Online clinical pathway for chronic kidney disease management in primary care: a retrospective cohort study.

BACKGROUND: Clinical pathways aim to improve patient care. We sought to determine whether an online chronic kidney disease (CKD) clinical pathway was associated with improvements in CKD management. METHODS: We conducted a retrospective pre/post population-based cohort study using linked health data from Alberta, Canada. We included adults 18 years or older with mean estimated glomerular filtration rate (eGFR) < 60 ml/min/1.73m2. The primary outcome was measurement of an outpatient urine albumin creatinine ratio (ACR) in a 28-day period, among people without a test in the prior year. Secondary outcomes included use of guideline-recommended drug therapies (angiotensin-converting enzyme inhibitors, angiotensin receptor blockers and statins). RESULTS: The study period spanned October 2010 to March 2017. There were 84 independent 28-day periods (53 pre, 31 post pathway implementation) including 345,058 adults. The population was predominantly female (56%) with median age 77 years; most had category 3A CKD (67%) and hypertension (82%). In adjusted segmented regression models, the increase in the rate of change of ACR testing was greatest in Calgary zone (adjusted OR 1.19 per year, 95% CI 1.16-1.21), where dissemination of the pathway was strongest; this increase was more pronounced in those without diabetes (adjusted OR 1.25 per year, 95% CI 1.21-1.29). Small improvements in guideline-concordant medication use were also observed. CONCLUSIONS: Following implementation of an online CKD clinical pathway, improvements in ACR testing were evident in regions where the pathway was most actively used, particularly among individuals without diabetes.

Can economic incentives increase the use of home dialysis?

There are advantages to home dialysis for patients, and kidney care programs, but use remains low in most countries. Health-care policy-makers have many levers to increase use of home dialysis, one of them being economic incentives. These include how health-care funding is provided to kidney care programs and dialysis facilities; how physicians are remunerated for care of home dialysis patients; and financial incentives-or removal of disincentives-for home dialysis patients. This report is based on a comprehensive literature review summarizing the impact of economic incentives for home dialysis and a workshop that brought together an international group of policy-makers, health economists and home dialysis experts to discuss how economic incentives (or removal of economic disincentives) might be used to increase the use of home dialysis. The results of the literature review and the consensus of workshop participants were that financial incentives to dialysis facilities for home dialysis (for instance, through activity-based funding), particularly in for-profit systems, could lead to a small increase in use of home dialysis. The evidence was less clear on the impact of economic incentives for nephrologists, and participants felt this was less important than a nephrologist workforce in support of home dialysis. Workshop participants felt that patient-borne costs experienced by home dialysis patients were unjust and inequitable, though participants noted that there was no evidence that decreasing patient-borne costs would increase use of home dialysis, even among low-income patients. The use of financial incentives for home dialysis-whether directed at dialysis facilities, nephrologists or patients-is only one part of a high-performing system that seeks to increase use of home dialysis.

Development and implementation of an online clinical pathway for adult chronic kidney disease in primary care: a mixed methods study.

BACKGROUND: Primary care physicians and other primary health care professionals from Alberta, Canada identified a clinical pathway as a potential tool to facilitate uptake of clinical practice guidelines for the diagnosis, management and referral of adults with chronic kidney disease. We describe the development and implementation of a chronic kidney disease clinical pathway (CKD-CP; www.ckdpathway.ca ). METHODS: The CKD-CP was developed and implemented based on the principles of the Knowledge-To-Action Cycle framework. We used a mixed methods approach to identify the usability and feasibility of the CKD-CP. This included individual interviews, an online survey and website analytics, to gather data on barriers and facilitators to use, perceived usefulness and characteristics of users. Results are reported using conventional qualitative content analysis and descriptive statistics. RESULTS: Eighteen individual interviews were conducted with primary care physicians, nephrologists, pharmacists and nurse practitioners to identify themes reflecting both barriers and facilitators to integrating the CKD-CP into clinical practice. Themes identified included: communication, work efficiency and confidence. Of the 159 participants that completed the online survey, the majority (52 %) were first time CKD-CP users. Among those who had previously used the CKD-CP, 94 % agreed or strongly agreed that the pathway was user friendly, provided useful information and increased their knowledge and confidence in the care of patients with CKD. Between November 2014 and July 2015, the CKD-CP website had 10,710 visits, 67 % of which were new visitors. The 3 most frequently visited web pages were home, diagnose and medical management. Canada, Indonesia and the United States were the top 3 countries accessing the website during the 9 month period. CONCLUSIONS: An interactive, online, point-of-care tool for primary care providers can be developed and implemented to assist in the care of patients with CKD. Our findings are important for making refinements to the CKD -CP website via ongoing discussions with end-users and the development team, along with continued dissemination using multiple strategies.

The effect of citrate dialysate on intradialytic heparin dose in haemodialysis patients: study design of a randomised controlled trial.

BACKGROUND: Unfractionated heparin is the most common anticoagulant used in haemodialysis (HD), although it has many potential adverse effects. Citrate dialysate (CD) has an anticoagulant effect which may allow reduction in cumulative heparin dose (CHD) compared to standard acetate dialysate (AD). METHODS: This double-blinded, randomised, cross-over trial of chronic haemodialysis patients determines if CD allows reduction in CHD during HD compared with AD. After enrolment, intradialytic heparin is minimised during a two-week run-in period using a standardised protocol based on a visual clotting score. Patients still requiring intradialytic heparin after the run-in period are randomised to two weeks of HD with AD followed by two weeks of CD (Sequence 1) or two weeks of HD with CD followed by two weeks of AD (Sequence 2). The primary outcome is the change in CHD with CD compared with AD. Secondary outcomes include metabolic and haemodynamic parameters, and dialysis adequacy. DISCUSSION: This randomised controlled trial will determine the impact of CD compared with AD on CHD during HD. TRIAL REGISTRATION: ClinicalTrials.gov NCT01466959.

An economic evaluation of rt-PA locking solution in dialysis catheters.

In a recent randomized trial, weekly recombinant tissue plasminogen activator (rt-PA), 1 mg per lumen, once per week, and twice-weekly heparin as a locking solution (rt-PA/heparin) resulted in lower risks of hemodialysis catheter malfunction and catheter-related bacteremia compared with thrice-weekly heparin (heparin alone). We collected detailed costs within this trial to determine how choice of locking solution would affect overall health care costs, including the cost of locking solutions and all other relevant medical costs over the course of the 6-month trial. Nonparametric bootstrap estimates were used to derive 95% confidence intervals (CIs) and mean cost differences between the treatment groups. The cost of the locking solution was higher in patients receiving rt-PA/heparin, but this was partially offset by lower costs for managing complications. Overall, the difference in unadjusted mean cost for managing patients with rt-PA/heparin versus heparin alone was Can$323 (95% CI, -$935 to $1581; P=0.62). When the costs were extrapolated over a 1-year time horizon using decision analysis, assuming ongoing rt-PA effectiveness, the overall costs of the strategies were similar. This finding was sensitive to plausible variation in the frequency and cost of managing patients with catheter-related bacteremia, and whether the benefit of rt-PA on catheter-related bacteremia was maintained in the long term. In summary, we noted no significant difference in the mean overall cost of an rt-PA/heparin strategy as a locking solution for catheters compared with thrice-weekly heparin. Cost savings due to a lower risk of hospitalization for catheter-related bacteremia partially offset the increased cost of rt-PA.

Prevention of dialysis catheter malfunction with recombinant tissue plasminogen activator.

BACKGROUND: The effectiveness of various solutions instilled into the central venous catheter lumens after each hemodialysis session (catheter locking solutions) to decrease the risk of catheter malfunction and bacteremia in patients undergoing hemodialysis is unknown. METHODS: We randomly assigned 225 patients undergoing long-term hemodialysis in whom a central venous catheter had been newly inserted to a catheter-locking regimen of heparin (5000 U per milliliter) three times per week or recombinant tissue plasminogen activator (rt-PA) (1 mg in each lumen) substituted for heparin at the midweek session (with heparin used in the other two sessions). The primary outcome was catheter malfunction, and the secondary outcome was catheter-related bacteremia. The treatment period was 6 months; treatment assignments were concealed from the patients, investigators, and trial personnel. RESULTS: A catheter malfunction occurred in 40 of the 115 patients assigned to heparin only (34.8%) and 22 of the 110 patients assigned to rt-PA (20.0%)--an increase in the risk of catheter malfunction by a factor of almost 2 among patients treated with heparin only as compared with those treated with rt-PA once weekly (hazard ratio, 1.91; 95% confidence interval [CI], 1.13 to 3.22; P = 0.02). Catheter-related bacteremia occurred in 15 patients (13.0%) assigned to heparin only, as compared with 5 (4.5%) assigned to rt-PA (corresponding to 1.37 and 0.40 episodes per 1000 patient-days in the heparin and rt-PA groups, respectively; P = 0.02). The risk of bacteremia from any cause was higher in the heparin group than in the rt-PA group by a factor of 3 (hazard ratio, 3.30; 95% CI, 1.18 to 9.22; P = 0.02). The risk of adverse events, including bleeding, was similar in the two groups. CONCLUSIONS: The use of rt-PA instead of heparin once weekly, as compared with the use of heparin three times a week, as a locking solution for central venous catheters significantly reduced the incidence of catheter malfunction and bacteremia. (Current Controlled Trials number, ISRCTN35253449.).

The impact of the Starting dialysis on Time, At home on the Right Therapy (START) project on the use of peritoneal dialysis.

BACKGROUND: Peritoneal dialysis (PD) is actively promoted, but increasing PD utilisation is difficult. The objective of this study was to determine if the Starting dialysis on Time, At Home, on the Right Therapy (START) project was associated with an increase in the proportion of dialysis patients receiving PD within 6 months of starting therapy. METHODS: Consecutive patients over age 18, with end-stage kidney failure, who started dialysis between 1 April 2015 and 31 March 2018 in the province of Alberta, Canada. Programmes were provided with high-quality data about the individual steps in the process of care that drive PD utilisation that were used to identify problem areas, design and implement interventions to address them, and then evaluate whether those interventions had impact. The primary outcome was the proportion of patients receiving PD within 6 months of starting dialysis. Secondary outcomes included hospitalisation, death or probability of transfer to haemodialysis (HD). Interrupted time series methodology was used to evaluate the impact of the quality improvement initiative on the primary and secondary outcomes. RESULTS: A total of 1962 patients started dialysis during the study period. Twenty-seven per cent of incident patients received PD at baseline, and there was a 5.4% (95% confidence interval: 1.5-9.2) increase in the use of PD in the province immediately after implementation. There were no changes in the rates of hospitalisation, death or probability of transfer to HD after the introduction of START. CONCLUSIONS: The approach used in the START project was associated with an increase in the use of PD in a setting with high baseline utilisation.

Hemoglobin stability in patients with anemia, CKD, and type 2 diabetes: an analysis of the TREAT (Trial to Reduce Cardiovascular Events With Aranesp Therapy) placebo arm.

BACKGROUND: Sparse data are available about the natural history of hemoglobin (Hb) level trends in contemporary patients with anemia, chronic kidney disease (CKD), and type 2 diabetes mellitus. We intended to describe Hb level trends over time with no or minimal administration of erythropoiesis-stimulating agents. STUDY DESIGN: Prospective clinical trial cohort. SETTING & PARTICIPANTS: 2,019 individuals with type 2 diabetes, moderate anemia, and CKD from the placebo arm of the Trial to Reduce Cardiovascular Events With Aranesp Therapy (TREAT) followed up for 2.3 years with an average of 32 monthly Hb level determinations per patient. Darbepoetin alfa was administered only if Hb level decreased to <9 g/dL. OUTCOMES & MEASUREMENTS: Number of protocol-directed doses of darbepoetin alfa received due to an Hb level decrease to <9 g/dL. RESULTS: 1,106 (55%) placebo patients consistently maintained an Hb level ≥9 g/dL and received no protocol-directed darbepoetin alfa. The other patients received 1 (16%), 2-4 (16%), or 5 or more (13%) doses of darbepoetin alfa. Those who received no darbepoetin alfa doses had higher baseline Hb levels, higher estimated glomerular filtration rates (eGFRs), less proteinuria, and lower ferritin and transferrin saturation values. On average, Hb levels were stable or increased in all groups. Compared with individuals who received no darbepoetin alfa, those who received 5 or more doses were more likely to receive intravenous iron therapy and blood transfusions and progress to renal replacement therapy, but were not at higher risk of death. The strongest predictors of requiring 5 or more doses of darbepoetin alfa were lower baseline Hb level, lower eGFR, and higher proteinuria level. LIMITATIONS: Post hoc analysis of a clinical trial of a specific population with diabetes, anemia, and non-dialysis-dependent CKD. CONCLUSIONS: In the TREAT placebo arm, Hb levels were stable with no or minimal protocol-directed darbepoetin alfa during 2.3 years of follow-up. Most patients with moderate anemia, non-dialysis-dependent CKD, and type 2 diabetes are able to maintain a stable Hb level without implementing long-term erythropoiesis-stimulating agent therapy.

Assessment of the Siksika chronic disease nephropathy-prevention clinic.

OBJECTIVE: To determine if a community-based multifactorial intervention clinic led by a nurse practitioner would improve management of First Nations people at risk of developing chronic kidney disease. DESIGN: Qualitative descriptive study. SETTING: A nephropathy-prevention clinic in Siksika Nation, Alta. PARTICIPANTS: First Nations people with diabetes, hypertension, or dyslipidemia who were referred to the clinic. MAIN OUTCOME MEASURES: Changes in blood pressure (BP), hemoglobin A(1c), and low-density lipoprotein levels, as well as in use of antiplatelet therapy, angiotensin-converting enzyme inhibitor or angiotensin receptor blocker medications, and statin therapy. RESULTS: Members of the Siksika Nation were treated according to clinical practice guidelines. A total of 78 patients had at least 2 visits to the clinic and were included in this analysis (61.5% were women; mean age 56 years). Among those initially above target, a significant reduction was achieved in mean hemoglobin A(1c) (0.96%; P < .01), systolic BP (15.84 mm Hg; P < .05), diastolic BP (7.16 mm Hg; P < .001), and low-density lipoprotein (0.62 mmol/L; P < .01) levels. There was a significant increase in the proportion of patients with clinical indications who were treated with acetylsalicylic acid (42.4%; P < .01), angiotensin-converting enzyme inhibitor or angiotensin receptor blocker medications (35.9%; P < .01), or statin therapy (35.9%; P < .01). CONCLUSION: A community-based, nurse practitioner-led clinic can improve many clinically relevant factors in patients at risk of developing chronic kidney disease. Studies have shown that achieving treatment targets is associated with a reduced risk of early death and cardiovascular events; the effect in the First Nations population on these hard clinical end points remains to be determined.

Use of sodium-glucose cotransporter 2 inhibitors in Alberta adults with chronic kidney disease: a cross-sectional study identifying care gaps to inform knowledge translation.

BACKGROUND: Sodium-glucose cotransporter 2 (SGLT2) inhibitors have important kidney and cardiovascular benefits in adults with chronic kidney disease. Among adults with diabetes, we characterized the prevalence of chronic kidney disease eligible for SGLT2 inhibitor treatment, based on definitions of eligibility from trials and diabetes guidelines, and assessed the predictors of SGLT2 inhibitor use. METHODS: We conducted a cross-sectional study using linked administrative data from Alberta Health in adults with diabetes (2002-2019). Chronic kidney disease was defined as an estimated glomerular filtration rate (eGFR) less than 90 mL/min/1.73 m2 with severe or greater proteinuria (trial-based definition); or eGFR less than 60 mL/min/1.73 m2 or moderate or greater proteinuria regardless of eGFR (diabetes guideline-based definition). Predictors (sociodemographic characteristics, comorbidities and health care utilization) of SGLT2 inhibitor use were identified using logistic regression. RESULTS: Of 446 315 adults with diabetes, 76 630 (17.2%, guideline-based definition; 12 867 [2.9%], trial-based definition) had chronic kidney disease eligible for SGLT2 inhibitor treatment. A total of 7.1% used SGLT2 inhibitors. Older age, lower hemoglobin A1c (HbA1c) levels, female sex, lower neighbourhood income, rural residence and hospital admission were among variables associated with nonuse of SGLT2 inhibitors (adjusted odds ratios [ORs] from 0.13 [age ≥ 85 yr] to 0.92 [rural residence], p < 0.05). Family physician visits were associated with higher SGLT2 inhibitor use (adjusted OR 4.01, p < 0.001 for > 4 visits/yr). Considering all adults, both with and without diabetes, 162 012 individuals with chronic kidney disease (5% of all Alberta adults) may benefit from treatment with SGLT2 inhibitors. INTERPRETATION: Many adults with chronic kidney disease would derive heart and kidney benefits from treatment with SGLT2 inhibitors but had low SGLT2 inhibitor use as of 2019. Efforts will be needed to address lower use of SGLT2 inhibitors among female, older and lower-income adults, and to enhance primary care and promote awareness of the benefits of SGLT2 inhibitors independent of glycemic control.

Use of Google Analytics to Explore Dissemination Activities for an Online CKD Clinical Pathway: A Retrospective Study.

Background: Data on dissemination strategies that generate awareness of clinical pathways for kidney care are limited. Objective: This study reports the application of Google Analytics to describe the reach and use of the Chronic Kidney Disease Pathway (CKD-P) using a multi-faceted dissemination strategy. Design: The design of this study is a retrospective descriptive study. Setting: This study was conducted in Alberta, Canada. Patients: Individuals who accessed the CKD-P Web site between November 5, 2014, and May 31, 2019. Measurements: Dissemination activities included print, electronic, in-person meetings, and a laboratory prompt. We used Google Analytics over a 5-year period to evaluate the following CKD-P Web site user metrics: number of sessions, pageviews, visit duration, user path, and bounce rate (when an individual visits a single page of the Web site and leaves the Web site without interacting with additional pages). Methods: We plotted dissemination activities alongside Web site metrics using control charts and described the data using means and percentages. We performed chi-square test for trends to evaluate year-over-year usage. Results: There were 83 294 users, 90 805 sessions, and 231 684 pageviews. The overall bounce rate was 45.7%. Each user had an average of 1.5 sessions and a session duration of 2 minutes and 8 seconds. There was a significant positive trend for total annual users (P = .008), new users (P = .009), number of sessions (P = .006), and pageviews per day (P = .016). Limitations: We were unable to confirm if users were primary care providers and if word-of-mouth dissemination among providers/researchers drove people to use the CKD-P. Conclusions: Google Analytics was a useful and accessible tool for evaluating CKD-P reach and use trends. It was challenging to identify how individual dissemination activities contributed to CKD-P reach; however, repeated dissemination appeared to play a role in increasing CKD-P use. Trial registration: Not applicable-observational study design.

Contexte: Il existe peu de données sur les stratégies de diffusion pour sensibiliser les différents intervenants aux plans d'intervention en santé rénale. Objectif: Cette étude rend compte de l'utilization de Google Analytics pour décrire la portée et l'utilization d'un plan d'intervention en ligne pour l'insuffisance rénale chronique (CKD-P ­ Chronic Kidney Disease Pathway) à l'aide d'une stratégie de diffusion à plusieurs facettes. Conception de l'étude: Étude descriptive rétrospective. Cadre: Alberta, Canada. Sujets: Les individus ayant accédé au site Web CKD-P entre le 5 novembre 2014 et le 31 mai 2019. Mesures: Les activités de diffusion comprenaient des documents imprimés, des documents électroniques, des réunions en personne et un lien internet vers le site web de CKD-P lors de la transmission d'un résultat anormal de laboratoire. Nous avons utilisé Google Analytics pendant cinq ans pour évaluer les mesures suivantes pour les utilisateurs du site Web CKD-P: nombre de sessions, vues de page, durée des visites, chemin d'accès utilisateur et taux de rebond (lorsqu'une personne visite une seule page du site Web et le quitte sans interagir avec d'autres pages). Méthodologie: Les activités de diffusion et les paramètres du site Web sont présentés à l'aide de tableaux de contrôle, et les données à l'aide de moyennes et de pourcentages. Un test de Chi-Deux a servi à déterminer les tendances et évaluer l'utilization d'une année sur l'autre. Résultats: Nous avons répertorié 83 294 utilisateurs, 90 805 sessions et 231 684 pages consultées. Le taux de rebond global était de 45,7 %. En moyenne, chaque utilisateur comptait 1,5 session dont la durée moyenne était de 2 minutes 8 secondes. On a observé une tendance positive significative pour le nombre total annuel d'utilisateurs (P = 0,008), les nouveaux utilisateurs (P = 0,009), le nombre de sessions (P = 0,006) et les vues de pages par jour (P = 0,016). Limites: Il n'a pas été possible de confirmer si les utilisateurs étaient des fournisseurs de soins primaires et si la diffusion de bouche-à-oreille entre les fournisseurs/chercheurs avait amené les gens à utiliser CKD-P. Conclusion: Google Analytics s'est avéré un outil utile et accessible pour évaluer les tendances de portée et d'utilization de CKD-P. Il est difficile d'établir comment les activités de diffusion individuelles contribuent à la portée de CKD-P; la diffusion répétée semble néanmoins jouer un rôle dans l'augmentation de l'utilization de CKD-P. Enregistrement de l'essai: Sans objet ­ étude observationnelle.

Impact of Home Telemonitoring and Management Support on Blood Pressure Control in Nondialysis CKD: A Systematic Review and Meta-Analysis.

Background: Hypertension is a major cause of cardiovascular disease, chronic kidney disease (CKD), and death. Several studies have demonstrated the efficacy of home blood pressure telemonitoring (HBPT) for blood pressure (BP) control and outcomes, but the effects of this intervention remain unclear in patients with CKD. Objective: To determine the impact of HBPT on cardiovascular-related and kidney disease-related outcomes in patients with CKD. Design: Systematic review and meta-analysis. Setting: All studies that met our criteria regardless of country of origin. Participants: Patients with chronic kidney disease included in studies using HBPT for BP assessment and control. Measurements: Descriptive and quantitative analysis of our primary and secondary outcomes. Methods: We searched MEDLINE, Embase, CINAHL Plus, PsycINFO, Cochrane CENTRAL, Web of Science, and gray literature from inception for observational and randomized controlled studies in nondialysis (ND) CKD using HBPT for BP control. We selected studies that used HBPT as intervention (with or without a control arm) for BP control in ND-CKD populations. The primary outcome was change in mean systolic BP (SBP) and mean diastolic BP (DBP). Results: We selected 7 studies from 1669 articles that were initially identified. Overall, pooled estimates in the mean difference (MD) for SBP and DBP were -8.8 mm Hg; 95% confidence interval (CI): -16.2 to -1.4; P = .02 and -2.4 mm Hg; 95% CI: -3.8 to -1.0; P < .001, respectively. For studies comparing intervention with usual care (UC), pooled estimate in MD for SBP was -8.0 mm Hg (P = .02) with no significant reduction for DBP (-2.6 mm Hg; P = .18). In studies without a UC arm, both SBP and DBP were not significantly reduced (P > .05). The pooled estimate in MD for estimated glomerular filtration rate showed a significant improvement (5.4 mL/min/1.73 m2; P < .001). Limitations: Heterogeneity and few available studies for inclusion limited our ability to identify a robust link between HBPT use and BP and kidney function improvement. Conclusion: Home blood pressure telemonitoring is associated with mild lowering of BP and moderately improved kidney function in patients with CKD. However, larger studies with improved designs and prolonged interventions are still needed to assess the effects of HBPT on patients' outcomes. PROSPERO registration ID: CRD42020190705.

Contexte: L'hypertension est une cause majeure de maladie cardiovasculaire, d'insuffisance rénale chronique (IRC) et de mortalité. Plusieurs études ont montré l'efficacité de la télésurveillance de la pression artérielle à domicile (TSPA) pour le contrôle de la pression artérielle (PA) et les évènements cliniques, mais les effets de cette intervention demeurent mal connus chez les patients atteints d'IRC. Objectif: Évaluer l'effet de la TSPA sur les évènements cardiovasculaires et rénaux chez les patients atteints d'IRC. Conception: Revue systématique et méta-analyse. Sources: Toutes les études satisfaisant nos critères, peu importe le pays d'origine. Sujets: Les patients atteints d'IRC inclus dans les études portant sur l'utilisation de la TSPA pour réguler la pression artérielle. Mesures: Analyse descriptive et quantitative de nos résultats primaires et secondaires. Méthodologie: Nous avons consulté les bases de données MEDLINE, embase, CINAHL plus, PsycINFO, Cochrane CENTRAL et Web of Science, de même que la littérature grise depuis leur début, à la recherche des études observationnelles contrôlées et randomisées portant sur l'utilisation de la TSPA pour contrôler la PA chez des patients atteints d'IRC non dialysés. Nous avons sélectionné les études (avec ou sans bras témoin) utilisant l'intervention (TSPA pour contrôler la PA) dans des populations de patients atteints d'IRC non dialysés. Le principal critère d'évaluation était un changement de la pression systolique moyenne (PSM) et de la pression diastolique moyenne (PDM). Résultats: Nous avons retenu sept études parmi les 1 669 articles initialement répertoriés. Dans l'ensemble, les estimations regroupées de la différence moyenne (DM) pour la PSM et la PDM étaient de −8,8 mmHg (IC 95%: −16,2 à −1,4; P = 0,02) et de −2,4 mmHg (IC 95%: −3,8 à −1,0; P < 0,001) respectivement. Dans les études qui comparaient l'intervention aux soins habituels (SH), les estimations regroupées de la DM s'établissaient à −8,0 mmHg (P = 0,02) pour la PSM, sans réduction significative pour la PDM (−2,6 mmHg; P = 0,18). Dans les études sans bras SH, aucune réduction significative n'a été observée pour la PSM et la PDM (P > 0,05). L'estimation groupée de la DM pour le débit de filtration glomérulaire estimé (DFGe) a montré une amélioration significative (5,4 ml/min/1,73 m2; P < 0,001). Limites: Le peu d'études disponibles pour inclusion et leur hétérogénéité limitent notre capacité à établir un lien robuste entre l'utilisation de la TSPA et une amélioration de la PA et de la fonction rénale. Conclusion: La TSPA est associée à une légère baisse de la PA et à une amélioration modérée de la fonction rénale chez les patients atteints d'IRC. Des études de plus grande envergure, avec des conceptions améliorées et des interventions prolongées, sont nécessaires pour mieux évaluer les effets de la TSPA sur les résultats des patients.

Telemonitoring and Case Management for Hypertensive and Remote-Dwelling Patients With Chronic Kidney Disease-The Telemonitoring for Improved Kidney Outcomes Study (TIKO): A Clinical Research Protocol.

BACKGROUND: Hypertension, together with poorly controlled blood pressure (BP) are known risk factors for kidney disease and progression to kidney failure as well as increased cardiovascular (CV) morbidity and mortality. Several studies in patients without kidney disease have demonstrated the efficacy of home BP telemonitoring (HBPT) for BP control. OBJECTIVE: The primary aim of this study is to assess the mean difference in systolic BP (SBP) at 12 months, from baseline in remote dwelling patients with hypertension and chronic kidney disease (CKD) in Northern Alberta, Canada, comparing HBPT + usual care versus HBPT + a case manager. Other secondary objectives, including cost-effectiveness and acceptability of HBPT as well as occurrence of adverse events will also be assessed. DESIGN: This study is designed as a pragmatic randomized controlled trial (RCT) of HBPT plus clinical case management compared to HBPT with usual care. SETTING: Peace River region in Northern Alberta Region, Canada. PATIENTS: Primary care patients with CKD and hypertension. MEASUREMENTS: Eligible patients will be randomized 1:1 to HBPT + BP case management versus HBPT + usual care. In the intervention arm, BP will be measured 4 times daily for 1 week, with medications titrated up or down by the study case manager until guideline targets (systolic BP [SBP]: <130 mmHg) are achieved. Once BP is controlled, (ie, to guideline-concordant targets), this 1-week protocol will be repeated every 3 months for 1 year. Patients in the control arm will also follow the same BP measurement protocol; however, there will be no interactions with the case manager; they will share their BP readings with their primary care physicians or nurse practitioners at scheduled visits. LIMITATIONS: Potential limitations of this study include the relatively short duration of follow-up, possible technological pitfalls, and need for patients to own a smartphone and have access to the internet to participate. CONCLUSIONS: As this study will focus on a high-risk population that has been characterized by a large care gap, it will generate important evidence that would allow targeted and effective population-level strategies to be implemented to improve health outcomes for high-risk hypertensive CKD patients in Canada's remote communities. TRIAL REGISTRATION: www.clinicaltrials.gov (NCT number: NCT04098354).

CONTEXTE: L'hypertension et la pression artérielle (PA) mal contrôlée sont des facteurs de risque reconnus pour la néphropathie et la progression vers l'insuffisance rénale, en plus de poser un risque accru de morbidité et de mortalité cardiovasculaires. Plusieurs études chez des patients sans néphropathie ont démontré l'efficacité de la télésurveillance de la PA à domicile (TSPA) pour le contrôle de la PA. OBJECTIFS: Le principal objectif est d'évaluer la différence moyenne de pression artérielle systolique (PAS) après 12 mois par rapport à sa valeur initiale chez des patients atteints d'hypertension et d'insuffisance rénale chronique (IRC) habitant les communautés éloignées du nord de l'Alberta (Canada). Cet objectif sera atteint en comparant la TSPA + soins habituels à la TSPA + gestionnaire de cas. D'autres objectifs secondaires, notamment le rapport coût/efficacité de la TSPA, son acceptation et la survenue d'événements indésirables seront également évalués. TYPE D'ÉTUDE: Cette étude est conçue comme un essai randomisé contrôlé (ERC) pragmatique comparant la TSPA + prise en charge clinique des cas à la TSPA + soins habituels. CADRE: Région de Peace River dans le nord de l'Alberta (Canada). SUJETS: Patients atteints d'IRC et d'hypertension recevant des soins de santé primaires. MESURES: Les patients admissibles seront répartis 1:1 dans le groupe TSPA + prise en charge du cas d'hypertension ou dans le groupe témoin (TSPA + soins habituels). Dans le groupe d'intervention, la PA sera mesurée quatre fois par jour pendant une semaine, avec augmentation ou réduction de la médication par le gestionnaire de cas de l'étude jusqu'à ce que la cible de référence (PAS : <130 mmHg) soit atteinte. Une fois la PA contrôlée (c.-à-d. conforme aux cibles recommandées), ce protocole sur une semaine sera répété tous les trois mois pendant un an. Les patients du groupe témoin suivront le même protocole de mesure de la PA, mais sans interactions avec le gestionnaire de cas, ils transmettront plutôt leurs mesures de PA à leur médecin de soins primaires ou aux infirmières praticiennes lors de visites prévues. LIMITES: Cette étude est notamment limitée par la durée relativement courte du suivi, de possibles difficultés technologiques et la nécessité pour les participants de posséder un téléphone intelligent et d'avoir accès à l'Internet. CONCLUSION: Puisque cette étude se penchera sur une population à risque élevé et marquée par d'importantes lacunes en matière de soins, elle générera des données importantes qui aideront à mettre en œuvre des stratégies ciblées et efficaces au niveau de la population afin d'améliorer les évènements cliniques des patients hypertendus et atteints d'IRC à haut risque habitant les communautés éloignées au Canada.

Starting Dialysis on Time, At Home on the Right Therapy (START): Description of an Intervention to Increase the Safe and Effective Use of Peritoneal Dialysis.

BACKGROUND: Most of the patients with end-stage kidney failure are treated with dialysis. Jurisdictions around the world are actively promoting peritoneal dialysis (PD) because it is equivalent to hemodialysis in terms of clinical outcomes, but is less costly. Unfortunately, PD penetration remains low. OBJECTIVES: The Starting dialysis on Time, At Home, on the Right Therapy (START) Project had 2 overarching goals: (1) to provide information that would help programs increase the safe and effective use of PD, and (2) to reduce inappropriate, early initiation of dialysis in patients with kidney failure. In this article, we focus on the first objective and describe the rationale for START and the methods employed. DESIGN: The START Project was a comprehensive, province-wide quality improvement intervention. SETTING: The START project was implemented in both Alberta Kidney Care (AKC)-South and AKC-North, including all 7 renal programs in the province. PATIENTS: The project included all patients who commenced maintenance dialysis between October 1, 2015, and March 31, 2018, in Alberta, Canada who met our inclusion criteria. MEASUREMENTS: We reported baseline characteristics of incident dialysis patients overall, and by site. Our key performance indicator was the proportion of patients who received PD for any period of time within 180 days of the first dialysis treatment. Reports also included detailed metrics pertaining to the 6 steps in the process of modality selection and we had the capacity to provide more granular data on an as-needed basis. To understand loss of PD patients, we reported the numbers of incident patients who recovered kidney function, experienced technique failure, received a transplant, were lost to follow-up, transferred to another program, or died. METHODS: START provided dialysis programs with a conceptual framework for understanding the drivers of PD utilization. High-quality, detailed data were collected using a tool that was custom-built for this purpose, and were mapped to steps in the process of care that drove the outcomes of interest. This allowed sites to identify gaps in care, develop action plans, and implement local interventions to address them. The process was supported by an Innovation Learning Collaborative consisting of 3 learning sessions that brought frontline staff together from across the province to share strategies and learnings. Ongoing data collection allowed teams to determine whether their interventions were effective at each subsequent learning session, and to revisit their interventions if required (the "Plan-Do-Study-Act Cycle"). RESULTS: Future work will report on the impact of the START project on incident PD utilization at a provincial and regional level. LIMITATIONS: The time required to design and implement interventions in practice, as well as the need for multiple PDSA (Plan-Do-Study-Act) cycles to see results, meant that the true potential may not be realized during a relatively short intervention period. Change required buy-in and support from local and provincial leadership and frontline staff. In the absence of accountability for local performance, we relied on the goodwill of participating programs to use the information and resources provided to effect change. Finally, the burden of documentation and data collection for frontline staff was high at baseline. We anticipated that adding supplemental data collection would be difficult. CONCLUSIONS: The START project was a comprehensive, province-wide initiative to maximize the safe and effective use of PD in Alberta, Canada. It standardized the management of incident dialysis patients, leveraged high-quality data to facilitate the reporting of metrics mapped to steps in the process of care that drove incident PD utilization, and helped programs to identify gaps in care and target them for improvement. Future work will report on the impact of the program on incident utilization at the provincial and regional level.

CONTEXTE: La majorité des patients atteints d'insuffisance rénale terminale (IRT) sont traités par dialyze. On s'efforce, partout dans le monde, de promouvoir la dialyze péritonéale (DP) parce qu'elle donne des résultats cliniques équivalents à ceux de l'hémodialyse, mais à moindres coûts. Malheureusement, l'adhésion à la DP demeure faible. OBJECTIFS: Le projet START (The Starting dialysis on Time, At Home, on the Right Therapy) avait deux objectifs principaux : (1) fournir de l'information qui aiderait les programs à accroître l'utilization sûre et efficace de la DP, et (2) réduire l'initiation précoce et inappropriée de la dialyze chez les patients atteints d'insuffisance rénale. Dans cet article, nous nous concentrons sur le premier objectif et nous décrivons la raison d'être de START et les méthodes employées. TYPE D'ÉTUDE: Le projet START était une intervention globale d'amélioration de la qualité à l'échelle provinciale. CADRE: Le projet START a été mis en œuvre au sein de l'Alberta Kidney Care (AKC) ­ South et de l'AKC-North, qui incluent les 7 programs rénaux de la province. SUJETS: Le projet a inclus tous les patients répondant aux critères d'inclusion qui avaient amorcé des traitements de dialyze d'entretien entre le 1er octobre 2015 et le 31 mars 2018 en Alberta (Canada). MESURES: Nous avons rapporté les caractéristiques de base des patients dialysés incidents de façon globale et par site. Notre principal indicateur de performance était la proportion de patients qui ont reçu la DP pendant une période quelconque au cours des 180 jours suivant le premier traitement de dialyze. Les rapports comprenaient également des mesures détaillées concernant les 6 étapes du processus de sélection de la modalité et nous étions en mesure de fournir des données plus précises au besoin. Pour mieux définir la perte de patients sur DP, nous avons rapporté le nombre de patients incidents ayant récupéré une fonction rénale, ayant vécu une défaillance technique, ayant reçu une greffe, ayant été perdus de vue, ayant été transférés à un autre program ou étant décédés. MÉTHODOLOGIE: START a fourni aux programs de dialyze un cadre conceptuel pour comprendre les facteurs d'utilization de la DP. Des données détaillées et de grande qualité ont été recueillies à l'aide d'un outil conçu spécifiquement à cette fin, et ont été mises en correspondance avec les étapes du processus de soins ayant conduit aux résultats d'intérêt. Ainsi, les sites ont pu déceler les lacunes dans les soins, élaborer des plans d'action et mettre en œuvre des interventions locales pour combler ces lacunes. Le processus a été appuyé par une collaboration d'apprentissage innovante constituée de trois séances d'apprentissage qui ont réuni le personnel de première ligne de toute la province afin que ceux-ci partagent leurs stratégies et apprentissages. La collecte continue de données a permis aux équipes de déterminer si leurs interventions étaient efficaces et de revoir leurs interventions si nécessaire (le cycle PDSA: Plan-Do-Study-Act) lors de chaque séance d'apprentissage ultérieure. RÉSULTATS: Les travaux futurs feront état de l'impact du projet START sur l'utilization de la DP à l'échelle provinciale et régionale. LIMITES: Le véritable potentiel du projet pourrait ne pas se révéler lors d'une période d'intervention relativement courte en raison du temps requis pour concevoir les interventions et les mettre en œuvre dans la pratique, et parce que le processus nécessite de procéder à plusieurs cycles PDSA avant de produire des résultats. Le changement exige l'adhésion et le soutien des directions locales et provinciales et du personnel de première ligne. En l'absence de responsabilisation à l'égard des réalisations locales, nous nous sommes appuyés sur la bonne volonté des programs participants à utiliser l'information et les ressources fournies pour faire le changement. Aussi, en début de processus, le fardeau de documenter et de collecter les données s'est avéré lourd pour le personnel de première ligne. Nous avions prévu qu'il serait difficile d'ajouter une collecte de données supplémentaire. CONCLUSION: Le projet START était une initiative globale à l'échelle provinciale qui visait à maximiser l'utilization sécuritaire et efficace de la DP en Alberta, au Canada. Le projet a normalisé la gestion des patients dialysés incidents, a exploité des données de haute qualité pour faciliter la déclaration des indicateurs correspondant aux étapes du processus de soins menant à l'utilization de la DP, et a aidé les programs à déceler les lacunes de soins et à les améliorer. Les travaux futurs feront état de l'impact du program sur l'utilization incidente au niveau régional et provincial.

Sex differences in the vascular access of hemodialysis patients: a cohort study.

BACKGROUND: We describe differences for probability of receiving a fistula attempt, achieving fistula use, remaining catheter-free and the rate of access-related procedures as a function of sex. METHODS: Prospectively collected vascular access data on incident dialysis patients from five Canadian programs using the Dialysis Measurement Analysis and Reporting System to determine differences in fistula-related outcomes between women and men. The probability of receiving a fistula attempt and the probability of fistula use were determined using binary logistic regression. Catheter and fistula procedure rates were described using Poisson regression. We studied time to fistula attempt and time to fistula use, accounting for competing risks. RESULTS: We included 1446 (61%) men and 929 (39%) women. Men had a lower body mass index (P < 0.001) and were more likely to have coronary artery disease (P < 0.001) and peripheral vascular disease (p < 0.001). A total of 688 (48%) men and 403 (43%) women received a fistula attempt. Women were less likely to receive a fistula attempt by 6 months {odds ratio [OR] 0.64 [95% confidence interval (CI) 0.52-0.79]} and to achieve catheter-free use of their fistula by 1 year [OR 0.38 (95% CI 0.27-0.53)]. At an average of 2.30 access procedures per person-year, there is no difference between women and men [incidence rate ratio (IRR) 0.97 (95% CI 0.87-1.07)]. Restricting to those with a fistula attempt, women received more procedures [IRR 1.16 (95% CI 1.04-1.30)] attributed to increased catheter procedures [IRR 1.50 (95% CI 1.27-1.78)]. There was no difference in fistula procedures [IRR women versus men 0.96 (95% CI 0.85-1.07)]. CONCLUSION: Compared with men, fewer women undergo a fistula attempt. This disparity increases after adjusting for comorbidities. Women have the same number of fistula procedures as men but are less likely to successfully use their fistula.

A Systematic Review and Jurisdictional Scan of the Evidence Characterizing and Evaluating Assisted Peritoneal Dialysis Models.

BACKGROUND AND OBJECTIVES: Compared with hemodialysis, home peritoneal dialysis alleviates the burden of travel, facilitates independence, and is less costly. Physical, cognitive, or psychosocial factors may preclude peritoneal dialysis in otherwise eligible patients. Assisted peritoneal dialysis, where trained personnel assist with home peritoneal dialysis, may be an option, but the optimal model is unknown. The objective of this work is to characterize existing assisted peritoneal dialysis models and synthesize clinical outcomes. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: A systematic review of MEDLINE, Cochrane Central Register of Controlled Trails, Cochrane Database of Systematic Reviews, Embase, PsycINFO, and CINAHL was conducted (search dates: January 1995-September 2018). A focused gray literature search was also completed, limited to developed nations. Included studies focused on home-based assisted peritoneal dialysis; studies with the assist provided exclusively by unpaid family caregivers were excluded. All outcomes were narratively synthesized; quantitative outcomes were graphically depicted. RESULTS: We included 34 studies, totaling 46,597 patients, with assisted peritoneal dialysis programs identified in 20 jurisdictions. Two categories emerged for models of assisted peritoneal dialysis on the basis of type of assistance: health care and non-health care professional assistance. Reported outcomes were heterogeneous, ranging from patient-level outcomes of survival, to resource use and transfer to hemodialysis; however, the comparative effect of assisted peritoneal dialysis was unclear. In two qualitative studies examining the patient experience, the maintenance of independence was identified as an important theme. CONCLUSIONS: Reported outcomes and quality were heterogeneous, and relative efficacy of assisted peritoneal dialysis could not be determined from included studies. Although the patient voice was under-represented, suggestions to improve assisted peritoneal dialysis included using a person-centered model of care, ensuring continuity of nurses providing the peritoneal dialysis assist, and measures to support patient independence. Although attractive elements of assisted peritoneal dialysis are identified, further evidence is needed to connect assisted peritoneal dialysis outcomes with programmatic features and their associated funding models.

Overview of the Alberta Kidney Disease Network.

BACKGROUND: The Alberta Kidney Disease Network is a collaborative nephrology research organization based on a central repository of laboratory and administrative data from the Canadian province of Alberta. DESCRIPTION: The laboratory data within the Alberta Kidney Disease Network can be used to define patient populations, such as individuals with chronic kidney disease (using serum creatinine measurements to estimate kidney function) or anemia (using hemoglobin measurements). The administrative data within the Alberta Kidney Disease Network can also be used to define cohorts with common medical conditions such as hypertension and diabetes. Linkage of data sources permits assessment of socio-demographic information, clinical variables including comorbidity, as well as ascertainment of relevant outcomes such as health service encounters and events, the occurrence of new specified clinical outcomes and mortality. CONCLUSION: The unique ability to combine laboratory and administrative data for a large geographically defined population provides a rich data source not only for research purposes but for policy development and to guide the delivery of health care. This research model based on computerized laboratory data could serve as a prototype for the study of other chronic conditions.

Protocol: Improving Access to Specialist Nephrology Care Among Rural/Remote Dwellers of Alberta: The Role of Electronic Consultation in Improving Care for Patients With Chronic Kidney Disease.

BACKGROUND: As the burden of chronic kidney disease (CKD) continues to increase, many geographically dispersed Canadians have limited access to specialist nephrology care, which tends to be centralized in major urban areas. As a result, many rural/remote-dwellers in Canada experience poor quality of care and related adverse outcomes. It is imperative to develop alternative care delivery mechanisms to ensure optimal health outcomes for all Canadians. OBJECTIVE: To investigate the feasibility and effectiveness of electronic consultation (eConsult) as a new model for interactions between specialists and primary care providers (PCPs) to improve access to care for patients with CKD. DESIGN: This is a sequential, mixed methods study that will be conducted in 3 phases. SETTING: The study will be conducted across the entire province of Alberta, supported by Alberta Kidney Care (formerly, Northern and Southern Alberta Renal Programs [NARP/SARP]). PATIENTS: Patients suffering from CKD will be included in the study. MEASUREMENTS: We will assess the barriers and enablers of implementation and adoption of an e-consultation protocol to facilitate access to care for patients with CKD in Alberta with a focus on rural/remote-dwellers with CKD. We will also evaluate the impact of the eConsult system (eg, improved access to specialist care, reduction in care gaps), assess the feasibility of province-wide implementation, and compare eConsult with practice facilitation versus eConsult alone in terms of access to specialist care, quality of care, and related outcomes. METHODS: The study will be conducted in 3 phases. In phase 1, we will assess the perceptions of stakeholders (ie, PCPs, nephrologists, patients, policymakers, and other care providers) to improve CKD care delivery, quality, and outcomes in Alberta with focus groups and semistructured interviews. Phase 2 will engage specific family physicians for their input on key factors and logistical issues affecting the feasibility of implementing eConsult for the care of patients with CKD. Phase 3 will provide academic detailing including practice facilitation to clinics in Alberta to assess how eConsult with practice facilitation compares with eConsult alone in terms of access to specialist care, quality of care, and related outcomes. RESULTS: We will assess stakeholder perceptions about potential barriers to and enablers of a new eConsult and decision support system strategy, focusing on elements that are most important for the design of a feasible and implementable intervention. We will develop, pilot test, and assess the impact of the eConsult model in improving access to specialist nephrology care and the feasibility of province-wide implementation. The final phase of the project will address key challenges for optimal care for patients with CKD living in rural, remote, and underserved areas of Alberta, particularly timely referral and disease management as well as the cost-effective benefits of eConsult. LIMITATIONS: Lack of high-speed Internet in many rural and remote areas of Alberta may lead to more time spent in completing the eConsult request online versus faxing a referral the traditional way. Allied health care staff (referral coordinators, administrative staff) require training to the eConsult system, and physicians at many remote sites do not have adequate staff to handle eConsult as an added task. CONCLUSIONS: Implementation of eConsult can favorably influence referral patterns, access to care, care quality, patient outcomes, and health care costs for people with CKD. Results of this study will inform the optimization of care for rural/remote-dwellers with CKD and will facilitate future partnerships with policymakers and provincial renal programs in Alberta to ensure optimal kidney health for all residents. TRIAL REGISTRATION: Not required.

CONTEXTE: Bien que le fardeau de l'insuffisance rénale chronique (IRC) ne cesse de s'alourdir, de nombreux Canadiens dispersés sur le plan géographique continuent d'avoir un accès limité à des soins spécialisés puisque ceux-ci sont davantage concentrés dans les grandes zones urbaines. Ainsi, dans les régions rurales/éloignées du Canada, de nombreux patients atteints d'IRC ne reçoivent pas les soins appropriés et subissent les conséquences néfastes des pathologies associées à leur état de santé. Il est donc essentiel de développer des mécanismes alternatifs de prestation de soins pour s'assurer que tous les Canadiens ont accès à des soins optimaux. OBJECTIF: Évaluer la faisabilité et l'efficacité d'un système de consultation électronique (eConsult) facilitant les interactions entre les spécialistes et les fournisseurs de soins primaires (FSP) dans le but d'améliorer l'accès des patients atteints d'IRC à des soins spécialisés. TYPE D'ÉTUDE: Une étude séquentielle en trois phases reposant sur des méthodes mixtes. CADRE: L'étude sera menée à la grandeur de l'Alberta avec le soutien financier du Alberta Kidney Care (anciennement Northern/Southern Alberta Renal Program [NARP/SARP]). SUJETS: Des patients atteints d'IRC participeront à l'étude. MESURES: Nous étudierons les facteurs qui entravent ou qui facilitent la mise en œuvre et l'adoption d'un système d'eConsult visant à améliorer l'accès des Albertains atteints d'IRT à des soins spécialisés, particulièrement ceux qui résident en région rurale/éloignée. Nous évaluerons les impacts de l'eConsult (meilleur accès à des soins spécialisés, réduction des disparités) et la faisabilité de son implantation à l'échelle de la province. Enfin, nous comparerons l'accès aux soins spécialisés, leur qualité et l'incidence des pathologies associées selon que l'eConsult est employée seule ou avec facilitation de la pratique. MÉTHODOLOGIE: L'étude se déroulera en trois étapes. Par l'entremise de groupes de discussion et d'interviews semi-structurées, la phase 1 évaluera la perception des différents intervenants (FSP, néphrologues, patients, décideurs et autres fournisseurs de soins) quant à l'amélioration de la prestation et de la qualité des soins spécialisés, et des résultats de santé. La phase 2 sondera l'avis de médecins de famille sélectionnés sur les problèmes logistiques et les principaux facteurs affectant l'implantation du système d'eConsult. La phase 3 fournira de la formation continue aux cliniques albertaines, notamment en facilitation de la pratique, et comparera les effets de l'eConsult avec facilitation de la pratique et de l'eConsult employée seule sur l'accès aux soins spécialisés, la qualité des soins et les pathologies associées. RÉSULTATS: Nous questionnerons les différents intervenants sur les éventuels obstacles et facilitateurs d'une nouvelle stratégie d'eConsult et d'aide à la prise de décision, en nous concentrant sur les éléments les plus importants pour la conception d'une intervention réalisable et applicable. Nous élaborerons le modèle d'eConsult, le mettrons à l'essai et évaluerons son incidence sur l'amélioration de l'accès aux soins spécialisés en néphrologie et sur la faisabilité de difficultés de prodiguer des soins optimaux aux patients atteints d'IRC des zones rurales, éloignées et mal desservies de l'Alberta, particulièrement en ce qui concerne l'aiguillage rapide et la gestion de la maladie. Les avantages économiques de l'eConsult seront également abordés au cours de cette phase. LIMITES: L'absence d'internet haute vitesse dans de nombreuses régions rurales et éloignées de l'Alberta pourrait faire en sorte qu'il soit plus rapide d'envoyer la demande par télécopieur que de la remplir en ligne. Le personnel paramédical (coordonnateurs de l'aiguillage, personnel administratif) doit être formé sur le système eConsult et plusieurs centers éloignés n'ont pas suffisamment de personnel pour s'en occuper comme tâche supplémentaire. CONCLUSION: L'implantation d'un système d'eConsult en contexte d'IRC pourrait améliorer les schémas d'aiguillage, l'accès aux soins spécialisés, leur qualité et les résultats des patients, de même que réduire les coûts de santé. Les résultats de cette étude guideront l'optimisation des soins en IRC dans les régions rurales/éloignées et faciliteront les futurs partenariats avec les décideurs et les programs provinciaux de néphrologie en Alberta, afin d'assurer une santé rénale optimale à tous les résidents.

Electronic Advice Request System for Nephrology in Alberta: Pilot Results and Implementation.

BACKGROUND: Residents of rural areas of Alberta face significant barriers regarding access to specialist care, resulting in delays in provision of optimal care. Electronic referral and consultation systems are promising tools for facilitating timely access to specialist care, especially for people living in rural locations. OBJECTIVE: To report our initial experience with the launch of an electronic advice request system for ambulatory kidney care in Alberta, Canada. METHODS: We analyzed electronic advice requests for nephrology services in Alberta after the system's pilot launch, from October 2016 to December 2017. Data for province-wide advice request utility by primary care providers (PCPs) were extracted from Alberta Netcare for analysis. RESULTS: The total number of electronic advice requests directed to nephrology was 118 (mean number of requests: 2 per week). Only 31 (26.3%) of the cases required a face-to-face clinic visit with a nephrologist. Most (87; 73.7%) cases were managed by PCPs with ongoing nephrologist support via the advice request tool. Typical nephrologist response time was 5.7 ± 0.6 (mean ± SEM) days. CONCLUSION: These preliminary data suggest that the electronic advice request program has potential to enhance timely access to specialist kidney care and minimize unnecessary nephrologist visits while reducing response time. Broad implementation of this system may have a substantial positive impact on health outcomes and improve cost-effectiveness for nephrology care in the long term, particularly in rural communities of Alberta.

CONTEXTE: Les résidents des zones rurales de l'Alberta se heurtent à des obstacles importants en ce qui concerne l'accès aux soins spécialisés, ce qui entraîne des retards dans la fourniture de soins adéquats. Les systèmes électroniques de référence et de consultation sont des outils prometteurs qui peuvent faciliter un accès rapide à des soins spécialisés, en particulier pour les personnes résidant en milieu rural. OBJECTIF: Présenter notre première expérience avec le lancement d'un système de demande de consultation électronique en soins rénaux ambulatoires en Alberta, Canada. MÉTHODOLOGIE: Nous avons analysé les demandes de consultation électroniques pour des services de néphrologie en Alberta, entre octobre 2016 et décembre 2017, après le lancement pilote du système. Les données sur la pertinence des demandes de consultation à l'échelle provinciale, et selon les fournisseurs de soins primaires, ont été extraites du registre Alberta Netcare pour fins d'analyze. RÉSULTATS: Le nombre total de consultations électroniques adressées en néphrologie était de 118 (moyenne de 2 demandes/semaine), et 31 cas seulement (26,3%) ont nécessité une visite en clinique avec un néphrologue. La majorité des cas (87), soit 73,7%, a été prise en charge par des fournisseurs de soins primaires qui bénéficiaient du soutien permanent d'un néphrologue par l'entremise de l'outil électronique. Le temps de réponse moyen des néphrologues était de 5,7 ± 0,6 jour (moyenne ± SEM). CONCLUSION: Ces données préliminaires suggèrent que le program de demande de consultation électronique pourrait faciliter l'accès rapide à des soins par un néphrologue et minimiser les visites inutiles en clinique, tout en réduisant le temps de réponse. La mise en œuvre à grande échelle de ce système pourrait avoir une incidence très positive sur les résultats de santé et améliorer la rentabilité des soins en néphrologie à long terme, en particulier dans les communautés rurales de l'Alberta.

Adrenal vein sampling may not be a gold-standard diagnostic test in primary aldosteronism: final diagnosis depends upon which interpretation rule is used. Variable interpretation of adrenal vein sampling.

BACKGROUND: Adrenal vein sampling (AVS) is considered the gold-standard test to demonstrate unilateral aldosterone excess in primary aldosteronism, yet no single approach to interpretation of AVS has been externally validated. HYPOTHESIS: There may be significant inter-observer variability in the final diagnosis of unilateral vs. bilateral aldosterone excess depending on which AVS interpretation rule is used. METHODS: Retrospective chart review of 63 subjects with primary aldosteronism undergoing AVS and 40 subsequent adrenalectomies for presumed unilateral aldosteronism. The data from the AVS were retrospectively re-analyzed according to a variety of interpretation criteria published in the literature. Using 40 subjects undergoing surgery, pathology and clinical outcomes defined the final diagnosis of aldosteronism subtype, and these subjects' AVS results were used to estimate the true sensitivity and specificity of the various approaches to AVS interpretation. RESULTS: Diagnostic discrepancies exist between the different AVS interpretation rules. Successful adrenal vein catheterization was confirmed in between 13% and 77% of AVS attempts. Sensitivity of AVS ranged from 47% to 100% and specificity 55-100%. Only 17% of all cases would be categorized uniformly by all interpretation criteria. Use of biochemical catheter placement criteria and ACTH infusion improved the proportions of AVS results defined as successful and showing lateralization. CONCLUSIONS: We found substantial variabilty in final diagnosis by using different systems of interpreting AVS results as suggested in the literature This suggests AVS may not always be considered a gold-standard diagnostic test.