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Perspectives on optimizing care of patients in multidisciplinary chronic kidney disease clinics Collister, David; Russell, Randall; Verdon, Josee; Beaulieu, Monica; Levin, Adeera May 12, 2016

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REVIEW Open AccessPerspectives on optimizing care of patientsin multidisciplinary chronic kidney diseaseclinicsDavid Collister1, Randall Russell2, Josee Verdon3, Monica Beaulieu4 and Adeera Levin4*AbstractPurpose of review: To summarize a jointly held symposium by the Canadian Society of Nephrology (CSN), theCanadian Association of Nephrology Administrators (CANA), and the Canadian Kidney Knowledge Translation andGeneration Network (CANN-NET) entitled “Perspectives on Optimizing Care of Patients in Multidisciplinary ChronicKidney Disease (CKD) Clinics” that was held on April 24, 2015, in Montreal, Quebec.Sources of information: The panel consisted of a variety of members from across Canada including amultidisciplinary CKD clinic patient (Randall Russell), nephrology fellow (Dr. David Collister), geriatrician (Dr. JoseeVerdon), and nephrologists (Dr. Monica Beaulieu, Dr. Adeera Levin).Findings: The objectives of the symposium were (1) to gain an understanding of the goals of care for CKD patients, (2)to gain an appreciation of different perspectives regarding optimal care for patients with CKD, (3) to examinethe components required for optimal care including education strategies, structures, and tools, and (4) to describe aframework and metrics for CKD care which respect patient and system needs. This article summarizes the key conceptsdiscussed at the symposium from a patient and physician perspectives. Key messages include (1) understandingpatient values and preferences is important as it provides a framework as to what to prioritize in multidisciplinaryCKD clinic and provincial renal program models, (2) barriers to effective communication and education are commonin the elderly, and adaptive strategies to limit their influence are critical to improve adherence and facilitate shareddecision-making, (3) the use of standardized operating procedures (SOPs) improves efficiency and minimizes practicevariability among health care practitioners, and (4) CKD scorecards with standardized system processes are useful inapproaching variability as well as measuring and improving patient outcomes.Limitations: The perspectives provided may not be applicable across centers given the differences in patientpopulations including age, ethnicity, culture, language, socioeconomic status, education, and multidisciplinaryCKD clinic structure and function.Implications: Knowledge transmission by collaborative interprovincial and interprofessional networks may playa role in facilitating optimal CKD care. Validation of system and clinic models that improve outcomes is needed prior todisseminating these best practices.Keywords: Multidisciplinary, Chronic kidney disease, Clinics, Communication, Standardized operating procedures,Scorecards* Correspondence: ALevin@providencehealth.bc.ca4Division of Nephrology, University of British Columbia, Vancouver, BC,CanadaFull list of author information is available at the end of the article© 2016 Collister et al. Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, andreproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link tothe Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.Collister et al. Canadian Journal of Kidney Health and Disease  (2016) 3:32 DOI 10.1186/s40697-016-0122-9AbrégéObjectif de la revue: Cette revue se veut une récapitulation des thèmes abordés lors du colloque intitulé «Perspectives on Optimizing Care of Patients in Multidisciplinary Chronic Kidney Disease Clinics ». Ce colloque organiséconjointement par la Société Canadienne de Néphrologie, la Canadian Association of Nephrology Administrators(CANA) et la Canadian Kidney Knowledge Translation and Generation Network (CANN-NET), s’est tenu le 24 avril 2015à Montréal, au Canada.Sources: Cette table ronde réunissait des membres provenant de partout au Canada. Les intervenants invités àdiscuter lors de ce colloque comptaient un patient fréquentant une clinique multidisciplinaire en suivi des maladiesrénales chroniques (Randall Russell) un chercheur boursier en néphrologie (Dr David Collister), une gériatre (DreJosée Verdon) et deux néphrologues (Dre Monica Beaulieu et Dre Adeera Levin).Observations: Ce colloque visait plusieurs objectifs. D’abord on voulait se faire une meilleure idée des objectifsfixés en matière de soins offerts aux patients souffrant d’IRC. On a ensuite tenté de faire le portrait des différentspoints de vue en matière de soins optimaux à prodiguer aux patients atteints d’IRC et se pencher sur les élémentsrequis pour y arriver, notamment les structures et outils nécessaires, et les méthodes pédagogiques à favoriser.Finalement, ce colloque visait à définir un cadre et des paramètres de soins en IRC qui respectent les besoins despatients et du système de santé. Le présent article résume les concepts-clés discutés lors de ce colloque du pointde vue du médecin traitant, mais également de celui d’un patient atteint d’IRC.Les messages-clés abordés incluent les observations suivantes:1) Il est important de tenir compte des valeurs et des préférences du patient dans l’établissement des priorités descliniques multidisciplinaires et des modèles de programmes provinciaux en IRC.2) On constate que les obstacles à une communication et à un enseignement efficaces sont fréquents chez lespatients âgés. Ainsi les stratégies adaptatives limitant leur influence sont cruciales pour améliorer l’adhésion dupatient au traitement et faciliter la prise de décision conjointe.3) On observe que l’usage de procédures opérationnelles normalisées améliore l’efficacité et minimise la variabilitédans la pratique chez les professionnels de la santé.4) Les fiches d’évaluation en IRC doublées d’une uniformisation des systèmes et des procédés, sont utiles pouraborder le traitement de la variabilité tout autant que pour mesurer et améliorer les résultats pour les patients.Limites de l’étude: Les points de vue exprimés peuvent ne pas s’appliquer dans tous les centres de soins comptetenu des différences appréciables parmi les patients souffrant d’IRC. Ces différences incluent notamment l’âgel’origine ethnique, les différences culturelles, la langue parlée, le statut socio-économique, le niveau de scolarité, demême que la structure et les fonctions de la clinique multidisciplinaire de suivi en IRC fréquentée par le patient.Conclusion: La transmission des connaissances par l’entremise d’un réseau interprovincial et interprofessionnel decollaboration pourrait contribuer à faciliter l’administration de soins optimaux en IRC. Une validation du système etdes modèles cliniques permettant l’amélioration des résultats pour les patients est requise préalablement à ladiffusion de ces pratiques exemplaires.What was known beforeMultidisciplinary CKD clinics improve patient out-comes, but there is variability in clinic structure andfunction across Canada. Exploring optimal CKD pa-tient care practices from the patient, physician, andprovincial renal program perspective is important inthe development of multidisciplinary CKD clinicsand to identify what practices are effective in im-proving outcomes.What this addsIncorporating patient values and preferences, employingeffective communication and education strategies, adopt-ing SOPs, and utilizing CKD scorecards are all practicesthat are valuable in improving the care of patients inmultidisciplinary CKD clinic settings.BackgroundCKD is a global public health concern that is increas-ing in incidence and prevalence. It is estimated that15 % of Canadians have CKD [1], and this epidemicis driven by the elderly with significant comorbidities[2]. There is a degree of variability in disease burdenacross Canada. The care of the CKD population iscomplex and requires many interactions between thepatient, family, primary care provider, and multidis-ciplinary CKD clinic team as well as several inpatientand outpatient services. Optimal care is generallyCollister et al. Canadian Journal of Kidney Health and Disease  (2016) 3:32 Page 2 of 7defined as care that leads to the best outcomes forthe individual, population, and society; it is the goalof any health care system. However, patient-centeredoutcomes such as engagement, symptom control, andsatisfaction may not necessarily align with thephysician-centric priorities of slowing the progressionof CKD, achieving clinical targets, and improvingmorbidity and mortality [3, 4]. Regardless, cliniciansstrive to deliver effective and efficient care with thegoals of identifying, risk stratifying, educating, andmanaging patients with CKD with appropriate prep-aration and transition to end-stage renal disease(ESRD) with renal replacement therapy (RRT: dialysisor transplantation) or conservative therapy. The con-cept of shared decision-making [5] has gained accept-ance in most clinical jurisdictions in this regard.ReviewPatient values and perspectivesUnderstanding patient values and exploring their per-spectives are critical to caring for the CKD popula-tion [6–8]. Randall Russell provided a contextualframework by sharing his personal journey as a CKDpatient transitioning from his primary nephrologist inthe community to the Progressive Renal InsufficiencyClinic at The Ottawa Hospital. Initially, he felt anx-iety regarding his illness trajectory and the transitionbetween clinic models but ultimately viewed the ex-perience as motivating and empowering. His prioritiesas a CKD patient include continuity through longitu-dinal care, accessibility, and the sense of support fromall members of the multidisciplinary team. He valuesautonomy in decision-making [9] and acquiring know-ledge [10] through renal education with clear andcomprehensive information. The availability of themultidisciplinary team members outside of clinic ap-pointments is also important to him. Lastly, he sharedhis gratefulness for healthcare engagement in improv-ing CKD care [11] and encouraged the active partici-pation of all CKD patients in their care. However, hemay not be representative of the entire CanadianCKD population given its diversity in age, ethnicity,culture, language, socioeconomic status and educa-tion. Tong et al [12] identified 5 themes in CKD pa-tient preferences and experiences including personalmeaning of CKD, managing and monitoring health,lifestyle consequences, family impact and informalsupport structures. 5 other themes emerged in adoles-cents and young adults [13] including inferiority, inse-curity, injustice, resilience and adjustment mentality.In the elderly [14], there is shock about a diagnosis,uncertainty about disease progression and a lack ofpreparation for living with dialysis. Thus, individualizingcare by exploring the patient’s values and perspectives isimportant in improving their well-being and satisfaction.Principles of care models for older adultsThe principles of care models designed for the elderlyhave relevance to the CKD population given that a sig-nificant portion of this population is considered elderlyfrom an aging or biologic perspective [2, 15, 16]. Normalaging affects senses (vision, hearing, touch, reaction) andfunctions (cognition, spatial orientation, motor coordin-ation, mobility, work rate, working memory, executivefunction, motor coordination and mobility) [17], whichmay create barriers to communication and education.Screening for sensory deficits [18, 19], intervening withhearing or visual aids, and using other techniques(adequate lighting, appropriate sized print, adequatevoice intensity, multimodal cues) may attenuate thesebarriers. Mood disorders [20, 21] and cognitive impair-ment are common in CKD [22, 23] patients and theelderly. Thus, formally screening for anxiety, depression[24] and cognitive impairment [25] on a routine basis(or alternatively if a threshold pre-test probability exists)may be valuable, as these conditions may negatively im-pact patient interaction and ability to retain informationpresented. Compliance can be improved by simplifyinginstructions, reinforcing behavior on a regular basis andby checking/rechecking comprehension. Involving acaregiver in all clinic visits is also crucial to corroborateillness trajectory and may improve adherence. As cogni-tive functions such attention, concentration, comprehen-sion and retention may be impaired, strategies toenhance communication are frequently necessary. Thesemay include the use of direct, concrete and actional lan-guage as well as “right branching” sentences (see Table1). Information should be broken down into simple ele-ments with each explained separately using techniquesto ensure attention and retention of information such as“teach-back”, utilizing multiple senses (e.g. oral and writ-ten instructions), and the repetition of concepts overmany sessions [26, 27]. Ideally, education sessionsshould last less than 15 minutes and only address 3-5points at a time to maximize concentration and reten-tion. Renal education should also be individually tailoredin format, length, frequency, and size (group vs. individ-ual) using a patient-centered approach addressing feasi-bility and acceptability. Lastly, deficits in health literacyare common in the CKD population [28] so cliniciansmust be sensitive with their use of language complexityand terminology in all forms of communication [29].Given the diversity of the CKD population acrossCanada, a tailored approach to these principles of careare needed to promote health literacy, learning and un-derstanding, As Canada is a multilingual country, trans-lators should be available during clinic visits and if not,Collister et al. Canadian Journal of Kidney Health and Disease  (2016) 3:32 Page 3 of 7caregivers can be utilized instead if language barriersexist. Additionally, educational materials including pam-phlets, posters and education sessions should be offeredin the languages most prevalent in the population.Standardized operating procedures for physicians andmultidisciplinary team members: defining inputs andoutputsMultidisciplinary CKD clinics improve clinical targets(blood pressure, ACE/ARB use, hemogloblin, calcium,phosphate, bicarbonate) and outcomes (rate of eGFR de-cline, acute RRT, vascular access, hospitalizations, mor-tality, costs) in both adult [30–36] and pediatricpopulations [37, 38]. However, it remains uncertain howto optimally structure multidisciplinary CKD clinics andwhat resources should be allocated to promote their op-eration. CKD care is highly variable across Canada by re-ferral, entry, staffing, resources, focus, size, andefficiency [39]. This context in which the care of CKDpatients is delivered influences quality but differs fromprovince to province and center to center depending onindividual program scope and current practices. Processimprovement is defined as a series of action taken toidentify, analyze, and improve existing processes withinan organization to meet goals and objectives [40].Process engineering (the identification of inputs, opera-tions and outputs for any process) for a multidisciplinaryCKD clinic involves clerks, nurses, dietician, pharma-cists, physicians, rooms, equipment and actions requiredto ensure healthy and satisfied CKD patients. In a multi-disciplinary stage 4/5 CKD clinic in Winnipeg, Manitoba[41], there was a redundancy in tasks and poor commu-nication among the team with significant “down time”and wait times for patients and no clear dynamic moni-toring of clinical and administrative outcomes. A timestudy and task consistency analysis demonstrated het-erogeneity in practice. A sequence of patient flowthrough the clinic was established with 15 minutes allo-cated per encounter, SOPs for all multidisciplinary teammembers were created focusing on core competenciesafter focus group discussions and a new clinic recordwas created based on these SOPs. The goal of the clinicredesign by process engineering was to eliminate bottle-necks, improve patient flow and standardize quality ofcare through the elimination occupational uncertainty. Apre/post time study, task analysis and chart review forquality of patient care parameters was performed. Meanthroughput times (time for a patient to progress throughthe clinic) decreased and the standard deviation of meancycle times and physician cycle time decreased with ad-herence to time standards. There was less variability oftask performance and no changes in clinical targets butthere was an association with favorable outcomes. SOPsplay an important role in multidisciplinary CKD clinicsto optimize quality, efficiency and accountability.Framework and goals of care: CKD scorecardsThe BC Renal Agency Provincial Kidney Care Commit-tee’s (KCC) goal is to provide infrastructure andTable 1 Principles of care for older adultsBarrier Identification StrategiesSensorydeficitsScreening for visualacuity and hearingloss formally,informally-Referral for aids (glasses, hearing aids)-Optimize the learning environment(adequate lighting, minimize glare,limit background noise)-Written instructions with large fontsizing and multimodal information(visual and verbal through writing,pictogram, hands-on experience,videos, web-links, online)-Appropriate voice intensity, pitch,pacing, eye level, direct visualizationto allow for lip readingCognitiveimpairmentScreening withMMSE, MoCA, clockdrawing, cognitivebattery testing-Breakdown information into smallunits (focus on only 3–5 issuesor ess per session, <15 minutesper session)-Explain each element separately-Direct, actional, concrete language(“take one tablet in the morning andone at night” not “take twice a day”)-Individualized, tailored educationalsessions-“Right branching” (“take a seat andyou won’t miss the session” not “ifyou don’t want to miss the session,take a seat”)-Teach-back technique-Involvement of caregiver-Refer for treatment as indicatedMooddisordersScreening formally,informally-Reassurance-Simplify-Pacing-Refer for treatment as indicated(medications, CBT)HealthliteracyAssuming baselinelimited healthliteracy vs. screening-Limiting language complexity-The use of appropriate terminologyin all forms and venues ofcommunications (“high bloodpressure” not “hypertension”)Adherence “How many timeshave you missed(behavior) in thelast week?”-Simplify-Explain (indications, consequences,prioritization)-Reinforce-Checking/rechecking understanding-Address feasibility, acceptability-Involvement of caregiverMMSE Mini Mental Status Examination, MoCA Montreal cognitive assessment,CBT cognitive behavioral therapyCollister et al. Canadian Journal of Kidney Health and Disease  (2016) 3:32 Page 4 of 7mechanisms to facilitate a provincial and interprofes-sional approach to improvements in CKD care [42].Since the establishment of the provincial KCC in 2011,the group has involved all provincial health authoritiesin the creation of a formal framework including defini-tions, best practice documents, and a set of metrics toensure accountability and enable quality improvement.There is a systematic gathering of data using a provincialdatabase, which permits a description of provincial CKDclinic demographics, comorbidities, and achievement ofclinical targets and outcomes. In collaboration withprovincial health authorities, KCC developed a workplan that included the creation of a document entitled“Best Practices in Organizing Kidney Care” (www.bcrena-lagency.ca) that outlines guidelines, protocols, and algo-rithms for ordering and reviewing of bloodwork,medication reconciliation, and modality education. Thegroup has also defined the goals of CKD clinics, referraland repatriation criteria, and interprofessional teammembers’ roles and responsibilities. In addition, thepathways for transitions between CKD and RRT modal-ities (hemodialysis, peritoneal dialysis, and renal trans-plantation) are well articulated, defining the roles forvarious team members.A scorecard approach in health care terms refers tothe process of formally adjudicating systems for bench-marks of quality of care defined by guidelines. Itsstrengths include standardized and mandatory reportingwith comparisons across centers with the potential forgoal setting and improvement in outcomes. The KCChas developed and reported CKD scorecards for allclinics in an unblinded manner after establishing a set ofindicators of quality of care and goals linked to bestpractices. For example, hemoglobin and iron targetachievements would reflect implementation of anemiaprotocol; ACE/ARB use would reflect recommendedbest practice for delay of renal progression and cardio-vascular health; the proportion of patients witheGFR<20ml/min and documented planned modalitywould indicate appropriate timing of education; the pro-portion of patients starting on the modality of theirchoice indicate appropriate timing and preparation; andindependent modality rates of those attending clinicswould be an ‘integrated’ measure of the entire process ofcare, including appropriate access creation and educa-tion, decision making and system functioning. Each ofthese measures can be mapped to a specific set of activ-ities important to patient outcomes and system func-tioning. The value of the KCC provincial approach isthat it has permitted knowledge translation, transpar-ency, and standardization of CKD care with the use ofthe “plan, study, do, act” cycle as an iterative process.Future goals are to include measures of patient orientedoutcomes and other relevant metrics, and incorporatethe assessment of how to address depression/anxiety,end of life, and advanced care planning activities intofuture metrics. Unfortunately, a limitation of scorecardsis the need for the infrastructure for informationFig. 1 A framework for optimal multidisciplinary CKD care. CKD chronic kidney diseaseCollister et al. Canadian Journal of Kidney Health and Disease  (2016) 3:32 Page 5 of 7management. This is currently available through provin-cially based CKD information systems in some regionsbut may not be readily available so alternatives with theirassociated costs are needed to properly evaluate pro-cesses and outcomes.ConclusionsThe symposium presented perspectives from a patient, ageriatric physician, nephrology trainee, and nephrolo-gists experiencing CKD and working within differentprovincial jurisdictions. Different perspectives inhealth care provision are important in understandingthe current state and may lead to improvementthrough collaboration. Key learnings included the im-portance of incorporating patient values and prefer-ences into planning multidisciplinary CKD clinicstructure and function, the importance of deliberateuse of strategies for effective communication and edu-cation in the elderly or those with impediments tolearning (cognitive, psychological, physiological), andthe value of adopting SOPs among team membersand standardizing renal program processes to improveefficiencies. Within a provincial framework and with arobust information system, it is possible to monitoroutcomes of both patients and the system using “CKDscorecards” as part of a continuous quality improvementcycle. The concepts and strategies described in the sympo-sium are synergistic (see Fig. 1) and, if integrated intocurrent existing systems, may serve as a template toimprove the care of patients with CKD across Canada.Understanding the barriers and opportunities to imple-mentation of standardized kidney care in different juris-dictions across Canada is an important future work.AbbreviationsACE/ARB: angiotensin converting enzyme/angiotensin receptor blocker;CANA: Canadian Association of Nephrology Administrators; CKD: chronickidney disease; CSN: Canadian Society of Nephrology; eGFR: estimatedglomerular filtration rate; ESRD: end-stage renal disease; RRT: renalreplacement therapy; SOPs: standardized operating procedures.Competing interestsThe authors declare that they have no competing interests.Authors’ contributionsDC drafted the manuscript which was critically revised by all authors. Allauthors have approved the final version of the manuscript.AcknowledgementsWe would like to thank Selina Allu for her work in preparation for andcoordination of the symposium and its participants.Author details1Section of Nephrology, University of Manitoba, Winnipeg, MB, Canada. 2TheOttawa Hospital, Ottawa, ON, Canada. 3Division of Geriatric Medicine, McGillUniversity, Montreal, QC, Canada. 4Division of Nephrology, University ofBritish Columbia, Vancouver, BC, Canada.Received: 2 December 2015 Accepted: 27 April 2016References1. CIHI. CORR Annual Report: Treatment of ESOF in Canada, 2004 to 2013.Canadian institute for health information. In: Canadian organ replacementregister annual report: Treatment of end-stage organ failure in canada, 2004to 2013. Ottawa, ON: CIHI; 2015.2. Stevens LA, Li S, Wang C, et al. Prevalence of CKD and comorbid illness inelderly patients in the united states: Results from the kidney earlyevaluation program (KEEP). 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Creating a model for improvedchronic kidney disease care: Designing parameters in quality, efficiency andaccountability. Nephrol Dial Transplant. 2010;25(11):3623–30.42. http://www.bcrenalagency.ca/documents/best-practices-guideline-kidney-care-clinics Accessed April 13, 2016.•  We accept pre-submission inquiries •  Our selector tool helps you to find the most relevant journal•  We provide round the clock customer support •  Convenient online submission•  Thorough peer review•  Inclusion in PubMed and all major indexing services •  Maximum visibility for your researchSubmit your manuscript atwww.biomedcentral.com/submitSubmit your next manuscript to BioMed Central and we will help you at every step:Collister et al. Canadian Journal of Kidney Health and Disease  (2016) 3:32 Page 7 of 7

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