Dataset Information

Patient Navigators for CKD and Kidney Failure: A Systematic Review.

ABSTRACT:

Rationale & objective

To what degree and how patient navigators improve clinical outcomes for patients with chronic kidney disease (CKD) and kidney failure is uncertain. We performed a systematic review to summarize patient navigator program design, evidence, and implementation in kidney disease.

Study design

A search strategy was developed for randomized controlled trials and observational studies that evaluated the impact of navigators on outcomes in the setting of CKD and kidney failure. Articles were identified from various databases. Two reviewers independently screened the articles and identified those meeting the inclusion criteria.

Setting & participants

Patients with CKD or kidney failure (in-center hemodialysis, peritoneal dialysis, home hemodialysis, or kidney transplantation).

Selection criteria for studies

Studies that compared patient navigators with a control, without limits on size, duration, setting, or language. Studies focusing solely on patient education were excluded.

Data extraction

Data were abstracted from full texts and risk of bias was assessed.

Analytical approach

No meta-analysis was performed.

Results

Of 3,371 citations, 17 articles met the inclusion criteria including 14 original studies. Navigators came from various healthcare backgrounds including nursing (n=6), social worker (n=2), medical interpreter (n=1), research (n=1), and also included kidney transplant recipients (n=2) and non-medical individuals (n=2). Navigators focused mostly on education (n=9) and support (n = 6). Navigators were used for patients with CKD (n=5), peritoneal dialysis (n=2), in-center hemodialysis (n=4), kidney transplantation (n=2), but not home hemodialysis. Navigators improved transplant workup and listing, peritoneal dialysis utilization, and patient knowledge.

Limitations

Many studies did not show benefits across other outcomes, were at a high risk of bias, and none reported cost-effectiveness or patient-reported experience measures.

Conclusions

Navigators improve some health outcomes for CKD but there was heterogeneity in their structure and function. High-quality randomized controlled trials are needed to evaluate navigator program efficacy and cost-effectiveness.

SUBMITTER: Taha A

PROVIDER: S-EPMC9516458 | biostudies-literature | 2022 Oct

REPOSITORIES: biostudies-literature

ACCESS DATA

Publications

Patient Navigators for CKD and Kidney Failure: A Systematic Review.

Taha Ali A Iman Yasmin Y Hingwala Jay J Askin Nicole N Mysore Priyanka P Rigatto Claudio C Bohm Clara C Komenda Paul P Tangri Navdeep N Collister David D

Kidney medicine 20220824 10

<h4>Rationale & objective</h4>To what degree and how patient navigators improve clinical outcomes for patients with chronic kidney disease (CKD) and kidney failure is uncertain. We performed a systematic review to summarize patient navigator program design, evidence, and implementation in kidney disease.<h4>Study design</h4>A search strategy was developed for randomized controlled trials and observational studies that evaluated the impact of navigators on outcomes in the setting of CKD and kidne ...[more]

PMID: 36185707

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Project description:Background and objectivesPatient navigators and enhanced personal health records improve the quality of health care delivered in other disease states. We aimed to develop a navigator program for patients with CKD and an electronic health record-based enhanced personal health record to disseminate CKD stage-specific goals of care and education. We also conducted a pragmatic randomized clinical trial to compare the effect of a navigator program for patients with CKD with enhanced personal health record and compare their combination compared with usual care among patients with CKD stage 3b/4.Design, setting, participants, & measurementsTwo hundred and nine patients from six outpatient clinics (in both primary care and nephrology settings) were randomized in a 2×2 factorial design into four-study groups: (1) enhanced personal health record only, (2) patient navigator only, (3) both, and (4) usual care (control) group. Primary outcome measure was the change in eGFR over a 2-year follow-up period. Secondary outcome measures included acquisition of appropriate CKD-related laboratory measures, specialty referrals, and hospitalization rates.ResultsMedian age of the study population was 68 years old, and 75% were white. At study entry, 54% of patients were followed by nephrologists, and 88% were on renin-angiotensin system blockers. After a 2-year follow-up, rate of decline in eGFR was similar across the four groups (P=0.19). Measurements of CKD-related laboratory parameters were not significantly different among the groups. Furthermore, referral for dialysis education and vascular access placement, emergency room visits, and hospitalization rates were not statistically significant different between the groups.ConclusionsWe successfully developed a patient navigator program and an enhanced personal health record for the CKD population. However, there were no differences in eGFR decline and other outcomes among the study groups. Larger and long-term studies along with cost-effectiveness analyses are needed to evaluate the role of patient navigators and patient education through an enhanced personal health record in those with CKD.

Project description:CKD is common in patients with heart failure, associated with high mortality and morbidity, which is even higher in people undergoing long-term dialysis. Despite increasing use of evidence-based drug and device therapy in patients with heart failure in the general population, patients with CKD have not benefitted. This review discusses prevalence and evidence of kidney replacement, device, and drug therapies for heart failure in CKD. Evidence for treatment with β-blockers, angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, angiotensin receptor neprilysin inhibitors, and sodium-glucose cotransporter inhibitors in mild-to-moderate CKD has emerged from general population studies in patients with heart failure with reduced ejection fraction (HFrEF). β-Blockers have been shown to improve outcomes in patients with HFrEF in all stages of CKD, including patients on dialysis. However, studies of HFrEF selected patients with creatinine <2.5 mg/dl for ACE inhibitors, <3.0 mg/dl for angiotensin-receptor blockers, and <2.5 mg/dl for mineralocorticoid receptor antagonists, excluding patients with severe CKD. Angiotensin receptor neprilysin inhibitor therapy was successfully used in randomized trials in patients with eGFR as low as 20 ml/min per 1.73 m2 Hence, the benefits of renin-angiotensin-aldosterone axis inhibitor therapy in patients with mild-to-moderate CKD have been demonstrated, yet such therapy is not used in all suitable patients because of fear of hyperkalemia and worsening kidney function. Sodium-glucose cotransporter inhibitor therapy improved mortality and hospitalization in patients with HFrEF and CKD stages 3 and 4 (eGFR>20 ml/min per 1.73 m2). High-dose and combination diuretic therapy, often necessary, may be complicated with worsening kidney function and electrolyte imbalances, but has been used successfully in patients with CKD stages 3 and 4. Intravenous iron improved symptoms in patients with heart failure and CKD stage 3; and high-dose iron reduced heart failure hospitalizations by 44% in patients on dialysis. Cardiac resynchronization therapy reduced death and hospitalizations in patients with heart failure and CKD stage 3. Peritoneal dialysis in patients with symptomatic fluid overload improved symptoms and prevented hospital admissions. Evidence suggests that combined cardiology-nephrology clinics may help improve management of patients with HFrEF and CKD. A multidisciplinary approach may be necessary for implementation of evidence-based therapy.

Project description:OBJECTIVE:Patient navigators are a promising mechanism to link patients with primary care. While navigators have been used in population health promotion and prevention programmes, their impact on access to primary care is not clear. The aim of this scoping review was to examine the use of patient navigators to facilitate access to primary care and how they were defined and described, their components and the extent to which they were patient centred. SETTING AND PARTICIPANTS:We used the Arksey and O'Malley scoping review method. Searches were conducted in MEDLINE, Embase, ProQuest Medical, other key databases and grey literature for studies reported in English from January 2000 to April 2016. We defined a patient navigator as a person or process creating a connection or link between a person needing primary care and a primary care provider. Our target population was people without a regular source of, affiliation or connection with primary care. Studies were included if they reported on participants who were connected to primary care by patient navigation and attended or made an appointment with a primary care provider. Data analysis involved descriptive numerical summaries and content analysis. RESULTS:Twenty studies were included in the final scoping review. Most studies referred to 'patient navigator' or 'navigation' as the mechanism of connection to primary care. As such, we grouped the components according to Freeman's nine-principle framework of patient navigation. Seventeen studies included elements of patient-centred care: informed and involved patient, receptive and responsive health professionals and a coordinated, supportive healthcare environment. CONCLUSIONS:Patient navigators may assist to connect people requiring primary care to appropriate providers and extend the concept of patient-centred care across different healthcare settings. Navigation requires further study to determine impact and cost-effectiveness and explore the experience of patients and their families.

Project description:BackgroundLow urine potassium excretion, as a surrogate for dietary potassium intake, is associated with higher risk for hypertension and cardiovascular disease in a general population. Few studies have investigated the relationship of urine potassium with clinical outcomes in chronic kidney disease (CKD).Study designLongitudinal cohort study.Setting & participantsThe MDRD (Modification of Diet in Renal Disease) Study was a randomized controlled trial (N = 840) conducted in 1989 to 1993 to examine the effects of blood pressure control and dietary protein restriction on kidney disease progression in adults aged 18 to 70 years with CKD stages 2 to 4. This post hoc analysis included 812 participants.PredictorThe primary predictor variable was 24-hour urine potassium excretion, measured at baseline and at multiple time points (presented as time-updated average urine potassium excretion).OutcomesKidney failure, defined as initiation of dialysis therapy or transplantation, was determined from US Renal Data System data. All-cause mortality was assessed using the National Death Index.ResultsMedian follow-up for kidney failure was 6.1 (IQR, 3.5-11.7) years, with 9 events/100 patient-years. Median all-cause mortality follow-up was 19.2 (IQR, 10.8-20.6) years, with 3 deaths/100 patient-years. Baseline mean urine potassium excretion was 2.39±0.89 (SD) g/d. Each 1-SD higher baseline urine potassium level was associated with an adjusted HR of 0.95 (95% CI, 0.87-1.04) for kidney failure and 0.83 (95% CI, 0.74-0.94) for all-cause mortality. Results were consistent using time-updated average urine potassium measurements.LimitationsAnalyses were performed using urine potassium excretion as a surrogate for dietary potassium intake. Results are obtained from a primarily young, nondiabetic, and advanced CKD population and may not be generalizable to the general CKD population.ConclusionsHigher urine potassium excretion was associated with lower risk for all-cause mortality, but not kidney failure.

Project description:BackgroundPatient navigators have been introduced across various countries to enable timely access to healthcare services and to ensure completion of diagnosis and follow-up of care. There is an increasing evidence on the the role of patient navigation for patients and healthcare systems. The aim of this study was to analyse the evidence on patient navigation interventions in ambulatory care and to evaluate their effects on individuals and health system outcomes.MethodsAn overview of reviews was conducted, following a prespecified protocol. All patients in ambulatory care or transitional care setting were included in this review as long as it was related to the role of patient navigators. The study analysed patient navigators covering a wide range of health professionals such as physicians, nurses, pharmacists, social workers and lay health workers or community-based workers with no or very limited training. Studies including patient-related measures and health system-related outcomes were eligible for inclusion. A rigorous search was performed in multiple data bases. After reaching a high inter-rater agreement of 0.86, title and abstract screening was independently performed. Of an initial 14,248 search results and an additional 62 articles identified through the snowballing approach, a total of 7159 hits were eligible for title/abstract screening. 679 articles were included for full-text screening.ResultsEleven systematic reviews were included covering various patient navigation intervention in cancer care, disease screening, transitional care and for various chronic conditions and multimorbidity. Nine systematic reviews primarily tailored services to ethnic minorities or other disadvantaged groups. Patient navigators performed tasks such as providing education and counselling, translations, home visits, outreach, scheduling of appointments and follow-up. Eight reviews identified positive outcomes in expanding access to care, in particular for vulnerable patient groups. Two reviews on patient navigation in transitional care reported improved patient outcomes, hospital readmission rates and mixed evidence on quality of life and emergency department visits. Two reviews demonstrated improved patient outcomes for persons with various chronic conditions and multimorbidity.ConclusionsPatient navigators were shown to expand access to screenings and health services for vulnerable patients or population groups with chronic conditions who tend to underuse health services.

Project description:BackgroundChronic kidney disease is a global problem characterized by a progressive decrease in kidney function with associated symptoms. A better understanding of these symptoms could lead to the development of personalized strategies.ObjectiveThis systematic review aims to describe the clusters of symptoms in kidney failure and categorize them according to their time of onset and how disabling they are for patients.DesignA systematic review was carried out.MethodsThis systematic review was conducted according to the PRISMA declaration standards. The search engines used were initially limited to WOS, Embase, and PubMed, and they were employed between November 2022 and January 2023. In addition, the bibliographic search was supplemented with databases of the grey literature, such as OpenGrey, in May 2023. The following inclusion criteria were established: cross-sectional studies, studies on adult populations, and studies dealing with clusters of symptoms associated with kidney failure. Before an article was definitively selected, the checklist of the STROBE initiative, with a maximum of 22 points, was applied, assessing the quality of cross-sectional articles. Articles were selected independently and blinded by two researchers, and a third researcher was involved in case of disagreement.ResultsAfter carrying out the bibliographic search, we found that eight articles, out of the 46 articles that were evaluated, fully met the inclusion criteria. Two tables were made, which include important information, such as the participants' profiles or the way the authors extracted a cluster of symptoms.LimitationsThe main area for improvement is that it was not possible to perform a meta-analysis due to the methodology used in the articles analysed. Constraining the selection of articles to those written in Spanish or English could be a limitation as not all articles dealing with symptom clusters in kidney failure were considered.ConclusionsCommon symptoms in clusters of symptoms in kidney failure were nausea or vomiting (gastrointestinal problems), fatigue or muscle weakness (neuromuscular symptoms/problems), low interest in sex or difficulty feeling sexually excited (sexual symptoms), dry skin or skin itching (skin problems), lack of appetite, feeling squeezed, feeling weak or dizzy and difficulty breathing (uraemic), fatigue or muscle weakness (energy/vitality), and chest pain (cardiac-related problems). Providing treatment based on clusters of symptoms would benefit the patient more than providing treatment based on isolated symptoms. The identification of symptom clusters in kidney failure has clinical relevance, and this research could facilitate the development of adequate intervention strategies, simplifying the treatment offered to patients and even reducing the side effects of treatments.

Dataset Information

Patient Navigators for CKD and Kidney Failure: A Systematic Review.

Rationale & objective

Study design

Setting & participants

Selection criteria for studies

Data extraction

Analytical approach

Results

Limitations

Conclusions

Publications

Patient Navigators for CKD and Kidney Failure: A Systematic Review.

Similar Datasets

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