| Author: | Tam, Mee Ling Bonnie |
| Title: | Effects of a transitional renal palliative programme for patients with end-stage renal failure : a pilot randomised controlled trial |
| Advisors: | Wong, Frances (SN) |
| Degree: | Ph.D. |
| Year: | 2022 |
| Subject: | Kidneys -- Diseases -- Patients -- Care Chronic renal failure -- Patients -- Care Kidneys -- Diseases -- Palliative treatment Chronic renal failure -- Palliative treatment Hong Kong Polytechnic University -- Dissertations |
| Department: | School of Nursing |
| Pages: | xxv, 414 pages : color illustrations |
| Language: | English |
| Abstract: | Background: Globally, chronic kidney disease (CKD) is a common prevalence with a mortality rate of 33.7%. In Hong Kong, end-stage renal failure (ESRF) accounted for the 6th leading cause of death. Previous studies have shown the positive effects of palliative care with palliation of symptoms and improved quality of life for cancer patients. Recently there have been recommendations to extend transitional palliative care to end-stage organ failure patients including ESRF patients. Despite renal palliative service being available to end-stage renal failure patients, empirical evidence is not available for reference. This study was therefore launched to fill this service and knowledge gap. Aims: The study aimed to examine the feasibility of the study and preliminary effects of the transitional renal palliative programme (TRPP) among patients with ESRF. Methods: In the first stage of the study, a 4Cs nurse-led multidisciplinary support TRPP was developed based on research evidence, clinical expertise and patient preference. It included three sets of standardised protocols: (1) pre-discharge assessment and planning, (2) post-discharge follow-up and (3) assessment and surveillance. A pilot randomised controlled trial was conducted in the second stage with participants recruited from August 2014 to September 2016 for palliative care in a Renal Unit of a regional hospital in Hong Kong. All participants received customary palliative care and the intervention group underwent the TRPP which had bi-monthly home visits and weekly telephone follow-ups in addition to customary care. The primary outcome measures included non-scheduled readmission, length of hospital stay, and Accident and Emergency Department attendance, and secondary outcomes included health-related quality of life, symptom manifestation, palliative performance scale, anxiety and depression, patient satisfaction and burden of caregivers and were assessed at baseline (T0), and at 1, 3, 6 and 12 month(s) after recruitment into the study (T1, T3, T6 and T12). Chi-square or fisher's exact test, Mann Whitney U test or independent t-test and repeated measure of analysis of variance were applied where appropriate in testing the outcomes of the TRPP. Missing data was managed by multiple imputations. Intention-to-treat (ITT) analysis and per-protocol (PP) analysis were performed. Alongside the pilot trial, continued face-to-face interviews were conducted to explore the experience of patients with ESRF and their caregivers regarding the transitional palliative care program and thematic analysis was conducted for qualitative data. Results: This study was undertaken according to the study plan with approximately 6 patients referred per month, 48.73% eligibility rate, and 52.63% attrition rate. A total of 76 patients with ESRF were randomly assigned to the intervention group (n=38) and control group (n=38). The baseline demographic characteristics of the two groups were comparable. The results of ITT analysis and PP analysis were similar. The chi-square test showed the intervention group had fewer unplanned readmission rate at T6 (control: 39.47% vs intervention: 18.42%, χ²=7.67, p=0.02) and at T12 (control: 31.58 % vs intervention: 26.32%, χ²=12.22, p=0.002. The Mann Whitney U test revealed significant differences in the intervention group with shortened length of hospitalisation at T6 (p=0.04) and T12 (p<0.01), and significant fewer Accident and Emergency Department visits at T1 (p<0.001), T3 (p<0.001), T6 (p<0.001) and T12 (p=0.02) when compared with the control group. The intervention group further revealed better secondary outcome measures than those in the control group. Employing ITT analyses, the 2-ways repeated measure of analysis of variance showed significant interaction effects between group and time in all the five domains of the Kidney Disease Quality of Life-36, Hong Kong (including Symptom Problem List, Effects of Kidney Disease, Burden of Kidney Disease, Physical Composite Score, and Mental Composite Score; all ps<0.001), Palliative Performance Scale (p<0.001), Hospital Anxiety and Depression Scale - Anxiety (p=0.01), Patient Satisfaction (p=0.001) and ZBI (p=0.01), while insignificant interactions were noted in Symptoms Manifestation (p=0.08), and Hospital Anxiety and Depression Scale - Depression (p=0.05). Participants in the intervention groups perceived improvement in quality of life, physical function, satisfaction with care and less degree of burden on informal caregivers. Regarding the qualitative information from the patients and their caregivers, thematic analysis of their experiences was aggregated into four themes: (1) positive value of TRPP, (2) preparation of self-management of ESRF, (3) support of nurse case manager and (4) scope of services. Participants appraised transitional palliative care positively. Conclusion: The study results provide strong support for the feasibility and acceptability of the study design, instrumentation and interventions. This pilot study provides the groundwork for a future main study and has demonstrated that the nurse-led transitional home-based palliative care produced significant effects in reducing the utilisation of health services. Furthermore, this trial exhibits improved patient outcomes in terms of improved quality of life, control of symptom intensity, improved functional status, less anxiety and depression, increased satisfaction rate, and less burden on the informal caregiver. The encouraging results of this trial show healthcare providers that TRPP benefits ESRF patients in terms of improved clinical outcomes and fewer healthcare expenditures. The provision of current strategies is the future trend of care. The limitations in this trial include the high attrition rate due to the high mortality, which suggests modification of the study duration for a future main study. A large trial using a similar methodology and instrumentation would help produce stronger evidence in supporting the effectiveness of the TRPP in clinical practice. To conclude, the encouraging preliminary findings of the pilot study could inform the renal specialty of the integration of transitional care into conventional renal care for the population of ESRF patients with non-dialysis therapy. |
| Rights: | All rights reserved |
| Access: | open access |
Copyright Undertaking
As a bona fide Library user, I declare that:
- I will abide by the rules and legal ordinances governing copyright regarding the use of the Database.
- I will use the Database for the purpose of my research or private study only and not for circulation or further reproduction or any other purpose.
- I agree to indemnify and hold the University harmless from and against any loss, damage, cost, liability or expenses arising from copyright infringement or unauthorized usage.
By downloading any item(s) listed above, you acknowledge that you have read and understood the copyright undertaking as stated above, and agree to be bound by all of its terms.
Please use this identifier to cite or link to this item:
https://theses.lib.polyu.edu.hk/handle/200/11837