Advertisement

Integrating a Medical Home in an Outpatient Dialysis Setting: Effects on Health-Related Quality of Life

  • Denise M. HynesEmail author
  • Michael Fischer
  • Marian Fitzgibbon
  • Anna C. Porter
  • Michael Berbaum
  • Linda Schiffer
  • Ifeanyi B. Chukwudozie
  • Hai Nguyen
  • Jose Arruda
Original Research

Abstract

Background

Integrating primary care has been proposed to reduce fragmented care delivery for patients with complex medical needs. Because of their high rates of morbidity, healthcare use, and mortality, patients with end-stage kidney disease (ESKD) may benefit from increased access to a primary care medical home.

Objective

To evaluate the effect of integrating a primary care medical home on health-related quality of life (HRQOL) for patients with ESKD receiving chronic hemodialysis.

Design

Before–after intervention trial with repeated measures at two Chicago dialysis centers.

Participants

Patients receiving hemodialysis at either of the two centers.

Intervention

To the standard hemodialysis team (nephrologist, nurse, social worker, dietitian), we added a primary care physician, a pharmacist, a nurse coordinator, and a community health worker. The intervention took place from January 2015 through August 2016.

Main Measures

Health-related quality of life, using the Kidney Disease Quality of Life (KDQOL) measures.

Key Results

Of 247 eligible patients, 175 (71%) consented and participated; mean age was 54 years; 55% were men and 97% were African American or Hispanic. In regression analysis adjusted for individual visits with the medical home providers and other factors, there were significant improvements in four of five KDQOL domains: at 12 and 18 months, the Mental Component Score improved from baseline (adjusted mean 49.0) by 2.64 (p = 0.01) and 2.96 (p = 0.007) points, respectively. At 6 and 12 months, the Symptoms domain improved from baseline (adjusted mean = 77.0) by 2.61 (p = 0.02) and 2.35 points (p = 0.05) respectively. The Kidney Disease Effects domain improved from baseline (adjusted mean = 72.7), to 6, 12, and 18 months by 4.36 (p = 0.003), 6.95 (p < 0.0001), and 4.14 (p = 0.02) points respectively. The Physical Component Score improved at 6 months only.

Conclusions

Integrating primary care and enhancing care coordination in two dialysis facilities was associated with improvements in HRQOL among patients with ESKD who required chronic hemodialysis.

KEY WORDS

medical home primary care hemodialysis quality of life kidney disease 

Notes

Contributors

We appreciate the time and effort of those who helped to develop and implement this study, especially the pre-implementation training team, the clinical study team, the dialysis center staff at both sites, and the research personnel. We are grateful to the patients and their families who volunteered their time to participate in the study.

Funders

This work was supported by funding from the Patient-Centered Outcomes Research Institute (PCORI), contract no. IH-12-11-5420. Infrastructure support was provided by Fresenius Medical Care through its companies Frenova Renal Research and Fresenius Kidney Care. Additional support for this project was provided by the Office of the Vice President for Health Affairs at the University of Illinois at Chicago. Data for this study was provided in part by the University of Illinois at Chicago Center for Clinical and Translational Science, funded by National Center for Advancing Translational Sciences, National Institutes of Health (NIH) (UL1TR002003). Dr. Hynes was supported on a US Department of Veterans Affairs Research Career Scientist Award (RCS-98-352). Ms. Chukwudozie was supported by the GUIDE Cancer Research Training Project (NCI: 1P20CA202908). The manuscript content is solely the responsibility of the authors and does not necessarily reflect the views of PCORI or the US Department of Veterans Affairs or the NIH.

Compliance with Ethical Standard

Conflict of Interest

The authors declare that they do not have a conflict of interest.

Supplementary material

11606_2019_5154_MOESM1_ESM.docx (15 kb)
ESM 1 (DOCX 15 kb)

References

  1. 1.
    US Renal Data System. USRDS 2017 Annual Data Report: Epidemiology of Kidney Disease in the United States. Bethesda, MD, National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases; 2017.Google Scholar
  2. 2.
    Stroupe KT, Fischer MJ, Kaufman JS, O’Hare AM, Sohn MW, Browning MM, Huo Z, Hynes DM. Predialysis nephrology care and costs in elderly patients initiating dialysis. Med Care 2011;49(3):248–256.CrossRefGoogle Scholar
  3. 3.
    Saban KL, Bryant FB, Reda DJ, Stroupe KT, Hynes DM. Measurement invariance of the kidney disease and quality of life instrument (KDQOL-SF) across veterans and non-veterans. Health Qual Life Outcomes 2010;8(1):120.CrossRefGoogle Scholar
  4. 4.
    Hynes DM, Stroupe KT, Fischer MJ, et al. Comparing VA and private sector healthcare costs for end-stage renal disease. Med Care 2012;50(2):161–170.CrossRefGoogle Scholar
  5. 5.
    Zimmerman DL, Selick A, Singh R, Mendelssohn DC. Attitudes of Canadian nephrologists, family physicians and patients with kidney failure toward primary care delivery for chronic dialysis patients. Nephrol Dial Transplant 2003;18(2):305–309.CrossRefGoogle Scholar
  6. 6.
    Mapes DL, Lopes AA, Satayathum S, et al. Health-related quality of life as a predictor of mortality and hospitalization: The Dialysis Outcomes and Practice Patterns Study (DOPPS). Kidney Int 2003; 64: 339–349.CrossRefGoogle Scholar
  7. 7.
    Lowrie EG, Curtin RB, LePain N, Schatell D: Medical outcomes study short form-36: A consistent and powerful predictor of morbidity and mortality in dialysis patients. Am J Kidney Dis 2003; 41: 1286–1292.CrossRefGoogle Scholar
  8. 8.
    Wingard RL, Pupim LB, Krishnan M, Shintani A, Alp Ikizler T, Hakim RM. Early Intervention Improves Mortality and Hospitalization Rates in Incident Hemodialysis Patients: RightStart Program. Clin J Am Soc Nephrol 2007; 2: 1170–1175.CrossRefGoogle Scholar
  9. 9.
    Lacson E, Xu J, Lin S-F, Dean SG, Lazarus JM,Hakim RM. A comparison of SF-36 and SF-12 composite scores and subsequent hospitalization and mortality risks in long-term dialysis patients. Clin J Am Soc Nephrol 2010;5(2): 252–260.CrossRefGoogle Scholar
  10. 10.
    Liebman S, Li NC, Lacson E. Change in quality of life and one-year mortality risk in maintenance dialysis patients. Qual Life Res 2016; 25(9):2295–306.CrossRefGoogle Scholar
  11. 11.
    US Department of Health and Human Services, Centers for Medicare and Medicaid Services. Conditions for coverage for ESRD facilities, final rule. 42 C.F.R. part 494.80. Condition: Patient Assessment. Fed Register. 2008; p. 20393.Google Scholar
  12. 12.
    Finkelstein FO, Arsenault KL, Taveras A, Awuah K, Finkelstein SH. Assessing and improving the health-related quality of life of patients with ESRD. Nat Rev Nephrol 2012;8(12):718–724.CrossRefGoogle Scholar
  13. 13.
    Bodenheimer T, Wagner EH, Grumbach K. Improving primary care for patients with chronic illness: the chronic care model, part 2. JAMA. 2002;288(15):1909–1914.CrossRefGoogle Scholar
  14. 14.
    Boyd CM, Darer J, Boult C, Fried LP, Boult L, Wu AW. Clinical practice guidelines and quality of care for older patients with multiple comorbid diseases: implications for pay for performance. JAMA. 2005;294(6):716–724.CrossRefGoogle Scholar
  15. 15.
    Bayliss EA, Bhardwaja B, Ross C, Beck A, Lanese DM. Multidisciplinary team care may slow the rate of decline in renal function. Clin J Am Soc Nephrol 2011;6(4):704–710.CrossRefGoogle Scholar
  16. 16.
    Carter BL, Bosworth HB, Green BB. The hypertension team: The role of the pharmacist, nurse, and teamwork in hypertension therapy. J Clin Hypertens (Greenwich) 2012;14(1):51–65.CrossRefGoogle Scholar
  17. 17.
    Philis-Tsimikas A, Walker C, Rivard L, et al. Improvement in diabetes care of underinsured patients enrolled in project dulce – A community-based, culturally appropriate, nurse case management and peer education diabetes care model. Diabetes Care 2004;27(1):110–115.CrossRefGoogle Scholar
  18. 18.
    Beckham S, Kaahaaina D, Voloch K, Washburn A. A community-based asthma management program: Effects on resource utilization and quality of life. Hawaii Med J 2004;63(4):121–126.Google Scholar
  19. 19.
    Norris SL, Chowdhury FM, Van Le K, et al. Effectiveness of community health workers in the care of persons with diabetes. Diabet Med 2006;23(5):544–556.CrossRefGoogle Scholar
  20. 20.
    Unruh M, Benz R, Greene T, et al. HEMO Study Group: Effects of hemodialysis dose and membrane flux on health-related quality of life in the HEMO Study. Kidney Int 2004; 66: 355–366.CrossRefGoogle Scholar
  21. 21.
    Chertow GMLN, Levin NW, Beck GJ, et al. FHN Trial Group: Incenter hemodialysis six times per week versus three times per week. N Engl J Med 2010; 363: 2287–2300.CrossRefGoogle Scholar
  22. 22.
    Hussey PS, Schneider EC, Rudin RS, Fox DS, Lai J, Pollack CE. Continuity and the costs of care for chronic disease. JAMA Intern Med 2014;174(5):742–748.CrossRefGoogle Scholar
  23. 23.
    Sweeney L, Halpert A, Waranoff J. Patient-centered management of complex patients can reduce costs without shortening life. Am J Manag Care. 2007;13(1936–2692; 1088–0224; 2):84–92.Google Scholar
  24. 24.
    Anvari E, Mojazi Amiri H, Aristimuno P, Chazot C, Nugent K. Comprehensive and personalized care of the hemodialysis patient in Tassin, France: a model for the patient-centered medical home for subspecialty patients. ISRN Nephrol 2013:1–6.Google Scholar
  25. 25.
    Flanagan S, Damery S, Combes G. The effectiveness of integrated care interventions in improving patient quality of life for patients with chronic conditions. An overview of the systematic review evidence Health Qual Life Outcomes 2017; 15:188.CrossRefGoogle Scholar
  26. 26.
    Porter AC, Fitzgibbon ML, Fischer MJ, et al. Rationale and design of a patient-centered medical home intervention for patients with end-stage renal disease on hemodialysis. Contemp Clin Trials. 2015;42:1–8.CrossRefGoogle Scholar
  27. 27.
    Hynes DM, Fischer MJ, Schiffer LA, et al. Evaluating a Novel Health System Intervention for Chronic Kidney Disease Care Using the RE-AIM Framework: Insights After Two Years. Contemp Clin Trials 2017;52:20–26.CrossRefGoogle Scholar
  28. 28.
    Cukor D, Cohen L, Cope E, et al. Patient and stakeholder engagement in kidney diseases related research. Clin J Am Soc Nephrol 2016; 11(9): 1703–12.CrossRefGoogle Scholar
  29. 29.
    Porter AC, Fitzgibbon ML, Fischer MJ, et al. Quality of Life among Participants in a Patient-Centered Medical Home Intervention for Patients with End-stage Renal Disease on Hemodialysis. Insights in Internal Medicine. 2017; [Version 1, Approved]. 1:3.1.Google Scholar
  30. 30.
    Chukwudozie IB, Fitzgibbon ML, Schiffer L, et al. Factors contributing to uptake of primary care provider visits among chronic hemodialysis patients in a patient-centered medical home intervention study. Transl Behav Med 2018; 8(3): 341–350.CrossRefGoogle Scholar
  31. 31.
    Andersen RM. Revisiting the behavioral model and access to medical care: does it matter? J Health Soc Behav 1995:1–10.Google Scholar
  32. 32.
    Wagner EH, Austin BT, Davis C, Hindmarsh M, Schaefer J, Bonomi A. Improving chronic illness care: Translating evidence into action. Health Aff (Millwood) 2001;20(6):64–78.CrossRefGoogle Scholar
  33. 33.
    Harris PA, Taylor R, Thielke R, Payne J, Gonzalez N, Conde JG. Research electronic data capture (REDCap)--a metadata-driven methodology and workflow process for providing translational research informatics support. J Biomed Inform 2009;42(2):377–381.CrossRefGoogle Scholar
  34. 34.
    Hays RD, Kallich JD, Mapes DL, Coons SJ, Carter WB. Development of the kidney disease quality of life (KDQOL™) instrument. Qual Life Res 1994;3(5):329–338.CrossRefGoogle Scholar
  35. 35.
    Ware J, Kosinski M, Keller SD. A 12-Item Short-Form Health Survey: construction of scales and preliminary tests of reliability and validity. Med Care 1996; 34(3):220–233.CrossRefGoogle Scholar
  36. 36.
    Dahmen G, Ziegler A. Generalized estimating equations in controlled clinical trials: Hypotheses testing. Biom J 2004;46(2):214–232.CrossRefGoogle Scholar
  37. 37.
    Rochon J Application of GEE procedures for sample size calculations in repeated measures experiments. Stat Med 1998;17(14):1643–1658.CrossRefGoogle Scholar
  38. 38.
    Dahmen G, Ziegler A. Independence estimating equations for controlled clinical trials with small sample sizes - interval estimation. Methods Inf Med 2006;45(4):430–434.CrossRefGoogle Scholar
  39. 39.
    SAS [computer program]. Version 9.4. SAS institute; 2014.Google Scholar
  40. 40.
    Samsa G, Edelman D, Rothman ML, et al.: Determining clinically important differences in health status measures: A general approach with illustration to the health utilities index mark II. Pharmacoeconomics. 1999; 15(2):141–155.CrossRefGoogle Scholar
  41. 41.
    Hays R, Woolley JM: The concept of clinically meaningful difference in health-related quality-of-life research. How meaningful is it? Pharmacoeconomics. 2000; 18(5):419–423.CrossRefGoogle Scholar
  42. 42.
    Simon GE, Revicki DA, Grothaus L, Vonkorff M. SF-36 summary scores: Are physical and mental health truly distinct? Med Care 1998;36(4):567–572.CrossRefGoogle Scholar
  43. 43.
    Hall YN, Larive B, Painter P, et al. Effects of six versus three times per week hemodialysis on physical performance, health, and functioning: Frequent hemodialysis network (FHN) randomized trials. Clin J Am Soc Nephrol 2012;7(5):782–794.CrossRefGoogle Scholar
  44. 44.
    Peipert JD, Bentler PM, Klicko K, Hays RD. Psychometric Properties of the Kidney Disease Quality of Life 36-Item Short-Form Survey (KDQOL-36) in the United States. Am J Kidney Dis 2018; 71(4): 461–468.CrossRefGoogle Scholar
  45. 45.
    Moss AH, Davison SN. How the ESRD Quality Incentive Program Could Potentially Improve Quality of Life for Patients on Dialysis. Clin J Am Soc Nephrol 2015 May 7; 10(5): 888–893.CrossRefGoogle Scholar
  46. 46.
    O’Hare AM, Armistead N, Schrag WL, Diamond L, Moss AH. Patient-centered care: an opportunity to accomplish the "three aims" of the national quality strategy in the Medicare ESRD program. Clin J Am Soc Nephrol 2014;9(12):2189–2194.CrossRefGoogle Scholar
  47. 47.
    CMS End Stage Renal Disease Care Model, Centers for Medicare and Medicaid Services. 2019. https://innovation.cms.gov/initiatives/comprehensive-esrd-care/ and Comprehensive ESRD Care Model (CEC) Model Fact Sheet https://innovation.cms.gov/Files/fact-sheet/cec-fs.pdf. Accessed 4-1-2019.
  48. 48.
    Berns JS, Glickman JD, Reese PP. Dialysis Payment Model Reform: Managing Conflicts Between Profits and Patient Goals of Care Decision Making. Am J Kidney Dis 2018; 71(1): 133–136.CrossRefGoogle Scholar
  49. 49.
    Lacson E, Xu J, Lin SF, Dean SG, Lazarus JM, Hakim R. Association between achievement of hemodialysis quality-of-care indicators and quality-of-life scores. Am J Kidney Dis 2009; 54: 1098–1107.CrossRefGoogle Scholar
  50. 50.
    Leaf DE, Goldfarb DS. Interpretation and review of health-related quality of life data in CKD patients receiving treatment for anemia. Kidney Int 2009; 75: 15–24.CrossRefGoogle Scholar
  51. 51.
    Farag YM, Keithi-Reddy SR, Mittal BV, Surana SP, Addabbo F, Goligorsky MS, Singh AK. Anemia, inflammation and health-related quality of life in chronic kidney disease patients. Clin Nephrol 2011 Jun;75(6):524–33.CrossRefGoogle Scholar
  52. 52.
    Kaysen GA, Larive B, Painter P, et al. on behalf of the FHN Trial Group. Baseline Physical Performance, Health, and Functioning of Participants in the Frequent Hemodialysis Network (FHN) Trial. Am J Kidney Dis 2011; 57(1): 101–112.CrossRefGoogle Scholar
  53. 53.
    Feroze U, Noori N, Kovesdy CP, et al. Quality-of-life and mortality in hemodialysis patients: roles of race and nutritional status. Clin J Am Soc Nephrol 2011;6(5):1100–1111.CrossRefGoogle Scholar
  54. 54.
    Unruh M, Miskulin D, Yan G, et al. Racial differences in health-related quality of life among hemodialysis patients. Kidney Int 2004;65(4):1482–1491.CrossRefGoogle Scholar
  55. 55.
    Hicks LS, Cleary PD, Epstein AM, Ayanian JZ. Differences in health-related quality of life and treatment preferences among black and white patients with end-stage renal disease. Qual Life Res 2004;13(6):1129–1137.CrossRefGoogle Scholar
  56. 56.
    Mandel EI, Bernacki RE, Block SD. Serious Illness Conversations in ESRD. Clin J Am Soc Nephrol 2017;12(5):854–863.CrossRefGoogle Scholar
  57. 57.
    Weisbord SD. Patient-Centered Dialysis Care: Depression, Pain, and Quality of Life. Semin Dial 2016;29(2):158–64.CrossRefGoogle Scholar

Copyright information

© Society of General Internal Medicine (This is a U.S. government work and not under copyright protection in the U.S.; foreign copyright protection may apply) 2019

Authors and Affiliations

  • Denise M. Hynes
    • 1
    • 2
    • 3
    Email author
  • Michael Fischer
    • 4
    • 5
    • 6
  • Marian Fitzgibbon
    • 7
    • 8
  • Anna C. Porter
    • 4
    • 5
  • Michael Berbaum
    • 8
  • Linda Schiffer
    • 8
  • Ifeanyi B. Chukwudozie
    • 9
  • Hai Nguyen
    • 10
  • Jose Arruda
    • 4
  1. 1.College of Public Health and Human Sciences and Center for Genome Research and Biocomputing Oregon State UniversityCorvallisUSA
  2. 2.Department of MedicineUniversity of Illinois at ChicagoChicagoUSA
  3. 3.Center of Innovation to Improve Veteran Involvement in CarePortland VA Healthcare SystemPortlandUSA
  4. 4.Department of Medicine, Division of NephrologyUniversity of Illinois at ChicagoChicagoUSA
  5. 5.Medical ServiceJesse Brown VA Medical CenterChicagoUSA
  6. 6.Center of Innovation for Complex Chronic HealthcareEdward Hines Jr. VA HospitalHinesUSA
  7. 7.Department of PediatricsUniversity of Illinois at ChicagoChicagoUSA
  8. 8.Institute for Health Research and PolicyUniversity of Illinois at ChicagoChicagoUSA
  9. 9.Office of Community Engaged Research and Implementation ScienceUniversity of Illinois Cancer CenterChicagoUSA
  10. 10.Department of Epidemiology and Biostatistics, School of Public HealthUniversity of Illinois at ChicagoChicagoUSA

Personalised recommendations