Mustafa ARICI, MD Ankaranefroloji.org.tr/folders/file/CME/mustafa_arici.pdfMustafa ARICI, MD...

Impact of Predialysis Patient Education Programs

Mustafa ARICI, MDHacettepe University, Nephrology

Ankara‐TURKEY

Turning Their World Aroundwww.isn-online.org

ISN Mission: Advancing the diagnosis, treatment

and prevention of kidney diseases in the developing and developed world

•

Raise public awareness•

Connect professionals

•

Support research•

Provide nephrology education and training worldwide, and ultimately

•

Reduce the frequency and impact of kidney diseases and their associated conditions

2010: ISN 50th AnniversaryISN celebrates historical milestones and discloses its plans for

the next 50

years!

ISN Global Outreach (GO) (previously known as COMGAN)

In 2009: 35 Fellowships45 Sister Renal Centers6 Research and Prevention programs45 Continuing Medical Education (CME) meetings

Impact of Predialysis Patient Education Programs

1.

Therapeutic patient education–

Health literacy

2.

Predialysis education–

Literature review

–

New studies–

Turkish experience

3.

Guidelines

Therapeutic Patient Education

•

In health care practice outside the hospital, about 80% of the diseases treated are chronic.

•

Many patients do not comply with instructions;

fewer than 50% follow

their treatment correctly.

WHO, Therapeutic Patient Education, 1998

•

Patients are inadequately informed about their condition and that

few have been

helped to manage or take responsibility for their treatment.

•

Though most physicians are highly competent in diagnosis and

treatment, too

few educate their patients

to manage their condition.

Therapeutic Patient Education


•

Health care providers tend to

talk to patients about their disease

rather than train them in the daily management of

their condition.WHO, Therapeutic Patient Education, 1998

Old‐Fashioned Patient Education

•

To enable patients to acquire and maintain abilities that allow them to

optimally manage their lives with

their disease.

•

A

continuous

process, integrated

in health

care.

•

Patient‐centred

Modern Patient Education‐1


•

Includes organized awareness, information,

self‐ care learning and psychosocial support regarding the disease,

prescribed treatment, care, hospital

and other health care settings,

organizational information, and behaviour related to health and

illness. •

Designed to help patients and their families

understand the

disease and the treatment, cooperate with health care providers, live

healthily,

and maintain or improve their quality of life.



•

Knowledge:– Successful contemporary

educational

interventions

for people

with a chronic disease typically incorporate informational

components to improve knowledge,

•

Behavior:–A variety of psychological methods to

empower patients and change behavior.



Health Literacy•

Health literacy is the ability to

understand health information and to use that information to make good

decisions about your health and medical care.

•

Health information can overwhelm even people with advanced literacy skills.

Education is important...She has studied in faculty

of medicine. She knows the place of all vessels.

Yes, educationis a must.

Most predialysis patients…

…for making healthier choices related to their illness,

…for keeping their current health status,…for delaying the need for renal replacement

therapies,and …for chosing best alternative when dialysis is

needed

do not have sufficient knowledge!

Health Literacy in CKD1.

To delay progression of the disease and the

need for dialysis2.

To reduce risk for early mortality

3.

To control for cardiovascular risks and other comorbid conditions

4.

To control anemia, phosphate and potassium balance

5.

To arrange a healthy diet program and to prevent malnutrition

6.

To chose a healthy RRT modality

•

Chronic Kidney Disease

‐

Early Stages

•

Predialysis

•

Dialysis

Educational Interventions in Chronic Kidney Disease

0

5

17

Predialysis Education

Levin A, et al. AJKD 1997; 29: 533-540.

•

9 centers in Canada•

n=297

•

Patients:–Progressive CKD– Serum Cre

3.4 mg /dl

–Will have a need for RRT in 6‐12 months

297

148149Randomisation

90 min interactiveeducation

Telephone interviewsOnce every 3 weeks

Visual presentations• Healthy kidneys• Kidney diseases• RRT types (HD, PD, Tx)• Dietary and pharmacologicaltreatment• Nutrition• Life style60 pages booklet

Usual careor

EducationalMaterialsupport

Time to Dialysis Therapy

Dialysis Initiation

Usual care14,2 mo

Education group17,1 mo

Chi‐square1

=14.02;

P 0.0001

Mediators of the Delay of Dialysis Therapy

1.

Increased illness

related

knowledge,2.

Reduced

depression and/or

anxiety3.

Enhanced

social support

Blunting

The avoidance of threat-relevant

information

Increased reliance on

blunting

was associated

with shorter times to

dialysis therapy

Blunting

Blunting

•

Patients who had or not educational intervention between 1983 to 1988

•

Education group : 172 patients•

Usual care: 163 patients

•

20‐yr survival data

Early–Late Referral


Median survival was 2.25 years longer after patients with CKD received predialysis psychoeducational

interventions

•

Phase 1 Education: Booklet and 15‐ min video

•

Phase 2 Education: 90‐minute small group interactive educational

session on self‐care dialysis

Kidney International, Vol. 68 (2005), pp. 1777–1783

70

3535Randomisation

34

28

30

Self‐care Dialysis

% 82,1 % 50

Kidney International, Vol. 68 (2005), pp. 1777–1783

•

176 patients who

underwent dialysis initiation for chronic renal failure

between

April 2002 and March 2005•

Two groups according to their participation

or

nonparticipation in an educational program. Participation

in the education

program was of their own free will.

Planned Initiation to Dialysis

Clin Exp Nephrol (2006) 10:274–278

Use of Dialysis Catheters


Dialysis Modality


Time and Cost of Hospitalization


Nephrol Dial Transplant (2009) 24: 3426–3433

•

12 centers, retrospective analysis of 1558 prevalent (68.9 % on HD and 31.1% on PD)

•

70.3 % were known to nephrology units before starting dialysis

•

Unprepared (acute) start in 52.6 %

Predialysis Education Programme: Initial Results of Turkish Multicenter Study

(8th European Peritoneal Dialysis Meeting, 2007, Helsinki)

Mustafa Arıcı, Hülya Karadayı, Hüseyin Çeliker, Mine Besler, Çetin Özener, Tuğrul Sezer, Rezzan Ataman, Erhan Ağca, Taner Çamsarı, Kenan Ateş, Mahmut Yavuz, Semra Bozfakıoğlu

Predialysis Education Programme: Initial Results of Turkish Multicenter Study

83

15

80

50

57

19

49

11

46

15

40

2328

10

27

4

1611

1515

0

10

20

30

40

50

60

70

80

90

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ve

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NBU

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T op lam H astaYen i E k lenen

Toplam: 441 Yeni : 173

Jan 2007- Oct 2008

Unplanned (Acute) Start % 12,5

Presented in TND Congress, 2008

What about Health Literacy in CKD ?

•

480 incident chronic hemodialysis patients from

77 dialysis clinics between 2005‐2007

•

Followed until April 2008•

Rapid

Estimate of Adult Literacy in Medicine

(REALM)•

32% of patients had limited (9th grade reading

level)

health literacyJ Am Soc Nephrol 21: 1979–1985, 2010

Health Literacy & Survival

J Am Soc Nephrol 21: 1979–1985, 2010

Higher risk for death (HR 1.54; 95% CI 1.01 to 2.36)

•

Low health literacy (assessed by

using Rapid Estimate of Adult Literacy in Medicine ‐

REALM)

was 16 % (7‐37 %).

CJASN ePress. Published on May 5, 2011 as doi: 10.2215/CJN.09761110

Clin J Am Soc Nephrol 4: 950–956, 2009

In conclusion....

•

Early referral is NOT enough•

“Solo nephrologist approach”

is not

satisfactory•

Multidisciplinary PDEP is best–Skilled non‐medical educators–Skilled dietitian


33 % had an acute start !!!

•

All RRT centres should try and

provide, or support in collaboration with other centres,

all available

treatment options: PD (including CAPD and

APD), HD (including home HD and nocturnal

programmes)

and transplantation (including cadaveric and

non‐cadaveric), to make sure that

all patients can select

the modality that is most suitable for them.


•

All patients and their families

should receive well‐balanced information about the

different

RRT modalities, by means of a structured education

programme.

•

This also applies to late‐referred patients

and those starting dialysis in an emergency

situation,

who should receive the information once their conditions

have stabilizedNephrol Dial Transplant (2010) 25: 1757–1759


•

Delay the need for renal replacament therapy

•

Increase the chance for a planned start to RRT

•

Decrease the hospitalization days and the cost

•

Increase survival•

Improve quality of life

•

Increase self‐care dialysis options

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