The effects of a nurse-led case management programme on patients undergoing peritoneal dialysis : a randomized controlled trial

Abstract

Background: The treatment of hospitalized patients receiving peritoneal dialysis is often critical. These patients need integrated health and social care in order to maintain a desirable quality of life and to decrease morbidity during the course of the disease. Nurse-led case management programmes have been tested on selected groups of chronically ill patients, such as those with coronary heart disease or diabetes mellitus. The health of patients receiving peritoneal dialysis is clearly an important issue; it is crucial to develop a nurse-led case management programme and test its effects upon patients undergoing peritoneal dialysis. Aim: This study aimed to develop an innovative nurse-led case management model and test its effectiveness within a sample of patients receiving peritoneal dialysis in Hong Kong. Design: The study used a randomized, controlled trial, in which seventy nine patients were recruited and assigned to two groups; the study group and the control group. The patients in the study group received a comprehensive pre-discharge assessment and individual education programme prior to leaving the hospital, with a weekly telephone follow-up service by the case manager for six weeks after discharge. The education programme covered health knowledge, possible complications and clinical procedure techniques related to peritoneal dialysis. The telephone follow-ups provided ongoing physiological and psychological support. The study protocols were developed from the literature and the expert input of the renal physicians and nurses. Outcome measures: The outcome indicators include amelioration of symptoms and complication control, utilization of health care services, non-adherence behaviours, quality of life and patient satisfaction. Data were collected before discharge, then at six weeks and 12 weeks after discharge. Results: Repeated measures analysis of variance, General Linear Model was performed for the main outcome variables. Patients randomized to the study group showed a significantly higher level of patient satisfaction. There was a statistically significant difference in the between-group (F=4.41, p<0.05) and within-group (F=2.98, p=0.05) analyses, as well as in the interaction effects (F=6.89, p<0.01) in the repeated measures. With regard to adherence behaviours, a statistically significant difference in the within-group measure (F=4.09, p<0.05) was observed in diet non-adherence behaviour across time. For medication non-adherence, a significant interaction effect (F=4.60, p<0.01) was noted. For quality of life, the parameters demonstrated significant within-group effects (p<0.05) including effects on the impact of kidney disease on daily life, emotional well-being, physical roles, symptoms, pain and social function. The dimensions showed significant positive interaction effects (p<0.05) including encouragement from dialysis staff, patient satisfaction, improved sleep and social function. There was, however, no significant difference (p>0.05) revealed in the blood chemistry results and utilization of health care services. Multivariate analysis was conducted using regression models to identify the significant predictors for medication non-adherence, dietary non-adherence and patient self-reported health status, respectively. Age and gender were found to be the significant predictors for diet non-adherence; educational attainment, comorbidities and patient group were the significant predictors for medication non-adherence, whilst emotional wellbeing, quality of sleep and effects of kidney disease contributed significantly to self-reported health status. This study also tested the overall psychometric properties of the research instruments with their validity and reliability established with evidence. Conclusion: This was a pioneer study on the effects of a nurse-led case management programme on renal patients, conducted by nurses in Hong Kong. The empirical findings provide useful direction for continuity of care from hospital to community. The study results showed that a nurse-led case management programme improved patients' quality of life and medication non-adherence behaviours to treatment regimens. The outcomes also revealed a high level of patient satisfaction with the service and nursing care received. Further research, using a larger sample size is required to demonstrate the effects on blood chemistry results and utilization of health care services. The predictors for non-adherence behaviours and self-reported health status provided understanding and insights into the potential contributory factors for non-adherence behaviours. The information is able to facilitate nurses to address any medical, social, and demographic factors that undermine the patient's will to adhere to health related behaviours. The findings show that this proactive programme has been effective and culturally appropriate in guiding future nursing practice in the Hong Kong Chinese patient population.