Peritoneal dialysis variability in teaching leading to variable outcomes?

Peritoneal dialysis variability in teaching leading to variable outcomes? Professor Matthew Jose MBBS, FRACP, PhD, FASN, AFRACMA FACULTY OF HEALTH

Learning Objectives Recognise clinical practice variation Recognise variation in clinical outcomes Understand variation in teaching of PD Know the current resources available to assist PD teaching Understand that clinician collaboration will benefit patients FACULTY OF HEALTH 2

Conflicts of Interest Member International Society of Peritoneal Dialysis (ISPD) Chairperson, PD working group of AKTN (Australasian Kidney Trials Network) Chairperson, ANZDATA Steering Committee (Australia and New Zealand Dialysis and Transplant Registry) No commercial conflicts of interest FACULTY OF HEALTH 3

Peritoneal Dialysis in Australia and New Zealand: Current practice and outcomes FACULTY OF HEALTH 4

Dialysis Modality by Country 2015 Australia New Zealand 20% 30% 9% 52% 70% 18% PD Home HD Facility HD 2016 ANZDATA Annual Report, Figure 2.4

100 Dialysis Modality by State at end of 2015 80 Percent 60 40 20 0 QLD NSW/ACT VIC TAS SA NT WA NZ PD Home HD Other HD 2016 ANZDATA Annual Report, Figure 2.6

6000 Method and Location of Dialysis Australia, 2011-2015 6000 5000 4000 5000 4000 3000 3000 2000 2000 1000 1000 0 0 2011 2012 2013 2014 2015 SAT HD 5938 (48%) HOSP HD 2844 (23%) APD 1676 (13%) HOME HD 1165 (9%) CAPD 838 (7%) 2016 ANZDATA Annual Report, Figure 2.9

Time on peritoneal dialysis Prevalent PD patients Australia 31 Dec 2015 250 Number of Patients 200 150 100 50 0 0 1 2 3 4 5 6 7 8 9 =10 Years on PD 2016 ANZDATA Annual Report, Figure 5.1

Age (%) of current peritoneal dialysis patients Australia 2015 25 Number of Patients=2514 20 Percent 15 10 5 0 0-14 15-24 25-34 35-44 45-54 55-64 65-74 75-84 85+ 2016 ANZDATA Annual Report, Figure 5.4

100 Icodextrin use by state and country Prevalent patients December 2015 80 Percent 60 40 20 0 NT NSW/ACT VIC QLD SA WA TAS NZ NT NSW/ACT VIC QLD SA WA TAS NZ Icodextrin Yes No CAPD APD Proportions not presented if <10 patients 2016 ANZDATA Annual Report, Figure 5.7

1.00 Patient survival - peritoneal dialysis at 90 days 2004-2015 Censored for transplant - Australia Patient Survival 0.75 0.50 0.25 0.00 Age <40 (1255) 40-59 (2655) 60-74 (3090) =75 (1441) 0 1 2 3 4 5 Years 2016 ANZDATA Annual Report, Figure 5.11

1.00 Technique survival - peritoneal dialysis at 90 days 2004-2015 Censored for transplant - Australia Technique Survival 0.75 0.50 0.25 0.00 Age <40 (1255) 40-59 (2655) 60-74 (3090) =75 (1441) 0 1 2 3 4 5 Years 2016 ANZDATA Annual Report, Figure 5.14

1.00 Technique survival - peritoneal dialysis at 90 days 2004-2015 Censored for transplant - Australia Technique Survival 0.75 0.50 0.25 0.00 Non-Diabetic (4826) Diabetic (3587) 0 1 2 3 4 5 Years 2016 ANZDATA Annual Report, Figure 5.15

1.00 First PD treatment to first peritonitis Related to age at first PD Australia 2011-2015 0.75 0.50 0.25 0.00 0 3 6 9 12 15 18 21 24 Months on PD 00-14 (112) 15-34 (427) 35-54 (1313) 55-64 (1076) 65-74 (1208) =75 (775) 2016 ANZDATA Annual Report, Figure 5.16

Clinical practice variation Local practice patterns in individual renal units Lack of high quality evidence for clinical nephrology practice Lack of clinical trials Albatross model Each renal unit doing its own thing 15

Clinical practice variation: observational data 16

Proportion of PD patients in unit

Catheter Flushing practice survey, ANZ 2017 (unpublished) Y.Cho 18

Episodes per year (95% CI) 2 1.5 1.5 0 PD peritonitis rate By treating unit, Australia 2006-2015 0 20 40 60 Treating unit Excludes units with <10 person-years PD over 2006-2015 6 12 18 36 Patient-months per episode 2016 ANZDATA Annual Report, Figure 5.25

.9 PD peritonitis rate By state, Australia 2006-2015 12 Episodes per year (95% CI).8.7.6.5.4 QLD NSW ACT VIC TAS SA NT WA 15 18 20 24 30 Patient-months per episode 2016 ANZDATA Annual Report, Figure 5.23

Percent of initial antibiotic regimens 80 60 40 20 0 2006 2007 2008 2009 2010 2011 Initial antibiotic regimen Australia 2006-2015 2012 2013 2014 2015 2016 ANZDATA Annual Report, Figure 5.29 Vancomycin Aminoglycoside

Variation: We often blame the patient It s your fault 22

Collaboration: to create new knowledge Individual unit practice Collaboration between units Acknowledgement: Tony Ibbott & David Reid, 9 th October 2008

.7 PD peritonitis rate Australia 2006-2015 18 Episodes per year (95% CI).6.5.4.3 2005 2007 2009 2011 2013 2015 20 24 30 Patient-months per episode 2016 ANZDATA Annual Report, Figure 5.22

Variability between PD Units Nadeau-Fredette et al, PDI 2016; 36: 509-518 27

A greater use of PD = less peritonitis Nadeau-Fredette et al, PDI 2016; 36: 509-518 28

Factors the impact on PD success 33

On average, how many hours does your unit spend on training a new PD nurse to become competent in training PD patients? 15.8% 21.1% 13.2% 23.7% 26.3% <15 hours 15-39 hours 40-69 hours 70-99 hours 100+ hours TEACH-PD, AKTN Survey 2016

In any one given training day, what is the usual duration of one training session for a PD patient? 11.4% 14.3% 57.1% 17.1% <2 hours 2-4 hours 4-6 hours >6 hours TEACH-PD, AKTN Survey 2016

What is the average duration of patient training prior to PD initiation at home? 14.3% 14.3% 17.1% 54.3% 2-3 days per patient 4-5 days per patient 6-7 days per patient >7 days per patient TEACH-PD, AKTN Survey 2016

INSERT FACULTY NAME IN FOOTER 40

Figueiredo et al, PDI 2016

https://ispd.org/nac/education/pd-curriculum/ 44

http://academy.theisn.org45

A Targeted Education ApproaCH to improve Peritoneal Dialysis outcomes The HOME Network & AKTN PD Working Group

Background & Rationale Major challenge of PD: treatment-related infections and technique survival large variation in peritonitis rates between PD units Cause unclear but possibly reflects variability in training of staff and subsequently patients ISPD Training Guidelines published but not yet evaluated Optimal education package not yet established

CURRENT PD TRAINING IN AUSTRALIA AUDIT [NZ in progress] Thirty-eight (70%) of 54 PD units in Australia completed an online survey. Considerable differences currently exist amongst Australian PD units in the education of staff and A written standardised curricula was utilised in 55% of units for PD nursing staff and 86% of units for patients patients. There is a general lack of delivery and 22% and 12% including an electronic delivery component for each group respectively. competency assessment to meet educational standards. It remains to be seen if harmonisation of educational Universal teaching of adult learning principles does not occur curricula can translate to improved clinical outcomes. The hours spent on teaching nursing staff ranged from <15 hours in 24% of units to >100 hours for 21 % of units. Staff competency assessed in 37% of units Boudville N, et al Nephrology (Carlton) 2017 epub ahead of print

TEACH-PD The HOME Network (Josephine Chow Chair) Educational package for training PD staff and patients A well-conducted RCT will result in potential for wider clinical impact

AKTN Working Group Nursegenerated trial idea (HOME Network) 3 nurses 3 nephrologists 1 project manager Workshop TSC 7 nurses 6 nephrologists Statistician Curriculum expert Project manager & CRA Clinical audit NUM HOME Network Module Development Nurse coinvestigators Site

TEACH-PD Trial Steering Committee Name Neil Boudville Josephine Chow Genevieve Steiner Yeoungjee Cho Melinda Tomlins Keri-Lu Equinox Carmel Hawley David Johnson Matthew Jose Anna Lee Jo-anne Moodie Elaine Pascoe Thu Nguyen Position TSC Co-Chair, AKTN Scientific Committee Chair, nephrologist TSC Co-Chair, Associate Director Strategic Projects, HOME Network Chair Online Curriculum Coordinator AKTN Clinical Trialist, nephrologist Nephrology nurse practitioner, HOME Network member HD nurse, HOME Network member AKTN Chair, nephrologist AKTN Deputy Chair, AKTN PD WG member, nephrologist AKTN PD WG Chair, nephrologist Nephrology nurse practitioner, HOME Network member Home dialysis unit NUM, AKTN PD WG member, HOME Network member Health Economist AKTN Head Biostatistics & Data Management, AKTN Methods WG Chair Auckland City Hospital, nephrologist

Prerequisite clinical knowledge Pre-assessment: multiple choice questionnaire Training framework: nurse trainers Lists core prerequisite clinical knowledge required by PD nurse trainers Recommended educational sources Online multiple choice assessment at end of each module (pass rate: 90%), plus practical assessment by in-unit mentor/accredited assessor Completion recorded on Nurse Competency Checklist Module 1a: home dialysis training an overview Assessment 1a: multiple choice questionnaire Module 1b: Personalised approaches to home dialysis training Assessment 1b: multiple choice questionnaire Modules 1a and 1b overview home dialysis training and personalised approaches for training patients to manage their PD Online Multiple choice assessment at end of each module (pass rate: 90%) Digital certificates of completion Completion recorded on Nurse Competency Checklist Module 2: Case study Somchai Assessment 2: multiple choice questionnaire Module 3: Case study Maggie Assessment 3: multiple choice questionnaire Assessment 4: case study-based assessment task Assessment 5: Nurse Competencies Checklist Case study-based modules Online multiple choice assessment at end of each module (pass rate: 100%) Digital certificates of completion Completion recorded on Nurse Competency Checklist Standardised case study assessment Case study assessed is similar to those presented in case study modules Assess patient factors and barriers impacting on home dialysis training Prepare a personalised lesson plan for a specific PD training step Assessed by in-unit mentor/accredited assessor using standard marking scheme Completion recorded on Nurse Competency Checklist Nurse Competencies Checklist In-unit mentor/accredited assessor confirms and signs record of: All completed modules and assessments Assessment of Practical competencies checklist

Training framework: patients Pre-dialysis education for patients Completion of local hospital/unit pre-dialysis education pathway Pre-dialysis education for patients Completion of local hospital/unit pre-dialysis education pathway May involve group education sessions and/or one-on-one pre-dialysis education Patients supported to undertake informed shared decision making process Patients choose PD option Patient PD training manual part 1: Getting Ready for Peritoneal Dialysis No assessment Patient training manual part 1: Getting Ready for Peritoneal Dialysis Standardised PD-related information/reference guide for patients prior to starting their PD training Information /reference guide only, no assessment Patient PD training manual part 2: Peritoneal Dialysis Training and Competencies Used alongside in-unit PD training CAPD/APD Competencies Checklist for patients Patient training manual part 2: Peritoneal Dialysis Training and Competencies Standardised PD-related information/reference guide for patients, including trouble shooting guide; used by patients during training and outside of the training environment Manual used alongside personalised approach to practical i(n-unit) PD training Nurse trainer also incorporates local hospital/unit PD training protocols Patient competencies assessed by nurse trainer against standardised CAPD or APD Competencies Checklist for patients

Current Status of Progress 2017 Survey: NZ Training Status (in progress) Modules: Final stage of revision Pilot study: To be launched in two PD units in Australia [John Hunter, NSW; Logan, Qld]

Objectives Pilot Study Primary Objective To determine the feasibility of implementing the newly developed training modules for PD patients and trainers. Secondary Objectives To inform the design of, a large-scale RCT with clinical endpoints using the newly developed standardised training modules To determine the quality of the modules through formal assessments To determine the quality of learning experience and level of satisfaction by PD trainers and patients using the developed modules

TEACH-PD Pilot Study Population and Interventions Pilot Study locations; John Hunter/Logan Hospital Induction Visit (to discuss and introduce): Curriculum, learning outcome Modules, Standardisation Patient Training Manuals Assessment and Pre-Requisite Interactive web-based training module to complete pre-requisites (4 hours to complete) Recruitment of incident patients who require PD training Training manuals and completion of 4 practical train the trainer modules (7 hours to complete, reimbursed) Clinical Assessment (Care Plan Development) (2 hours to complete, reimbursed) 6 Months Follow-up Week One Wee k Two Wee k Thre e - Four Study Outcomes Primary: Feasibility of PD training implementation - Identify barriers to practical implementation - Reproducibility Secondary: Nurse Educators training results Assessment of patient compliance, behaviour and understanding Patient retraining requirement Patient outcome (less important for pilot study) Feedback on o Quality of modules/training manual o Interphase/experience of training

TEACH-PD funding For the training modules development, clinical audit and the pilot study, the TEACH-PD Trial Steering Committee has secured the following funding: Baxter Competitor Educational Grant - A$60,000 Kidney Health Australia Enabling Grant A$10,000 BEAT-CKD Program Grant funding - A$100,000 International collaboration local context Australia New Zealand Canada Others in discussion

Our aim is to collaborate, to create new knowledge Individual unit practice Collaboration between units Acknowledgement: Tony Ibbott & David Reid, 9 th October 2008

Questions and discussion Acknowledgements Japanese Society of Nephrology (JSN) Asia-Pacific Society of Nephrology (APSN) Home Network ANZDATA AKTN P-DOPPS BEAT-CKD Program