A bundled phosphate control intervention (4Ds) for adults with end‐stage kidney disease receiving haemodialysis: A cluster randomized controlled trial

Abstract

Aim To evaluate the effectiveness of a bundled self‐management intervention (taking control of your phosphate with the 4Ds) to improve phosphate control among adults receiving haemodialysis. Background Hyperphosphataemia occurs in end‐stage kidney disease and is managed by diet, drinks, drugs (phosphate binder medication), and dialysis (the 4Ds). Adherence to the 4Ds is challenging for patients. Design A pragmatic cluster randomized controlled trial with repeated measures. Methods Participants were adults receiving haemodialysis with high serum phosphate (>1.6 mmol/L for at least 3 months) recruited between August 2017 ‐May 2018. Cluster randomization was according to haemodialysis treatment shifts. The ‘teach‐back’ intervention was designed to improve phosphate control. Expected outcomes were reduced serum phosphate and increased knowledge of phosphate in end‐stage kidney disease, self‐efficacy and adherence to diet, drugs, and dialysis. Results There were no differences between groups at baseline. Both groups had similar mean serum phosphate over time; at three months, 46% of the intervention group achieved reductions that met the target serum phosphate level compared with 33% of the control group. There were significant improvements in knowledge of phosphate in end‐stage kidney disease, self‐efficacy and adherence to diet, drugs, and dialysis (missing) in the intervention group compared with control group. Conclusion The 4Ds, a bundled self‐management intervention, was effective in improving patient confidence and adherence to phosphate control methods. Impact The 4Ds intervention bundles together four essential strategies for preventing and controlling hyperphosphataemia in end‐stage kidney disease. Trial registration ACTRN12617000703303 Registered 16/05/2017.

Effectiveness of teach‐back for chronic kidney disease patient education: A systematic review

“…The total number of participants was 520 (192 females, 328 males), with sample sizes ranging from 45 (Abianeh et al, 2020) to 198 (Hu et al, 2020). Participants' mean age ranged from 31.7 ± 9.2 (Hu et al, 2020) to 60.2 ± 14.3 (Milazi et al, 2021). The characteristics of the included studies are provided in Table 1.…”

“…All six studies were self-management education interventions (see Table 2), and three studies were underpinned by a theoretical framework (Hu et al, 2020;Kim, 2018;Milazi et al, 2021). Of the included studies, the number of educational sessions ranged from three (Abianeh et al, 2020;Borzou et al, 2020) to eight (Kim, 2018), and the length of a session varied from 30 to 45 min (Borzou et al, 2020;Milazi et al, 2021) to 1 h (Abianeh et al, 2020;Mollazadeh & Maslakpak, 2018). Education programmes were delivered by nurses (Hu et al, 2020;Kim, 2018;Milazi et al, 2021), or researchers (Abianeh et al, 2020;Borzou et al, 2020; Mollazadeh (Page et al, 2021).…”

“…Of the included studies, the number of educational sessions ranged from three (Abianeh et al, 2020;Borzou et al, 2020) to eight (Kim, 2018), and the length of a session varied from 30 to 45 min (Borzou et al, 2020;Milazi et al, 2021) to 1 h (Abianeh et al, 2020;Mollazadeh & Maslakpak, 2018). Education programmes were delivered by nurses (Hu et al, 2020;Kim, 2018;Milazi et al, 2021), or researchers (Abianeh et al, 2020;Borzou et al, 2020; Mollazadeh (Page et al, 2021). Educational strategies varied across studies; two studies (Abianeh et al, 2020;Mollazadeh & Maslakpak, 2018) used only teach-back to deliver the education intervention while the remaining studies employed teach-back along with a variety of other teaching methods and learning resources like education booklets, PowerPoint presentations, brochures, posters, puzzle games, ask-me activities, lectures, discussions, mobile applications, group discussions, reenactments and demonstrations (Borzou et al, 2020;Hu et al, 2020;Kim, 2018;Milazi et al, 2021).…”

“…Education programmes were delivered by nurses (Hu et al, 2020;Kim, 2018;Milazi et al, 2021), or researchers (Abianeh et al, 2020;Borzou et al, 2020; Mollazadeh (Page et al, 2021). Educational strategies varied across studies; two studies (Abianeh et al, 2020;Mollazadeh & Maslakpak, 2018) used only teach-back to deliver the education intervention while the remaining studies employed teach-back along with a variety of other teaching methods and learning resources like education booklets, PowerPoint presentations, brochures, posters, puzzle games, ask-me activities, lectures, discussions, mobile applications, group discussions, reenactments and demonstrations (Borzou et al, 2020;Hu et al, 2020;Kim, 2018;Milazi et al, 2021). Various forms of written education resources such as education booklet, instruction sheets, brochures and posters were supplemented to facilitate the teach-back process.…”

“…Disease-specific knowledge and confidence are also core skills for active involvement by people in their treatment plan, and selfmanagement education can boost these essential skills (Novak et al, 2013). In CKD, self-management education interventions have contributed to improving knowledge (Havas et al, 2018;Nguyen et al, 2019), self-efficacy (Havas et al, 2018;Milazi et al, 2021), HRQoL (Bonner et al, 2014), psychological well-being (Lee et al, 2016) and clinical outcomes like BP, interdialytic weight gain and blood work (Peng et al, 2019;Yangöz et al, 2021). Despite this, having knowledge (i.e., understanding) of CKD and being confident to know what to do and when, is not sufficient in isolation to ensure adherence with treatment because sufficient health literacy skills are also required (Chen et al, 2018;Osborn et al, 2011;Shah et al, 2021;Suarilah & Lin, 2022).…”