Palliative care competencies in nephrology: a scoping review

Introduction: There is a growing need to train nonpalliative physicians in palliative care, as it is increasingly recognized by the medical profession. Political and opinion leaders are also becoming aware of the urgent and growing need for palliative care education. Objective: The aim of this study is to provide an overview of the information available in the literature on the topic of palliative care competencies for nephrologists, using clearly defined and transparent methods to search, summarize, and interpret the relevant literature based on a systematic review approach. Methods: The scoping review is based on the Joanna Briggs Institute methodology. The search was conducted in December 2019 using publications in national and international databases and grey literature in English, Spanish, French and Portuguese. Results: Of the total 4668 publications, 168 were eligible for review based on title and abstract. A full-text review of these 168 publications resulted in the selection of 27 articles that met the predefined inclusion and exclusion criteria and were therefore included in the study. The following competencies were considered necessary to provide high quality PC in various nephrology settings: Communication skills (21.3%); End-of-life care, loss, grief, and bereavement (18.6%); Control of pain and other renal symptoms (16%); Advance care planning (16%); Ethical and legal issues in dialysis decision making (12.2%); Teamwork (6.6%); Ability to provide psychosocial and spiritual support to patients and families (5.6%). Application of palliative care principles (3.7%). Percentage refers to the number of publications addressing each topic. Conclusion: The implementation of an integrated care model that includes both PC and curative treatments places high demands on nephrologists, who must acquire PC competencies. Training in palliative care should be included in the curricula for nephrologists.info:eu-repo/semantics/publishedVersio

Diabetes Guidelines Implementation Toolkit

Diabetes Guidelines Implementation Toolkit is a capstone project aimed to help the Grady North Fulton Health Center to implement the American Diabetes Association (ADA) “Standards in Medical Care in Diabetes, 2011” guidelines. This toolkit can also be used to implement the diabetes guidelines in any other primary or community healthcare facility to improve diabetes care. Diabetes can affect many parts of the body and can lead to serious complications such as blindness, kidney damage, and lower-limb amputations. Working together, people with diabetes, their support network, and their health care providers can reduce the occurrence of these and other diabetes complications by controlling the levels of blood glucose, blood pressure, blood lipids, and by receiving other preventive care practices in a timely manner. Once the decision to put into practice the evidence-based diabetes guidelines has been made, this implementation toolkit will serve as a guide to help go through the process of implementation. The toolkit will suggest practical ways to implement the use of the guidelines using a stepwise approach, resources and template materials such as information handouts, flow sheets, referral forms, sample patient letters, etc. will be provided in the toolkit to facilitate the implementation. The final goal of the implementations is to improve the delivery of effective preventive health care services and promote diabetes preventive behaviors in order to prevent diabetes, its complications and disabilities, and the burden associated with the disease

A Patient-Centered Approach to Hemodialysis Vascular Access in the Era of Fistula First

The primary vascular access options for the hemodialysis population are arteriovenous fistulas (AVF), arteriovenous grafts, and cuffed central venous catheters (CVC). AVFs are associated with the most favorable outcomes with respect to complications, interventions required to maintain functionality and patency, and overall cost. These population-based outcomes, in conjunction with the efforts of the Fistula First Breakthrough Initiative, have propelled the prevalence of AVFs in the US hemodialysis population. While this endeavor remains steadfast in assuring the continued dominance of this policy for AVF preference, it fails to take into account a subset of the dialysis population who will fail to see the benefits of an AVF. This subset of patients may include the elderly, those with poor vasculature anatomy, those with slowly progressive CKD who are more likely to die than progress to ESRD, and those with an overall poor long-term prognosis and shortened life expectancy. Thus, in an effort to avoid numerous unnecessary surgical and interventional procedures with minimal to no gains in clinical outcomes, an individualized patient approach must be adopted. The Centers for Medicare and Medicaid Services–instituted quality incentive program is designed to reward high AVF prevalence while also penalizing high CVC prevalence. The current model is devoid of case-based adjustment, thus penalties are disbursed to dialysis providers in accordance with a “one-size-fits-all” fistula only approach. The most suitable access for a patient remains the one that takes into account the characteristics unique to the individual patient with a primary focus on patient comfort, satisfaction, quality of life, and clinical outcomes

Teaching the Use of Systems Dynamics for Strategic Decision Making in Healthcare

Having worked in the healthcare system and taught healthcare MBAs for over a decade, we have observed that healthcare systems and departments operate in independent silos. This paper shows how to use systems dynamics as a method to help students examine the big picture of how components fit together to form a system. We demonstrate the application of this approach and provide an example from one of our healthcare professional graduate student teams

Intravenous magnesium sulfate for treating adults with acute asthma in the emergency department.

BACKGROUND: Asthma is a chronic respiratory condition characterised by airways inflammation, constriction of airway smooth muscle and structural alteration of the airways that is at least partially reversible. Exacerbations of asthma can be life threatening and place a significant burden on healthcare services. Various guidelines have been published to inform management personnel in the acute setting; several include the use of a single bolus of intravenous magnesium sulfate (IV MgSO4) in cases that do not respond to first-line treatment. However, the effectiveness of this approach remains unclear, particularly in less severe cases. OBJECTIVES: To assess the safety and efficacy of IV MgSO4 in adults treated for acute asthma in the emergency department. SEARCH METHODS: We identified trials from the Cochrane Airways Review Group Specialised Register (CAGR) up to 2 May 2014. We also searched www.ClinicalTrials.gov and reference lists of other reviews, and we contacted trial authors to ask for additional information. SELECTION CRITERIA: We included randomised controlled trials (RCTs) of adults treated in the emergency department (ED) for exacerbations of asthma if they compared any dose of IV MgSO4 with placebo. DATA COLLECTION AND ANALYSIS: All review authors screened titles and abstracts for inclusion, and at least two review authors independently extracted study characteristics, risk of bias and numerical data. Disagreements were resolved by consensus, and we contacted trial investigators to obtain missing information.We analysed dichotomous data as odds ratios using study participants as the unit of analysis, and we analysed continuous data as mean differences or standardised mean differences using fixed-effect models. We rated all outcomes using GRADE and presented results in Summary of findings table 1.We carried out subgroup analyses on the primary outcome for baseline severity of exacerbations and whether or not ipratropium bromide was given as a co-medication. Unpublished data and studies at high risk of bias for blinding were removed from the main analysis in sensitivity analyses. MAIN RESULTS: Fourteen studies met the inclusion criteria, randomly assigning 2313 people with acute asthma to the comparisons of interest in this review.Most studies were double-blinded trials comparing a single infusion of 1.2 g or 2 g IV MgSO4 over 15 to 30 minutes versus a matching placebo. Eleven were conducted at a single centre, and three were multi-centre trials. Participants in almost all of the studies had already been given at least oxygen, nebulised short-acting beta2-agonists and IV corticosteroids in the ED; in some studies, investigators also administered ipratropium bromide. Ten studies included only adults, and four included both adults and children; these were included because the mean age of participants was over 18 years.Intravenous MgSO4 reduced hospital admissions compared with placebo (odds ratio (OR) 0.75, 95% confidence interval (CI) 0.60 to 0.92; I(2) = 28%, P value 0.18; n = 972; high-quality evidence). In absolute terms, this odds ratio translates into a reduction of seven hospital admissions for every 100 adults treated with IV MgSO4 (95% CI two to 13 fewer). The test for subgroup differences revealed no statistical heterogeneity between the three severity subgroups (I(2) = 0%, P value 0.73) or between the four studies that administered nebulised ipratropium bromide as a co-medication and those that did not (I(2) = 0%, P value 0.82). Sensitivity analyses in which unpublished data and studies at high risk for blinding were removed from the primary analysis did not change conclusions.Within the secondary outcomes, high- and moderate-quality evidence across three spirometric indices suggests some improvement in lung function with IV MgSO4. No difference was found between IV MgSO4and placebo for most of the non-spirometric secondary outcomes, all of which were rated as low or moderate quality (intensive care admissions, ED treatment duration, length of hospital stay, readmission, respiration rate, systolic blood pressure).Adverse events were inconsistently reported and were not meta-analysed. The most commonly cited adverse events in the IV MgSO4 groups were flushing, fatigue, nausea and headache and hypotension (low blood pressure). AUTHORS' CONCLUSIONS: This review provides evidence that a single infusion of 1.2 g or 2 g IV MgSO4 over 15 to 30 minutes reduces hospital admissions and improves lung function in adults with acute asthma who have not responded sufficiently to oxygen, nebulised short-acting beta2-agonists and IV corticosteroids. Differences in the ways the trials were conducted made it difficult for the review authors to assess whether severity of the exacerbation or additional co-medications altered the treatment effect of IV MgSO4. Limited evidence was found for other measures of benefit and safety.Studies conducted in these populations should clearly define baseline severity parameters and systematically record adverse events. Studies recruiting participants with exacerbations of varying severity should consider subgrouping results on the basis of accepted severity classifications

Pharmacist collaborative practice and the development and implementation of team-based care in outpatient healthcare settings: A case study at El Rio Community Health Center

Background: The United States is experiencing a primary care physician shortage that will grow in the next decade as demand for primary care services is projected to increase. The growth in physician, Nurse Practitioner, and Physician Assistant supply alone will not be adequate to meet the demand for primary care services by 2020. Creating pharmacist-inclusive collaborative care teams for outpatient clinical care can help alleviate this health care delivery shortage. Methods: A qualitative mixed-methods case study was conducted in Tucson, Arizona to determine the supports and structures behind the Pharmacy-Based Diabetes Management Program (PBDMP) at El Rio Community Health Center. Using key informant interviews from El Rio, other outpatient clinical pharmacy programs (OCPPs), and the Tucson Accountable Care Organization, coupled with Lean Management brainstorming group sessions, the study elicited information about how the experience of El Rio with the PBDMP can inform nationwide development and implementation guidelines for other OCPPs. Results: The PBDMP at El Rio provides a blueprint for other programs interested in creating an OCPP. Key contributing factors to program success within El Rio and the other OCPPs interviewed included a focus on six key practices. Challenges inhibiting success were pharmacist provider status and reimbursement of clinical services provided. Translation: Three public health practice products were developed as a framework to provide future OCPPs interested in implementing a pharmacist-inclusive practice model: 1) implementation guidelines, 2) a self-assessment outpatient clinical pharmacy program worksheet for clinics looking to create or expand an OCPP, and 3) a student management decision case study. Conclusion: This study demonstrates the value of considering all potential members of a care team for diabetes care management. The decision by a clinic to create an OCPP should be based on team-based approaches to patient-centered chronic disease care management. Clinics looking to participate in a CDTM model OCPP need to identify if organizational transformation is needed for program buy-in and consider relational coordination between clinical roles as a major component of the coordinated work needed for a successful OCPP

Improving Identification of High-Risk Obstructive Sleep Apnea Patients in Primary Care: An Integrative Review

Obstructive sleep apnea continues to be an area that is underdiagnosed and therefore undertreated. Left untreated, the condition is associated with increased morbidity and mortality as it can amplify the risk of multiple health conditions. Due to the negative impact of obstructive sleep apnea it is necessary for healthcare providers to provide timely detection. Primary care providers are in a position to identify high-risk individuals and refer them for further follow up testing. High-risk identification can be accomplished by integrating validated screening tools into patient assessments. This integrative review provides an overview of current screening tools for use in the primary care setting, barriers to screening adoption, and successful practices

A Mixed Methods Evaluation of Patient and Provider Perspectives of Chronic Illness Management Following Kidney Transplantation

Introduction: Inconsistent, fragmented care coordination in kidney transplant recipients (KTRs)—whose management requires long-term, complex care, and multiple handoffs among providers—has been shown to result in suboptimal care and higher costs. In order to move forward in improving long-term outcomes, it is necessary to fully assess current practice patterns with appropriate measures. With a full and accurate picture of how elements of the management plan influence both KTR and the health care provider (HCP), it will be possible to implement changes that improve long-term outcomes.Methods: The Chronic Care Model (CCM) was the framework for the study. A mixed method research approach was employed, integrating quantitative and qualitative methodologies in a single cross-sectional, correlational study with data collected from both KTRs and physicians. The 659 KTRs were selected from a list of KTRs who had received a kidney transplant at Methodist University Transplant Institute (MUTI). Physicians were recruited from a list of 96 referring nephrologists who practice in the region. The quantitative data were dichotomized results from Patient Assessment of Chronic Illness Care (PACIC) and Assessment of Chronic Illness Care (ACIC) questionnaires. Continuous data characteristics of the KTRs and HCPs were summarized, with means and standard deviations and medians and quartiles. Categorical data were reported as proportions. Chi-Square and Fisher’s Exact tests, as appropriate, were used to determine if any significant associations existed between categorical independent variables and the scale scores. Continuous variables were analyzed using t-tests and Wilcoxon Rank Sum, as appropriate.For qualitative data, NVivo 10 was used to organize the interviews and focus group discussion. Data were analyzed using five phase thematic content analysis.Results: There was variation in the perceptions of chronic illness management as assessed by the PACIC and the ACIC. The number of hospitalizations, time on dialysis and time with graft were the patient variables most associated with PACIC scores. Type of practice, embedded decision support, time in practice and age were the variables most associated with ACIC scores. Patients and providers recognized coordinated care/ follow- up, education, and community resources as barriers to chronic illness management.Discussion: The initial work presented here sought to clarify patient and provider perceptions of the influence of community resources and policies, as well as healthcare system organization using the CCM as a framework. An understanding of the perceptions and experiences of patients and providers will provide the foundation for future work that will address ways in which productive patient-provider interactions can be enhanced, thereby improving patient outcomes

Expanding Use of Sodium-Glucose Cotransporter-2 Inhibitor (SGLT2i) In Managing Patients with Diabetes and Chronic Kidney Disease in Primary Care

Practice Problem: In 2022, the addendum of standards of medical care in diabetes management was annotated to recommend the broader use of sodium-glucose cotransporter 2 inhibitors (SGLT2i) to treat patients with Type 2 diabetes mellitus (DM) and diabetic nephropathy. Despite the Department of Veterans Affairs’ (VA) efforts to include SLGT2i as a formulary, non-restrictive prescription in the primary care ordering menu, the overall utilization rates of SGLT2i remained relatively low in primary care. PICOT: The PICOT question that guided this project was: In patients with DM and chronic kidney disease (CKD) (P), how does an evidence-based guideline algorithm bundle (I) compared to standard care (C) affect providers’ adherence and prescribing practices of including SGLT2 inhibitors (O) within 10 weeks (T)? Evidence: An extensive evidence literature review supported that the algorithm approach with current guidelines has allowed clinicians to identify patients eligible for SGLT2i was based on comprehensive risk assessment with various comorbidities and risk factors. The guideline-based algorithm was a quick reference guide to provide clarity and indication for patients with the most significant potential benefits from SGLT2i therapy. Intervention: The algorithm bundle, designed to reflect the current guidelines, was intended to enhance primary care clinicians\u27 prescribing confidence in SGLT2i and guide better decision-making. The algorithm bundle comprised the physical laminated algorithm card, embedded reminder in the e-prescribing menu, and a focused education session for the primary care providers. Outcome: The project outcomes reflected that the algorithm bundle has clinical significance in improving prescribers’ knowledge of SGLT2i agents and practice compliance, as evidenced by a rise in SGLT2i prescriptions. Conclusion: The algorithm bundle intervention in this project resonates with the American Diabetic Association’s (2022) latest recommendation to widen indications for using SGLT2 to optimize the management of DM and CKD patients. The evidence supports using a guideline-based algorithm to guide clinicians with a comprehensive assessment of high-risk patients and a better decision-making tool. Continued efforts to educate and audit primary care providers are essential to identify potential knowledge gaps and to sustain practice compliance of using SGLT2i as part of the standard of care

The Effect of Medical Cooperation in the CKD Patients: 10-Year Multicenter Cohort Study

Introduction: While chronic kidney disease (CKD) is one of the most important contributors to mortality from non-communicable diseases, the number of nephrologists is limited worldwide. Medical cooperation is a system of cooperation between primary care physicians and nephrological institutions, consisting of nephrologists and multidisciplinary care teams. Although it has been reported that multidisciplinary care teams contribute to the prevention of worsening renal functions and cardiovascular events, there are few studies on the effect of a medical cooperation system. Methods: We aimed to evaluate the effect of medical cooperation on all-cause mortality and renal prognosis in patients with CKD. One hundred and sixty-eight patients who visited the one hundred and sixty-three clinics and seven general hospitals of Okayama city were recruited between December 2009 and September 2016, and one hundred twenty-three patients were classified into a medical cooperation group. The outcome was defined as the incidence of all-cause mortality, or renal composite outcome (end-stage renal disease or 50% eGFR decline). We evaluated the effects on renal composite outcome and pre-ESRD mortality while incorporating the competing risk for the alternate outcome into a Fine-Gray subdistribution hazard model. Results: The medical cooperation group had more patients with glomerulonephritis (35.0% vs. 2.2%) and less nephrosclerosis (35.0% vs. 64.5%) than the primary care group. Throughout the follow-up period of 5.59 +/- 2.78 years, 23 participants (13.7%) died, 41 participants (24.4%) reached 50% decline in eGFR, and 37 participants (22.0%) developed end-stage renal disease (ESRD). All-cause mortality was significantly reduced by medical cooperation (sHR 0.297, 95% CI 0.105-0.835, p = 0.021). However, there was a significant association between medical cooperation and CKD progression (sHR 3.069, 95% CI 1.225-7.687, p = 0.017). Conclusion: We evaluated mortality and ESRD using a CKD cohort with a long-term observation period and concluded that medical cooperation might be expected to influence the quality of medical care in the patients with CKD