Selzman Institute for Kidney Health, Section of Nephrology, Department of Medicine, Baylor College of Medicine, Houston, Texas.
Section of Nephrology, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas.
Clin J Am Soc Nephrol. 2017 Sep 7;12(9):1418-1427. doi: 10.2215/CJN.02100217. Epub 2017 Aug 4.
Patient 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, & MEASUREMENTS: Two 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: () enhanced personal health record only, () patient navigator only, () both, and () 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.
Median 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 (=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.
We 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.
患者导航员和增强型个人健康记录可提高其他疾病状态下的医疗质量。我们旨在为慢性肾脏病（CKD）患者开发一个导航员计划，并建立一个基于电子健康记录的增强型个人健康记录，以传播 CKD 特定阶段的治疗目标和教育内容。我们还开展了一项实用的随机临床试验，比较 CKD 患者导航员计划和增强型个人健康记录的效果，并比较 CKD 3b/4 期患者中两者的联合应用与常规护理的效果。
设计、设置、参与者和测量：从六个门诊诊所（包括初级保健和肾脏病学环境）招募了 209 名患者，采用 2×2 析因设计将他们随机分为四组进行研究：（1）仅增强型个人健康记录，（2）仅患者导航员，（3）两者，（4）常规护理（对照组）。主要结局指标是 2 年随访期间 eGFR 的变化。次要结局指标包括获得适当的 CKD 相关实验室检测结果、专科转介和住院率。
研究人群的中位年龄为 68 岁，75%为白人。研究开始时，54%的患者由肾病医生随访，88%的患者使用肾素-血管紧张素系统阻滞剂。经过 2 年的随访，四组患者的 eGFR 下降率相似（=0.19）。四组患者的 CKD 相关实验室参数测量值无显著差异。此外，透析教育和血管通路安置、急诊就诊和住院率在各组之间也无统计学差异。
我们成功开发了用于 CKD 人群的患者导航员计划和增强型个人健康记录。然而，研究组之间在 eGFR 下降和其他结局方面没有差异。需要开展更大规模和长期的研究，并进行成本效益分析，以评估患者导航员和通过增强型个人健康记录进行患者教育在 CKD 患者中的作用。
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