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TITLE AND

AUTHOR
Evaluation of a
collaborative chronic
care approach to
improve outcomes in
kidney transplant
recipients
Bissonnette J,
Woodend K, Davies
B, Stacey D, Knoll
GA.

ALVAREZ, Ronilyn A.

KEYWORDS

OBJECTIVES

DESIGN

advanced
practice nurse
chronic care
interprofessiona
l kidney
transplantation
propensity score

The purpose of the


study was to evaluate
the effectiveness of
an advanced practice
nurse-led
interprofessional
collaborative chronic
care approach, guided
by the chronic care
model, on achieving
clinical targets for
renal transplant
patients with chronic
kidney disease.

This was
a before
and after
study
with
casematched
controls.

BSN III-B2

SAMPLE AND POPULATION

STATISTICAL
TREATMENT
The target population was adult renal Propensity scores were
transplant patients with chronic
used to match patients in
kidney disease followed in a tertiary the control and
care hospital transplant clinic. The
intervention periods. The
intervention period included all
propensity score
eligible patients, as defined above
matching model assumed
that were followed in an advanced
that individuals, with the
practice nurse-led interprofessional
same characteristics used
collaborative chronic care clinic
for matching, have an
from March 2006 (date clinic
equal probability of
opened) until September 2009. The
being in either the
control period consisted of eligible
intervention or the
patients, as defined above that were
control period. All
followed in the renal transplant
statistical analyses were
clinic from their date of transplant to conducted using
October 2003. This date was
SAS (version 9.1).
purposively chosen as necessary, and
complete data were abstracted from
the medical record of these patients
as part of another study in October
2003. Control period kidney
transplant patients were followed
under the traditional physician-led
healthcare approach.

FINDINGS
Of 40 patients in the matched
intervention period,
27 (68%) reached the primary
outcome (i.e., achieved at least
seven of nine clinical targets)
compared to only four (10%) in
the control period. Patients in the
intervention period achieved a
mean of 7.1 clinical targets
compared to only 4.8 in the
control period. When looking at
the individual clinical targets, the
intervention period had a greater
proportion of achieved calcium,
LDL, and parathyroid hormone
thresholds compared with
controls (Table 4). In addition,
patients in the intervention period
were more likely to have
discussed end-stage renal disease
treatment options (Table 4). There
were no significant differences in
systolic/diastolic blood pressure,
carbon dioxide, hemoglobin, or
phosphate targets (Table 4). The
intervention period patients had a
significantly lower rate of
emergency room visits compared
with the control period. Similarly,
the intervention period had a
significantly lower rate of
hospital admissions compared
with the control period patients.
The intervention period patients
were more likely to receive ASA,
erythropoiesis-stimulating
agent, ACE-inhibitor/angiotensin
receptor blocker,
statin, phosphate binder, and
calcitriol according

CONCLUSION
In summary, this is the
first study to evaluate
the implementation of
an advanced practice
nurse-led
interprofessional
collaborative chronic
care approach using a
structure and process
analysis for
enhancement of
outcomes in kidney
transplant patients. The
evaluation showed that
patients exposed to the
advanced practice
nurse-led clinic were
more likely to attain
targeted clinical
outcomes, participate in
discussions about endstage renal disease
treatment options and
have fewer emergency
room visits and hospital
admissions. As
the first study of an
alternate approach to
the management
of renal transplant
recipients with chronic
kidney disease, these
results provide the
foundation
for a multicenter
randomized trial to test
the
hypothesis that an
interprofessional
chronic care patient-

RECOMMENDATION
This study, however,
does provide strong
rationale and useful
data for the design of a
randomized controlled
trial comparing usual
transplant clinic care to
an advanced practice
nurse-led model of
care. Ideally, this would
be a cluster-randomized
design given the
complex intervention
under study and the
need
to minimize
contamination at the
individual sites

RELATION TO PATIENT

LIMITATIONS
The following
limitations of this study
should be considered.
First, the study design
was nonrandomized
which may have
introduced selection
bias. We tried to mitigate
this bias using a
propensity score
matching procedure.
Although such matching
will improve the
comparability of groups,
it does not eliminate
potential bias associated
with unmeasured
variables that may
influence the patients
propensity to be
allocated to the
intervention or control
group. Second, we had a
relatively small sample
size of patients with
chronic kidney disease.
This limited the number
of observed covariates
that could be included in
the propensity score
model. Third, this was a
single-center study,
which might limit
generalizability.

Sources:
Ferreira, S., Echer, I., & Lucena, A. (2013). Nursing Diagnoses Among Kidney Transplant Recipients: Evidence From Clinical Practice. International
Journal Of Nursing Knowledge, 25(1), 49-53. http://dx.doi.org/10.1111/2047-3095.12006
De Souza, T., Trindade, T., de Mendona, A., & da Silva, R. (2015). Changes in basic human needs in patients after renal transplantation: a cross
sectional study: EBSCOhost. Web.a.ebscohost.com. Retrieved 3 November 2016, from
http://web.a.ebscohost.com/ehost/pdfviewer/pdfviewer?sid=6462b2a8-5642-496a-adf4- 767ecb3919cd
%40sessionmgr4006&vid=4&hid=4106

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