Haakan Strand

Effects of multidisciplinary models of care for adult pre-dialysis patients with chronic kidney disease: a systematic review

AIM To compare the effectiveness of multidisciplinary care with traditional medical care on the progression of chronic kidney disease (CKD) in adult pre-dialysis patients (stages 3-5). METHODS Eleven databases were searched for articles published between January 1990 and July 2009. The Joanna Briggs Institute-Meta Analysis of Statistics Assessment and Review Instrument was used to assess the methodological quality of retrieved articles and extract data. RESULTS Only four articles out of 927 were included in the systematic review. Two reported the results of randomised controlled trials and two reported observational studies. The data were not presented in a format that allowed a meta-analysis to be performed and therefore a narrative summary of these articles is presented. CONCLUSION Multidisciplinary care is deemed to be effective in delaying the progression of CKD in adults who are in the pre-dialysis phase of this condition. Education that aims to increase the knowledge and understanding of the causes of CKD is an important component of the care. IMPLICATIONS FOR PRACTICE Members of the multidisciplinary team should draw on their specific expertise to educate the patient about CKD. The nephrologist or a nurse practitioner should devise a management plan jointly with the patient and provide regular reviews.

Exercise training in CKD: efficacy, adherence, and safety.

BACKGROUND Exercise training increasingly is recommended as an important part of the management of cardiovascular disease. However, few studies have evaluated the effectiveness of exercise training in patients with chronic kidney disease (CKD), and those that have included very selective populations. STUDY DESIGN Analysis of secondary outcomes of a randomized controlled trial, with participants randomly assigned to either lifestyle intervention or usual care (control). SETTING & PARTICIPANTS Patients with CKD stages 3 to 4 and one or more uncontrolled cardiovascular risk factor were recruited from an outpatient clinic at a large tertiary hospital. INTERVENTION Lifestyle intervention included access to multidisciplinary care through a nurse practitioner-led CKD clinic, exercise training, and a lifestyle program. The exercise training was a 2-phased program in which participants received 8 weeks of supervised training before commencing 10 months of home-based training. OUTCOMES & MEASUREMENTS Efficacy, as assessed by metabolic equivalent tasks (METs), 6-minute walk distance, Timed Get-Up-and-Go test, grip strength, and anthropomorphic measures; adherence, as assessed by self-reported physical activity; and safety, as assessed by reported serious adverse events, were recorded. RESULTS 83 patients were randomly assigned and 72 patients completed follow-up testing (intervention, n=36; control, n=36). The intervention resulted in a significant improvement in METs (pre, 7.2±3.3; post, 9.7±3.6), 6-minute walk distance (pre, 485±110m; post, 539±82m), and body mass index (pre, 32.5±6.7kg/m(2); post, 31.9±7.3kg/m(2)). Reported physical activity levels significantly increased in the intervention group at 6 months, but decreased at 12 months. There were no serious adverse events related to the exercise training. LIMITATIONS This study was not powered to evaluate the safety of exercise training on serious adverse events. CONCLUSIONS The findings from the present study suggest that an exercise program that includes a supervised and home-based training phase is effective, adhered to, and safe in patients with CKD.

Association between left ventricular global longitudinal strain, health‐related quality of life and functional capacity in chronic kidney disease patients with preserved ejection fraction

Patients with chronic kidney disease (CKD) have a significant burden of dyspnoea and fatigue in spite having normal left ventricular (LV) ejection fraction (EF). Global longitudinal strain (GLS) can detect subtle changes in LV function. This study aimed to evaluate the relationship between LV function, functional capacity and quality of life (QOL) in CKD patients with preserved EF.

Practice audit of the role of the Non‐medical surgical assistant in Australia, an online survey

The term Non-Medical Surgical Assistant (NMSA) encompasses all roles where healthcare clinicians without a medical degree provide clinical services during the perioperative cycle. The role of NMSA is gaining momentum within Australia. It is timely to ascertain who is preforming the role and quantify the practice setting and scope of practice to enable a nationally recognised platform for role evolution. For two months in 2015 a NMSA Practice Audit was available online. Sampling was initially of a convenience modality. A total of 83 clinicians responded. The majority of NMSAs were experienced RNs [>11yrs]; held post-graduate qualifications [80%], practiced predominantly in metropolitan areas [65%] and had been performing the role for 8 years or less. The specialty with the highest uptake of the NMSAs is orthopaedic surgery. This paper provides an overview of NMSAs practicing in Australia and provides cost effective evidence of the need for this service in Australian healthcare.The term Non-Medical Surgical Assistant (NMSA) encompasses all roles where healthcare clinicians without a medical degree provide clinical services during the perioperative cycle. The role of NMSA is gaining momentum within Australia. It is timely to ascertain who is preforming the role and quantify the practice setting and scope of practice to enable a nationally recognised platform for role evolution. For two months in 2015 a NMSA Practice Audit was available online. Sampling was initially of a convenience modality. A total of 83 clinicians responded. The majority of NMSAs were experienced RNs [>11yrs]; held post-graduate qualifications [80%], practiced predominantly in metropolitan areas [65%] and had been performing the role for 8 years or less. The specialty with the highest uptake of the NMSAs is orthopaedic surgery. This paper provides an overview of NMSAs practicing in Australia and provides cost effective evidence of the need for this service in Australian healthcare.

Valuing the role of the non‐medical surgical assistant in Australia

The aim of this study is to achieve professional recognition, governance and remuneration of the non-medical surgical assistant (NMSA) in Australia. An NMSA is a clinician who cares for the perioperative patient but is not a doctor. This role is well established, regulated and remunerated in the international setting. This role has existed in Australia for more than 20 years but is not professionally recognized or governed by the Australian Health Practitioner Regulation Agency (AHPRA) via either the Board of Nursing and Midwifery Australia or the Medical Board of Australia. An example of input by surgical groups in the international setting is the Royal College of Surgeons England who have been proactive with curricula input for the role in the UK, the Royal Australasian College of Surgeons (RACS) has had little input into formal recognition, curricula and governance of the role in Australia. Meetings held in Canberra in 2015 between the Australian Association of Nurse Surgical Assistants and representatives from the Medicare Benefits Schedule (MBS) investigated how the NMSA could progress to a stage where the MBS would remunerate the NMSA for ‘Assisting at Operation’ as this does not currently occur. Lack of remuneration renders the NMSA role unsustainable to many clinicians. Currently, the most common payment method for the NMSA in Australia is an out-of-pocket expense paid by the surgeon or the patient versus the medical surgical assistant who is remunerated by the MBS. During these meetings, MBS representatives emphasized that the opinions of Australian surgeons regarding the role of the NMSA were highly relevant. This relevance regarding medical services is supported by a recent RACS publication noting that the Department of Health and the Medical Services Advisory Committee are actively seeking participation from surgeons on the ‘acceptability’ of medical services. Surgeons’ opinions are critical because they work closely with the NMSA, are the team leaders in the operating theatre and the primary carer of the patient. An online survey of Australian surgeons’ opinions on the role of the NMSA was distributed by RACS via ‘Fax Mentis’ during December 2015 to February 2016. Respondents (n = 445 with a completion rate of 75%) highlighted several points: • The majority of respondents (n = 180, 66%) were ‘Not Supportive’ or ‘Undecided’ of the NMSA role in the Public Sector. This may be attributed to a concern that the NMSA will negatively impact junior doctor training; however, this is not supported in the literature; • The NMSA role was well supported in the Private Sector in Australia, 188 (69%) respondents were ‘Very Supportive’ or ‘Supportive to some degree’, with 108 (38%) ‘Undecided’ or ‘Not supportive’; • Uptake of the NMSA role was highest in General and Orthopaedic surgery; and • Current practice reflects that 105 (35%) respondents currently utilize an NMSA in the Private Sector and 30 (9%) respondents utilize an NMSA in the Public Sector. A number of respondents (n = 16, 5%) utilize an NMSA for public patients in the Private Sector.

The Association Between Quality of Life and Global Longitudinal Strain in Patients with Chronic Kidney Disease Stages 3 and 4

Aim: Patency after percutaneous balloon angioplasty (PTA) for haemodialysis fistula stenosis is highly variable. This study aimed to assess factors associated with patency following first episode of treatment with PTA. Background: Restenosis recurs commonly after PTA. Previous studies have shown that some intrinsic fistula and biochemical factors may influence patency after PTA. Methods: We retrospectively reviewed all endovascular procedures performed by nephrologists between 2007 and 2012 at a single centre. Anatomical, clinical, biochemical and medication information was subjected to cox regression analysis to identify factors influencing post-intervention patency. Results: 120 patients were identified as having first episode treatment with PTA. During a median follow-up period of 22.66 months (5.24–53 months), 171 follow-up procedures were performed. Post-intervention primary patency rates at 6, 12 and 18 months were 46%, 25% and 15% respectively. Cumulative (functional) patency rates at 6, 12 and 18 months were 97%, 94 and 92% respectively with 1.4 additional procedures per patient. In univariate cox regression analysis, the presence of multiple lesions (p = 0.037) was associated with early restenosis at 6 months, while upper arm fistulae were associated with early restenosis (p = 0.004) and shorter primary patency (p = 0.001). Other anatomical characteristics (fistula age, lesion length, pre-procedure stenosis), clinical history (diabetes, coronary and peripheral artery disease), medications, and biochemical parameters (HbA1c, CRP, albumin and lipids) did not influence patency. Conclusion: Multiple stenoses and upper arm fistulae may be associated with shorter patency after PTA. More large volume prospective studies are required to further assess factors associated with patency after PTA in haemodialysis fistulae, particularly the role of metabolic and inflammatory markers.