Pediatric hemodialysis and peritoneal dialysis: Report rewards program☆☆☆

For pediatric renal dietitians, nutrition education and compliance with diets and medications can be a challenge. One of the most challenging groups is adolescents. They typically have a need for “acceptance” from their peer group. In addition, independence issues arise and risk-taking behaviors are common. Moreover, food choices prove problematic. For example, what is an adolescent's favorite food? Hamburgers, pizza, tacos, fried chicken, and french fries are typical answers. These are foods that we dietitians normally cringe at when we hear them in a diet recall, but they are a staple for renal teens. Adolescents feel the pressure to eat certain foods to fit in, and this includes consuming these nonkidney friendly items. In addition, teens typically avoid taking medications such as phosphorus binders.

To motivate our renal kids and teens to improve compliance, DaVita Children's Dialysis Center Continuous Quality Improvement team developed the rewards program “You Deserve an A ...,” which is focused this quarter on phosphorus control. We chose to begin the program in August 2001 to coincide with going back to school and tap into the excitement the children feel about the start of the academic year.

Similar to the start of the school year, the “You Deserve an A ...” rewards program starts patients off with a clean slate. An “A” is earned if there is a 10% improvement from the previous laboratory value and/or the patient is within the normal laboratory value for their age. For each “A” that is earned, prizes are awarded (pencils, pens, folders, and so on). At the end of the quarter, a rewards party is held with recognition and prizes awarded according to the following categories: Top of the Class (earned 4 As), Honor Roll (3 As), Halfway there (2 As), and Needs Improvement (1 A).

Importantly, if the patient does not meet the monthly goal, they earn a score of “I” or incomplete. The interdisciplinary team discusses ways to help improve with every patient. A variety of techniques are used for this effort, including the following:

Each month after tests are performed, the team meets to discuss the progress of every patient. The report cards are distributed and must be signed by the parent or guardian and returned. If any medications or extra blood draws are necessary, that information will be included on the report card. In addition to the individualized report cards, we recognize the children who achieved an “A” by mentioning their name in our monthly newsletter and by recognizing them on the dialysis bulletin board. We believe this tool motivates our patients to improve because they are able to see how well their peers are doing.

We use a variety of resources for phosphorus education, including Food Power: A Nutrition Book for Kids with Kidney Disease by Charlotte Stall, MA, RD, as well as other customized materials we have developed ourselves. Since the start of this program, we have seen impressive improvements in compliance. The hemodialysis and peritoneal dialysis populations' compliance results from the start of the program in August 2001 through January 2002 improved by 12% and 15%, respectively.

Incorporating the school theme into our dialysis program allows the children to relate to a familiar system. It focuses on laboratory values over an extended period of time and allows them to visualize their progress (or lack there of) over time and be rewarded accordingly. Most children/adolescents want to do well in school and realize the importance of good grades. The “You Deserve an A ...” program helps children have a better understanding of their health-related progress.

The report cards on the following pages (presented in English and Spanish versions) were developed to teach and reinforce phosphorus control in a fun and age-appropriate way. It is my hope that other dietitians will find these report cards helpful and this tool will stimulate your own creativity and encourage our young patients to improve compliance.