Peer Mentorship to Improve Outcomes in Patients on Maintenance Hemodialysis

Study Overview
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Brief Summary
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This project tests a peer mentor intervention to improve outcomes in patients with end-stage renal disease (ESRD). The investigators will train peer mentors to deliver social support and to provide information and motivation in order to improve adherence behaviors and self management practices in assigned mentees who are also patients on maintenance hemodialysis. The intervention will consist of a weekly telephone call between mentor and mentee, over a period of 3 months. The study will recruit patients at 7 dialysis facilities (5 in the Bronx, NY and 2 in Nashville, TN) and randomize the patients to the peer mentorship intervention versus usual care. The primary outcome will be the sum of number of emergency department visits and hospitalizations during 3 months of intervention and 9 or 15 months of follow-up observation.

Detailed Description
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The overarching goal of this research is to improve End Stage Renal Disease (ESRD) related morbidity and mortality. The medical care of patients with ESRD is highly complex and enormously expensive. Hospitalizations drive up to 40% of the cost for ESRD care. Cardiovascular disease and infections account for over 50% of ESRD-related hospitalizations and contribute to disproportionate mortality in this patient population. This study tests the implementation and impact on hospitalization outcomes of a peer mentor led intervention designed to increase effective self-management in patients receiving hemodialysis, in a real-world setting with high potential for widespread dissemination. Patients receiving hemodialysis who can self-manage their fluid status effectively, are adherent to their dialysis schedule and to their dietary plan are hospitalized less frequently and have lower morbidity and mortality than patients who are less adherent. However, numerous impediments to dialysis self-management exist including facility, physician and patient-level barriers. The following are patient-level barriers to optimal self-management: 1) poor knowledge about the rationale and metrics of estimated dry weight (EDW), 2) poor knowledge about the metrics of urea clearance and nutritional parameters, 3) under-utilization of available hours for unscheduled dialysis, and 4) low self-efficacy leading to non-adherent schedule and dietary behaviors. Dialysis self-management education is often not successful in improving patients' skills. Educational tools from dialysis facilities and providers are didactic, have medical jargon and lack concrete steps to mitigate patient visits to emergency departments (ED) and subsequent hospitalizations. A culturally sensitive, easy to understand educational program that can increase hemodialysis self-management is critically needed. Peer mentorship has been used effectively to enhance self-efficacy and self-management behaviors in patients with chronic disease. A single study of peer mentorship for ESRD patients found that peer mentors improved adherence and satisfaction with care among mentees. This strategy has high potential to improve the factors that drive hospitalizations among this high-risk patient group. The goal of this research is to implement a peer mentor training program to increase patients' knowledge about the metrics of hemodialysis, enhance self-management to meet EDW, nutritional and adherence goals, and to enhance self-efficacy in mentees. The peer-mentor intervention is based on the information, motivation, behavior (IMB) model of health behavior and the Chronic Disease Self-Management Program. There will be a didactic component to increase knowledge, and a semi-structured component to increase perception of social support. The investigators will test the feasibility of implementation of this program and the efficacy of it to reduce hospitalizations in a pragmatic trial comparing the peer mentor intervention on mentees to a control group assigned to usual care. The study will also test the intervention at two geographically diverse locations (Bronx, NY and Nashville, TN) to provide evidence of its scalability and acceptability in different patient populations. The study hypothesis states: a structured peer mentor telephone intervention will be more effective than usual care in increasing hemodialysis related knowledge, self-management adherent behaviors and in decreasing ED visits and hospitalizations in ESRD. Specific Aim 1: To evaluate the effects of a 3-month semi-structured and telephone delivered peer mentor intervention on a composite of ED visits and hospitalizations in 100 high risk patients on hemodialysis randomized to peer mentor intervention as compared to 100 high risk patients on hemodialysis assigned to usual care. Secondary outcomes include: 1) dialysis adherence (mean weekly minutes of dialysis), 2) mean monthly inter-dialytic weight gain (IDWG), and 3) mean monthly albumin levels, in the intervention mentees as compared to the controls. To compare by group patient dialysis knowledge, self-efficacy and social support. Specific Aim 2: To test the feasibility of a peer training program focused on teaching self-management skills focused on adherence, dietary and fluid management, in dialysis facilities. To test the feasibility of a training program conducted in 7 dialysis facilities the investigators will conduct peer training of 20 recruited mentors (10 in New York and 10 in Nashville), using a semi-structured curriculum taught in 4 sets of 2-hour sessions, over 4 weeks per facility. To test the fidelity of the curriculum training the investigators will use attendance records, content analysis, pre- and post-knowledge assessments and course evaluations. This pragmatic trial will test the effects and implementation of a low cost, educational, telephone-based, peer-mentor intervention to increase self-management behaviors of patients receiving hemodialysis.

Official Title
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Peer Mentorship to Improve Outcomes in Patients on Maintenance Hemodialysis

Conditions
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Dialysis

Intervention / Treatment
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* Behavioral: Peer mentorship


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: Age >21 years One of the following: One or more hospitalizations or ED visits in the previous month >1 missed treatment or 2 shortened dialysis treatments in the last month use of catheter as only access >4% intradialytic weight gain serum albumin less than 3.5 in the last month Incident dialysis patient Willing to give informed consent and to be randomized and to allow a telephone intervention with mentors Speaks Spanish or English Exclusion Criteria: Intellectual disability/ active mental illness or active substance abuse less than a 6- month life expectancy not a patient at one of the participating dialysis facilities

Ages Eligible for Study
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Minimum Age: 21 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Prevention
Allocation: Randomized
Intervention Model: Parallel Assignment
Masking: None (Open Label)


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Experimental: Peer mentorship intervention<br>This arm of mentees will be assigned to weekly telephone calls with a matched mentor over a period of 3 months. | Behavioral: Peer mentorship<br>* Participants randomized to this arm of the study will speak with their dialysis peer mentor once a week about fluid intake and adherence to dialysis.<br>|
| No Intervention: Usual Care<br>This arm of mentees will not get a telephone intervention by an assigned mentee | |

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Rate of ED visits and Hospitalizations | Composite outcome | 12 or 18 months | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Rate of missed or cut dialysis treatments | Mean weekly missed minutes of dialysis treatments by intervention mentees as compared to control mentees during the intervention and follow-up periods | 12 or 18 months | 
| Mean monthly interdialytic weight gain in intervention mentees as compared to control mentees during the intervention and follow-up periods | Mean monthly amount of changed fluid weight in-between dialysis treatments by intervention mentees as compared to control mentees during intervention and follow-up periods. | 12 or 18 months | 
| Mean monthly albumin levels | The monthly albumin levels in intervention mentees as compared to control mentees during intervention and follow-up periods. | 12 or 18 months | 
| Efficacy of intervention to change dialysis knowledge in mentees | The scores on Chronic Hemodialysis Knowledge Survey (CHeKS) and knowledge assessments in mentees assigned to intervention as compared mentees assigned to control. CHeKS: percent correct out of a total of 23 questions | 3 months (immediately post intervention) and 12 or 18 months | 
| Efficacy of intervention to change curriculum specific dialysis knowledge in mentees | The scores on Chronic Hemodialysis Knowledge Survey (CHeKS) plus knowledge assessments in mentees assigned to intervention as compared mentees assigned to control. CHeKS Plus: percent correct out of a total of 8 questions | 3 months (immediately post intervention) and 12 or 18 months | 
| Efficacy of intervention to change quality of life in intervention mentees as compared to control mentees | The scores on SF36 Health Survey(36 item short form health survey by RAND) in mentees assigned to intervention as compared to control mentees. For the SF-36 Health Survey, the scoring varies depending on question with some questions having a scale from 1-6 and others having a scale from 1-3. All items are scored so a high score defines a more favorable health state.(https://www.rand.org/health-care/surveys_tools/mos/36-item-short-form/scoring.html) | At 3 months (immeditely post intervention) and 12 or 18 months. | 
| Efficacy of intervention to change self-efficacy by intervention mentees as compared to usual care mentees | Scores on Perceived Dialysis Self Management Scale(PKDSMS) and Kidney Disease Self Management Behavioral Index(KDBI) in mentees assigned to intervention as compared to mentees assigned to control. PKDSMS: scores on a scale from 1 to 5 for each of 8 items, with 1 representing strongly agree to 5 representing strongly disagree. KDBI: scores on a scale of 1 to 4 with 1 representing not at all to 4 representing all the time | At 3 months and 12 or 18 months. | 
| Efficacy of intervention to change curriculum taught dialysis knowledge in intervention mentees as compared to usual care mentees | The scores on the Chronic Hemodialysis Knowledge Survey-Plus (CHeKS Plus) (developed by investigators) assessment in mentees assigned to intervention as compared mentees assigned to control. CHeKS Plus: percent correct out of a total of 8 questions | 3 months (immediately post intervention) and 12 or 18 months | 
| Efficacy of intervention to change coping ability in intervention mentees as compared to usual care mentees | The score on Brief KCOPE in mentees assigned to intervention as compared to control mentees. For the brief KCOPE (developed by C.S. Carver (1997)): Scale 1-4 with 1 indication not at all and 4 indicating  doing it a lot. | At 3 months and 12 or 18 months. | 
| Efficacy of intervention to change depression scores in intervention mentees as compared to usual care mentees | The scores on CESD-10 (Center for Epidemiologic Studies Depression Scale Revised)in mentees assigned to intervention as compared to control mentees. For the CESD-R10 questions have a scale of 1-4 with 1 indicating rarely or none of the time and 4 indicating all of the time. (https://cesd-r.com/) | At 3 months and 12 or 18 months. | 
| Efficacy of intervention to change perception of social support by intervention mentees as compared to usual care mentees | Scores on the Multi-dimensional Scare of Perceived Social Support(MSPSS) and Dialysis Specific Social Support Survey(developed by PI's) in mentees assigned to intervention as compared to mentees assigned to control. MSPSS: scores on a scale of 1-7 with 1 representing very strongly disagree and 7 representing very strongly agree. Dialysis specific social support survey: scores on a scale from 1-5 with 1 indicating none of the time and 5 indication  all of the time. | At 3 months and 12 or 18 months. | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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Hospitalizations, Dialysis patients, Peer mentorship