CULTURAL OF HOME DIALYSIS

Transcription

1 Patient Selection What Would You Choose? Yvonne Hornyak, RN CULTURAL OF HOME DIALYSIS

2 PATIENT SELECTION Disclosure

3 PATIENT SELECTION Objectives Understand the relationship between social, clinical, and patient preference in selecting a dialysis treatment option How the relationship of the HCT influences patient choice The importance of early referrals and education

4 2005

5 2005

6 2005 CMS started the discussion of updating the Conditions for Coverage for ESRD in February, first time since 1976 Final Rule published in April 15, Patients Rights & Responsibilities Patients must be assessed by the IDT for suitability for various dialysis modalities including transplant and that this must be reviewed annually

7 All-cause mortality rates in Medicare CKD & non-ckd patients, by CKD diagnosis code, 2011 Figure 3.15 (Volume 1) January 1, 2011 point prevalent patients age 66 & older. Adj: age/gender/race/prior hospitalization/comorbidities. Ref: 2011, all patients.

8 Change in adjusted all-cause & cause- specific hospitalization rates, by modality Figure 3.1 (Volume 2) Period prevalent ESRD patients. Adj: age/gender/race/primary diagnosis; ref: ESRD patients, 2010.

9 Estimated numbers of point prevalent ESRD patients Figure 11.3 (Volume 2) December 31 point prevalent ESRD patients.

10 Total Medicare ESRD expenditures, by modality Figure 11.6 (Volume 2) Period prevalent ESRD patients.

11 Incidence of ESRD, 2011 Figure 12.3 (Volume 2) Data presented only for countries from which relevant information was available;. signifies data not reported. All rates unadjusted. ^UK: England, Wales, & Northern Ireland (Scotland data reported separately). Data for Belgium do not include patients younger than 20. *Latest data for Taiwan are from Incident data for Croatia start at day 91, Data for France include 25 regions in All rates are unadjusted.

12 Percent distribution of prevalent dialysis patients, by modality, 2011 Figure 12.7 (Volume 2) Data presented only for countries from which relevant information was available;. signifies data not reported. All rates unadjusted. ^UK: England, Wales, & Northern Ireland (Scotland data reported separately). **Data for Belgium do not include patients younger than 20. *Latest data for Taiwan are from Data for France include 25 regions in 2011.

13 INFORMED PATIENT Clinical guidelines in United States as well as Europe and Asia, recommend treatment options education for CKD patients, to achieve a fully informed patient regarding Modality Transplant Palliative care

14 PATIENT SELECTION The low incidence of patients on Home Therapies suggest that patients Don t receive adequate education Do not have adequate time to discuss the management of their disease with family and care givers

15 PATIENT SELECTION British Qualitative Study of Modality Selection studies reviewed 375 patients & on modality options 3 transplant 1 palliative care

16 PATIENT SELECTION Awareness associated with decision making in the treatment of CKD to provide healthcare professionals the insights into how to best: provide the education necessary Enhance communication Improve patient and family involvement in the decision making

17 PATIENT SELECTION

18 PATIENT SELECTION Mortality ( choosing life/ death) Understanding that they had life threatening disease Not wanting to be a burden to family Not living in limbo

19 PATIENT SELECTION Lack of choice Perceived lack of choice as clinicians didn t give them all the options Lack of resources Medical contradictions

20 PATIENT SELECTION Lack of information 18 studies indicated patients were not educated on treatment options by healthcare professionals Peers Lack of resources ( support) Timing of information After hospitalization

21 PATIENT SELECTION Lack of knowledge ( US) Insurance coverage No desire to discuss living donor transplant with friends and family

22 PATIENT SELECTION Netherlands 1,347 patients 36% contraindications to home therapies 64% made their choice based on preference Age was a factor elderly Lived alone Had more comorbidities

23 PATIENT SELECTION Self-Management Patients were actively encouraged towards selfmanagement; most likely picked transplant home therapy

24 PATIENT SELCTION Staff Education Direct experience with Home Therapies

25 PATIENT SELECTION Winning hearts and minds is first step in this patient pathway to relative freedom Hutchison

26 PATIENT SELECTION Healthcare team bias 2006, HCW stated 46% patient would do well on Home Therapies Leaving the choice to HCP doesn t work Ease in placing a patient on HD Time-consuming to discuss & educate patients on Home Hemodialysis & PD

27 PATIENT SELECTION Staff Education Staff must be convinced that home therapies is a viable option & benefits the patient All staff must have the ethos of home therapies Physicians Nurses MSW Dieticians PCT

28 PATIENT SELECTION Patient Education Patients who have adequate preparation chose home therapy option Education can not default to listing facts, but give recommendations once the patient has accepted the change in their lives Stages of Change Model

29 Thinking about starting dialysis the ladder of contemplation. Hutchison A J, and Courthold J J NDT Plus 2011;4:iii7- iii10 The Author Published by Oxford University Press on behalf of ERA-EDTA. All rights reserved. For permissions, please journals.permissions@oup.com

30 PATIENT SELECTION Staff must have experience & confidence in the therapy Staff must develop a trust relationship Staff must engage the patient in conversation about: Freedom Independence Safety Quality & quanity of life

31 PATIENT SELECTION DMMS study 3794 patients in the US were analized 48.4% chose PD 51.6% chose HD

32 PD White Young females Older males Physically active Insurance Married Less comorbidities Higher education independent PATIENT SELECTION

33 PD Early referrals to nephrologist More nephrologist offive visits Pre-ESRD education More involved in decision making Less BMI PATIENT SELECTION

34 PATIENT SELECTION Early referrals More interaction with nephrologist More Pre-ESRD education Patients were two times more likely to chose PD if they were counseled and seen more frequently

35 PATIENT SELECTION Late referrals Patient with late referrals and education were more like to chose HD and had poor recall of receiving education Patients with more comorbidities were less likely to be referred for Pre-ESRD education

36 PATIENT SELECTION Treatment Options Maintain current lifestyle Considered family & friends opinions Pathways towards self-management

37 PATIENT SELECTION Conclusion of studies Modality education must begin sooner ( GFR<30) Must take into account patients preferences to life style in the education Must include Behavioral Interviewing techniques to assist the patient in accepting Pathway to Change Must be repeated by confident, knowledgeable staff Must be timely When possible include peers

38 PATIENT SELECTION Maintaining lifestyle Less concerned with the outcome as quality of life Staying employed Raising children ( grandchildren) Social life Minimizing the disruption to usual activities

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40 CAPD BENEFITS Portable do it anywhere Flexible suit your own schedule Time fewer trips to the clinic Easy learn it in a week or two No needles avoid needle sticks Less restrictive easier diet CCPD BENEFITS Portable do it anywhere Convenient have your days free Easy learn it in a week or two No needles avoid needle sticks Less restrictive easier diet Routine feel healthy, not sick Time fewer trips to the clinic HOME DIALYSIS

41 CONVENTIONAL HHD 3x/week with similar machines used in our clinics Uses portable RO or DI for water treatment in the home Can be accomplished staffassisted if no partner/caregiver available As with incenter HD, the AV fistula is the preferred access BENEIFITS HHD Flexible plan your own schedule, keep your job Control eat, drink, and have visitors Access lasts longest because you insert your own needles Time fewer trips to the clinic HOME DIALYSIS

42 SHORT DAILY DIALYSIS Treatments are generally hours long 5-6 days a week AV Fistula is the preferred access and buttonhole cannulation is common due to increased treatment times BENEFITS OF SHHD Flexible plan your own schedule, keep your job Quality get more dialysis to feel better Control eat, drink, and have visitors Access lasts longest because you insert your own needles Less restrictive easier diet Time fewer trips to the clinic HOME DIALYSIS

43 NOCTURNAL HHD May be done with a partner or through external monitoring Treatments are 6-8 hours each 3+ days a week Water treated with portable RO or DI Av fistula is access of choice BENEFITS OF NOCTURAL HHD Convenient have your days free Quality get 2-5 times as much dialysis Gentle easy on your heart Feel better more energy, libido, and appetite Less restrictive easier diet, fewer drugs HOME DIALYSIS

44 PATIENT SELECTION Strong need for independence and control of own care Motivation and willingness to set up a safe area in their home for treatment Ability to learn and apply theory, principles, and practical procedures Active lifestyle employed or desire to stay active

45 PATIENT SELECTION Distance from dialysis facility Limited mobility/capability Nursing home patients for example Frail/elderly patients especially if they have a motivated caregiver to assist

46 MEDICAL INDICATION FOR HOME Any new ESRD patient with severe cardiovascular disease Reduction in dialysis-associated symptoms A patient whose blood pressure is not well controlled with medications

47 MEDICAL INDICATIONS FOR PD Patients with hemodialysis access failure or fear of needles Diabetic patients No vascular access required Blood sugar can be well-controlled even though sugar is the base of PD solution

48 MEDICAL INDICATIONS HHD Large/obese; conventional HD and PD are not adequate Pregnant or who desire to be pregnant Diagnosed with left ventricular hypertrophy (LVH), amyloidosis, or uncontrolled hypertension

49 PATIENT SELECTION Conclusions Options education when GFR < 30 Include peers in the education process Take patient s lifestyle into account Be provided by experience and confident teams

50 PATIENT SELECTION Health care teams need to create pathways to include transplant and palliative care as options as well as home therapies

51 WHO IS A CANDIDATE FOR HOME THERAPIES? The most important factor that determines if a patient is successful doing Home Therapies is their motivation

52 QUESTIONS?

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54 REFERENCES ANNA Journal / American Nephrology Nurses' Association [1996, 23(4):369-75; American Journal of Kidney Diseases Volume 43, Issue 5, Pages , May 2004 Ndt nephrology dialysis transplantation; Volume 28 Issue 10 October 2013 Nephrol. Dial. Transplant. (2008) 23 (12): doi: BMJ 2010; 340 ; Published 19 January 2010 The best dialysis therapy? Results from an international survey among nephrology professionals. NDT Plus 2008;1: In search of how people change. Applications to addictive behaviors. Am Psychol 1992;47: JASN May 1, 2002 vol. 13 no