Effectiveness, cost effectiveness, acceptability and implementation barriers/facilitators of chronic kidney disease management programs for Indigenous people in Australia, New Zealand and Canada: a systematic review of mixed evidence

Abstract

Background: Indigenous peoples in Australia, New Zealand and Canada carry a greater burden of chronic kidney disease (CKD) than the general populations in each country, and this burden is predicted to increase. Given the human and economic cost of dialysis, understanding how to better manage CKD at earlier stages of disease progression is an important priority for practitioners and policy-makers. Objective: To examine the evidence relating to the effectiveness, cost-effectiveness and acceptability, as well as barriers and facilitators of implementation of chronic kidney disease management programs designed for Indigenous people in Australia, Canada and New Zealand. Inclusion criteria: Types of participants: Indigenous people in Australia, Canada and New Zealand diagnosed with chronic kidney disease. Types of intervention(s)/phenomena of interest: Health sector-led management programs explicitly designed to manage, slow progression or otherwise improve the lives of Indigenous people with chronic kidney disease in outpatient/community settings were considered, excluding dialysis or other forms of renal replacement therapy. Qualitative phenomena of interest were healthcare worker or patient experiences of relevant programs. Types of studies: A broad range of study-types were considered for inclusion, including quantitative studies of effectiveness, cost and cost-effectiveness, and all types of qualitative study designs. Types of outcomes: Outcomes of interest were indicators of clinical effectiveness, ability to self-manage, quality of life, cost and cost-benefit, acceptability, and barriers and enablers of implementation. Search strategy: A four-step search strategy was employed to identify relevant studies published between 2000 and 2014. Methodological quality: The studies were critically appraised using the standardized critical appraisal instruments from the Joanna Briggs Institute. Data collection and synthesis: Quantitative and qualitative data addressing the research questions were extracted using standardised tools. Due to the heterogeneity of the included studies, quantitative data on effectiveness and cost-effectiveness were summarised in narrative and tabular form. Qualitative data was synthesized using the Joanna Briggs Institute meta-aggregation approach. Results: Ten studies were included. Six studies provided evidence of clinical effectiveness relevant programs, two provided evidence of cost and cost-effectiveness, two provided qualitative evidence of barriers and facilitators of implementation of effective programs, and one provided quantitative evidence on the acceptability of a community-based chronic kidney disease management program. Conclusions: The quantitative, economic and qualitative evidence in this review indicates that CKD programs tailored for Indigenous people may be effective and cost-effective, and has identified a number of facilitators to the implementation of effective and acceptable CKD management programs. Given the human cost of dialysis and the growing population of people living with CKD, it is important that we draw lessons from the available evidence, including this and other sources in Australia and internationally, to better serve Indigenous people with programs that address the barriers to receiving high-quality care and improve quality of life. Implication for practice: Common features of effective and acceptable programs that may be incorporated into future programs were: integration within existing, trusted primary care services, adequate funding, intensive follow-up, provision of culturally-appropriate education, governance structures supporting community ownership, robust clinical systems supporting communication and a central role for Indigenous Health Workers and nurses.