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

Enhancing treatment adherence in dialysis patients through digital health interventions: a systematic review and meta-analysis of randomized controlled trials

OBJECTIVE

To systematically assess the efficacy of digital health interventions (DHIs) for improving treatment adherence among dialysis patients through a meta-analysis of randomized controlled trials (RCTs).

METHODS

Five databases were systematically searched from inception to April 2024. Meta-analyses were performed to calculate standardized mean differences (SMDs) and 95% confidence intervals (CIs) for adherence outcomes. Evidence quality was evaluated using the GRADE approach.

RESULTS

Seventeen RCTs involving 1,438 dialysis patients were analyzed. DHIs significantly improved overall adherence (SMD 1.88 [95% CI: 0.46-3.29]; 4 trials, low-certainty evidence). Specifically, DHIs demonstrated large improvements in medication adherence (SMD 1.45 [95% CI 0.38-2.52]; 4 trials, 300 patients; low-certainty evidence) and dialysis treatment adherence (SMD 1.88 [95% CI 0.46-3.29]; 4 trials, 245 patients; low-certainty evidence). Moderate improvements were observed in dietary adherence (SMD 0.58 [95% CI 0.25-0.91]; 4 trials, 344 patients; moderate-certainty evidence) and fluid management adherence (SMD -0.36 [95% CI -0.64 to -0.07]; 7 trials, 619 patients; moderate-certainty evidence).

CONCLUSIONS

Digital health interventions effectively enhance multiple dimensions of treatment adherence in dialysis patients, underscoring their value for incorporation into routine clinical practice.

Promoting self-management in chronic disease: a systematic review and meta-analysis of behaviour change interventions for patients on dialysis

Given the importance of patients' ability to effectively self-manage their kidney disease, researchers have developed interventions focused on improving self-management for patients on dialysis. The review and meta-analysis aimed to evaluate the efficacy of these interventions and identify the characteristics of more effective interventions in this domain. A meta-analysis of randomised controlled trials to promote self-management in patients on dialysis (N = 4201, k = 45) evaluated: the effect of the interventions on psychological, behavioural, and physiological outcomes; the relationships between changes in outcomes; the moderation of outcomes by behaviour change techniques employed in the interventions; and intervention duration. The meta-analysis obtained moderate effect sizes, demonstrating improvement in behavioural (g = 0.50 to 0.65) and physiological health outcomes (g = -0.32 to -0.57). Fewer studies assessed psychological intervention targets, but large effects were obtained for knowledge change and quality of life (g = 0.65 and 1.17, respectively). Improved knowledge was positively associated with improved medication adherence, which in turn was associated with one physiological outcome. Interventions incorporating psychotherapeutic techniques such as CBT or rational emotive therapy achieved superior physiological outcomes, particularly when used in isolation. The findings support the interpretation that intervention strategies to enhance emotional self-management are effective in optimising outcomes for patients on dialysis.

The impact of nurse-led care in chronic kidney disease management: a systematic review and meta-analysis

BACKGROUND

A multidisciplinary approach is widely recommended for the effective management of chronic kidney disease (CKD), with the objective of improving both clinical and psychosocial outcomes. However, resource constraints and increasing demands on healthcare systems have emphasized the necessity for alternative models of care, such as nurse-led interventions. These interventions possess the potential to address critical challenges in CKD management by providing accessible, patient-centered care across diverse healthcare settings.

OBJECTIVE

This systematic review and meta-analysis aims to compare the effects of nurse-led care with routine care in CKD management to determine its efficacy across diverse cultural backgrounds.

METHODS

Following PRISMA guidelines, a comprehensive search was conducted on PubMed, EMBASE, Scopus, and Cochrane databases, supplemented by manual searches and clinical trial registries. Inclusion criteria were randomized controlled trials (RCTs) involving nurse-led care for CKD patients aged 18 or older. Data extraction focused on study and baseline characteristics, and outcomes related to quality of life (symptoms/problems associated with kidney disease, sleep, energy/fatigue, patient satisfaction, overall health, depression, physical functioning, emotional well-being, role-physical, burden of kidney disease), depression, eGFR, and blood pressure. Statistical analysis used RevMan and STATA software, with results reported as standardized mean differences, along with their confidence intervals.

RESULTS

The analysis included 10 RCTs with a total of 964 participants. Nurse-led care significantly improved symptoms/problems associated with kidney disease, sleep quality, pain, energy/fatigue, overall health, and depression. However, no significant improvements were observed in the burden of kidney disease, physical functioning, role-physical, patient satisfaction and emotional well-being. Variability in outcomes related to depression highlights potential heterogeneity among studies. While some trials reported enhanced hospitalization rates and treatment adherence, others showed inconsistent findings, suggesting a need for more rigorous research.

CONCLUSION

Nurse-led care provides notable benefits in managing certain aspects of CKD, including symptom control, sleep disturbances, energy levels, and overall health. However, its limited impact on kidney function and other clinical outcomes underscores the necessity for developing robust, standardized nurse-led care models and conducting long-term studies to evaluate their comprehensive efficacy.

Comparing the effectiveness of a blended video plus face-to-face educational program with a face-to-face educational program on quality of life among adolescents undergoing hemodialysis in Palestine

INTRODUCTION

Hemodialysis is frequently used as a primary treatment for individuals with end-stage kidney disease (ESKD), and it significantly impacts the quality of life in adolescents undergoing this procedure. Providing a hemodialysis education to these patients is a valuable strategy for enhancing their well-being. The aim of the study is to assess the effect of the video-assisted educational program on the quality of life among adolescents undergoing hemodialysis in Palestine.

METHODS

This study employed a quasi-experimental design, a pre-test-post-test interventional study, involving a sample of 68 adolescent patients between the ages of 13 and 18 diagnosed with ESKD. The quality of life level was assessed in both groups using an Arabic version of the Pediatric Quality of Life Inventory™ version 3.0 ESKD Module survey. The study was conducted at the dialysis units in four hospitals associated with Augusta Victoria Hospital, An-Najah University Hospital, Palestine Medical Complex/Ramallah, and Beit Jala (Al Housain) Hospital. The study involved providing tailored face-to-face educational sessions with video assistance to the experimental group, while the control group received regular face-to-face education.

FINDINGS

The Generalized Estimating Equation analysis revealed no significant differences in quality of life between the experimental and control groups over time, across pre-test, post-test, and follow-up periods (p ≥ 0.05). However, within the experimental group, there was a significant improvement in total quality of life scores between the pre-test, post-test, and post-test follow-up (p ≤ 0.001), although the difference between the pre-test and follow-up approached significance but was not statistically significant (p = 0.056). In contrast, the control group showed significant differences in quality of life across the pre-test, post-test, and follow-up time points (p ≤ 0.05).

DISCUSSION

Implementing suitable interventions can potentially enhance the quality of life for individuals undergoing hemodialysis. Consequently, we suggest using video-based education as a cost-effective, uncomplicated, and engaging approach for educating hemodialysis patients.

Nurse-Led Interventions for Improving Medication Adherence in Chronic Diseases: A Systematic Review

Background: Poor medication adherence results in negative health outcomes and increased healthcare costs. Several healthcare professionals provide interventions to improve medication adherence, with the effectiveness of nurse-led interventions in people with chronic diseases remaining unclear. Objective: This study sought to evaluate the effectiveness of nurse-led interventions for improving medication adherence in adults with chronic conditions. Methods: Five databases (MEDLINE, CINAHL, EMBASE, Cochrane Library, SCOPUS) were searched without applying a temporal limit. Studies evaluating the effects of nurse-led interventions on medication adherence in adults with one or multiple chronic conditions were included. Interventions only targeting a single acute disease were excluded. Results: A total of twenty-two studies with 5975 participants were included. Statistically significant improvements in adherence were reported in five out of seven studies involving face-to-face visits to patients with heart failure (n = 2), chronic myeloid leukemia (n = 1), hypertension (n = 1) and multimorbidity (n = 1) and in four out of nine studies adopting a mixed method involving face-to-face visits and telephone follow-up for patients with heart failure (n = 1), hypertension (n = 1), coronary disease (n = 1) and multimorbidity (n = 1). Remote interventions were effective in improving medication adherence in one out of six studies. No statistically significant differences were found between tablet computer-based patient education and nurse-led educational sessions. The motivational approach was found to be one of the most common strategies used to promote patient medication adherence. Conclusions: Nurse-led face-to-face visits may be effective in improving medication adherence in people with chronic diseases. However, further research is needed because current methods for measuring medication adherence may not accurately capture patient behaviour and medication consumption patterns.

Subjective cognitive complaints in end-stage renal disease: a systematic review and meta-analysis

Cognitive impairment is common in patients with end-stage renal disease (ESRD) and is associated with compromised quality of life and functional capacity, as well as worse clinical outcomes. Most previous research and reviews in this area were focused on objective cognitive impairment, whereas patients' subjective cognitive complaints (SCCs) have been less well-understood. This systematic review aimed to provide a broad overview of what is known about SCCs in adult ESRD patients. Electronic databases were searched from inception to January 2022, which identified 221 relevant studies. SCCs appear to be highly prevalent in dialysis patients and less so in those who received kidney transplantation. A random-effects meta-analysis also shows that haemodialysis patients reported significantly more SCCs than peritoneal dialysis patients (standardised mean difference -0.20, 95% confidence interval -0.38 to -0.03). Synthesis of longitudinal studies suggests that SCCs remain stable on maintenance dialysis treatment but may reduce upon receipt of kidney transplant. Furthermore, SCCs in ESRD patients have been consistently associated with hospitalisation, depression, anxiety, fatigue, and poorer quality of life. There is limited data supporting a strong relation between objective and subjective cognition but preliminary evidence suggests that this association may be domain-specific. Methodological limitations and future research directions are discussed.

Interventions for fatigue in people with kidney failure requiring dialysis

BACKGROUND

Fatigue is a common and debilitating symptom in people receiving dialysis that is associated with an increased risk of death, cardiovascular disease and depression. Fatigue can also impair quality of life (QoL) and the ability to participate in daily activities. Fatigue has been established by patients, caregivers and health professionals as a core outcome for haemodialysis (HD).

OBJECTIVES

We aimed to evaluate the effects of pharmacological and non-pharmacological interventions on fatigue in people with kidney failure receiving dialysis, including HD and peritoneal dialysis (PD), including any setting and frequency of the dialysis treatment.

SEARCH METHODS

We searched the Cochrane Kidney and Transplant Register of Studies up to 18 October 2022 through contact with the Information Specialist using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Registry Platform (ICTRP) Search Portal and ClinicalTrials.gov.

SELECTION CRITERIA

Studies evaluating pharmacological and non-pharmacological interventions affecting levels of fatigue or fatigue-related outcomes in people receiving dialysis were included. Studies were eligible if fatigue or fatigue-related outcomes were reported as a primary or secondary outcome. Any mode, frequency, prescription, and duration of therapy were considered.

DATA COLLECTION AND ANALYSIS

Three authors independently extracted data and assessed the risk of bias. Treatment estimates were summarised using random effects meta-analysis and expressed as a risk ratio (RR) or mean difference (MD), with a corresponding 95% confidence interval (CI) or standardised MD (SMD) if different scales were used. Confidence in the evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach.

MAIN RESULTS

Ninety-four studies involving 8191 randomised participants were eligible. Pharmacological and non-pharmacological interventions were compared either to placebo or control, or to another pharmacological or non-pharmacological intervention. In the majority of domains, risks of bias in the included studies were unclear or high. In low certainty evidence, when compared to control, exercise may improve fatigue (4 studies, 217 participants (Iowa Fatigue Scale, Modified Fatigue Impact Scale, Piper Fatigue Scale (PFS), or Haemodialysis-Related Fatigue scale score): SMD -1.18, 95% CI -2.04 to -0.31; I2 = 87%) in HD. In low certainty evidence, when compared to placebo or standard care, aromatherapy may improve fatigue (7 studies, 542 participants (Fatigue Severity Scale (FSS), Rhoten Fatigue Scale (RFS), PFS or Brief Fatigue Inventory score): SMD -1.23, 95% CI -1.96 to -0.50; I2 = 93%) in HD. In low certainty evidence, when compared to no intervention, massage may improve fatigue (7 studies, 657 participants (FSS, RFS, PFS or Visual Analogue Scale (VAS) score): SMD -1.06, 95% CI -1.47, -0.65; I2 = 81%) and increase energy (2 studies, 152 participants (VAS score): MD 4.87, 95% CI 1.69 to 8.06, I2 = 59%) in HD. In low certainty evidence, when compared to placebo or control, acupressure may reduce fatigue (6 studies, 459 participants (PFS score, revised PFS, or Fatigue Index): SMD -0.64, 95% CI -1.03 to -0.25; I2 = 75%) in HD. A wide range of heterogenous interventions and fatigue-related outcomes were reported for exercise, aromatherapy, massage and acupressure, preventing our capability to pool and analyse the data. Due to the paucity of studies, the effects of pharmacological and other non-pharmacological interventions on fatigue or fatigue-related outcomes, including non-physiological neutral amino acid, relaxation with or without music therapy, meditation, exercise with nandrolone, nutritional supplementation, cognitive-behavioural therapy, ESAs, frequent HD sections, home blood pressure monitoring, blood flow rate reduction, serotonin reuptake inhibitor, beta-blockers, anabolic steroids, glucose-enriched dialysate, or light therapy, were very uncertain. The effects of pharmacological and non-pharmacological treatments on death, cardiovascular diseases, vascular access, QoL, depression, anxiety, hypertension or diabetes were sparse. No studies assessed tiredness, exhaustion or asthenia. Adverse events were rarely and inconsistently reported.

AUTHORS' CONCLUSIONS

Exercise, aromatherapy, massage and acupressure may improve fatigue compared to placebo, standard care or no intervention. Pharmacological and other non-pharmacological interventions had uncertain effects on fatigue or fatigue-related outcomes in people receiving dialysis. Future adequately powered, high-quality studies are likely to change the estimated effects of interventions for fatigue and fatigue-related outcomes in people receiving dialysis.

Effect of Educational Intervention on Knowledge and Level of Adherence among Hemodialysis Patients: A Randomized Controlled Trial

Purpose. The purpose of the study was to assess the impact of an educational intervention on the level of knowledge and adherence to the treatment regimen among hemodialysis (HD) patients as well as to describe the association between these variables. Methods. In this randomized controlled trial, 160 HD patients at an HD centre of a 2030-bed tertiary teaching hospital in Southern India were randomly assigned into intervention (N = 80, received education and a booklet) and control (N = 80, received standard care) groups. Knowledge and adherence were measured preintervention and postintervention using a validated questionnaire for knowledge and the ESRD-AQ (End-Stage Renal Disease Questionnaire) for the level of adherence. The statistical analysis of the data was performed with the help of the Statistical Program SPSS version 19.0. The statistical significance level was set at 0.05. Results. The increase in knowledge on disease management, fluid adherence, and dietary adherence in the intervention group was significantly higher compared to the control group. There was no significant correlation between knowledge and adherence. Adherence improved for all the domains, i.e., dialysis attendance, episodes of shortening, adherence to medication, fluid restriction, and dietary restriction. Adherence to fluid and dietary restriction was statistically significant. This trail is registered with https://clinicaltrials.gov/ct2/show/CTRI/2018/05/014166.

Effect of remote patient monitoring for patients with chronic kidney disease who perform dialysis at home: a systematic review

OBJECTIVE

The purpose of the systematic review was to assess the effectiveness of remote patient monitoring (RPM) follow-up compared with standard care, for patients with chronic kidney disease (CKD) who perform dialysis at home.

METHODS

We conducted a systematic review in accordance with international guidelines. We performed systematic searches for publications from 2015 to 2021 in five databases (eg, Medline, Cinahl, Embase) and a search for grey literature in reference lists. Included effect measures were quality of life, hospitalisation, technical failure as the cause for transfer to a different dialysis modality, infections and time patients use for travel. Screening of literature, data extraction, risk-of-bias assessment and certainty of evidence assessment (using the Grading of Recommendations Assessment, Development and Evaluation approach) were done by two researchers. We conducted meta-analyses when possible.

RESULTS

Seven studies met the inclusion criteria, of which two were randomised controlled trials and five were retrospective cohort studies with control groups. The studies included 9975 participants from 5 countries, who were a good representation of dialysis patients in high-income and upper-middle-income countries. The patients were on peritoneal dialysis (six studies) or home haemodialysis (one study). There was very low certainty of evidence for the outcomes, except for hospitalisations: there was low certainty evidence from three cohort studies for fewer hospitalisation days in the RPM group. No studies included data for time patients used for travel.

CONCLUSION

We found low to very low certainty evidence that indicate there may be positive effects of RPM follow-up, in comparison to standard care only, for adult patients with CKD who perform dialysis at home. Offering RPM follow-up for home dialysis patients as an alternative or supplement to standard care appears to be safe and provide health benefits such as fewer hospitalisation days. Future implementation should be coupled with robust, high-quality evaluations.

PROSPERO REGISTRATION NUMBER

CRD42021281779.

Interventions for improving health literacy in people with chronic kidney disease

BACKGROUND

Low health literacy affects 25% of people with chronic kidney disease (CKD) and is associated with increased morbidity and death. Improving health literacy is a recognised priority, but effective interventions are not clear.

OBJECTIVES

This review looked the benefits and harms of interventions for improving health literacy in people with CKD.

SEARCH METHODS

We searched the Cochrane Kidney and Transplant Register of Studies up to 12 July 2022 through contact with the Information Specialist using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Register (ICTRP) Search Portal and ClinicalTrials.gov. We also searched MEDLINE (OVID) and EMBASE (OVID) for non-randomised studies.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) and non-randomised studies that assessed interventions aimed at improving health literacy in people with CKD.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed studies for eligibility and performed risk of bias analysis. We classified studies as either interventions aimed at improving aspects of health literacy or interventions targeting a population of people with poor health literacy. The interventions were further sub-classified in terms of the type of intervention (educational, self-management training, or educational with self-management training). Results were expressed as mean difference (MD) or standardised mean difference (SMD) with 95% confidence intervals (CI) for continuous outcomes and risk ratios (RR) with 95% CI for dichotomous outcomes.

MAIN RESULTS

We identified 120 studies (21,149 participants) which aimed to improve health literacy. There were 107 RCTs and 13 non-randomised studies. No studies targeted low literacy populations. For the RCTs, selection bias was low or unclear in 94% of studies, performance bias was high in 86% of studies, detection bias was high in 86% of studies reporting subjective outcomes and low in 93% of studies reporting objective outcomes. Attrition and other biases were low or unclear in 86% and 78% of studies, respectively. Compared to usual care, low certainty evidence showed educational interventions may increase kidney-related knowledge (14 RCTs, 2632 participants: SMD 0.99, 95% CI 0.69 to 1.32; I² = 94%). Data for self-care, self-efficacy, quality of life (QoL), death, estimated glomerular filtration rate (eGFR) and hospitalisations could not be pooled or was not reported. Compared to usual care, low-certainty evidence showed self-management interventions may improve self-efficacy (5 RCTs, 417 participants: SMD 0.58, 95% CI 0.13 to 1.03; I² = 74%) and QoL physical component score (3 RCTs, 131 participants: MD 4.02, 95% CI 1.09 to 6.94; I² = 0%). There was moderate-certainty evidence that self-management interventions probably did not slow the decline in eGFR after one year (3 RCTs, 855 participants: MD 1.53 mL/min/1.73 m², 95% CI -1.41 to 4.46; I² = 33%). Data for knowledge, self-care behaviour, death and hospitalisations could not be pooled or was not reported. Compared to usual care, low-certainty evidence showed educational with self-management interventions may increase knowledge (15 RCTs, 2185 participants: SMD 0.65, 95% CI 0.36 to 0.93; I² = 90%), improve self-care behaviour scores (4 RCTs, 913 participants: SMD 0.91, 95% CI 0.00 to 1.82; I² =97%), self-efficacy (8 RCTs, 687 participants: SMD 0.50, 95% CI 0.10 to 0.89; I² = 82%), improve QoL physical component score (3 RCTs, 2771 participants: MD 2.56, 95% CI 1.73 to 3.38; I² = 0%) and may make little or no difference to slowing the decline of eGFR (4 RCTs, 618 participants: MD 4.28 mL/min/1.73 m², 95% CI -0.03 to 8.85; I² = 43%). Moderate-certainty evidence shows educational with self-management interventions probably decreases the risk of death (any cause) (4 RCTs, 2801 participants: RR 0.73, 95% CI 0.53 to 1.02; I² = 0%). Data for hospitalisation could not be pooled.

AUTHORS' CONCLUSIONS

Interventions to improve aspects of health literacy are a very broad category, including educational interventions, self-management interventions and educational with self-management interventions. Overall, this type of health literacy intervention is probably beneficial in this cohort however, due to methodological limitations and high heterogeneity in interventions and outcomes, the evidence is of low certainty.

Nurse-based educational interventions in patients with peritoneal dialysis: A systematic review and meta-analysis

Background

Peritoneal dialysis (PD) is a major renal replacement therapy modality for patients with end-stage kidney disease (ESKD) worldwide. As poor self-care of PD patients could lead to serious complications, including peritonitis, exit-site infection, technique failure, and death; several nurse-based educational interventions have been introduced. However, these interventions varied and have been supported by small-scale studies so the effectiveness of nurse-based educational interventions on clinical outcomes of PD patients has been inconclusive.

Objectives

To evaluate the effectiveness of nurse-based education interventions in PD patients.

Design

A systematic review and meta-analysis of Randomized Controlled Trials (RCTs).

Methods

We performed a systematic search using PubMed, Embase, and CENTRAL up to December 31, 2021. Selection criteria included Randomized Controlled Trials (RCTs) relevant to nurse-based education interventions in ESKD patients with PD in the English language. The meta-analyses were conducted using a random-effects model to evaluate the summary outcomes of peritonitis, PD-related infection, mortality, transfer to hemodialysis, and quality of life (QoL).

Results

From 9,816 potential studies, 71 theme-related abstracts were selected for further full-text articles screening against eligibility criteria. As a result, eleven studies (1,506 PD patients in seven countries) were included in our systematic review. Of eleven studies, eight studies (1,363 PD patients in five countries) were included in the meta-analysis. Sleep QoL in the intervention group was statistically significantly higher than control (mean difference = 12.76, 95% confidence intervals 5.26-20.27). There was no difference between intervention and control groups on peritonitis, PD-related infection, HD transfer, and overall QoL.

Conclusions

Nurse-based educational interventions could help reduce some PD complications, of which only the sleep QoL showed statistically significant improvement. High-quality evidence on the nurse-based educational interventions was limited and more RCTs are needed to provide more robust outcomes.

Tweetable abstract

Nurse-based educational interventions showed promising sleep quality improvement and potential peritonitis risk reduction among PD patients.

Patient Navigators for CKD and Kidney Failure: A Systematic Review

Rationale & Objective

To what degree and how patient navigators improve clinical outcomes for patients with chronic kidney disease (CKD) and kidney failure is uncertain. We performed a systematic review to summarize patient navigator program design, evidence, and implementation in kidney disease.

Study Design

A search strategy was developed for randomized controlled trials and observational studies that evaluated the impact of navigators on outcomes in the setting of CKD and kidney failure. Articles were identified from various databases. Two reviewers independently screened the articles and identified those meeting the inclusion criteria.

Setting & Participants

Patients with CKD or kidney failure (in-center hemodialysis, peritoneal dialysis, home hemodialysis, or kidney transplantation).

Selection Criteria for Studies

Studies that compared patient navigators with a control, without limits on size, duration, setting, or language. Studies focusing solely on patient education were excluded.

Data Extraction

Data were abstracted from full texts and risk of bias was assessed.

Analytical Approach

No meta-analysis was performed.

Results

Of 3,371 citations, 17 articles met the inclusion criteria including 14 original studies. Navigators came from various healthcare backgrounds including nursing (n=6), social worker (n=2), medical interpreter (n=1), research (n=1), and also included kidney transplant recipients (n=2) and non-medical individuals (n=2). Navigators focused mostly on education (n=9) and support (n = 6). Navigators were used for patients with CKD (n=5), peritoneal dialysis (n=2), in-center hemodialysis (n=4), kidney transplantation (n=2), but not home hemodialysis. Navigators improved transplant workup and listing, peritoneal dialysis utilization, and patient knowledge.

Limitations

Many studies did not show benefits across other outcomes, were at a high risk of bias, and none reported cost-effectiveness or patient-reported experience measures.

Conclusions

Navigators improve some health outcomes for CKD but there was heterogeneity in their structure and function. High-quality randomized controlled trials are needed to evaluate navigator program efficacy and cost-effectiveness.

WeChat-Based Comprehensive Education on Egg White Protein Intake for Patients Undergoing Peritoneal Dialysis: A Combined Prospective and Retrospective Study

Protein malnutrition is a well-described complication of peritoneal dialysis (PD), a standard mode of treatment for end-stage renal disease (ESRD), and contributes to morbidity, treatment failure, and mortality. To assess the usefulness of WeChat-based education for ensuring optimal protein intake through the consumption of egg white protein, 140 young and middle-aged patients undergoing PD are assigned to either the intervention group or the control group. The results show that reinforcing comprehensive PD education using WeChat can improve nutritional parameters, clinical parameters, and quality of life.

Effects of a nurse-led transitional burns rehabilitation programme (4Cs-TBuRP) for adult burn survivors: protocol for a randomised controlled trial

BACKGROUND

Transitioning from the burn unit to the home/community can be chaotic with limited professional support. Some adult burn survivors may face varied concerns leading to poor outcomes in the early post-discharge period with limited access to professional help. Based on these, a nurse-led transitional burns rehabilitation programme has been developed and the current trial aims to ascertain its effects as well as explore the implementation process.

METHODS

A single-centre, double-arm randomised controlled trial with a process evaluation phase will be utilised for this study. All adult burn survivors aged ≥ 18 years with burn size ≥ 10% total burn surface area at the site during the study period will be screened for eligibility at least 72 h to discharge. A sample size of 150 will be block randomised to treatment (receiving the nurse-led transitional care programme and routine post-discharge service) and control groups (receiving routine post-discharge service). The nurse-led transitional care programme comprises of predischarge and follow-up phases with the delivery of bundle of holistic interventions lasting for 8 weeks. There are three timelines for data collection: baseline, immediate post intervention, and 4 weeks post-intervention.

DISCUSSION

The findings from this study can potentially inform the development and organisation of post-discharge care and affirm the need for ongoing comprehensive home-based care for burn survivors and their families TRIAL REGISTRATION: ClinicalTrials.gov NCT04517721 . Registered on 20 August 2020.

Effectiveness 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

BACKGROUND

Globally, chronic disease is a leading cause of illness, disability and death and an important driver of health system utilization and spending. Continuity of care is a significant component of quality healthcare. However, an association between nurse-led services, interventions, patient outcomes and continuity of care at the primary and secondary interface as an outcome, has not been established for people with chronic disease.

OBJECTIVE

To identify the effectiveness of nurse-led services for people with chronic disease in achieving an outcome of continuity of care at the primary-secondary healthcare interface.

DESIGN

Quantitative systematic review.

DATA SOURCES

Systematic searches of Medline, Cochrane, Embase, Emcare, JBI and Scopus databases were conducted of studies published between 1946 and May 2019 using the search terms "nurse", "continuity of care" and "chronic disease".

REVIEW METHODS

Quality of the included studies was assessed using the Cochrane risk of bias tool for randomized controlled trials and Joanna Briggs Institute quality appraisal checklists. A second reviewer screened 10% of full text articles and all articles in critical appraisal. Studies were excluded from the review if they were of poor methodological quality or the description of the effect of the nurse-led service was inadequately reported.

RESULTS

Fourteen studies were included in the review (n=4,090 participants). All studies incorporated recognized continuity of care interventions. The nurse-led services were associated with fewer hospitalizations, reduced by 2-8.9% and re-admissions reduced by 14.8-51% (n=886). Reporting of positive patient experiences and improvement in symptoms and lifestyle was also evident. An association of nurse-led services with improved continuity of care between primary and secondary health services as an outcome per se could not be concluded.

CONCLUSION

Nurse-led services for adults provide coordinated interventions that support continuity of care for people with chronic disease in both the primary and secondary healthcare settings that are associated with reduced hospitalizations or readmissions and patient satisfaction. However, the limited use of validated continuity of care outcome measurement tools precluded establishing correlations between interventions, patient outcomes and continuity of care as a specific outcome.

The effect of salutogenesis-based care on the sense of coherence in peritoneal dialysis patients

AIMS

This research is conducted to determine the effect of salutogenesis-based home care on the sense of coherence in patients with peritoneal dialysis.

BACKGROUND

Recent studies on the salutogenesis model have shown that the model is effective in promoting and improving health. It was observed that studies based on the salutogenesis model were carried out in the form of a training programme, and there was no study that shows its effectiveness on patient care by integrating it into the nursing process.

DESIGN

The research is conducted as a pre-test-post-test control group experimental study.

METHODS

The study included 73 patients, including 36 in the intervention group and 37 in the control group. The research data are collected using the Patient Identifier Information Form, Dialysis Symptom Index (DSI), General Self-Efficacy Scale (GSES) and the Sense of Coherence Scale (SIS). The intervention group is provided care based on the salutogenesis model by making home visits 1 time per week for 8 weeks. In this study, the TREND checklist was followed for non-randomised controlled trials.

RESULTS

In the study, the pre-test DSI, GSES and SIS (meaningfulness, comprehensibility, manageability sub-dimension) mean scores of the individuals in the intervention and control groups are similar. The third-month and sixth-month intervention group SIS total and sub-dimension scores and GSES scores are found to be statistically significantly higher than the scores of the control group.

CONCLUSIONS

As a result of the study, it is determined that the care based on the salutogenesis model provided to peritoneal dialysis patients increases the sense of coherence and self-efficacy and provides symptom control and decreases the dialysis symptoms.

RELEVANCE TO CLINICAL PRACTICE

It has been observed that the salutogenesis model can be used as a step of nursing care in providing symptom control by strengthening the self-efficacy of patients in clinical and home care.

Self-management program for adolescents with chronic kidney disease: A randomized controlled trial

BACKGROUND

It is important to develop self-management behaviours in adolescents to prevent chronic kidney disease progression.

OBJECTIVES

This study evaluates the effect of a self-management program that was developed based on individual and family self-management theory to aid adolescents with chronic kidney disease in the acquisition of competencies in the management of their disease.

DESIGN

This is a randomized controlled study.

PARTICIPANTS

The study was conducted with 20 intervention and 20 control patients, who were treated at two hospitals in Ankara between December 2018 and May 2019.

MEASUREMENTS

Self-Management Assessment Form, Paediatric Quality of Life Inventory-Adolescent Form and clinical parameters. A training program, specific to chronic kidney disease, was administered over three sessions in a group training setting when the patients came to the clinic for follow-up. After the training program was completed, the patients were monitored for three months through home visits once every two weeks, totalling six visits.

RESULTS

Following the application of self-management training, a statistically significant difference was found self-management knowledge and behaviours, quality of life and anxiety mean scores of intervention and control group (p <.05), a significant decrease in only blood urea nitrogen among the clinical parameters when compared to the control group.

CONCLUSIONS

In this study, a self-management training program was developed based on Individual and Family Self-Management Theory, aiming to have a positive effect on the self-management behaviours of adolescents in the cognitive and psychosocial domains.

A Personalized Patient-Centered Intervention to Empower through Physical Activity the Patient in the Dialysis Center: Study Protocol for a Pragmatic Nonrandomized Clinical Trial

Sedentariness of patients affected by end-stage kidney disease (ESKD) expose them to high risk of unfavorable clinical outcomes. Exercise training is effective in improving physical function, quality of life (QoL) and long-term outcomes. However, the existing barriers related to patients, programs and dialysis staff limit patient participation and call for new strategies. This pragmatic nonrandomized trial will test the impact on ESKD population of an intervention proposed by an exercise facilitator regularly present in a dialysis center. The patient will be free to choose among three-month walking and/or resistance low-intensity training programs: (a) guided physical activity increase; (b) home-based exercise; (c) in-hospital (pre/post dialysis) supervised exercise; (d) performance assessment only. The first phase will define feasibility and the characteristics and preference of responders. The second phase will evaluate safety and patients' adherence. Outcome measures will be collected at baseline, after three-month and at six-month follow-up. They will include: aerobic capacity, QoL, gait speed, strength, depression and long-term clinical outcomes (hospitalization and mortality). The trial was approved by the Area-Vasta Emilia-Romagna Centro Ethics Committee with approval number 48/2019. Written informed consent will be obtained from all participants. The results of the study will be presented in international congresses, published in peer-reviewed journals and communicated to the patient community. Registration details: Clinicaltrials.gov NCT04282616 [Registered:24/02/2020].

Challenges encountered by patients with end-stage kidney disease in accessing symptom management services: A narrative inquiry

AIM

To understand the storied experiences of accessing symptom management services of patients with end-stage kidney disease (ESKD) who are receiving maintenance dialysis.

DESIGN

Narrative inquiry.

METHODS

Ten patients with ESKD who were receiving dialysis were recruited at two regional hospitals in Hong Kong and interviewed three times each between July 2017-July 2018 to capture their narratives. The data were analysed using the narrative inquiry approach from the perspective of Levesque's framework of access to care.

RESULTS

Five themes emerged from the participants' narratives. The first theme illustrated access to care as a process by which symptom management needs were met. However, clinicians occasionally identified patients based on their diseases instead of their needs and this process was affected differently by interpersonal and system factors. The themes 'building trust' and 'facilitating communication' described interpersonal factors that were essential to maintaining a constructive patient-clinician partnership. The themes 'balancing efficiency' and 'navigating fragmented system' described system-related factors.

CONCLUSIONS

This study identified the factors that influenced the delivery and/or reception of symptom management services for patients with ESKD who were receiving dialysis. The results suggest that healthcare services should be streamlined based on patients' needs and that this process should address the important elements of trust and communication.

IMPACT

The study's results suggest potential improvements to symptom management services that would enable patients' needs to be addressed in a timely and humanistic manner.

The effects of a brief hope intervention on decision-making in chronic kidney disease patients: A study protocol for a randomized controlled trial

AIMS

This study describes the study protocol of a manualized brief hope intervention that is based on the theoretical proposition - hope theory.

BACKGROUND

Patients with stage 5 chronic kidney disease often had decisional regret when facing the tension of treatment alternatives between dialysis initiation and palliative care. Hope has been found to account for therapeutic changes in clients with depressive symptoms, heightens positive expectations, and striving to accomplish chosen goals. Nevertheless, little is known about the effect of hope on decisional conflict and its influences to the quality of life in these chronic kidney disease patients.

DESIGN

This study is a single-blinded, randomized controlled trial.

METHODS

Participants will be recruited from a regional hospital (approved in April 2018). They will be randomly assigned in equal numbers to either the brief hope intervention or the control arm on completion of the baseline assessment on the possible need of dialysis initiation. Participants in the intervention group will receive the pre-dialysis education and a 4-week Brief Hope Intervention [consisting of four sessions at weekly intervals (two face-to-face sessions and two telephone follow-up sessions in between)], while those allocated to the control arm will receive the renal education and social chats. Outcome measures will be carried out prior to the intervention (baseline), immediately, and 1 month after the intervention. These consist of the hope level, decisional conflict, and quality of life. Healthcare resources use data will be reported.

IMPACT

The study results have the potential to add scientific evidence to the research-tested programme when developing renal services integral to multimodal care management to optimize decision-making and attain better health outcomes.

The effects of nurse-driven self-management programs on chronic obstructive pulmonary disease: A systematic review and meta-analysis

AIMS

To analyse the effects of nurse-driven self-management (SM) programs on physical and psychosocial health variables in people with chronic obstructive pulmonary disease (COPD).

DESIGN

A systematic review and meta-analysis.

DATA SOURCES

An exhaustive scanning of PubMed, Cochrane Controlled Register of Trials, CINAHL, ScienceDirect and Medline databases between January 2010-December 2019 was conducted for this meta-analysis.

REVIEW METHODS

Randomized controlled trials (RCTs) related to nurse-driven SM programs in COPD population were included. The standardized mean differences with 95% confidence intervals were determined for the main variables and heterogeneity was analysed using the I² test. The Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) was used.

RESULTS

Twelve studies were included. The results indicated that significant difference in physical health scores based on COPD Assessment Tool (CAT) and walking distance according to the 6-min walk distance (6MWD) test in the intervention groups compared with the control groups. About psychosocial health findings, the quality of life increased and the Hospital Anxiety and Depression Scale (HADS) scores decreased following SM programs. All of the studies had good quality (varying from 5-8 points) according to The Modified Jadad Scale.

CONCLUSION

Nurse-driven SM programs may contribute to prognosis in patients with COPD. Due to methodological weaknesses in the included trials, high-quality RCTs are needed to better determine the effects of nurse-driven SM programs in the management of COPD. Nurse-driven SM programs may be employed as a useful strategy to improve health status and QOL and psychosocial health in the COPD population, as well.

IMPACT

Current evidence shows that nurse-driven SM programs could be safely integrated into the clinical practice for patients with COPD. Future studies are warranted that evaluating the effects of nurse-driven SM programs on other frequently observed COPD symptoms such as dyspnoea, fatigue and sleep disturbance.

The evaluation of a nurse-led hypertension management model in an urban community healthcare: A randomized controlled trial

BACKGROUND

Hypertension is a silent disease of the masses with an increasing prevalence and poor control rates. This study aims to establish and test the efficacy of a nurse-led hypertension management model in the community.

METHODS

A single-blind, randomized controlled trial was performed. 156 hypertensive patients with uncontrolled blood pressure were equally and randomly allocated into 2 groups. Patients in the study group received a 12-week period of hypertension management. Blood pressure, self-care behaviors, self-efficacy, and satisfaction were assessed at the start of recruitment, 12 and 16 weeks thereafter.

RESULTS

After the intervention, blood pressure of patients in the study group had greater improvement in self-care behaviors and a higher level of satisfaction with the hypertensive care compared to the control group (both P < .05).

CONCLUSIONS

The nurse-led hypertension management model is feasible and effective for patients with uncontrolled blood pressure in the community.

Factors for self-management activities among rural patients with chronic hepatitis B: A cross-sectional study

AIMS AND OBJECTIVES

To assess the self-management activities among rural patients with chronic hepatitis B (CHB), and the influence of psychosocial and demographic factors on their self-management activities.

BACKGROUND

Chronic hepatitis B is a serious public health concern. Rural patients may have limited access to healthcare services. Although self-management is important for controlling chronic hepatitis B, few studies focus on the self-management activities among rural patients with chronic hepatitis B. Understanding self-management activities and related factors in this population are important to design and implement appropriate intervention strategies.

DESIGN

A cross-sectional study.

METHODS

From June-December 2017, totally 236 rural patients with chronic hepatitis B were recruited from hepatology department in two hospitals in Chongqing, China. The questionnaire included demographic characteristics, Chronic Hepatitis B Self-Management Scale, Self-Efficacy for Managing Chronic Disease, and Social Support Rating Scale. The study followed the STROBE checklist.

RESULTS

Rural patients with chronic hepatitis B reported poor self-management activities for the score indexes of symptom management (57.36%), lifestyle management (54.89%), psychosocial coping (54.84%) and disease information management (53.11%) were all below 60%. Self-efficacy, objective support, subjective support, gender, education level and marital status showed significant effect on self-management activities.

CONCLUSION

Rural patients with chronic hepatitis B were found to perform insufficient self-management activities. Self-efficacy, social support, gender, education level and marital status were identified to influence their self-management activities.

RELEVANCE TO CLINICAL PRACTICE

Self-management activities should be promoted among rural patients with chronic hepatitis B. The factors that were identified in this study should be addressed when developing interventions to promote the performance of self-management activities for rural patients with chronic hepatitis B.

Interventions for improving sleep quality in people with chronic kidney disease

BACKGROUND

Sleep disorders are commonly experienced by people with chronic kidney disease (CKD). Several approaches for improving sleep quality are used in clinical practice including relaxation techniques, exercise, acupressure, and medication.

OBJECTIVES

To assess the effectiveness and associated adverse events of interventions designed to improve sleep quality among adults and children with CKD including people with end-stage kidney disease (ESKD) treated with dialysis or kidney transplantation.

SEARCH METHODS

We searched the Cochrane Kidney and Transplant Register of Studies up to 8 October 2018 with the Information Specialist using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Register (ICTRP) Search Portal and ClinicalTrials.gov.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) or quasi-randomised RCTs of any intervention in which investigators reported effects on sleep quality. Two authors independently screened titles and abstracts of identified records.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data and assessed the risk of bias for included studies. The primary outcomes were sleep quality, sleep onset latency, sleep duration, sleep interruption, and sleep efficiency. Risks of bias were assessed using the Cochrane tool. Evidence certainty was assessed using the GRADE approach. We calculated treatment estimates as risk ratios (RR) for dichotomous outcomes or mean difference (MD) or standardised MD (SMD) for continuous outcomes to account for heterogeneity in measures of sleep quality.

MAIN RESULTS

Sixty-seven studies involving 3427 participants met the eligibility criteria. Thirty-six studies involving 2239 participants were included in meta-analyses. Follow-up for clinical outcomes ranged between 0.3 and 52.8 weeks (median 5 weeks). Interventions included relaxation techniques, exercise, acupressure, cognitive-behavioural therapy (CBT), educational interventions, benzodiazepine treatment, dopaminergic agonists, telephone support, melatonin, reflexology, light therapy, different forms of peritoneal dialysis, music, aromatherapy, and massage. Incomplete reporting of key methodological details resulted in uncertain risk of bias in many studies.In very low certainty evidence relaxation techniques had uncertain effects on sleep quality and duration, health-related quality of life (HRQoL), depression, anxiety, and fatigue. Studies were not designed to evaluate the effects of relaxation on sleep latency or hospitalisation. Exercise had uncertain effects on sleep quality (SMD -1.10, 95% CI -2.26 to 0.05; I2 = 90%; 5 studies, 165 participants; very low certainty evidence). Exercise probably decreased depression (MD -9.05, 95% CI -13.72 to -4.39; I2 = 0%; 2 studies, 46 participants; moderate certainty evidence) and fatigue (SMD -0.68, 95% CI -1.07 to -0.29; I2 = 0%; 2 studies, 107 participants; moderate certainty evidence). Compared with no acupressure, acupressure had uncertain effects on sleep quality (Pittsburgh Sleep Quality Index (PSQI) scale 0 - 21) (MD -1.27, 95% CI -2.13 to -0.40; I2 = 89%; 6 studies, 367 participants: very low certainty evidence). Acupressure probably slightly improved sleep latency (scale 0 - 3) (MD -0.59, 95% CI -0.92 to -0.27; I2 = 0%; 3 studies, 173 participants; moderate certainty evidence) and sleep time (scale 0 - 3) (MD -0.60, 95% CI -1.12 to -0.09; I2 = 68%; 3 studies, 173 participants; moderate certainty evidence), although effects on sleep disturbance were uncertain as the evidence certainty was very low (scale 0 - 3) (MD -0.49, 95% CI -1.16 to 0.19; I2 = 97%). In moderate certainty evidence, acupressure probably decrease fatigue (MD -1.07, 95% CI -1.67 to -0.48; I2 = 0%; 2 studies, 137 participants). Acupressure had uncertain effects on depression (MD -3.65, 95% CI -7.63 to 0.33; I2 = 27%; 2 studies, 137 participants; very low certainty evidence) while studies were not designed to evaluate the effect of acupressure on HRQoL, anxiety, or hospitalisation. It was uncertain whether acupressure compared with sham acupressure improved sleep quality (PSQI scale 0 to 21) because the certainty of the evidence was very low (MD -2.25, 95% CI -6.33 to 1.82; I2 = 96%; 2 studies, 129 participants), but total sleep time may have been improved (SMD -0.34, 95% CI -0.73 to 0.04; I2 = 0%; 2 studies, 107 participants; low certainty evidence). 2 =2 =There were no studies designed to directly examine and/or correlate efficacy of any interventions aimed at improving sleep that may have been attempted for the spectrum of sleep disordered breathing. No studies reported treatment effects for children. Adverse effects of therapies were very uncertain.

AUTHORS' CONCLUSIONS

The evidence base for improving sleep quality and related outcomes for adults and children with CKD is sparse. Relaxation techniques and exercise had uncertain effects on sleep outcomes. Acupressure may improve sleep latency and duration, although these findings are based on few studies. The effects of acupressure were not confirmed in studies in which sham acupressure was used as the control. Given the very low certainly evidence, future research will very likely change the evidence base. Based on the importance of symptom management to patients, caregivers and clinicians, future studies of sleep interventions among people with CKD should be a priority.

A Brief Hope Intervention to Increase Hope Level and Improve Well-Being in Rehabilitating Cancer Patients: A Feasibility Test

This article reports on the feasibility and effect of the brief hope intervention (BHI) in terms of increasing the hope level and psychological and physical health outcomes of rehabilitating cancer patients (RCP). Chinese RCP living in the community were invited to join the study. The BHI consisted of four one-on-one sessions: two (1-hour) face-to-face sessions and two (30-minute) telephone follow-up sessions in between. There were three core features in the hope therapy: (a) goal thoughts: finding workable goals, (b) pathway thoughts: finding ways to reach the targets, and (c) agency thoughts: positive self-talk to optimize their motivation to accomplish the set goals. A one-group pre- and postintervention design was used. Outcome measures included the Memorial Symptom Assessment Scale, the Center for Epidemiological Studies Depression Scale (CES-D), and the State Hope Scale. Recruitment, attrition, and qualitative feedback were collected to understand their comments on BHI. A total of 40 participants were recruited (female 92.3%). The mean age was 57.2 years (SD = 6.7). The participants had significant improvement in all aspects of the Memorial Symptom Assessment Scale, with moderate-to-large effect sizes (d = 0.49-0.74). The changes in present hope and depression scores were insignificant, with small effect sizes (d = 0.17-0.34). The BHI seemed to be promising in producing both physical and psychological benefits in RCP.

Strategies to improve dietary, fluid, dialysis or medication adherence in patients with end stage kidney disease on dialysis: A systematic review and meta-analysis of randomized intervention trials

Background

In patients with end stage kidney disease (ESKD) on dialysis, treatment non-adherence is common and results in poor health outcomes. However, the clinical benefits of interventions to improve adherence in dialysis patients are difficult to evaluate since trialled interventions and reported outcomes are highly diverse/ heterogeneous. This review summarizes existing literature on randomized controlled trials (RCTs) evaluating adherence interventions in ESKD patients focusing on the intervention category, outcome efficacy and persistence of benefit beyond the intervention.

Methods

We performed electronic database searches in Medline, Embase & Cochrane CENTRAL upto 1^st July 2018 for RCTs evaluating interventions to improve diet, fluid, medication or dialysis adherence in ESKD patients. Study characteristics including category of interventions, outcomes, efficacy and follow-up were assessed. Meta-analysis was used to compute pooled estimates of the effects on the commonest reported outcome measures.

Results

From 1311 citations, we included 36 RCTs (13 cluster-randomized trials), recruiting a total of 3510 dialysis patients (mean age 55.1 ± 5.8 years, males 58.1%). Overall risk of bias was ‘high’ for 24 and of ‘some concern’ for 12 studies. Most interventions (33 trials, 92%) addressed patient related factors, and included educational/cognitive (N = 11), behavioural / counselling (N = 4), psychological/affective (N = 4) interventions or a combination (N = 14) of the above. A majority of (28/36) RCTs showed improvement in some reported outcomes. Surrogate measures like changes in phosphate (N = 19) and inter-dialytic weight gain (N = 15) were the most common reported outcomes and both showed significant improvement in the meta-analysis. Sixteen trials reported follow-up (1–12 months) beyond intervention and the benefits waned or were absent in nine trials within 12 months post-intervention.

Conclusions

Interventions to improve treatment adherence result in modest short-term benefits in surrogate outcome measures in dialysis patients, but significant improvements in trial design and outcome reporting are warranted to identify strategies that would achieve meaningful and sustainable clinical benefits.

Limitations

Poor methodological quality of trials. Frequent use of surrogate outcomes measures. Low certainly of evidence.

Asymptomatic fluid overload predicts survival and cardiovascular event in incident Chinese peritoneal dialysis patients

Background

Fluid overload is common among asymptomatic peritoneal dialysis (PD) patients. We aim to determine the prevalence and prognostic significance of fluid overload, as measured by bioimpedance spectroscopy, in asymptomatic incident PD patients.

Methods

We performed a single-center study on 311 incident PD patients. Volume status was represented by the volume of overhydration (OH), OH/extracellular water (ECW) ratio, ECW/total body water (TBW) ratio, and ECW to intracellular water (ICW) ratio (E:I ratio). Patient survival, technique survival and cardiovascular event-free survival were determined.

Results

The median period of follow up was 27.3 months. Fluid overload was present in 272 patients (87.5%) when defined as OH volume over 1.1L. All hydration parameters significantly correlated with Charlson Comorbidity Index, and inversely with total Kt/V, and serum albumin. Multivariate cause-specific Cox analysis showed that volume status independently predicted patient survival; every 0.1 unit increase in E:I ratio was associated with 24.5% increase in all-cause mortality (adjusted cause-specific hazard ratio [ACSHR] 1.245, p = 0.002). Hydration status was also an independent predictor of cardiovascular event-free survival after excluding hospital admission for congestive heart failure; each 0.1 unit increase in E:I ratio was associated with 18.7% decrease in cardiovascular event-free survival (ACSHR 1.187, p = 0.011). In contrast, hydration parameters were not associated with technique survival.

Conclusions

Fluid overload is common in asymptomatic incident PD patients and is a strong predictor of patient survival and cardiovascular event. The impact of bioimpedance spectroscopy-guided fluid management on the outcome of PD patients deserves further study.

Hydration and nutritional status in patients on home-dialysis-A single centre study

BACKGROUND

Over-hydration (OH) and malnutrition are prevalent among patients on dialysis therapy. The prevalence of OH and malnutrition as well as the risk factors associated with OH and malnutrition in our patients on home peritoneal dialysis (PD) and home haemodialysis (HD) are examined.

DESIGN AND METHODS

This was a cross-sectional study. The hydration and nutritional status of the study groups were assessed by a Body Composition Monitor. Patients who were stable on home dialysis therapy for over one year were invited to participate. Univariate and multivariate analyses were performed to identify associated factors and determine the predictors of OH and malnutrition, respectively.

RESULTS

Eighty-eight patients (41 PD and 47 home HD) were recruited. A 32.95% of our patients on home dialysis therapy were in OH status. There was a significance difference in the prevalence of hydration status between patients on PD and home HD (p = 0.014), as overhydration was more common in patients on PD than home HD (46.34 vs. 21.28%). Dehydration was more common in patients on home HD than PD (29.79 vs. 9.76%). Male gender, decreasing haemoglobin level and presence of diabetes mellitus (DM) were risk factors of OH on multivariable analysis. There was no significance difference in the prevalence of malnutrition between patients on PD and home HD (p = 0.27). Increasing Fat Tissue Index (FTI), height and patients on PD therapy were at higher risk of malnutrition.

CONCLUSION

OH and malnutrition were prevalent patients on home dialysis therapy.

Person-Centered Integrated Care for Chronic Kidney Disease: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

BACKGROUND AND OBJECTIVES

The effectiveness of person-centered integrated care strategies for CKD is uncertain. We conducted a systematic review and meta-analysis of randomized, controlled trials to assess the effect of person-centered integrated care for CKD.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

We searched MEDLINE, Embase, and Cochrane Central Register of Controlled Trials (from inception to April of 2016), and selected randomized, controlled trials of person-centered integrated care interventions with a minimum follow-up of 3 months. Random-effects meta-analysis was used to assess the effect of person-centered integrated care.

RESULTS

We included 14 eligible studies covering 4693 participants with a mean follow-up of 12 months. In moderate quality evidence, person-centered integrated care probably had no effect on all-cause mortality (relative risk [RR], 0.86; 95% confidence interval [95% CI], 0.68 to 1.08) or health-related quality of life (standardized mean difference, 0.02; 95% CI, -0.05 to 0.10). The effects on renal replacement therapy (RRT) (RR, 1.00; 95% CI, 0.65 to 1.55), serum creatinine levels (mean difference, 0.59 mg/dl; 95% CI, -0.38 to 0.36), and eGFR (mean difference, 1.51 ml/min per 1.73 m2; 95% CI, -3.25 to 6.27) were very uncertain. Quantitative analysis suggested that person-centered integrated care interventions may reduce all-cause hospitalization (RR, 0.38; 95% CI, 0.15 to 0.95) and improve BP control (RR, 1.20; 95% CI, 1.00 to 1.44), although the certainty of the evidence was very low.

CONCLUSIONS

Person-centered integrated care may have little effect on mortality or quality of life. The effects on serum creatinine, eGFR, and RRT are uncertain, although person-centered integrated care may lead to fewer hospitalizations and improved BP control.

Development and evaluation of a nurse-led hypertension management model: A randomized controlled trial

BACKGROUND

The hypertension prevalence rate is increasing but the control rate is unsatisfactory. Nurse-led healthcare may be an effective way to improve outcomes for hypertensive patients but more evidence is required especially at the community level.

OBJECTIVE

This study aims to establish a nurse-led hypertension management model and to test its effectiveness at the community level.

DESIGN

A single-blind, randomized controlled trial was performed in an urban community healthcare center in China. Hypertensive patients with uncontrolled blood pressure (systolic blood pressure ≥140mmHg and/or diastolic blood pressure ≥90mmHg) were randomly allocated into two groups: the study group (n=67) and the control group (n=67). The nurse-led hypertension management model included four components (delivery system design, decision support, clinical information system and self-management support). Patients in the control group received usual care. Patients in the study group received a 12-week period of hypertension management. The patient outcomes, which involved blood pressure, self-care behaviors, self-efficacy, quality of life and satisfaction, were assessed at three time points: the baseline, immediately after the intervention and 4 weeks after the intervention.

RESULTS

After the intervention, the blood pressure of patients in the study group decreased significantly compared to those in the control group, and the mean reduction of systolic/diastolic blood pressure in the study and control groups was 14.37/7.43mmHg and 5.10/2.69mmHg, respectively (p<0.01). In addition, patients in the study group had significantly greater improvement in self-care behaviors than those in the control group (p<0.01). The study group had a higher level of satisfaction with hypertensive care than the control group (p<0.01). No statistically significant difference in self-efficacy and quality of life was detected between the two groups after the intervention.

CONCLUSIONS

The nurse-led hypertension management model is feasible and effective in improving the outcomes of patients with uncontrolled blood pressure at the community level.

Reporting of Telehealth-Delivered Dietary Intervention Trials in Chronic Disease: Systematic Review

BACKGROUND

Telehealth-delivered dietary interventions are effective for chronic disease management and are an emerging area of clinical practice. However, to apply interventions from the research setting in clinical practice, health professionals need details of each intervention component.

OBJECTIVE

The aim of this study was to evaluate the completeness of intervention reporting in published dietary chronic disease management trials that used telehealth delivery methods.

METHODS

Eligible randomized controlled trial publications were identified through a systematic review. The completeness of reporting of experimental and comparison interventions was assessed by two independent assessors using the Template for Intervention Description and Replication (TIDieR) checklist that consists of 12 items including intervention rationale, materials used, procedures, providers, delivery mode, location, when and how much intervention delivered, intervention tailoring, intervention modifications, and fidelity. Where reporting was incomplete, further information was sought from additional published material and through email correspondence with trial authors.

RESULTS

Within the 37 eligible trials, there were 49 experimental interventions and 37 comparison interventions. One trial reported every TIDieR item for their experimental intervention. No publications reported every item for the comparison intervention. For the experimental interventions, the most commonly reported items were location (96%), mode of delivery (98%), and rationale for the essential intervention elements (96%). Least reported items for experimental interventions were modifications (2%) and intervention material descriptions (39%) and where to access them (20%). Of the 37 authors, 14 responded with further information, and 8 could not be contacted.

CONCLUSIONS

Many details of the experimental and comparison interventions in telehealth-delivered dietary chronic disease management trials are incompletely reported. This prevents accurate interpretation of trial results and implementation of effective interventions in clinical practice.

Effects of self-management on chronic kidney disease: A meta-analysis

BACKGROUND

Self-management programs may facilitate the improvement of outcomes in medical, role, and emotional management and health-related quality of life in patients with chronic kidney disease. Studies on the effect of three self-management tasks have reported conflicting findings. In addition, systematic reviews are unavailable.

OBJECTIVE

This study evaluated the effects of self-management programs on medical, role, and emotional management and health-related quality of life in chronic kidney disease.

DESIGN

Meta-analysis of randomized controlled studies.

DATA SOURCES

The meta-analysis involved an online search of the English literature from PubMed, Cochrane, Web of Science, and CINAHL and the Chinese literature from the Airiti Library that were published from the inception of the websites until January 1, 2017.

REVIEW METHODS

The meta-analysis was conducted to evaluate the effects of self-management on chronic kidney disease outcomes. Electronic databases were searched by using keywords: chronic kidney disease, end-stage renal disease, renal failure, dialysis, self-management, self-efficacy, empowerment, cognitive behavioral, and educational. The methodological quality of randomized controlled trials was assessed using the Cochrane Handbook. Data were analyzed using Comprehensive Meta-Analysis software 2.0.

RESULTS

Eighteen randomized controlled trials met our inclusion criteria. The results revealed that the self-management program significantly enhanced the effects of self-management on outcomes of medical, role, and emotional management and health-related quality of life in patients with chronic kidney disease. The following Hedges' g (effect size) values were obtained: (1) interdialytic weight gain, -0.36 (95% confidence interval, -0.60 to -0.12, p<0.01); (2) self-efficacy, 0.57 (95% confidence interval, 0.18-0.96, p<0.01); (3) anxiety, -0.95 (95% confidence interval, -1.65 to -0.25, p=0.01); (4) depression, -0.63 (95% confidence interval, -0.85 to -0.41, p<0.01) (5) health-related quality of life for the mental component of the SF-36, 0.71 (95% confidence interval, 0.45-0.97, p<0.01); (6) the physical component of the SF-36, 0.61 (95% confidence interval, 0.35-0.86, p<0.01); and (7) the Kidney Disease Quality of Life, 0.41 (95% confidence interval, 0.17-0.65, p<0.01).

DISCUSSION

This study revealed a small effect of self-management on interdialytic weight gain; medium effects on self-efficacy, depression, and health-related quality of life; and a large effect on anxiety. However, high-quality randomized controlled trial designs are required to confirm these results, although the existing evidence can guide clinical practitioners and health policy makers.

Telehealth methods to deliver dietary interventions in adults with chronic disease: a systematic review and meta-analysis

BACKGROUND

The long-term management of chronic disease requires the adoption of complex dietary recommendations, which can be facilitated by regular coaching to support behavioral changes. Telehealth interventions can overcome patient-centered barriers to accessing face-to-face programs and provide feasible delivery methods, accessible regardless of geographic location.

OBJECTIVE

This systematic review assessed the effectiveness of telehealth dietary interventions at facilitating dietary change in chronic disease.

DESIGN

A structured systematic search was conducted for all randomized controlled trials evaluating multifactorial dietary interventions in adults with chronic disease that provided diet education in an intervention longer than 4 wk. Meta-analyses that used the random-effects model were performed on diet quality, dietary adherence, fruit and vegetables, sodium intake, energy, and dietary fat intake.

RESULTS

A total of 25 studies were included, involving 7384 participants. The telehealth dietary intervention was effective at improving diet quality [standardized mean difference (SMD): 0.22 (95% CI: 0.09, 0.34), P = 0.0007], fruit and vegetable intake [mean difference (MD) 1.04 servings/d (95% CI: 0.46, 1.62 servings/d), P = 0.0004], and dietary sodium intake [SMD: -0.39 (-0.58, -0.20), P = 0.0001]. Single nutrients (total fat and energy consumption) were not improved by telehealth intervention; however, after a telehealth intervention, important clinical outcomes were improved, such as systolic blood pressure [MD: -2.97 mm Hg (95% CI: -5.72, -0.22 mm Hg), P = 0.05], total cholesterol [MD: -0.08 mmol/L (95% CI: -0.16, -0.00 mmol/L), P = 0.04], triglycerides [MD: -0.10 mmol/L (95% CI: -0.19, -0.01 mmol/L), P = 0.04], weight [MD: -0.80 kg (95% CI: -1.61, 0 kg), P = 0.05], and waist circumference [MD: -2.08 cm (95% CI: -3.97, -0.20 cm), P = 0.03].

CONCLUSIONS

Telehealth-delivered dietary interventions targeting whole foods and/or dietary patterns can improve diet quality, fruit and vegetable intake, and dietary sodium intake. When applicable, they should be incorporated into health care services for people with chronic conditions. This review was registered at http://www.crd.york.ac.uk/PROSPERO/ as CRD42015026398.

Influence of Staff Encouragement on Perceived Burden of Dietary Restriction Among Patients Living Alone

To help relieve the burden of dietary restrictions experienced by many hemodialysis (HD) patients, dialysis staff may encourage patients, with no consideration to the degree of family support. Here, we clarified the effect of staff encouragement and living conditions on the burden of dietary restrictions in HD patients. This retrospective cohort study was conducted using data from the Dialysis Outcomes and Practice Patterns Study (DOPPS) I and III. We enrolled patients aged 18-75 years on HD therapy for at least 3 months. We categorized patients into four groups based on combinations of level of staff encouragement (high or low) and living condition (alone or with family) at baseline survey. Patients who felt they received high staff encouragement and lived with their family were set as the control. The main outcome was increase in patients' perceived burden of dietary restriction after 1 year. 1377 (69.1%) felt they received high staff encouragement, and 176 (9.1%) were living alone. After 1 year, 537 (26.9%) patients reported feeling an increased burden of dietary restriction. A low level of staff encouragement did not increase the burden in any patients, regardless of living situation. However, a high level of staff encouragement did increase the burden in patients living alone (adjusted odds ratio: 1.57, 95% confidence interval: 1.05-2.36). We observed an unexpected association between high staff encouragement and increased burden of dietary restriction among patients living alone. Staff encouragement may not relieve patients' burden with respect to dietary restriction and may in fact exacerbate it.

The Efficacy of a Nurse-Led Disease Management Program in Improving the Quality of Life for Patients with Chronic Kidney Disease: A Meta-Analysis

BACKGROUND

The impacts of nurse-led disease management programs on the quality of life for patients with chronic kidney disease have not been extensively studied. Furthermore, results of the existing related studies are inconsistent. The focus of the proposed meta-analysis is to evaluate the efficacy of nurse-led disease management programs in improving the quality of life for patients with chronic kidney disease.

METHODS

Literature survey was performed to identify the eligible studies from PubMed, Current Nursing and Allied Health Literature, and Cochrane Central Register of Controlled Trials with predefined terms. The outcome measured was quality of life. This meta-analysis was conducted in line with recommendations from the preferred reporting items for systematic reviews and meta-analyses.

RESULTS

Eight studies comprising a total of 1520 patients were included in this meta-analysis, with 766 patients assigned to the nurse-led disease management program. Nurse-led disease management improved the quality of life in terms of symptoms, sleep, staff encouragement, pain, general health perception, energy/fatigue, overall health and mental component summary when evaluated 6 weeks after the beginning of intervention. When evaluated 12 weeks later, the quality of life in terms of symptoms, sleep, staff encouragement, energy/fatigue, and physical component summary was improved. Stratified by the modalities of dialysis, similar results of pooled analyses were observed for patients with peritoneal dialysis or hemodialysis, compared with the overall analyses. The results of sensitivity analyses were the same as the primary analyses. The symmetric funnel plot suggested that the possibility of potential publication bias was relatively low.

CONCLUSION

Nurse-led disease management program seems effective to improve some parameters of quality of life for patients with chronic kidney disease. However, the seemingly promising results should be cautiously interpreted and generalized and still need to be confirmed through well-designed large-scale prospective randomized controlled trials.

Effects of a transitional palliative care model on patients with end-stage heart failure: study protocol for a randomized controlled trial

Background

Heart failure (HF) is characterized by high rates of readmission after hospitalization, and readmission is a major contributor to healthcare costs. The transitional care model has proven efficacy in reducing the readmission rate and economic outcomes, and increasing satisfaction with care. However, the effectiveness of the transitional care model has not been evaluated in patients with end-stage HF. This study was designed to compare the customary hospital-based care and a comprehensive transitional care model, namely the Home-based Palliative HF Program (HPHP), in terms of readmission rate, quality of life, and satisfaction with care among end-stage HF patients under palliative care.

Methods/design

This is a randomized controlled trial taking place in hospitals in Hong Kong. We have been recruiting patients with end-stage HF who are identified as appropriate for palliative care during hospitalization, on referral by their physicians. A set of questionnaires is collected from each participant upon discharge. Participants are randomized to receive usual care (customary hospital-based care) or the intervention (HPHP). The HPHP will be implemented for up to 12 months. Outcome measures will be performed at 1, 3, 6, and 12 months post-discharge. The primary outcome of this study is quality of life measured by the Chronic Heart Failure Questionnaire - Chinese version; secondary outcomes include readmission rate, symptom intensity, functional status, and satisfaction with care.

Discussion

This study is original and will provide important information for service development in the area of palliative care. The introduction of palliative care to end-stage organ failure patients is new and has received increasing attention worldwide in the last decade. This study adopts the randomized controlled trial, a vigorous research design, to establish scientific evidence in exploring the best model for end-stage HF patients receiving palliative care.

Trial registration

This trial was registered as NCT02086305 on 7 March 2014 in the United States Clinical Trials Registration, and in the Clinical Trials Registry, Hong Kong University with the trial number UW12202.

Electronic supplementary material

The online version of this article (doi:10.1186/s13063-016-1303-7) contains supplementary material, which is available to authorized users.

Effectiveness of Self-Care Education on the Enhancement of the Self-Esteem of Patients Undergoing Hemodialysis

Introduction and Aim:

The assessment of self-esteem in hemodialysis people is becoming increasingly important and necessary. Low self-esteem as a problem in patients undergoing hemodialysis decreases adherence to treatment. The researcher intends to carry out a study in order to investigate the effect of self-care education on enhancement of the self-esteem of patients undergoing hemodialysis in Iran.

Method and material:

This is a quasi-experimental study. The subjects of the study who were selected based on purposive sampling method consisted of 50 patients with advanced chronic renal disease treated with hemodialysis. Before the intervention, two questionnaires were completed by patients. There was no intervention in the control group and the patients received only routine care in the hospital. In the experimental group, the hemodialysis patients received 5 consecutive one-hour training sessions by the researcher. Then the Rosenberg scale was filled out by the patients 2 month later.

Result:

According to the results, Paired t-test showed a significant difference between the mean self-esteem score in both groups before and after intervention.

Conclusion:

Increasing the knowledge and awareness of hemodialysis patients must constitute a cornerstone of therapy and an integral part of nursing responsibilities. Nurses should educate the patients about self-care behaviors and remind them of the dangerous complications of abandoning these.

Participant survey results from the Starting Hizentra Administration with Resources and Education (SHARE) program

Increased use of specialized infusion therapies has necessitated training of health care providers and patients. The Starting Hizentra Administration with Resources and Education (SHARE) program provided 709 US participants with information to educate patients with primary immunodeficiency disease (PIDD) on self-administration of 20% subcutaneous immunoglobulin (SCIG). Postprogram surveys assessed participants' experience and opinion of 20% SCIG. The most frequent questions about 20% SCIG regarded subcutaneous challenges (29%). Participants stated that all attributes of SCIG were beneficial (51%), and they expressed interest in future programs on non-PIDD diseases (26%). Survey results will assist in future SHARE and other relevant educational program optimization.

A nurse-led case management program on home exercise training for hemodialysis patients: A randomized controlled trial

BACKGROUND

Patients on maintenance hemodialysis suffer from diminished physical health. Directly supervised exercise programs have been shown to be effective at improving physical function and optimizing well-being. However, nurses seldom include an exercise intervention in the care plan for hemodialysis patients.

OBJECTIVES

The purpose of this study was to examine the effects of a 12-week nurse-led case management program on home exercise training for hemodialysis patients.

DESIGN

The study was a randomized, two-parallel group trial.

SETTINGS

Hemodialysis units in two tertiary hospitals in Nanjing, mainland China.

PARTICIPANTS

One hundred and thirteen adult patients who have been in stable condition while on dialysis treatment for more than 3 months were recruited and randomly assigned to either the study group (n=57) or the control group (n=56).

METHODS

Both groups underwent a brief weekly in-center exercise training session before their dialysis sessions for the first 6 weeks. The study group received additional nurse case management weekly for the first 6 weeks and biweekly for the following 6 weeks. The intervention was to facilitate patients in performing regular exercise at home. Outcome measures, including gait speed, 10-repetition sit-to-stand performance, and quality of life were collected at baseline, and at 6 and 12 weeks into the program.

RESULTS

The results revealed that patients in the study group demonstrated greater increases in normal gait speed [F(1,111)=4.42, p=0.038] than the control group. For the study group, a mean increase of 12.02 (±3.03)centimeters/second from baseline to week 12 was found. With regard to the fast gait speed, there was a marginally significant between-group effect [F(1,111)=3.93, p=0.050]. The study group showed a mean improvement of 11.08 (±3.32)cm/s, from baseline to week 12. Patients from both groups showed improvements in their 10-repetition sit-to-stand performance. The between-group differences approached significance [F(1,111)=3.92, p=0.050], with the study group showed greater improvement than the control group. The time taken by the patients in the study group to complete the 10-STS test increased by 5.75 (±3.88)s from baseline to week 12. Significant improvements in quality of life across three time points were found only in the study group.

CONCLUSIONS

Home exercise using a nurse-led case management approach is practical and effective in improving the physical function and self-perceived health of stable hemodialysis patients.

Educational interventions in peritoneal dialysis: a narrative review of the literature

OBJECTIVES

To review the current literature on educational interventions used in peritoneal dialysis (PD). Educational interventions have become increasingly relevant because they play a key role in helping individuals to actively participate in their therapy and to manage their chronic condition. The paper will focus on two areas: (a) educational interventions for individuals living with PD and (b) educational interventions for PD nurses.

DESIGN

A narrative review of primary research.

DATA SOURCES

Electronic searches of the MEDLINE, CINAHL, EMBASE, ERIC and Cochrane Library (2006-2013) databases were undertaken using terms such as peritoneal dialysis, insertive training, curriculum, nursing education, train the trainer, coach the coach, tutor the tutor, and patient education were used. All studies were reviewed by two researchers.

REVIEW METHODS

Titles and abstracts of 555 studies were screened and read. Full text articles retrieved were further screened against the inclusion and exclusion criteria. Relevant data on the educational interventions for people receiving PD and nurse training programs were extracted and synthesized narratively.

RESULTS

Eighteen articles met the inclusion criteria. Most of them focused on educational intervention programs for people undergoing PD. Findings on the link between the PD trainer's background and peritonitis rates among individuals undergoing PD are inconsistent. PD learners should be taught self-management skills as well as technical skills. They might also benefit from receiving decision-making aids. Older people, people with co-morbidities and people with low educational status need more time to acquire self-care skills and are more likely to develop peritonitis. Home visits have the potential to improve learning outcomes. Re-training needs should be assessed and fulfilled as appropriate. Case and disease management programs have been shown to have positive outcomes for individuals receiving PD.

CONCLUSIONS

Educational interventions for PD remain an under-researched area, despite the potential they have to make this type of therapy more successful. Further research on education and training for people receiving PD and for PD nurses is needed. In the meantime, educational interventions used for other chronic conditions could provide guidance.

The unique contribution of community clinical nurse specialists in rural Wales

To date, quality indicators that have been developed for nursing tend to focus on acute, secondary care settings. It remains unclear whether such quality indicators are applicable to community settings, particularly in rural environments. This research aims to identify the consensus view among specialist nurses regarding their unique nursing contribution within their rural community. Identifying agreed aspects of the unique role within the rural community area will enable quality care metrics to be developed, allowing specialist nurses to measure their unique contribution to rural health care in the future. The research used the Delphi technique to identify a consensus view among a population of specialist community nurses working in a designated rural area in Wales. The strongest area of consensus related to clinical and teaching expertise, where participants perceive educational expertise as being at the forefront of their role. In terms of care for individuals, consensus was focused on four main areas: developing appropriate criteria for referral in to the service, collaborative working, education, and advocacy roles. The findings highlight similarities to models of care provision elsewhere. Specific quality indicators are required for clinical nurse specialists working in rural areas. Current quality indicators may not be applicable across all clinical settings. Further work is required to explore the nature of rural nursing practice.

Reducing Care Utilisation through Self-management Interventions (RECURSIVE): a systematic review and meta-analysis

Background

A critical part of future service delivery will involve improving the degree to which people become engaged in ‘self-management’. Providing better support for self-management has the potential to make a significant contribution to NHS efficiency, as well as providing benefits in patient health and quality of care.

Objective

To determine which models of self-management support are associated with significant reductions in health services utilisation (including hospital use) without compromising outcomes, among patients with long-term conditions.

Data sources

Cochrane Central Register of Controlled Trials, Cumulative Index to Nursing and Allied Health, EconLit (the American Economic Association’s electronic bibliography), EMBASE, Health Economics Evaluations Database, MEDLINE (the US National Library of Medicine’s database), MEDLINE In-Process & Other Non-Indexed Citations, NHS Economic Evaluation Database (NHS EED) and PsycINFO (the behavioural science and mental health database), as well as the reference lists of published reviews of self-management support.

Methods

We included patients with long-term conditions in all health-care settings and self-management support interventions with varying levels of additional professional support and input from multidisciplinary teams. Main outcome measures were quantitative measures of service utilisation (including hospital use) and quality of life (QoL). We presented the results for each condition group using a permutation plot, plotting the effect of interventions on utilisation and outcomes simultaneously and placing them in quadrants of the cost-effectiveness plane depending on the pattern of outcomes. We also conducted conventional meta-analyses of outcomes.

Results

We found 184 studies that met the inclusion criteria and provided data for analysis. The most common categories of long-term conditions included in the studies were cardiovascular (29%), respiratory (24%) and mental health (16%). Of the interventions, 5% were categorised as ‘pure self-management’ (without additional professional support), 20% as ‘supported self-management’ (< 2 hours’ support), 47% as ‘intensive self-management’ (> 2 hours’ support) and 28% as ‘case management’ (> 2 hours’ support including input from a multidisciplinary team). We analysed data across categories of long-term conditions and also analysed comparing self-management support (pure, supported, intense) with case management. Only a minority of self-management support studies reported reductions in health-care utilisation in association with decrements in health. Self-management support was associated with small but significant improvements in QoL. Evidence for significant reductions in utilisation following self-management support interventions were strongest for interventions in respiratory and cardiovascular disorders. Caution should be exercised in the interpretation of the results, as we found evidence that studies at higher risk of bias were more likely to report benefits on some outcomes. Data on hospital use outcomes were also consistent with the possibility of small-study bias.

Limitations

Self-management support is a complex area in which to undertake literature searches. Our analyses were limited by poor reporting of outcomes in the included studies, especially concerning health-care utilisation and costs.

Conclusions

Very few self-management support interventions achieve reductions in utilisation while compromising patient outcomes. Evidence for significant reductions in utilisation were strongest for respiratory disorders and cardiac disorders. Research priorities relate to better reporting of the content of self-management support, exploration of the impact of multimorbidity and assessment of factors influencing the wider implementation of self-management support.

Study registration

This study is registered as PROSPERO CRD42012002694.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Public health service options for affordable and accessible noncommunicable disease and related chronic disease prevention and management

Globally, nations are confronted with the challenge of providing affordable health services to populations with increasing levels of noncommunicable and chronic disease. Paradoxically, many nations can both celebrate increases in life expectancy and bemoan parallel increases in chronic disease prevalence. Simply put, despite living longer, not all of that time is spent in good health. Combined with factors such as rising levels of obesity and related noncommunicable disease, the demand for health services is requiring nations to consider new models of affordable health care. Given the level of disease burden, all staff, not just doctors, need to be part of the solution and encouraged to innovate and deliver better and more affordable health care, particularly preventative primary health care services. This paper draws attention to a range of exemplars to encourage and stimulate readers to think beyond traditional models of primary health service delivery. Examples include nurse-led, allied health-led, and student-led clinics; student-assisted services; and community empowerment models. These are reported for the interest of policy makers and health service managers involved in preventative and primary health service redesign initiatives.

Task shifting interventions for cardiovascular risk reduction in low-income and middle-income countries: a systematic review of randomised controlled trials

OBJECTIVE

To evaluate evidence from published randomised controlled trials (RCTs) for the use of task-shifting strategies for cardiovascular disease (CVD) risk reduction in low-income and middle-income countries (LMICs).

DESIGN

Systematic review of RCTs that utilised a task-shifting strategy in the management of CVD in LMICs.

DATA SOURCES

We searched the following databases for relevant RCTs: PubMed from the 1940s, EMBASE from 1974, Global Health from 1910, Ovid Health Star from 1966, Web of Knowledge from 1900, Scopus from 1823, CINAHL from 1937 and RCTs from ClinicalTrials.gov.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

We focused on RCTs published in English, but without publication year. We included RCTs in which the intervention used task shifting (non-physician healthcare workers involved in prescribing of medications, treatment and/or medical testing) and non-physician healthcare providers in the management of CV risk factors and diseases (hypertension, diabetes, hyperlipidaemia, stroke, coronary artery disease or heart failure), as well as RCTs that were conducted in LMICs. We excluded studies that are not RCTs.

RESULTS

Of the 2771 articles identified, only three met the predefined criteria. All three trials were conducted in practice-based settings among patients with hypertension (2 studies) and diabetes (1 study), with one study also incorporating home visits. The duration of the studies ranged from 3 to 12 months, and the task-shifting strategies included provision of medication prescriptions by nurses, community health workers and pharmacists and telephone follow-up posthospital discharge. Both hypertension studies reported a significant mean blood pressure reduction (2/1 mm Hg and 30/15 mm Hg), and the diabetes trial reported a reduction in the glycated haemoglobin levels of 1.87%.

CONCLUSIONS

There is a dearth of evidence on the implementation of task-shifting strategies to reduce the burden of CVD in LMICs. Effective task-shifting interventions targeted at reducing the global CVD epidemic in LMICs are urgently needed.

A randomized controlled trial of a nurse-led case management programme for hospital-discharged older adults with co-morbidities

AIM

To examine the effects of a nurse-led case management programme for hospital-discharged older adults with co-morbidities.

BACKGROUND

The most significant chronic conditions today involve diseases of the cardiovascular, respiratory, endocrine and renal systems. Previous studies have suggested that a nurse-led case management approach using either telephone follow-ups or home visits was able to improve clinical and patient outcomes for patients having a single, chronic disease, while the effects for older patients having at least two long-term conditions are unknown. A self-help programme using motivation and empowerment approaches is the framework of care in the study.

DESIGN

Randomized controlled trial.

METHOD

The study was conducted from 2010-2012. Older patients having at least two chronic diseases were included for analysis. The participants were randomized into three arms: two study groups and one control group. Data were collected at baseline and at 4 and 12 weeks later.

RESULTS

Two hundred and eighty-one patients completed the study. The interventions demonstrated significant differences in hospital readmission rates within 84 days post discharge. The two intervention groups had lower readmission rates than the control group. Patients in the two study arms had significantly better self-rated health and self-efficacy. There was significant difference between the groups in the physical composite score, but no significant difference in mental component score in SF-36 scale.

CONCLUSION

The postdischarge interventions led by the nurse case managers on self-management of disease using the empowerment approach were able to provide effective clinical and patient outcomes for older patients having co-morbidities.

Comparing the effect of two educational programs on the quality of life of hemodialysis patients in iran

Background:

Various researchers have shown that the health level, performance status, and quality of life (QOL) are often less than expected especially in hemodialysis (HD) patients.

Objectives:

This study aimed to determine the effect of the two methods of educational programs on health- related QOL (HRQOL) in Iranian HD patients.

Patients and Methods:

In this quasi-experimental, pretest-posttest interventional study, we employed each subject as his/her own control. The study was conducted at the dialysis units in three major general hospitals affiliated with Ahvaz Jundishapur University of Medical Sciences. A total of 90 HD patients were randomly allocated to two 45-patient groups of oral and video education programs, respectively. The educational programs included dietary and fluid regimens, the care of fistula and skin, and stress management. HRQOL was assessed in both groups using a Farsi version of the Short Form Health Survey (SF-36) before and after the educational programs. Repeated measures analysis of variance and ANOVA were used for data analysis through SPSS.

Results:

SF-36 domains of physical functioning (P < 0.021), role physical (P < 0.031), social functioning (P < 0.001) and mental health (P < 0.001) were significantly increased in both oral and vide education groups after the interventions. There was no difference in the effectiveness of the two educational programs.

Conclusions:

Appropriate interventions may potentially lead to improvement in the HRQOL of these patients. Therefore, video education as an effective, inexpensive, simple, and attractive method is recommended for HD patients.