Evaluation of a collaborative chronic care approach to improve outcomes in kidney transplant recipients

Abstract

Several studies found that renal transplant recipients with chronic kidney disease have untreated complications and do not attain recommended clinical targets. Using a before/after design with propensity score-matched controls, we evaluated whether an advanced practice nurse-led interprofessional collaborative chronic care approach could improve clinical outcomes for CKD transplant patients compared with a traditional physician-led model. The intervention included strategies for disease self-management, shared decision making, and healthcare system reorganization. The primary outcome was the proportion of patients attaining at least seven of nine targets as per published guidelines. A greater proportion of intervention patients achieved the outcome (68% vs. 10%; p = 0.0001) and had discussions about end-stage treatment options (88% vs. 13%; p = 0.0001) compared with controls. The intervention patients had significantly fewer emergency room visits (incidence rate ratio [IRR] 0.53; 95% CI 0.29-0.91; p = 0.02) and hospital admissions (IRR 0.34; 95% CI 0.16-0.68; p = 0.001) compared with the control patients. There were no significant differences found between the groups in systolic/diastolic blood pressure, carbon dioxide, hemoglobin, or phosphate parameters. An advanced practice nurse-led approach, based on the chronic care model, has the potential to improve clinical outcomes for renal transplant recipients and needs to be tested in a multicenter randomized controlled trial.

Heart transplant centers with multidisciplinary team show a higher level of chronic illness management – Findings from the International BRIGHT Study

“…Their findings showed that adherence to guidelines improved and, more importantly, that emergency room visits and hospital admissions decreased in the intervention group. 10 Similarly, a randomized controlled trial that examined the impact of a telemedicine-supported chronic care case management intervention showed that renal transplant recipients in the intervention group had significantly fewer unplanned admissions and shorter Table 1 Center and patient characteristics and average level of chronic illness management (PACIC). length of unplanned hospital stay compared to those in the standard care group.…”

“…5 Chronic illness management (CIM), a care model which emphasizes continuity of care and promotes self-management support for patients, could therefore provide an opportunity to improve long-term outcomes post HTx given promising results in other chronic patient populations. 5,8,9 Studies in non-HTx populations have shown that CIM is associated with decreased healthcare utilization, 10,11 improvements in health-related behaviors, 12 increased quality-of-life, 11 and greater patient and caregiver satisfaction. 12 In transplantation, the reengineering of transplant follow-up care according to the principles of CIM has resulted in improved clinical outcomes, reduced health care utilization, and reduced costs.…”

“…12 In transplantation, the reengineering of transplant follow-up care according to the principles of CIM has resulted in improved clinical outcomes, reduced health care utilization, and reduced costs. 10,13 In the most recent guidelines for the care of HTx recipients, the International Society of Heart and Lung Transplantation (ISHLT) recommended that transplant centers utilize a multidisciplinary approach to patient management. 6 This recommendation is similar to the Centers for Medicare and Medicaid policy that specifies that a multidisciplinary team should be involved in the care of transplant recipients throughout all phases of the transplantation.…”

Necessidades humanas básicas alteradas em pacientes pós-transplante renal: estudo transversal

“…Além disso, em virtude do aumento da ingestão hídrica e do uso de diuréticos após o transplante, o transplantado interrompa o sono várias vezes durante a noite, em virtude da urgência urinária, o que contribui para o aparecimento dessa necessidade alterada (19,20) . Diante dessa necessidade alterada, o enfermeiro visando promover o sono e repouso adequado do paciente pode realizar intervenções como: ensinar ao cliente técnicas de relaxamento; determinar o efeito dos medicamentos sobre o sono; discutir com o paciente e a família as medidas de conforto, técnicas de monitoramento do sono e as mudanças no estilo de vida e oferecer ambiente calmo e agradável para o descanso adequado (17,18) .…”

“…Algumas atividades de lazer e recreação podem promover mais conforto para os clientes, assim como favorecer a manutenção de relacionamento interpessoal e afastamento da solidão (17) . Dessa forma, o enfermeiro deve desenvolver atividades relaxantes e de lazer compatíveis com a sua condição clínica do paciente, bem como rever a história de atividades/passatempos prediletos e possíveis modificações (19,20) . As necessidades humanas básicas alteradas listadas anteriormente são relevantes, visto que englobam quase todos os pacientes renais crônicos no pós-transplante renal.…”