PD Masterclass 2018Home Dialysis: Empowering Patients as A Driver for Better Outcome

Dr Sunny WongHead of Division of NephrologyDepartment of Medicine & GeriatricsUnited Christian HospitalHong Kong

United Christian Hospital

• Major tertiary referral centre of Eastern Kowloon

• Has 1403 hospital beds

• One of the major renal centre in HK

• Started the first CAPD program in HK in 1980

• As at 1st July 2018, we have 455 PD patients, 192 HD patients and 319 renal transplant patients

PD First Policy in Hong Kong

• In 1985, the Central Renal Committee of Hong Kong was established to plan and develop the provision of renal replacement therapy to HK

• Not every patient with chronic renal failure can receive renal replacement therapy at that time

• Because of its cost-effectiveness, CAPD was chosen as the first-line dialysis modality for all patients with chronic renal failure who require dialysis therapy

• This allow the government to treat more patient with the limited provision of funding

Costing Comparison of Different Modes of RRT in HA

HK$0

HK$50,000

HK$100,000

HK$150,000

HK$200,000

HK$250,000

HK$300,000

Hospital HD HD PPP NHHD (FirstYear)

NHHD(Subsequent

Years)

CAPD APD (FirstYear)

APD(Subsequent

Years)

Patient Payment Charity Funded HA Funded

(Per Year)

(Pathology, pharmacy and radiology costs of hospital HD in HA excluded)

PD First Policy in Hong Kong

• For patients with ESRD who would like to seek treatment in the public hospitals will be offered PD first unless the patient have medical contraindications to undergo PD

Home Therapy • A Patient Centred Approach

• Patient Empowerment – is an integral part in patient Treatment/Rehabilitation

Continuous AmbulatoryPeritoneal Dialysis CAPD

Empowerment

• The process of gaining freedom and power to do what you want or to control what happens to you (Cambridge Dictionary)

Empowerment in the health care context

• promote autonomous self-regulation

• individual’s potential for health and wellness is maximised

Does Empowerment Improve Outcome?

• primary health status indicators (SF-36 general health and bed disability days) were significantly better

• significantly fewer specialty and emergency room visits

• Better patient satisfaction

• A number of clinical outcome, including blood sugar control/HbA1c improves

• Changes behaviour and decrease functional limitations, greater self-efficacy and greater self-care

• More compliant to treatment and produces better outcome

Does Empowerment Improve Outcome?

• Faster shared understanding, better able to adapt to end stage renal failure

• Less depression

• Create happier patients, have better relationship with staff, which makes staff happier—which, in turn, increase job satisfaction and reduces turnover.

• Empowered patients are more likely to remain employed during their treatments.

J Gen Intern Med 1988;3:448-457J Ment Health 1992;1:25-37 BMJ 2000;320: 1663-4Diabetes Care 25:695-700, 2001

Question:Patient will be happier with in-centre Haemodialysis when they are being served, compared with self care home dialysis?

Not Necessarily!

• patients treated with continuous CAPD reported better psychological health than individuals receiving hospital-based in-centerhemodialysis

• the in-center hemodialysis group described being in more emotional distress than patients who received home hemodialysis

Am J Kidney Dis. 2000;35(4):629-637.

• Patients treated with PD were 1.5 times more likely to call their care excellent overall than were hemodialysis patients

• Many PD patients rated specific facets of their care higher than did hemodialysis patients

JAMA. 2004;291(11):697-703

• PD was shown to have a clinically higher mean utility-based quality of life estimate than hemodialysis (0.72 vs 0.69), although the difference was not statistically significant (P 0.075)

PLoS Med. 2012;9(9): e1001307

Self Care Dialysis is a form of EMPOWERMENT!

Psychosocial support for PD patients

• every 1-point increase in MOS-SSS-C (Medical Outcomes Study Social Support Survey, Chinese Version) total score was associated with a 0.6% (95% CI, 0.2%-0.9%; P 0.003) reduction in risk of death and 0.5% (95% CI, 0.1%-1.0%; P 0.037) reduction in risk of technique failure

Perit Dial Int. 2008;28(3):252-258

Psychosocial support for PD patients

• 6% increase in mortality risk for each 1-point increase in discrepancy score for social companionship, a 10% increase for each point in daily emotional support, and a 2% increase for each point in total support.

Nephrol Dial Transplant. 2007;22(3):845-850

Clin J Am Soc Nephrol. 2010;5(8):1480-1488

• A decrease in social support has been linked with increased risk of hospitalization in a US cohort of incident dialysis patients

How to do it?

Empowerment in the health care context

• begins with information and education

• actively participating in treatment decisions

• requires an individual to take care of one’s self

Funnell et al. Diabetes Educ1991;17: 37-41.

Pre-Dialysis Program

• Monthly educational program for patients and their relative

• preparing patients to face ESRF• Doctor• Renal Nurse Specialist• Dietitian• Physiotherapist• Medical Social Worker• Patient Group Representatives

PD vs HD

Am J Kidney Dis. 62(5):993-1005

All showed an initial survival advantage of patients who received PD during their first 1-2 years of dialysis or no difference in survival

PD vs HD: Residual Renal Function

• PD preserve residual renal function better than HD, which contributes substantially to the overall health and survival benefit of dialysis patients

PD vs HD: Infectious Complications

PD:

• Peritonitis but some program has peritonitis rate down to 0.2/patient-year

HD:

• 1-year mortality was similar in hemodialysis patients who used an arteriovenous fistula or arteriovenous graft, but was 80% higher in those who initiated hemodialysis with a central venous catheter compared with PD

J Am Soc Nephrol. 2011;22(6):1113-1121

PD vs HD: Infectious Complications

• In a USRDS study of incident dialysis patients, hemodialysis was associated significantly with pneumonia even after adjustment (adjusted HR of 1.41 when PD was the reference group)

• According to 2009 USRDS data, hospital admission rates for hemodialysis patients for bacteremia or sepsis, are 2-fold higher than they are for PD patients

Nephrol Dial Transplant. 2008;23(2):680-686.

Am J Kidney Dis. 2012;59(1)(suppl 1):e1-e420

PD vs HD: Quality of Life• Improved health-related quality of life and home based therapy with

patient autonomy and satisfaction

Automated PD as a further option to improve quality of life!

Renal Replacement Therapy Assessment

• Nephrologists, Renal Nurses

• MSW

• Dietitian

• Occupational Therapist & Physiotherapist

• Clinical Psychologist

• Pharmacist

Renal Nurse Clinic• personal counseling

• education

• wound care

• evaluation of patient’s psychosocial & vocational condition with appropriate referral

• patient assessment and formulation of care plan

• PD Theory & Technique training

• Advice on living with ESRF and dialysis

• Rapport building with the staff and the renal unit

• Perform home visit and inspection of home environment and report to renal assessment meeting

• Give advice on appropriate home modification to prepare for home PD

• Supervised 1st PD exchange at home after training

• Other home nursing care as necessary

Community Nurse Service (CNS)

24 hour Renal Hotline

Patient Sharing Program• Mixing new and experienced patient

in the program

• Ventilation on problem encountered after self performing PD at home

• Sharing by experienced patients, under the supervision of MSW and Renal Nurses

• Introduction of Patient Support Group!

– “P to P Home Visit Program”

– providing psychosocial support at home and

– Mobilizing patients back to community activities

Home Visit Program

Local Renal Patient Exercise Groups

At the 10th anniversary of our CRP in 2009

128 prevalent Participant patients reviewed

Outcome of CRP

Hospitalization rates - CRP Vs sampled consecutive control

13.5

18.4

0

2

4

6

8

10

12

14

16

18

20

CRP Control Group

Ho

spitaliz

atio

n R

ate

s - d

ays/p

atie

nt y

ears

p=0.01

Significantly lower hospitalization rates

Significantly longer Patient Survival

Median patient survival 6.6 years for the CRP group Vs 4.3 years in control group

Tai Chi Class

A powerful resource that helps patients to cope with end stage renal failure.....

Started in 1981, the 1st renal patient group in HK

-

Patient Empowerment and Rehabilitation

Health Talk, Psychosocial

Education Program

Leisure and Recreational

Activities: Overnight

Camp, Picnic

Volunteer Training, Caregiver Support Program

Ultrabag Connecting Device (UC Device)

UC Device

454545

UC devicePatient can perform independent and safe PD exchange

Unsafe PD connection

46

Achievement / Contribution

p = 0.00

0.000

0.250

0.500

0.750

1.000

0 1 2 3 4 5

Technique Survival - Death Censored - Device Vs Control

Duration in YearsSur

viva

l Pro

babi

lity p= 0.7914

UC Device

Control

Similar Technique Survivals

LESS Peritonitis complications

• a study performed in 2010

• 44 patients using UC device were compared with 66 control group patients

The

results

The empowered patients can

deliver superior results

474747

• So far, more than 230 patients have used UC Device• In 2017, 98 patients received Continuous Ambulatory Peritoneal Dialysis (CAPD)

training. • There were 31 patients (~32%) who required UC device. • 7 patients (~22.6% who required UC device) could retain their job after PD

training. • And the other 24 patients could perform PD independently and their family

members could retain their usual role as well.

Current Data

UC DeviceUCH 2012 Bright Suggestion Scheme- Silver Award

UC DeviceAsia Hospital Management Award 2013- Excellent Award

The empowered patients with appropriate adjustments in living with ESRF can become an important partnerin PD management

They can share their experience with new patients

They can provide psychosocial support as peers in “P to P Home Visit Program”

They can be leaders in Community Rehabilitation Exercise groups

Patient as partner in PD management

They organize annual patient gatherings

Health talks

Trainings

Sharing in Pre-Dialysis Program

Visit patients in wards

Female Dialysis Patient Overall Champion, Male Dialysis Patient First Runner Up, Female Transplant Patient First Runner Up

3rd Hong Kong Transplant & Dialysis Game

Take Home Message

• For a home based therapy to be successful, patient centred care and patient empowerment are essential

• Patient Empowerment can result in better clinical outcome

• Staff and Peers are important source of Patient Empowerment

• Patient Group is a power resource and partner in Patient Empowerment

Patient Empowerment!