Review of predialysis education programs: a need for standardization

Figures & data

Figure 1 Flowchart of literature selection.

Table 1 Studies evaluating predialysis education programs: design, outcome, and summary of results

Author	Year	Country	Study design	Patient numbers	Patient characteristics	Summary of results
Agraharkar et al^Citation29	2003	USA	Patient survey 2001–2002	136 (all received education)	Age unknown, CKD IV–V, new patients on dialysis	Capture rate home dialysis (PD and HHD): 13% in 2001/2002, which is 117% growth as compared to 2000/2001.
Chanouzas et al^Citation30	2012	UK	Patient survey	118 (questionnaires returned, 49%)	CKD IV–V, incident predialysis patients	20% of patients had chosen PD. 50% of patients choosing PD attended a formal education day vs 33% of HD patients.
Cho et al^Citation31	2012	Korea	Retrospective cohort 2007–2008	298 (149 in [intervention = education] and control group)	Mean age 57.8 years, predialysis patients, eGFR 17.3 mL/min per 1.73 m^2	Intervention group had significantly less unplanned urgent dialysis (8.7% vs 24.2%); shortened hospital days (2.16 vs 5.05 days/patient per year), less cardiac events (2.7% vs 9.4%), and less infections (4.0% vs 12.1%). No difference in modality choice.
Goovaerts et al^Citation33	2005	Belgium	Retrospective review patient files 1994–2000	185 (all received predialysis education)	CKD IV–V, mean age 53 years	Eight patients preemptive transplantation, 177 on dialysis: 75 (40%) in-center HD, 102 patients self-care modality: 55 (31%) PD, 30 (16%) self-care dialysis in satellite unit, 17 (9%) home HD.
Gomez et al^Citation32	1999	Spain	Multicenter patient survey 1996–1997	174 (86 informed, 88 uninformed patients)	Mean age 55.8 years, any patient in predialysis program	Informed patients: 57% chose hemodialysis, 31.4% CAPD, 11.6% APD. Uninformed patients: 83% hemodialysis, 13.6% chose CAPD, 3.4% chose APD.
King et al^Citation34	2008	USA	Patient survey 1994–2006	1,844 patients	Median age 61 years, 82% not yet on dialysis, CKD stage unknown	Significant change in PD selection: 30% preferred PD before the education, 46% selected PD after education. Significant knowledge gains. No significant changes in feelings of hope and fear.
Klang et al^Citation36	1999	Sweden	Intervention study. Pre and post- dialysis design, intervention is predialysis education 1991–1993	56 (28 intervention, 28 control group)	CKD IV–V, mean age: 54 years treatment group, 58 years control group	Significantly more patients in the intervention group stated that they had sufficient knowledge to participate in choosing dialysis modality. And they were significantly more informed in the post-education evaluation than in the pretest.
Klang et al^Citation35	1998	Sweden	Intervention study. Pre- post (dialysis) design, intervention is predialysis education 1991–1993	56 (28 intervention, 28 control group)	CKD IV–V, mean age: 54 years treatment group, 58 years control group	No significant differences in symptoms, duration of kidney disease, choice of dialysis treatment, cause of renal disease, symptoms, or overall health. The intervention group scored significantly better in terms of mood, less mobility problems, less functional disabilities, and lower levels of anxiety.
Lacson et al^Citation37	2011	USA	Observational cohort 2006–2008	30,217 patients of which 3,165 exposed to educational program	Mean age 63 years, CKD III–V	Educational program group was significantly more likely to select PD (25.2% vs 4.1%; adjusted OR 5.13), and they had a significant better survival rate (adjusted HR 0.61).
Levin et al^Citation38	1997	Canada	Prospective cohort study 1992–1995	76 (37 exposed to educational program, 39 standard care)	CKD III–V, age unknown	53% of the educational program group chose PD compared to 42% in the control group (not significant), and they had significantly less hospital days (6.5 vs 13.5). The educational-program group had better biochemical markers: blood pressure, calcium, phosphate, and anemia.
Little et al^Citation39	2001	UK	Patient survey 1992–1998	254 (165 counseled before commencing dialysis; 89 after)	CKD V, mean age 62.2 years, patients starting dialysis or just on dialysis	50.9% of patients educated/counseled before starting dialysis chose PD vs 34.8% of patients who received education after commencing dialysis.
Manns et al^Citation40	2005	Canada	Randomized trial 2003	70 randomized patients Two-phase patient-centered educational intervention vs standard care and education	CKD III–IV, median age 64 years	82.1% of the intervention group chose SCD vs 50% of the control group. There was no increase in patients choosing SCD after receiving books and video. The small group education session was the only statistically significant factor in selecting SCD.
McLaughlin et al^Citation41	2008	Canada	Randomized trial 2003 (same as previous study)	70 randomized patients Two-phase patient-centered educational intervention vs standard care and education	CKD III–IV, median age 64 years	Freedom, lifestyle, and control were identified as three reasons to engage in SCD. Patients who received the educational intervention were more likely to perceive freedom and control as advantages and were more likely to select SCD.
Pagels et al^Citation42	2000	Sweden	Observational cohort 2004	223 (70 exposed to nurse-led clinics, 153 comparison group)	CKD IV–V, mean age 65.5 years	52% (n=11) of the nurse-led clinics group initiated home dialysis (HHD: n=4, PD: n=7) as compared to 33% in the comparison group.
Piccoli^Citation43	2006	Italy	Questionnaire 1999	50 (18 followed educational program)	Mean age 62.9 years	12 of 18 patients (66%) who followed the education program chose home dialysis. Of another 31 patients who started dialysis in the center, 13 (42%) chose PD, 3 (10%) HHD, and 15 (48%) chose hospital dialysis.
Rasgon et al^Citation44	1996	USA	Patient records review 1995	30 patients on home dialysis (2 HHD, 28 CAPD)	Mean age 46.8 years, CKD stage not mentioned	74% (14 out of 19) of employed patients maintained their employment status after initiating home RRT.
Ribitsch et al^Citation45	2013	Austria	Retrospective cohort study 2004–2008	227 patients (70 received predialysis education, 152 did not)	Mean age 57.5 years education group, 56 years others CKD V	In the group receiving education, 54.3% started with PD vs 28% in the comparison group; in the education group, 45.7% started with HD vs 72% among the standard-care comparators.
Rioux et al^Citation46	2011	Canada	Retrospective observational cohort 2005–2009	228 patients (all receiving multimedia education)	Mean age 58 years, emergency start renal therapy, CKD V	35% of all acute starters adopted home dialysis after the implementation of the in-hospital education program vs 13% before the program.
Watson^Citation47	2008	Canada	Observational study: pre and post- comparison advanced practice nurse 26 months	119 on chronic dialysis	CKD V	The proportion of patients on in-center dialysis was reduced from 87% to 33% after the intervention, and the proportion of patients on home dialysis increased from 13% to 67%.

Abbreviations: APD, automated PD; CAPD, continuous ambulatory PD; CKD, chronic kidney disease; eGFR, estimated glomerular filtration rate; HD, hemodialysis; HHD, home HD; HR, hazard ratio; PD, peritoneal dialysis; OR, odds ratio; RRT, renal replacement therapy; SCD, self-care dialysis.

Table 2 Summary description of predialysis educational programs evaluated in (quasi-) experimental or observational studies

Author	Year	Country	Educational program
Agraharkar et al^Citation29	2003	USA	Predialysis option education:
			• Meet with nephrologist, options explained.
			• Dialysis education by home dialysis coordinator (includes demonstration of PD on mannequin), video provided.
			• Meeting with current home dialysis patients.
			• Disposition meeting with multidisciplinary group for patient and family.
Chanouzas et al^Citation30	2012	UK	Standard pre-dialysis education program:
			• When GFR <25 mL/min, meeting with the kidney failure support team. Home visit is arranged.
			• Home visit: visual, verbal, and written formats (leaflets, booklets, and DVDs). All modalities are described in detail. Visits typically last 2–4 hours. Interpreter present if needed and family advised to be present.
			• Further education is offered at home if the patient is still uncertain.
			• Invitations to PD and HD unit to meet patients and nurses. Option to meet expert patients.
			• A formal education day every 3 months: half-day workshop on lifestyle and dietary modifications for each modality.
			• All patients seen within 4 weeks to discuss modality choice, and encouraged to come to a decision within 3 months.
Cho et al^Citation31	2012	Korea	Multidisciplinary predialysis education:
			• Group session by multidisciplinary team (2 hours). Education on: normal kidney function; pathophysiological alterations in CKD; nutritional and medical treatment; and RRT options. Multidisciplinary team.
			• Individual session by nurse and dietician (1.5–2 hours): patient and family; slide presentation on diet and RRT options (benefits, complications, and outcomes); video on different RRT choices. Dietician prescribes diet, take home booklets.
Goovaerts et al^Citation33	2005	Belgium	Predialysis education program for all patients with a GFR of <25 mL/min:
			• PDEP run by a team of eight nurses. Patients are informed on an individual basis.
			• Watch three in-house videos (one on each, HD, CAPD, and APD) (60 minutes in total).
			• Patients receive a brochure summarizing key points, are invited to speak with other patients on the different RRTs, and can visit centers if they wish.
			• Contact with a social worker and dietician is arranged.
			• The patient meets again with the nephrologist where a final decision on treatment is usually made.
Gomez et al^Citation32	1999	Spain	Standardized information package from Baxter Healthcare:
			• First appointment. Flip chart explaining treatment options is shown. Patient is given guidebook to read at home.
			• Second appointment. Starts by discussing and clarifying doubts the patient may have, answering questions. Video is shown. It is also recommended that the patient sees how the various techniques of dialysis are carried out in practice.
King et al^Citation34	2008	USA	Statewide kidney education program. Multidisciplinary education to patients prior to starting dialysis as well as to patients who wish to switch modality:
			• Six classes of 60–75 minutes each on the following topics: 1) introduction to kidney disease; 2) diet and kidney disease; 3) financing and coping with kidney disease; 4) hemodialysis; 5) peritoneal dialysis; and 6) kidney transplant.
			• Facilitators: social worker, various registered nurses, dietician, patients, and their families.
Klang et al^Citation36	1999	Sweden	Specific educational salutogenic program based on relationship between health, stress and coping.^Citation67
			• Four sessions (2 hours each) of group teaching with a classroom approach, covering one theme per session.
			• Themes: renal disease and dietary management; active renal replacement therapies; physical exercise training; and possible impact of renal failure on finances, family, and social life.
			For each series, 5–7 patients (of similar age) were invited to attend along with a relative. Patients were divided into three groups based on age: 1) young adults; 2) middle-aged; and 3) elderly. Throughout the program, the patients and their relatives had established contact with the nephrology team, consisting of a physician, a specialist-nurse, a clinical nutritionist, a physiotherapist, and a clinical social worker.
Klang et al^Citation35	1998	Sweden	Same as the above
Lacson et al^Citation37	2011	USA	Treatment option education: a multiple-touch program.
			• Initial education completed in a single group class session.
			• With patient consent, followed up by contact at 30, 90, and 180 days thereafter to: 1) review treatment options; 2) inquire about each patient’s kidney function/status and, if appropriate, dialysis access planning; and 3) provide feedback to the referring physician.
Levin et al^Citation38	1997	Canada	All patients were referred for a formal orientation to dialysis sessions of 2–3 hours delivered by a nurse educator and social worker. Session consisted of an educational video; a standardized discussion of RRT options; demonstration of PD and HD techniques; and discussion of no treatment.
			In addition, the educational group following the multidisciplinary predialysis care clinic for CKD patients followed a predialysis clinic which included: discussions about renal function, blood pressure, bone disease, and diet therapy, delivered in a stepwise fashion over the course of multiple visits.
			Frequency of visits and lab tests determined by CKD stage and severity.
			Initial visit lasted 3 hours, after that, visits are 1.5 hours, every 2, 3, or 6 months depending on CKD stage.
Little et al^Citation39	2001	UK	Modality-choice education program of Birmingham dialysis center:
			• At initial interview written information on CAPD and HD.
			• At follow-up: more detailed counseling and assessment. Lasts 1–2 hours. Video package is provided in addition to verbal and written materials.
			• Patients given tour of HD unit and invited to discuss dialysis with HD and CAPD patients.
			• Patient’s initial modality choice recorded and a follow-up telephone call scheduled. Additional follow-up and counseling arranged as required.
Manns et al^Citation40	2005	Canada	In addition to multidisciplinary care, two-phase education: phase1: education materials, phase 2: small group problem solving education session. Timetable phase 2:
			• (10 minutes) introductions, overview, and goals of the course (nurse facilitator).
			• (10 minutes) introduction of topic: self-care dialysis (physician facilitator).
			• (20 minutes) brainstorming session (physician facilitator).
			• (20 minutes) what type of dialysis (patients discuss in small groups).
			• (10 minutes) group presentations (patient presenters).
			• (10 minutes) video presentation (nurse).
			• Feedback for the course and close (physician).
McLaughlin et al^Citation41	2008	Canada	Same as the above
Pagels et al^Citation42	2008	Sweden	Nurse-led educational clinics (duration, approximately 1 hour) in conjunction with physician outpatient care: the content of each visit was determined largely by each individual patient’s questions and wishes. Focus was on:
			• discussions aimed at motivating, guiding, and supporting the patient;
			• education (ie, kidney function, symptoms, test results, medication, treatment alternatives);
			• self-care (diet, controlling edema);
			• daily life with chronic illness;
			• well-being and quality of life; and
			• on health check-ups.
Piccoli	2000	Italy	A multistep education program that follows patients along the extended path from chronic renal failure to dialysis. Monthly 2-hour lessons on the main aspects of ESRD (dialysis, transplantation, diet, drugs, etc). Subjects are chosen in consultation with patients. Lessons consist of informal discussions held by the familiar caregivers, with the occasional help of experts.
Rasgon et al^Citation44	1996	USA	Multidisciplinary predialysis education program:
			• Psychosocial assessment by LCSW.
			• Education about dialysis and choices of modalities by LCSW and/or renal nurse educator.
			• Orientation to dialysis unit and counseling sessions with patient and family members by LCSW.
			• Peer counseling facilitated by LCSW and/or renal nurse educator.
Ribitsch et al^Citation45	2013	Austria	Multidisciplinary predialysis education program:
			• Two consecutive days, small groups (maximum 6 patients plus relatives).
			• Multidisciplinary team: nurse, dietician, nephrologist.
			• First day, 2-hour session: basic information on medical, dietary, and lifestyle issues.
			• Second day, 2-hour session: practical demonstration HD and PD.
Rioux et al^Citation46	2011	Canada	Multidisciplinary education program:
			• Advanced nurse practitioner provides multimedia education on dialysis modalities to patients using manuals, flipcharts, pamphlets, and DVDs.
			• In-hospital education occurs over 3–5 appointments. Family encouraged to attend.
			• Attempt is made to assess and match patient’s values, abilities, and lifestyle to their RRT modality needs.
			• Discharge plan of RRT is discussed. Different modalities are discussed, including benefits and barriers.
			• Patients invited to visit HHD and PD units.
Watson^Citation47	2008	Canada	Advanced practice nurses were hired to intervene on unplanned dialysis-start patients, to give them “predialysis education” after they had begun dialysis. Number of sessions not specified; flexible to patient’s needs. Topics covered among others:
			• Social situation (home? employed?).
			• Values and lifestyle (independence?).
			• Educate the basics (fundamental renal function, RRT).
			• Find education medium that suits patient learning style (video, written).
			• Discuss modalities (positive and negative aspects).
			• Tours of dialysis facilities.
			• Assess patient coping styles (helps determine modality and give patient strength).

Abbreviations: APD, automated peritoneal dialysis; CAPD, continuous ambulatory peritoneal dialysis; CKD, chronic kidney disease; ESRD, end-stage renal disease; GFR, glomerular filtration rate; HD, hemodialysis; HHD, home HD; LCSW, licensed social worker; PD, peritoneal dialysis; PDEP, PD education program; RRT, renal replacement therapy.

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