Manjula Kurella Tamura|Suying Li|Shu?Cheng Chen|Kerri L. Cavanaugh|Adam Whaley?Connell|Peter A. McCullough|Rajnish Mehrotra
Educational programs improve the preparation for dialysis and survival of patients with chronic kidney disease
VA Palo Alto Health Care System|Stanford University|Orthopaedic Research Foundation|Orthopaedic Research Foundation|Vanderbilt University Medical Center|Harry S. Truman Memorial Veterans' Hospital|University of Missouri|Ascension|Harborview Medical Center|University of Washington
preparation endstage renal disease esrd widely acknowledged suboptimal united states sought determine whether participation kidney disease screening education program resulted improved esrd preparation survival 595 adults developed esrd participating national kidney foundation kidney early evaluation program keep communitybased screening education program nonkeep patients selected national esrd registry matched keep participants based demographic clinical characteristics main outcomes preesrd nephrologist care placement permanent vascular access use peritoneal dialysis preemptive transplant wait listing transplantation mortality esrd participation keep associated significantly higher rates preesrd nephrologist care 760 vs 693 peritoneal dialysis 103 vs 64 preemptive transplant wait listing 242 vs 171 transplantation 97 vs 64 higher rates permanent vascular access 234 vs 201 participation keep associated lower risk mortality hazard ratio 080 statistically significant adjusting esrd preparation thus participation voluntary community kidney disease screening education program associated higher rates esrd preparation survival preparation endstage renal disease esrd widely acknowledged suboptimal united states sought determine whether participation kidney disease screening education program resulted improved esrd preparation survival 595 adults developed esrd participating national kidney foundation kidney early evaluation program keep communitybased screening education program nonkeep patients selected national esrd registry matched keep participants based demographic clinical characteristics main outcomes preesrd nephrologist care placement permanent vascular access use peritoneal dialysis preemptive transplant wait listing transplantation mortality esrd participation keep associated significantly higher rates preesrd nephrologist care 760 vs 693 peritoneal dialysis 103 vs 64 preemptive transplant wait listing 242 vs 171 transplantation 97 vs 64 higher rates permanent vascular access 234 vs 201 participation keep associated lower risk mortality hazard ratio 080 statistically significant adjusting esrd preparation thus participation voluntary community kidney disease screening education program associated higher rates esrd preparation survival preparation endstage renal disease esrd condition affecting 600000 americans widely acknowledged suboptimal1narva optimal preparation esrdclin j soc nephrol 2009 4 s110s113crossref pubmed scopus 9 google scholar2saggi sj allon bernardini j et alconsiderations optimal preparation patients dialysisnat rev nephrol 2012 8 381389crossref pubmed scopus 47 google scholar despite dissemination practice guidelines chronic kidney disease ckd medicare benefit supporting preesrd education many patients experience care falls short recommendations example 80 patients start hemodialysis central venous catheter rather arteriovenous fistula graft3collins aj foley rn chavers b et alunited states renal data system 2011 annual data report atlas chronic kidney disease endstage renal disease united statesam j kidney dis 2012 59 e215e228abstract full text full text pdf scopus 175 google scholar approximately 3060 potentially eligible patients receive information peritoneal dialysis type home dialysis transplantation esrd4kutner ng johansen kl zhang r et alperspectives new kidney disease education benefit early awareness race kidney transplant access usrds studyam j transplant 2012 12 10171023crossref pubmed scopus 19 google scholar 5kutner ng zhang r huang et alpatient awareness initiation peritoneal dialysisarch intern med 2011 171 119124crossref pubmed scopus 36 google scholar 6mehrotra r marsh vonesh e et alpatient education access esrd patients renal replacement therapies beyond incenter hemodialysiskidney int 2005 68 378390abstract full text full text pdf pubmed scopus 209 google scholar result fewer 10 patients receive treatment modalities onset esrd3collins aj foley rn chavers b et alunited states renal data system 2011 annual data report atlas chronic kidney disease endstage renal disease united statesam j kidney dis 2012 59 e215e228abstract full text full text pdf scopus 175 google scholar suboptimal preparation esrd contributes high mortality first year dialysis initiation excess costs7mendelssohn dc curtis b yeates k et alsuboptimal initiation dialysis without early referral nephrologistnephrol dial transplant 2011 26 29592965crossref pubmed scopus 107 google scholar suboptimal preparation esrd reflects deficiencies one processes care identification patients high risk progression education esrd treatment options timely referral evaluation surgery dialysis access placement transplantation several lines evidence including two small trials suggest education programs patients advanced ckd increase uptake peritoneal dialysis may improve survival8levin lewis mortiboy p et almultidisciplinary predialysis programs quantification limitations impact patient outcomes two canadian settingsam j kidney dis 1997 29 533540abstract full text pdf pubmed scopus 183 google scholar 9devins gm mendelssohn dc barre pe et alpredialysis psychoeducational intervention extends survival ckd 20year followupam j kidney dis 2005 46 10881098abstract full text full text pdf pubmed scopus 144 google scholar 10manns bj taub k vanderstraeten c et althe impact education chronic kidney disease patients plans initiate dialysis selfcare dialysis randomized trialkidney int 2005 68 17771783abstract full text full text pdf pubmed scopus 175 google scholar 11lacson jr e wang w devries c et aleffects nationwide predialysis educational program modality choice vascular access patient outcomesam j kidney dis 2011 58 235242abstract full text full text pdf pubmed scopus 111 google scholar 12plantinga lc boulware le coresh j et alpatient awareness chronic kidney disease trends predictorsarch intern med 2008 168 22682275crossref pubmed scopus 203 google scholar unfortunately low awareness ckd including among patients advanced ckd12plantinga lc boulware le coresh j et alpatient awareness chronic kidney disease trends predictorsarch intern med 2008 168 22682275crossref pubmed scopus 203 google scholar may limit impact programs screening ckd one approach increase awareness however universal even targeted ckd screening programs remain controversial owing lack evidence benefit13fink ha ishani taylor bc et alscreening monitoring treatment chronic kidney disease stages 1 3 systematic review us preventive services task force american college physicians clinical practice guidelineann intern med 2012 156 570581crossref pubmed scopus 137 google scholar yet studies ckd screening considered potential effects screening may esrd preparation outcomes studies knowledge assessed effects combined ckd screening education program assessed esrd preparation survival among participants kidney early evaluation program keep national communitybased kidney disease screening education program matched nonkeep patients national registry individuals developed esrd 2005 2010 hypothesized keep participants would higher rates preparation esrd favorable profile esrd preparation among keep participants would largely explain esrd mortality differences keep participants matched nonkeep patients keep participants progressed esrd mean age 632139 years 472 men 422 white 575 diabetes matching notable imbalances keep participants nonkeep patients esrd table 1 example keep participants likely nonwhite female individuals less likely functional status limitations standardized differences 10 matching measured characteristics significantly imbalanced table 1 supplementary table 1 onlinetable 1baseline characteristics keep participants esrd nonkeep patients matchingbefore matchingafter matchingnonkeepkeepstandardized differencenonkeepkeepstandardized differencen2902525952975595mean age years6236326163263200race white race 58342232643042208 black race 35643215642843208 race 6114628214214611hispanic ethnicity 1189189989125male 55747217147847212full parttime employment 1141191611211923incidence year 2005 9767110736916 2006 177184181881905 2007 178149781521506 2008 1791770517217303 2009 18525116024524500 2010 1841713417017308medicaid coverage 747112717100diabetes 5295759360157553coronary artery disease 1941754917217508peripheral arterial disease 1269889949814stroke 931043710710410congestive heart failure 3152895729028902chronic lung disease 846189566121cancer 716428586425unable walk 6727190222732unable transfer 3412147091229needs assistance activities daily living 1177114737715morbid obesity 90900949014alcohol dependence 170796070704drug dependence 1605104050506abbreviations esrd endstage renal disease keep kidney early evaluation program open table new tab download doc 05 mb help doc files suplementary tables abbreviations esrd endstage renal disease keep kidney early evaluation program keep participants likely see nephrologist esrd 760 vs 693 p001 likely use peritoneal dialysis versus hemodialysis 103 vs 64 p001 likely placed transplant waiting list esrd 242 vs 171 p001 likely undergo transplantation 97 vs 64 p001 although likely undergo preemptive transplantation 17 vs 15 p07 table 2 keep participants slightly likely use arteriovenous fistula graft 234 vs 201 p009 first outpatient dialysis slightly likely mature maturing arteriovenous fistula graft first outpatient dialysis 440 vs 396 p006 differences statistically significanttable 2preparation esrd among keep participants matched nonkeep patientsfrequencyindicators esrd preparationkeep participant n control n pvaluenephrology care esrdaexcluding missing value calculating percentage409 7601847 693001arteriovenous fistula graft used first outpatient dialysis vs catheteraexcluding missing value calculating percentagebindividuals preemptive transplant using peritoneal dialysis excluded122 234550 201009arteriovenous fistula graft present first outpatient dialysis vs catheter onlyaexcluding missing value calculating percentagebindividuals preemptive transplant using peritoneal dialysis excluded227 4401075 396006peritoneal dialysis initiationcindividuals preemptive transplant excluded60 103186 64001placed transplant waiting list esrd144 242510 171001preemptive transplant10 1743 15070transplantation end followup48 81148 50001 living donor21 3560 20 deceased27 4588 30abbreviations esrd endstage renal disease keep kidney early evaluation programa excluding missing value calculating percentageb individuals preemptive transplant using peritoneal dialysis excludedc individuals preemptive transplant excluded open table new tab abbreviations esrd endstage renal disease keep kidney early evaluation program median followup 16 years onset esrd 175 deaths among keep participants 1037 deaths among nonkeep patients hazard ratio 080 95 confidence interval 068094 table 3 association keep participation mortality similar included adults esrd adjusted variables propensity score model directly adjusted propensity score supplementary table 2 onlinetable 3unadjusted adjusted risk death among keep participants versus matched nonkeep patients esrdmodelhazard ratio 95 confidence intervalpvaluemodel 1 unadjusted080 068094001model 2amodel adjusted anemia hypoalbuminemia080 068094001model 2nephrology referral081 069095001model 2use peritoneal dialysis081 069095001model 2use arteriovenous access first outpatient dialysis082 070096001model 2maturing arteriovenous access present first outpatient dialysis083 071097002model 2transplant waitlist status088 075103010model 2kidney transplantation084 071098002fully adjustedbmodel adjusted anemia hypoalbuminemia nephrology referral use peritoneal dialysis presence mature arteriovenous access presence maturing arteriovenous access waitlist status transplantation088 075104013abbreviations esrd endstage renal disease keep kidney early evaluation programthere 175 deaths among keep participants n595 1037 deaths among nonkeep patients n2975a model adjusted anemia hypoalbuminemiab model adjusted anemia hypoalbuminemia nephrology referral use peritoneal dialysis presence mature arteriovenous access presence maturing arteriovenous access waitlist status transplantation open table new tab abbreviations esrd endstage renal disease keep kidney early evaluation program 175 deaths among keep participants n595 1037 deaths among nonkeep patients n2975 association keep participation mortality similar adjustment anemia hypoalbuminemia table 3 additional adjustment indicators esrd preparation nephrology care vascular access peritoneal dialysis use waitlist status transplantation statistically significant difference mortality keep participants nonkeep patients mean durations keep screening esrd among participants ckd stages 12 3 4 48320 445229 314213 months respectively p001 compared keep participants ckd stage 12 screening advanced ckd keep screening likely arteriovenous fistula graft onset esrd likely undergo transplantation table 4 trend toward frequent preesrd nephrology care greater use peritoneal dialysis among screened later disease stages analyses adjusted clinical characteristics participants stage 4 ckd keep event likely placed transplant waiting list compared participants stage 12 ckdtable 4esrd preparation according ckd stage keep screeningindicators esrd preparationfrequency pvalueadjusted oramodel adjusted age sex race education diabetes cardiovascular disease awareness ckd95 cinephrology care esrdstage 12679008100 refstage 3798198 094419stage 4813179 081396arteriovenous fistula graft used first dialysis vs catheterstage 12157001100 refstage 3196135 055334stage 4319241 095610maturing arteriovenous fistula graft present first dialysis vs catheter onlystage 12279074100 refstage 3302152 062372stage 4309162 063420peritoneal dialysis vs hemodialysisstage 12105008100 refstage 371074 024226stage 4156155 052465placed transplant waiting list beforeesrd19004100 refstage 12223287 113728stage 3240435 1641157stage 4transplantation end followupstage 1217001100 refstage 3631193 11512386stage 41233992 35744672abbreviations ci confidence interval ckd chronic kidney disease esrd endstage renal disease keep kidney early evaluation program odds rationote n58 participants stage 12 ckd n175 participants stage 3 ckd n171 participants stage 4 ckda model adjusted age sex race education diabetes cardiovascular disease awareness ckd open table new tab abbreviations ci confidence interval ckd chronic kidney disease esrd endstage renal disease keep kidney early evaluation program odds ratio note n58 participants stage 12 ckd n175 participants stage 3 ckd n171 participants stage 4 ckd 196 participants aware kidney disease keep event 364 participants aware participants aware kidney disease keep likely receive preesrd nephrology care arteriovenous fistula graft esrd onset use peritoneal dialysis table 5 associations persisted adjustment clinical characteristics stage ckd association awareness transplant preparationtable 5esrd preparation according awareness ckd keep screeningindicators esrd preparationfrequency pvalueadjusted oramodel adjusted age sex race education diabetes cardiovascular disease awareness ckd 95 cinephrology care esrd ckd aware728001100 ref ckd aware845229 138379arteriovenous fistula graft used first dialysis vs catheter187001100 ref ckd aware319211 130342 ckd awarematuring arteriovenous fistula graft present first dialysis vs catheter ckd aware276026100 ref ckd aware333146 086248peritoneal dialysis vs hemodialysis ckd aware84003100 ref ckd aware142171 093316placed transplant waiting list esrd ckd aware228026100 ref ckd aware270128 079208transplantation end followup ckd aware71021100 ref ckd aware102090 042192abbreviations ci confidence interval ckd chronic kidney disease esrd endstage renal disease keep kidney early evaluation program odds rationote n364 participants aware ckd keep n196 participants aware ckd keep n35 missing values awarenessa model adjusted age sex race education diabetes cardiovascular disease awareness ckd open table new tab abbreviations ci confidence interval ckd chronic kidney disease esrd endstage renal disease keep kidney early evaluation program odds ratio note n364 participants aware ckd keep n196 participants aware ckd keep n35 missing values awareness participants national communitybased kidney disease screening education program nkf keep likely prepared esrd compared matched nonkeep patients improved preparation observed across several clinical domains spanning preesrd nephrology care use peritoneal dialysis access kidney transplantation furthermore keep participants longer survival initiation dialysis associated better preparation esrd prior studies ckd screening primarily focused utility screening prevention esrd us preventive services task force recently concluded role screening ckd stages 13 performed context chronic disease management uncertain13fink ha ishani taylor bc et alscreening monitoring treatment chronic kidney disease stages 1 3 systematic review us preventive services task force american college physicians clinical practice guidelineann intern med 2012 156 570581crossref pubmed scopus 137 google scholar14moyer va screening chronic kidney disease us preventive services task force recommendation statementann intern med 2012 157 567570crossref pubmed scopus 92 google scholar two trials testing strategies ckd detection clinical setting adding pointofcare clinical reminders estimated glomerular filtration rate egfr reporting effective egfr reporting alone increasing proportion patients receiving guidelineconcordant care ckd improving risk factor control15abdelkader k fischer gs li j et alautomated clinical reminders primary care providers care ckd small clusterrandomized controlled trialam j kidney dis 2011 58 894902abstract full text full text pdf pubmed scopus 42 google scholar16manns b tonelli culleton b et ala cluster randomized trial enhanced egfr prompt chronic kidney 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detect asymptomatic disease catalyze adoption healthy behaviors reduce risk adverse outcomes evidence supporting effect mixed18hollands gj hankins marteau tm visual feedback individuals medical imaging results changing health behaviourcochrane database syst rev 2010 1 cd007434pubmed google scholar 19omalley pg feuerstein im taylor aj impact electron beam tomography without case management motivation behavioral change cardiovascular risk profile randomized controlled trialjama 2003 289 22152223crossref pubmed scopus 149 google scholar 20rodondi n collet th nanchen et alimpact carotid plaque screening smoking cessation cardiovascular risk factors randomized controlled trialarch intern med 2012 172 344352crossref pubmed scopus 32 google scholar 21rozanski gransar h shaw lj et alimpact coronary artery calcium scanning coronary risk factors downstream testing eisner early identification subclinical atherosclerosis noninvasive imaging research prospective randomized trialj coll cardiol 2011 57 16221632abstract full text full text pdf pubmed scopus 272 google scholar knowledge first study assess whether ckd screening followed personalized diseasespecific educational efforts might promote positive health behaviors case preparing esrd important question whether participation keep activated patients prepare esrd primed physicians cared keep participants followup whether simply motivated patients physicians account results observed observational study cannot conclusively determine whether keep participation increased esrd preparation survival several reasons results could consistent causal relation keep participation esrd preparation reduce confounding used propensity score matching identify esrd patients similar characteristics participated keep identified control cohort closely matched observable characteristics including demographics zip code health insurance clinical conditions functional status addition findings consistent prior small trials demonstrating effectiveness preesrd education programs improving esrd preparation mortality9devins gm mendelssohn dc barre pe et alpredialysis psychoeducational intervention extends survival ckd 20year followupam j kidney dis 2005 46 10881098abstract full text full text pdf pubmed scopus 144 google scholar10manns bj taub k vanderstraeten c et althe impact education chronic kidney disease patients plans initiate dialysis selfcare dialysis randomized trialkidney int 2005 68 17771783abstract full text full text pdf pubmed scopus 175 google scholar increased access transplantation appeared relatively important aspects esrd preparation least short term potential explanation lower esrd mortality among keep versus nonkeep patients legitimate concern keep may select patients motivated participate selfcare behaviors obtain health care therefore findings may generalizable however several observations support conclusion first 710 keep participants ckd meet clinical guidelines cardiovascular risk factor control22jurkovitz ct elliott li et alphysician utilization riskfactor control ckd progression among participants kidney early evaluation program keepam j kidney dis 2012 59 s24s33abstract full text full text pdf pubmed scopus 24 google scholar suggesting motivation engage selfcare behaviors keep different broader population ckd second onethird participants keep cohort progressed esrd aware kidney disease time keep screening thus seems unlikely participants initiated esrd preparation activities keep third earlier studies observed fewer 30 keep participants stage 4 5 ckd seen nephrologist keep event percentage increased keep screening22jurkovitz ct elliott li et alphysician utilization riskfactor control ckd progression among participants kidney early evaluation program keepam j kidney dis 2012 59 s24s33abstract full text full text pdf pubmed scopus 24 google scholar23agrawal v jaar bg frisby xy et alaccess health care among adults evaluated ckd findings kidney early evaluation program keepam j kidney dis 2012 59 s515abstract full text full text pdf pubmed scopus 30 google scholar one implication study communitybased ckd screening education programs could broaden reach preesrd education efforts low patient provider awareness ckd may contributing factor limited implementation success providerbased education programs12plantinga lc boulware le coresh j et alpatient awareness chronic kidney disease trends predictorsarch intern med 2008 168 22682275crossref pubmed scopus 203 google scholar24kurella tamura anand li et alcomparison ckd awareness screening population using modification diet renal disease mdrd study ckd epidemiology collaboration ckdepi equationsam j kidney dis 2011 57 s17s23abstract full text full text pdf pubmed scopus 22 google scholar r