Nurse Practitioner Care Compared with Primary Care or Nephrologist Care in Early CKD.

BACKGROUND: Early interventions in CKD have been shown to improve health outcomes; however, gaps in access to nephrology care remain common. Nurse practitioners can improve access to care; however, the quality and outcomes of nurse practitioner care for CKD are uncertain. METHODS: In this propensity score-matched cohort study, patients with CKD meeting criteria for nurse practitioner care were matched 1:1 on their propensity scores for ( 1 ) nurse practitioner care versus primary care alone and ( 2 ) nurse practitioner versus nephrologist care. Processes of care were measured within 1 year after cohort entry, and clinical outcomes were measured over 5 years of follow-up and compared between propensity score-matched groups. RESULTS: A total of 961 (99%) patients from the nurse practitioner clinic were matched on their propensity score to 961 (1%) patients receiving primary care only while 969 (100%) patients from the nurse practitioner clinic were matched to 969 (7%) patients receiving nephrologist care. After matching to patients receiving primary care alone, those receiving nurse practitioner care had greater use of angiotensin-converting enzyme inhibitors/angiotensin receptor blocker (82% versus 79%; absolute differences [ADs] 3.4% [95% confidence interval, 0.0% to 6.9%]) and statins (75% versus 66%; AD 9.7% [5.8% to 13.6%]), fewer prescriptions of nonsteroidal anti-inflammatory drugs (10% versus 17%; AD -7.2% [-10.4% to -4.2%]), greater eGFR and albuminuria monitoring, and lower rates of all-cause hospitalization (34.1 versus 43.3; rate difference -9.2 [-14.7 to -3.8] per 100 person-years) and all-cause mortality (3.3 versus 6.0; rate difference -2.7 [-3.6 to -1.7] per 100 person-years). When matched to patients receiving nephrologist care, those receiving nurse practitioner care were also more likely to be prescribed angiotensin-converting enzyme inhibitors/angiotensin receptor blockers and statins, with no difference in the risks of experiencing adverse clinical outcomes. CONCLUSIONS: Nurse practitioner care for patients with CKD was associated with better guideline-concordant care than primary care alone or nephrologist care, with clinical outcomes that were better than or equivalent to primary care alone and similar to those with care by nephrologists. PODCAST: This article contains a podcast at https://dts.podtrac.com/redirect.mp3/www.asn-online.org/media/podcast/CJASN/2023_12_08_CJN0000000000000305.mp3.

Redesigning Kidney Care for the Anthropocene: A New Framework for Planetary Health in Nephrology.

Climate change is one of the greatest threats to human health in the 21st century. The human health impacts of climate change contribute to approximately 1 in 4 deaths worldwide. Health care itself is responsible for approximately 5% of annual global greenhouse gas (GHG) emissions. Canada is a recent signatory of the 26th United Nations Climate Change Conference (COP26) health agreement that is committed to developing low carbon and climate resilient health systems. Kidney care services have a substantial environmental impact and there is opportunity for the kidney care community to climate align clinical care. We introduce a framework of redesigned kidney care and describe examples of low carbon kidney disease management strategies to expand our duty of care to the environment which completes the triple bottom line of optimal patient outcomes and cost effectiveness in the Anthropocene.

Overview of Self-Management Resources Used by Canadian Chronic Kidney Disease Clinics: A National Survey.

BACKGROUND: Chronic kidney disease (CKD) clinics across Canada provide tailored care for patients with CKD with an aim to slow progression and prevent complications. These clinics provide CKD self-management resources; however, there is limited information about what resources are being used by clinics. We undertook a survey of CKD clinics across Canada to identify self-management resources for adults aged 18 years and over with CKD categories 1 to 5 and not requiring dialysis or transplant. OBJECTIVE: To identify and collate self-management resources (eg, strategies, tools, educational materials) used by CKD clinics across Canada for adults with CKD (categories 1 to 5, not requiring kidney replacement therapy). DESIGN: Self-administered, semistructured electronic survey. SETTING PARTICIPANTS: Canadian CKD clinics with previously identified contact information. METHODS AND MEASUREMENTS: We contacted 57 CKD English-speaking clinics and invited them to complete an online survey. The survey was available from October 2016 to January 2017 and consisted of 17 questions regarding the use and attributes of self-management resources including topic, delivery format, provider, target population, where the intervention was provided, and resource languages. RESULTS: Forty-four clinics (77%) completed the survey. The most common topic was modality education provided in print format, by nurses. The most frequently used resource was the Kidney Foundation of Canada (KFOC) Living With Kidney Disease manual. We also identified that the majority of resources were available in English, targeting both patients and caregivers in the outpatient setting. LIMITATIONS: Our survey included Canadian adult CKD clinics, which may not be generalizability to other settings, such as care of people with CKD in primary care. CONCLUSIONS: Adult CKD clinics across Canada provide some similar resources, but also provide many different self-management resources. Even though some of the same resources were used by multiple clinics, the way they were provided them (ie, provider, location, delivery format) varied by the individual clinics. Knowledge of self-management resources currently provided in CKD clinics, along with synthesis of the literature and patient preferred self-management strategies, will inform the design and development of a novel self-management intervention that is patient-centric and adheres to the principles of self-management.

CONTEXTE: Au Canada, les cliniques de néphropathie chronique prodiguent des soins spécifiques aux patients atteints d'insuffisance rénale chronique (IRC) dans le but de ralentir la progression de la maladie et de prévenir les complications. Ces cliniques offrent des ressources de prise en charge autonome de la maladie, mais on dispose de peu d'information sur les ressources qui sont effectivement offertes aux patients. OBJECTIFS DE L'ÉTUDE: L'étude visait le recensement des ressources de prise en charge autonome (stratégies, outils, documents informatifs et autres) offertes par les cliniques de néphropathie canadiennes à leurs patients adultes atteints d'IRC de stade 1 à 5 ne requérant pas de thérapie de remplacement rénal. TYPE D'ÉTUDE: L'étude a été menée sous la forme d'un sondage électronique semi-structuré et auto-administré. CADRE DE L'ÉTUDE: Le sondage a été présenté à des cliniques de néphropathie chronique canadiennes pour lesquelles nous avions préalablement trouvé une personne-ressource. MÉTHODOLOGIE: Nous avons invité les personnes-ressources de 57 cliniques anglo-canadiennes à compléter notre sondage diffusé en ligne entre octobre 2016 et janvier 2017. Le sondage comptait 17 questions relatives à la nature et à l'utilisation des ressources de prise en charge autonome offertes (sujet, forme, fournisseur, population ciblée, langues, lieu de l'intervention, etc.). RÉSULTATS: Des 57 répondants potentiels approchés, 44 (77 %) ont complété le sondage. La demande d'information la plus souvent mentionnée concernait les modalités de dialyse et la ressource alors fournie consistait en un document informatif remis en version papier par le personnel infirmier. La ressource la plus souvent employée était le guide Vivre à sa façon (en 2 livrets) rédigé par la Fondation canadienne du rein. On a de plus constaté que la majorité des ressources étaient en anglais, la langue commune aux patients et aux fournisseurs de soins en consultation externe. LIMITES DE L'ÉTUDE: Notre sondage s'est limité à des cliniques traitant des adultes atteints d'IRC. Nos résultats pourraient ne pas être généralisables dans d'autres contextes, notamment aux soins prodigués aux patients atteints d'IRC dans les établissements de soins primaires. CONCLUSION: Les cliniques de néphropathie chronique canadiennes proposent certaines ressources similaires de prise en charge autonome aux adultes souffrant d'IRC, mais les ressources diffèrent passablement d'un établissement à un autre. Et bien que plusieurs cliniques recourent aux mêmes ressources, on a noté des variations dans façon de les fournir (fournisseur, lieu de l'intervention, support du document). Une meilleure connaissance des stratégies de gestion autonome privilégiées par les patients et des ressources actuellement offertes dans les cliniques de néphropathie chronique, combinée à une synthèse de la littérature, favorisera l'élaboration de stratégies d'intervention centrées sur les besoins des patients et conformes aux principes de la prise en charge autonome.

Self-management interventions for adults with chronic kidney disease: a scoping review.

OBJECTIVE: To systematically identify and describe self-management interventions for adult patients with chronic kidney disease (CKD). SETTING: Community-based. PARTICIPANTS: Adults with CKD stages 1-5 (not requiring kidney replacement therapy). INTERVENTIONS: Self-management strategies for adults with CKD. PRIMARY AND SECONDARY OUTCOME MEASURES: Using a scoping review, electronic databases and grey literature were searched in October 2016 to identify self-management interventions for adults with CKD stages 1-5 (not requiring kidney replacement therapy). Randomised controlled trials (RCTs), non-RCTs, qualitative and mixed method studies were included and study selection and data extraction were independently performed by two reviewers. Outcomes included behaviours, cognitions, physiological measures, symptoms, health status and healthcare. RESULTS: Fifty studies (19 RCTs, 7 quasi-experimental, 5 observational, 13 pre-post intervention, 1 mixed method and 5 qualitative) reporting 45 interventions were included. The most common intervention topic was diet/nutrition and interventions were regularly delivered face to face. Interventions were administered by a variety of providers, with nursing professionals the most common health professional group. Cognitions (ie, changes in general CKD knowledge, perceived self-management and motivation) were the most frequently reported outcome domain that showed improvement. Less than 1% of the interventions were co-developed with patients and 20% were based on a theory or framework. CONCLUSIONS: There was a wide range of self-management interventions with considerable variability in outcomes for adults with CKD. Major gaps in the literature include lack of patient engagement in the design of the interventions, with the majority of interventions not applying a behavioural change theory to inform their development. This work highlights the need to involve patients to co-developed and evaluate a self-management intervention based on sound theories and clinical evidence.

Quality of life and patient satisfaction after artificial urinary sphincter.

BACKGROUND: We assessed satisfaction and quality of life (QOL) in men with artificial urinary sphincter (AUS) placement. METHODS: We identified 39 men who had AUS placement. A retrospective chart review was conducted. Validated questionnaires, including the International Consultation on Incontinence Questionnaire-Short Form (ICIQ-SF), Post-Operative Patient Global Impression of Improvement (PGI-I), Incontinence Impact Questionnaire-Short Form (IIQ-SF), and Urogenital Distress Index (UDI-SF), were used to measure patient-reported outcome. Global satisfaction was also assessed. RESULTS: At chart review, 34 of 39 questionnaires were assessed for QOL, satisfaction and surgical outcome. Follow-up ranged from 7 to 60 months (median = 24 months). Surgical revisions were required in 6 (17.6%) patients due to infection (1), erosion (1), combined infection and erosion (1), device failure (1) and second cuff placement (2). Quality of life was assessed using the IIQ-SF and UDI-SF, with mean scores of 15.4 and 24.8, respectively; these scores indicated a low negative impact on QOL. The ICIQ-SF mean score was 8.2, well below the worst possible score. The number of men using more than 1 pad per day dropped from 27 preoperatively to 10 postoperatively. Most patients (31/34) described their urinary condition as better, 2 had no change and 1 was worse. Most patients (31/34, 91.2%) would be willing to undergo the procedure again, 2 were undecided, and 1 would not. Similarly, 28 patients (82.4%) would recommend the procedure to a friend, 3 respondents would "with reservation," 1 respondent was undecided, and 2 would not recommend the AUS placement. CONCLUSION: Treatment of urinary incontinence with the AUS has a positive effect on QOL with high patient satisfaction and reasonably low complication rates.