Effects of Self-Monitoring on Outcome: How can we support hypertensive Chronic Kidney Patients and improve their health and autonomy?
In October 2009, Yvette Meuleman started her PhD research project at the Medical Psychology department of the Leiden University Medical Center (LUMC), under supervision of Prof. dr. Stan Maes and dr. Sandra van Dijk. The ESMO project is a cooperation between the LUMC, Hans Mak Instituut, Nierpatiënten Vereniging Nederland (Dutch Renal Patient Association), Nierstichting Nederland (Dutch Kidney Foundation) and Medimate. The goal of the ESMO project is to develop, test and evaluate a self-management program directed at hypertension control and supporting hypertensive Chronic Kidney Disease (CKD) patients.
In the Netherlands an estimated 750.000 patients suffer from CKD, with a kidney function of less than 60%, and it can be expected that this number will increase significantly in the forthcoming decades. A typical characteristic of this patient population is the high level of co-morbidity: Hypertension is the most frequent complication of CKD. For CKD patients blood pressure control is not only vital for decreasing cardiovascular risk, but also for the possibility to slow down the progression of CKD and subsequently postpone renal replacement therapy (dialysis and kidney transplantation). Unfortunately, adequate blood pressure control is hard to achieve. CKD patients generally have two treatment options to control their blood pressure: pharmacological treatment and reducing salt intake. Regarding the salt intake, this is hard to achieve due to salt ‘hidden’ in prepared meals and not added by the patients themselves. In usual care, CKD patients collect urine for 24 hours and return it to the laboratory. Usually, they get the results days (or sometimes even months) later during their next doctor’s appointment. The current procedure to measure salt intake is inefficient, lacks immediate feedback and therefore this opportunity to monitor salt intake is hardly used. Recently, innovative Lab-on-a-Chip technology has been developed that is also applicable for self-monitoring of sodium (salt) levels in 24 hours urine. Self-monitoring is a vital element of self-management and the last couple of years self-management is becoming increasingly important. Several studies have shown that self-management increases treatment results and enhances psychological well-being of patients. The interventions that are most effective for long-term adherence are complex and combine self-monitoring with information, psychological therapy, counseling and feedback. However, self-management in patients with CKD is hardly applied.
In this multicentre open randomized controlled trial, 150 hypertensive CKD patients in stage III (a stage before dialysis and/or kidney transplantation) are randomly assigned to either the control condition or intervention condition. The control group receives the care as usual and the intervention group receives (besides the care as usual) a self-management program consisting of: self-monitoring salt intake and blood pressure, keeping dietary diaries, receiving feedback at the salt intake and blood pressure, two motivational interviews and if necessary tailored self-management modules. The intervention is based on the self regulation theory, which suggests that patients profit most from a multi-component approach in which a patient’s motivation plays a crucial role.In the preparation phase focus group interviews will be conducted with CKD patients and health care workers who are involved in the treatment of CKD patients, for fine-tuning the intervention. During these focus group interviews insights are gained about the attitude and wishes of CKD patients and health care workers regarding self-management.The intervention will be tested in at least four hospitals across the Netherlands; Leiden Universitair Medisch Centrum (LUMC), Academisch Medisch Centrum-Universiteit van Amsterdam (AMC), Universitair Medisch Centrum Groningen (UMCG) and Antonius Ziekenhuis Nieuwegein. After the intervention period of three months, two follow-up measurements (three and six months after the start of the intervention groups) will take place and focus group interview will be conducted to evaluate the intervention.
The main goal of the ESMO project is to improve health outcomes and autonomy of CKD patients; the primary outcomes are change in sodium intake and blood pressure, and secondary outcomes include renal function, antihypertensive medication and psychological outcome measures. Furthermore, this study will investigate the impeding and facilitating factors for implementation of self-management and provide knowledge about the attitude and wishes of the patients and health care workers regarding self-management. The ESMO project is important because it offers a new possibility for CKD patients to monitor their illness (due to the new Lab-on-a-chip technology), the potential impact of the intervention on health outcomes and the knowledge gained about self-management related to CKD patients and health care workers.
Meuleman just started her PhD project and is very excited about the upcoming years; realizing the ESMO project, working with the CKD patients and health care workers involved with the ESMO project. She is not sure what she wants to do after her PhD project, but one thing is for sure; she will focus on patients with a chronic disease. Nowadays, psychology plays an important role in the treatment of many chronic diseases, for example in the treatment of Coronary Heart Disease, Diabetes, Asthma and Cancer. Meuleman views this as a positive development, but there is still a lot of room for improvement and work to be done when it comes to chronic ill patients, their autonomy and their quality of life.