In this study, customized video counseling which designed for local context in terms of socioeconomic status, home environment, northeastern regional Thai dialects and added the common concerns for PD, including PD catheter insertion, PD-related peritonitis and the consequences of delayed PD, was not significant difference to conventional video counselling video in term of the acceptance rate along with PD catheter insertion on schedule in CKD stage 5 under PD first policy. Moreover, patients’ knowledge and confidence of PD after the counseling process with both customized and conventional video counseling increased, but there was no significant difference between both groups. However, the reasons for postponing PD in each group were obvious differences.
We try to overcome the challenge of un-decision to PD in CKD stage 5 at the suitable timepoint before life-threatening CKD complication occurred with customized video counseling. For the background hypothesis in the diversity of patients in each region of PD center in term of household income, home environment, way of life, and illness belief will affect PD dialysis decision making. Our study found the reasons for un-decision to start PD were different between 2 video counseling groups. The barrier to start PD in term of concern for infection from limited home environment and fear for PD catheter insertion were fewer in customized video counseling than conventional video counseling group (3 vs. 13 and one vs. 5, respectively). These finding may explain from our customized video counseling was added the example from successful PD patient not only middle socioeconomic status with the quite perfect home environment but also low household income patient with a limit home environment. The baseline socioeconomic status and education background of PD was different in each region of Thailand. One PD center in Bangkok, the capital city of Thailand, 65% of PD was high school education and household income per month was 1,240 USD. Meanwhile, our center in Nakornratchasima Provinces, Northeastern region of Thailand, Most of CAPD patients (79%) had a primary school education, 156 USD in household income per month. Because the difference in these patient’s background of each region, so the customized video counseling for accepting to PD was needed. Moreover, the customized video counseling added the common concern in PD especially PD catheter insertion procedure, so the reasons of fear for PD catheter insertion in patients who postpone the decision to accept PD in customized video counseling was diminished.
However, the acceptance rate along with PD catheter insertion on schedule among those who watched the customized video counseling was not significantly differenced with conventional video counseling. This finding may from the reasons as follow; Firstly, a counseling video of short duration is not sufficient to change a patient’s attitude. Secondly, most of the participants (67.5%) had a short follow-up duration and a lack of pre-dialysis care by a nephrologist, so they had a high tendency to refuse dialysis. Thirdly, even though the surrogate outcome, the patients’ knowledge and confidence in PD were increasing after video counseling, but it was not a significant difference between customized and conventional video counseling group. Deciding to have dialysis depends on many abstract aspects such other than knowledge and confidence in dialysis as personal values, beliefs, and feelings toward life, suffering, death and other patients experience(13–16). In-depth interviews on this issue should be further evaluated.
There was some doubt in the rate of acceptance along with PD catheter insertion on schedule. In our center before conducting this study, acceptance rate along with PD catheter insertion with conventional video was 55%. However, the acceptance rate along with PD catheter insertion with the same conventional video increased to 70% during conduct this study. The increase in the rate of accept PD along with PD catheter insertion was increasing 27% despite the same conventional video counseling but the protocol for counseling and education had been systematized. In this study, we create a systematized protocol including a script for PD nurse who counselor the CKD stage 5 that aims to reduce bias between 2 groups of video counseling. The rate of accept PD may not only depend on the content of the video counseling but also protocol and process including a script for counseling and education.
Our study aimed to answer the hypothesis that video counseling with a sample of patients in a local setting could help overcome barriers for accepting CAPD. To the best of our knowledge, our study was the first randomized controlled trial to answer this question, especially in the PD first policy setting. Nowadays, there are few proven strategies for improving survival in PD patients including planned start dialysis (1,17–21). However, in the real world, more than half of the patients start PD with unplanned. Thus, dialysis decision-making is the first step for planned start dialysis. Our study encourages health care providers to focus on customized educational and counseling programs. These easy interventions may lead to planned start dialysis and improve PD patients’ survival. Another advantage of our study was that there were no dropout participants.
However, there were points of concern in our study. First, the nurse who was involved in the counseling process and asked for a patient’s final dialysis decision was not blind to video counseling groups, so bias could have occurred in the outcome assessment. Second, we calculated the sample size based on optimism that the accept rate along with PD catheter insertion with conventional was increasing from 55% to 80% with 80% power. However, when conduct the study; the acceptance rate was increased to around 70% in both groups, so this study had underpowered. Third, there were contamination factors in the period around two weeks during finished PD decision-making to schedule PD catheter insertion. Some patients who accept PD after counseling protocol but did not come along with PD catheter insertion on schedule. They may influenced from other people during 2 weeks that were contamination factors. Lastly, due to late presentation and counseling, patients who said they would accept PD may not always go ahead with planned start dialysis. Some patients need temporary hemodialysis for improve uremic symptoms, then come along with PD catheter insertion.
We encourage each PD center to focus on counseling and the educational process for PD decision-making at an appropriate time. This will lead to a planned start PD. In addition, customized video counseling in the local contexts should be set in place in each PD center, especially in the PD first policy setting. Moreover, we suggest to systematized protocol counseling process including a script for the counselor. The systematized counseling process may increase in the accept for PD other than the content of video counseling. Lastly, the counseling and educational process for dialysis decision making in PD first policy is still a challenge and needs to improve. The randomized controlled trial to compare only video counseling with other methods or combined methods, e.g., focus groups, sharing patients’ experiences, motivational interviews, or interactive interviews regarding the rate of acceptance of PD or the rate of planned start dialysis in CKD stage 5 should be urgently needed. Furthermore, in-depth interview in reasons for deferring PD was necessary to a feedback loop to improve the counseling process.