Phosphate Control - secrets of ‘good’ units Hugh Cairns on behalf of Tyrone Hospital, Royal Berkshire Hospital and King’s

Approach similar in different hospitals Strong multidisciplinary approach Strong multidisciplinary approach Involving patient / patient education central to process Involving patient / patient education central to process Commitment to quality / ‘competition’ between areas Commitment to quality / ‘competition’ between areas Dieticians actively changing treatment / holding prescriber status Dieticians actively changing treatment / holding prescriber status Use of full range of phosphate binders Use of full range of phosphate binders Use of ultra low calcium dialysate Use of ultra low calcium dialysate

Multidisciplinary approach Dietetic, pharmacist, nurse, doctor input Dietetic, pharmacist, nurse, doctor input Monthly reviews look at many factors - difficult for an individual to concentrate on all Monthly reviews look at many factors - difficult for an individual to concentrate on all Importance of several individuals reviewing results regularly Importance of several individuals reviewing results regularly Education for patient comes from many sources and more frequently Education for patient comes from many sources and more frequently

Patient Education Phosphate control depends on adherence / compliance Phosphate control depends on adherence / compliance Difficult for patients to understand reasons to control phosphate Difficult for patients to understand reasons to control phosphate Anxiety about bone disease not an incentive for patients Anxiety about bone disease not an incentive for patients Focus on cardiovascular risk may make easier Focus on cardiovascular risk may make easier Need to educate repeatedly and in different ways Need to educate repeatedly and in different ways Feedback of patient results - monthly sheet Feedback of patient results - monthly sheet

King’s HD Patient Information Sheet

Quality control Monthly review of laboratory results Monthly review of laboratory results Minimum dialysis nurse and doctor. Usually nurse, pharmacist, dietician and doctor Minimum dialysis nurse and doctor. Usually nurse, pharmacist, dietician and doctor Highlighting results outside of desired range Highlighting results outside of desired range Dieticians confirming compliance / adherence with medication / diet Dieticians confirming compliance / adherence with medication / diet Specific clinic for patients with poor results - Bone Club (Reading) Specific clinic for patients with poor results - Bone Club (Reading) Patients seen 2 weekly by consultant/nurse/dietician Patients seen 2 weekly by consultant/nurse/dietician Dramatically improved PO4 results Dramatically improved PO4 results

Quality Control - competition Comparing results between HD areas Comparing results between HD areas Regular audit comparing with RA guidelines and between areas Regular audit comparing with RA guidelines and between areas Regional audits / national audit (Fresenius) Regional audits / national audit (Fresenius) Annual audit - comparison with RR data Annual audit - comparison with RR data

King’s Monthly HD Audit Summary

Dietetic Involvement Dieticians central to process Dieticians central to process Diet advice to patients Diet advice to patients Oversee choice of phosphate binders - check compliance / timing / palatability Oversee choice of phosphate binders - check compliance / timing / palatability Empowered to change patients’ treatment Empowered to change patients’ treatment Alter doses / change binders / change Vit D Alter doses / change binders / change Vit D Write letters to GP / patient Write letters to GP / patient

Ultra low calcium dialysate - Tyrone Hospital Use of 0.75 mmol Ca in selected patients Use of 0.75 mmol Ca in selected patients Enables use of calcium containing phosphate binders Enables use of calcium containing phosphate binders Small number of patients cannot tolerate (paraesthesia, hypotension) Small number of patients cannot tolerate (paraesthesia, hypotension)

Areas of Failure Significant minority of patients with persistently raised phosphate Significant minority of patients with persistently raised phosphate % of patients - ethnic minorities, younger % of patients - ethnic minorities, younger Mechanistic, ‘scientific’ approach to problem - ‘solve by changing phosphate binder’ Mechanistic, ‘scientific’ approach to problem - ‘solve by changing phosphate binder’ Clinicians adopt fatalistic view Clinicians adopt fatalistic view

Interventions to change behaviour Health Belief Model Health Belief Model Individual perceptions Individual perceptions Modifying factors Modifying factors Likelihood of action Likelihood of action Locus of control - external v internal Locus of control - external v internal Beattie’s model of health promotion Beattie’s model of health promotion

Beattie’s model of health promotion practice Health Persuasion Legislative Action Personal Counselling Community Development Mode of intervention Authoritative Mode of thought Objective knowledge Mode of intervention Mode of intervention Negotiated Mode of thought Participatory, subjective knowledge IndividualCollective

Refocus on patients with poor phosphate control Patient education Patient education Consider other approaches Consider other approaches Counsellor Counsellor Explore patients’ understanding Explore patients’ understanding Group patient sessions Group patient sessions Education materials Education materials

‘Secrets’ of good phosphate control - Summary Phosphate can be controlled with good patient adherence to diet and binders Phosphate can be controlled with good patient adherence to diet and binders Requires patient education from different sources and repeated frequently Requires patient education from different sources and repeated frequently Audit and competition drives improvement Audit and competition drives improvement Multidisciplinary approach - many minds / pairs of eyes Multidisciplinary approach - many minds / pairs of eyes Still fail in significant minority Still fail in significant minority

Steps to good phosphates 1. Recognising patients in whom phosphate raised Monthly blood tests  Multi-disciplinary review 2. Patient Education Different individuals Information provided in different ways 3. Use range of dietary measures and phosphate binders 4. Feedback results to patients monthly 5. Monthly audit / competition / appraisal 6. Special clinic for persistent raised PO4