title: Augmented Nurse Care Management in CKD Stages 4 to 5: A Randomized Trial.
abstract: BACKGROUND
  Outcomes for patients with late-stage chronic kidney disease (CKD) in the United States are suboptimal. There is poor education and preparation for end-stage kidney disease, as well as a high rate of hospitalization in this group of patients.
  
  
  METHODS
  A randomized, parallel-group, 2-arm, controlled trial.
  
  
  METHODS
  The study was conducted at 3 sites: a clinic of an academic medical center, a public hospital academic clinic, and a community-based private practice. All participants had late-stage CKD (stages 4-5 CKD). Patients were excluded only if they had significant cognitive impairment.
  
  
  METHODS
  The care management intervention involved nurse care manager coordination aided by the use of a disease-based informatics system for monitoring patients' clinical status, enhancing CKD education, and facilitating preparation for end-stage kidney disease. The comparison control group received usual late-stage CKD care alone.
  
  
  RESULTS
  The primary outcome was rate of hospitalization.
  
  
  METHODS
  Rates of preemptive transplantation, home dialysis, hemodialysis (HD) starts without a hospitalization, and HD therapy initiation rates with catheters or with functioning accesses.
  
  
  RESULTS
  130 patients were randomly assigned. The hospitalization rate was significantly lower in the intervention group versus controls: 0.61 versus 0.92 per year, respectively (incidence rate ratio, 0.66; 95% CI, 0.43-0.99; P=0.04). Peritoneal dialysis or preemptive transplantation was the initial end-stage kidney disease treatment in 11 of 30 (37%) participants receiving the intervention versus 3 of 29 (10%) receiving usual care. Among HD starts, treatment was initiated without hospitalization in 11 of 19 (58%) participants in the intervention group versus 6 of 26 (23%) in the control group. At the time of HD therapy initiation, a catheter was present in 7 of 19 (37%) participants in the intervention group versus 18 of 26 (69%) in the control group. A functioning arteriovenous access was in place in 10 of 19 (53%) participants in the intervention group and 7 of 26 (27%) in the control group LIMITATIONS: Moderate sample size, limited geographic scope.
  
  
  CONCLUSIONS
  The augmented nurse care management intervention resulted in reduced hospitalizations in late-stage CKD and there were suggestions of improved end-stage kidney disease preparation. Given suboptimal outcomes in late-stage CKD, care management interventions could potentially improve patient outcomes.
authors.affiliation: Division of Kidney Diseases and Hypertension, Department of Medicine, North Shore University Hospital and Long Island Jewish Medical Center, Hofstra Northwell School of Medicine, Great Neck, NY. Electronic address: sfishbane@northwell.edu.
authors.forename: Steven
authors.initials: S
authors.lastname: Fishbane
authors.affiliation: Division of Kidney Diseases and Hypertension, Department of Medicine, North Shore University Hospital and Long Island Jewish Medical Center, Hofstra Northwell School of Medicine, Great Neck, NY.
authors.forename: Sofia
authors.initials: S
authors.lastname: Agoritsas
authors.affiliation: Division of Kidney Diseases and Hypertension, Department of Medicine, North Shore University Hospital and Long Island Jewish Medical Center, Hofstra Northwell School of Medicine, Great Neck, NY.
authors.forename: Alessandro
authors.initials: A
authors.lastname: Bellucci
authors.affiliation: Division of Kidney Diseases and Hypertension, Department of Medicine, North Shore University Hospital and Long Island Jewish Medical Center, Hofstra Northwell School of Medicine, Great Neck, NY.
authors.forename: Candice
authors.initials: C
authors.lastname: Halinski
authors.affiliation: Division of Kidney Diseases and Hypertension, Department of Medicine, North Shore University Hospital and Long Island Jewish Medical Center, Hofstra Northwell School of Medicine, Great Neck, NY.
authors.forename: Hitesh H
authors.initials: HH
authors.lastname: Shah
authors.affiliation: Division of Kidney Diseases and Hypertension, Department of Medicine, North Shore University Hospital and Long Island Jewish Medical Center, Hofstra Northwell School of Medicine, Great Neck, NY.
authors.forename: Vipul
authors.initials: V
authors.lastname: Sakhiya
authors.affiliation: Division of Nephrology, Department of Medicine, Nassau University Medical Center, East Meadow, NY.
authors.forename: Leah
authors.initials: L
authors.lastname: Balsam
mesh_terms: D000368:Aged; D005260:Female; D006801:Humans; D007676:Kidney Failure, Chronic / Q000451:nursing; D008297:Male; D008875:Middle Aged; D009736:Nursing Process; D051436:Renal Insufficiency, Chronic / Q000451:nursing*; D012720:Severity of Illness Index
keywords: Chronic kidney disease (CKD); RRT modality; care management; home dialysis; hospitalization; kidney transplantation; late-stage CKD; medical informatics; nurse care manager; patient education; peritoneal dialysis (PD); randomized controlled trial (RCT); renal replacement therapy (RRT); transition of care; vascular access