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Optimizing Dialysis Modality Choices Around
The World: A Review of Literature Concerning
The Role of Enhanced Early Pre-ESRD
Education in Choice of Renal Replacement
Therapy Modality
Continuing Nursing
Education
Sharon M. Key
s a parent and active caregiver
of a renal patient, this author
has heard many accounts of
how patients made their renal
replacement therapy (RRT) choice –
or had it made for them. The author’s
daughter received an early diagnosis
of chronic kidney disease (CKD),
allowing for close, consistent management and delay of end stage renal disease (ESRD). The entire family benefited from the “luxury” of adequate
time for pre-ESRD education on
CKD, ESRD, and all modalities of
RRT, which was available well before
the need to make a decision. Over a
20-year period, the author has become
acquainted with many adult patients,
pediatric patients, and families dealing
with sudden onset ESRD or late
nephrology referral.
These people usually recounted an
experience of receiving minimal preESRD education and having little perceived control. Most were confused
about renal failure, various RRT
modalities, and the CKD/ESRD/
RRT trajectory. Some clinics in this
author’s experience had an extensive
pre-ESRD education program; in
other clinics, quick verbal explanations
and pamphlets were all that patients
received from busy nephrology professionals. Experiencing renal care in six
states and one foreign country has provided the author with a unique per-
A
Sharon M. Key, MSN, RN, ACNP-BC, is a
Recent Graduate, Vanderbilt University School of
Nursing, Nashville, TN, and is a Member of
ANNA’s Memphis Blues Chapter.
Disclosure Statement: The authors reported no
actual or potential conflict of interest in relation to
this continuing nursing education article.
NEPHROLOGY NURSING JOURNAL
This article presents recent studies on factors affecting choice of self-care dialysis from
around the world, denoting the relationship between early pre-end stage renal disease
(ESRD) education and increased selection of self-care dialysis modalities. Style and content of various pre-ESRD education programs, barriers to early pre-ESRD education,
and programs designed to decrease late referral are discussed. Economic factors favoring
referral to incenter hemodialysis despite the lower cost of self-care dialysis are reviewed.
Goal:
To increase awareness about pre-ESRD education programs, barriers to early preESRD education, and programs designed to decrease late referral from nurses and
other healthcare providers.
Objectives:
1. Explain how early pre-ESRD education can enhance a patient’s choice for self-care.
2. Discuss the ways nurses can provide pre-ESRD education to patients.
3. Identify the barriers to pre-ESRD education and the ability to offer multiple dialysis
modalities.
4. Describe pre-ESRD education on a global scale.
5. Discuss solutions and research recommendations for providing pre-ESRD education and various RRT modality choices.
spective on similarities and differences
among clinics. The following inquiry
was motivated by patients’ stories of
various educational experiences leading to actively choosing a modality,
relinquishing that choice, or having no
choice offered.
The phenomenon of interest for
this review is, “What is the nature of
current evidence related to the effect of
early pre-ESRD education and the
availability of RRT modalities on the
choice of self-care RRT modalities?” A
self-care RRT modality is defined as
one that takes place outside of a fullcare dialysis center and includes
home-based hemodialysis (HD), peritoneal dialysis (PD), and various levels
of self-care in outpatient dialysis settings, such as satellite clinics (including
assisting with set up of dialysis station,
self-cannulation, and self monitoring).
This offering for 1.5 contact hours is being provided by the American Nephrology Nurses’
Association (ANNA).
ANNA is accredited as a provider of continuing nursing education (CNE) by the American
Nurses Credentialing Center’s Commission on Accreditation.
ANNA is a provider approved by the California Board of Registered Nursing, provider number
CEP 00910.
This CNE article meets the Nephrology Nursing Certification Commission’s (NNCC’s) continuing nursing education requirements for certification and recertification.
July-August 2008
Vol. 35, No. 4
387
Optimizing Dialysis Modality Choices Around the World: A Review
This article compares recent studies from renal clinics around the world
concerning early, enhanced preESRD education and the level of selfcare chosen by patients. In the studies
reviewed, enhanced programs are usually described as including classes on
medication and nutritional education,
videos and/or written accounts of
patients describing how they fit their
choice of RRT into their life, and visits
to a dialysis clinic. Standard information provided to patients with CKD
generally refers to verbal instruction
and pamphlets on medication, nutrition, and various RRT modalities
received during clinic visits. Additionally, the effect of early referral
versus late referral on the patient’s ability to participate in pre-ESRD education and the resultant choice among
RRT modalities will be reviewed.
Finally, the effect of neutral presentation of multiple RRT modalities will
be discussed.
Background
The overall incident rate of ESRD
in the United States is approximately
350 per million population (US Renal
Data System [USRDS], 2007).
Individuals with diabetes and/or
hypertension account for the source of
about 70% of the ESRD population
(USRDS, 2007). In 2005, over
460,000 Americans were treated for
ESRD; of those, over 300,000 were on
dialysis (USRDS, 2007). In 2005, total
Medicare costs for the ESRD program
were about $20 billion; Medicare
HMO costs were $1.35 billion, nonMedicare costs were around $7.2 billion, and Medicare patient obligation
costs reached $3.5 billion (USRDS,
2007). In 2005, the per capita payments for patients undergoing maintenance HD were $69,758 compared to
$50,847 for chronic PD (USRDS,
2007). If the percentage of patients on
PD were doubled, the Center for
Medicare and Medicaid Services
(CMS) could save over $300 million a
year (Mehrotra, Marsh, Vonesh,
Peters, & Nissenson, 2005).
CMS guidelines call for unbiased
presentation of all modalities to
388
patients with ESRD before initiating
RRT. However, the USRDS Wave
Study (1997) found only 25% of
patients on HD remembered receiving information about PD. Self-care
options, such as PD, are underutilized
in the U.S. (Golper, 2001). This is surprising because patients on PD are
more likely to be satisfied with the care
they receive (Rubin et al., 2004). Furth
et al. (2001) reported the PD rate in
Canada as 37% of the adults on dialysis, while in England, 50% of adults on
dialysis use PD. In 2005, the USRDS
(2007) reported the highest PD rates in
Hong Kong (83%) and Jalisto, Mexico
(72%). Other countries with prominent
PD rates include Iceland (35%),
Australia (21%), the UK (including
Wales, Ireland, and England) (20%),
and Canada (18.5 %). It is notable that
New Zealand and Australia report
home HD as the RRT modality for
14% and 10%, respectively, of their
dialysis populations (USRDS, 2007).
In 2005, only 7.6% of Americans on
dialysis used PD, the only widely available self-care modality in America
(home HD was available at only a
few centers in the U.S.), while over
90% on HD were dialyzed incenter
(USRDS, 2007). This 8% PD to 90%
HD distribution is incongruent with
studies of American nephrologists’ attitudes toward PD. In a study by
Mendelssohn, Mullaney, Jung, Blake,
and Mehta (2001), more than 500
American nephrologists were surveyed
with a scenario questionnaire. The consensus was that if maximizing survival,
wellness, and quality of life were the
most important factors in deciding
mode for dialysis, 67% of patients dialyzing should be on HD and 33% on
PD. When cost effectiveness was the
most important factor to be considered,
the same nephrologists indicated 60%
should be prescribed HD and 40% PD
(Mendelssohn et al., 2001).
It is likely that consistent, early preESRD education will enhance the
patient’s choice for self-care RRT
modalities (Diaz-Buxo, 1998). A questionnaire sent to members of the
American Association of Kidney
Patients provided 1,700 replies, indicating provision of patient information
was associated with greater willingness
to adhere to therapies (Swartz,
Robinson, Davy, & Politoski, 1999).
Another survey sent to members of the
National Kidney Foundation (NKF)
Patient Organization indicated a need
for patients to be given information on
the NKF guidelines and a need to
understand the direct impact of the
guidelines on their health and disease
outcomes (Swartz et al., 1999).
According to Golper (2001), patients
feel strongly about participating in
health care decisions that affect their
therapies and outcomes. Other benefits may include delayed progression
to ESRD, better outcomes, fewer hospital stays, and greater satisfaction with
therapy for patients (Golper, 2001).
The benefit of stretching health
care dollars during a time of dwindling
resources is not to be overlooked; costs
of home PD can be substantially less
than incenter HD (Mehrotra et al.,
2006). According to Lee and colleagues (2002), self-care dialysis not
only preserves nursing resources but
costs about $20,000 less per year than
incenter HD. With increased sophistication and decreased costs associated
with technological advances, even
home-based self-care HD can be
cheaper than incenter HD once training is accomplished (Kroeker et al.,
2003). Furthermore, as the health care
worker shortage coincides with the
burgeoning ESRD population, provision for self-care dialysis options
reserves labor-intensive therapies
(incenter HD) for those unwilling or
unable to participate in self-care
(Piccoli et al., 2005).
Relevance to Nursing
The nursing metaparadigm includes
four interrelated concepts – person,
health, environment, and nursing
(McEwen & Wills, 2002), and provides
a conceptual framework for preESRD education. The person with
CKD is destabilized by changes in
health, which become more pronounced with progression to ESRD.
The environment at home and work,
and social life are affected by those
changes, and in turn, resultant changes
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July-August 2008
Vol. 35, No. 4
in the environment affect the person,
often influencing the state of health.
Nurses assist the individual with CKD
attain a new balance through holistic,
patient-centered care, and patient education. Nephrology nurses are frequently suppliers of pre-ESRD education. The nephrology nurse practitioner and the nephrology nurse are
uniquely suited to ensure that patients
with pre-ESRD are educated and
empowered to choose the modality of
RRT best suited to their lifestyle,
needs, and capabilities.
In clinical practice, nephrology
nurse practitioners and nephrology
nurses can positively influence biased
colleagues and staff by maintaining an
updated, thorough knowledge base to
advocate for pre-ESRD education and
neutral presentation of multiple modalities. Through informed nursing leadership and peer education, RRT modality choices available to patients who
are pre-ESRD may be expanded and
the patient’s clinical environment
improved.
Nursing has a rich history of holistic patient assessment and patient-centered care, as well as patient education
and advocacy. Within the realm of
renal care, the nephrology nurse is in a
unique position and has the training to
assess the patient’s knowledge deficits,
abilities and needs, environment, personality, and lifestyle. Nephrology
nurses can provide patients with information on the various RRT modalities
based on their preferred method of
learning and empower them to determine the RRT modality best suited to
their unique situation. Since patients
with renal failure are very likely to use
more than one modality in their lifetime, a broad initial education in RRT
modalities lays important groundwork
for adapting to any future changes in
therapy.
Interest in CKD clinics has been
gaining momentum since the CKD
guidelines were published by the NKF
in 2002 (USRDS, 2007). The ESRD
population growth rate has been 3% or
less per annum since 2000, primarily
due to a slowing growth in incident
counts (USRDS, 2007). According to
the USRDS (2007), “This decreased
NEPHROLOGY NURSING JOURNAL
growth in terms of patient counts,
however, is not expected to continue,
as the effect of the baby boomers, of
changing patient distribution by race
and ethnicity, and of a continued rise
in the prevalence of diabetes will drive
future increases in ESRD counts, even
if there is no further growth in rates of
ESRD.” This increase may be fueled
partly by the American obesity epidemic with its concomitant complications of diabetes and hypertension.
Additionally, the overall burden of cardiovascular disease in patients with
CKD is twice that of patients who do
not have CKD.
Nephrology nurse practitioners can
work to create a holistic, optimal environment for the care and education of
patients with CKD by facilitating the
establishment of CKD clinics by
nephrology nurse practitioners with
oversight by nephrologists as required
by state law. In the nephrology practice setting or the CKD clinic, nephrology nurse practitioners can actively
advocate for patient primacy in choosing a modality and for offering multiple RRT modality options by providing colleagues with evidence that
choice leads to better adherence and
better outcomes.
Advanced practice nurses involved
in primary care should be aware of the
NKF guidelines for staging CKD and
risk factors of CKD (such as diabetes
and hypertension). Regular screening
for kidney disease should be encouraged for at-risk populations to facilitate
early nephrology referral for optimal
CKD care and education. Patients
with diabetes and hypertension need
to be educated about target organ
damage, and about evidence supporting tight glycemic and hypertensive
control to minimize microvascular
damage to the kidneys.
Timeliness of Referral Relating
To Pre-ESRD Education and Choice
For Self-Care
Late referral is usually defined as
occurring after the estimated GFR has
dropped below 10 mL/min/1.73m2
(Owen et al., 2006). A major barrier to
pre-ESRD education is late referral of
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Vol. 35, No. 4
patients with CKD from primary care
to nephrologists or from nephrologists
to pre-ESRD education programs
(Heaf, 2004; Owen et al., 2006; Piccoli
et al., 2005). Inadequate time for
patient education and preparation,
compounded by the patient’s compromised condition requiring immediate
dialysis via a temporary vascular
access, immediately moves a patient
into HD (Heaf, 2004). Since a significant logistical effort is required to
switch the patient to PD, late referral
can cut the incidence of PD use by
50%, depriving the patient of the
chance to choose a home therapy
(Heaf, 2004; Piccoli et al., 2005).
According to Heaf (2004), if dialysis
education begins before the GFR
decreases to 15 mL/min/1.73m2, while
symptoms are still mild, the modality
choice can be made by empowered
patients according to their own social
and medical situations. However, studies reveal the problem of late referral
affects self-care choice (Heaf, 2004;
Owen et al., 2006).
Renal care centers around the
world have endeavored to understand
issues surrounding late referral and to
quantify the effects. For example, as
with many dialysis services, the
Australian North West Dialysis Service
had no automatic administrative or
medical triggers to facilitate notification. The overriding issues seemed to
be that “there was no requirement for
a nephrologist to register a patient for
dialysis, and often geographic considerations and the nature of private consulting practices appeared to discourage early referral” (Owen et al., 2006,
p. 147). Despite guidelines and the
existence of an education pathway for
patients with CKD, 50% of patients
presented less than one month before
commencing dialysis. According to
Owen et al. (2006), 29% of referrals
were late, and 57% of patients referred
to the dialysis service were unknown
to the service at commencement of
dialysis.
In one of the oldest dialysis centers
in Italy, which serves 850 patients,
Piccoli et al. (2005) analyzed the pattern of modality choices and their clinical correlates in a cohort of patients
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Optimizing Dialysis Modality Choices Around the World: A Review
chronically followed in an outpatient
network dedicated to patients with
CKD. In a logistic regression model,
only early pre-ESRD nephrology
management correlated with the
choice of self-care dialysis (Piccoli et
al., 2005). The authors noted that in
the three-year retrospective study,
only five patients started dialysis within three months from the first clinical
visit (indication for dialysis is creatinine clearance less than 10 mL/min or
higher if accompanied by severe malnutrition or various uremic symptoms). According to Piccoli et al.
(2005), a policy of early referral of
patients with CKD was progressively
developed at the clinic, and from then
on, all cases from Stage 1 CKD have
been regularly followed – Stage 1 yearly to Stage 5 at least monthly. One
might surmise that the local level of
cooperation in early referral arises
from caring for a primarily diabetic
CKD population. The authors state
that pre-RRT care in their units was
much longer than the usual international standards reported.
In a six-year retrospective study of
a Belgian pre-ESRD education program, Goovaerts, Jadoul, and Goffin
(2005) noted that a total of 58 late
referrals were admitted to the center.
During the study period, nephrologists
directed 50 patients with comorbidities
to incenter HD; of those, half were late
referral, accounting for 25 of the late
referral patients. Contrary to expectations, all remaining 33 late referrals
participated to some extent in the preESRD education program, and a surprising 20 of those were able to initiate
self-care (Goovaerts et al., 2005).
Results of the Canadian study by
Manns et al. (2005) indicated that during the study year, 40% of the 138 new
patients presenting to the CKD clinic
for education were either already on
dialysis or started within weeks of the
first visit. Additionally, during the time
the study was being conducted, “25%
to 35% of patients starting dialysis did
so urgently in hospital or as an outpatient...locally, it has been our experience that the majority of such patients
end up on incenter hemodialysis”
(Manns et al., 2005, p. 1782).
390
A Creative Solution to Enhance
Early Referral
Owen et al. (2006) performed an
extensive process improvement study
for the Australian North West Dialysis
Service and developed a clinical pathway to decrease the number of late
referrals of new patients for chronic
dialysis. A pre-ESRD program was
instituted, and nephrologists were
encouraged to register all patients with
a GFR of 30 mL/min/1.73m2 or less,
following current the Kidney Disease
Outcomes Quality Initiative (K/DOQI)
(NKF, 2002) and Caring for Australians
with Renal Insufficiency (CARI) recommendations to ensure evidencebased best practice.
The registration was logged into a
database that generated recommended actions, including invitations to
patient education sessions, anemia
management, and access provision.
There was no mandatory requirement
for the nephrologist to register the
patient or follow the care pathway.
Conference with nephrologists resulted in agreement upon three targets:
• Patients should be referred for permanent access placement when
the GFR is 25 mL/min/1.73m2 or
less.
• 95% of patients new to HD should
initiate dialysis with a permanent
vascular access.
• The access should be established
at least six weeks before initiating
dialysis.
The clinic contacted nephrologists
with the policy change as a proposal to
streamline education and provide
patients with a smooth transition to
dialysis.
Before the implementation of these
targets, 50% of patients presented to
the Australian North West Dialysis
Service less than one month before
commencing dialysis; within two
years, the median was six months
before dialysis, and after four years, it
increased to 14 months. Late registration, defined as having a GFR less
than 10 mL/min/1.73m2, decreased
from 29% to 6% over the four years.
Patients not known to the service at
commencement of dialysis decreased
from 57% to 0% after four years.
Descriptions of Enhanced
Pre-ESRD Education Programs
And the Effect on Self-Care Choice
In the U.S., results of the National
Pre-ESRD Education Initiative Survey
suggest that choice of dialysis modality
can be influenced by the extent of
patient education (Golper, 2001). The
study involved 932 referring nephrologists, 2,580 patients, and 28 educators
throughout the U.S. Completed questionnaires from the 2,580 patients
showed demographics of the participants were similar to the American
CKD population as a whole. Enhanced
education was individualized and ongoing throughout CKD. Options offered
were incenter HD and home-based
PD; 45% of the 2,580 patients had chosen PD, and 55% had chosen HD.
Follow-up studies indicated 98% of
patients choosing HD initiated on HD,
while only 75% of the patients who
chose PD actually initiated on PD.
Nonetheless, the PD rate in the initiative study was two to three times higher than the percentage of patients who
selected PD nationally (Golper 2001).
In the Australian study, the North
West Dialysis Service provided an
enhanced pre-ESRD education program, “Managing Kidney Failure”
(MKF), to small classes of three to six
patients and their families. According
to Owen et al. (2006), the introductory
education session provides an
overview of renal failure and RRT
modalities followed by a medical
review session to confirm records and
answer individual patient questions. A
second education session takes place
three weeks later, providing insight
into dialysis lifestyle and available support. This is followed by a second
review, during which patients choose
their intended modality. Finally, planning for dialysis education and access
occurs, and the patient visits PD and
HD training units and meets the staff
(Owen, et al. 2006). Before the MKF
program was instituted, 50% of
patients had attended an education
session, and afterward, attendance rate
rose to 74% (Owen et al., 2006). No
information is provided concerning
the percentage of patients choosing
incenter HD and self-care PD before
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Vol. 35, No. 4
the MKF program, but during the
four-year study, 80% of patients initiated on incenter HD, and 20% chose to
initiate on home-based PD (Owen et
al., 2006).
In Italy, Piccoli et al. (2005) performed a retrospective study of all
patients (n = 43), excluding admissions
from the emergency department, initiating on dialysis in a hospital-based
center during a three-year period. The
clinic began as a diabetes/CKD center, and thus, nearly 80% of the patient
population is diabetic in contrast to the
region’s overall diabetic population of
16%. The well-established pre-ESRD
education program provides written
materials, videos, and visits to PD clinics, as well as HD clinics spread out
over time for all patients at the center.
During the study period, 67.4% opted
for self-care dialysis. Primary reasons
given by patients for choosing a selfcare modality were autonomy; desire
to continue with their original clinic;
desire for a gentler, more natural treatment at home (PD); and tailored (HD)
programs. Only 32.6% opted for inhospital dialysis, primarily citing the
desire to receive standard treatment in
a protected setting and not being personally involved in their dialysis management.
In Belgium, Goovaerts et al.
(2005) performed a six-year retrospective study of a dialysis center’s
pre-ESRD education program. The
center provided a structured pre-dialysis education program for patients
and their families based on individualized information sessions with an
experienced nurse and use of inhouse video tapes (Goovaerts et al.
2005). Patients were informed in
detail about all RRT modalities. It
was noted that 33 of 185 patients who
participated in the education program
were late referrals, which usually culminates in initiation on incenter HD;
however, 20 of those opted for selfcare modalities. This indicates that
program flexibility may allow some
late referral patients to fully participate in choosing their modality for
RRT. After two years, 43% of the 102
patients choosing self-care received a
transplant, and 38% remained on
NEPHROLOGY NURSING JOURNAL
their chosen modality, 9% had to
change modality, and of those, only
one was due to non-adherence to prescribed dialysis regimen.
In Canada, Manns et al. (2005) performed a controlled, randomized
study of an enhanced pre-ESRD education program designed to address
patient-specific barriers to choosing
self-care dialysis. A previous study by
McLaughlin, Manns, and Mortis
(2003) revealed deficiencies in knowledge, skills, and attitudes as barriers.
The three most important barriers are
understanding explanations of selfcare dialysis, concerns over social isolation, and concerns about the unsupervised nature of self-care dialysis.
Results of a power analysis indicated that a sample population of 30 to 40
patients in each of the two arms was
necessary (Manns et al., 2005). Two
groups of 35 patients received the clinic’s standard teaching about kidney
disease, including dietary instruction
and detailed information about the
various modalities of RRT in a threehour, one-on-one session with a nurse,
dietician, and social worker. After
computer-generated randomization,
the control group received no additional formal education, and the
enhanced education group participated in two educational sessions.
The design was based on previous
studies, suggesting isolated interventions are generally ineffective in changing behavior and that combinations
are better (Manns et al., 2005). The
generic stages of behavior change are
described as pre-contemplative, contemplative, preparation, action, and
maintenance or relapse (Prochaska &
DiClemente, 1983). The first educational session was a predisposing intervention designed to achieve the stage
of preparation by presenting self-care
dialysis as a desirable, life-enhancing,
and attainable skill in a positive,
empowering manner. Patients received
four written manuals, one describing
advantages of self-care dialysis and the
last three containing detailed descriptions of self-care RRT modalities,
along with a video showing detailed
visuals of each type of dialysis with
patient testimonials. The second com-
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Vol. 35, No. 4
ponent, an enabling intervention
designed to achieve the stage of action,
occurred two weeks later. It consisted
of a 90-minute, small group, interactive problem-solving session to overcome barriers to self-care dialysis in a
case study scenario.
There was no difference in the proportion of control group patients planning to start self-care dialysis at study
completion compared to baseline.
When compared with the control
group, there was no statistically significant increase in the proportion of the
enhanced education group planning to
start self-care dialysis after receiving
the self-care dialysis booklets and
video. However, after the small group
session, the proportion of the
enhanced education group planning to
initiate on self-care dialysis was 82 %
compared with the control group at
50% (Manns et al., 2005).
Offering an Extensive Array
Of RRT Modalities Supports
The Choice for Self-Care
“Where [pre-ESRD care] is long
enough, where choices are many and
caregivers offer them without prejudices, the choice of RRT depends
more on the individual patient’s preference...If this hypothesis is confirmed
in further follow-up analysis, true
patient empowerment has [probably]
been reached” (Piccoli et al., 2005, p.
273). The nephrology clinic at the
University of Torino has an 85% incidence of patients with diabetes as
described in the study by Piccoli et al.
(2005). It provides renal and/or pancreatic transplant services, an array of
in-hospital HD (including daily dialysis), and an extensive array of self-care
dialysis modalities (including several
variations of home HD, variations of
PD, and various levels of self-care at
satellite clinics with flexible scheduling). Forty-nine percent of study participants chose self-care modalities.
According to Piccoli et al. (2005), the
study’s small sample size (n = 48) is a
weakness. However, the major
strength of the study is the extensive
“multiple choice network” of dialysis
options available to patients in an out-
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Optimizing Dialysis Modality Choices Around the World: A Review
patient setting, including the availability of a nursing team to follow homecare patients and provide quick
response in the event of acute problems.
In addition to incenter HD, the
Belgian clinic in the study by
Goovaerts et al. (2005) offers an extensive array of self-care dialysis modalities. These include various schedules
for home HD, several variations of
PD, and multiple levels of self-care at
satellite HD units. Overall, of the 185
participants in the pre-ESRD education program, 55% chose self-care
modalities (Goovaerts et al., 2005).
Age seemed to be a factor in modality
choice. Analysis showed younger
patients tended to choose self-care
modalities (p < 0.001 for each modality using ANOVA and Scheffe tests),
but all modalities were chosen by
some patients in their 70s and 80s. The
younger the age group, the higher the
probability of choosing a self-care
modality (p < 0.01 Mann Whitney U
test); however, up to 40% of patients
over 60 years in age did not choose
incenter HD.
In the study by Manns et al. (2005),
a Canadian clinic provided incenter
HD, various self-care options (including an array of home HD options, two
PD choices, and a self-care option
within a hemodialysis clinic). Although
the enhanced intervention group had
an impressive outcome of 82% of participants choosing self-care dialysis, it is
interesting to note that 50% of the standard intervention group chose a selfcare dialysis modality.
In California, a retrospective,
descriptive study of 428 patients was
performed for ESRD Network 18 to
determine variables relating to preESRD education in the selection of
dialysis modality. These centers routinely provide only incenter HD and
home-based PD as RRT modality
options (Mehrotra et al., 2005).
According to the study, the majority
of patients stated they were not provided with information about PD,
home HD, or renal transplantation as
options (66%, 88%, and 74% respectively). Not surprisingly, multivariate
analyses showed that only two vari-
392
ables were significantly associated
with a self-care modality choice, limited in this case to PD – the probability of being offered PD as a RRT
option and the time spent on patient
education.
In contrast, a study by Robar, Doss,
and Moran (2006) in northern
California took place in four freestanding centers dedicated to offering a full
menu of renal replacement therapies
with special emphasis on home therapies. All options were presented, including transplant incenter HD, a variety of
home HD machines and schedules, and
varieties of PD. Over a period of 21
months, 576 patients took part in the
pre-ESRD options education program,
and 42% chose a home therapy.
Economic Barriers to Offering
Multiple Dialysis Modalities
Both Heaf (2004) and Rubin et al.
(2004) point out that bias based on
economic factors may affect how
patients in the U.S. are directed into
RRT. Despite the lower overall costs of
PD compared to incenter HD,
Medicare’s current payment system
pays similarly for either modality.
Many third-party payers who are primary for the first 32 months of dialysis
follow Medicare’s lead. This may seem
to make either modality equally attractive, and even make PD more attractive; however, the cost of maintaining
an HD facility may encourage clinicians to direct patients to incenter HD
to fill all available slots (Heaf, 2004).
Since the expense of the slot will exist
whether filled or not, it becomes more
profitable for already under-reimbursed
providers to make use of the HD slot
(Heaf, 2004). Setting up a patient at
home for PD incurs all new costs and
leaves the HD center with an empty,
profit-draining chair. Proposed changes in Medicare physician payment
policy to pay by the number of in-person contacts (which are reduced in
patients on PD to once a month) may
create an even greater disincentive for
physicians to provide the option of
home PD to patients (Rubin et al.,
2004).
Applications to Practice and Health
Systems Management
Despite knowledge of guidelines,
inertia within the medical community
seems to engender the problem of late
referral and continues to undermine
efforts at early pre-ESRD education,
thus robbing patients of the opportunity to choose an RRT option other than
incenter HD. To enhance early education and smooth the transition to RRT
for Australians, Owen et al. (2006)
introduced a clinical pathway to
nephrologists and internists who
agreed to register patients when the
GFR was 30 mL/min/1.73m2 or less.
This study sets the stage for large dialysis providers to step in and set up clinical pathways, including early preESRD education in terms of registration of patients rather than referral.
Referral to nephrology from primary
care providers needs to occur when
the GFR is 30 mL/min/1.73m2 or less
to allow delay of progression and timely education (Owen et al. 2006). Rubin
et al. (2004) recommended addressing
the reimbursement disincentives associated with PD; additionally, it makes
sense to avoid disincentives and possibly provide incentives associated with
other self-care modalities, such as
home HD. Incentives for dialysis centers to support a wide array of self-care
modalities can also be offered.
Education
Recently, there has been a push to
create CKD clinics to provide close
management of CKD and gradual and
thorough patient education. It makes
sense to provide consistent and appropriate Medicare reimbursement for
pre-ESRD education at the same rate
as current diabetes education, especially in light of the patient population
overlap between diabetes and CKD.
All APN students should be taught risk
factors and screening for kidney disease, emphasizing studies that have
shown early referral to nephrology
care (when the GFR is at or below 30
mL/min/1.73m2) can delay renal failure. It may be useful for nephrology
nurse practitioners to take part in community education initiatives to
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July-August 2008
Vol. 35, No. 4
increase awareness of renal disease
and screenings. Additionally, it may be
useful to take part in or initiate educational sessions for local primary care
providers and nephrologists concerning benefits of renal screening and
early pre-ESRD education.
need to assess and intervene with
fatigued and overburdened caregivers
before burnout occurs (Schneider,
2004). Research led by professional
nephrology nurses is needed to identify valid assessment tools for this
important aspect of clinical nursing
practice (Schneider, 2004).
Research Recommendations
There is little information on costs
and savings associated with self-care
dialysis modalities; a large, multicenter study comparing incenter and selfcare dialysis costs is needed (Piccoli et
al., 2005). Likewise, a complementary, large, multicenter study to delineate costs versus benefits of enhanced
and early pre-ESRD education would
be helpful. Two such studies could
add momentum to current efforts
directed at encouraging early preESRD education and offering
patients multiple self-care modalities
as a clinical norm across the U.S.
Reasons for RRT modality choices should be studied during the CKD
period at the time of choice rather
than retrospectively, then analyzed to
determine future guidelines for education programs (Piccoli et al., 2005).
Follow-up research of patients on
dialysis who participated in enhanced
pre-ESRD programs is necessary to
determine outcomes (Piccoli et al.,
2005). Choice satisfaction, increased
adherence, and better outcomes
could further substantiate the value of
patient education and broad RRT
choice, making both more desirable
to medical and financial entities.
Finally, with the graying of America,
increase in longevity, and financial
constraints, the professional nephrology nurse is acutely aware of the vital
role played by the ESRD home caregiver in self-care RRT. Nephrology
nurses may experience an increasing
Conclusion
Substantive research has been
done to elucidate the benefits of a preESRD educational program. Currently, the CMS recommends early
referral and patient education on all
RRT modalities. However, barriers to
early referral and lack of presentation
of all available modalities still plague
renal care systems in the U.S. and
worldwide. Recent studies from various countries comparing the relationship between early pre-ESRD education and increased selection of self-care
RRT modality were reviewed. Studies
comparing modality choices of patients with little pre-ESRD education
to those with an enhanced pre-ESRD
education underscores the importance
of knowledge, patient empowerment,
and availability of multiple RRT
modalities. Late referral often results in
a missed chance for pre-ESRD education and almost guarantees initiation
on incenter HD with a temporary
catheter for access, thereby robbing
the patient of primacy in choosing
their RRT. In light of the U.S. diabetes
epidemic and aging of the Baby
Boomers, it is increasingly important
to educate primary care professionals
about kidney disease risk factors, regular renal screening, CKD staging, and
K/DOQI guidelines. Pathways are
needed to promote early referral to
nephrology and early pre-ESRD education.
Nephrology Nursing Journal Editorial Board Statements of Disclosure
In accordance with ANCC-COA governing rules Nephrology Nursing Journal Editorial Board statements of disclosure are published with each CNE offering. The statements of disclosure for this offering are published below.
Paula Dutka, MSN, RN, CNN, disclosed that she is a consultant for Hoffman-La Roche and Coordinator of
Clinical Trials for Roche.
Patricia B. McCarley, MSN, RN, NP, disclosed that she is on the Consultant Presenter Bureau for Amgen,
Genzyme, and OrthoBiotech. She is also on the Advisory Board for Amgen, Genzyme, and Roche and is the
recipient of unrestricted educational grants from OrthoBiotech and Roche.
Holly Fadness McFarland, MSN, RN, CNN, disclosed that she is an employee of DaVita, Inc.
Karen C. Robbins, MS, RN, CNN, disclosed that she is on the Speakers’ Bureau for Watson Pharma, Inc.
NEPHROLOGY NURSING JOURNAL
July-August 2008
Vol. 35, No. 4
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NEPHROLOGY NURSING JOURNAL
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Vol. 35, No. 4
ANNJ0812
ANSWER/EVALUATION FORM
Optimizing Dialysis Modality Choices Around The World: A Review of Literature
Concerning The Role of Enhanced Early Pre-ESRD Education in Choice of Renal
Replacement Therapy Modality
Sharon M. Key, MSN, RN, ACNP-BC
1.5 Contact Hours
Expires: August 31, 2010
ANNA Member Price: $15
Regular Price: $25
Complete the Following:
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Address: __________________________________________________________
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Note: If you wish to keep the journal intact, you may photocopy the answer sheet or access this posttest at
www.annanurse.org/journal
1. What would be different in your practice if you applied what you have learned
from this activity?
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
To increase awareness about pre-ESRD education
programs, barriers to early pre-ESRD education,
and programs designed to decrease late referral
from nurses and other healthcare providers.
Please note that this continuing nursing education activity does not
contain multiple-choice questions. This posttest substitutes the multiple-choice questions with an open-ended question. Simply answer
the open-ended question(s) directly above the evaluation portion of
the Answer/Evaluation Form and return the form, with payment, to the
National Office as usual.
Strongly
disagree
Evaluation
2. By completing this offering, I was able to meet the stated objectives
a. Explain how early pre-ESRD education can enhance a patient’s choice for self-care.
b. Discuss the ways nurses can provide pre-ESRD education to patients.
c. Identify the barriers to pre-ESRD education and the ability to offer multiple dialysis modalities.
d. Describe pre-ESRD education on a global scale.
e. Discuss solutions and research recommendations for providing pre-ESRD education
and various RRT modality choices.
3. The content was current and relevant.
4. This was an effective method to learn this content.
5. Time required to complete reading assignment: _________ minutes.
Strongly
agree
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I verify that I have completed this activity ________________________________________________________________________________
(Signature)
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