Systematic Evaluation of a Provincial Initiative to Improve Transition to Home Dialysis Therapies
Authors: Wang Alice , Turnbull Linda , Williams Janet , Thomas Sarah , Saunders Sushila , Levin Adeera , Djurdjev Ognjenka , Copland Michael , Singh Suneet , Hemmett Juliya 
Published: August 2020

Background: The transition from choosing to initiating home dialysis therapies (HDTs) is not clearly standardized for patients and staff, causing increased anxiety and suboptimal self-management for chronic kidney disease (CKD) patients. At BC Renal, a “Transition to HDTs” guidebook (the Guide) was designed, outlining a step-wise approach to transitioning to HDTs for patients, to help address some of these concerns. Objective: We used the Logic Model evaluation framework to assess the value of the Guide to improve patient and staff experience with transitioning to HDTs. Design: This is a prospective cohort quality improvement study. Setting: This study took place at home dialysis programs in British Columbia, Canada, with 2 pilot sites and 2 control sites. Patients: Patients above age 18 who attended kidney care clinics and identified HDT as their renal replacement treatment of choice were included in this study. Measurements: Patient demographics were obtained from British Columbia Renal Patient Records and Outcomes Management Information System, with differences analyzed using Mann-Whitney U test and chi-square test where applicable. Patient surveys were based on Likert rating scales, analyzed using Cochran-Armitage trend test. All tests were 2-sided, with P < .05 considered significant. Methods: The study enrolled patients from December 2018 to April 2019 at 2 pilot and 2 control sites. Patients were followed up for 8 months. The intervention strategies included (1) training of front-line staff to use the Guide and (2) dissemination of the guide to patients. Evaluation tools measuring data at baseline and at the 8-month point included (1) qualitative and quantitative patient surveys, (2) qualitative staff surveys, (3) structured feedback session with renal care staff, and (4) transition rate and time between choosing and starting a HDT. Results: In total, 108 patients were enrolled: 43 patients at pilot sites and 65 in control sites. Twenty-three of 65 in control vs 18 of 43 in pilot transitioned to a HDT by 8-month follow-up. Transition time was 80 vs 89 days in pilot vs control group, but it was not statistically different ( P = .37). The proportion of patients that transitioned to a HDT was 42% vs 35% in pilot vs control group ( P = .497). Patients’ anxiety, illness knowledge, and activation of resources were not significantly different between patients who successfully transitioned at control and pilot sites. During interviews, patients confirmed that the Guide was effective and helped retain knowledge. The staff felt that the intervention did not increase their workload and that the Guide was a good communication tool, but was used inconsistently. Limitations: We had a small sample size and limited number of patients enrolled who chose home hemodialysis, with none in the control group. The results are therefore more applicable to peritoneal dialysis. Conclusions: The Logic Model was useful to evaluate our multi-intervention strategy. While there were no statistically significant differences in transition time, rate, and patient anxiety with or without the Guide, qualitative opinions from patients indicate that the Guide was a useful supplement. In addition, feedback from renal care staff suggested that the Guide served as a framework for communicating the transition process with patients, and was perceived as a useful tool. Future work is required to standardize the Guide’s utilization. Trial registration: As this is a quality improvement evaluation study, trial registration is not applicable.