Nurse Practitioner-Coordinated Multidisciplinary Care for Patients with Chronic Kidney Disease: A Mixed-Method Study

Abstract

Background: Chronic kidney disease (CKD) is increasing in prevalence both nationally and internationally, and is associated with a high rate of cardiovascular morbidity and mortality leading to increased risk of premature death. The wellbeing of patients with CKD, as reflected in quality of life (QOL), is important especially before starting dialysis. There is at present limited research on QOL before dialysis in CKD patients. QOL can be negatively affected by lifestyle-associated risk factors and comorbidities such as a sedentary lifestyle, smoking, obesity, diabetes, hypertension and anaemia. A multifaceted approach to reducing cardiovascular risk factors that incorporates lifestyle modifications has been proposed; however, the patientrs engagement and confidence are critical to the success and sustainability of such approach. In Australia, the Landmark 3 study is trialling a model of multidisciplinary care with lifestyle interventions as one way to reduce cardiovascular risk factors and increase patient QOL. Aim: The aim of this study was to compare the effects of traditional care versus multidisciplinary care coordinated by a nurse practitioner on participantsr wellbeing and clinical outcomes. QOL was used as the indicator of wellbeing. Methods: The study was a multicentre, randomised clinical trial (RCT) that included patients with stage 3n4 CKD recruited from outpatient clinics. After written consent was received, patients were randomised to standard care or nurse practitioner-coordinated multidisciplinary care. Thenmultidisciplinary care included both review and follow-up visits along with educational sessions, physical training and dietary education and advice. Data regarding QOL were collected using the SF-12v2 and EQ-5D. These data along with clinical data were collected at 0, 6 and 12 months, and all analysis followed the intention-to-treat principle. A subgroup of the patients (26 from the control group, 29 from the intervention group) was interviewed at 12 months about their experience of the care provided and living with CKD.Results: One hundred and forty-two patients were recruited and were followed for 12 months: 72 patients in the control group and 70 in the intervention group. At baseline, there were no significant differences between groups on the SF-12v2 physical (control 42.9, intervention 42.6) and mental (control 50.9, intervention 51.7) component summary scores. The physical component summary score improved with significance at 12 months in the intervention group (control 41.8, intervention 45.6; pl0.05), the mental component summary score did also show an improvement but this was not significant (control 54.0, intervention 53.6; pg0.05). Blood pressure differed significantlynbetween groups at a comparison over time: mean 133 (SD 19) in the intervention group, and 138, (SD 21) in the control group (pl0.05). HBA1c level changed significantly over time in the control group: mean 6.52% (SD 1.30) at baseline, 6.84% (SD 1.84) at 12 months (pl0.05). Body weight differed significantly between the groups. The intervention group lost a mean of 2 kg, and the control group gained a mean of 2 kg (pl0.001). The total number of antihypertensive medications also decreased significantly with time in the intervention group (pl0.05). From the qualitative data obtained for 55 patients, three main themes emerged: understanding, concordance, and coping. The participants in the intervention group reported more-positive experiences, especially coping. They were more engaged in their care, took greater part in decision making and felt more confident and in control of their health. In the theme concordance, there was less detectable difference between the groups, especially regarding how they dealt with their medication.Conclusions: Multidisciplinary care with the nurse practitioner as care coordinator can improve physical functioning and QOL. The model of care implemented as part of Landmark 3 increased patients' engagement in their care. This may lead to an increase in the sustainability of their self-care.