Perit Dial Int
29(Supplement_2):
83-89
2009
© 2009 International Society for Peritoneal Dialysis
Part 3: Clinical Experiences |
IS FREQUENCY OF PATIENT–PHYSICIAN CLINIC CONTACT IMPORTANT IN PERITONEAL DIALYSIS PATIENTS?
Ying Xu,
Jie Dong and
Li Zuo
Renal Division, Department of Medicine, Peking University First Hospital;
Institute of Nephrology, Peking University; and Key Laboratory of Renal
Disease, Ministry of Health of China, Beijing, PR China
Correspondence to: J. Dong, Renal Division, Peking University First Hospital,
8 Xishiku Street, Xicheng District, Beijing 100034 PR China.
dongjie{at}medmail.com.cn
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ABSTRACT
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Objective: In a single-center retrospective cohort
study, we investigated whether the frequency of clinic patient–physician
contact (PPC) correlates with quality of care and can predict outcome in
peritoneal dialysis (PD) patients.
Patients and Methods: We enrolled 307 incident PD
patients who started PD from July 2002 to February 2007. All patients who
visited the clinic at least once every 6 months and who lived for at least 6
months were followed until death, transfer to hemodialysis, renal
transplantation, or February 2008 (censor date). Throughout the study period,
an integrative follow-up strategy was used, including PPC and three other
modes of contact between patients and non-physicians. Patients' PPC frequency
was divided into 3 categories: high frequency (monthly or more often),
intermediate frequency (every 1–3 months), and low frequency (every
3–6 months). Baseline demographic and biochemical data were collected.
Indices of diet, dialysis adequacy, biochemistry, and nutrition were measured
at every visit and then calculated as mean values.
Results: We followed the 307 patients for a mean of
31.45 ± 13.62 months (range: 12–64 months). By PPC frequency, 127
patients (41.3%) were in the high-frequency group; 136 (44.3%), in the
intermediate-frequency group; and 44 (14.3%), in the low-frequency group. We
observed no difference of baseline demographic and biochemical data between
the three groups (p > 0.05). Patients in the low-frequency group
had lower mean hemoglobin and total urea clearance rates, but higher serum
phosphate than did patients in the intermediate- or high-frequency groups
(p < 0.05). Mean indices of nutrition, including serum albumin,
daily protein and energy intake, and lean body mass were not different between
the three groups (p > 0.05). Frequency of PPC did not show an
effect on the survival of PD patients (p = 0.37 by Kaplan–Meier
plot). Age (p = 0.002), Charlson comorbidity score (p =
0.001), and pre-dialysis albumin (p = 0.019) were independent
negative risk factors for death in multivariate Cox proportional hazard
models, which were adjusted for sex, PPC frequency, baseline hemoglobin, and
glomerular filtration rate.
Conclusions: Frequency of PPC did not predict outcome
in PD patients after an integrative care strategy was implemented. Control of
anemia and hyperphosphatemia needs to be strengthened in patients with a low
frequency of PPC.
KEY WORDS: Patient–physician clinic contact; integrative care; non-physician clinician; self-management.
In view of the rapid increase in the end-stage renal disease population, it
has been hypothesized that dialysis health care professionals, especially
physicians, should play an important role in the care of dialysis patients.
Although patients desire greater interaction with their physicians
(1), the ability to schedule
frequent clinic visits between patients and physicians is affected by limited
time and labor resources. However, not only visits with physicians, but also
visits with non-physician clinicians (including nurses, dietitians, and
technicians), an often-ignored factor, can affect the care of dialysis
patients. Peritoneal dialysis (PD), an effective homecare modality independent
of complicated machine and hospital resources, has the advantage of
economizing on health care costs. Successful patient education and empowerment
may also help to nurture self-care and thus avoid more frequent visits to
doctors (2).
Little evidence is available on the subject of whether more frequent
patient–physician contact (PPC) can lead to better quality of care and
patient outcome in dialysis patients. A large national cohort study looked at
the relationship between PPC frequency and care quality in hemodialysis
patients. One report from this study noted that hospitalization rates, quality
of life, and survival did not vary by frequency of physician contact, but that
patient satisfaction and compliance were lower in the low-frequency group
(3). A second report revealed
that hemodialysis patients reporting less frequent physician contact reached
fewer therapy targets, but had a greater chance of achieving their hemoglobin
target (4). The effect of PPC
frequency in PD patients is not known.
In our PD unit, "integrative follow-up," which includes more
than traditional clinic PPC, has been applied for the past 5 years.
Integrative follow-up is expected to provide effective care for PD patients
through various non-physician clinician contacts. The present study set out to
verify that hypothesis through a retrospective cohort study.
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PATIENTS AND METHODS
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Our single-center retrospective cohort study enrolled a total of 307
incident patients who started PD in our unit from July 2002 to February 2007.
All patients could visit a physician at least once every 6 months. Patients
who died within 6 months of PD start were excluded. All patients were followed
until death, transfer to hemodialysis, renal transplantation, or February 2008
(censor date). Every episode of peritonitis was recorded. The peritonitis rate
was calculated by totaling all patient follow-up months and dividing by the
number of peritonitis episodes. All patients were dialyzed with
lactate-buffered glucose PD solutions and the twin-bag connection system
(Baxter Healthcare, Guangzhou, China).
INTEGRATIVE FOLLOW-UP AND CLINIC PPC FREQUENCY
The "integrative follow-up" strategy was in effect throughout
the study period. It included four aspects: traditional clinic PPC,
patient–nurse telephone (PNT) contact, patient–nurse meeting (PNM)
contact, and patient–physician–dietitian–nurse Internet
(PPDNI) contact (Figure 1).
Traditional PPC meant patients coming to visit a physician at the regular
frequency, depending on the distance between their home and the hospital and
also on family support for transportation. In PPC, evaluations of physical and
mental symptoms, biomedical parameters, diet and nutrition, and PD exchange
and exit-site care skills were systematically provided to each patient.
Frequency of PPC was recorded by primary nurses in three categories: high
frequency (monthly or more often), intermediate frequency (every 1–3
months), and low frequency (every 3–6 months). The PNT contact included
24-hour on-call service by a nurse on duty to handle emergent cases, and
daytime telephone monitoring by a primary nurse to handle current clinical
complications weekly, or even daily when necessary—for example, poor
control of blood pressure and glucose, or volume overload. The PNM contact was
provided by monthly cyclical education sessions on common topics and
occasional group meetings covering special topics. Patients and their families
take part in the activities together with their team of medical professionals.
They talk about a particular subject and learn a lot from each other. We
usually organize 20–30 people for each session, including patients and
their families. The PPDNI contact occurs as unscheduled communication through
e-mail. Patients might send diet and dialysis records, pictures of the exit
site, or uncomfortable symptoms and signs to us. Physicians, nurses, and
dietitians will consult with each other and then respond to the patient as
soon as possible. The PD staff members provide continuous monitoring and
education to the patients through these four modes of integrative
follow-up.
BIOCHEMICAL, DIALYSIS ADEQUACY, AND NUTRITION VARIABLES
Baseline demographic data were collected within the week preceding PD
catheter implantation. The data collected included age, sex, height, weight,
diabetes mellitus (DM) status, and Charlson comorbidity index calculated for a
PD population (5). Baseline
biochemical indices—hemoglobin (Hb), serum albumin (Alb), blood urea
nitrogen (BUN), serum creatinine (sCr), calcium, and phosphate (P)—were
examined using an automatic Hitachi chemistry analyzer the day before PD
catheter insertion and regularly thereafter at every clinic visit. Estimated
glomerular filtration rate (eGFR) was calculated using the Chinese equation
according to baseline creatinine level
(6). The CaxP product was
calculated.
Indices of dialysis adequacy and nutrition were measured at every visit and
then calculated as mean values. Collections of 24-hour dialysate and urine
were obtained for calculation of fluid removal and solute clearances. Weekly
total, peritoneal, and renal Kt/V urea, and weekly total, peritoneal, and
renal creatinine clearance (CCr) were calculated using standard methods. The
distribution volume of urea (V), which is generally assumed to be equal to
total body water, was calculated using the Watson equation. Lean body mass
(LBM) was measured by the creatinine kinetics method according to the formula
recommended by Blake (7), which
was verified as a good predictor in our PD population
(8). All patients completed
3-day dietary records before visiting the dietitian. Daily protein and energy
intake (DPI and DEI) were calculated using a computer software program (PD
Information Management System: Peritoneal Dialysis Center, Peking University,
Beijing, China). Total calorie intakes included intakes from both diet and
dialysate. The DPI and DEI were both normalized for standard body weight.
STATISTICAL ANALYSES
Statistical analysis was performed using the SPSS software package (version
13.0: SPSS, Chicago, IL, U.S.A.). Continuous variables are expressed as mean
± standard deviation; categorical variables are expressed as
percentages. The one-way ANOVA was used to compare differences between groups.
The chi-square and nonparametric statistical tests were used where
appropriate. Kaplan–Meier survival plots were used to display
hypothesized relationships. Recognized outcome predictors combined with visit
frequency were evaluated by the Cox proportional regression (forward
conditional) model to determine risk of death in PD patients. In model 1, the
variables included age, sex, Charlson comorbidity score, visit frequency,
pre-dialysis eGFR, and baseline Alb and Hb. In model 2, the variables included
age, sex, Charlson comorbidity score, frequency of PPC, mean Alb and Hb,
CaxP product, and dialysis adequacy. The final models contained the
variables that remained in the model with a significance level of 0.05. We
accepted p < 0.05 as the indicator of statistical
significance.
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RESULTS
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We followed 307 patients (131 men, 176 women) of mean age 59.5 ±
14.2 years (range: 15–94 years) for 31.45 ± 13.62 months (range:
12–64 months). At the end of the study, 190 patients were still being
maintained on PD, 72 had died, 17 had transferred to hemodialysis, 24 had
undergone renal transplantation, and 4 had transferred to other hospitals. The
causes of death were cardiovascular disease in 31 patients, systemic infection
in 30, severe malnutrition in 3, and unknown causes or multiple organ failure
in 8. The 1-, 2-, 3-, 4-, and 5-year survival rates were 97%, 82%, 71%, 64%,
and 51% respectively.
By frequency of clinic PPC, the high-frequency group (monthly or more
often) contained 127 patients (41.3%), the intermediate-frequency group (every
1–3 months) contained 136 patients (44.3%), and the low-frequency group
(every 3–6 months) contained 44 patients (14.3%). We observed no
differences in age, sex, height, weight, DM, Charlson comorbidity score, or
baseline Hb, Alb, BUN, sCr, and eGFR between the three groups (p >
0.05, Table 1). Peritonitis
rates in the high-, intermediate-, and low-frequency groups were 1 episode in
63.63 patient–months, 76.69 patient–months, and 50.13
patient–months respectively. During the study period, mean Alb, BUN, Ca,
CaxP; peritoneal and renal Kt/V; peritoneal, renal and total CCr; and
levels of DPI, DEI, LBM were not different between the three groups
(p > 0.05). Patients in the low-frequency group had lower mean Hb
and total Kt/V levels, but higher serum P levels than did patients in the
intermediate- and high-frequency groups (p < 0.05,
Table 2). We observed no effect
of clinic PPC frequency on the survival of PD patients as analyzed by
Kaplan–Meier survival plot (p = 0.37,
Figure 2).
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TABLE 1 Basic Demographics, Clinic Characteristics, and Biochemical Parameters of
Peritoneal Dialysis
Patientsa with
Different Physician–Patient Contact Frequencies
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TABLE 2 Mean Biochemical Parameters, Dialysis Adequacy, and Indices of
Nutritiona by
Physician–Patient Contact Frequency During the Study Period
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Figure 2 — Different frequencies of physician–patient contact (PPC) and
cumulative survival analysis in peritoneal dialysis patients (n =
307).
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Multivariate Cox proportional hazard model 1 was used to determine
independent risk factors by combining PPC frequency with baseline age, sex,
Charlson comorbidity score, and pre-dialysis Hb, Alb, and eGFR levels of the
patients. Only age, Charlson score, and pre-dialysis Alb were independent
negative risk factors for death (Table
3). Multivariate Cox proportional hazard model 2 was used to
determine independent risk factors for death by combining PPD contact
frequency with patient age, sex, Charlson comorbidity score, mean Hb and Alb,
peritoneal and renal Kt/V, peritoneal and renal CCr, and CaxP product
during the study period. Only age, Charlson score, and mean Hb and Alb were
independent negative risk factors for death
(Table 4).
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TABLE 3 Frequency of Physician–Patient Contact, Demographic Data, and
Baseline Biochemical Variables Determined to Be Associated with Death by the
Multiple Cox Proportional Hazards
Modela
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TABLE 4 Frequency of Physician–Patient Contact, Demographic Data, and the
Mean Dialysis Adequacy and Nutrition Variables Determined to Be Associated
with Death by the Multivariate Cox Proportional Hazards
Modela
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DISCUSSION
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It has been hypothesized that frequent clinic PPC will result in a better
quality of care and better outcomes in chronic disease. However, this
hypothesis has not yet been verified even in hemodialysis patients, who were
the subjects of a large national cohort study. As mentioned earlier, this
study
(3,4)
reached conflicting conclusions. There is no direct evidence at all in PD
patients, although Tonelli et al. recently reported that Canadians
treated by PD in remote locations have a higher adjusted death rate, which was
suspected to relate to less frequent or less comprehensive contact with
nephrologists (9). No baseline
comparison of patients living at different distances from nephrologists was
achieved in that study.
In the present study, 85% of the 307 patients visited doctors at least once
every 3 months. During the study period, patients with different clinic PPC
frequencies were comparable in baseline demographics and clinical data, and
maintained similar dialysis adequacy, nutrition status, and survival rates. We
observed no effect of visit frequency on death adjusted for some recognized
risk factors. With an integrative care strategy in place, clinic PPC frequency
did not predict outcome in PD patients in this first study focusing on the
correlation between PPC frequency and quality of care and outcome in PD
patients.
In fact, frequent clinic PPC is not necessarily practical in PD patients.
More-frequent PPC may allow for more engagement of physicians with patients,
more opportunities for new medical problems to be detected, closer monitoring
of treatment regimens, and more opportunities for discovery of complications
that might compromise long-term outcomes. However, additional time spent with
patients demands a large physician staff. Strengthening clinic PPC will be
very difficult with the dialysis population increasing as rapidly as it is.
For example, the number of PD patients of our unit increased to 360 from 60
over the past 5 years, but staffing (two doctors and one dietitian) has not
changed. During the weekly regular clinic, each doctor would have to see about
20–30 patients, and the dietitian, about 40–60 patients if every
patient visits once monthly. As Sullivan and colleagues reported, a higher
patient:renal dietitian ratio was associated with a lower quality of patient
care provided (10). In
addition, in view of the characteristics of PD therapy per
se—that is, a treatment performed in the patient's home, involving
more autonomy—patients living in rural and remote areas are more likely
to choose PD first in the future. Even in developed countries, it is difficult
to build up satellite hemodialysis units
(11), and available evidence
already shows that aboriginal PD patients in remote areas of Canada have an
adjusted risk of death similar to that of urban patients
(12). Limited medical
resources in rural and remote areas make it impossible to increase clinic PPC
frequency. Therefore, to effectively improve the quality of care, a method
other than strengthening clinic PPC must be found.
In our study, the disadvantages of low clinic PPC frequency may be offset
by contact with non-physician clinicians and by patient self-management in a
variety of approaches such as telephone, Internet, and meeting contacts. Our
clinical practice is aimed at providing patient-centered care that is
congruent with and responsive to the values, needs, and preferences of
patients (13).
Physicians, as one part of the therapy group often oversee medical records
and care plans, and consult with other non-physician clinicians including
nurses, dietitians, and technicians. Good physicians should share their
opinions and therapy decisions with non-physician clinicians during the
consultative process, because those staff members can serve to extend the
capacity of busy physicians, responding to patients' questions and concerns
(14). Currently, ward rounds
in internal medicine actually serve as the central marketplace for medical
communication, in which the knowledge of nurses is underrepresented
(15). Non-physician clinicians
have backgrounds, knowledge, and experiences that are different from those of
the physician. In collaboration with the physician, they can provide more
holistic care than physicians can provide alone—an approach that is
becoming a trend, as can be seen in the interdisciplinary health care
workforces in recent decades
(16,17).
In addition, patient-centered care also means that patients themselves are
increasingly being asked to take more responsibility for their health care and
health outcomes (18). The new
patient–physician relationship in chronic disease ideally involves
informed, proactive patients in partnership with their physicians. We
therefore educate PD patients, providing them with disease-related knowledge
through regular classes and group meetings. In every communication by
telephone and e-mail, self-efficacy and self-management are continuously
improved and a real partnership between our PD patients and our group is built
(19).
The present study showed that patients in the low-frequency PPC group had
significantly lower mean levels of Hb and higher levels of P. Anemia therapy
is a continuous quality improvement process that involves careful adjustment
of the doses of iron and erythropoietin according to iron deficiency status
(20). It is reasonable to
observe worse anemia control in patients with less clinic PPC. Serum P can be
viewed as a measure of patient adherence to diet and medications. More clinic
PPC may result in more discussion about the complications of
hyperphosphatemia, which may help remind patients to maintain an appropriate
low-P diet and to use P-lowering medications properly
(21).
The present study has some limitations. First, it was conducted in a single
PD center, and the case-mix characteristics may not have been representative
of a general PD population. Second, "integrative follow-up" is a
new concept, and it really needs more detailed study. We do not measure how
often the non-physician clinicians contact patients: telephone, Internet, and
group meeting contacts are under the control of the patients. Third, this is
not a randomized controlled study, whose conclusion might be more persuasive.
Fourth, all of the patients involved visited the clinic at least once every 6
months. A few patients who live far from the hospital (in suburbs or other
provinces) were excluded. We can not entirely preclude a selection bias.
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CONCLUSIONS
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Frequency of PPC did not predict outcome in PD patients in the context of
an integrative care strategy that includes contact by various means between
patients and both physician and non-physician clinicians, accompanied by an
applied self-care concept. However, anemia and hyperphosphatemia control need
to be strengthened in patients with low-frequency PPC. This finding provides
an opportunity for development of more home-care patient-centered PD therapy,
even in rural and remote areas of China.
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ACKNOWLEDGMENTS
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The authors express their appreciation to the patients and staff of the
peritoneal dialysis center of First Hospital, Peking University, for their
participation in this study. The study was funded by the National "211
project," Peking University EBM group (38-18). Author Dong Jie is
thanked for contributing to design and oversight of the study and drafting of
the paper. Author Zuo Li is thanked for contributing to drafting of the
paper.
This study was the basis of an oral presentation at the 2008 International
Society for Peritoneal Dialysis conference in Istanbul, Turkey.
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ABSTRACT
PATIENTS AND METHODS
