Experiments in 6 regions
With the aim of improving the care pathway for these patients with chronic kidney failure, experiments were carried out in 6 regions: Rhône-Alpes, Alsace, Aquitaine, Languedoc-Roussillon, Pays de la Loire and Réunion. Main objectives of these experiments: develop prevention, as well as replacement (kidney transplantation and out-of-center dialysis). “The objective was also to determine to what extent these organizations can be reproduced, or even generalized”, add the authors. The pilot projects focused on two patient segments: a first segment called “pre-replacement”, targets patients with early-stage renal failure. In this segment, we distinguish “prevention” patients., in whom health professionals will seek to delay or avoid locum replacement, and those in whom they will actively prepare the transition to locum replacement. The second “replacement” segment concerns patients treated by dialysis or transplant: this involves evaluating the possibility of resorting to a transplant, or home dialysis for patients on dialysis. In total, 19 projects were identified, between 2017 and 2021.
First segment, early stage
For “prevention” patients At the early stage, various actions were undertaken: screening, information of the general public, involvement of health professionals, in particular general practitioners, but also pharmacists. With a view to switching to locum, the coordinating nurse directs the patient to the appropriate care professional, “whether it is the general practitioner or the nephrologist”. In certain projects, in addition to information actions, therapeutic education programs and multi-professional consultation meetings have been set up. “For most projects, care at this stage was supported by the recruitment of nurses mobilized to monitor patients, coordinate care with nephrologists and the dietician in addition to the actors mentioned”, explain the authors, while adding that it was not possible to identify a single organizational model. However, initial results have been established: preventive actions have reduced the incidence rate of chronic kidney failure, but not significantly, analyzes Irdes.
Second segment
The second segment includes patients who have been diagnosed with chronic disease and are under treatment: for them, it is a question of choosing between a transplant, dialysis, or conservative treatment. A multi-professional team operates under the responsibility of the nephrologist, coordinated by coordinating nurses. These last “provide information on the various treatment modalities available and organize therapeutic patient education programs (TPE)”. Patients already on dialysis can be referred outside the center – the promotion of outside centers consists of encouraging the development of peritoneal dialysis, autonomous hemodialysis (autodialysis) and hemodialysis in a medical unit, as opposed to hemodialysis in center – or registered on the transplant waiting list. “The results highlight that the impact of the pilot projects was to increase access to the transplant waiting list for patients”, note the authors. These experiments also made it possible to reduce dialysis initiated urgently, a result which is nevertheless not very significant, adds Irdes. On the other hand, deployment outside the center remains limited “and few actions have been proposed with this objective”.
Although these experiments are not, quantitatively speaking, significant, the authors note that they have opened up new perspectives, “such as the recent extension of the prevention package to take into account the arrival of advanced practice nurses and also its expansion to other professionals (psychologist, social worker)”.
