more conclusive if a larger number of patients were followed up for a longer time period alongside an evaluation of costs. Interviews could be conducted with patients in the control group in order to understand what led to within group improvements for the control group. For example, does this group adhere more if they feel more symptomatic or does the initial information given cause the effect? Also do they notice any difference in approach between the contacts with general and specialist nurses?
Even though this study was performed in a Chinese setting, the results are generalisable if all the factors mentioned are taken into account.