Educational programs improve the preparation for dialysis and survival of patients with chronic kidney disease
2013; Elsevier BV; Volume: 85; Issue: 3 Linguagem: Inglês
10.1038/ki.2013.369
ISSN1523-1755
AutoresManjula Kurella Tamura, Suying Li, Shu‐Cheng Chen, Kerri L. Cavanaugh, Adam Whaley‐Connell, Peter A. McCullough, Rajnish Mehrotra,
Tópico(s)Blood Pressure and Hypertension Studies
ResumoPreparation for end-stage renal disease (ESRD) is widely acknowledged to be suboptimal in the United States. We sought to determine whether participation in a kidney disease screening and education program resulted in improved ESRD preparation and survival in 595 adults who developed ESRD after participating in the National Kidney Foundation Kidney Early Evaluation Program (KEEP), a community-based screening and education program. Non-KEEP patients were selected from a national ESRD registry and matched to KEEP participants based on demographic and clinical characteristics. The main outcomes were pre-ESRD nephrologist care, placement of permanent vascular access, use of peritoneal dialysis, pre-emptive transplant wait listing, transplantation, and mortality after ESRD. Participation in KEEP was associated with significantly higher rates of pre-ESRD nephrologist care (76.0% vs. 69.3%), peritoneal dialysis (10.3% vs. 6.4%), pre-emptive transplant wait listing (24.2% vs. 17.1%), and transplantation (9.7% vs. 6.4%) but not with higher rates of permanent vascular access (23.4% vs. 20.1%). Participation in KEEP was associated with a lower risk for mortality (hazard ratio 0.80), but this was not statistically significant after adjusting for ESRD preparation. Thus, participation in a voluntary community kidney disease screening and education program was associated with higher rates of ESRD preparation and survival. Preparation for end-stage renal disease (ESRD) is widely acknowledged to be suboptimal in the United States. We sought to determine whether participation in a kidney disease screening and education program resulted in improved ESRD preparation and survival in 595 adults who developed ESRD after participating in the National Kidney Foundation Kidney Early Evaluation Program (KEEP), a community-based screening and education program. Non-KEEP patients were selected from a national ESRD registry and matched to KEEP participants based on demographic and clinical characteristics. The main outcomes were pre-ESRD nephrologist care, placement of permanent vascular access, use of peritoneal dialysis, pre-emptive transplant wait listing, transplantation, and mortality after ESRD. Participation in KEEP was associated with significantly higher rates of pre-ESRD nephrologist care (76.0% vs. 69.3%), peritoneal dialysis (10.3% vs. 6.4%), pre-emptive transplant wait listing (24.2% vs. 17.1%), and transplantation (9.7% vs. 6.4%) but not with higher rates of permanent vascular access (23.4% vs. 20.1%). Participation in KEEP was associated with a lower risk for mortality (hazard ratio 0.80), but this was not statistically significant after adjusting for ESRD preparation. Thus, participation in a voluntary community kidney disease screening and education program was associated with higher rates of ESRD preparation and survival. Preparation for end-stage renal disease (ESRD), a condition affecting more than 600,000 Americans, is widely acknowledged to be suboptimal.1.Narva A.S. Optimal preparation for ESRD.Clin J Am Soc Nephrol. 2009; 4: S110-S113Crossref PubMed Scopus (9) Google Scholar,2.Saggi S.J. Allon M. Bernardini J. et al.Considerations in the optimal preparation of patients for dialysis.Nat Rev Nephrol. 2012; 8: 381-389Crossref PubMed Scopus (47) Google Scholar Despite dissemination of practice guidelines for chronic kidney disease (CKD) and a Medicare benefit supporting pre-ESRD education, many patients experience care that falls short of recommendations. For example, more than 80% of patients who start hemodialysis do so with a central venous catheter rather than an arteriovenous fistula or graft.3.Collins A.J. Foley R.N. Chavers B. et al.United States Renal Data System 2011 Annual Data Report: Atlas of chronic kidney disease & end-stage renal disease in the United States.Am J Kidney Dis. 2012; 59: e215-e228Abstract Full Text Full Text PDF Scopus (175) Google Scholar Approximately 30–60% of potentially eligible patients do not receive information about peritoneal dialysis, a type of home dialysis, or transplantation before ESRD;4.Kutner N.G. Johansen K.L. Zhang R. et al.Perspectives on the new kidney disease education benefit: early awareness, race and kidney transplant access in a USRDS study.Am J Transplant. 2012; 12: 1017-1023Crossref PubMed Scopus (19) Google Scholar, 5.Kutner N.G. Zhang R. Huang Y. et al.Patient awareness and initiation of peritoneal dialysis.Arch Intern Med. 2011; 171: 119-124Crossref PubMed Scopus (36) Google Scholar, 6.Mehrotra R. Marsh D. Vonesh E. et al.Patient education and access of ESRD patients to renal replacement therapies beyond in-center hemodialysis.Kidney Int. 2005; 68: 378-390Abstract Full Text Full Text PDF PubMed Scopus (209) Google Scholar as a result, fewer than 10% of patients receive these treatment modalities at the onset of ESRD.3.Collins A.J. Foley R.N. Chavers B. et al.United States Renal Data System 2011 Annual Data Report: Atlas of chronic kidney disease & end-stage renal disease in the United States.Am J Kidney Dis. 2012; 59: e215-e228Abstract Full Text Full Text PDF Scopus (175) Google Scholar Suboptimal preparation for ESRD contributes to high mortality in the first year after dialysis initiation and excess costs.7.Mendelssohn D.C. Curtis B. Yeates K. et al.Suboptimal initiation of dialysis with and without early referral to a nephrologist.Nephrol Dial Transplant. 2011; 26: 2959-2965Crossref PubMed Scopus (107) Google Scholar Suboptimal preparation for ESRD reflects deficiencies in one or more processes of care: identification of patients at high risk of progression, education about ESRD treatment options, and timely referral, evaluation, and surgery for dialysis access placement and transplantation. Several lines of evidence, including two small trials, suggest that education programs for patients with advanced CKD increase uptake of peritoneal dialysis and may improve survival.8.Levin A. Lewis M. Mortiboy P. et al.Multidisciplinary predialysis programs: quantification and limitations of their impact on patient outcomes in two Canadian settings.Am J Kidney Dis. 1997; 29: 533-540Abstract Full Text PDF PubMed Scopus (183) Google Scholar, 9.Devins G.M. Mendelssohn D.C. Barre P.E. et al.Predialysis psychoeducational intervention extends survival in CKD: a 20-year follow-up.Am J Kidney Dis. 2005; 46: 1088-1098Abstract Full Text Full Text PDF PubMed Scopus (144) Google Scholar, 10.Manns B.J. Taub K. Vanderstraeten C. et al.The impact of education on chronic kidney disease patients’ plans to initiate dialysis with self-care dialysis: a randomized trial.Kidney Int. 2005; 68: 1777-1783Abstract Full Text Full Text PDF PubMed Scopus (175) Google Scholar, 11.Lacson Jr., E. Wang W. DeVries C. et al.Effects of a nationwide predialysis educational program on modality choice, vascular access, and patient outcomes.Am J Kidney Dis. 2011; 58: 235-242Abstract Full Text Full Text PDF PubMed Scopus (111) Google Scholar, 12.Plantinga L.C. Boulware L.E. Coresh J. et al.Patient awareness of chronic kidney disease: trends and predictors.Arch Intern Med. 2008; 168: 2268-2275Crossref PubMed Scopus (203) Google Scholar Unfortunately, low awareness of CKD, including among patients with advanced CKD,12.Plantinga L.C. Boulware L.E. Coresh J. et al.Patient awareness of chronic kidney disease: trends and predictors.Arch Intern Med. 2008; 168: 2268-2275Crossref PubMed Scopus (203) Google Scholar may limit the impact of these programs. Screening for CKD is one approach to increase awareness; however, universal or even targeted CKD screening programs remain controversial owing to the lack of evidence of benefit.13.Fink H.A. Ishani A. Taylor B.C. et al.Screening for, monitoring, and treatment of chronic kidney disease stages 1 to 3: a systematic review for the U.S. Preventive Services Task Force and for an American College of Physicians Clinical Practice Guideline.Ann Intern Med. 2012; 156: 570-581Crossref PubMed Scopus (137) Google Scholar Yet, most studies of CKD screening have not considered the potential effects that screening may have on ESRD preparation and outcomes nor have any studies to our knowledge assessed the effects of a combined CKD screening and education program. We assessed ESRD preparation and survival among participants in the Kidney Early Evaluation Program (KEEP), a national community-based kidney disease screening and education program, and matched non-KEEP patients from a national registry of individuals who developed ESRD between 2005 and 2010. We hypothesized that KEEP participants would have higher rates of preparation for ESRD, and that a more favorable profile of ESRD preparation among KEEP participants would largely explain ESRD mortality differences between KEEP participants and matched non-KEEP patients. KEEP participants who progressed to ESRD had a mean age of 63.2±13.9 years, 47.2% were men, 42.2% were white, and 57.5% had diabetes. Before matching, there were notable imbalances between KEEP participants and non-KEEP patients with ESRD (Table 1). For example, KEEP participants were more likely to be non-white and female individuals and less likely to have functional status limitations (standardized differences >10%). After matching, there were no measured characteristics that were significantly imbalanced (Table 1 and (Supplementary Table 1 online)).Table 1Baseline characteristics of KEEP participants with ESRD and non-KEEP patients before and after matchingBefore matchingAfter matchingNon-KEEPKEEPStandardized differenceNon-KEEPKEEPStandardized differenceN290,2525952975595Mean age (years)62.363.26.163.263.20.0Race White race (%)58.342.2-32.643.042.2-0.8 Black race (%)35.643.215.642.843.20.8 Other race (%)6.114.628.214.214.61.1Hispanic ethnicity (%)11.89.1-8.99.89.1-2.5Male (%)55.747.2-17.147.847.2-1.2Full- or part-time employment (%)11.411.91.611.211.92.3Incidence year 2005 (%)9.76.7-11.07.36.9-1.6 2006 (%)17.718.41.818.8190.5 2007 (%)17.814.9-7.815.215-0.6 2008 (%)17.917.7-0.517.217.30.3 2009 (%)18.525.116.024.524.50.0 2010 (%)18.417.1-3.417.017.30.8Medicaid coverage (%)7.47.1-1.27.17.10.0Diabetes (%)52.957.59.360.157.5-5.3Coronary artery disease (%)19.417.5-4.917.217.50.8Peripheral arterial disease (%)12.69.8-8.99.49.81.4Stroke (%)9.310.43.710.710.4-1.0Congestive heart failure (%)31.528.9-5.729.028.9-0.2Chronic lung disease (%)8.46.1-8.95.66.12.1Cancer (%)7.16.4-2.85.86.42.5Unable to walk (%)6.72.7-19.02.22.73.2Unable to transfer (%)3.41.2-14.70.91.22.9Needs assistance in activities of daily living (%)117.7-11.47.37.71.5Morbid obesity (%)9.09.009.49.0-1.4Alcohol dependence (%)1.70.7-9.60.70.7-0.4Drug dependence (%)1.60.5-10.40.50.5-0.6Abbreviations: ESRD, end-stage renal disease; KEEP, Kidney Early Evaluation Program. Open table in a new tab Download .doc (.05 MB) Help with doc files Suplementary Tables Abbreviations: ESRD, end-stage renal disease; KEEP, Kidney Early Evaluation Program. KEEP participants were more likely to see a nephrologist before ESRD (76.0% vs. 69.3%, P<0.01), more likely to use peritoneal dialysis versus hemodialysis (10.3% vs. 6.4%, P<0.01), more likely to be placed on the transplant waiting list before ESRD (24.2% vs. 17.1%, P<0.01), and more likely to undergo transplantation (9.7% vs. 6.4%, P<0.01), although they were not more likely to undergo pre-emptive transplantation (1.7% vs. 1.5%, P=0.7) (Table 2). KEEP participants were slightly more likely to use an arteriovenous fistula or graft (23.4% vs. 20.1%, P=0.09) at the first outpatient dialysis and slightly more likely to have a mature or maturing arteriovenous fistula or graft at the first outpatient dialysis (44.0% vs. 39.6%, P=0.06), but these differences were not statistically significant.Table 2Preparation for ESRD among KEEP participants and matched non-KEEP patientsFrequencyIndicators of ESRD preparationKEEP participant, N (%)Control, N (%)P-valueNephrology care before ESRDaExcluding missing value when calculating the percentage.409 (76.0)1847 (69.3)<0.01Arteriovenous fistula or graft used at first outpatient dialysis (vs. catheter)aExcluding missing value when calculating the percentage.,bIndividuals with pre-emptive transplant or using peritoneal dialysis excluded.122 (23.4)550 (20.1)0.09Arteriovenous fistula or graft present at first outpatient dialysis (vs. catheter only)aExcluding missing value when calculating the percentage.,bIndividuals with pre-emptive transplant or using peritoneal dialysis excluded.227 (44.0)1075 (39.6)0.06Peritoneal dialysis at initiationcIndividuals with pre-emptive transplant excluded.60 (10.3)186 (6.4)<0.01Placed on transplant waiting list before ESRD144 (24.2)510 (17.1)<0.01Pre-emptive transplant10 (1.7)43 (1.5)0.70Transplantation through end of follow-up48 (8.1)148 (5.0)<0.01 Living donor21 (3.5)60 (2.0) Deceased27 (4.5)88 (3.0)Abbreviations: ESRD, end-stage renal disease; KEEP, Kidney Early Evaluation Program.a Excluding missing value when calculating the percentage.b Individuals with pre-emptive transplant or using peritoneal dialysis excluded.c Individuals with pre-emptive transplant excluded. Open table in a new tab Abbreviations: ESRD, end-stage renal disease; KEEP, Kidney Early Evaluation Program. Over a median follow-up of 1.6 years after the onset of ESRD, there were 175 deaths among KEEP participants and 1037 deaths among non-KEEP patients (hazard ratio, 0.80; 95% confidence interval: 0.68–0.94) (Table 3). The association between KEEP participation and mortality was similar when we included all adults with ESRD and adjusted for variables in the propensity score model or when we directly adjusted for the propensity score (Supplementary Table 2 online).Table 3Unadjusted and adjusted risk of death among KEEP participants versus matched non-KEEP patients with ESRDModelHazard ratio (95% confidence interval)P-valueModel 1 (unadjusted)0.80 (0.68–0.94)<0.01Model 2aModel adjusted for anemia and hypoalbuminemia.0.80 (0.68–0.94)<0.01Model 2+nephrology referral0.81 (0.69–0.95)<0.01Model 2+use of peritoneal dialysis0.81 (0.69–0.95)<0.01Model 2+use of arteriovenous access at first outpatient dialysis0.82 (0.70–0.96)0.01Model 2+maturing arteriovenous access present at first outpatient dialysis0.83 (0.71–0.97)0.02Model 2+transplant waitlist status0.88 (0.75–1.03)0.10Model 2+kidney transplantation0.84 (0.71–0.98)0.02Fully adjustedbModel adjusted for anemia, hypoalbuminemia, nephrology referral, use of peritoneal dialysis, presence of mature arteriovenous access, presence of maturing arteriovenous access, waitlist status, and transplantation.0.88 (0.75–1.04)0.13Abbreviations: ESRD, end-stage renal disease; KEEP, Kidney Early Evaluation Program.There were 175 deaths among KEEP participants (N=595) and 1037 deaths among non-KEEP patients (N=2975)a Model adjusted for anemia and hypoalbuminemia.b Model adjusted for anemia, hypoalbuminemia, nephrology referral, use of peritoneal dialysis, presence of mature arteriovenous access, presence of maturing arteriovenous access, waitlist status, and transplantation. Open table in a new tab Abbreviations: ESRD, end-stage renal disease; KEEP, Kidney Early Evaluation Program. There were 175 deaths among KEEP participants (N=595) and 1037 deaths among non-KEEP patients (N=2975) The association between KEEP participation and mortality was similar after adjustment for anemia and hypoalbuminemia (Table 3). After additional adjustment for indicators of ESRD preparation (nephrology care, vascular access, peritoneal dialysis use, waitlist status, and transplantation), there was no statistically significant difference in mortality between KEEP participants and non-KEEP patients. Mean durations from KEEP screening to ESRD among participants with CKD stages 1–2, 3, and 4 were 48.3±20, 44.5±22.9, and 31.4±21.3 months, respectively (P<0.01). Compared with KEEP participants with CKD stage 1–2 at screening, those with more advanced CKD at KEEP screening were more likely to have an arteriovenous fistula or graft at the onset of ESRD and more likely to undergo transplantation (Table 4). There was a trend toward more frequent pre-ESRD nephrology care and greater use of peritoneal dialysis among those screened at later disease stages. In analyses adjusted for clinical characteristics, participants with stage 4 CKD at the KEEP event were more likely to be placed on the transplant waiting list compared with participants with stage 1–2 CKD.Table 4ESRD preparation according to CKD stage at KEEP screeningIndicators of ESRD preparationFrequency (%)P-valueAdjusted ORaModel adjusted for age, sex, race, education, diabetes, cardiovascular disease, and awareness of CKD.(95% CI)Nephrology care before ESRDStage 1–267.90.081.00 (Ref.)Stage 379.81.98 (0.94–4.19)Stage 481.31.79 (0.81–3.96)Arteriovenous fistula or graft used at first dialysis (vs. catheter)Stage 1–215.7<0.011.00 (Ref.)Stage 319.61.35 (0.55–3.34)Stage 431.92.41 (0.95–6.10)Maturing arteriovenous fistula or graft present at first dialysis (vs. catheter only)Stage 1–227.90.741.00 (Ref.)Stage 330.21.52 (0.62–3.72)Stage 430.91.62 (0.63–4.20)Peritoneal dialysis (vs. hemodialysis)Stage 1–210.50.081.00 (Ref.)Stage 37.10.74 (0.24–2.26)Stage 415.61.55 (0.52–4.65)Placed on transplant waiting list beforeESRD19.00.41.00 (Ref.)Stage 1–222.32.87 (1.13–7.28)Stage 324.04.35 (1.64–11.57)Stage 4Transplantation through end of follow-upStage 1–21.7<0.011.00 (Ref.)Stage 36.311.93 (1.15–123.86)Stage 412.339.92 (3.57–446.72)Abbreviations: CI, confidence interval; CKD, chronic kidney disease; ESRD, end-stage renal disease; KEEP, Kidney Early Evaluation Program; OR, odds ratio.Note: There were N=58 participants with stage 1–2 CKD, N=175 participants with stage 3 CKD, and N=171 participants with stage 4 CKD.a Model adjusted for age, sex, race, education, diabetes, cardiovascular disease, and awareness of CKD. Open table in a new tab Abbreviations: CI, confidence interval; CKD, chronic kidney disease; ESRD, end-stage renal disease; KEEP, Kidney Early Evaluation Program; OR, odds ratio. Note: There were N=58 participants with stage 1–2 CKD, N=175 participants with stage 3 CKD, and N=171 participants with stage 4 CKD. There were 196 participants who were aware of having kidney disease before the KEEP event and 364 participants who were not aware. Participants who were aware of kidney disease before KEEP were more likely to receive pre-ESRD nephrology care, have an arteriovenous fistula or graft at ESRD onset, and use peritoneal dialysis (Table 5). These associations persisted with adjustment for clinical characteristics and the stage of CKD. There was no association between awareness and transplant preparation.Table 5ESRD preparation according to awareness of CKD at KEEP screeningIndicators of ESRD preparationFrequency (%)P-valueAdjusted ORaModel adjusted for age, sex, race, education, diabetes, cardiovascular disease, and awareness of CKD. (95% CI)Nephrology care before ESRD CKD not aware72.8<0.011.00 (Ref.) CKD aware84.52.29 (1.38–3.79)Arteriovenous fistula or graft used at first Dialysis (vs. catheter)18.7<0.011.00 (Ref.) CKD not aware31.92.11 (1.30–3.42) CKD awareMaturing arteriovenous fistula or graft present at first dialysis (vs. catheter only) CKD not aware27.60.261.00 (Ref.) CKD aware33.31.46 (0.86–2.48)Peritoneal dialysis (vs. hemodialysis) CKD not aware8.40.031.00 (Ref.) CKD aware14.21.71 (0.93–3.16)Placed on transplant waiting list before ESRD CKD not aware22.80.261.00 (Ref.) CKD aware27.01.28 (0.79–2.08)Transplantation through end of follow-up CKD not aware7.10.211.00 (Ref.) CKD aware10.20.90 (0.42–1.92)Abbreviations: CI, confidence interval; CKD, chronic kidney disease; ESRD, end-stage renal disease; KEEP, Kidney Early Evaluation Program; OR, odds ratio.Note: There were N=364 participants who were not aware of CKD before KEEP, N=196 participants who were aware of CKD before KEEP, and N=35 with missing values for awareness.a Model adjusted for age, sex, race, education, diabetes, cardiovascular disease, and awareness of CKD. Open table in a new tab Abbreviations: CI, confidence interval; CKD, chronic kidney disease; ESRD, end-stage renal disease; KEEP, Kidney Early Evaluation Program; OR, odds ratio. Note: There were N=364 participants who were not aware of CKD before KEEP, N=196 participants who were aware of CKD before KEEP, and N=35 with missing values for awareness. Participants in a national community-based kidney disease screening and education program, the NKF KEEP, were more likely to be prepared for ESRD compared with matched non-KEEP patients. Improved preparation was observed across several clinical domains spanning from pre-ESRD nephrology care and use of peritoneal dialysis to access to kidney transplantation. Furthermore, KEEP participants had longer survival after initiation of dialysis, and this was associated with better preparation for ESRD. Prior studies of CKD screening have primarily focused on the utility of screening for prevention of ESRD. The US Preventive Services Task Force recently concluded that the role of screening for CKD stages 1–3 when not performed in the context of chronic disease management was uncertain.13.Fink H.A. Ishani A. Taylor B.C. et al.Screening for, monitoring, and treatment of chronic kidney disease stages 1 to 3: a systematic review for the U.S. Preventive Services Task Force and for an American College of Physicians Clinical Practice Guideline.Ann Intern Med. 2012; 156: 570-581Crossref PubMed Scopus (137) Google Scholar,14.Moyer V.A. Screening for chronic kidney disease: U.S. Preventive Services Task Force Recommendation Statement.Ann Intern Med. 2012; 157: 567-570Crossref PubMed Scopus (92) Google Scholar In two trials testing strategies for CKD detection in the clinical setting, adding point-of-care clinical reminders to estimated glomerular filtration rate (eGFR) reporting was not more effective than eGFR reporting alone in increasing the proportion of patients receiving guideline-concordant care for CKD or in improving risk factor control.15.Abdel-Kader K. Fischer G.S. Li J. et al.Automated clinical reminders for primary care providers in the care of CKD: a small cluster-randomized controlled trial.Am J Kidney Dis. 2011; 58: 894-902Abstract Full Text Full Text PDF PubMed Scopus (42) Google Scholar,16.Manns B. Tonelli M. Culleton B. et al.A cluster randomized trial of an enhanced eGFR prompt in chronic kidney disease.Clin J Am Soc Nephrol. 2012; 7: 565-572Crossref PubMed Scopus (33) Google Scholar These studies focus on the role detection of CKD has on physician practices to reduce risk, for example, measuring albuminuria or prescribing renin–angiotensin system inhibitors, whereas assuming the patient’s role is passive. A key difference between KEEP and point-of-care clinical reminders is that patients, in addition to providers, directly receive results from the screening event and information about guideline-based management strategies for CKD. As a consequence, disease education is not dependent on provider time or crowded out by other health priorities. Another important difference is that KEEP is community based. Community-based health promotion efforts may be especially important for reaching minorities and those with poor access to health care, groups with very high rates of ESRD, and low rates of ESRD preparation.17.Hall Y.N. Choi A.I. Chertow G.M. et al.Chronic kidney disease in the urban poor.Clin J Am Soc Nephrol. 2010; 5: 828-835Crossref PubMed Scopus (58) Google Scholar Disease screening is sometimes described as a ‘teachable moment’ in which patients are more receptive to counseling and behavioral change. In this respect, the role of screening is not simply to detect asymptomatic disease but to catalyze adoption of healthy behaviors to reduce the risk of adverse outcomes. Evidence supporting this effect is mixed.18.Hollands G.J. Hankins M. Marteau T.M. Visual feedback of individuals’ medical imaging results for changing health behaviour.Cochrane Database of Syst Rev. 2010; 1: CD007434PubMed Google Scholar, 19.O'Malley P.G. Feuerstein I.M. Taylor A.J. Impact of electron beam tomography, with or without case management, on motivation, behavioral change, and cardiovascular risk profile: a randomized controlled trial.JAMA. 2003; 289: 2215-2223Crossref PubMed Scopus (149) Google Scholar, 20.Rodondi N. Collet T.H. Nanchen D. et al.Impact of carotid plaque screening on smoking cessation and other cardiovascular risk factors: a randomized controlled trial.Arch Intern Med. 2012; 172: 344-352Crossref PubMed Scopus (32) Google Scholar, 21.Rozanski A. Gransar H. Shaw L.J. et al.Impact of coronary artery calcium scanning on coronary risk factors and downstream testing the EISNER (Early Identification of Subclinical Atherosclerosis by Noninvasive Imaging Research) prospective randomized trial.J Am Coll Cardiol. 2011; 57: 1622-1632Abstract Full Text Full Text PDF PubMed Scopus (272) Google Scholar To our knowledge, this is the first study to assess whether CKD screening followed by personalized disease-specific educational efforts might promote positive health behaviors, in this case, preparing for ESRD. An important question is whether participation in KEEP activated patients to prepare for ESRD, primed the physicians who cared for KEEP participants in follow-up, or whether simply more motivated patients and physicians account for the results we observed. As this is an observational study, we cannot conclusively determine whether KEEP participation increased ESRD preparation and survival. There are several reasons why these results could be consistent with a causal relation between KEEP participation and ESRD preparation. To reduce confounding, we used propensity score matching to identify ESRD patients with similar characteristics to those who participated in KEEP. We identified a control cohort closely matched on observable characteristics including demographics, zip code and health insurance, clinical conditions, and functional status. In addition, our findings are consistent with prior small trials demonstrating the effectiveness of pre-ESRD education programs for improving ESRD preparation and mortality.9.Devins G.M. Mendelssohn D.C. Barre P.E. et al.Predialysis psychoeducational intervention extends survival in CKD: a 20-year follow-up.Am J Kidney Dis. 2005; 46: 1088-1098Abstract Full Text Full Text PDF PubMed Scopus (144) Google Scholar,10.Manns B.J. Taub K. Vanderstraeten C. et al.The impact of education on chronic kidney disease patients’ plans to initiate dialysis with self-care dialysis: a randomized trial.Kidney Int. 2005; 68: 1777-1783Abstract Full Text Full Text PDF PubMed Scopus (175) Google Scholar Increased access to transplantation appeared to be relatively more important than other aspects of ESRD preparation, at least in the short term, as a potential explanation for lower ESRD mortality among KEEP versus non-KEEP patients. A legitimate concern is that KEEP may select for patients who are more motivated to participate in self-care behaviors or obtain health care, and therefore the findings may not be generalizable. However, several observations do not support this conclusion. First, only 7–10% of KEEP participants with CKD meet clinical guidelines for cardiovascular risk factor control,22.Jurkovitz C.T. Elliott D. Li S. et al.Physician utilization, risk-factor control, and CKD progression among participants in the Kidney Early Evaluation Program (KEEP).Am J Kidney Dis. 2012; 59: S24-S33Abstract Full Text Full Text PDF PubMed Scopus (24) Google Scholar suggesting that their motivation to engage in self-care behaviors before KEEP was not different from the broader population with CKD. Second, only one-third of the participants of the KEEP cohort who progressed to ESRD were aware that they had kidney disease at the time of their KEEP screening. Thus, it seems unlikely that these participants had initiated ESRD preparation activities before KEEP. Third, earlier studies observed that fewer than 30% of KEEP participants with stage 4 or 5 CKD had seen a nephrologist before the KEEP event, but that this percentage increased after the KEEP screening.22.Jurkovitz C.T. Elliott D. Li S. et al.Physician utilization, risk-factor control, and CKD progression among participants in the Kidney Early Evaluation Program (KEEP).Am J Kidney Dis. 2012; 59: S24-S33Abstract Full Text Full Text PDF PubMed Scopus (24) Google Scholar,23.Agrawal V. Jaar B.G. Frisby X.Y. et al.Access to health care among adults evaluated for CKD: findings from the Kidney Early Evaluation Program (KEEP).Am J Kidney Dis. 2012; 59: S5-15Abstract Full Text Full Text PDF PubMed Scopus (30) Google Scholar One implication of our study is that community-based CKD screening and education programs could broaden the reach of pre-ESRD education efforts. Low patient and provider awareness of CKD may be a contributing factor to the limited implementation and success of provider-based education programs.12.Plantinga L.C. Boulware L.E. Coresh J. et al.Patient awareness of chronic kidney disease: trends and predictors.Arch Intern Med. 2008; 168: 2268-2275Crossref PubMed Scopus (203) Google Scholar,24.Kurella Tamura M. Anand S. Li S. et al.Comparison of CKD awareness in a screening population using the Modification of Diet in Renal Disease (MDRD) study and CKD Epidemiology Collaboration (CKD-EPI) equations.Am J Kidney Dis. 2011; 57: S17-S23Abstract Full Text Full Text PDF PubMed Scopus (22) Google Scholar As a r
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