Archives of Medical Research 44 (2013) 611e615
REVIEW ARTICLE
Multidisciplinary Strategies in the Management of Early Chronic Kidney Disease Hector R. Martınez-Ramırez, Laura Cortes-Sanabria, Enrique Rojas-Campos, Aurora Hernandez-Herrera, and Alfonso M. Cueto-Manzano Medical Research Unit in Kidney Disease, Specialty Hospital, CMNO, IMSS, Guadalajara, Jalisco, Mexico Received for publication August 22, 2013; accepted October 22, 2013 (ARCMED-D-13-00464).
Chronic kidney disease (CKD) is a worldwide epidemic especially in developing countries, with clear deficiencies in identification and treatment. Better care of CKD requires more than only economic resources, utilization of health research in policy-making and health systems changes that produce better outcomes. A multidisciplinary approach may facilitate and improve management of patients from early CKD in the primary health-care setting. This approach is a strategy for improving comprehensive care, initiating and maintaining healthy behaviors, promoting teamwork, eliminating barriers to achieve goals and improving the processes of care. A multidisciplinary intervention may include educational processes guided by health professional, use of self-help groups and the development of a CKD management plan. The complex and fragmented care management of patients with CKD, associated with poor outcome, enhances the importance of implementing a multidisciplinary approach in the management of this disease from the early stages. Multidisciplinary strategies should focus on the needs of patients (to increase their empowerment) and should be adapted to the resources and health systems prevailing in each country; its systematic implementation can help to improve patient care and slow the progression of CKD. Ó 2013 IMSS. Published by Elsevier Inc. Key Words: Multidisciplinary strategies, Early chronic kidney disease, Primary health care.
Introduction Problem Description Chronic kidney disease (CKD) is a worldwide epidemic, especially in disadvantaged populations, with marked deficiencies in its identification and treatment (1e3). Moreover, due to the excessive economic cost of end-stage renal disease (ESRD) treatment, the situation of developing countries is particularly worrisome because many of them currently have very high incidence rates, mostly due to diabetes (4).
Address reprint requests to: Dr. Alfonso M. Cueto-Manzano, Unidad de Investigaci on Medica en Enfermedades Renales, Hospital de Especialidades, CMNO, IMSS, Belisario Domınguez No. 1000, Col. Independencia, Guadalajara, Jalisco, Mexico; Phone: þ52 (33) 36683000, ext. 32204; FAX: þ52 (33) 36245050; E-mail: [email protected]
The Mexican CKD scenario is extraordinarily complex: it has displayed the highest general and diabetic incidence rates of ESRD over the last years (4), which could be related, at least partially, with the increased prevalence of risk factors for developing CKD in our population (5e9) and the incongruity between CKD patients’ needs and the health-care delivery systems, largely designed for managing acute illnesses (10). Need for Optimal Care in Patients with Early Chronic Renal Disease In some developing countries like Mexico, there is an increasingly high prevalence of overweight and obesity from early ages, associated with changes in dietary (5) and physical activity (6) patterns. There is also an increase of noncommunicable diseases such as type 2 diabetes mellitus (DM2) and hypertension (7e9) which, on the other hand, are the main causes of CKD (4). Moreover, it is very
0188-4409/$ - see front matter. Copyright Ó 2013 IMSS. Published by Elsevier Inc. http://dx.doi.org/10.1016/j.arcmed.2013.10.013
612
Martınez-Ramırez et al./ Archives of Medical Research 44 (2013) 611e615
common that patients during early stages of CKD do not meet clinical practice recommendations for an effective control (3). They have negative lifestyle habits, which are strongly associated with kidney damage and difficult to change only with medical intervention (11,12). Serious difficulties for primary physicians to provide the optimal management to CKD patients include the overwhelming work at the primary care units and the limited time available from their saturated schedule (13). In addition, current healthcare systems are designed to respond rapidly and efficiently to any acute illness or injury but they are poorly configured to treat chronic diseases (10) (such as CKD), which require cooperation from the patients themselves to perform self-care (14). Evidence shows that multidisciplinary models should be included from the early stages of CKD. These models should be based on patient’s needs and seek encouragement and promotion of the active participation of patients to increase self-care and to modify negative lifestyle habits associated with progression of renal damage (14e17). Recently, a call for more resources has been made to improve renal health in developing countries (1). Better care of CKD requires more than only economic resources, including utilization of health research in policy-making (18) and health systems changes (10) to produce better outcomes and models to promote effective interactions between health teams and patients (15,16). A multidisciplinary approach may facilitate and improve management of patients from early CKD in the primary healthcare setting. Multidisciplinary Strategies to Improve Self-care in Patients with Chronic Kidney Disease Multidisciplinary approach is a strategy to improve health care and is very useful to initiate and maintain healthy behaviors, promote teamwork, eliminate barriers to achieve goals and improve the processes of care for each patient (19e22). Strategies to increase the empowerment and self-care of patients with early CKD are strongly related with the involvement of multidisciplinary teams and include educational processes guided by health professionals, self-help groups and development of a management plan (14,19e23). Educational Processes Educational processes guided by professionals and focused on the patients’ needs can help to increase the skills to solve problems, improve efficiency and support the application of knowledge to real situations (19e24). These processes are related with the better understanding of the disease, increase self-confidence, achieve healthy behaviors, decrease symptomatology and improve outcomes (19e24). Physicians and the multidisciplinary team interact to identify and remove barriers and to promote patient education with available community resources. Success of these strategies,
particularly in patients with CKD, requires an adequately trained multidisciplinary team (15,16). Additionally, patients must be supported by the integration of self-help groups to encourage the development of individual skills to maintain renal function and general health. Self-help Groups The simple transmission of information to patients is insufficient to modify risky behaviors. The most successful interventions for this purpose are those promoting patient empowerment (19e24). Integration of patients within selfhelp groups may contribute to increase the decision-making skills, promote the active participation in self-care actions, and help to increase the motivation in the search for solutions of common problems (for instance, lack of metabolic control, hypertension, smoking, sedentary lifestyle, unhealthy diet and lack of adherence to treatment) (25e28). These groups also increase the self-confidence in patients and promote changes towards healthy behaviors, identifying family, social and health team support networks (23,24,29). Positive effects of the use of these kinds of groups have been demonstrated in patients with early CKD (15e17). Long-term preservation of healthy behaviors can be supported by additional community resources such as groups like Alcoholics Anonymous, Neurotics Anonymous, Compulsive Eaters Anonymous, Diabetes Clubs, and Stop-Smoking Clinics, among others (24e29). Patients may gain experience in self-care actions inspired by models of community leaders and improve their everyday skills as well as increase their ability to reinterpret symptoms and to distinguish discomfort due to illness or other causes (24e29). Development of a Management Plan for Chronic Kidney Disease The most important action that should be made by the healthcare team in conjunction with the patient to prevent or stop the progression of kidney damage is the development of a management plan for the disease. This plan should have specific actions according to the stage of CKD (14,22,29). The management plan is a dialogue between the healthcare team and the patient in which the latter identifies steps, removes barriers and provides the necessary resources to achieve their goals. The healthcare team must be aware of the patients’ motivation and selfconfidence in order to achieve and maintain healthy behavioral changes over time (14,22,29). The healthcare team should support patients to develop and implement the management plan for establishing clear and reachable goals to reduce risk factors of renal damage progression (14,22,29). With a CKD management plan, the control of other chronic diseases such as diabetes and hypertension could be obtained. Strategies to modify risky behaviors and to improve self-care require the effort and frequent
Multidisciplinary Intervention Model and Early CKD
contact with the multidisciplinary team in order to achieve the goals of training and treatment to assess the patient’s progress and to teach the tools for solving the everyday problems. The approach must be individualized, taking into consideration the cultural and economic status, beliefs and knowledge of the patients. Multidisciplinary participation is needed to assess the abilities of patients and their demands for self-care generation (14,22,29). Perspectives of Care for Chronic Kidney Disease The essential elements in any multidisciplinary intervention of care for a chronic condition are based on appropriate and early identification of patients, a supportive system for longitudinal follow-up evaluation (as opposed to episodic care), and the implementation of interventions to delay progression of the condition. In the case of progression of CKD, the multidisciplinary intervention will also help to provide a timely preparation for renal replacement therapy (dialysis or transplantation) (30). Complexity of the factors involved in the management of CKD makes necessary the multidisciplinary approach to optimize renal care (14e17,30e35). Several models with comprehensive approaches have been proposed (14e16,30,36,37). Systems developed in some developed countries suggest the implementation of models for chronic care focused on the needs of patients through the implementation of specialized multidisciplinary clinics (30). However, extrapolation or implementation of such systems in disadvantaged populations will depend on the capacity of the health system in each country. Therefore, evaluation of multidisciplinary strategies must be a constant with the available resources that every health system could support while moving towards a specific model of CKD care (14e16,30,36,37). A more feasible strategy in countries with limited resources (as Mexico), considering the excessive variability of the CKD management, could be the systematization of care for highrisk patients or patients with early stages of CKD (37). Such a management systematization would facilitate the identification of patients at risk, their clinical assessment, CKD diagnosis and classification as well as the establishment of a multidisciplinary management plan (Figure 1) (37). This conceptual model for CKD care is the backbone of the systematic approach; multidisciplinary strategies promoting self-care (educational processes, self-help groups, and the management plan) must be integrated in the process of care. A successful translation of knowledge into practice requires the active participation of patients, multidisciplinary efforts, and financial and administrative resources (37). Impact of the Multidisciplinary Approach on Early Chronic Kidney Disease In recent years there has been an interest in the use of multidisciplinary approaches for the management of patients with
613
CKD. Most reports, however, have described the outcomes of patients referred to nephrologists, with linkage to primary care, aimed at moderate to late stages of CKD (30e35). The advantage of a multidisciplinary approach on kidney function in patients with those stages of CKD is controversial. Some studies have failed to demonstrate improvement in renal function, mortality or control of risk factors with the employment of multidisciplinary teams in patients with CKD stage 3e5 (31e33), whereas others have shown a better survival (34) or slower decline in glomerular filtration rate (35) compared to patients receiving usual care. Several measures are recognized to decrease the risk or slow the progression of renal damage and are most effective when initiated early in the course of renal disease (38,39). Interestingly, however, few studies have evaluated the benefit of multidisciplinary models at early stages of CKD (before the referral to nephrologists). In this regard, several multidisciplinary strategies have been evaluated by our group to counteract the progression of renal damage at early stages of CKD (11,12,15e17). A very early referral to the nephrologist and the adequate training of family physicians preserve significantly better the renal function of DM2 patients with early nephropathy (11,12). However, several variables strongly related with negative lifestyle habits (such as metabolic and weight control, and stopping tobacco and alcohol intake) were not adequately controlled by either nephrologists (11) or by family physicians (12), probably because of the fact that these factors involve psychological, sociocultural and economic factors that are difficult to modify only by physicians. In another study (15), in patients without CKD but at high risk for developing it, the use of educational strategies for patients guided by health professionals (a multidisciplinary team including social worker, dietitian, physical trainer and family physician) and supported by self-help groups were effective in modifying negative lifestyle and nutritional habits (15). Based on the previous results, we recently evaluated the hypothesis that, in addition to adequate training to family physicians, a multiple approach guided by a multidisciplinary healthcare team may attain better results on lifestyle and renal function of DM2 patients with early CKD compared with a conventional approach in which primary physicians play the major role in treating patients and deciding when to refer them to other health professionals (16). This study included multiple and complementary strategies to potentiate a positive impact on patients: educational interventions, self-help groups and group dynamics. Results showed that a multidisciplinary approach had better control of lifestyle variables compared with the conventional approach (16), which supports previous evidence and reinforces the notion that multidisciplinary strategies could help to improve the care of patients with early CKD in the primary healthcare setting. In conclusion, the complex and fragmented care management of patients with CKD associated with poor
614
Martınez-Ramırez et al./ Archives of Medical Research 44 (2013) 611e615
Figure 1. General model of care for chronic kidney disease. (A color figure can be found in the online version of this article.)
outcome enhances the importance of implementing a multidisciplinary approach in the management of this disease from the early stages. Multidisciplinary strategies should focus on the needs of patients (to increase their empowerment) and should be adapted to the resources and health systems prevailing in each country; its systematic implementation can help to improve patient care and slow the progression of CKD.
References 1. Pugsley D. Kidney disease in disadvantaged populations: still a Herculean challenge. Kidney Int 2013;3(suppl 3):151e152.
2. Cueto-Manzano AM, Cortes-Sanabria L, Martınez-Ramırez HR, et al. Detection of early nephropathy in Mexican patients with type 2 diabetes mellitus. Kidney Int 2005;68(suppl 97):S40eS45. 3. Martınez-Ramırez HR, Cortes-Sanabria L, Rojas-Campos E, et al. How frequently the clinical practice recommendations for nephropathy are achieved in patients with type 2 diabetes mellitus in a primary health-care setting? Rev Invest Clin 2008;60:217e226. 4. The United States Renal Data System (USRDS): http://www.usrds.org (accessed April 23, 2013). 5. Shamah-Levy T, Cuevas-Nasu L, Mendez-Gomez-Humaran, et al. Obesity in Mexican school age children is associated with out-ofhome food consumption: in the journey from home to school. Arch Latinoam Nutr 2011;61:288e295. 6. Jauregui A, Villalpando S, Rangel-Baltazar E, et al. The physical activity level of Mexican children decreases upon entry to elementary school. Salud Publica Mex 2011;53:228e236.
Multidisciplinary Intervention Model and Early CKD 7. Villapando S, Shamah-Levy T, Rojas R, et al. Trends for type 2 diabetes and other cardiovascular risk factors in Mexico from 1993e2006. Salud Publica Mex 2010;52(suppl 1):S72eS79. 8. Olaız-Fernandez G, Rivera-Dommarco J, Shamah-Levy T, et al. Encuesta Nacional de Salud y Nutricion 2006. Cuernavaca, Mexico: Instituto Nacional de Salud Publica, 2006. http://www.insp.mx/ensanut/ ensanut2006.pdf (accessed 16 July 2013). 9. Gutıerrez JP, Rivera-Dommarco J, Shamah-Levy T, et al. Encuesta Nacional de Salud y Nutricion 2012. Resultados Nacionales. Cuernavaca, Mexico: Instituto Nacional de Salud Publica (MX) 2012. http://ensanut. insp.mx/informes/ENSANUT2012ResultadosNacionales.pdf (accessed July 16, 2013). 10. Wagner EH, Austin BT, Davis C, et al. Improving chronic illness care: translating evidence into action. Health Aff 2001;20:64e78. 11. Martınez Ramırez HR, Jalomo-Martınez B, Cortes-Sanabria L, et al. Renal function preservation in type 2 diabetes mellitus patients with early nephropathy: a comparative prospective cohort study between primary health care doctors and a nephrologist. Am J Kidney Dis 2006;47:78e87. 12. Cortes-Sanabria L, Cabrera-Pivaral CE, Cueto-Manzano AM, et al. Improving care of patients with diabetes and CKD: a pilot study for a cluster-randomized trial. Am J Kidney Dis 2008;51:777e788. 13. Lee TH. Perspective: The future of primary care. The need for reinvention. N Engl J Med 2008;359:2085e2086. 14. Thomas-Hawkins C, Zazworsky D. Self-management of chronic kidney disease. Am J Nurs 2005;105:40e48. 15. Cueto-Manzano AM, Martınez-Ramırez HR, Cortes-Sanabria L. Management of chronic kidney disease: primary health-care setting, selfcare and multidisciplinary approach. Clin Nephrol 2010;74(suppl 1): S99eS104. 16. Cueto-Manzano AM, Martınez-Ramırez HR, Cortes-Sanabria L. Comparison of primary health-care models in the management of chronic kidney disease. Kidney Int Suppl 2013;3:210e214. 17. Cueto-Manzano AM, Cortes-Sanabria L, Martınez-Ramırez HR. Role of the primary health-care physician in diagnosis and treatment of patients with early renal damage. Ethn Dis 2009;19(1suppl 1):S68eS72. 18. Hanney SR, Gonzalez-Block MA, Buxton MJ, et al. The utilization of health research in policy-making: concepts, examples and methods of assessment. Health Res Policy Syst 2003;1:2. http://dx.doi.org/10. 1186/1478-4505-1-2. 19. Coulter A, Ellis J. Effectiveness of strategies for informing, educating, and involving patients. BMJ 2007;335:24e27. 20. Coleman MT, Newton KS. Supporting self-management in patients with chronic illness. Am Fam Physician 2005;72:1503e1510. 21. Orem DE. Nursing Concepts of Practice. 6th ed. St. Louis: Mosby; 2001. 22. Rivera Mercado S, Villouta Cassinelli MF, Ilabaca Grez A. Motivational interviews: what is their effectiveness in prevalent primary care problems? Aten Primaria 2008;40:257e261. 23. Wallerstein N. What is the evidence on effectiveness of empowerment to improve health? Copenhagen, WHO Regional Office for Europe (Health Evidence Network Report.http://www.euro.who.int/_data/ assest/pdf_file/0010/74656/E88086.pdf (accessed June 23, 2013). 24. Organizaci on Mundial de la Salud. Informe sobre la salud en el mundo 2008: La atenci on primaria de salud, mas necesaria que nunca. http:// www.who.int/whr/2008/08_report_es.pdf (accessed July 16, 2013).
615
25. Brown SA, Blozis SA, Kouzekanani K, et al. Dosage effects of diabetes self-management education for Mexican Americans: The Starr Country border health initiative. Diabetes Care 2005;28:527e532. 26. Manzini FC, Simonetti JP. Nursing consultation applied to hypertensive clients: application of Orem’s self-care theory. Rev Lat Am Enfermagem 2009;17:113e119. 27. Staten LK, Cutshaw CA, Davidson C, et al. Effectiveness of the pasos adelante chronic disease prevention and control program in a USMexico border community, 2005e2008. Prev Chronic Dis 2012;9: 100301. http://dx.doi.org/10.5888/pcd9.100301 (accessed July 16, 2013). 28. Coleman T, Agboola S, Leornadi-Bee J, et al. Relapse prevention in UK stop smoking services: current practice, systematic reviews of effectiveness and cost-effectiveness analysis. Health Technol Assess 2010;14:1e152. 29. Martınez Ramırez HR, Hernandez Herrera A. Autocuidado y enfermedad renal cronica. In: Cueto-Manzano AM, Cortes-Sanabria L, Martınez-Ramırez HR, Rojas-Campos E, eds. Enfermedad Renal Cronica Temprana, Prevencion, Diagnostico y Tratamiento. Mexico: Editorial Panamericana; 2013. pp. 207e225. 30. Beaulieu M, Levin A. Analysis of multidisciplinary care models and interface with primary care in management of chronic kidney disease. Semin Nephrol 2009;29:467e474. 31. Harris LE, Luft FC, Rudy DW, et al. Effects of multidisciplinary case management in patients with chronic renal insufficiency. Am J Med 1998;105:464e471. 32. Isbel NM, Haluska B, Johnson DW, et al. Increased targeting of cardiovascular risk factors in patients with chronic kidney disease does not improve atheroma burden or cardiovascular function. Am Heart J 2006;151:745e753. 33. Barret BJ, Garg AX, Goeree R, et al. A nurse-coordinated model of care versus usual care for stage 3/4 chronic kidney disease in the community: a randomized controlled trial. Clin J Am Soc Nephrol 2011;6: 1241e2147. 34. Hemmelgarn BR, Manns BJ, Zhang J, et al. Association between multidisciplinary care and survival for elderly patients with chronic kidney disease. J Am Soc Nephrol 2007;18:993e999. 35. Bayliss EA, Bhardwaja B, Ross C, et al. Multidisciplinary team care may slow the rate of decline in renal function. Clin J Am Soc Nephrol 2011;6:704e710. 36. Calderon RB, Depine S. Sustainable and tenable renal health model: a Latin American proposal of classification, programming, and evaluation. Kidney Int 2005;(suppl 97):S23eS30. 37. Cueto-Manzano AM, Martınez- Ramırez HR, Cortes-Sanabria L, et al. Modelo de atencion de la enfermedad renal cronica. In: CuetoManzano AM, Cortes-Sanabria L, Martınez-Ramırez HR, RojasCampos E, eds. Enfermedad Renal Cronica Temprana, Prevencion, Diagnostico y Tratamiento. Mexico: Editorial Panamericana; 2013. pp. 59e64. 38. Kidney Disease Outcomes Quality Initiative. K/DOQI Clinical Practice Guidelines for Chronic Kidney Disease: Clinical Practice Guidelines and Clinical Practice Recommendations for Diabetes in Chronic Kidney Disease. Am J Kidney Dis 2007;49(suppl 2):S1eS182. 39. Kidney Disease Improving Global Outcomes. KDIGO 2012 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease. Kidney Int 2013;(suppl 3):1e150.
REVIEW ARTICLE
Multidisciplinary Strategies in the Management of Early Chronic Kidney Disease Hector R. Martınez-Ramırez, Laura Cortes-Sanabria, Enrique Rojas-Campos, Aurora Hernandez-Herrera, and Alfonso M. Cueto-Manzano Medical Research Unit in Kidney Disease, Specialty Hospital, CMNO, IMSS, Guadalajara, Jalisco, Mexico Received for publication August 22, 2013; accepted October 22, 2013 (ARCMED-D-13-00464).
Chronic kidney disease (CKD) is a worldwide epidemic especially in developing countries, with clear deficiencies in identification and treatment. Better care of CKD requires more than only economic resources, utilization of health research in policy-making and health systems changes that produce better outcomes. A multidisciplinary approach may facilitate and improve management of patients from early CKD in the primary health-care setting. This approach is a strategy for improving comprehensive care, initiating and maintaining healthy behaviors, promoting teamwork, eliminating barriers to achieve goals and improving the processes of care. A multidisciplinary intervention may include educational processes guided by health professional, use of self-help groups and the development of a CKD management plan. The complex and fragmented care management of patients with CKD, associated with poor outcome, enhances the importance of implementing a multidisciplinary approach in the management of this disease from the early stages. Multidisciplinary strategies should focus on the needs of patients (to increase their empowerment) and should be adapted to the resources and health systems prevailing in each country; its systematic implementation can help to improve patient care and slow the progression of CKD. Ó 2013 IMSS. Published by Elsevier Inc. Key Words: Multidisciplinary strategies, Early chronic kidney disease, Primary health care.
Introduction Problem Description Chronic kidney disease (CKD) is a worldwide epidemic, especially in disadvantaged populations, with marked deficiencies in its identification and treatment (1e3). Moreover, due to the excessive economic cost of end-stage renal disease (ESRD) treatment, the situation of developing countries is particularly worrisome because many of them currently have very high incidence rates, mostly due to diabetes (4).
Address reprint requests to: Dr. Alfonso M. Cueto-Manzano, Unidad de Investigaci on Medica en Enfermedades Renales, Hospital de Especialidades, CMNO, IMSS, Belisario Domınguez No. 1000, Col. Independencia, Guadalajara, Jalisco, Mexico; Phone: þ52 (33) 36683000, ext. 32204; FAX: þ52 (33) 36245050; E-mail: [email protected]
The Mexican CKD scenario is extraordinarily complex: it has displayed the highest general and diabetic incidence rates of ESRD over the last years (4), which could be related, at least partially, with the increased prevalence of risk factors for developing CKD in our population (5e9) and the incongruity between CKD patients’ needs and the health-care delivery systems, largely designed for managing acute illnesses (10). Need for Optimal Care in Patients with Early Chronic Renal Disease In some developing countries like Mexico, there is an increasingly high prevalence of overweight and obesity from early ages, associated with changes in dietary (5) and physical activity (6) patterns. There is also an increase of noncommunicable diseases such as type 2 diabetes mellitus (DM2) and hypertension (7e9) which, on the other hand, are the main causes of CKD (4). Moreover, it is very
0188-4409/$ - see front matter. Copyright Ó 2013 IMSS. Published by Elsevier Inc. http://dx.doi.org/10.1016/j.arcmed.2013.10.013
612
Martınez-Ramırez et al./ Archives of Medical Research 44 (2013) 611e615
common that patients during early stages of CKD do not meet clinical practice recommendations for an effective control (3). They have negative lifestyle habits, which are strongly associated with kidney damage and difficult to change only with medical intervention (11,12). Serious difficulties for primary physicians to provide the optimal management to CKD patients include the overwhelming work at the primary care units and the limited time available from their saturated schedule (13). In addition, current healthcare systems are designed to respond rapidly and efficiently to any acute illness or injury but they are poorly configured to treat chronic diseases (10) (such as CKD), which require cooperation from the patients themselves to perform self-care (14). Evidence shows that multidisciplinary models should be included from the early stages of CKD. These models should be based on patient’s needs and seek encouragement and promotion of the active participation of patients to increase self-care and to modify negative lifestyle habits associated with progression of renal damage (14e17). Recently, a call for more resources has been made to improve renal health in developing countries (1). Better care of CKD requires more than only economic resources, including utilization of health research in policy-making (18) and health systems changes (10) to produce better outcomes and models to promote effective interactions between health teams and patients (15,16). A multidisciplinary approach may facilitate and improve management of patients from early CKD in the primary healthcare setting. Multidisciplinary Strategies to Improve Self-care in Patients with Chronic Kidney Disease Multidisciplinary approach is a strategy to improve health care and is very useful to initiate and maintain healthy behaviors, promote teamwork, eliminate barriers to achieve goals and improve the processes of care for each patient (19e22). Strategies to increase the empowerment and self-care of patients with early CKD are strongly related with the involvement of multidisciplinary teams and include educational processes guided by health professionals, self-help groups and development of a management plan (14,19e23). Educational Processes Educational processes guided by professionals and focused on the patients’ needs can help to increase the skills to solve problems, improve efficiency and support the application of knowledge to real situations (19e24). These processes are related with the better understanding of the disease, increase self-confidence, achieve healthy behaviors, decrease symptomatology and improve outcomes (19e24). Physicians and the multidisciplinary team interact to identify and remove barriers and to promote patient education with available community resources. Success of these strategies,
particularly in patients with CKD, requires an adequately trained multidisciplinary team (15,16). Additionally, patients must be supported by the integration of self-help groups to encourage the development of individual skills to maintain renal function and general health. Self-help Groups The simple transmission of information to patients is insufficient to modify risky behaviors. The most successful interventions for this purpose are those promoting patient empowerment (19e24). Integration of patients within selfhelp groups may contribute to increase the decision-making skills, promote the active participation in self-care actions, and help to increase the motivation in the search for solutions of common problems (for instance, lack of metabolic control, hypertension, smoking, sedentary lifestyle, unhealthy diet and lack of adherence to treatment) (25e28). These groups also increase the self-confidence in patients and promote changes towards healthy behaviors, identifying family, social and health team support networks (23,24,29). Positive effects of the use of these kinds of groups have been demonstrated in patients with early CKD (15e17). Long-term preservation of healthy behaviors can be supported by additional community resources such as groups like Alcoholics Anonymous, Neurotics Anonymous, Compulsive Eaters Anonymous, Diabetes Clubs, and Stop-Smoking Clinics, among others (24e29). Patients may gain experience in self-care actions inspired by models of community leaders and improve their everyday skills as well as increase their ability to reinterpret symptoms and to distinguish discomfort due to illness or other causes (24e29). Development of a Management Plan for Chronic Kidney Disease The most important action that should be made by the healthcare team in conjunction with the patient to prevent or stop the progression of kidney damage is the development of a management plan for the disease. This plan should have specific actions according to the stage of CKD (14,22,29). The management plan is a dialogue between the healthcare team and the patient in which the latter identifies steps, removes barriers and provides the necessary resources to achieve their goals. The healthcare team must be aware of the patients’ motivation and selfconfidence in order to achieve and maintain healthy behavioral changes over time (14,22,29). The healthcare team should support patients to develop and implement the management plan for establishing clear and reachable goals to reduce risk factors of renal damage progression (14,22,29). With a CKD management plan, the control of other chronic diseases such as diabetes and hypertension could be obtained. Strategies to modify risky behaviors and to improve self-care require the effort and frequent
Multidisciplinary Intervention Model and Early CKD
contact with the multidisciplinary team in order to achieve the goals of training and treatment to assess the patient’s progress and to teach the tools for solving the everyday problems. The approach must be individualized, taking into consideration the cultural and economic status, beliefs and knowledge of the patients. Multidisciplinary participation is needed to assess the abilities of patients and their demands for self-care generation (14,22,29). Perspectives of Care for Chronic Kidney Disease The essential elements in any multidisciplinary intervention of care for a chronic condition are based on appropriate and early identification of patients, a supportive system for longitudinal follow-up evaluation (as opposed to episodic care), and the implementation of interventions to delay progression of the condition. In the case of progression of CKD, the multidisciplinary intervention will also help to provide a timely preparation for renal replacement therapy (dialysis or transplantation) (30). Complexity of the factors involved in the management of CKD makes necessary the multidisciplinary approach to optimize renal care (14e17,30e35). Several models with comprehensive approaches have been proposed (14e16,30,36,37). Systems developed in some developed countries suggest the implementation of models for chronic care focused on the needs of patients through the implementation of specialized multidisciplinary clinics (30). However, extrapolation or implementation of such systems in disadvantaged populations will depend on the capacity of the health system in each country. Therefore, evaluation of multidisciplinary strategies must be a constant with the available resources that every health system could support while moving towards a specific model of CKD care (14e16,30,36,37). A more feasible strategy in countries with limited resources (as Mexico), considering the excessive variability of the CKD management, could be the systematization of care for highrisk patients or patients with early stages of CKD (37). Such a management systematization would facilitate the identification of patients at risk, their clinical assessment, CKD diagnosis and classification as well as the establishment of a multidisciplinary management plan (Figure 1) (37). This conceptual model for CKD care is the backbone of the systematic approach; multidisciplinary strategies promoting self-care (educational processes, self-help groups, and the management plan) must be integrated in the process of care. A successful translation of knowledge into practice requires the active participation of patients, multidisciplinary efforts, and financial and administrative resources (37). Impact of the Multidisciplinary Approach on Early Chronic Kidney Disease In recent years there has been an interest in the use of multidisciplinary approaches for the management of patients with
613
CKD. Most reports, however, have described the outcomes of patients referred to nephrologists, with linkage to primary care, aimed at moderate to late stages of CKD (30e35). The advantage of a multidisciplinary approach on kidney function in patients with those stages of CKD is controversial. Some studies have failed to demonstrate improvement in renal function, mortality or control of risk factors with the employment of multidisciplinary teams in patients with CKD stage 3e5 (31e33), whereas others have shown a better survival (34) or slower decline in glomerular filtration rate (35) compared to patients receiving usual care. Several measures are recognized to decrease the risk or slow the progression of renal damage and are most effective when initiated early in the course of renal disease (38,39). Interestingly, however, few studies have evaluated the benefit of multidisciplinary models at early stages of CKD (before the referral to nephrologists). In this regard, several multidisciplinary strategies have been evaluated by our group to counteract the progression of renal damage at early stages of CKD (11,12,15e17). A very early referral to the nephrologist and the adequate training of family physicians preserve significantly better the renal function of DM2 patients with early nephropathy (11,12). However, several variables strongly related with negative lifestyle habits (such as metabolic and weight control, and stopping tobacco and alcohol intake) were not adequately controlled by either nephrologists (11) or by family physicians (12), probably because of the fact that these factors involve psychological, sociocultural and economic factors that are difficult to modify only by physicians. In another study (15), in patients without CKD but at high risk for developing it, the use of educational strategies for patients guided by health professionals (a multidisciplinary team including social worker, dietitian, physical trainer and family physician) and supported by self-help groups were effective in modifying negative lifestyle and nutritional habits (15). Based on the previous results, we recently evaluated the hypothesis that, in addition to adequate training to family physicians, a multiple approach guided by a multidisciplinary healthcare team may attain better results on lifestyle and renal function of DM2 patients with early CKD compared with a conventional approach in which primary physicians play the major role in treating patients and deciding when to refer them to other health professionals (16). This study included multiple and complementary strategies to potentiate a positive impact on patients: educational interventions, self-help groups and group dynamics. Results showed that a multidisciplinary approach had better control of lifestyle variables compared with the conventional approach (16), which supports previous evidence and reinforces the notion that multidisciplinary strategies could help to improve the care of patients with early CKD in the primary healthcare setting. In conclusion, the complex and fragmented care management of patients with CKD associated with poor
614
Martınez-Ramırez et al./ Archives of Medical Research 44 (2013) 611e615
Figure 1. General model of care for chronic kidney disease. (A color figure can be found in the online version of this article.)
outcome enhances the importance of implementing a multidisciplinary approach in the management of this disease from the early stages. Multidisciplinary strategies should focus on the needs of patients (to increase their empowerment) and should be adapted to the resources and health systems prevailing in each country; its systematic implementation can help to improve patient care and slow the progression of CKD.
References 1. Pugsley D. Kidney disease in disadvantaged populations: still a Herculean challenge. Kidney Int 2013;3(suppl 3):151e152.
2. Cueto-Manzano AM, Cortes-Sanabria L, Martınez-Ramırez HR, et al. Detection of early nephropathy in Mexican patients with type 2 diabetes mellitus. Kidney Int 2005;68(suppl 97):S40eS45. 3. Martınez-Ramırez HR, Cortes-Sanabria L, Rojas-Campos E, et al. How frequently the clinical practice recommendations for nephropathy are achieved in patients with type 2 diabetes mellitus in a primary health-care setting? Rev Invest Clin 2008;60:217e226. 4. The United States Renal Data System (USRDS): http://www.usrds.org (accessed April 23, 2013). 5. Shamah-Levy T, Cuevas-Nasu L, Mendez-Gomez-Humaran, et al. Obesity in Mexican school age children is associated with out-ofhome food consumption: in the journey from home to school. Arch Latinoam Nutr 2011;61:288e295. 6. Jauregui A, Villalpando S, Rangel-Baltazar E, et al. The physical activity level of Mexican children decreases upon entry to elementary school. Salud Publica Mex 2011;53:228e236.
Multidisciplinary Intervention Model and Early CKD 7. Villapando S, Shamah-Levy T, Rojas R, et al. Trends for type 2 diabetes and other cardiovascular risk factors in Mexico from 1993e2006. Salud Publica Mex 2010;52(suppl 1):S72eS79. 8. Olaız-Fernandez G, Rivera-Dommarco J, Shamah-Levy T, et al. Encuesta Nacional de Salud y Nutricion 2006. Cuernavaca, Mexico: Instituto Nacional de Salud Publica, 2006. http://www.insp.mx/ensanut/ ensanut2006.pdf (accessed 16 July 2013). 9. Gutıerrez JP, Rivera-Dommarco J, Shamah-Levy T, et al. Encuesta Nacional de Salud y Nutricion 2012. Resultados Nacionales. Cuernavaca, Mexico: Instituto Nacional de Salud Publica (MX) 2012. http://ensanut. insp.mx/informes/ENSANUT2012ResultadosNacionales.pdf (accessed July 16, 2013). 10. Wagner EH, Austin BT, Davis C, et al. Improving chronic illness care: translating evidence into action. Health Aff 2001;20:64e78. 11. Martınez Ramırez HR, Jalomo-Martınez B, Cortes-Sanabria L, et al. Renal function preservation in type 2 diabetes mellitus patients with early nephropathy: a comparative prospective cohort study between primary health care doctors and a nephrologist. Am J Kidney Dis 2006;47:78e87. 12. Cortes-Sanabria L, Cabrera-Pivaral CE, Cueto-Manzano AM, et al. Improving care of patients with diabetes and CKD: a pilot study for a cluster-randomized trial. Am J Kidney Dis 2008;51:777e788. 13. Lee TH. Perspective: The future of primary care. The need for reinvention. N Engl J Med 2008;359:2085e2086. 14. Thomas-Hawkins C, Zazworsky D. Self-management of chronic kidney disease. Am J Nurs 2005;105:40e48. 15. Cueto-Manzano AM, Martınez-Ramırez HR, Cortes-Sanabria L. Management of chronic kidney disease: primary health-care setting, selfcare and multidisciplinary approach. Clin Nephrol 2010;74(suppl 1): S99eS104. 16. Cueto-Manzano AM, Martınez-Ramırez HR, Cortes-Sanabria L. Comparison of primary health-care models in the management of chronic kidney disease. Kidney Int Suppl 2013;3:210e214. 17. Cueto-Manzano AM, Cortes-Sanabria L, Martınez-Ramırez HR. Role of the primary health-care physician in diagnosis and treatment of patients with early renal damage. Ethn Dis 2009;19(1suppl 1):S68eS72. 18. Hanney SR, Gonzalez-Block MA, Buxton MJ, et al. The utilization of health research in policy-making: concepts, examples and methods of assessment. Health Res Policy Syst 2003;1:2. http://dx.doi.org/10. 1186/1478-4505-1-2. 19. Coulter A, Ellis J. Effectiveness of strategies for informing, educating, and involving patients. BMJ 2007;335:24e27. 20. Coleman MT, Newton KS. Supporting self-management in patients with chronic illness. Am Fam Physician 2005;72:1503e1510. 21. Orem DE. Nursing Concepts of Practice. 6th ed. St. Louis: Mosby; 2001. 22. Rivera Mercado S, Villouta Cassinelli MF, Ilabaca Grez A. Motivational interviews: what is their effectiveness in prevalent primary care problems? Aten Primaria 2008;40:257e261. 23. Wallerstein N. What is the evidence on effectiveness of empowerment to improve health? Copenhagen, WHO Regional Office for Europe (Health Evidence Network Report.http://www.euro.who.int/_data/ assest/pdf_file/0010/74656/E88086.pdf (accessed June 23, 2013). 24. Organizaci on Mundial de la Salud. Informe sobre la salud en el mundo 2008: La atenci on primaria de salud, mas necesaria que nunca. http:// www.who.int/whr/2008/08_report_es.pdf (accessed July 16, 2013).
615
25. Brown SA, Blozis SA, Kouzekanani K, et al. Dosage effects of diabetes self-management education for Mexican Americans: The Starr Country border health initiative. Diabetes Care 2005;28:527e532. 26. Manzini FC, Simonetti JP. Nursing consultation applied to hypertensive clients: application of Orem’s self-care theory. Rev Lat Am Enfermagem 2009;17:113e119. 27. Staten LK, Cutshaw CA, Davidson C, et al. Effectiveness of the pasos adelante chronic disease prevention and control program in a USMexico border community, 2005e2008. Prev Chronic Dis 2012;9: 100301. http://dx.doi.org/10.5888/pcd9.100301 (accessed July 16, 2013). 28. Coleman T, Agboola S, Leornadi-Bee J, et al. Relapse prevention in UK stop smoking services: current practice, systematic reviews of effectiveness and cost-effectiveness analysis. Health Technol Assess 2010;14:1e152. 29. Martınez Ramırez HR, Hernandez Herrera A. Autocuidado y enfermedad renal cronica. In: Cueto-Manzano AM, Cortes-Sanabria L, Martınez-Ramırez HR, Rojas-Campos E, eds. Enfermedad Renal Cronica Temprana, Prevencion, Diagnostico y Tratamiento. Mexico: Editorial Panamericana; 2013. pp. 207e225. 30. Beaulieu M, Levin A. Analysis of multidisciplinary care models and interface with primary care in management of chronic kidney disease. Semin Nephrol 2009;29:467e474. 31. Harris LE, Luft FC, Rudy DW, et al. Effects of multidisciplinary case management in patients with chronic renal insufficiency. Am J Med 1998;105:464e471. 32. Isbel NM, Haluska B, Johnson DW, et al. Increased targeting of cardiovascular risk factors in patients with chronic kidney disease does not improve atheroma burden or cardiovascular function. Am Heart J 2006;151:745e753. 33. Barret BJ, Garg AX, Goeree R, et al. A nurse-coordinated model of care versus usual care for stage 3/4 chronic kidney disease in the community: a randomized controlled trial. Clin J Am Soc Nephrol 2011;6: 1241e2147. 34. Hemmelgarn BR, Manns BJ, Zhang J, et al. Association between multidisciplinary care and survival for elderly patients with chronic kidney disease. J Am Soc Nephrol 2007;18:993e999. 35. Bayliss EA, Bhardwaja B, Ross C, et al. Multidisciplinary team care may slow the rate of decline in renal function. Clin J Am Soc Nephrol 2011;6:704e710. 36. Calderon RB, Depine S. Sustainable and tenable renal health model: a Latin American proposal of classification, programming, and evaluation. Kidney Int 2005;(suppl 97):S23eS30. 37. Cueto-Manzano AM, Martınez- Ramırez HR, Cortes-Sanabria L, et al. Modelo de atencion de la enfermedad renal cronica. In: CuetoManzano AM, Cortes-Sanabria L, Martınez-Ramırez HR, RojasCampos E, eds. Enfermedad Renal Cronica Temprana, Prevencion, Diagnostico y Tratamiento. Mexico: Editorial Panamericana; 2013. pp. 59e64. 38. Kidney Disease Outcomes Quality Initiative. K/DOQI Clinical Practice Guidelines for Chronic Kidney Disease: Clinical Practice Guidelines and Clinical Practice Recommendations for Diabetes in Chronic Kidney Disease. Am J Kidney Dis 2007;49(suppl 2):S1eS182. 39. Kidney Disease Improving Global Outcomes. KDIGO 2012 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease. Kidney Int 2013;(suppl 3):1e150.
