Can augmented care in CKD stages 4-5 change the path to ESRD?

Editor’s note: Can a stronger focus on late-stage CKD and creating a healthy start at ESRD improve long-term outcomes? We reviewed with authors two clinical papers that look at the value of coordinated nursing intervention at both levels of care.

Caring for a patient in the early stages of chronic kidney disease focuses on reducing its progression through medication and change of diet. As the disease progresses to stages 4-5, the treatment approach changes. Therapeutic options are discussed to treat kidney failure, and hospitalizations tend to increase to help treat developing comorbid conditions. Can the risk for pending ESRD be reduced or better controlled with a focus on care coordination in the late stages of CKD?

NN&I Editorial Board member Nancy Pelfrey, MSN, RN, ACNP, CNN-NP, reviewed the recent paper, “Augmented nursing care management in CKD stages 4 to 5: A randomized trial” (Am. Jrnl. Kid Dis (23) 6: (2017), on whether nursing care intervention made late-stage CKD patients healthier and better prepared for renal replacement therapy. Lead author of the paper, Steven Fishbane, MD, VP and Chief of Kidney Diseases and Hypertension at Hofstra Northwell Health, answered some questions about the study.

Nancy Pelfrey, MSN, RN, ACNP, CNN-NP | Describe what you think you learned from this RCT vs. other studies on CKD intervention.

Steven Fishbane, MD | There haven’t been many RCTs performed in late stage CKD (LS-CKD). We believe there are important performance gaps in LS-CKD and a need for research to test better care models. We found that a nursing care management model resulted in improved patient outcomes and better preparation for ESRD.

NP | Describe the disease-based informatics system used in the study. What obstacles did the nurses have in using the program?

SB | We wrote the informatics system in house and were able to tailor it to increase efficiency of nursing interventions. A major obstacle was designing a system that worked as well in the office as it did on the road. The nurses do home visits and work in several different doctor offices, and this created challenges.

NP | Describe the information on training nurse managers. What characteristics do you think could make them more successful?

SB | We’ve had the most success with nurses who were previously in care management or were dialysis nurses. The training is a two-week intensive immersion in CKD care and all related issues.

NP | You saw improvements in reducing hospitalizations (primary goal) and indications that some patients were better prepared for ESRD. What were you hoping for that did not occur with the more intense focus on late-stage CKD?

SB | The study was a bit underpowered so some of our outcomes were not statistically significant. However, we know from four years of work in addition to the RCT that our results are consistent: with over 800 patients treated, preemptive transplant is sharply increased, home dialysis rates and placement of arteriovenous fistulas for in-center hemodialysis are greatly increased, and that initiation of hemodialysis without a hospitalization is consistently achieved.

NP | Describe ideas about additional payment for this approach. How could we create a model for direct reimbursement of the nursing care managementservices with a nephrologist for late-stage CKD?

SB | The published RCT did not include an economic analysis; we are currently working on this. The financial impact of this type of program should be a dramatically reduced total cost of care. It is interesting to note that there is a time dissociation issue. Investments made in stage 4-5 CKD could increase costs initially; for example, fistula surgeries, increased education, and preemptive transplantation. The ultimate return on investment is great, but occurs after the patient reaches ESRD. Different types of payment models could succeed in improving LS-CKD care; flexibility to allow for payment for care management services would be ideal.

NP | Since Medicare is now covering payment for care of patients with AKI in outpatient dialysis centers, providers have an excellent opportunity to prepare these patients for chronic ESRD care. Will this program be useful for this group of patients?

SB | There’s heterogeneity among the dialyzed AKI patients. We’ll know a lot more in a couple of years, but presumably some of these patients will regain enough renal function to come off dialysis. For others, the dialysis facilities will have responsibility to transition the patient from AKI to ESRD. - by Mark E. Neumann

Summary: Study components and outcomes

Paper: “Augmented nursing care management in CKD stages 4 to 5: A randomized trial” (Am. Jrnl. Of Kid Dis (23) 6: (2017)

Authors: Steven Fishbane, MD, Sofia Agoritsas, MPA, Alessandro Bellucci, MD, Candice Halinski, MSN, NP-C, Hitesh H. Shah, MD, and Vipul Sakhiya, MPH, Division of Kidney Diseases and Hypertension at North Shore University Hospital and Long Island Jewish Medical Center, and Leah Balsam, MD, from the Division of Nephrology, Department of Medicine, Nassau University Medical Center, East Meadows, NY.

Study type: Randomized, parallel-group, 2-arm, controlled trial

Intervention: Care management intervention – nurse care manager coordination aided by the use of a disease-based informatics system for monitoring patients’ clinical status, enhancing CKD education and facilitating preparation for ESRD; comparison control group received usual late stage CKD care alone

Outcome (primary): rate of hospitalization

Measurements:

Rate of pre-emptive transplantation

Increase in home dialysis placement

Hemodialysis starts without a hospitalization

HD start with a catheter or a functioning access – AVF, AVG

Sample Size: 130 patients randomly assigned

Results:

Reduced hospitalization

Suggestions of improved ESRD preparation