The WISHED Trial: implementation of an interactive health communication application for patients with chronic kidney disease
In a person-centered care model, patients with advanced chronic kidney disease (CKD) are provided with the necessary tools and information to select the type of dialysis therapy for which they are best suited. Many programs utilize a specially trained nurse to provide modality education to patients with more advanced CKD (i.e., estimated glomerular filtration rate [eGFR] less than 20 ml/min/1.73 m2). There are several modality choices for patients approaching end-stage renal disease (ESRD); these include peritoneal dialysis (PD), a home therapy, or hemodialysis (HD), which either can be at home (HHD) or performed in a facility. In Ontario, Canada, the provincial renal agency’s target for the home dialysis prevalence rate is 40 %, in contrast to the current provincial prevalence of 24 % [1].
Home dialysis offers many advantages over facility-based HD for patients. Home dialysis provides patients with scheduling flexibility which is rarely possible in facility-based HD. PD patients in particular have more freedom to travel and usually enjoy a less restrictive diet with respect to potassium than facility-based HD [2, 3]. Most observational studies suggest that home dialysis patients enjoy better scores in many quality of life domains, particularly treatment satisfaction and therapy intrusiveness [4–6], although some studies have not seen such a difference [7–9]. Home-based dialysis is also beneficial from the payer perspective; overall, healthcare costs are reduced by as much as US$20,000 per patient-year [10–12].
Numerous barriers to initiation of home-based therapies have been described, including provider beliefs, practices, and lack of adequate patient and provider education [13]. In addition to these systemic barriers to home dialysis, many barriers exist at the patient level, including lack of self-efficacy and confidence in performing the therapy, burden on family members, and fear of a catastrophic event [14–18]. Information gaps despite education being provided by care providers may lead to increased decisional uncertainty and conflict, particularly in an era when home-based therapies are being more actively encouraged. On the other hand, medical contraindication to a home therapy is uncommon; in one study, only 11 % of patients had a medical contraindication [18].
Interactive health communication applications (IHCAs) are computer-based packages for patients which are usually web-based and in addition to providing health information offer some form of social, decisional, and/or behavioral change support [19]. IHCAs facilitate the transfer of information and enable informed decision-making as well as the promotion of healthy behaviors and choices, peer information exchange and support, and self-care. A systematic review of IHCAs developed for individuals with chronic diseases such as diabetes mellitus (DM) and asthma identified 24 randomized controlled trials involving 3739 participants. IHCAs had a beneficial effect on knowledge, social support, self-efficacy, and behavioral and clinical outcomes [19]. Websites designed for patients with CKD who must make decisions regarding treatment options exist but to our knowledge have not been formally evaluated.
The primary objective therefore of this study is to determine if utilization of a website dedicated to the promotion of home-based dialysis will increase the proportion of patients who initiate dialysis using a home-based modality.