NN&I - June 2010

Rehabilitation Update Subscribe to our free eNewsletter at www.nephronline.comJune 2010 Nephrology News & Issues 37allows the interdisciplinary team to help the patient answer, "How well will I live?" Interventions identified by the Medical Education Institute as effec-tive in improving quality of life dem-onstrates the interdisciplinary nature of this measure. For instance, more fre-quent hemodialysis, exercise training, anemia treatment, improved bone min-eral metabolism, and treatment of rest -less leg syndrome all require multiple disciplines to intervene.8 Lopes9 reports unemployment and psychiatric diseases are associated with lower HRQOL mea-sures. Elder et al.10 demonstrates that poor sleep quality also affects HRQOL.At the dialysis center level, the edu-cation described above was provided to center staff, including physicians, nurses, technicians, dietitians, and administrative assistants. The team used research described by Callahan11 as a model for integrating use of KDQOL-36 into center processes. Callahan demonstrated effectiveness of interdisciplinary goal setting in addressing HRQOL in the care plan -ning process in improving QOL scores. In this study, the social worker assisted the team in interpreting the HRQOL scores and facilitated interdisciplin-ary goals designed to increase patient rehabilitation. This allowed for each discipline and team members unique clinical skills to contribute to patient established goals. This study was com-pleted in multiple dialysis centers and could be translated into current clinic culture and climate. The greatest barrier to success of this process was effective reporting of patient QOL scores to the treatment team and patient. To overcome this barrier, Renal Advantage Inc. purchased the KDQOL Complete. The tool provides a chart report and patient report that eased interpretation challenges and allowed focus on intervention. The practice of introducing patient self-reported prob-lems to the treatment team has allowed the team to better conceptualize patient problems and complete specific, mea- Case Study: KDQOL-36 in practiceSteven L. is a 55 year-old male who has been on in-center hemodialysis for three years. He presents to dialysis with a bright affect and reports stable mood. Mr. L. has a history of substance abuse and homelessness. He reads at an eighth grade level and presents with low health literacy. Mr. L. has an average Kt/V of 1.5, a fis-tula, hemoglobin of 11, albumin of 4.0 and well controlled phosphorus. Previous assessments by the treatment team did not identify any problems, as patients typi-cally respond with, "I am fine. I thank you for asking." One month prior to a comprehensive patient assessment due date, the center social worker presented Mr. L. with the KDQOL-36 (for more information regard-ing introducing the survey to the patient, see Prescott2). The patient's subscales (physical component score, mental component score, burden of kidney disease, effect of kidney disease on daily life, and symptoms and problems) were all within the above average range for men in his age group with diabetes. The Response Trend report from KDQOL Complete indicated that the patient's response to "I feel frustrated dealing with my kidney disease" was significantly lower than other responses within the Burden of Kidney Disease subscale. The chart report dem-onstrated that the patient was "very much" bothered by cramps and "extremely bothered" by nausea or upset stomach. The patient reported that he had not dis-cussed any of these issues with treatment team in the past, as he thought these concerns were "normal for people with my disease." Consistent with center practice, the social worker introduced the patient results in a bi-weekly interdisciplinary team meeting. The KDQOL working group concurs that informing the treatment team of scores maximizes the "usefulness of health related quality of life data in clinical practice."12 The interdisciplinary team dis-cussed potential causes of patient complaints (need for urology consult, high inter -dialytic weight gain, gastroperesis) and continued assessment of the patient during treatment. The subsequent plan of care meeting (called Treatment Plan meeting) established goals based on patient identified problems. The patient was ultimately referred to a urologist for evaluation of urinary incontinence, his dry weight was adjusted, and ongoing evaluation of nausea and vomiting was initiated. surable, attainable, and relevant goals with the patient. KDQOL-36 in QAPI Health related quality of life is now included as an indicator of quality of care. Condition 494.110 includes mea-sure of adequacy of dialysis, nutritional status, mineral metabolism, anemia management, and center morbidity and mortality.1 As described above, HRQOL is a predictive measure of morbidity and mortality. Currently the number of surveys completed has been used in Quality Assessment and Performance Im- provement (QAPI), though data could be used more effectively to understand the impact of quality of life on center quality assessment. DeOreo's6 research demonstrated that patient-perceived outcome data are an important ele -ment of quality assessment. Identifying trends in center level QOL measures could increase center profitability by reducing the number of missed treat -ments and hospitalizations.7Currently the KDQOL Complete has tools to contribute general aggregate data to the QAPI process. This provides aggregate data of the patient's physical component summary, and the mental component summary as well as kidney specific subscales for the center. The tool currently includes filter options for exploring scores in center action Rehabilitation_NNI0610_4.indd 37 5/17/10 3:54:21 PM