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Grove BE, de Thurah A, Ivarsen P, Kvisgaard AK, Hjollund NH, Grytnes R, Schougaard LMV. Remote Symptom Monitoring Using Patient-Reported Outcomes in Patients With Chronic Kidney Disease: Process Evaluation of a Randomized Controlled Trial. JMIR Form Res 2024; 8:e48173. [PMID: 38656781 PMCID: PMC11079764 DOI: 10.2196/48173] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2023] [Revised: 02/02/2024] [Accepted: 03/15/2024] [Indexed: 04/26/2024] Open
Abstract
BACKGROUND In Denmark, outpatient follow-up for patients with chronic kidney disease (CKD) is changing from in-hospital visits toward more remote health care delivery. The nonuse of remote patient-reported outcomes (PROs) is a well-known challenge, and it can be difficult to explain which mechanisms of interventions influence the outcome. Process evaluation may, therefore, be used to answer important questions on how and why interventions work, aiming to enhance the implications for clinical practice. OBJECTIVE This study aimed to provide insight into the intervention process by evaluating (1) the representativity of the study population, (2) patient and physician use patterns, (3) patient adherence to the intervention, and (4) clinical engagement. METHODS A process evaluation determining the reach, dose, fidelity, and clinical engagement was carried out, alongside a multicenter randomized controlled trial (RCT). We developed and implemented an intervention using PRO measures to monitor outpatients remotely. Data were collected for the PRO intervention arms in the RCT from 4 sources: (1) PRO data from the participants to determine personal factors, (2) the web-based PRO system to identify key usage intervention patterns, (3) medical records to identify clinical factors relating to the use of the intervention, and (4) semistructured interviews conducted with involved physicians. RESULTS Of the 320 patients invited, 152 (47.5%) accepted to participate. The study population reflected the target population. The mean adherence rate to the PRO intervention arms was 82% (95% CI 76-87). The questionnaire response rate was 539/544 (99.1%). A minority of 13 (12.9%) of 101 patients needed assistance to complete study procedures. Physicians assessed 477/539 (88.5%) of the questionnaires. Contact was established in 417/539 (77.4%) of the cases, and 122/539 (22.6%) of the patients did not have contact. Physicians initiated 288/417 (69.1%) and patients requested 129/417 (30.9%) of all the contacts. The primary causes of contact were clinical data (242/417, 58%), PRO data (92/417, 22.1%), and medication concerns and precautionary reasons (83/417, 19.9%). Physicians found the use of PRO measures in remote follow-up beneficial for assessing the patient's health. The inclusion of self-reported clinical data in the questionnaire motivated physicians to assess patient responses. However, some barriers were emphasized, such as loss of a personal relationship with the patient and the risk of missing important symptoms in the absence of a face-to-face assessment. CONCLUSIONS This study demonstrates the importance and practical use of remote monitoring among patients with CKD. Overall, the intervention was implemented as intended. We observed high patient adherence rates, and the physicians managed most questionnaires. Some physicians worried that distance from the patients made it unfeasible to use their "clinical glance," posing a potential risk of overlooking crucial patients' symptoms. These findings underscore key considerations for the implementation of remote follow-up. Introducing a hybrid approach combining remote and face-to-face consultations may address these concerns. TRIAL REGISTRATION ClinicalTrials.gov NCT03847766; https://clinicaltrials.gov/study/NCT03847766.
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Affiliation(s)
- Birgith Engelst Grove
- AmbuFlex, Centre for Patient-Reported Outcomes, Gødstrup Hospital, Herning, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Annette de Thurah
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
- Department of Rheumatology, Aarhus University Hospital, Aarhus, Denmark
| | - Per Ivarsen
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
- Department of Renal Medicine, Aarhus University Hospital, Aarhus, Denmark
| | | | - Niels Henrik Hjollund
- AmbuFlex, Centre for Patient-Reported Outcomes, Gødstrup Hospital, Herning, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
- Department of Clinical Epidemiology, Aarhus University, Aarhus, Denmark
| | - Regine Grytnes
- AmbuFlex, Centre for Patient-Reported Outcomes, Gødstrup Hospital, Herning, Denmark
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Kim K, Kim JE, Kim JH, Ahn SH, Jung CY, Hwang SD, Lee SW, Song JH. Real-world evidence of constipation and laxative use in the Korean population with chronic kidney disease from a common data model. Sci Rep 2024; 14:6610. [PMID: 38503885 PMCID: PMC10951406 DOI: 10.1038/s41598-024-57382-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2023] [Accepted: 03/18/2024] [Indexed: 03/21/2024] Open
Abstract
Constipation is a highly prevalent gastrointestinal disorder in patients with chronic kidney disease (CKD). However, our understanding of its epidemiology and management in CKD is limited. We aimed to explore real-world data on constipation and laxative use in patients with CKD in a nationwide population-based cohort from the Korean Health Insurance Review and Assessment-National Patient Sample database. This study analyzed retrospective health claims data in Korea from 2012 to 2017 that were transformed into the Observational Medical Outcomes Partnership Common Data Model. The pooled proportion of constipation diagnoses was 30.5% in all patients with CKD and 15.9%, 16.5%, 17.4%, 29.9%, and 43.3% in patients with CKD stages 1-5, respectively, suggesting a higher prevalence in advanced CKD. Patients receiving peritoneal dialysis or hemodialysis had the highest prevalence of constipation, while transplant recipients showed a prevalence comparable to that of patients with early CKD. Patients with CKD had a significantly higher risk of constipation than age- and sex-matched non-CKD individuals (range of odds ratio [OR]:1.66-1.90). Laxative prescribing patterns differed by CKD severity. Osmotic agents were prescribed in more than half of patients with advanced CKD, while magnesium salts and bulking agents were prescribed less frequently. The CKD patients with constipation were more likely to be prescribed constipation-inducing medications, including antipsychotic and neurological medications. Our findings provide real-world constipation and laxative prescription status in the Korean CKD population, revealing a significantly higher risk of constipation and different laxative prescribing patterns in patients with CKD.
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Affiliation(s)
- Kipyo Kim
- Division of Nephrology and Hypertension, Department of Internal Medicine, Inha University Hospital, Inha University College of Medicine, Incheon, 22332, Republic of Korea
| | - Ji-Eun Kim
- Division of Nephrology and Hypertension, Department of Internal Medicine, Inha University Hospital, Inha University College of Medicine, Incheon, 22332, Republic of Korea
| | - Jae Ho Kim
- Division of Nephrology and Hypertension, Department of Internal Medicine, Inha University Hospital, Inha University College of Medicine, Incheon, 22332, Republic of Korea
| | - Seong Hee Ahn
- Department of Endocrinology and Metabolism, Inha University Hospital, Inha University College of Medicine, Incheon, 22332, Republic of Korea
| | - Chai Young Jung
- Biomedical Research Institute, Inha University Hospital, Incheon, 22332, Republic of Korea
| | - Seun Deuk Hwang
- Division of Nephrology and Hypertension, Department of Internal Medicine, Inha University Hospital, Inha University College of Medicine, Incheon, 22332, Republic of Korea
| | - Seoung Woo Lee
- Division of Nephrology and Hypertension, Department of Internal Medicine, Inha University Hospital, Inha University College of Medicine, Incheon, 22332, Republic of Korea
| | - Joon Ho Song
- Division of Nephrology and Hypertension, Department of Internal Medicine, Inha University Hospital, Inha University College of Medicine, Incheon, 22332, Republic of Korea.
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Anderson NE, Kyte D, McMullan C, Cockwell P, Aiyegbusi OL, Verdi R, Calvert M. Global use of electronic patient-reported outcome systems in nephrology: a mixed methods study. BMJ Open 2023; 13:e070927. [PMID: 37438075 DOI: 10.1136/bmjopen-2022-070927] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/14/2023] Open
Abstract
OBJECTIVES The use of electronic patient-reported outcome (ePRO) systems to support the management of patients with chronic kidney disease is increasing. This mixed-methods study aimed to comprehensively identify existing and developing ePRO systems, used in nephrology settings globally, ascertaining key characteristics and factors for successful implementation. STUDY DESIGN ePRO systems and developers were identified through a scoping review of the literature and contact with field experts. Developers were invited to participate in a structured survey, to summarise key system characteristics including: (1) system objectives, (2) population, (3) PRO measures used, (4) level of automation, (5) reporting, (6) integration into workflow and (7) links to electronic health records/national registries. Subsequent semistructured interviews were conducted to explore responses. SETTING AND PARTICIPANTS Eligible systems included those being developed or used in nephrology settings to assess ePROs and summarise results to care providers. System developers included those with a key responsibility for aspects of the design, development or implementation of an eligible system. ANALYTICAL APPROACH Structured survey data were summarised using descriptive statistics. Interview transcripts were analysed using Codebook Thematic Analysis using domains from the Consolidated Framework for Implementation Research. RESULTS Fifteen unique ePRO systems were identified across seven countries; 10 system developers completed the structured survey and 7 participated in semistructured interviews. Despite system heterogeneity, reported features required for effective implementation included early and sustained patient involvement, clinician champions and expanding existing electronic platforms to integrate ePROs. Systems demonstrated several common features, with the majority being implemented within research settings, thereby affecting system implementation readiness for real-world application. CONCLUSIONS There has been considerable research investment in ePRO systems. The findings of this study outline key system features and factors to support the successful implementation of ePROs in routine kidney care.Cite Now.
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Affiliation(s)
- Nicola Elizabeth Anderson
- Institute of Applied Heath Research, Centre for Patient Reported Outcomes Research, University of Birmingham, Birmingham, UK
- Research, Development and Innovation, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
- NIHR Applied Research Collaboration, West Midlands, University of Birmingham, Birmingham, UK
| | - Derek Kyte
- Institute of Applied Heath Research, Centre for Patient Reported Outcomes Research, University of Birmingham, Birmingham, UK
- School of Allied Health and Community, University of Worcester, Worcester, UK
| | - Christel McMullan
- Institute of Applied Heath Research, Centre for Patient Reported Outcomes Research, University of Birmingham, Birmingham, UK
- NIHR SRMRC, University Hospitals Birmingham NHS Foundation Trust and University of Birmingham, Birmingham, UK
- NIHR Blood and Transplant Research Unit (BTRU) in Precision Transplant and Cellular Therapeutics, University of Birmingham, Birmingham, UK
| | - Paul Cockwell
- Institute of Applied Heath Research, Centre for Patient Reported Outcomes Research, University of Birmingham, Birmingham, UK
- Department of Renal Medicine, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Olalekan Lee Aiyegbusi
- Institute of Applied Heath Research, Centre for Patient Reported Outcomes Research, University of Birmingham, Birmingham, UK
- NIHR Applied Research Collaboration, West Midlands, University of Birmingham, Birmingham, UK
- NIHR Blood and Transplant Research Unit (BTRU) in Precision Transplant and Cellular Therapeutics, University of Birmingham, Birmingham, UK
- NIHR Birmingham Biomedical Research Centre, University of Birmingham and University Hospitals Birmingham NHS Foundation Trust, University of Birmingham, Birmingham, UK
- Birmingham Health Partners Centre for Regulatory Science and Innovation, University of Birmingham, Birmingham, UK
| | - Rav Verdi
- Patient Partner, Institute of Applied Health Research,Centre for Patient-Reported Outcomes Research (CPROR), University of Birmingham, Birmingham, UK
| | - Melanie Calvert
- Institute of Applied Heath Research, Centre for Patient Reported Outcomes Research, University of Birmingham, Birmingham, UK
- NIHR Applied Research Collaboration, West Midlands, University of Birmingham, Birmingham, UK
- NIHR SRMRC, University Hospitals Birmingham NHS Foundation Trust and University of Birmingham, Birmingham, UK
- NIHR Blood and Transplant Research Unit (BTRU) in Precision Transplant and Cellular Therapeutics, University of Birmingham, Birmingham, UK
- NIHR Birmingham Biomedical Research Centre, University of Birmingham and University Hospitals Birmingham NHS Foundation Trust, University of Birmingham, Birmingham, UK
- Birmingham Health Partners Centre for Regulatory Science and Innovation, University of Birmingham, Birmingham, UK
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Hjollund NHI, Larsen LP, de Thurah AL, Grove BE, Skuladottir H, Linnet H, Friis RB, Johnsen SP, May O, Jensen AL, Hansen TK, Taarnhøj GA, Tolstrup LK, Pappot H, Ivarsen P, Dørflinger L, Jessen A, Sørensen NT, Schougaard LMV, Team TA. Patient-reported outcome (PRO) measurements in chronic and malignant diseases: ten years' experience with PRO-algorithm-based patient-clinician interaction (telePRO) in AmbuFlex. Qual Life Res 2023; 32:1053-1067. [PMID: 36639598 PMCID: PMC10063508 DOI: 10.1007/s11136-022-03322-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/06/2022] [Indexed: 01/15/2023]
Abstract
BACKGROUND Patient-reported Outcome (PRO) measures may be used as the basis for out-patient follow-up instead of fixed appointments. The patients attend follow-up from home by filling in questionnaires developed for that specific aim and patient group (telePRO). The questionnaires are handled in real time by a specific algorithm, which assigns an outcome color reflecting clinical need. The specific questionnaires and algorithms (named solutions) are constructed in a consensus process with clinicians. We aimed to describe AmbuFlex' telePRO solutions and the algorithm outcomes and variation between patient groups, and to discuss possible applications and challenges. METHODS TelePRO solutions with more than 100 processed questionnaires were included in the analysis. Data were retrieved together with data from national registers. Characteristics of patients, questionnaires and outcomes were tabulated for each solution. Graphs were constructed depicting the overall and within-patient distribution of algorithm outcomes for each solution. RESULTS From 2011 to 2021, 29 specific telePRO solutions were implemented within 24 different ICD-10 groups. A total of 42,015 patients were referred and answered 171,268 questionnaires. An existing applicable instrument with cut-off values was available for four solutions, whereas items were selected or developed ad hoc for the other solutions. Mean age ranged from 10.7 (Pain in children) to 73.3 years (chronic kidney disease). Mortality among referred patients varied between 0 (obesity, asthma, endometriosis and pain in children) and 528 per 1000 patient years (Lung cancer). There was substantial variation in algorithm outcome across patient groups while different solutions within the same patient group varied little. DISCUSSION TelePRO can be applied in diseases where PRO can reflect clinical status and needs. Questionnaires and algorithms should be adapted for the specific patient groups and clinical aims. When PRO is used as replacement for clinical contact, special carefulness should be observed with respect to patient safety.
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Affiliation(s)
- Niels Henrik I Hjollund
- AmbuFlex - Center for Patient-Reported Outcomes, Central Denmark Region, Gødstrup Hospital, Herning, Denmark.
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark.
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark.
| | - Louise Pape Larsen
- AmbuFlex - Center for Patient-Reported Outcomes, Central Denmark Region, Gødstrup Hospital, Herning, Denmark
| | | | - Birgith Engelst Grove
- AmbuFlex - Center for Patient-Reported Outcomes, Central Denmark Region, Gødstrup Hospital, Herning, Denmark
| | | | - Hanne Linnet
- Department of Oncology, Gødstrup Hospital, Herning, Denmark
| | | | - Søren Paaske Johnsen
- Danish Center for Clinical Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Ole May
- Department of Medicine, Gødstrup Hospital, Herning, Denmark
| | | | | | - Gry Assam Taarnhøj
- Department of Oncology, University of Copenhagen, Rigshospitalet, Copenhagen, Denmark
| | - Lærke Kjær Tolstrup
- Department of Oncology, University of Copenhagen, Rigshospitalet, Copenhagen, Denmark
| | - Helle Pappot
- Department of Oncology, University of Copenhagen, Rigshospitalet, Copenhagen, Denmark
| | - Per Ivarsen
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
- Department of Renal Medicine, Aarhus University Hospital, Aarhus, Denmark
| | | | - Anne Jessen
- AmbuFlex - Center for Patient-Reported Outcomes, Central Denmark Region, Gødstrup Hospital, Herning, Denmark
| | - Nanna Toxvig Sørensen
- AmbuFlex - Center for Patient-Reported Outcomes, Central Denmark Region, Gødstrup Hospital, Herning, Denmark
| | - Liv Marit Valen Schougaard
- AmbuFlex - Center for Patient-Reported Outcomes, Central Denmark Region, Gødstrup Hospital, Herning, Denmark
| | - The AmbuFlex Team
- AmbuFlex - Center for Patient-Reported Outcomes, Central Denmark Region, Gødstrup Hospital, Herning, Denmark
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Remote follow-up based on patient-reported outcomes in patients with chronic kidney disease: A qualitative study of patient perspectives. PLoS One 2023; 18:e0281393. [PMID: 36763600 PMCID: PMC9916608 DOI: 10.1371/journal.pone.0281393] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2022] [Accepted: 01/20/2023] [Indexed: 02/11/2023] Open
Abstract
BACKGROUND Patient-reported outcomes (PROs) are increasingly used in outpatient follow-up. PRO-based remote follow-up offers a new healthcare delivery model, where PROs are used as the basis for outpatient follow-up in patients with chronic kidney disease. However, the patient's perspective of this novel remote care delivery remains unknown. OBJECTIVES This study aimed to explore the patients' experiences using PROs in remote care and how this mode of follow-up may enhance patient engagement. DESIGN A qualitative approach was employed, guided by Focused Ethnography and Interpretive Description. PARTICIPANTS Purposively, 15 patients with chronic kidney disease experienced with PRO-based remote follow-up in 3 renal outpatient clinics in the Central Denmark Region, were recruited. MEASURES Field studies comprising participant observation in remote PRO consultations and individual, semi-structured interviews with the patients constituted the empirical data. Thematic analysis was performed according to Braun and Clarke's six-phase process. RESULTS PRO-based remote follow-up may enhance patient engagement by a) improving communication, b) increasing disease knowledge, c) inducing flexibility, d) ensuring clinician feedback on PRO data, and e) prompting clinical action. Barriers to enhanced patient engagement were identified as a) lack of feedback on PRO data, b) lower disease knowledge, c) PRO in competition with biomedical data, and d) loss of personal relation. CONCLUSION PRO-based follow-up in remote care holds several advantages for the patients. However, some barriers need clinical awareness before PROs may enhance the patients' engagement in remote follow-up. Future studies should explore the impact of involving relatives in PRO-based follow-up.
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Ruszkowski J, Majkutewicz K, Heleniak Z, Witkowski JM, Dębska-Ślizień A. Prevalence and Severity of Lower Gastrointestinal Symptoms amongst Non-Dialysis Chronic Kidney Disease Patients: A Systematic Review and Meta-Analysis. J Clin Med 2022; 11:6363. [PMID: 36362591 PMCID: PMC9656905 DOI: 10.3390/jcm11216363] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2022] [Revised: 10/21/2022] [Accepted: 10/24/2022] [Indexed: 12/27/2023] Open
Abstract
Chronic kidney disease (CKD) patients experience a wide range of symptoms that deteriorate their health-related quality of life (HRQoL). We aimed to estimate the prevalence and severity of lower gastrointestinal (GI) symptoms in non-dialysis CKD adult outpatients, and to summarize the relationships between these symptoms and HRQoL, laboratory test results, and clinical data. The protocol of the study was preregistered (PROSPERO CRD42021255122). We searched MEDLINE, Scopus, Web of Science, and grey literature sources from the databases' inception up until 27 November 2021. Wide citation chasing was conducted. Single proportions (prevalence of functional constipation, self-reported constipation, diarrhea, abdominal bloating, fecal incontinence, and abdominal/rectal pain) were pooled using generalized linear mixed models. A total of 37 studies with 12,074 patients were included. We found that lower GI symptoms, especially self-reported abdominal bloating [CKD G1-2: 48.45% (95% CI: 43.5-53.4%; 2 studies); G3: 46.95% (95% CI: 45.0-48.9%; 2 studies), G4-5: 36.1% (95% CI: 25.4-48.5%; 8 studies)] and constipation [CKD G1-2: 31.8% (95% CI: 13.9-54.9%); G3: 29.8% (95% CI: 21.2-40.1%; 4 studies); G4-5: 38.8% (95% CI: 30.9-47.4%); 22 studies)], were common in non-dialysis CKD patients. The severity of the symptoms was limited. Self-reported constipation was most consistently associated with worse HRQoL, whereas hard stool consistency was associated with higher uremic toxins levels. To conclude, since lower GI symptoms are common in CKD, using symptom questionnaires that do not take them into account cannot provide full insight into the patient's experience. Further studies are needed to cover identified knowledge gaps, including the exploration of the pathophysiology of GI symptoms in CKD with multi-omics data.
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Affiliation(s)
- Jakub Ruszkowski
- Department of Pathophysiology, Faculty of Medicine, Medical University of Gdańsk, 80-211 Gdańsk, Poland
- Department of Nephrology, Transplantology and Internal Medicine, Faculty of Medicine, Medical University of Gdańsk, 80-214 Gdańsk, Poland
| | - Katarzyna Majkutewicz
- Student Scientific Circle, Department of Nephrology, Transplantology and Internal Medicine, Faculty of Medicine, Medical University of Gdańsk, 80-214 Gdańsk, Poland
| | - Zbigniew Heleniak
- Department of Nephrology, Transplantology and Internal Medicine, Faculty of Medicine, Medical University of Gdańsk, 80-214 Gdańsk, Poland
| | - Jacek M. Witkowski
- Department of Pathophysiology, Faculty of Medicine, Medical University of Gdańsk, 80-211 Gdańsk, Poland
| | - Alicja Dębska-Ślizień
- Department of Nephrology, Transplantology and Internal Medicine, Faculty of Medicine, Medical University of Gdańsk, 80-214 Gdańsk, Poland
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