Evaluation of a nurse-led disease management programme for chronic kidney disease: A randomized controlled trial

https://doi.org/10.1016/j.ijnurstu.2009.07.001Get rights and content

Abstract

Background

Patients with end stage renal failure require dialysis and strict adherence to treatment plans to sustain life. However, non-adherence is a common and serious problem among patients with chronic kidney disease. There is a scarcity of studies in examining the effects of disease management programmes on patients with chronic kidney disease.

Objectives

This paper examines whether the study group receiving the disease management programme have better improvement than the control group, comparing outcomes at baseline (O1), at 7 weeks at the completion of the programme (O2) and at 13 weeks (O3).

Methods

This is a randomized controlled trial. The outcome measures were non-adherence in diet, fluid, dialysis and medication, quality of life, satisfaction, symptom control, complication control and health service utilisation.

Results

There was no significant difference between the control and study group for the baseline measures, except for sleep. Significant differences (p < 0.05) were found between the control and study group at O2 in the outcome measures of diet degree non-adherence, sleep, symptom, staff encouragement, overall health and satisfaction. Sustained effects at O3 were noted in the outcome measures of continuous ambulatory peritoneal dialysis (CAPD) non-adherence degree, sleep, symptom, and effect of kidney disease.

Conclusions

Many studies exploring chronic disease management have neglected the group with end stage renal failure and this study fills this gap. This study has employed an innovative model of skill mix using specialist and general nurses and demonstrated patient improvement in diet non-adherence, CAPD non-adherence, aspects of quality of life and satisfaction with care. Redesigning chronic disease management programmes helps to optimize the use of different levels of skills and resources to bring about positive outcomes.

Introduction

Patients with end-stage renal failure (ESRF) rely on artificial means, haemodialysis, continuous ambulatory peritoneal dialysis (CAPD) and the like, to sustain life. The treatment of CAPD demands that the patients take an active role in following a regular schedule of dialysis treatment regimens, strict medication and diet advice (Christensen, 2000). Literature suggests that non-adherence is a common and serious problem among patients with chronic kidney disease. Studies have been done to explore whether adherence can be enhanced among different chronically ill patient groups using a disease management approach. However, there is a scarcity of studies using the chronic kidney disease group as subjects.

Statistics in 2006 showed that 506,256 individuals in the United States (United States Renal Data System, 2006), 107,825 in the United Kingdom (United Kingdom National Health Service Information Centre, 2006), and 83,189 in Hong Kong (Hong Kong Hospital Authority, 2006) suffered from ESRF. Concerns commonly identified among the ESRF patients are disruption of lifestyles, experience of continuing symptoms, stress and uncertainty of life (Polaschek, 2003). Hospital admission rates for renal patients range from 1.8–2.2 admissions per year (Lamping et al., 2000) to 4–7 times per year (Wong and Chung, 2006). When the progress of disease is not well controlled, patients suffer from poor quality of life (Lindqvist and Sjoden, 1998) and in turn make higher demands on the healthcare system (Lamping et al., 2000, Wong and Chung, 2006). Goals in the management of ESRF patients are therefore to improve symptom management, complication control and delay disease progression (Golper, 2001, Wong and Chung, 2006). Achieving these outcomes involves changing lifelong behaviours (Christensen and Ehlers, 2002) but this is not easy. A number of studies reported a non-adherence rate of 30–81.4%, mainly in fluid intake and dietary restrictions among the ESRF patients (Pang et al., 2001, Vlaminck et al., 2001, Christensen and Ehlers, 2002). One study found that one-third of peritoneal dialysis patients are believed to miss prescribed exchanges (Kutner, 2001).

The involvement of patients in adherence to a treatment regime is particularly important for ESRF patients because of the extreme dependence on artificial means to ensure treatment success and sustain life (Christensen and Ehlers, 2002). In the current disease management literature, it is recognized that single and episodic approach is not adequate to bring about sustainable adherence behaviour (Williams et al., 2008). A number of studies using different patient groups revealed that intensive coaching and collaborative self-management with active participation of the client are important to bring about positive outcomes. Studies using groups of diabetic patients have shown that the intensive disease management approach is effective for glycaemic control (Norris et al., 2002, Wong et al., 2005a), screening for complications (Norris et al., 2002), and better blood monitoring and exercise adherence (Wong et al., 2005b). A systematic review of studies involving patients with heart failure supports disease management as a means to save costs and reduce hospitalizations (Riegel et al., 2002), improve symptoms and quality of life particularly related to physical functioning (Polaschek, 2003), improve adherence to treatment plans, and improve satisfaction (Riegel et al., 2002). Similar results were reported using patients with chronic obstructive pulmonary disease, including improved quality of life (Bourbeau et al., 2003), appropriate use of medication to control symptoms, improved psychological wellness (Egan et al., 2002) and reduced hospital admissions and emergency room visits (Bourbeau et al., 2003). For ESRF patients, some exploratory work illustrated that this specific group requires intensive care management to achieve desirable clinical outcomes (Holland, 1998, Nissenson, 2002) but no experimental study was conducted. This study is therefore launched to examine whether a disease management approach to managing the chronic kidney disease group would help enhance health outcomes similar to other disease groups. We focussed on the patients undergoing CAPD in this study.

This study adopts a disease management model that captures key features that have been identified in studies as important to support chronic care. The goals of chronic care are to control symptoms, prevent complications and promote a lifestyle that will delay disease progression (Rothman and Wagner, 2003). Wong et al., 2005b, Wong et al., 2008 have consolidated these features in a four-Cs model consisting of comprehensiveness, collaboration, coordination and continuity. Usually a nurse supported by a multi-disciplinary team will act as a case manager (Yu et al., 2006, Wong et al., 2008). Being comprehensive means that the case manager conducts a systematic assessment of patients’ condition (Wong et al., 2008) including physical, psychological, and social, and is responsible for anticipating patients’ health concerns (Hickey et al., 2000, Wong et al., 2008). The design of care support should include sustained follow-up to ensure early detection of complications, and patients’ concerns and to reinforce adherence behaviours (Wagner et al., 2002). A collaborative process requires an appropriately organized healthcare network linked with available resources if patients need care from other providers (Wagner et al., 2002). The renal team in Hong Kong, like many other countries, is multi-disciplinary composed of nephrologists, nurses, social workers, dieticians and other health care providers by referrals. However, collaboration not only occurs between healthcare professionals, also between the providers and the patients. Patients need to be involved as partners and active agents of care. The ultimate goal is to empower patients to assume responsibility for their own health (Von Korff et al., 1997). Coordination of services involves a delivery system designed to enable the case manager to operate across a spectrum of care in collaboration with physicians and the healthcare team in order to respond to patients’ needs (Wong et al., 2008). The case manager has access to the expertise necessary to care for patients and his/her decision making is supported by the team (Wagner et al., 2002). Continuity emphasizes on care that is regular, active and has sustained follow-ups (Von Korff et al., 1997, Wagner et al., 2002).

Section snippets

Design and research questions

This is a randomized controlled trial. 120 sets of computer-generated random numbers were used, and patients who fitted the criteria were randomized to the study or control group. Please refer to Appendix A for a brief outline of this study.

We asked whether the study group receiving the disease management programme was different from the control group in the outcome measures of non-adherence, quality of life, satisfaction, symptom and complication control and health care utilization.

Setting and participants

Subjects

Baseline data

There were more males (53.1%) than females (46.9%). The mean age was 62.4 years and most of them were married (63.3%). Their education level varied, 20.4% having no formal education and most being educated up to primary (41.8%) or secondary (33.7%) level. Only 9.2% were in employment and the rest were unemployed (11.2%), retired (53.1%) or homemakers (24.5). The majority of them had a place to live, in a self-owned flat (46.9%), public housing (39.8%), or rented accommodation (10.2%). Over

Discussion

This study has provided evidence to support an effective chronic kidney disease management model that uses a specialty-general nurse model. Results demonstrated patient improvement in non-adherence to self-care management in diet and CAPD, aspects of quality of life and satisfaction with care. Many studies exploring chronic disease management have neglected the group with ESRF, and this study fills this gap. It employed an innovative model of skill mix using specialist and general nurses, which

Conclusion

Effective chronic disease management is important in maintaining quality of life and bringing about positive clinical outcomes. Disease management is a collaborative endeavour between patients and healthcare providers. Patients’ involvement in self-care management contributes greatly to successful disease management, but they often need coaching and support from healthcare providers. Redesigning chronic disease management programmes helps to optimize the use of different levels of skills and

Limitations of the study

We acknowledge that there are a number of limitations to this study. The subjects were confined to renal patients receiving CAPD only and the results may not be able to be generalized to other chronic disease groups. With a small sample size and relatively short duration of follow-up, the effects of intervention could not be shown for outcome indicators, such as blood chemistry, that need a higher power or longer time to take effect.

Conflicts of interest

None declared.

Acknowledgement

The authors would like to thank the renal nurses, general nurses and the patients who contributed to this study with the facilitation of Ms. Bonnie Tam, Nurse Specialist (Renal), Ms. Rebecca Yip, Ward Manager (Renal), and Ms. Helen Lee, Nursing Officer (Renal) of the study centres.

Funding: This research was funded by Research Grants Council of Hong Kong (PolyU 5435/05H).

Ethical approval: Ethical approval was given by the Hong Kong Polytechnic University (EA/03/229) and Queen Elizabeth Hospital

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