A nurse-led case management program on home exercise training for hemodialysis patients: A randomized controlled trial
Introduction
Patients on maintenance hemodialysis, regardless of age, suffer from impaired physical function (Kaysen et al., 2011, Matsuzawa et al., 2014, Painter and Roshanravan, 2013), which subsequently results in unemployment (van Manen et al., 2001), dependence in activities of daily living, disability (Altintepe et al., 2006), and an increased risk of hospitalization and mortality (Peng et al., 2010). Being physically inactive has been recognized as an important contributor to deterioration in the physical functioning of the dialysis population (Painter et al., 1999). Both diminished physical function and reduced daily physical activity have been associated with adverse clinical outcomes in observational studies of patients on hemodialysis treatment (Johansen et al., 2013, Matsuzawa et al., 2012, Tentori et al., 2010).
Systematic reviews and meta-analyses have shown that exercise, as a subcategory of physical activity, is effective at improving the physical function, depression, and health-related quality of life (HRQOL) of patients on hemodialysis (Cheema and Singh, 2005, Heiwe and Jacobson, 2011, Ouzouni et al., 2009, Segura-Orti et al., 2009). Meanwhile, K/DOQI clinical practice guidelines state that “all dialysis patients should be counseled and regularly encouraged by nephrologists and dialysis staff to increase their level of physical activity” (K/DOQI Workgroup, 2005).
Unfortunately, the various observational studies have consistently shown that the majority of dialysis patients lead sedentary lives (Avesani et al., 2012, Kim et al., 2014, Longenecker et al., 2002, O’Hare et al., 2003). Moreover, exercise programs are not commonly implemented in most hemodialysis facilities (Painter et al., 2014). Both clinical investigations and qualitative interviews revealed a range of barriers to participating in exercise and implementing exercise programs. From the perspective of patients, a lack of exercise-related knowledge, a fear of injuries, experiencing symptoms of debilitation, a low capacity for exercise, and a lack of motivation are some common barriers to engaging in exercise (Delgado and Johansen, 2012, Heiwe and Tollin, 2012, Kontos et al., 2007, Painter et al., 2004). From the perspective of dialysis facilities, resource restrictions are the major concern, such as a lack of professionals to supervise exercise programs, the limited involvement of health care providers, and a lack of financial support (Bennett et al., 2010). The lack of exercise equipment is another barrier to implementing exercise programs in clinical practice (Kontos et al., 2007).
Nurse case management is described as the strategies and process of providing health care to high-risk populations, including those in acute care, long-term care, and community settings (Lamb, 1992). A systematic review and meta-analysis showed that nurse case management using complex interventions can preserve the physical function and independence of elderly people living in the community (Beswick et al., 2008). Through the multidisciplinary coordination of care, individualized exercise programs, counseling, and continuous monitoring, case management offers opportunities to provide interventions to overcome the obstacles that patients face to participating in exercise. The meta-analyses and reviews, which include studies of different chronic disease groups, have demonstrated the effects of nurse case management on improving functionality, quality of life, treatment adherence, self-care ability, and patient satisfaction; as well as on decreasing service use and costs (Latour et al., 2007, Sutherland and Hayter, 2009, Welch et al., 2010). In the chronic kidney disease population, the results from previous randomized controlled trials support the argument that nurse case management is effective at improving clinical and patient outcomes, such as fewer hospitalizations (Dixon et al., 2011, Steele et al., 2007) and improvements in quality of life and patient satisfaction (Chow and Wong, 2010, Li et al., 2014, Wong et al., 2010). The self-efficacy levels and self-management capacities of patients were found to have increased after they received support from a nurse-led multidisciplinary team (Su et al., 2009, Wong et al., 2010).
To address the resource challenges faced by dialysis facilities, home exercise, with its fewer resource requirements, is a possible alternative. It is recommended as a way to easily incorporate physical activity into an individual's daily life (Delgado and Johansen, 2012, Kontos et al., 2007). Exercising at home gives patients on dialysis the flexibility to adjust exercise schedules to accommodate their fatigue levels (Horigan, 2012). Preliminary studies have revealed that home and center-based exercise led to equal gains in clinical and patient outcomes, but that home exercise was more likely to be sustained (Dalal et al., 2010, Malagoni et al., 2008).
Exercise should not be regarded as the exclusive domain of physiotherapists. The whole nephrology team should advise, encourage, and help patients to engage in physical activity, and regard these activities as an integral part of the patient care plan (Smith and Burton, 2012). Nurses have the obligation to help patients reach their full life potential, and are more likely than physicians to discuss patient outcomes with both patients and family members (Coulter and Ellins, 2007). They are well positioned to help patients take up exercise and engage in home exercise programs, due to their prolonged and sustained contact with the patients and their family members.
Although exercise has been shown to be effective at improving the physical function and quality of life of hemodialysis patients, studies investigating the effects of home exercise on physical function (Koh et al., 2009, Malagoni et al., 2008) have not provided sound evidence of its benefits for this group of patients. Thus, further studies in this area are warranted. Although the findings of nurse case management for patients with chronic kidney disease are promising; the results cannot be generalized to home exercise programs for hemodialysis patients. To our knowledge, the effects of a nurse-led exercise program adopting a case management approach have not been previously evaluated for hemodialysis patients.
Section snippets
Objective and hypotheses
The objective of this study is to examine the effects of a nurse-led case management program on home exercise training in improving the physical function and quality of life of hemodialysis patients.
The hypotheses are:
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Patients in the study group that received nurse case management in home exercise will show higher physical functioning than those in the control group that received only brief in-center group exercise.
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Patients in the study group that were provided with nurse case management of
Study design
This study was a randomized, two-parallel group trial. All eligible participants were randomly assigned to either the study group or the control group, at a ratio of 1:1, to receive the corresponding interventions.
The intervention was 12 weeks in duration. Data were collected at three time points: at the baseline before the intervention, at week 6, and at week 12. The second time point for data collection was based on the study by Chow and Wong (2010) in which nurse case management was shown to
Results
Four hundred and sixty-six hemodialysis patients were assessed for eligibility, and 277 of them were excluded. A total of 113 patients were recruited and randomly allocated – 57 to the study group and 56 to the control group. Five patients in the control group and one from the study group discontinued the intervention. Fig. 3 displays the CONSORT flowchart (Moher et al., 2012).
Discussion
The results of the study indicated that the 12-week program on nurse case management of home exercise is effective at improving the physical function of patients and further improving their overall quality of life.
Conclusions
The positive results from this research suggest that nurse case management using a collaborative and behavioral change approach has a role to play in promoting home exercise among hemodialysis patients. The improvement in their physical function that resulted from applying a case management approach provides strong evidence for the desirability of implementing a cost-effective intervention to promote the physical and psychological well-being of patients. Although our program resulted in an
Conflict of interest
None declared.
Funding
This research was funded by a Postgraduate Research Student Grant from The Hong Kong Polytechnic University (Ref. RPZN)
Ethical approval
This study was approved by the Human Subjects Ethical Sub-committee of The Hong Kong Polytechnic University (HSEARS20121105002).
Registration
The clinical trial was registered in ClinicalTrial.gov with the unique identifier of NCT02075879.
Acknowledgments
Special thanks go to the healthcare providers at the hemodialysis units of the affiliated hospitals. The authors would like to thank all of the patients who voluntarily participated in this study.
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