Effects of educational practices on the peritonitis risk in peritoneal dialysis: a retrospective cohort study with data from the French peritoneal Dialysis registry (RDPLF)

Abstract

Background: Peritoneal dialysis (PD) is a home-based therapy performed by patients or their relatives in numerous cases, and the role of patients' educational practices in the risk of peritonitis is not well assessed. Our aim was to evaluate the effect of PD learning methods on the risk of peritonitis.

Methods: This was a retrospective multicentric study based on data from a French registry. All incident adults assisted by family or autonomous for PD exchanges in France between 2012 and 2015 were included. The event of interest was the occurrence of peritonitis. Cox and hurdle regression models were used for statistical analysis to asses for the survival free of peritonitis, and the risk of first and subsequent peritonitis.

Results: 1035 patients were included. 967 (93%) received education from a specialized nurse. Written support was used for the PD learning in 907 (87%) patients, audio support in 221 (21%) patients, and an evaluation grid was used to assess the comprehension in 625 (60%) patients. In the "zero" part of the hurdle model, the use of a written support and starting PD learning with hands-on training alone were associated with a lower survival free of peritonitis (respectively HR 1.59, 95%CI 1.01-2.5 and HR 1.94, 95%CI 1.08-3.49), whereas in the "count" part, the use of an audio support and starting of PD learning with hands-on training in combination with theory were associated with a lower risk of presenting further episodes of peritonitis after a first episode (respectively HR 0.55, 95%CI 0.31-0.98 and HR 0.57, 95%CI 0.33-0.96).

Conclusions: The various PD education modalities were associated with differences in the risk of peritonitis. Prospective randomized trials are necessary to confirm causal effect. Caregivers should assess the patient's preferred learning style and their literacy level and adjust the PD learning method to each individual.

Keywords: Educational practices; Health literacy; Patient education; Peritoneal dialysis; Peritonitis.

Fig. 1

Flowchart of the study

Fig. 2

Upset diagram representing the overlapping between educational practices. “Within 1 month” and “More than 1 month before” correspond to the timing of PD learning compared with catheter placement. “Starting: combined” and “Starting: theory” are respectively the starting of PD learning with theory and hands-on training at the same time, and theory alone

Fig. 3

Kaplan-Meier curve for peritonitis-free survival and 95% confidence interval

Fig. 4

Multivariate Cox model for peritonitis-free survival due to all germs, and to handled germs (individual-level analysis). HR: hazard ratio, 95%CI: 95% confidence interval, BMI: body mass index, RRT: renal replacement therapy, PD: peritoneal dialysis, CCI: Charlson comorbidity index, CAPD: continuous ambulatory PD, APD: automated PD. Handled germs are cocci Gram positive germs excluding Enterococcus and Streptococcus agalactiae.

Fig. 5

Multivariate hurdle model for risk of peritonitis (individual-level analysis). The “count” part assesses for the risk of presenting further peritonitis after a first episode, and the “zero” part assesses for the risk of presenting a first episode of peritonitis. HR: hazard ratio, 95%CI: 95% confidence interval, BMI: body mass index, RRT: renal replacement therapy, PD: peritoneal dialysis, CCI: Charlson comorbidity index, CAPD: continuous ambulatory PD, APD: automated PD.