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Background: The prevalence of depressive affect is not well defined in the incident hemodialysis (HD) population. We investigated the prevalence of and associated risk factors and hospitalization rates for depressive affect in incident HD patients. Methods: We performed a prospective investigation using the Patient Health Questionnaire 2 (PHQ2) depressive affect assessment. From January to July of 2013 at 108 in-center clinics randomly selected across tertiles of baseline quality measures, we contacted 577 and 543 patients by telephone for depressive affect screening. PHQ2 test scores range from 0 to 6 (scores ≥3 suggest the presence of depressive affect). The prevalence of depressive affect was measured at 1-30 and 121-150 days after initiating HD; depressive affect risk factors and hospitalization rates by depressive affect status at 1-30 days after starting HD were computed. Results: Of 1120 contacted patients, 340 completed the PHQ2. In patients screened at 1-30 or 121-150 days after starting HD, depressive affect prevalence was 20.2% and 18.5%, respectively (unpaired t-test, P=0.7). In 35 patients screened at both time points, there were trends for lower prevalence of depressive affect at the end of incident HD, with 20.0% and 5.7% of patients positive for depressive affect at 1-30 and 121-150 days, respectively (paired t-test, P=0.1). Hospitalization rates were higher in patients with depressive affect during the first 30 days, exhibiting 1.5 more admissions (P<0.001) and 10.5 additional hospital days (P=0.008) per patient-year. Females were at higher risk for depressive affect at 1-30 days (P=0.01). Conclusions: The prevalence of depressive affect in HD patients is high throughout the incident period. Rates of hospital admissions and hospital days are increased in incident HD patients with depressive affect. [ABSTRACT FROM AUTHOR]

Background. Our own data shows that 30% of patients in their first 90 days of treatment (tx) vs. 57% of patients greater than 90 days have an albumin of 3.8 g/dL or greater. Stage 5 CKD patients new to hemodialysis (HD) are often malnourished. Oral nutritional supplements (ONS) are often prescribed, but compliance remains a problem. To address compliance and compensate for amino acid losses that occur during HD, Kayser et al. (2002) followed 85 patients for 3 months without ONS, followed by 6 months of in-center ONS. There were significant rises in mean albumin (3.33 ± 0.32 to 3.65 ± 0.26 g/dL), prealbumin, and Subjective Global Assessment scores. To apply these findings to new HD patients, an in-center ONS program was implemented. Program. A team led by the corporate dietitian (RD) developed a policy that addressed implementation of in-center ONS. New HD patients in their first 120 days of tx with albumin of 3.5 or less and/or weight loss greater than 5% in 1 month may receive ONS with each HD treatment until albumin is equal to or greater than 3.8 g/dL, up to 40 doses/year. There are two ONS options per MD order: ProStat RC 30 ml or Nepro 8 oz liquid, each with 15, and 16.7 grams protein, respectively. All doses appear in the electronic medical record med orders to assure dose delivery and ease of tracking, and are delivered to the patient during HD by the nurse, technician, or RD. RDs, who received training via conference calls, trained clinical staff. MDs received information via the MD newsletter. Tracking outcomes. Each dose is documented with data if ONS was refused by the patient, less than 50%, or 50%-100% consumed. A monthly report provides staff with patient-specific ONS data with a count of ONS, consumption data, and albumin levels. Corporate level reports track ONS purchasing data, and clinics prescribing supplements and their volume. Finally, report design is in progress to track changes in albumin level, hospitalization, and mortality, according to amount of ONS consumed vs. patients with no ONS. Conclusion. We believe that this program design is a novel and practical way to apply research findings. The benefits are optimal use of staff time, efficient documentation, and outcomes tracking. New HD patient outcomes will also be improved. [ABSTRACT FROM AUTHOR]

Background: The annualized mortality rate of HD pts in the first 90 days of treatment is up to double the rate of patients past the first 90 days (24%-50%, Ikizler et al., 2007). We previously reported on the RightStart Program for new patients in their first 3 months, which showed improved hospitalization and mortality compared to the control group. The improved mortality was also seen long term at 1 year, which was 9 months after the intervention period was completed (Wingard et al., 2005, see table below). The SPIDER Program is the next phase of RightStart, with increased emphasis on more individualized patient education and empowerment, and innovative ways to improve outcomes, particularly for diabetes mellitus (DM) and nutrition. Approach: This case manager (CM) model provides for a CM to see all eligible new HD patients for a period of 4 months. Initial assessments specific to current HD and DM knowledge, reading level, and diabetes care are carried out. Based on this, an individualized teaching plan is developed to be carried out with the patient by the CM and multidisciplinary team (MDT). In addition, the CM tracks lab values, medical and psychosocial needs to facilitate prompt treatment by working through the MDT. On average, the CM covers 5-7 dialysis clinics, and sees patients in person 8-10 times during the 4 months with phone and family contact as needed. The individualized teaching plan employs strategies to match the patient's learning style and needs. A written patient handbook is provided to each patient and is used as a "textbook." However, other aids such as flip charts, flash cards, reading to patients, audiotapes, and videotapes are used. Implications. This program provides a process to individualize the teaching approach to overcome literacy, visual or language barriers. The CM provides continuity and coordination that prevents fragmentation of care, and staff time is efficiently focused on tasks essential for the MDT to carry out according to their expertise. The specific implementation strategies for SPIDER foot check programs and intradialytic nutritional supplements can be found in separately submitted ANNA abstracts. [ABSTRACT FROM AUTHOR]

Background: ESRD patients with diabetes are clearly at higher risk for foot problems. Studies show that peripheral vascular disease (PVD) and peripheral neuropathy (PN) are much more common in diabetes patients on dialysis than in patients without renal insufficiency. Since PVD and PN contribute to the development of foot problems, diabetes patients on dialysis are at an even-greater risk of developing non-healing foot ulcers leading to amputation and increased morbidity and mortality. To prevent these foot problems, daily foot care and inspection is recommended for all people with diabetes. However, compliance with home foot checks and obtaining therapeutic shoes is often low. Approach: To reduce foot complications, we implemented within the SPIDER program in-center interventions of routine foot checks, patient education and referrals for therapeutic shoes. Case Managers were trained to perform foot exams per a corporate policy/procedure, slide presentation, instructor demonstration and participant return demonstration. The comprehensive foot exam included skin assessment, checking pedal pulses, and sensory testing. Patient handouts were specifically designed for teaching daily foot inspection, lubrication, and safety. Electronic documentation and reporting systems were set up to track foot check completion and actions for follow-up. As a result, on average, 85% or more of foot checks were completed monthly in the dialysis clinics as compared to only sporadic or no foot checks being done. Foot problems were identified promptly and patients were referred to appropriate specialists. Patients that qualified for therapeutic shoes were evaluated and fit when applicable. Implications: The patient/staff awareness and satisfaction in finding foot problems through an efficient and manageable process has been significant. Increasing attention to the diabetic foot can benefit in the areas of prevention, early identification of problems, and prompt referrals that can ultimately prevent amputations and subsequently decrease mortality in this high-risk ESRD population. [ABSTRACT FROM AUTHOR]