Patient-provider communication in nephrology care for adolescents and young adults

Bridging the Gap: Assessing Nephrology Transition Practices in Pediatric and Adult Medical Centers

Key Points

Despite recommendations, many nephrology programs lack a structured transition clinic or transition protocol for young adults. There is a lack of coordination between partnered adult and pediatric programs to establish formal transition practices. Adult nephrology programs generally perceive a lower need for health care transition practices compared to pediatric nephrology programs.

Background

The transition from pediatric to adult care can be challenging for young adults living with kidney disease. The International Society of Nephrology recommends establishing a transition process for this vulnerable population. The prevalence of nephrology transition clinics and protocols in academic medical centers, however, is currently unknown.

Methods

General nephrology and transplant nephrology programs were surveyed at both pediatric and adult medical centers to explore the current state of nephrology transition practices. Programs without transition clinics were asked to identify obstacles preventing the establishment of a transition clinic.

Results

Overall, there were 488 programs targeted for survey distribution. There were 188 survey responses with an overall response rate of 39%. Only 20% of programs had a transition clinic, and 32% of programs reported neither having an established transition clinic nor a transition protocol. Adult programs were more likely to lack an established transition clinic or protocol compared with pediatric programs (42% versus 20%, P = 0.001). Of partnered pediatric and adult programs that both responded to the survey, 51% were discordant in their transition practices. For the 150 programs without a transition clinic, there were 119 comments regarding obstacles to the establishment of such a clinic. Resource and financial obstacles were mentioned most frequently (50% of comments). Adult programs were more likely to mention no perceived need or obstacles compared with pediatric programs (17% versus 4%, P = 0.04).

Conclusions

Despite guidelines recommending pediatric to adult transition programs for young adults with kidney disease, transition clinics remain uncommon. Although there are many cited barriers to the establishment of a nephrology transition clinic, our study highlights the lack of coordination and cooperation between adult and pediatric centers, which may stem from a lack of perceived need or interest from adult nephrology programs.

Pediatric Transplant Surgeons' Perspectives on Palliative Care for Children With Chronic Kidney Disease: A National Cross-Sectional Survey

BACKGROUND

Some adult transplant surgeons consider transplant to be contraindicated in patients receiving palliative care (PC). Little is known about pediatric transplant surgeons' attitudes toward PC. We sought to ascertain pediatric kidney transplant surgeons' perspectives regarding the routine integration of PC for children with chronic kidney disease.

METHOD

We administered a cross-sectional web-based survey to members of the American Society of Transplant Surgeons listserv in summer 2021. We adapted the survey from the previously validated Provider Survey about Palliative Care for Children with Heart Disease and pretested it with representative kidney transplant surgeons, nephrologists, and PC physicians; queries related to PC included institutional and personal experience, knowledge, and education. Data were summarized descriptively.

RESULTS

There were 21 participants. Over half of the respondents were white (57%) males (62%), practicing in urban, academic centers (94%). Although 67% of the participants practiced in an institution with a subspecialty PC team, 24% were unsure if such a team existed in their institution. A minority (19%) perceived PC consultation and kidney transplant to be mutually exclusive. Most surgeons (86%) believed that PC should not be restricted to when a child is dying, and 59% reported that PC consultation should happen at diagnosis for life-threatening conditions. However, surgeons indicated that PC consultation is rarely utilized for pediatric kidney transplant recipients. Transplant surgeons expressed a desire for additional PC-focused training and willingness to engage in additional education.

CONCLUSIONS

Although a minority of pediatric transplant surgeons perceived PC to be contraindicated for kidney transplant, most indicated openness to PC engagement for their patients.

Dietary Phosphate Educational Materials for Pediatric Chronic Kidney Disease: Are Confused Messages Reducing Their Impact?

OBJECTIVE

This study aimed to review the quality and content of phosphate educational materials used in pediatric chronic kidney disease.

METHODS

The quality of text-based (TB) pediatric phosphate educational materials was assessed using validated instruments for health literacy demands (Suitability Assessment of Materials, Patient Education Material Assessment Tool [PEMAT-P]) readability (Flesch Reading Ease, and Flesch-Kincaid Grade Level). Codes were inductively derived to analyse format, appearance, target audience, resource type, and content, aiming for intercoder reliability > 80%. The content was compared to Pediatric Renal Nutrition Taskforce (PRNT) recommendations.

RESULTS

Sixty-five phosphate educational materials were obtained; 37 were pediatric-focused, including 28 TB. Thirty-two percent of TB materials were directed at caregivers, 25% at children, and 43% were unspecified. Most (75%) included a production date, with 75% produced >2 years ago. The median Flesch Reading Easetest score was 68.2 (interquartile range [IQR] 61.1-75.3) and Flesch-Kincaid Grade Level was 5.6 (IQR 4.5-7.7). Using Suitability Assessment of Materials, 54% rated "superior" (≥70), 38% rated "adequate" (40-69), and 8% rated "not suitable" (≤39). Low-scoring materials lacked a summary (12%), cover graphics (35%), or included irrelevant illustrations (50%). Patient Education Material Assessment Tool-P scores were 70% (IQR 50-82) for understandability and 50% (IQR 33-67) for actionability. An intercoder reliability of 87% was achieved. Over half of limited foods are in agreement with PRNT (including 89% suggesting avoiding phosphate additives). Recommendations conflicting with PRNT included reducing legumes and whole grains. Over a third contained inaccuracies, and over two-thirds included no practical advice.

CONCLUSIONS

TB pediatric phosphate educational materials are pitched at an appropriate level for caregivers, but this may be too high for children under 10 years. The inclusion of relevant illustrations may improve this. Three-quarters of materials scored low for actionability. The advice does not always align with the PRNT, which (together with the inaccuracies reported) could result in conflicting messages to patients and their families.

The Influence of Patient Provider Educational Interactions and Associated Preoperative Variables on Outcomes in the Hip Dysplasia Population

Background

Patient provider interactions influence patient treatment adherence, clinical outcomes, patient satisfaction, and an overall patient's engagement in healthcare decisions. The purpose of this study was to examine the effectiveness of patient provider educational interactions and associated variables on patient reported outcomes in the hip dysplasia population.

Methods

A secondary data analysis was completed with 6-month postoperative survey data from participants, who had undergone periacetabular osteotomy. Data analysis including demographic variables, patient reported outcome results, and pre-operative knowledge retention.

Results

A significant difference was found between participants' expectations of crutch use and physical therapy care with actual performance (p<0.001 and p=0.01) and with engagement in pre-operative support based on mental health history (p=0.02).

Conclusion

Pre-operative interactions with a provider team and prior patients (pre-operative support) can influence a patient's educational experience. Providers should review educational interventions and offer pre-operative support to patients. Level of Evidence: VI.

Building Partnerships to Improve Health Outcomes: Pediatric Patient and Family Engagement in Nephrology Practice

As health care practices have evolved from a disease-oriented to patient-focused paradigm, patient and family engagement (PFE) has been recognized as an important aspect of health care delivery and outcomes. While pediatricians have long approached care delivery with a family-centered lens, PFE may be a less familiar concept to situate among related concepts such as shared decision-making, self-efficacy, patient activation, and family-centered care. Children with CKD and their families indicate a need and desire for enhanced PFE efforts in pediatric nephrology. Improving PFE offers the opportunity to provide our patients and families with skills that will positively impact their health and wellness throughout their lives. In this review, we define PFE, describe the components of and levels at which PFE occurs across the health care system, examine PFE interventions of promise, and finally suggest future directions to support PFE in pediatric nephrology.

Child participation in triadic medical consultations: A scoping review and summary of promotive interventions

OBJECTIVES

To promote patient centered care, children with health issues should be supported to participate in consultations with health care professionals. We aimed to summarize, in a scoping review, the evidence on child participation in triadic encounters and its promotive interventions.

METHODS

Two researchers systematically searched four major databases, and included studies on child participation in medical consultations. A synthesis of quantitative and qualitative data was made.

RESULTS

Of 1678 retrieved records, 39 papers were included: 22 quantitative, 14 qualitative and 3 mixed-methods studies. Child participation, measured by utterances, turns or speech time, ranged between 4% and 14%. Participation increased with age. Equidistant seating arrangements, child-directed gaze and finding the appropriate tone of voice by the physician promoted child participation. Despite all facilitative efforts of doctors and parents, such as social talk, eHealth tools or consultation education, no increase in child participation was observed over the last 50 years.

CONCLUSIONS

Children continue to participate only marginally in medical consultations, despite their desire to be involved in various aspects of the clinical encounter and their right to have their voice heard.

PRACTICE IMPLICATIONS

Health care professionals should provide more opportunities for children to participate in triadic medical encounters and create an inclusive environment.

Enabling flourishing: novel approaches in palliative medicine for children with advanced kidney disease

PURPOSE OF REVIEW

Paediatric kidney disease results in considerable burden on children and their families. Paediatric palliative care is a holistic, family-centred care approach intended to enable flourishing and address the many impediments to life participation which advanced kidney disease can impose. To date, palliative care resources have been underutilized in paediatric nephrology. This review will highlight recent literature targeting the engagement and life participation of children with advanced kidney disease through implementation of novel palliative care approaches and propose directions for future research.

RECENT FINDINGS

Children with advanced kidney disease and their families highly value incorporation of their perspectives, particularly on life participation, within care plan development; but what it means to participate in life can be variable, and clinicians need improved tools to ascertain and incorporate these perspectives. Novel palliative care interventions developed for application in comparable disease states offer potential opportunities for paediatric nephrologists to support this goal.

SUMMARY

Children with advanced kidney disease and their families will benefit from incorporation of their perspectives and values, facilitated by palliative interventions.

Promoting High-Quality Health Communication Between Young Adults With Diabetes and Health Care Providers

Young adults with diabetes assume increasing responsibility for communicating with their health care providers, and engaging in high-quality health communication is an integral component of overall diabetes self-management. This article provides an overview of the main features of health communication, factors that may influence communication quality, interventions to promote communication skills, and practical strategies for clinicians working with young adults with diabetes. The review concludes with a comprehensive summary of future directions for health communication research.

Empowering patients to adhere to their treatment regimens: A multifaceted approach

It is well-recognized that adolescence and early adulthood are a high-risk period for non-adherence with treatment regimens in solid organ transplant recipients, leading to high rates of rejection and graft loss (Transplantation, 92, 2011, 1237; Pediatr Transplant, 9, 2005, 381; Transplantation, 77, 2004, 769). Preventing medication non-adherence is the holy grail of transplant adolescent care. If we can determine how best to support our patients in taking their daily medications as prescribed, we can improve long-term health, reduce need for re-transplantation, and reduce healthcare costs. In the last few years, several studies have provided us with additional insights into potentially effective interventions and have highlighted existing gaps in knowledge. This article reviews recent literature published over the last 5 years on the topic of adherence in transplant recipients, highlighting insights and opportunities to promote adherence at the individual patient level, family level, healthcare system level, and community level. Above all, the recent work that is highlighted suggests that adherence interventions for prevention and treatment must be multifaceted, individualized, and longitudinal to be effective.

Psychological functioning and psychosocial issues in pediatric kidney transplant recipients

Research demonstrates that psychological factors are important for positive transplant outcomes, though there is little literature that synthesizes these factors in a comprehensive model among pediatric kidney transplant patients. This review analyzes psychological and psychosocial factors related to medical outcomes and overall well-being post-transplant by utilizing the PPPHM and referencing the existing literature on risk and resilience. Pediatric kidney transplant recipients are more susceptible to mental health concerns such as depression, anxiety, and ADHD, as well as developmental and neurocognitive delays, compared to healthy peers. Complex medical care and psychosocial needs for patients have implications for family functioning, parental and sibling mental health, and youth readiness to transition to adult care. It is important to carefully monitor patient functioning with empirically validated tools and to intervene in a multidisciplinary setting as early as possible to identify patients at risk and reduce potential negative impact. Psychologists are uniquely trained to assess and address these issues and are a valuable component of multidisciplinary, culturally competent care. While research in this expansive field is improving, more data are needed to establish gold standard approaches to mental health and psychosocial care in this population.

Evaluating provider communication in pediatric chronic kidney disease care using a global coding system

OBJECTIVE

Among adolescents and young adults (AYAs) with chronic illness, effective provider communication is essential for patient-centered care during a sensitive developmental period. However, communication in chronic illness care for AYAs is not well studied. Our objectives were to describe the provider communication skills in pediatric chronic kidney disease (CKD) care visits; and determine if communication skills differ by AYA characteristics.

METHODS

We adapted a global consultation rating system for pediatric subspecialty care using audiotaped clinic encounters of 18 pediatric nephrologists with 99 AYAs (age M(SD) = 14.9(2.6)) with CKD stages 1-5 and 96 caregivers. We hypothesized that provider communication skills would differ by AYA characteristics (age, gender, and race).

RESULTS

The strongest provider skills included initiating the session and developing rapport; lowest rated skills were asking patient's perspective and checking understanding. Communication scores did not consistently differ by AYA age or race, but were rated higher with female AYAs in several domains (ps<0.05).

CONCLUSIONS

Pediatric providers generally had adequate or good communication scores with AYAs, but improvement in certain skills, particularly with male AYAs, may further support patient-centered care.

PRACTICE IMPLICATIONS

To achieve consistent, patient-centered communication with AYAs, an observation-based global assessment may identify areas for provider improvement.

The role of resilience in healthcare transitions among adolescent kidney transplant recipients

PURPOSE

AYAs with KTs experience high rates of premature allograft loss during the HCT. There is a critical need to identify protective factors associated with stable HCT. Resilience-the ability to adapt and thrive in the setting of adversity-has known positive impact on health outcomes. This study explored the novel role of resilience constructs as protective factors in securing stable HCT among AYA with KT.

METHODS

We conducted semi-structured interviews of adolescents and young adults who transitioned from a single pediatric transplant center to multiple adult nephrology centers between 2010 and 2017. Interviews explored the role of key resilience constructs in participants' lives around the time of HCT. Participants were stratified into stable or unstable HCT groups based on biological markers of allograft function and clinical data from chart review. Content analyses of interview transcripts were reviewed and compared among HCT groups.

RESULTS

Thirty-two participants enrolled (17 stable; 15 unstable). Key resilience constructs more salient in the stable versus unstable HCT group were confidence in and connection to one's healthcare team. Reports of healthcare self-management competencies were similar across both HCT groups.

CONCLUSIONS

Confidence in and connection to one's healthcare team appear to be linked with a stable HCT among AYA with KT. This suggests that interdependence, the ability to foster connections with and elicit support from healthcare providers, as opposed to complete independence or autonomy, which is often advised in the HCT process, is a critical component of resilience linked to stable HCT.

A pilot study of observed physician-parent-child communication and child satisfaction in a gastroenterology clinic

BACKGROUND

Child participation in pediatric medical visits is low. In this pilot study, we sought to better understand relationships between observed communication and child-reported perceptions of communication in a clinical setting.

MATERIALS AND METHODS

For this cross-sectional observational study, pediatric gastroenterology appointments (n=39) were videotaped and coded to quantify various adult affective (eg, chit-chat, empathy) and facilitative (eg, asking questions, encouraging responses) behaviors toward the child, interference with child participation (eg, interrupting or ignoring child), and child verbal participation. Post-visit surveys assessed child perceptions of having voice in the clinical encounter, ease of understanding, and satisfaction with communication.

RESULTS

Parent and provider chit-chat was associated with child-reported ease of understanding. Provider facilitation was positively associated with child participation, but affective communication strategies were not. Physician interference was negatively associated with ease of understanding but positively associated with perception of voice.

CONCLUSION

Facilitative communication may improve outcomes by enhancing child participation and thus exchange of medical information, whereas chit-chat appears to positively impact children's perceptions of communication.