Psychological Symptoms Are Greater in Caregivers of Patients on Hemodialysis Than Those of Peritoneal Dialysis

Background: The purpose of this study was to evaluate and compare psychosocial characteristics in caregiving relatives (caregivers) of hemodialysis (HD) and peritoneal dialysis (PD) patients. Methods: Thirty‐three caregivers (17 women, 16 men) of HD patients, 27 caregivers (11 women, 16 men) of PD patients, and a control group of 49 subjects who do not care for family members with chronic illness (23 women, 26 men) are included in this study. The brief symptom inventory (BSI), social disability schedule (SDS), and brief disability questionnaire (BDQ) were used for the psychosocial evaluation. Results: The mean age, men‐to‐women ratios, duration of education, and distribution of marital status did not differ significantly among the three groups. In addition, dialysis duration and distribution of caregiver type were not different between the HD and PD groups. Although the mean global severity index scores of the three groups were similar, somatization and depression scores from BSI subitems were greater in the HD group than the scores of the PD and control groups. Although the mean SDS and BDQ scores were higher in the HD group, the differences did not achieve statistical significance. BSI subitems such as somatization, obsession–compulsion, interpersonal sensitivity, depression, and anxiety were positively correlated among themselves. Hostility and somatization were negatively correlated with age and education, respectively. Nevertheless, somatization was positively correlated with age. Social disability was negatively correlated with duration of education. Conclusion: Somatization and depression are greater in the caregivers of center HD patients compared to PD and control groups. According to the findings of this study, we suggest that caregiving family members of dialysis patients especially on HD also should be evaluated for psychosocial problems and supported as needed. Further studies are needed to explore whether psychosocial parameters of caregivers predict outcomes for caregivers and patients.     

Is home hemodialysis a practical option for older people?

An increasing demand for in-center dialysis services has been largely driven by a rapid growth of the older population progressing to end-stage kidney disease. Since the onset of the COVID-19 pandemic, efforts to encourage home-based dialysis options have increased due to risks of infective transmission for patients receiving hemodialysis in center-based units. There are various practical and clinical advantages for patients receiving hemodialysis at home. However, the lack of caregiver support, cognitive and physical impairment, challenges of vascular access, and preparation and training for home hemodialysis (HHD) initiation may present as barriers to successful implementation of HHD in the older dialysis population. Assessment of an older patient's frailty status may help clinicians guide patients when making decisions about HHD. The development of an assisted HHD care delivery model and advancement of telehealth and technology in provision of HHD care may increase accessibility of HHD services for older patients. This review examines these factors and explores current unmet needs and barriers to increasing access, inclusion, and opportunities of HHD for the older dialysis population.     

Tools, methods, and strategies. Do innovative models of health care delivery improve quality of care for selected vulnerable populations? A systematic review.

BACKGROUND: A criticism of conventional office or clinic-based models of care is that they focus on patients' urgent problems and do not provide the comprehensive assessments, education, and psychosocial support that vulnerable patients also need. Innovative models have emerged to address these needs. A systematic review of prospective studies involving searches of computerized databases, reviews of reference lists, and contacts with authors, was conducted to determine whether multidisciplinary teams, outreach or home care, and case management improve the quality of the care in two vulnerable populations-the terminally ill and the mentally ill. RESULTS: Literature searches identified 730 citations. 52 original articles met screening standards, and 24 studies fulfilled all criteria. Patient and caregiver satisfaction was consistently higher with innovative models. In no study was satisfaction lower. Functional, clinical, or psychological improvements were not consistently demonstrated. For mentally ill patients, multidisciplinary outreach strategies were effective in reducing inpatient hospitalizations. Costs were inadequately assessed in the studies to draw a summary conclusion. DISCUSSION: Like other interventions, health care delivery models can be assessed from an evidence-based perspective. More needs to be learned about the costs and health improvements of innovative models before we can determine whether the increased patient and caregiver satisfaction found justifies widespread use of these models. Development of a uniform set of quality outcome measures and encouragement to evaluate efforts and disseminate results will help accomplish this goal.     

Issues in the development, dissemination, and effect of an evidence-based guideline for managing sore throat in adults

BACKGROUND: In October 1995 the University of Michigan Healthcare System initiated a program to develop and implement guidelines for primary care in an effort to improve the quality and cost-effectiveness of care for common conditions associated with wide variations in clinical practice. One of these conditions was Group A beta-hemolytic streptococcus (GABHS), present in 5% to 20% of adults complaining of sore throat. METHODS: A draft guideline was developed on the basis of a theoretical model of sore throat management, local data, and research evidence. The guideline was revised to reflect physicians' beliefs and practices regarding sore throat management. Guideline recommendations depended only on the number of clinical signs experienced by the patient and included testing only if it was likely to provide additional information about the probability of GABHS. Data on pre- and postdissemination data on patients presenting with sore throat were collected. RESULTS: When physicians believed testing or antibiotics were unnecessary, only 7% of patients demanded screening and only 6% of patients wanted antibiotics. Physician beliefs about a patient's need for testing agreed with guideline recommendations in 63% of patients both before and after guideline dissemination. DISCUSSION: Disseminating locally modified, evidence-based guidelines may not be sufficient to produce practice changes. If the guideline had been followed, the amount of testing would have been reduced by 17% and the appropriateness of testing improved for 32% of sore throat patients. The results indicate the need for implementation efforts that go beyond presenting evidence, even when that evidence is from both the literature and the local practice setting.     

Can practice guidelines be transported effectively to different settings? Results from a multicenter interventional study

RATIONALE: Although clinical guidelines have become increasingly popular as a means to reduce variation in care, increase efficiency, and improve patient outcomes, little is known about their effectiveness when they are transported outside their original setting, or about the factors that influence their successful translation into clinical practice. This study assessed whether a clinical guideline for low-risk chest pain patients, implemented with a standardized protocol, could be effectively transported to five hospital settings. METHODS: In a prospective, interventional trial, a standardized protocol for low-risk chest pain was implemented at each site. A total of 553 consecutively hospitalized low-risk patients with chest pain were enrolled during a 3-month baseline period followed by a standardized 6-month intervention period. During the intervention period, each patient's physician was contacted about eligibility for discharge within the specified 2-day guideline period. Guideline adherence (discharged within 48 hours) and postdischarge patient outcomes were measured. Local guideline champions were interviewed about their implementation experience. RESULTS: Guideline adherence during the intervention period ranged from 61% to 100%, with only two sites achieving significant increases of > or = 10% from the baseline values. Guideline implementation did not affect clinical outcomes or patient satisfaction. Implementation factors such as preexisting hospital environment, implementation team staffing, and the rapid identification and resolution of barriers may influence the successful translation of guidelines into practice. CONCLUSIONS: Even with a standardized implementation protocol, consistent results across institutions were not obtained when a clinical guideline for chest pain was implemented beyond its original setting. These findings demonstrate the importance of understanding the local factors that influence guideline implementation.     

Appraising clinical practice guidelines in England and Wales: the development of a methodologic framework and its application to policy.

BACKGROUND: Clinical guidelines are pervading all aspects of health care. Their potential benefits are vast--from decreasing unjustified variation in treatment, to improving outcomes for patient, to containing escalating costs. However, there is increasing concern that many of the guidelines produced may be of low quality and recommend ineffective treatment. A framework to appraise the methodologic quality of clinical guidelines, commissioned by the NHS in 1997, was developed and validated in the United Kingdom (UK) under the auspices of the National Research and Development Programme. THE INDEPENDENT APPRAISAL SERVICE: This framework is now used to assess all national guidelines funded by the National Health Service (NHS) in the UK as part of an independent appraisal service. The appraisal provides a basis for policymakers to decide which guidelines should be commended for use in the NHS. Each guideline is appraised by a minimum of six appraisers. Twenty-one guidelines had been appraised as of July 1999. The mean time for completion of the appraisals, from receipt of the guidelines to dispatch of the reports, was just over ten weeks. There has been a marked improvement in the quality of documentation for national guidelines--including the search strategy and synthesis of evidence--in the past three years, although some areas of development remain inadequately reported. POLICY IMPLICATIONS: Ensuring that the clinical guidelines are sound before recommending their use is essential to policymakers responsible for guideline programs, and a formal appraisal should be an integral part of those programs.     

Taking the national guideline for care of acute myocardial infarction to the bedside: developing the guideline applied in practice (GAP) initiative in Southeast Michigan.

BACKGROUND: The Guideline Applied in Practice (GAP) program was developed in 2000 to improve the quality of care by improving adherence to clinical practice guidelines. For the first GAP project, the American College of Cardiology (ACC) partnered with the Southeast Michigan Quality Forum Cardiovascular Subgroup and the Michigan Peer Review Organization (MPRO) to develop interventions that might facilitate the use of the ACC/AHA Acute Myocardial Infarction (AMI) guideline in the practice setting. Ten Michigan hospitals participated in implementing the project, which began in March 2000. DESIGNING THE PROJECT: The project developed a multifaceted intervention aimed at key players in the care delivery triangle: the physician, nurse, and patient. Intervention components included a project kick-off presentation and dinner, creation and implementation of a customized tool kit, identification and assignment of local nurse and physician opinion leaders, grand rounds site visits, and measurement before and after the intervention. IMPLEMENTING THE PROJECT: The GAP project experience suggests that hospitals are enthusiastic about partnering with ACC to improve quality of care; partners can work together to develop a program for guideline implementation; rapid-cycle implementation is possible with the GAP model; guidelines and quality indicators for AMI are well accepted; and hospitals can adapt the national guideline for care into usable tools focused on physicians, nurses, and patients. DISCUSSION: Important structure and process changes--both of which are required for successful QI efforts--have been demonstrated in this project. Ultimately, the failure or success of this initiative will depend on an indication that the demonstrated improvement in the quality indicators is sustained over time.     

Implementing evidence-based recommendations for health care: a roundtable comparing European and American experiences

BACKGROUND: A roundtable held October 5-6 1999, in Maidstone, Kent, United Kingdom, was convened to identify current strategies and ongoing challenges in implementing evidence-based practice guidelines in health care. Despite numerous new medical research findings for improving health care and despite the dissemination of many practice guidelines, the recommendations from these efforts are not being uniformly adopted. Overuse, underuse, and misuse plague the practice of medicine today. IMPLEMENTING GUIDELINES: Multiple implementation strategies are more likely to succeed that a single implementation method; local selection and adaptation of guidelines are critical; and reminders, educational outreach (for prescribing), and interactive educational workshops are generally effective. EXPERIENCE IN EUROPE: In most countries, guideline development has progressed from consensus conference, to evidence-based statements, and finally to evidence-based guidelines that also consider cost-effectiveness. Guideline development is the most advanced in The Netherlands, where physicians have coordinated their efforts with the government to achieve more uniformity than is found elsewhere. EXPERIENCE IN THE UNITED STATES: Designing systems that will facilitate change--not changing physician behavior--should be the focus. The concern for effecting improvement in health care is now more acute because of the increased attention being given to medical errors and patient safety. SUMMARY STATEMENT: Multifaceted approaches are clearly the most important method for improving care. Such approaches may include many improvement methods, none of which work well alone most of the time or any of the time.     

Evidence-based medicine: is translating evidence into practice a solution to the cost-quality challenges facing medicine?

BACKGROUND: Evidence-based medicine (EBM) and practice guidelines have been embraced by increasing numbers of scholars, administrators, and medical journalists as an intellectually attractive solution to the dilemma of improving health care quality while reducing costs. However, certain factors have thus far limited the role that EBM might play in resolving cost-quality trade-offs. FACTORS FOR SUCCESS OF EBM RECOMMENDATIONS AND GUIDELINES: Beyond the quality of the guideline and the evidence base itself, critical factors for success include local clinician involvement, a unified or closed medical staff, protocols that minimize use of clinical judgment and that call for involvement of so-called physician extenders (such as nurse practitioners and physician assistants), and financial incentive. TROUBLESOME ISSUES RELATED TO COST-QUALITY TRADE-OFFS: Rationing presents many dilemmas, but for physicians one critical problem is determining what is the physician's responsibility. Is the physician to be the patient's advocate, or should the physician be the advocate of all patients (the patients' advocate)? How do we get physicians out of potentially conflicted roles? EBM guidelines are needed to help minimize the number of instances physicians are asked to ration care at the bedside. If the public can decide to share and limit resources--presumably based on shared priorities--physicians would have a basis to act as advocates for all patients. CONCLUSIONS: Although EBM alone is not a simple solution to the problems of increasing costs and public expectations, it can be an important source of input and information in relating the value of service and medical technology to public priorities.     

Association between patient psychosocial characteristics and receipt of in‐center nocturnal hemodialysis among prevalent dialysis patients

Introduction: Compared to traditional in‐center hemodialysis (HD), in‐center nocturnal dialysis (INHD) is characterized by longer sessions and nighttime administration, which may lead to better outcomes for some patients. Given the importance of patient choice in the decision to initiate INHD, we explored associations between patients’ psychosocial characteristics and their receipt of INHD. Methods: Among hemodialysis patients at a medium‐sized dialysis organization, we identified INHD patients as those for whom ≥80% of dialysis sessions were INHD sessions—starting at 6:30 pm or later and lasting ≥5 hours—over the 3 months (≥20 sessions total) after their first INHD session. We extracted dialysis session data from electronic medical records and psychosocial data from social worker assessments. We tested associations of patients’ psychosocial characteristics—as well as demographic and clinical characteristics—with INHD receipt among all hemodialysis patients (INHD and HD) in bivariate analyses and multivariable logistic regression models. Findings: Among 759 patients with complete data, we identified 47 (6.2%) as INHD patients. On average, these patients were more likely than HD patients to be employed (full‐time 10.6% vs. 5.2%; part‐time 17.0% vs. 4.2%; P < 0.001), and they were significantly less likely to require ambulatory assistance (14.9% vs. 39.6%, P < 0.001). In multivariable regressions, we found that part‐time employment (versus being unemployed) was associated with a 7.1 percentage‐point higher likelihood of being an INHD patient (P = 0.01), and the negative association with ambulatory assistance needs approached statistical significance (P = 0.056). No other psychosocial factors included in this main regression analysis were statistically significantly associated with INHD patient status. Discussion: Researchers comparing the outcomes of patients undergoing INHD versus other treatment modalities will need to account for differences in employment status—and other factors like requiring ambulatory assistance and age which may predict the ability to work—between INHD users and comparison patients to avoid bias in estimates.     

Impact of hypertension guideline implementation on blood pressure control and drug use in primary care clinics

BACKGROUND: A worsening of blood pressure control has occurred in the 1990s despite the availability of sophisticated technologic, pharmacologic, and educational advances applicable to hypertension care. Clinical guidelines that are intended to improve hypertension care by making specific recommendations on drug use, frequency of follow-up care, and target levels of blood pressure have been developed. METHODS: The Institute for Clinical Systems Integration's (ICSI's; Minneapolis) Hypertension Treatment Guideline was developed in 1994 and is updated annually. This study employed a quasi-experimental, before-and-after design at two medical groups to assess changes in the care provided to patients 18 years of age and older with identified hypertension (International Classification of Diseases-9 codes 401.0, 401.1, or 401.9). RESULTS: Among adults with hypertension, the proportion meeting the blood pressure goal of < 140/90 mm Hg increased from 36.8% (of 685 patients) preguideline to 50.3% (of 928 patients) postguideline (chi-square = 29.4, p < 0.001); the mean arterial pressure decreased from 102.7 mm Hg to 99.4 mm Hg (t = 5.45, p < 0.001). Cohort analysis of patients enrolled at both points in time confirmed these findings and showed an increase in the number of office visits from 5.4 to 6.7 visits per patient per year after guideline implementation (F = 10.9, p = 0.001). The use of a guideline-recommended medication for treatment of blood pressure was 35.9% preguideline and 36.2% postguideline. CONCLUSIONS: Implementation of a hypertension treatment guideline in primary care clinics was related to significantly improved hypertension control. Identification, tracking, and active outreach to patients with hypertension were used by all clinics.     

Implementing guidelines for interdisciplinary care of low back pain: a critical role for pre-appointment management of specialty referrals.

BACKGROUND: Improving health care will require more effective guideline implementation and redesign of delivery processes and systems. Patient referral for specialty care is a key component of health system function that needs to be improved. Low back pain care is a widely documented example of the need for improvement. An interdisciplinary systemwide back pain program was developed using process improvement methods. Proactively managing referrals for specialty care-a departure from traditional referral processes-played a critical role in implementing the program. METHODS: Program components included guidelines for care, defined provider roles, uniform service coding, provider and patient education, pre-appointment specialty referral management, and monitoring of management processes. To evaluate program performance, system back pain visits were compared before, during, and after implementation of referral management. A case series study was performed on 581 consecutive patients with low back pain or lumbar radiculopathy referred for consultative spine care between April 1998 and March 1999. RESULTS: A shift of care was accomplished for acute back pain from spine orthopedists to primary physicians and for chronic back pain from spine orthopedists to medical specialists. More than 95% of initial assignments were accurate. Seventy-six percent of surveyed chronic back pain patients improved, and 90% were highly satisfied with the referral management process. This program has saved an estimated $400,000 per year in manpower cost and has reduced specialty service billings by 20%. DISCUSSION: Pre-appointment referral management offers an approach for improving guideline implementation, access to specialty services, and the effectiveness of care for complex health problems. It deserves broader study and adoption.     

The built environment as a component of quality care: understanding and including the patient's perspective.

BACKGROUND: Although there has been little systematic assessment of how the built environment of health care facilities affects the quality of care, the built environment is a major element of structure of care--one of three facets of quality. Yet in contrast to the growing trend of using consumer perceptions of both processes and outcomes of care in QI activities, quality assessments of the structure of care do not currently rely on patient feedback. PURPOSE OF PROJECT: During the initial phase of a multiphase project, nine focus groups were conducted in 1997 to identify the salient dimensions of experience from the patient's perspective. The content of these focus groups guided the development of assessment tools in the second phase of the project, which began in February 1998. FINDINGS: Participants in three focus groups that were held in each of three settings--ambulatory care, acute care, and long term care--described in detail a variety of reactions to the built environment. Analysis revealed eight consistent themes in what patients and family member consumers look for in the built environment of health care. In all three settings, they want an environment, for example, that facilitates a connection to staff and caregivers, is conducive to a sense of well-being, and facilitates a connection to the outside world. DISCUSSION: Data derived from the focus group research has guided the development of quantitative survey and assessment tools. For each setting, patient-centered checklists and questionnaires are designed to help institutions set priorities for the improvement of facility design from the patient's perspective.     

The utility of decision support, clinical guidelines, and financial incentives as tools to achieve improved clinical performance

BACKGROUND: Whether one seeks to reduce inappropriate utilization of resources, improve diagnostic accuracy, increase utilization of effective therapies, or reduce the incidence of complications, the key to change is physician involvement in change. Unfortunately, a simple approach to the problem of inducing change in physician behavior is not available. COMPREHENSIVE CLINICAL GUIDELINES: There is a generally accepted view that expert, best-practice guidelines will improve clinical performance. However, there may be a bias to report positive results and a lack of careful analysis of guideline usage in routine practice in a "postmarketing" study akin to that seen in the pharmaceutical industry. FINANCIAL INCENTIVES: Systems that allow the reliable assessment of quality of outcomes, efficiency of resource utilization, and accurate assessment of the risks associated with the care of given patient populations must be widely available before deciding whether an incentive-based system for providing the full range of medical care is feasible. DECISION SUPPORT: Decision support focuses on providing information, ideally at the "point of service" and in the context of a particular clinical situation. Rules are self-imposed by physicians and are therefore much more likely to be adopted. CONCLUSION: As health care becomes corporatized, with increasing numbers of physicians employed by large organizations with the capacity to provide detailed information on the nature and quality of clinical care, it is possible that properly constructed guidelines, appropriate financial incentives, and robust forms of decision support will lead to a physician-led, process improvement approach to more rational and affordable health care.     

Quality improvement in a managed care organization from a medical director's perspective: an interview with Bruce Perry. Interview by Douglas Roblin

BACKGROUND: In late 1994 the Quality Forum commissioned the Interdisciplinary Prevention Committee [IPC]. One of the IPC's charges was to identify priorities for QI in preventive health services. The IPC established priorities through a review of scientific literature, identification of national and state health initiative priorities, and consideration of what services to establish as priorities and of the practicality of implementing low-cost interventions to achieve specific QI goals. Breast cancer screening was selected as a top-ten priority for guideline development and for focused intervention because of the disease's prevalence, morbidity, and mortality and because of the fact that it is most treatable and curable when it is found early through routine screening. The national HEDIS (Health Plan Employer Data and Information Set; National Committee on Quality Assurance (NCQA), Washington, DC] result of 71%, reported in May 1995, provided our baseline performance measurement. This result fell short of our goal of being in the 90th percentile of performance on each HEDIS effectiveness of care measure. In August 1995 the Quality Forum accepted the IPC's recommendations, which had been endorsed by the department of medicine. These recommendations emphasized the importance of annual clinical breast exam and mammography for women of targeted age groups. In November 1997, a new "Excellence in Quality: HEDIS Improvement Team" began work. Its charge was to undertake analyses of underlying causes of reduced performance and to develop additional steps to improve performance by changes in care delivery processes in 1998. In March 1998 the Quality Forum's executive committee designated breast cancer screening one of the six organizationwide quality priorities for 1998 and designated two "owners" who would be accountable for this performance--the chief and director of radiology. RESULTS: The screening rate increased from 73.8% in 1996 to 84.0% in 1999. National benchmarks [90th percentile] in 1998 were 81% for commercially insured members and 84% for Medicare members. The 84% screening rate made the Georgia region the Kaiser Permanente national leader and put the region in the top 10% of all health plans in the United States. CONCLUSIONS: The program has achieved these results with a broad array of activities: Saturday hours, mobile mammography, medical record reminders (fuschia-colored inserts), patient and physician reminders, call-center outreach, provider feedback on performance, and provider financial incentives. Several of these innovations demonstrate the ability to integrate improved care management into evolving service delivery in Kaiser Permanente--such as use of call-center technologies and redesign of primary care delivery. While we cannot point to any one of these innovations as a key driver of improvement, it is clear that substantial improvements in care delivery can be achieved. All these activities are relatively low cost and easily implemented in other managed care organizations and in other areas of medical care.     

Quality of life, self‐care and sense of coherence in patients on hemodialysis: A comparative study

The number of patients treated for end-stage renal disease increases in Sweden like the rest of the world. During the last six years more than 1000 persons a year started renal replacement therapy. Today hemodialysis patients have the opportunity to choose different treatment modalities—home hemodialysis, self‐care dialysis, or conventional dialysis. Purpose:  The aim of the study was to investigate differences in patient on home hemodialysis, self‐care dialysis, and conventional dialysis regarding quality of life, self‐care, and sense of coherence. Methods:  Questionnaires were used: Short Form (SF‐36), Appraisal of Self‐Care Agency (ASA‐scale), and Sense of Coherence scale (SOC). 19 patients were included in the study (five patients on home hemodialysis, six self‐care patients, and eight patients on conventional dialysis). Results:  The results showed a tendency of higher scores in quality of life, self‐care, and sense of coherence for the home hemodialysis patients. Conclusion:  Since the number of participants in this study was low, it is necessary to include more patients in a future study in order to verify the results.