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-

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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.

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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.

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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

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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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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

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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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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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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).

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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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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

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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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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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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-

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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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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.

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References Diaz-Buxo, J. (1998). The importance of pre-ESRD education and early nephrological care in peritoneal dialysis selection and outcome. Peritoneal Dialysis International, 18, 363-365. Furth, S., Hwang, W., Yang, C., Neu, A., Fivush, B., & Powe, N. (2001). Relation between pediatric experience and treatment recommendations for children and adolescents with kidney failure [electronic version]. Journal of the American Medical Association, 285(8), 1027-1033. Golper, T. (2001) Patient education: Can it maximize the success of therapy? Nephrology Dialysis Transplantation, 16(Suppl. 7), 20-24. Goovaerts, T., Jadoul, M., & Goffin, E. (2005) Influence of a pre-dialysis education programme (PDEP) on the mode of renal replacement therapy. Nephrology Dialysis Transplantation, 20, 1842-1847. Heaf, J. (2004). Underutilization of peritoneal dialysis [electronic version]. Journal of the American Medical Association, 291(6), 740-742. Kroeker, A., Clark, W., Heidenheim, A., Keunzig, L., Leitch, R., Meyetter, M., et al. (2003). An operating cost comparison between conventional and home quotidian hemodialysis. American Journal of Kidney Diseases, 42(Suppl. 1), 49-55. Lee, H., Manns, B., Taub, K., Ghali, W.A., Dean, S., Johnson, D., et al. (2002). Cost analysis of ongoing care of patients with end-stage renal disease: The impact of dialysis modality and dialysis access. American Journal of Kidney Diseases, 40(3), 611-622. Manns, B., Taub, K., VanderStraeten, C., Jones, H., Mills, C., Visser, M., et al. (2005). The impact of education on chronic kidney disease patient’s plans to initiate dialysis with self-care dialysis: A randomized trial. Kidney International, 68, 1777-1178. McEwen, M., & Willis, E. (2002). Theoretical basis for nursing. Philadelphia: Lippincott, Williams & Wilkins. McLaughlin, K., Manns, B., & Mortis, G. (2003). Why patients with end-stage renal disease do not select self-care dialysis as a treatment option. American Journal of Kidney Diseases, 4, 380-385. Mehrotra, R., Marsh, D., Vonesh, E., Peters, V., & Nissenson, A. (2005). Patient education and access of ESRD patients to renal replacement therapies beyond incenter hemodialysis. Kidney International, 68, 378- 390.

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Mendelssohn, D., Mullaney, S., Jung, B., Blake, P., & Mehta, R. (2001). What do American nephrologists think about dialysis modality selection? American Journal of Kidney Disease, 37, 22-29. National Kidney Foundation (NKF). (2002). K/DOQI clinical practice guidelines for chronic kidney disease: Evaluation, classification, and stratification. Retrieved July 1, 2008, from http://www.kidney.org/Professionals/Kdoqi/guidelines_ckd/toc.htm Owen, J., Walker, R., Edgell, L., Collie, J., Douglas, L., Hewitson, T., et al. (2006). Implementation of a pre- dialysis clinical pathway for patients with chronic kidney disease. International Journal for Quality in Health Care, 18(2),145-151. Piccoli, G.B., Mezza, E., Burdese, M., Consiglio, V., Vaggione, S., Mastella, C., et al. (2005). Dialysis choice in the context of an early referral policy: There is room for self care. Journal of Nephrology, 18, 267-275.

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Prochaska, J., & DiClemente, C. (1983). Stages and processes of self-change of smoking: Toward an integrative model of change. Journal of Consulting Clinical Psychology, 51, 390-395. Robar, A., Doss, S., & Moran, J. (2006). What choices do patients make when all maintenance dialysis options are available? [ANNA National Symposium Abstracts.] Nephrology Nursing Journal, 33(2), 143. Rubin, H.R., Fink, N.E., Plantinga, L.C., Sadler, J.H., Kliger, A.S., & Powe, N.R. (2004). Patient ratings of dialysis care with peritoneal dialysis vs hemodialysis [electronic version]. Journal of the American Medical Association, 291(6), 697-703. Schneider, R.A. (2004). Chronic renal failure: Assessing the Fatigue Severity Scale for use among caregivers [electronic version]. Journal of Clinical Nursing, 13(2), 219-225.

Swartz, M., Robinson, K., Davy, T., & Politoski, G. (1999). The role of patients in the implementation of the National Kidney Foundation – Dialysis Outcomes Quality Initiative. Advanced Renal Replacement Therapy, 6, 52-58. U.S. Renal Data System (USRDS). (1997). Dialysis morbidity and mortality study: Wave 2. United States Renal Data System. American Journal of Kidney Diseases, 30(Suppl.), S67-S85. U.S. Renal Data System (USRDS). (2007). 2007 annual data report: Atlas of endstage renal disease in the United States. Bethesda, MD: National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases. Retrieved July 1, 2008, from www.usrds.org/adr.htm

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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: Name: ____________________________________________________________ Address: __________________________________________________________

Posttest Instructions • Select the best answer and circle the appropriate letter on the answer grid below. • Complete the evaluation. • Send only the answer form to the ANNA National Office; East Holly Avenue Box 56; Pitman, NJ 080710056; or fax this form to (856) 5897463. • Enclose a check or money order payable to ANNA. Fees listed in payment section. • If you receive a passing score of 70% or better, a certificate for the contact hours will be awarded by ANNA. • Please allow 2-3 weeks for processing. You may submit multiple answer forms in one mailing, however, because of various processing procedures for each answer form, you may not receive all of your certificates returned in one mailing.

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Special Note Your posttest can be processed in 1 week for an additional rush charge of $5.00. ■ Yes, I would like this posttest rush processed. I have included an additional fee of $5.00 for rush processing.

Online submissions through a partnership with HDCN.com are accepted on this posttest at $20 for ANNA members and $30 for nonmembers. CNE certificates will be available immediately upon successful completion of the posttest. 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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