Evaluation of a nurse-led disease management programme for chronic kidney disease: A randomized controlled trial
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
References (49)
- et al.
Clinical outcomes, quality of life, and costs in the North Thames Dialysis Study of elderly people on dialysis: a prospective cohort study
The Lancet
(2000) - et al.
The effectiveness of disease and case management for people with diabetes: a systematic review
American Journal of Preventive Medicine
(2002) - et al.
Does disease management improve clinical and economic outcomes in patients with chronic diseases? A systematic review
The American Journal of Medicine
(2004) - et al.
Nonadherence in hemodialysis: associations with mortality, hospitalization, and practice patterns in the DOPPS
Kidney International
(2003) - et al.
Reduction of hospital utilization in patients with chronic obstructive pulmonary disease: a disease-specific self-management intervention
Archives of Internal Medicine
(2003) - et al.
Patient problems, advanced practice nurse (APN) interventions, time and contacts among five patient groups
Journal of Nursing Scholarship
(2003) - Chow, S.K.Y. 2005. The effect of a nurse-led case management programme on patients undergoing peritoneal dialysis: a...
Patient-by-treatment context interaction in chronic disease: a conceptual framework for the study of patient adherence
Psychosomatic Medicine
(2000)- et al.
Psychological factors in end-stage renal disease: an emerging context for behavioural medicine research
Journal of Consulting & Clinical Psychology
(2002) - et al.
Advanced practice nursing model for comprehensive care with chronic illness: model for promoting process engagement
Advances in Nursing Science
(2004)
The influences of postdischarge management by nurse practitioners on hospital readmission for heart failure
Journal of the American Academy of Nurse Practitioners
A randomized control trial of nursing-based case management for patients with chronic obstructive pulmonary disease
Lippincott's Case Management
nQuery Advisor R 4.0. Statistical Solutions
Ongoing follow-up and support for chronic disease management in the Robert Wood Johnson Foundation Diabetes Initiative
Diabetes Educator
Patient education: can it maximize the success of therapy?
Nephrology Dialysis Transplantation
Improving outcomes after myocardial infarction: a randomized controlled trial evaluating effects of a telephone follow-up intervention
European Journal of Cardiovascular Prevention & Rehabilitation
Development of the kidney disease quality of life (KDQOL) instrument
Quality of Life Research
Effect of case managers with a general medical patient population
Journal of Evaluation in Clinical Practice
Integrating the role of the renal nurse case manager
Nephrology News & Issues
Self-report adherence measures in chronic illness: retest reliability and predictive validity
Medical Care
Adherence in patients on dialysis: strategies for success
Nephrology Nursing Journal
Improving compliance in dialysis patients: does anything work?
Seminars in Dialysis
Effect of a pharmacy care program on medication adherence and persistence, blood pressure, and low-density lipoprotein cholesterol: a randomized controlled trial
JAMA
Cited by (73)
Nurse-based educational interventions in patients with peritoneal dialysis: A systematic review and meta-analysis
2022, International Journal of Nursing Studies AdvancesCitation Excerpt :Causes of ESKD, including chronic glomerular disease, hypertension, diabetes mellitus, systemic lupus erythematosus, was shown in six studies (Chang et al., 2018, Chow and Wong, 2010, Ljungman et al., 2020, Luo et al., 2019, Luo et al., 2020, Chen et al., 2008) and were different in detail across the studies. Nine studies (Chang et al., 2018, Xu et al., 2020, Chow and Wong, 2010, Hare et al., 2014, Luo et al., 2019, Luo et al., 2020, Wong et al., 2010, Pungchompoo et al., 2020, Li et al., 2021) demonstrated educational levels of participants using numerous scales depending on the conducting country of the study. Six studies (Chow and Wong, 2010, Hare et al., 2014, Luo et al., 2019, Luo et al., 2020, Wong et al., 2010, Pungchompoo et al., 2020) reported marital status.
Patient Navigators for CKD and Kidney Failure: A Systematic Review
2022, Kidney MedicineEffectiveness of nurse–led services for people with chronic disease in achieving an outcome of continuity of care at the primary-secondary healthcare interface: A quantitative systematic review
2021, International Journal of Nursing StudiesCitation Excerpt :Fig. 1 outlines the study selection process. In total 14 studies met inclusion criteria for this review, including five RCTs (Chow and Wong, 2014; Hendriks, 2014; Liang et al., 2019; Wong, et al. 2010; Zhu, 2014) eight cohort studies (Berglund, 2015; Carter, 2016; Charlton, 2004; Cheng, 2016; Hill, 1997; Ko et al., 2012; Pritchard-Jones, 2015; Woodward, 2005) and one quasi-experimental study (Sindhu, 2010). Total number of participants in the 14 included studies was n=4,090, with sample sizes ranging from n=60-962.
Interventions for fatigue in people with kidney failure requiring dialysis
2023, Cochrane Database of Systematic ReviewsEffect of Educational Intervention on Knowledge and Level of Adherence among Hemodialysis Patients: A Randomized Controlled Trial
2023, Global Health, Epidemiology and Genomics
- 1
Tel.: +65 6516 8684.