Nursing Intervention Aimed at Improving
Nursing Intervention Aimed at Improving
Nursing Intervention Aimed at Improving
Publishers Note: Author biographical statements and acknowledgments can be found on the
following page.
Statements of Disclosure: Abhijit V. Kshirsagar
is on the Fresenius Medical Care Advisory Board.
All other authors reported no actual or potential
conflict of interest in relation to this continuing
nursing education activity.
Note: Additional statements of disclosure and
instructions for CNE evaluation can be found on
page 256.
Continuing Nursing
Education
Ronald J. Falk
Donna H. Harward
Abhijit V. Kshirsagar
Copyright 2015 American Nephrology Nurses Association.
Jacobson Vann, J.C., Hawley, J., Wegner, S., Falk, R.J., Harward, D.H., & Kshiragar, A.V.
(2015). Nursing intervention aimed at improving self-management for persons with
chronic kidney disease in North Carolina Medicaid: A pilot project. Nephrology
Nursing Journal, 42(3), 239-255.
This pilot project aimed to improve knowledge and self-management among Medicaid
beneficiaries with Stage 3b and 4 chronic kidney disease who were identified using a
population-based approach. Participants received up to six in-person educational sessions delivered by a nurse practitioner. Increases in knowledge and self-reported behavior changes were generally observed among participants.
Key Words: Chronic kidney disease, self-management, nurse intervention, education, and population-based approach.
Goal
To provide an overview of a pilot project designed to improve knowledge and self-management among Medicaid beneficiaries with chronic kidney disease 9CKD) Stages 3b and 4.
Objectives
1.
2.
This offering for 1.5 contact hours is provided by the American Nephrology Nurses
Association (ANNA).
American Nephrology Nurses Association is accredited as a provider of continuing nursing
education by the American Nurses Credentialing Center 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 Commissions (NNCCs) continuing nursing education requirements for certification and recertification.
May-June 2015
239
Julie C. Jacobson Vann, PhD, MS, RN, is a Senior Researcher, American Institutes for Research, Chapel Hill,
NC; an Evaluation Consultant, AccessCare, Morrisville, ND; and an Adjunct Assistant Professor, University of
North Carolina at Chapel Hill, School of Nursing, Chapel Hill, NC. She may be contacted directly via email at
[email protected]
Jenny Hawley, MSN, RN, FNP-BC, is a Family Nurse Practitioner, University of North Carolina at Chapel
Hill, UNC Kidney Center, Chapel Hill, NC, and a member of ANNAs Cardinal Chapter.
Steven Wegner, MD, JD, is President, AccessCare, Morrisville, NC; a Professor, University of North Carolina
at Chapel Hill, Department of Pediatrics, Chapel Hill, NC; and Senior Vice President & Chief Innovations
Officer, Community Care of North Carolina, Raleigh, NC.
Ronald J. Falk, MD, is a Doc J. Thurston Professor of Medicine; Chief, Division of Nephrology & Hypertension;
and Director, UNC Kidney Center, University of North Carolina at Chapel Hill, Chapel Hill, NC.
Donna H. Harward, is Director of Education and Outreach, University of North Carolina at Chapel Hill,
UNC Kidney Center, Chapel Hill, NC.
Abhijit V. Kshirsagar, MD, MPH, is an Assistant Professor of Medicine, University of North Carolina at
Chapel Hill, UNC Kidney Center, Chapel Hill, NC.
Acknowledgments: This pilot project was conducted as a collaboration between the North Carolina Kidney
Center and AccessCare. The authors wish to acknowledge the support of NC Tracs, the North Carolina
Community Care Network (CCNC), and the CCNC care coordinators.
240
May-June 2015
Julie C. Jacobson Vann, PhD, MS, RN, is a Senior Researcher, American Institutes for Research, Chapel Hill,
NC; an Evaluation Consultant, AccessCare, Morrisville, ND; and an Adjunct Assistant Professor, University of
North Carolina at Chapel Hill, School of Nursing, Chapel Hill, NC. She may be contacted directly via email at
[email protected]
Jenny Hawley, MSN, RN, FNP-BC, is a Family Nurse Practitioner, University of North Carolina at Chapel
Hill, UNC Kidney Center, Chapel Hill, NC, and a member of ANNAs Cardinal Chapter.
Steven Wegner, MD, JD, is President, AccessCare, Morrisville, NC; a Professor, University of North Carolina
at Chapel Hill, Department of Pediatrics, Chapel Hill, NC; and Senior Vice President & Chief Innovations
Officer, Community Care of North Carolina, Raleigh, NC.
Ronald J. Falk, MD, is a Doc J. Thurston Professor of Medicine; Chief, Division of Nephrology & Hypertension;
and Director, UNC Kidney Center, University of North Carolina at Chapel Hill, Chapel Hill, NC.
Donna H. Harward, is Director of Education and Outreach, University of North Carolina at Chapel Hill,
UNC Kidney Center, Chapel Hill, NC.
Abhijit V. Kshirsagar, MD, MPH, is an Assistant Professor of Medicine, University of North Carolina at
Chapel Hill, UNC Kidney Center, Chapel Hill, NC.
Acknowledgments: This pilot project was conducted as a collaboration between the North Carolina Kidney
Center and AccessCare. The authors wish to acknowledge the support of NC Tracs, the North Carolina
Community Care Network (CCNC), and the CCNC care coordinators.
240
May-June 2015
Transtheoretical Model
The Transtheoretical Model and
the five stages of change are important to this initiative because the
model views change as a process
where individuals may move through
the stages of readiness to change
May-June 2015
241
Study Aims
In response to the concerns about
delayed access to care for persons
with CKD, our team developed and
implemented a pilot project aimed at
1) using population-based approaches
to identify and quantify North
Carolina Medicaid and dually eligible
Medicare and Medicaid beneficiaries
who have CKD Stage 3b (30 to 45
mL/minute/1.73 m2) or Stage 4 (15 to
29 mL/minute/1.73m2) and have not
been linked with needed care
providers and services; and 2) evaluating the effect of a nurse education
intervention on patients self-perceived health status, health services
utilization patterns, costs of care, selfefficacy in managing chronic kidney
disease, and CKD-related short-term
outcomes. It was expected that taking
a population-based approach would
facilitate reaching patients earlier in
the care and decision-making process.
In the longer term, it is expected that
earlier access to CKD education and
linkage with care providers may help
to improve care and reduce emergency department and inpatient utilization.
Methods
Setting and Project Partners
The setting for this project is the
UNC CKD Clinic, which opened in
2008. The project was implemented
in two of three clinic locations, Chapel
Hill and Burlington, North Carolina.
The purpose of this clinic is to educate
patients about CKD, complications of
the disease, and care options. The
clinic is directed by a physician and
staffed by nurses who provide educa-
242
Intervention
The study intervention was
developed and delivered by the CKD
nurse educator who is a family nurse
practitioner (FNP). The intervention
components and steps were documented in detail in the written plan
for CKD Education Program. This
intervention consisted of the CKD
educational sessions with the CKD
nurse educator, assessment of readiness to change, a CKD toolkit individualized for each participant, and
collaborative goal-setting between the
CKD nurse educator and the patient.
The CKD educational content was
based on the NKDEP (2012), an initiative of the National Institute of
Diabetes and Digestive and Kidney
Diseases (NIDDK). The content consisted of 20 categories of topics classified into five content areas: overview
of CKD; general CKD management;
co-morbidities and special issues for
persons with CKD; effect of CKD on
symptoms and self-care management
strategies and behaviors; and treatment options and/or modalities (see
Table 1).
Major concepts were displayed
in visual tools during the visits, for
example, by using handouts and a
whiteboard, to reinforce educational
content that was discussed. Each participant was provided with a UNC
Kidney Center canvas tote bag to
carry intervention handouts, which
were developed by the CKD nurse
educator. These handouts included a
12-page Patients Guide to Chronic
Evaluation Design
A pre-intervention post-intervention design and case series approach
was used to evaluate the pilot project.
The study was approved by the UNCChapel Hill School of Medicine Institutional Review Board.
Eligibility Criteria
Persons were eligible for this intervention and study if a) 18 years of age
or older at the time of enrollment; b)
living in the service areas of at least
one of the two UNC Chronic Kidney
Disease Clinic locations; c) insured by
NC Medicaid as primary or secondary
payer, for example, Medicare may be
primary for dually eligible beneficiar-
May-June 2015
Table 1
Topic List of CKD Educational Intervention and Number and Percent of Participants Who
Demonstrated Improvement in Knowledge by Meeting Established Evaluation Criteria after
Receiving the Educational Intervention.
Met Knowledge Criteria # (n)
List of CKD Educational Topics
PreTest
PostTest
%
Improved
Overview of CKD
1.
2 (9)
8 (9)
66.7
2.
4 (9)
7 (9)
33.3
3.
1 (9)
6 (9)
55.6
0 (9)
4 (9)
44.4
2 (9)
8 (9)
66.7
1 (7)
1 (9)
5 (7)
8 (9)
57.1
77.8
4 (8)
7 (8)
37.5
1 (8)
8 (8)
87.5
4 (8)
8 (8)
50.0
4.
6.
0 (8)
7 (8)
87.5
7.
2 (8)
8 (8)
75.0
8.
3 (8)
6 (8)
37.5
5 (7)
7 (7)
28.6
0 (7)
2 (7)
28.6
0 (7)
5 (7)
71.4
0 (7)
4 (7)
57.1
0 (7)
5 (7)
71.4
May-June 2015
243
Table 1 (continued)
Topic List of CKD Educational Intervention and Number and Percent of Participants Who
Demonstrated Improvement in Knowledge by Meeting Established Evaluation Criteria after
Receiving the Educational Intervention.
Met Knowledge Criteria # (n)
List of CKD Educational Topics
PreTest
PostTest
%
Improved
1 (5)
2 (5)
20.0
3 (5)
3 (5)
0.0
2 (5)
4 (5)
40.0
2 (7)
3 (7)
14.3
4 (7)
5 (7)
14.3
2 (7)
5 (7)
42.9
4 (5)
5 (5)
20.0
2 (5)
5 (5)
60.0
3 (5)
5 (5)
40.0
4 (5)
5 (5)
20.0
0 (5)
4 (5)
80.0
1 (5)
5 (5)
80.0
1 (5)
4 (5)
60.0
0 (5)
3 (5)
60.0
0 (5)
2 (5)
40.0
1 (5)
4 (5)
60.0
0 (5)
5 (5)
100.0
0 (5)
1 (5)
20.0
5 (5)
5 (5)
0.0
2 (5)
5 (5)
60.0
Note: n = the number of persons in the denominator for measuring improvement in knowledge.
244
May-June 2015
Study Procedures
Population-based approach to
identifying participants. Population-based strategies were used to
identify potentially eligible Medicaid
beneficiaries using a series of steps. In
step one, electronic files of eGFR laboratory values for North Carolina
Medicaid beneficiaries drawn between May 1, 2009, and December 2,
2011, were screened to identify participants with eGFR values in the eligibility range. This step was intended to
be sensitive but not specific. In step
two, the CKD nurse educator reviewed electronic health records and
Medicaid files of potentially eligible
persons to further screen for eligibility. Because laboratory value data
were reported for a range of dates, the
screening lab data needed to be supported with a review of records to further assess eligibility, such as whether
the person was currently living, the
current CKD stage, and whether
treatment, such as dialysis, was being
received. In step three, the CKD
nurse educator checked North
Carolina Medicaid care management
records to determine whether the
potentially eligible person was receiving community-based care management services. If so, the AccessCare
community-based care manager was
asked to make the initial contact with
the person to assess potential interest
in receiving CKD education. The
CKD nurse educator contacted the
person by telephone and/or letter to
describe the program, determine
whether the person was interested in
participating, and assess potential barriers to participation if not interested.
Patients were eligible to receive the
Data Sources
Data for this study were obtained
from a hospital database extract, electronic health records, populationbased electronic Medicaid files, patient
questionnaires and assessment tools,
and documentation of interactions
with patients. A series of three data
requests were made to UNC Health
Care between May 2010 and
December 2011 to obtain records of all
adult Medicaid beneficiaries who had
received health services at UNC
Health Care in any department and
had an eGFR laboratory result during
the previous year for the first request
and during the previous six months for
subsequent requests. Data were provided in ExcelTM files on a secured
May-June 2015
server. Data elements for each potential participant were Medicaid identification number, date of service, gender,
race, and eGFR. Medical records at
UNC Health Care were reviewed for
beneficiaries who had eGFR lab values within the range of 15 to 45 mL/
minute/1.73m2. The North Carolina
Medicaid Clinical Management Information System (CMIS) is the primary
database used by care managers to
document care management needs
and services provided. It also includes
some data extracted from the North
Carolina Medicaid claims database.
This database was reviewed to assess
whether or not beneficiaries received
care management services.
Measurement
During visits with participants,
self-report data were collected using
four tools: four-item Healthy Days
component of the Health-Related
Quality-Of-Life 14-Item Measure
(HRQOL-14) (CDC, 2011); four-item
Health Care Utilization measure
(Stanford Patient Education Research
Center, n.d.); eight-item Perceived
Kidney Self-Management Scale (see
Table 2); and the Nurse Education
Intervention Checklist. The four-item
Healthy Days Measure is a standard
set of questions that is included in the
State-Based Behavioral Risk Factor
Surveillance System, National Health
and Nutrition Examination Survey,
and the Medicare Health Outcome
Survey (CDC, 2011). Psychometric
testing of the four-item Health Care
Utilization measure has been reported in a study that compared selfreported health services utilization
with health records (Ritter, Kaymaz,
Stewart, Sobel & Lorig, 2001). This
study demonstrated that participants
have a tendency to under-report
physician visits (r = 0.64) and overreport emergency department visits (r
= 0.60); however, the authors concluded that self-reported utilization is
a potentially viable alternative to
reviewing provider records (Ritter et
al., 2001). The Perceived Kidney SelfManagement Scale is a modified version of the eight-item Perceived
Medical Condition Self-Management
245
Table 2
List of Study Instruments and Frequency and Timing of Administration
Tool Name
Intake Tool and Demographic
Information
Patient Interview tool
Part I Healthy Days
Part II Health Care Utilization
Part III Perceived Kidney
Self-Management Scale
Nurse Education Intervention
Checklist
Part A. Measurement of Patient
Knowledge or Understanding
Part B. Measurement of PatientDirected Goals and Goal
Achievement
Part C. Measurement (Time) of Nurse
Intervention (Education)
Health Measures Abstract Tool
Part A. Agencies and Services Involved
in Care
Part B. Diagnoses
Part C. Medications
Part D: Lab Values and Other Health
Measures
246
Types of Measures
(# of Questions)
Demographic and contact information.
cause the questions asked about utilization over the past six-month time
period.
The Nurse Education Intervention Checklist was developed by the
research team after conducting an
unsuccessful literature search to find a
tool that would guide the CKD educational intervention and assess learning. However, the knowledge assessment component was modeled after
the Spoken Knowledge in Low Literacy patients with Diabetes (SKILLD)
(Rothman et al., 2005). The CKD
knowledge checklist assessed the following: CKD content taught, baseline
knowledge for 20 topics, post-intervention knowledge, health behavior
goals and goal achievement, and
duration of the CKD nurse educational session in minutes (see Table 1).
The educational intervention
process was measured by indicating
for each topic whether it was covered,
May-June 2015
Table 3
Survey Questions and Participant Responses Assessing Self-Perceived Health Status, Health Care
Utilization, and Self-Perceived Self Management
Survey Questions
Response Options
Pre-Test
Post-Test
1 (9)
1 (9)
3 (9)
3 (9)
1 (9)
0 (4)
1 (4)
2 (4)
1 (4)
0 (4)
Excellent
Very good
Good
Fair
Poor
2.
Number of days
Mean
Range
7.1 (8)
0 to 15
6.5 (4)
0 to 14
Number of days
Mean
Range
10.1 (9)
0 to 30
5.3 (4)
0 to 16
During the past 30 days, for about how many days did poor physical or mental health keep you from doing your usual activities,
such as self-care, work, or recreation?
Number of days
Mean
Range
0.8 (9)
0 to 5
4.0 (4)
0 to 14
3.
4.
In the past 6 months, how many times did you visit a physician?
Do not include visits while in the hospital or to a hospital emergency room. Fill in with 0 or another number.
Number of times
Mean
Range
7.3 (9)
4 to 25
8.8 (4)
3 to 8
Number of times
Mean
Range
1.1 (9)
0 to 4
1.5 (4)
0 to 4
Number of times
Mean
Range
0.4 (9)
0 to 2
0.25 (4)
0 to 4
How many total nights did you spend in the hospital in the past 6
months? Fill in with 0 or another number.
Number of nights
Mean
Range
1.1 (9)
0 to 7
1.8 (4)
0 to 7
1 = Strongly Disagree
to 5 = Strongly Agree
Pre-Test
Post-Test
1 to 2
3
4 to 5
3 (9)
3 (9)
3 (9)
4 (4)
0 (4)
0 (4)
10. I find that efforts to change things I dont like about my kidney disease arent helpful.
12
3
4 to 5
4 (9)
3 (9)
2 (9)
3 (4)
1 (4)
0 (4)
1 to 2
3
4 to 5
2 (9)
0 (9)
7 (9)
0 (4)
0 (4)
4 (4)
1 to 2
3
4 to 5
1 (9)
0 (9)
8 (9)
0 (4)
0 (4)
4 (4)
1 to 2
3
4 to 5
2 (9)
0 (9)
7 (9)
0 (4)
0 (4)
4 (4)
6.
7.
8.
May-June 2015
247
Table 3 (continued)
Survey Questions and Participant Responses Assessing Self-Perceived Health Status, Health Care
Utilization, and Self-Perceived Self Management
Managing Your Health Problem:
Perceived Kidney Disease Self-Management Scale
1 = Strongly Disagree
to 5 = Strongly Agree
Pre-Test
Post-Test
1 to 2
3
4 to 5
5 (9)
1 (9)
3 (9)
4 (4)
0 (4)
0 (4)
1 to 2
3
4 to 5
5 (9)
0 (9)
4 (9)
3 (4)
1 (4)
0 (4)
16. Im generally able to accomplish my goals with respect to managing my kidney disease.
1 to 2
3
4 to 5
2 (9)
2 (9)
5 (9)
0 (4)
0 (4)
4 (4)
Analysis
Data from this pilot project were
assessed using descriptive approaches. First, changes in participant knowledge, as assessed using the Nurse
Education Intervention Checklist,
were summarized as the number and
percentage of participants who did
not provide an accurate response to
the knowledge assessment prior to
receiving the educational intervention
248
Figure 1
Screening, Selection, and Enrollment of Study Participants
Results
Of the 3,029 patients who were
screened for potential eligibility, 53
(1.7%) were found to be eligible for
the pilot project based on a review of
health records. Of these, 9 (0.3%) persons screened agreed to participate in
the study (see Figure 1). Persons
screened were identified as being
ineligible because of: improved
eGFR after initial screening, declining eGFR, on dialysis, status post kid-
May-June 2015
Table 4
Demographic Characteristics of Study Participants
Frequency
(%)
Demographic Characteristic
Age
50 to 59 years
60 to 69 years
70 to 79 years
80 to 89 years
Gender
Male
Female
Ethnicity
Not Hispanic or Latino
Hispanic or Latino
Race
Black or African American
White
Asian
American Indian or Alaskan Native
Native Hawaiian or Pacific Islander
Patients Preferred Language
English
Spanish
Marital Status
Single, never married
Married
Widowed
Divorced
Highest Level of Education Achieved
Elementary School (K 5)
Middle School (6 8)
Some High School
High School or GED
Some College
2-Year College Degree (Associates) or higher
Type of Residence
Owns Home
Rents Home or Apartment
Other
Number of People at Residence (for past 2 months)
One person
Two persons
Three persons
Four persons
May-June 2015
2
2
3
2
(22.2)
(22.2)
(33.3)
(22.2)
4
5
(44.4)
(55.6)
9 (100.0)
0
(0.0)
6
2
1
0
0
(66.7)
(22.2)
(11.1)
(0.0)
(0.0)
9 (100.0)
0
(0.0)
3
1
3
2
(33.3)
(11.1)
(33.3)
(22.2)
1
2
1
3
2
0
(11.1)
(22.2)
(11.1)
(33.3)
(22.2)
(0.0)
2
5
2
(22.2)
(55.6)
(22.2)
3
4
0
2
(33.3)
(44.4)
(0.0)
(22.2)
Changes in Participant
Knowledge
The percent of participants
whose knowledge of CKD concepts
increased after the intervention varied by content type. Knowledge
improvement was generally more
consistent among participants for the
content areas of overview of CKD,
general CKD management, and treat-
249
Table 5
Frequency and Length of Participant Visits with CKD Nurse Educator
Measure
Frequency
Mean
Range
N/A
4.3
1 to 6
1 visit
N/A
N/A
3 visits
N/A
N/A
5 visits
N/A
N/A
6 visits
N/A
N/A
All visits
N/A
63.4
45 to 90
N/A
81.7
60 to 90
N/A
57.8
45 to 75
250
May-June 2015
Table 6
Examples of Individualized Behavioral Goals and Outcomes for Study Participants
Demographic
Characteristics
CKD Stage
Brief History
CKD Stage 4;
hypertension; diabetes
mellitus; obese; focal
segmental glomerulosclerosis; gout
May-June 2015
General Goal
Outcomes
Weight loss
Exercise
Weight loss
Exercise
Increase exercise
Avoid contraindicated
over-the-counter
medications
Decrease weight
251
agreement to the statement, I succeed in the goals I undertake to manage my kidney disease. And, four of
four participants at post-test indicated
disagreement to the statement, It is
hard for me to find effective ways to
deal with problems that occur with
managing my kidney disease. In
contrast, the pre-test responses were
generally distributed across the
response options.
Discussion
The results of this pilot project
were mixed because the populationbased approach to identify persons
with CKD during Stages 3b and 4
was minimally successful. The officebased approach was not very accessible for patients; however, the educational intervention demonstrated
short-term successes for those persons
who participated in the pilot project.
In general, the population-based strategy used to identify persons with
CKD Stage 3b or 4 was relatively
time-intensive and resulted in identifying only 53 people who were eligible for the intervention. This finding
was somewhat lower than expected
because of the clinics history of having more than 80% of referrals to clinic being patients in CKD Stage 4 or 5.
One possible explanation for
identifying a relatively small number
of eligible persons was the use of
datasets that included eGFR results
obtained over a 6- to 12-month period.
Some potentially eligible persons had
progressed to CKD Stage 5, were on
dialysis, had received a kidney transplant, or had died by the time we
reviewed health records to further
assess eligibility. Of those eligible for
the intervention, 83% declined to participate. The most frequently reported
reasons for declining the educational
intervention were transportation-related barriers, including costs, and lack of
interest. An office-based educational
intervention was not sufficiently convenient for many persons with CKD
who expressed initial interest in receiving the intervention. The NP-delivered
intervention was the most successful
component of the pilot project.
252
Knowledge improvement was observed to increase in at least 50% of participants for approximately 60% of the
questions. Participants also reported
making incremental health behavior
changes generally related to nutrition
and physical activity.
Population-Based Strategies
to Identify Persons with CKD
Our effort to implement a population-based strategy to identify persons
with CKD Stage 3b or 4 who were not
linked with appropriate specialty care
services appears to be less successful
than in other published studies. For
example, a population-based disease
management approach was implemented in the West Lincolnshire
Primary Care Trust (WLPCT) area in
the United Kingdom (UK) to identify
persons 15 years of age and older with
CKD Stage 4 and not known to a
nephrologist (Richards et al., 2008). In
the WLPCT study, eGFR was calculated using the four-variable Modification of Diet in Renal Disease
(MDRD) formula and reported to
requesting physicians for 47,119
patients of the 185,434 persons in the
population database. More than 1,200
persons with CKD Stage 4 and not
known to nephrologists were identified. The proportion of participants
identified with CKD Stage 4 in the UK
study (2.5%) was somewhat higher
than the proportion eligible in our
study (1.75%); however, because of differences in age ranges and CKD stages
between the studies, these are not ideal
comparisons. In the UK study, referrals to nephrologists initially spiked to
approximately 2.7 times higher than
the
pre-eGFR-reporting
period
(Richards et al., 2008). After introduction of a referral assessment process to
review appropriateness, referrals to
nephrologists remained elevated at
about 1.5 times the pre-eGFR identification and notification period
(Richards et al., 2008). Approximately
40% of referrals did not follow guidelines. Yet the availability of a population-based database and use of a
prospective approach may have been
a more successful strategy than our use
of retrospective lab data.
May-June 2015
CKD Educational
Interventions
The success of our CKD educational intervention on changing participant health behaviors and improving
health status seems comparable to
other published interventions. However, a number of these other interventions focused on more targeted
health education topics and behaviors
with varying intensity of interventions,
whereas our intervention covered the
full range of CKD health education
topics and only included a NP-led
educational intervention. For example, one controlled trial in Australia
with 36 intervention patients with
CKD Stage 3 or 4 evaluated the effect
of a lifestyle intervention and aerobic
and resistance exercise training on
cardiorespiratory
fitness
levels
(Howden et al., 2013). This intervention consisted of usual care, cardiovascular risk factor management provided by a CKD nurse practitioner and
other health professionals, 150 minutes of moderate intensity exercise per
week with eight weeks of training
supervised by an exercise physiologist
(including gym sessions with aerobic
exercise and weight and resistance
training, telephone, and email follow
up), and four weeks of group behavior
and lifestyle modification facilitated
by a dietician and psychologist. This
intensive intervention was associated
with an average weight loss of 1.8 kilograms, increased peak VO2 (2.8 mL/
kg/minute), and improved diastolic
function (Howden et al., 2013). A less
intense intervention was studied
among 150 patients on hemodialysis
to assess the effect of watching a 45minute educational video on serum
phosphate levels (Baldwin, 2013). In
the month following the video viewing, serum phosphorous levels were reduced, on average, from 6.82 to 6.35
g/dL among participating patients.
Study Limitations
There are several limitations to
consider when interpreting the findings from our pilot project. One limitation is the small sample of persons
with CKD who completed the intervention. The small sample precludes
the ability to make valid pre-intervention/post-intervention comparisons in
self-efficacy, and changes to participant knowledge and health behaviors. However, the series of cases provides some evidence to suggest that
the intensive educational intervention
was associated with increases in
understanding of CKD and incremental behavior changes. Second, the
lack of a comparison group further
weakens the ability to link the
changes in behavior to the intervention because other influences in the
participants lives could account for
these changes. The post-intervention
assessment of understanding of CKD
tends to support the intervention as
the catalyst for these changes. Third,
because patients self-selected to
receive the intervention, it is possible
that those who participated and completed the study were more motivated
to exhibit positive changes in knowledge and behaviors than those who
refused to participate. It is not clear
whether this intervention would be
effective among persons who are not
interested in making the effort to
come to the clinic if, for example, the
intervention were offered at a more
convenient location.
May-June 2015
tegies. For example, would it be feasible and more effective to reduce the
overall societal burden of CKD by
testing interventions aimed at improving health behaviors and health
status for persons at high risk for
CKD, such as those with hypertension, diabetes, obesity, and/or a family history of CKD? Additionally, as
U.S. health care delivery systems
expand the use of integrated electronic health records, more automated
processes for identifying persons with
CKD could be explored and tested.
The second set of future research
questions pertains to behavior change
strategies, including access to interventions.
In our study, the office-based intervention was not very convenient
for many potential participants. To
reach a larger audience, it would be
helpful to develop and test interventions that are community-based, perhaps using outreach and/or group
models of outreach with multiple
encounters with each participant. For
example, the mobile outreach unit of
the UNC Kidney Centers Kidney
Education Outreach Program (KEOP)
provides targeted CKD screening
and educational programs for underserved high-risk populations in locations where nephrologists are absent
and primary care providers are
scarce. However, the existing outreach screening and educational interventions are short-term, whereas
our pilot intervention involved up to
six encounters per participant. The
acceptability of interventions that are
provided in the context of a targeted,
community-based program with or
without a mobile unit that can reduce
patients travel could be tested in
future studies.
Because some CKD topics in our
pilot project did not seem to be as
well-understood as others, future
studies could examine other teaching
and learning strategies to enhance
participant learning as well as tools,
such as reminders, to help patients
achieve established goals for behavior
change. For example, it may be helpful to identify the amount of content
that can be learned on average by
253
Conclusions
Improvements in CKD-related
knowledge were observed among all
participants after receiving the educational intervention in this pilot project. However, knowledge improvement did not occur for all topics. Incremental behavior changes were
observed for participants with multiple visits with the CKD nurse educator. Further, participants who completed the full intervention reported
overall agreement with their ability to
self-manage their CKD. Even though
improvements were observed among
participants, the population-based
approach used to identify persons
who met the eligibility criteria was
time-intensive and not efficient. In
addition, the clinic-based setting did
not seem to be accessible to the majority of persons eligible to receive the
intervention. This study highlights the
need to learn more about strategies
for identifying persons with CKD
who have not been linked with
appropriate care and health education, and strategies for effectively
delivering interventions in acceptable
and accessible locations.
References
Allen, A.S., Forman J.P., Orav E.J., Bates
D.W., Denker B.M., & Sequist, T.D.
(2010). Primary care management of
chronic kidney disease. Journal of
General Internal Medicine, 26(4), 386392.
Baldwin, D.M. (2013). Viewing an educational video can improve phosphorous control in patients on hemodialysis: A pilot study. Nephrology Nursing
Journal, 40(5), 437-442.
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May-June 2015
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