TĀCcare Intervention Reduces Dialysis-Related Symptoms

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A technology-assisted, stepped, collaborative care intervention called TĀCcare provides a clinically meaningful reduction in debilitating symptoms for patients undergoing hemodialysis, according to a clinical trial report in JAMA Internal Medicine.

The TĀCcare randomized trial included 160 patients with end stage kidney disease (ESKD) on long-term hemodialysis with at least moderate levels of fatigue, pain, and/or depression. The patients were 88 men and 72 women, mean age 58 years, enrolled at two sites in New Mexico and Pennsylvania. Race and ethnicity included 52% White patients, 28% Black, 18% Hispanic, and 13% American Indian.

TĀCcare focused on individualized treatment targeting any or all of the three symptoms of interest, following a stepped approach to treatment intensification with shared decision-making. The intervention included 12 weekly sessions of cognitive behavioral therapy (CBT), delivered via telemedicine at home or in a hemodialysis center. Pharmacotherapy for pain and/or depression was added if clinically indicated or preferred by the patient, with dose escalation based on evidence-based protocols.

Patients assigned to the attention control group received six telehealth sessions of health education. Co-primary outcomes of changes in fatigue, average pain severity, and depression were evaluated at 3 months, with follow-up to 12 months.

At 3 months, the TĀCcare group had “statistically and clinically significant reductions” in fatigue, mean difference (MD) was 2.81 on the Functional Assessment of Chronic Illness Therapy–Fatigue scale, and pain severity of MD was −0.96 on the Brief Pain Inventory. There was also a “statistically significant but small” improvement in depression: MD, −1.73 on the Beck Depression Inventory II.

Improvements in fatigue and pain were sustained at 6 months: MD, 3.73 and −1.49, respectively. Adverse events were rare and similar between groups. Most patients in the TĀCcare group preferred CBT over pharmacotherapy; adherence to CBT was high.

Patients experiencing long-term hemodialysis had a high burden of symptoms, which are commonly underrecognized and undertreated. The TĀCcare intervention was designed to provide a flexible approach to addressing these gaps in symptom management.

The new trial shows significant and lasting reductions in fatigue and pain symptoms for patients on hemodialysis assigned to TĀCcare. The researchers write, “Leveraging telemedicine to deliver CBT that targets symptom clusters…may provide a scalable and resource-efficient approach to improve patient-centered outcomes among patients with ESKD who are undergoing long-term hemodialysis” [Jhamb M, et al. Effects of technology assisted stepped collaborative care intervention to improve symptoms in patients undergoing hemodialysis: The TĀCcare randomized clinical trial. JAMA Intern Med 2023; 183:795–805. doi: 10.1001/jamainternmed.2023.2215].