SYSTEMATIC REVIEW OF STRATEGIES TO INCREASE UPTAKE OF COMPREHENSIVE CONSERVATIVE CARE FOR ADVANCED CHRONIC KIDNEY DISEASE PATIENTS

Introduction:

Patients with advanced chronic kidney disease (CKD) and their caregivers face several challenges such as coping with physical symptoms and deciding treatment modalities. Comprehensive conservative care (CCC) is a holistic approach to care that focuses on improvement in quality of life through symptom control, advanced care planning and end of life and bereavement care for the patient and family. Despite its benefits in reducing symptom burden, consistent care with patient preferences and reduced healthcare costs, insights from the Thai Learning Committee workshop in January 2024 indicates that palliative care may be underutilized in advanced CKD in Thailand. This research aims to identify interventions and its outcome in promoting palliative care for CKD patients that would help inform relevant policy options for future CKD management policies in Thailand.

Methods:

This systematic review searched three databases: Medline, Scopus and CINAHL from the year 2000 onwards. Studies which have patients with advanced CKD or end stage kidney disease undergoing interventions or policies which promote or improve conservative care uptake and report their impact are included. The exclusion criteria are clinical interventions, narrative reviews, qualitative studies and studies without impact evaluation. The outcomes of interest are uptake of CCC, measured by use of palliative care services, and preference of CCC for CKD patients. The risk of bias tools employed are according to the study design which include the revised Cochrane risk of bias tool for randomized trials, the Newcastle-Ottawa Scale and the risk of bias in non-randomized studies of interventions tool. Direct meta-analyses were performed using random effects models.

Results:

7 studies were eligible for inclusion of which 1 was a randomized controlled trial, 5 were cohort studies and 2 were non-randomized pre-post studies. The majority of participants (6/7 studies) included were CKD patients at stage 4-5 who have not undergone renal replacement therapy. The intervention and policy characteristics include those engaging in education and service provision such as information booklets, VDO education, implementing new communication tools, using prognostic prediction tools and facilitating palliative care referral. 1 study had 2 interventions and was analyzed as two different interventions. 6 studies reported preference for CCC as an outcome which the meta-analysis showed no significant change with odds ratio of 2.4 (95% confidence interval 0.96 to 6.27), see Figure 1. Uptake of CCC was reported in 2 studies which also did not show a significant result with odds ratio of 7.22 (0.65 to 79.82), see Figure 2. There was substantial heterogeneity in both the meta-analyses. All 7 studies had moderate, intermediate or some concerns in their risk of bias, according to their risk of bias tools.

Conclusions:

The findings suggest that the interventions and policies studied have a positive trend on increasing CCC preference and uptake though this is not statistically significant. The findings are based on a small number of studies and participants. There is insufficient evidence available to help inform policy makers on how to improve the utilization of CC for CKD patients and more research should be done to evaluate such policies.

I have no potential conflict of interest to disclose.

I did not use generative AI and AI-assisted technologies in the writing process.