Kaiser Paulina, Pipitone Olivia, Franklin Anthony, Jackson Dixie R, Moore Elizabeth A, Dubuque Christopher R, Peralta Carmen A, De Mory Anthony C
Samaritan Health Services, Corvallis, OR, United States.
Cricket Health, San Francisco, CA, United States.
J Med Internet Res. 2020 Feb 12;22(2):e17194. doi: 10.2196/17194.
It is not well established whether a virtual multidisciplinary care program for persons with advanced chronic kidney disease (CKD) can improve their knowledge about their disease, increase their interest in home dialysis therapies, and result in more planned outpatient (versus inpatient) dialysis starts.
We aimed to evaluate the feasibility and preliminary associations of program participation with disease knowledge, home dialysis modality preference, and outpatient dialysis initiation among persons with advanced CKD in a community-based nephrology practice.
In a matched prospective cohort, we enrolled adults aged 18 to 85 years with at least two estimated glomerular filtration rates (eGFRs) of less than 30 mL/min/1.73 m2 into the Cricket Health program and compared them with controls receiving care at the same clinic, matched on age, gender, eGFR, and presence of heart failure and diabetes. The intervention included online education materials, a virtual multidisciplinary team (nurse, pharmacist, social worker, dietician), and patient mentors. Prespecified follow-up time was nine months with extended follow-up to allow adequate time to determine the dialysis start setting. CKD knowledge and dialysis modality choice were evaluated in a pre-post survey among intervention participants.
Thirty-seven participants were matched to 61 controls by age (mean 67.2, SD 10.4 versus mean 68.8, SD 9.5), prevalence of diabetes (54%, 20/37 versus 57%, 35/61), congestive heart failure (22%, 8/37 versus 25%, 15/61), and baseline eGFR (mean 19, SD 6 versus mean 21, SD 5 mL/min/1.73 m2), respectively. At nine-month follow-up, five patients in each group started dialysis (P=.62). Among program participants, 80% (4/5) started dialysis as an outpatient compared with 20% (1/5) of controls (OR 6.28, 95% CI 0.69-57.22). In extended follow-up (median 15.7, range 11.7 to 18.1 months), 19 of 98 patients started dialysis; 80% (8/10) of the intervention group patients started dialysis in the outpatient setting versus 22% (2/9) of control patients (hazard ratio 6.89, 95% CI 1.46-32.66). Compared to before participation, patients who completed the program had higher disease knowledge levels (mean 52%, SD 29% versus mean 94%, SD 14% of questions correct on knowledge-based survey, P<.001) and were more likely to choose a home modality as their first dialysis choice (36%, 7/22 versus 68%, 15/22, P=.047) after program completion.
The Cricket Health program can improve patient knowledge about CKD and increase interest in home dialysis modalities, and may increase the proportion of dialysis starts in the outpatient setting.
晚期慢性肾脏病（CKD）患者的虚拟多学科护理项目能否提高其对自身疾病的认知、增强其对家庭透析治疗的兴趣并使更多患者选择计划性门诊（而非住院）透析起始治疗，目前尚无定论。
我们旨在评估在社区肾脏科实践中，晚期CKD患者参与该项目的可行性，以及项目参与与疾病认知、家庭透析方式偏好和门诊透析起始治疗之间的初步关联。
在一项匹配的前瞻性队列研究中，我们将年龄在18至85岁、估算肾小球滤过率（eGFR）至少两次低于30 mL/min/1.73 m²的成年人纳入Cricket Health项目，并将他们与在同一诊所接受治疗的对照组进行比较，对照组在年龄、性别、eGFR以及是否存在心力衰竭和糖尿病方面进行了匹配。干预措施包括在线教育材料、虚拟多学科团队（护士、药剂师、社会工作者、营养师）以及患者导师。预定的随访时间为9个月，并进行延长随访，以便有足够时间确定透析起始治疗地点。在干预参与者的前后调查中评估CKD知识和透析方式选择。
37名参与者与61名对照组在年龄（平均67.2岁，标准差10.4岁对平均68.8岁，标准差9.5岁）、糖尿病患病率（54%，20/37对57%，35/61）、充血性心力衰竭（22%，8/37对25%，15/61）和基线eGFR（平均19，标准差6对平均21，标准差5 mL/min/1.73 m²）方面进行了匹配。在9个月的随访中，每组有5名患者开始透析（P = 0.62）。在项目参与者中，80%（4/5）以门诊方式开始透析，而对照组为20%（1/5）（比值比6.28，95%置信区间0.69 - 57.22）。在延长随访（中位数15.7个月，范围11.7至18.1个月）中，98名患者中有19名开始透析；干预组80%（8/10）的患者在门诊开始透析，而对照组为22%（2/9）（风险比6.89，95%置信区间1.46 - 32.66）。与参与项目前相比，完成项目的患者疾病知识水平更高（基于知识的调查中正确回答问题的平均比例分别为52%，标准差29%对94%，标准差14%，P < 0.001），并且在项目完成后更有可能选择家庭透析方式作为首选透析方式（36%，7/22对68%，15/22，P = 0.047）。
Cricket Health项目可以提高患者对CKD的认知，增加对家庭透析方式的兴趣，并可能提高门诊透析起始治疗的比例。
