Abstract
Background and Aims
Survival on Peritoneal Dialysis (PD) is comparable to or better than in-centre haemodialysis (HD), but with the added benefit of enhanced patient autonomy, improved quality of life, and preservation of residual renal function. Despite this, only a minority of patients choose this as their first choice renal replacement therapy (RRT).
In the West Suffolk (East of England) catchment, patient preparation for RRT has historically been the remit of the tertiary referral centre (Cambridge University Hospitals NHS Trust; CUHT), who employ lecture-based group education to supplement Low Clearance Clinic (LCC) visits. Due to the growing population exceeding clinic capacity, a new LCC service was established at the West Suffolk Hospital (WSH) in December 2018. The clinic utilises a multidisciplinary team (MDT) approach involving a Consultant Nephrologist, Clinical Nurse Specialist (CNS), Dietician, Palliative Care Consultant, and a Counsellor.
To enhance uptake of PD and address the perceived barrier of lack of individualised education, the MDT agreed a ‘home-first’ dialysis ethos, and designed a bespoke programme to address this, with home-based 1:1 training, follow-up group meetings, and peer-networking opportunities.
Aims
Method
On first attendance at the WSH LCC, a 1:1 home visit is offered to discuss RRT education. All appropriate modalities of RRT are discussed, including conservative management. The CNS simultaneously assesses the environment for home therapy suitability. Regular group ‘RRT Roadshows’ are also offered, where the LCC MDT are available for informal question and answer sessions regarding RRT options. This helps reinforce patient education, and peer-to-peer support is offered by current dialysis patients.
Anonymised patient questionnaires have been given out prospectively following both home education/group sessions. Data regarding patient outcomes and incident RRT modality is collected as part of UK Renal Registry (UKRR) returns, with national data (90-day incident RRT modality) taken from the 21st UKRR Report 2017.
Results were analysed using Microsoft Excel and R software.
Results
Since December 2018 WSH LCC has had 127 incident patients (Age 76 ± 13 years, 70% male); 18 have started RRT; 13 initiated HD (72%), 4 started PD (22%, none of whom were eligible for transplant), and 1 (6%) received a transplant. The PD rate is almost twice that seen in the same area previously, and above the national average (Table 1).
With regards to RRT education, 93% of patients found the home visit useful/extremely useful, compared to 76% finding the RRT Roadshow useful/extremely useful. Prior to the home visit, patient preference for RRT modality was as follows (multiple choices allowed): 27% HD, 13% PD, 13% pre-emptive transplant, 27% conservative management, and 20% were unsure. Following education, this changed to 33% for HD, 33% for PD (60% of whom had not considered PD beforehand), 13% pre-emptive Tx, 13% for conservative management, and 7% remained unsure.
Conclusion
Initial data would suggest a personalised RRT education programme delivered at home enhances uptake and access to PD as first choice modality, over group-based education. The vast majority of patients found home-based education beneficial for shared decision making with regards to planning RRT.
Whilst the numbers are small and there are a number of confounders that need to be acknowledged, this is promising pilot data which if sustained in the coming months may suggest a strategy to increase PD numbers for other units.
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