Anita Molzahn

A Nurse-coordinated Model of Care versus Usual Care for Stage 3/4 Chronic Kidney Disease in the Community: A Randomized Controlled Trial

BACKGROUND AND OBJECTIVES It is unclear how to optimally care for chronic kidney disease (CKD). This study compares a new coordinated model to usual care for CKD. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS A randomized trial in nephrology clinics and the community included 474 patients with median estimated GFR (eGFR) 42 ml/min per 1.73 m(2) identified by laboratory-based case finding compared care coordinated by a general practitioner (controls) with care by a nurse-coordinated team including a nephrologist (intervention) for a median (interquartile range [IQR]) of 742 days. 32% were diabetic, 60% had cardiovascular disease, and proteinuria was minimal. Guided by protocols, the intervention team targeted risk factors for adverse kidney and cardiovascular outcomes. Serial eGFR and clinical events were tracked. RESULTS The average decline in eGFR over 20 months was -1.9 ml/min per 1.73 m(2). eGFR declined by ≥4 ml/min per 1.73 m(2) within 20 months in 28 (17%) intervention patients versus 23 (13.9%) control patients. Control of BP, LDL, and diabetes were comparable across groups. In the intervention group there was a trend to greater use of renin-angiotensin blockers and more use of statins in those with initial LDL >2.5 mmol/L. Treatment was rarely required for anemia, acidosis, or disordered mineral metabolism. Clinical events occurred in 5.2% per year. CONCLUSIONS Patients with stage 3/4 CKD identified through community laboratories largely had nonprogressive kidney disease but had cardiovascular risk. Over a median of 24 months, the nurse-coordinated team did not affect rate of GFR decline or control of most risk factors compared with usual care.

Quality of Life of Older Adults in Canada and Brazil

In this study, we examined the factors contributing to quality of life (QOL) of older adults in regions of Canada and Brazil. The WHOQOL-BREF and a demographic data sheet were administered to random samples of 202 older adults from Canada and 288 from Brazil. Ratings on overall QOL and on the physical, psychological, and environmental domains were higher in the Canadian sample. Social domain scores were not significantly different. The authors found the same pattern of factors (health satisfaction, enough money, meaning in life, and opportunities for leisure activities) contributed to the variance of QOL in both countries, except for physical environment, which was significant in Brazil and not in Canada. Health satisfaction was the strongest contributor to QOL in both samples, and satisfaction with personal relationships was not significant in either country.

Chinese Canadian Beliefs Toward Organ Donation

The authors’ purpose in this study is to explore the values and beliefs regarding organ donation of Chinese Canadians. Data collection involved individual interviews (n = 15) and focus groups. The major organizing categories were the importance of context, and values and beliefs. The context included little knowledge about donation and possible influence of spiritual or cultural values. Lack of communication and the need to preserve an intact body were themes that emerged in relation to death and dying. In relation to organ donation, most participants thought it was “a noble deed,” but fears about organ donation were similar to those reported in other studies. It is important to note the considerable diversity in beliefs among these participants.

Cost-effectiveness analysis of a randomized trial comparing care models for chronic kidney disease.

BACKGROUND AND OBJECTIVES Potential cost and effectiveness of a nephrologist/nurse-based multifaceted intervention for stage 3 to 4 chronic kidney disease are not known. This study examines the cost-effectiveness of a chronic disease management model for chronic kidney disease. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS Cost and cost-effectiveness were prospectively gathered alongside a multicenter trial. The Canadian Prevention of Renal and Cardiovascular Endpoints Trial (CanPREVENT) randomized 236 patients to receive usual care (controls) and another 238 patients to multifaceted nurse/nephrologist-supported care that targeted factors associated with development of kidney and cardiovascular disease (intervention). Cost and outcomes over 2 years were examined to determine the incremental cost-effectiveness of the intervention. Base-case analysis included disease-related costs, and sensitivity analysis included all costs. RESULTS Consideration of all costs produced statistically significant differences. A lower number of days in hospital explained most of the cost difference. For both base-case and sensitivity analyses with all costs included, the intervention group required fewer resources and had higher quality of life. The direction of the results was unchanged to inclusion of various types of costs, consideration of payer or societal perspective, changes to the discount rate, and levels of GFR. CONCLUSIONS The nephrologist/nurse-based multifaceted intervention represents good value for money because it reduces costs without reducing quality of life for patients with chronic kidney disease.

Stories of Liminality Living With Life-Threatening Illness

Purpose: The purpose of the study is to examine liminal experiences of living with the uncertainty of life-threatening illness. Increasing numbers of people with life-threatening illness live in-between the promise of treatment and the threat of recurrence or progression of disease, and yet this experience is not well understood. Design: A narrative inquiry methodology within a constructionist frame was used. Method: Semistructured in-depth interviews were conducted with 32 participants from three populations of interest: (a) 10 people living with cancer, (b) 13 people with chronic renal disease, and (c) 9 people living with HIV/AIDS. Findings: An overarching theme of “pervasive liminality” and four narratives are identified: storying into fear(lessness), being alive but not living; knowing and not knowing, and the (in)visibility of disease. Conclusions: Over time, living with a life-threatening illness produces complex and paradoxical experiences that do not easily fit within familiar categories of experience. Findings highlight pervasive liminal experiences as in-between narratives that are neither problematic nor need to be resolved, and endure over time.

Strategies to use tablet computers for collection of electronic patient-reported outcomes

BackgroundMobile devices are increasingly being used for data collection in research. However, many researchers do not have experience in collecting data electronically. Hence, the purpose of this short report was to identify issues that emerged in a study that incorporated electronic capture of patient-reported outcomes in clinical settings, and strategies used to address the issues.FindingsThe issues pertaining to electronic patient-reported outcome data collection were captured qualitatively during a study on use of electronic patient-reported outcomes in two home dialysis units. Fifty-six patients completed three surveys on tablet computers, including the Kidney Disease Quality of Life-36, the Edmonton Symptom Assessment Scale, and a satisfaction measure. Issues that arose throughout the research process were recorded during ethics reviews, implementation process, and data collection. Four core issues emerged including logistics of technology, security, institutional and financial support, and electronic design.ConclusionsAlthough use of mobile devices for data collection has many benefits, it also poses new challenges for researchers. Advance consideration of possible issues that emerge in the process, and strategies that can help address these issues, may prevent disruption and enhance validity of findings.

Quality of life of older adults in Canada and Norway: Examining the Iowa model.

In this study, Glick and Tripp-Reimers (1996) Iowa model for gerontological nursing serves as a guiding framework for a descriptive exploratory study of quality of life (QOL) of older adults. Using secondary data, the authors explored whether the effects of health appraisal, morbidities, social support transitions (SST), and the environment on QOL would be partly mediated by cognitive developmental transitions (CDT). Data sets were available from studies with random samples of community-dwelling older adults from Canada (n = 202) and Norway (n = 490). The partly and fully mediated effects found suggest positive CDT in older age might be significantly enhanced by the presence of intimate ties, positive perceptions of ones health limitations, and residence in a healthy, safe, and resource-rich physical environment. These findings represent a novel attempt at testing complex linkages between aspects of elder, environment, and nursing concepts within the Iowa model warranting further research.

Variation in the Level of eGFR at Dialysis Initiation across Dialysis Facilities and Geographic Regions

BACKGROUND AND OBJECTIVES The relative influence of facilities and regions on the timing of dialysis initiation remains unknown. The purpose of the study is to determine the variation in eGFR at dialysis initiation across dialysis facilities and geographic regions in Canada after accounting for patient-level factors (case mix). DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS In total, 33,263 dialysis patients with an eGFR measure at dialysis initiation between January of 2001 and December of 2010 representing 63 dialysis facilities and 14 geographic regions were included in the study. Multilevel models and intraclass correlation coefficients were used to evaluate the variation in timing of dialysis initiation by eGFR at the patient, facility, and geographic levels. RESULTS The proportion initiating dialysis with an eGFR≥10.5 ml/min per 1.73 m(2) was 35.3%, varying from 20.1% to 57.2% across geographic regions and from 10% to 67% across facilities. In an unadjusted, intercept-only linear model, 90.7%, 6.6%, and 2.7% of the explained variability were attributable to patient, facility, and geography, respectively. After adjustment for patient and facility factors, 96.9% of the explained variability was attributable to patient case mix, 3.1% was attributable to the facility, and 0.0% was attributable to the geographic region. These findings were consistent when the eGFR was categorized as a binary variable (≥10.5 ml/min per 1.73 m(2)) or in an analysis limited to patients with >3 months of predialysis care. CONCLUSIONS Patient characteristics accounted for the majority of the explained variation regarding the eGFR at the initiation of dialysis. There was a small amount of variation at the facility level and no variation among geographic regions that was independent of patient- and facility-level factors.

Contrasting stories of life-threatening illness: a narrative inquiry.

BACKGROUND Advances in science and technology have resulted in longer lives for people with life-threatening illnesses. However, little research compares the stories of people with different life-threatening illnesses. OBJECTIVES The objectives of this study were to explore and contrast how people story and re-story life-threatening illness specifically cancer, chronic kidney disease (CKD) and HIV. DESIGN Narrative inquiry within a social constructionist perspective was used. METHODS A total of 113 in-depth interviews were conducted with 32 participants over a period of three years. PARTICIPANTS Study participants included 32 people: 10 with cancer, 14 with CKD and 8 with HIV/AIDS. Participants varied in age (37-83 years old, mean=61.2 years), gender (17 men and 14 women), location (urban and rural), time post-diagnosis (median=8 years), intensity or invasiveness of treatment, and prognosis (continuous treatment, remission, cure, palliative). RESULTS Participants described living with a life-threatening illness as a delicate balance. They focused on living their lives yet were fully and acutely aware of their own mortality. There was an undercurrent of sustained uncertainty that permeated their lives. Stories of life-threatening illness differed across the three illness groups and shifted over time as disease trajectories changed. Each disease brought specific challenges. With cancer, turning points and uncertainty were prominent. With CKD, a stealthy beginning to life-extending treatment through dialysis or transplant was evident, and with HIV, a shift from a perceived death sentence to a focus on hope and living was notable. CONCLUSIONS Findings revealed that trajectories of illness for participants living with cancer, CKD and HIV are complex and differ markedly across the groups. Narratives shifted across all of the illness groups as participants navigated and re-storied the terrains of their life-threatening illness. Findings illuminated the need for health care providers to focus on person specific and contextualized aspects of the illness experience.

Language and the (Im)possibilities of Articulating Spirituality

Despite growing interest in spiritual matters throughout society, definitions and descriptions of spirituality seem incomplete or otherwise unsatisfactory. In this article, the authors consider the possibility that such incompleteness is perhaps necessary and welcomed in addressing spirituality. In particular, they investigate the challenges of using metaphor and metonymic approaches to “languaging” spirituality. By exploring these figures of speech they hope to diversify how nurses articulate deeply personal and perhaps enigmatic human phenomena such as spirituality. Metaphoric language uses everyday structures to help make sense of complex, emotional, and abstract experience. Whereas metaphor creates substitutive relationships between things and provides insights into conceptualizing spirituality, metonymy and metonymic writing establish relationships of contiguity. Whereas metaphor functions to represent and facilitates understanding and feelings about spirituality, metonymy disrupts while opening possibilities of moving beyond binary thinking. Attending to language and its various ontological assumptions opens diverse and potentially more inclusive possibilities.