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    Small steps (tasks) within shared care provides a framework to unlock potential.

  • 1.

    Elliott J, et al. Substantial reductions in the number of diabetic ketoacidosis and severe hypoglycaemia episodes requiring emergency treatment lead to reduced costs after structured education in adults with type 1 diabetes. Diabet Med 2014; 31:847853.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 2.

    The NHS Long Term Plan. NHS England, 2019.

  • 3.

    Taylor DM, et al. A systematic review of the prevalence and associations of limited health literacy in CKD. Clin J Am Soc Nephrol 2017; 12:10701084.

  • 4.

    Nitsch D, et al. Outcomes in patients on home haemodialysis in England and Wales, 1997–2005: a comparative cohort analysis. Nephrol Dial Transplant 2011; 26:16701677.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 5.

    Wilkie M, Barnes T. Shared hemodialysis care: increasing patient involvement in center-based dialysis. Clin J Am Soc Nephrol 2019; 14021404.

  • 6.

    Glidewell L, et al. Using behavioural theories to optimise shared haemodialysis care: a qualitative intervention development study of patient and professional experience. Implement Sci 2013; 8:118.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 7.

    Fotheringham J, et al. Rationale and design for SHAREHD: a quality improvement collaborative to scale up shared haemodialysis care for patients on centre based haemodialysis. BMC Nephrol 2017; 18:335.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 8.

    Morton RL, Sellars M. From patient-centered to person-centered care for kidney diseases. Clin J Am Soc Nephrol 2019; 14:623625.

  • 9.

    Chan CT, et al. Dialysis initiation, modality choice, access, and prescription: conclusions from a Kidney Disease: Improving Global Outcomes (KDIGO) Controversies Conference. Kidney Int 2019; 96:3747.

    • Crossref
    • Search Google Scholar
    • Export Citation

Shared-Care Dialysis Improves Patient Outcomes: Building the Evidence

  • 1 Martin Wilkie, MD, FRCP, is a consultant renal physician at Sheffield Teaching Hospitals, NHS Foundation Trust. Steve Ariss, PhD, is a senior research fellow, ScHARR, at The University of Sheffield.
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All across medicine, there is strong evidence that people who understand and are engaged in their own healthcare have better outcomes. There are several reasons for this, including being able to make quality healthcare choices, knowing when to seek help, and knowing how to reduce the risk for the development of complications (1). The body of literature in this area is large; diabetes mellitus care is a strong example. Indeed, it is not possible to deliver successful diabetes care without high levels of patient engagement, and there has been considerable interest and investment in patient training to improve outcomes.

From a strategic point of view, healthcare organizations have recognized this and have prioritized patient training and self-efficacy as key objectives (2). Within kidney medicine, there is evidence of a link between health literacy and outcomes; a strong example is home dialysis, whereby people who are trained to undertake their own treatment do well (3, 4). A key question is how to reliably extend these opportunities to people who undergo in-center dialysis so that they can reap the potential benefits that come from greater self-efficacy.

One approach is to develop mechanisms that encourage people who undergo in-center dialysis to have the choice to learn and engage in tasks related to their own treatment. This is described as shared hemodialysis care (SHC). Home dialysis (HD) can be broken down into approximately 14 tasks, which range from easy to more complex (Figure 1) (5). The level and complexity of tasks an individual decides to learn is flexible, and the logical approach is to start with simple aspects before progressing to more complex tasks as confidence is gained. Benefits reported by patients include a greater sense of independence and control over their own condition and, for some, the opportunity to conduct independent dialysis (6).

Figure 1.
Figure 1.

Small steps (tasks) within shared care provides a framework to unlock potential.

Citation: Kidney News 12, 2

Reprinted with permission from Wilkie and Barnes (5).

It is therefore important to discover the best approaches to support the delivery of SHC and how they can best be measured. The key is to test metrics that can be used to assess individual progress and to demonstrate the level of engagement that is offered by providers. Until such measures are used routinely, it will not be possible to develop evidence-based mechanisms that create optimal opportunities for SHC.

In 2016, a quality improvement collaborative was established in England, supported by the Health Foundation, with the objective of scaling up SHC for patients in center-based HD (7). The work involved multidisciplinary teams that included patient partners from 12 kidney centers. It focused on patient and nurse education, and it incorporated quality improvement measures such as rapid tests of change and peer assistance to examine and share the most effective approaches. The impact was tested through a stepped wedge cluster randomized controlled trial of approximately 600 prevalent HD patients. The primary outcome measure was the number of patients engaged in five or more treatment-related tasks. The results of that study are being prepared for publication.

In addition to quantitative assessments, which included the number of patients conducting independent dialysis by the end of the study, a logic model was developed through qualitative evaluation of the drivers and inhibitors that had an impact on successful delivery. This enabled the development of “involvement models,” which described the most effective approaches to achieve both patient and staff involvement. It became clear from this work that the most successful approach to involve patients is rehabilitative and is focused on the principles of person-centered care and goal-directed dialysis (8, 9). In this model, most patients at a particular dialysis center are facilitated to be as involved as much as they wish; and training becomes part of the culture of the organization, performed by all on an ongoing basis. As for the staff involvement model with the most impact, that is one of coproduction, whereby all staff members are committed to supporting SHC.

The recent change in emphasis in dialysis targets from a focus on small solute clearance to the broader concepts of goal-directed dialysis requires a system change (9). SHC responds to that challenge by giving individuals the choice and opportunity to learn aspects of their own care and to make decisions about it irrespective of whether home dialysis is a possibility for them. The most successful approaches to this are likely based on rehabilitation and coproduction in which patient training is an integral part of the culture of the organization.

References

  • 1.

    Elliott J, et al. Substantial reductions in the number of diabetic ketoacidosis and severe hypoglycaemia episodes requiring emergency treatment lead to reduced costs after structured education in adults with type 1 diabetes. Diabet Med 2014; 31:847853.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 2.

    The NHS Long Term Plan. NHS England, 2019.

  • 3.

    Taylor DM, et al. A systematic review of the prevalence and associations of limited health literacy in CKD. Clin J Am Soc Nephrol 2017; 12:10701084.

  • 4.

    Nitsch D, et al. Outcomes in patients on home haemodialysis in England and Wales, 1997–2005: a comparative cohort analysis. Nephrol Dial Transplant 2011; 26:16701677.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 5.

    Wilkie M, Barnes T. Shared hemodialysis care: increasing patient involvement in center-based dialysis. Clin J Am Soc Nephrol 2019; 14021404.

  • 6.

    Glidewell L, et al. Using behavioural theories to optimise shared haemodialysis care: a qualitative intervention development study of patient and professional experience. Implement Sci 2013; 8:118.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 7.

    Fotheringham J, et al. Rationale and design for SHAREHD: a quality improvement collaborative to scale up shared haemodialysis care for patients on centre based haemodialysis. BMC Nephrol 2017; 18:335.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 8.

    Morton RL, Sellars M. From patient-centered to person-centered care for kidney diseases. Clin J Am Soc Nephrol 2019; 14:623625.

  • 9.

    Chan CT, et al. Dialysis initiation, modality choice, access, and prescription: conclusions from a Kidney Disease: Improving Global Outcomes (KDIGO) Controversies Conference. Kidney Int 2019; 96:3747.

    • Crossref
    • Search Google Scholar
    • Export Citation
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