Abstract
Background:
While home dialysis therapies are more cost effective and may offer improved
health-related quality of life, uptake compared to in-center hemodialysis
remains low.
Objective:
To test whether a web-based interactive health communication application
(IHCA) compared to usual care would increase home dialysis use.
Design:
Randomized control trial
Setting:
Patients were recruited from 3 multidisciplinary kidney clinics across
Ontario, Canada (Hamilton, Kingston, London).
Patients:
We included adults with advanced chronic kidney disease (CKD) followed in
multidisciplinary kidney clinics. Patients who had not completed dialysis
modality education, who did not have access to a home computer or the
internet, who had significant hearing or vision impairment, who could not
read/write/speak English, who had a medical contraindication for home
dialysis, or who had selected conservative kidney care were excluded.
Measurements:
The primary outcome was any use of home dialysis (peritoneal dialysis or home
hemodialysis) within 90 days of dialysis initiation. Secondary outcomes were
social support, decision conflict and dialysis knowledge measured at
baseline, 6 months and 1 year.
Methods:
Eligible patients were randomized to either usual care or the IHCA in
addition to usual care in a 1:1 ratio. As part of usual care, all patients
received education about dialysis modalities and kidney transplantation
delivered by clinic nurses according to local practices. Randomization was
performed using a computer-generated sequence in randomly permuted block
sizes, stratified by site, and allocation occurred using sequentially
numbered sealed, opaque envelopes. Participants, care providers, and outcome
assessors were not blinded to the intervention. All analyses were performed
blinded using an intention to treat approach. We estimated the effect of the
ICHA on the odds of the primary outcome using unadjusted logistic regression
models. Linear mixed models for repeated measures over time were used to
analyze the impact of the IHCA on the secondary outcomes of interest.
Results:
We randomized 140 (usual care, n = 71; IHCA, n = 69) out of a planned 264
patients (mean [SD] age 61 [14.5] years, 65% men). Among patients randomized
to the IHCA group that completed 6-month and 1-year follow-up visits, 56.8%
and 71.4%, respectively, had not accessed the IHCA website within the past
month. There were 23 (32.4%) and 26 (37.7%) patients in the usual care and
IHCA groups who received a home dialysis therapy within 90 days of dialysis
initiation (odds ratio, OR = 1.3, 95% CI = [0.6-2.5], P =
.5). Among the 78 patients who initiated dialysis (n = 38 usual care, n = 40
IHCA), 60.5% and 65% in the usual care and IHCA groups received a home
therapy within 90 days of dialysis initiation (OR = 1.2, 95% CI = [0.5-3.0],
P = .7). Secondary outcomes did not differ by
intervention group over time.
Limitations:
The trial was underpowered due to poor recruitment and use of the IHCA was
low.
Conclusions:
We did not find evidence of a difference in home dialysis uptake with IHCA
use, but our analyses were notably underpowered. The incorporation of
greater patient engagement, qualitative research and design research, and
pilot implementation may help future evaluations of strategies to improve
home dialysis uptake.
Trial Registration:
ClinicalTrials.gov #NCT01403454, registration date: Jul 21,
2011
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