Evaluation of an Advanced Practice Nurse Led Inter-professional Collaborative Chronic Care Approach for Kidney Transplant Patients: The TARGET Study

Abstract

The purpose of this study was to evaluate the effectiveness of an Advanced Practice Nurse (APN) led inter-professional collaborative chronic care approach on the achievement of clinical outcomes for adult kidney transplant chronic kidney disease (CKD) patients, as compared to a traditional transplant nephrologist led approach in one Canadian hospital transplant setting. Methods: In this non-randomized, controlled study guided by the Chronic Care Model (CCM), a propensity-score matched analysis was used to control for confounding variables and potential selection bias. The propensity-score model included the co-variates: a) estimated glomerular filtration rate, b) age, c) sex, d) kidney donor type, and e) diagnosis of diabetes. Based on the CCM elements and CKD clinical practice guidelines, the intervention included strategies for patient disease self-management, end-stage renal disease shared decision-making, healthcare system re-organization, and clinical decision support. The primary outcome was the proportion of patients achieving a target score of 78% (7 out of 9 targets), based on the recommended standards and patient participation in discussions about ESRD options. Results: Targets included blood pressure, serum lipids, hemoglobin, phosphate, calcium, parathyroid hormone levels, acid-base balance and clinical practice guideline standards. Propensity-score matching of 61 intervention patients to 119 controls, resulted in 40 pairs with an equivalent balance of measured co-variates. Compared to the control group, a greater proportion of intervention patients achieved the target score (68% versus 10%, p=0.0001), participated in endstage renal disease shared decision-making (88% versus 13%, p=0.0001), and had clinical practice guideline treatments implemented (ASA 50% versus 23%, p=0.01; ACE-I/ARB 53% versus 13%, p=0.004; statins 80% versus 45%, p=0.004). Compared to the intervention group, the control patients experienced a higher incidence of all cause hospital admissions (35 versus 12, IRR 0.34, p=0.02) and emergency department visits (40 versus 21, IRR 0.53, p=0.001).Conclusions: A CCM based, APN-led approach to care improves both the processes and outcomes of care for kidney transplant CKD patients.