Recruitment, Engagement, Experiences, and Self-Reported Changes in a Digital Patient Activation Intervention to Improve Hemodialysis Session Stability: Mixed Methods Study
Journal of Medical Internet Research ·
Background: When chronic kidney disease progresses to end-stage kidney disease, many patients receive in-center hemodialysis. Although lifesaving, hemodialysis is associated with intradialytic hypotension. Peer mentoring and patient activation support in hemodialysis have not been well studied. Objective: This Dialysafe study combined patient education and peer mentoring to promote health behaviors supporting prevention of intradialytic hypotension. We aimed to describe recruitment, engagement, completion, and attrition; assess participants’ health goals and self-reported behavior changes; and evaluate satisfaction and recommendations for improvement. Methods: At 10 Dialysafe hemodialysis centers assigned to patient activation, all eligible English-speaking patients were invited. The intervention comprised 5 educational modules and 5 videoconference peer-mentoring sessions. Mixed methods analyses integrated electronic health record and platform data, postintervention surveys, and clinic operations committee notes. An engagement score (range 0-50) summarized intervention use. Descriptive statistics, t tests, chi-square tests, logistic regression, and zero-inflated Poisson regression were used to assess recruitment, completion (all 5 mentoring sessions), and engagement. Qualitative data were inductively coded and integrated through joint displays. Results: Of the 639 eligible patients, 155 (24.3%) were recruited. Recruited patients were younger than nonrecruited patients (mean 57.6, SD 13.8, vs 64.3, SD 14.7 y; P <.001); each additional year was associated with 4% lower odds of recruitment (odds ratio [OR] 0.96, 95% CI 0.94-0.98; P <.001). Recruitment was more likely among college graduates (OR 1.70, 95% CI 1.02-2.83; P =.04) and patients with sleep disorders (OR 2.27, 95% CI 1.06-4.87; P =.03). Attrition was concentrated before mentoring sessions began. Of recruited patients, 72 of 155 (46.5%) met with a peer mentor and 58 of 155 (37.4%) completed all 5 sessions. Completers were 1.9 years younger (56.4, SD 13.8, vs 58.3, SD 13.9 y) and had Charlson Comorbidity Index scores 0.4 points higher (3.4, SD 2.0, vs 3.0, SD 2.3) than noncompleters. The average engagement score was 18.4 of 50 (SD 20.1). Engagement was higher among men (incidence rate ratio [IRR] 1.33, 95% CI 1.22-1.45; P <.001), Black patients (IRR 1.27, 95% CI 1.16-1.39; P <.001), and patients with dialysis vintage <1 year (IRR 1.22, 95% CI 1.05-1.42; P =.01). Higher Charlson Comorbidity Index scores predicted engagement (IRR 1.04, 95% CI 1.01-1.07; P =.002) and completion (OR 1.37, 95% CI 1.05-1.79; P =.02). Of 79 patients who set goals, 64 (81%) selected communication with the care team; 22 of 54 (40.7%) survey respondents identified this as their main behavior change. Both mentees and mentors identified peer-mentoring sessions as the most valuable component. Among mentee respondents, 55 of 55 (100%) respondents rated the program good or excellent, and 53 of 54 (98.1%) respondents would recommend it. Conclusions: Participants constituted a self-selecting group. Patient-clinician communication was a priority, and participants valued peer mentoring. Digital patient activation intervention strategies to increase reach are needed. Trial Registration: ClinicalTrials.gov NCT03171545; https://clinicaltrials.gov/ct2/show/NCT03171545