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Gonzales KM, Koch-Weser S, Kennefick K, Lynch M, Porteny T, Tighiouart H, Wong JB, Isakova T, Rifkin DE, Gordon EJ, Rossi A, Weiner DE, Ladin K. Decision-Making Engagement Preferences among Older Adults with CKD. J Am Soc Nephrol 2024; 35:772-781. [PMID: 38517479 DOI: 10.1681/asn.0000000000000341] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Accepted: 03/18/2024] [Indexed: 03/23/2024] Open
Abstract
Key Points
Clinicians’ uncertainty about the degree to which older patients prefer to engage in decision making remains a key barrier to shared decision making.Most older adults with advanced CKD preferred a collaborative or active role in decision making.
Background
Older adults with kidney failure face preference-sensitive decisions regarding dialysis initiation. Despite recommendations, few older patients with kidney failure experience shared decision making. Clinician uncertainty about the degree to which older patients prefer to engage in decision making remains a key barrier.
Methods
This study follows a mixed-methods explanatory, longitudinal, sequential design at four diverse US centers with patients (English-fluent, aged ≥70 years, CKD stages 4–5, nondialysis) from 2018 to 2020. Patient preferences for engagement in decision making were assessed using the Control Preferences Scale, reflecting the degree to which patients want to be involved in their decision making: active (the patient prefers to make the final decision), collaborative (the patient wants to share decision making with the clinician), or passive (the patient wants the clinician to make the final decision) roles. Semistructured interviews about engagement and decision making were conducted in two waves (2019, 2020) with purposively sampled patients and clinicians. Descriptive statistics and ANOVA were used for quantitative analyses; thematic and narrative analyses were used for qualitative data.
Results
Among 363 patient participants, mean age was 78±6 years, 42% were female, and 21% had a high school education or less. Control Preferences Scale responses reflected that patients preferred to engage actively (48%) or collaboratively (43%) versus passively (8%). Preferred roles remained stable at 3-month follow-up. Seventy-six participants completed interviews (45 patients, 31 clinicians). Four themes emerged: control preference roles reflect levels of decisional engagement; clinicians control information flow, especially about prognosis; adapting a clinical approach to patient preferred roles; and clinicians' responsiveness to patient preferred roles supports patients' satisfaction with shared decision making.
Conclusions
Most older adults with advanced CKD preferred a collaborative or active role in decision making. Appropriately matched information flow with patient preferences was critical for satisfaction with shared decision making.
Clinical Trial registry name and registration number:
Decision Aid for Renal Therapy (DART), NCT03522740.
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Affiliation(s)
- Kristina M Gonzales
- Department of Community Health, Tufts University, Medford, Massachusetts
- Research on Ethics, Aging, and Community Health (REACH Lab), Medford, Massachusetts
| | - Susan Koch-Weser
- Department of Public Health and Community Medicine, Tufts University School of Medicine, Boston, Massachusetts
| | - Kristen Kennefick
- Research on Ethics, Aging, and Community Health (REACH Lab), Medford, Massachusetts
| | - Mary Lynch
- Research on Ethics, Aging, and Community Health (REACH Lab), Medford, Massachusetts
| | - Thalia Porteny
- Mailman School of Public Health, Columbia University, New York, New York
| | - Hocine Tighiouart
- Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, Massachusetts
- Tufts Clinical and Translational Science Institute, Tufts University, Boston, Massachusetts
| | - John B Wong
- Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, Massachusetts
- Tufts Clinical and Translational Science Institute, Tufts University, Boston, Massachusetts
| | - Tamara Isakova
- Center for Translational Metabolism and Health, Institute for Public Health and Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Dena E Rifkin
- Division of Nephrology, Veterans' Affairs Healthcare System, University of California, San Diego, San Diego, California
| | - Elisa J Gordon
- Department of Surgery, Center for Biomedical Ethics and Society, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Ana Rossi
- Piedmont Transplant Institute, Atlanta, Georgia
| | - Daniel E Weiner
- Division of Nephrology, Tufts Medical Center, Boston, Massachusetts
| | - Keren Ladin
- Department of Community Health, Tufts University, Medford, Massachusetts
- Research on Ethics, Aging, and Community Health (REACH Lab), Medford, Massachusetts
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Zhang Y, Baharani J. Educating acute dialysis patients - can we do better? Future Healthc J 2024; 11:100003. [PMID: 38646054 PMCID: PMC11025065 DOI: 10.1016/j.fhj.2024.100003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/23/2024]
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Cotta A, Kristiansen M. Enacting person-centred care: a multi-perspective study of practices in clinical encounters for people living with chronic kidney disease. BMC Nephrol 2023; 24:185. [PMID: 37349691 PMCID: PMC10288716 DOI: 10.1186/s12882-023-03245-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Accepted: 06/16/2023] [Indexed: 06/24/2023] Open
Abstract
BACKGROUND There is growing emphasis on the need for ensuring person-centred care for patients living with chronic kidney disease as this will benefit patients, providers, and healthcare systems alike. Nevertheless, less emphasis is given to how this complex concept is practiced in clinical encounters and how it is experienced by patients. This qualitative multi-perspective study investigates how person-centred care for people living with chronic kidney disease is practiced and experienced by patients in clinical encounters at a nephrological ward at a hospital in the capital region of Denmark. METHODS The study builds upon qualitative methodologies, including field notes from observations of clinical encounters between clinicians and patients in an out-patient clinic (n = ~ 80) and in-person interviews with patients in peritoneal dialysis (n = 4). Key themes from field notes and interview transcripts were identified through thematic analysis. Analyses were informed by practice theory. RESULTS Findings illustrate that person-centred care is practiced in a relational and situational encounter between patients and clinicians as dialogues about choice of treatment modality, which is shaped by the individual's life circumstances, preferences, and values. The practice of person-centred care appeared to be complex and interlinked with a range of factors, individual to each patient. We identified three themes of relevance for practices and experiences related to person-centred care: (1) Patients' perceptions of living with chronic kidney disease. Perceptions differed according to medical history, life situation and prior experiences with treatment in the healthcare system. These patient-related factors were perceived to be important for person-centred care to unfold; (2) Relations between patients and healthcare professionals were important for patients' experiences of trust and appeared fundamental for the practice and experiences of person-centred care; and (3) Decision-making on treatment modality that is the best fit for each patient's everyday life, appear to be shaped by the patient's need for knowledge about treatment modalities and level of self-determination in the decision-making. CONCLUSIONS The context of clinical encounters influences the practices and experiences of person-centred care, where health policies and lack of embodiment are identified as barriers for providing and experiencing person-centred care.
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Affiliation(s)
- Amie Cotta
- Center for IT and Medical technology, Capital Region, Borgervaenget 5, 2100 Copenhagen Ø, Denmark
| | - Maria Kristiansen
- Department of Public Health, Center for Healthy Aging, University of Copenhagen, Øster Farimagsgade 5, DK 1353 Copenhagen K, Denmark
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Palliative Care for Patients with Kidney Disease. J Clin Med 2022; 11:jcm11133923. [PMID: 35807208 PMCID: PMC9267754 DOI: 10.3390/jcm11133923] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Revised: 06/27/2022] [Accepted: 07/02/2022] [Indexed: 11/16/2022] Open
Abstract
Interest in palliative care has increased in recent times, particularly in its multidisciplinary approach developed to meet the needs of patients with a life-threatening disease and their families. Although the modern concept of palliative simultaneous care postulates the adoption of these qualitative treatments early on during the life-threatening disease (and potentially just after the diagnosis), palliative care is still reserved for patients at the end of their life in most of the clinical realities, and thus is consequently mistaken for hospice care. Patients with acute or chronic kidney disease (CKD) usually experience poor quality of life and decreased survival expectancy and thus may benefit from palliative care. Palliative care requires close collaboration among multiple health care providers, patients, and their families to share the diagnosis, prognosis, realistic treatment goals, and treatment decisions. Several approaches, such as conservative management, extracorporeal, and peritoneal palliative dialysis, can be attempted to globally meet the needs of patients with kidney disease (e.g., physical, social, psychological, or spiritual needs). Particularly for frail patients, pharmacologic management or peritoneal dialysis may be more appropriate than extracorporeal treatment. Extracorporeal dialysis treatment may be disproportionate in these patients and associated with a high burden of symptoms correlated with this invasive procedure. For those patients undergoing extracorporeal dialysis, individualized goal setting and a broader concept of adequacy should be considered as the foundations of extracorporeal palliative dialysis. Interestingly, little evidence is available on palliative and end of life care for acute kidney injury (AKI) patients. In this review, the main variables influencing medical decision-making about palliative care in patients with kidney disease are described, as well as the different approaches that can fulfill the needs of patients with CKD and AKI.
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Yabe H, Okada K, Kono K, Imoto Y, Onoyama A, Ito S, Moriyama Y, Kasuga H, Ito Y. Effects of cognitive impairment and assisted peritoneal dialysis on exit-site infection in older patients. Clin Exp Nephrol 2022; 26:593-600. [PMID: 35195815 DOI: 10.1007/s10157-022-02199-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2021] [Accepted: 02/11/2022] [Indexed: 11/03/2022]
Abstract
BACKGROUND Elderly peritoneal dialysis (PD) patients required assistance for a variety of PD-related tasks. The usefulness of assisted PD in reducing the peritonitis risk has been reported; however, there is little evidence on the effectiveness of assisted PD in preventing exit-site infections in older patients. METHODS This was a single-center, prospective cohort study. Thirty-three patients (mean age: 74.8 ± 5.9 years) on PD were evaluated for cognitive impairment (CI) using the Japanese version of the Montreal Cognitive Assessment. They were also evaluated to determine whether they performed the exit-site care procedure alone or with assistance. Patients were categorized into four groups based on the presence or absence of CI and the presence or absence of exit-site care assistance. They were followed up until the occurrence of peritonitis and exit-site infection at the end of the follow-up. RESULTS Altogether, 8, 8, and 17 patients were assigned to the "without CI and without assistance", "without CI and with assistance", and "with CI and with assistance groups", respectively; no patients were assigned to the "with CI and without assistance group". Six and 16 patients experienced peritonitis and exit-site infection during follow-up, respectively. Kaplan-Meier analysis and log-rank tests revealed that the "without CI and without assistance group" was significantly associated with exit-site infection (log-rank < 0.05). CONCLUSION Patients who did not receive assistance for exit-site care were at a higher risk of exit-site infections, even in the absence of CI. Caregiver assistance is important for preventing exit-site infections in older patients on PD.
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Affiliation(s)
- Hiroki Yabe
- Department of Physical Therapy, School of Rehabilitation Sciences, Seirei Christopher University, 3453 Mikatahara, Kita-ku, Hamamatsu, Shizuoka, 433-8558, Japan. .,Department of Rehabilitation, Nagoya Kyoritsu Hospital, 1-172 Hokke, Nakagawa-ku, Nagoya, Aichi, 454-0933, Japan.
| | - Keiko Okada
- Department of Nephrology, Nagoya Kyoritsu Hospital, 1-172 Hokke, Nakagawa-ku, Nagoya, Aichi, 454-0933, Japan
| | - Kenichi Kono
- Department of Physical Therapy, School of Health Sciences at Narita, International University of Health and Welfare, 4-3, Kozunomori, Narita, Chiba, 286-8686, Japan
| | - Yuto Imoto
- Department of Rehabilitation, Nagoya Kyoritsu Hospital, 1-172 Hokke, Nakagawa-ku, Nagoya, Aichi, 454-0933, Japan
| | - Ayaka Onoyama
- Department of Rehabilitation, Nagoya Kyoritsu Hospital, 1-172 Hokke, Nakagawa-ku, Nagoya, Aichi, 454-0933, Japan
| | - Sayaka Ito
- Department of Rehabilitation, Nagoya Kyoritsu Hospital, 1-172 Hokke, Nakagawa-ku, Nagoya, Aichi, 454-0933, Japan
| | - Yoshifumi Moriyama
- Department of Wellness Center, Nagoya Kyoritsu Hospital, 1-172 Hokke, Nakagawa-ku, Nagoya, Aichi, 454-0933, Japan
| | - Hirotake Kasuga
- Department of Nephrology, Nagoya Kyoritsu Hospital, 1-172 Hokke, Nakagawa-ku, Nagoya, Aichi, 454-0933, Japan
| | - Yasuhiko Ito
- Department of Nephrology and Rheumatology, Aichi Medical University, 1-1 Karimata, Yazako, Nagakute, 480-1195, Japan
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Eroglu E, Heimbürger O, Lindholm B. Peritoneal dialysis patient selection from a comorbidity perspective. Semin Dial 2020; 35:25-39. [PMID: 33094512 DOI: 10.1111/sdi.12927] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Revised: 09/27/2020] [Accepted: 09/30/2020] [Indexed: 12/17/2022]
Abstract
Despite many medical and socioeconomic advantages, peritoneal dialysis (PD) is an underutilized dialysis modality that in most countries is used by only 5%-20% of dialysis patients, while the vast majority are treated with in-center hemodialysis. Several factors may explain this paradox, such as lack of experience and infrastructure for training and monitoring of PD patients, organizational issues, overcapacity of hemodialysis facilities, and lack of economic incentives for dialysis centers to use PD instead of HD. In addition, medical conditions that are perceived (rightly or wrongly) as contraindications to PD represent barriers for the use of PD because of their purported potential negative impact on clinical outcomes in patients starting PD. While there are few absolute contraindications to PD, high age, comorbidities such as diabetes mellitus, obesity, polycystic kidney disease, heart failure, and previous history of abdominal surgery and renal allograft failure, may be seen (rightly or wrongly) as relative contraindications and thus barriers to initiation of PD. In this brief review, we discuss how the presence of these conditions may influence the strategy of selecting patients for PD, focusing on measures that can be taken to overcome potential problems.
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Affiliation(s)
- Eray Eroglu
- Division of Nephrology, Department of Internal Medicine, Erciyes University School of Medicine, Kayseri, Turkey.,Division of Renal Medicine and Baxter Novum, Department of Clinical Science Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
| | - Olof Heimbürger
- Division of Renal Medicine and Baxter Novum, Department of Clinical Science Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
| | - Bengt Lindholm
- Division of Renal Medicine and Baxter Novum, Department of Clinical Science Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
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Bradshaw CL, Gale RC, Chettiar A, Ghaus SJ, Thomas IC, Fung E, Lorenz K, Asch SM, Anand S, Kurella Tamura M. Medical Record Documentation of Goals-of-Care Discussions Among Older Veterans With Incident Kidney Failure. Am J Kidney Dis 2019; 75:744-752. [PMID: 31679746 DOI: 10.1053/j.ajkd.2019.07.024] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2019] [Accepted: 07/26/2019] [Indexed: 11/11/2022]
Abstract
RATIONALE & OBJECTIVE Elicitation and documentation of patient preferences is at the core of shared decision making and is particularly important among patients with high anticipated mortality. The extent to which older patients with incident kidney failure undertake such discussions with their providers is unknown and its characterization was the focus of this study. STUDY DESIGN Retrospective cohort study. SETTING & PARTICIPANTS A random sample of veterans 67 years and older with incident kidney failure receiving care from the US Veterans Health Administration between 2005 and 2010. EXPOSURES Demographic and facility characteristics, as well as predicted 6-month mortality risk after dialysis initiation and documentation of resuscitation preferences. OUTCOMES Documented discussions of dialysis treatment and supportive care. ANALYTICAL APPROACH We reviewed medical records over the 2 years before incident kidney failure and up to 1 year afterward to ascertain the frequency and timing of documented discussions about dialysis treatment, supportive care, and resuscitation. Logistic regression was used to identify factors associated with these documented discussions. RESULTS The cohort of 821 veterans had a mean age of 80.9±7.2 years, and 37.2% had a predicted 6-month mortality risk>20% with dialysis. Documented discussions addressing dialysis treatment and resuscitation were present in 55.6% and 77.1% of patients, respectively. Those addressing supportive care were present in 32.4%. The frequency of documentation varied by mortality risk and whether the patient ultimately started dialysis. In adjusted analyses, the frequency and pattern of documentation were more strongly associated with geographic location and receipt of outpatient nephrology care than with patient demographic or clinical characteristics. LIMITATIONS Documentation may not fully reflect the quality and content of discussions, and generalizability to nonveteran patients is limited. CONCLUSIONS Among older veterans with incident kidney failure, discussions of dialysis treatment are decoupled from other aspects of advance care planning and are suboptimally documented, even among patients at high risk for mortality.
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Affiliation(s)
| | - Randall C Gale
- Center for Innovation to Implementation, VA Palo Alto VA Health Care System, Palo Alto, CA
| | - Alexis Chettiar
- Program of Health Policy, University of California San Francisco, San Francisco, CA
| | - Sharfun J Ghaus
- Division of Nephrology, Stanford University School of Medicine, Palo Alto, CA
| | - I-Chun Thomas
- Geriatric Research and Education Clinical Center, VA Palo Alto Health Care System, Palo Alto, CA
| | - Enrica Fung
- Division of Nephrology, VA Loma Linda Healthcare System, Loma Linda, CA
| | - Karl Lorenz
- Geriatric Research and Education Clinical Center, VA Palo Alto Health Care System, Palo Alto, CA
| | - Steven M Asch
- Center for Innovation to Implementation, VA Palo Alto VA Health Care System, Palo Alto, CA
| | - Shuchi Anand
- Division of Nephrology, Stanford University School of Medicine, Palo Alto, CA
| | - Manjula Kurella Tamura
- Division of Nephrology, Stanford University School of Medicine, Palo Alto, CA; Geriatric Research and Education Clinical Center, VA Palo Alto Health Care System, Palo Alto, CA
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Shukla AM, Hinkamp C, Segal E, Ozrazgat Baslanti T, Martinez T, Thomas M, Ramamoorthy R, Bozorgmehri S. What do the US advanced kidney disease patients want? Comprehensive pre-ESRD Patient Education (CPE) and choice of dialysis modality. PLoS One 2019; 14:e0215091. [PMID: 30964936 PMCID: PMC6456188 DOI: 10.1371/journal.pone.0215091] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2018] [Accepted: 03/26/2019] [Indexed: 11/18/2022] Open
Abstract
Improvement in Home Dialysis (HoD) utilizations as a mean to improve the patient reported and health services outcomes, has been a long-held goal of the providers and healthcare system in United States. However, measures to improve HoD rates have yielded limited success so far. Lack of patient awareness of chronic kidney disease (CKD) and its management options, is one of the important barriers against patient adoption of HoD. Despite ample evidence that Comprehensive pre-ESERD Patient Education (CPE) improves patient awareness and informed HoD choice, use of CPE among US advanced CKD patients is low. Need for significant resources, lack of validated data showing unequivocal and reproducible benefits, and the lack of validated CPE protocols proven to have consistent efficacy in improving not only patient awareness but also HoD rates in US population, are major limitations deterring adoption of CPE in routine clinical practice. We recently demonstrated that if a structured, protocol based CPE is integrated within the routine nephrology care for patients with advanced CKD, it substantially improves informed HoD choice and utilizations. However, this requires establishing CPE resources within each nephrology practice. Efficacy of a stand-alone CPE model, independent of clinical care, has not been examined till date. In this report we report the efficacy of our structured CPE protocol, delivered outside the realm of routine nephrology care-as a stand-alone patient education program, in a geographically distant region, and show that: when provided opportunity for informed dialysis choice, a majority of advanced CKD patients in US would prefer HoD. We also show that initiating CPE leads to accelerated growth in HoD utilizations and reduces disparities in HoD utilizations, goals for system improvements. Finally, the reproducibility of our structured CPE protocol with consistent efficacy data suggest that initiating such programs at institutional levels has the potential to improve informed dialysis selection and HoD rates across any similar large healthcare institute within US.
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Affiliation(s)
- Ashutosh M. Shukla
- Department of Medicine, North Florida / South Georgia Veteran Healthcare System, Gainesville, Florida, United States of America
- Division of Nephrology, Hypertension, and Transplantation, Department of Medicine, University of Florida, Gainesville, Florida, United States of America
- * E-mail:
| | - Colin Hinkamp
- Division of Nephrology, Hypertension, and Transplantation, Department of Medicine, University of Florida, Gainesville, Florida, United States of America
| | - Emma Segal
- Division of Nephrology, Hypertension, and Transplantation, Department of Medicine, University of Florida, Gainesville, Florida, United States of America
| | - Tezcan Ozrazgat Baslanti
- Division of Nephrology, Hypertension, and Transplantation, Department of Medicine, University of Florida, Gainesville, Florida, United States of America
| | - Teri Martinez
- Division of Nephrology, Hypertension, and Transplantation, Department of Medicine, University of Florida, Gainesville, Florida, United States of America
| | - Michelle Thomas
- Dialysis Clinic Inc (DCI), Gainesville, Florida, United States of America
| | - Ramya Ramamoorthy
- Department of Medical Socidal Worker, UF Health, Gainesville, Florida, United States of America
| | - Shahab Bozorgmehri
- Division of Nephrology, Hypertension, and Transplantation, Department of Medicine, University of Florida, Gainesville, Florida, United States of America
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Combes G, Sein K, Allen K. How does pre-dialysis education need to change? Findings from a qualitative study with staff and patients. BMC Nephrol 2017; 18:334. [PMID: 29169332 PMCID: PMC5701386 DOI: 10.1186/s12882-017-0751-y] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2016] [Accepted: 11/13/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Pre-dialysis education (PDE) is provided to thousands of patients every year, helping them decide which renal replacement therapy (RRT) to choose. However, its effectiveness is largely unknown, with relatively little previous research into patients' views about PDE, and no research into staff views. This study reports findings relevant to PDE from a larger mixed methods study, providing insights into what staff and patients think needs to improve. METHODS Semi-structured interviews in four hospitals with 96 clinical and managerial staff and 93 dialysis patients, exploring experiences of and views about PDE, and analysed using thematic framework analysis. RESULTS Most patients found PDE helpful and staff valued its role in supporting patient decision-making. However, patients wanted to see teaching methods and materials improve and biases eliminated. Staff were less aware than patients of how informal staff-patient conversations can influence patients' treatment decision-making. Many staff felt ill equipped to talk about all treatment options in a balanced and unbiased way. Patient decision-making was found to be complex and patients' abilities to make treatment decisions were adversely affected in the pre-dialysis period by emotional distress. CONCLUSIONS Suggested improvements to teaching methods and educational materials are in line with previous studies and current clinical guidelines. All staff, irrespective of their role, need to be trained about all treatment options so that informal conversations with patients are not biased. The study argues for a more individualised approach to PDE which is more like counselling than education and would demand a higher level of skill and training for specialist PDE staff. The study concludes that even if these improvements are made to PDE, not all patients will benefit, because some find decision-making in the pre-dialysis period too complex or are unable to engage with education due to illness or emotional distress. It is therefore recommended that pre-dialysis treatment decisions are temporary, and that PDE is replaced with on-going RRT education which provides opportunities for personalised education and on-going review of patients' treatment choices. Emotional support to help overcome the distress of the transition to end-stage renal disease will also be essential to ensure all patients can benefit from RRT education.
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Affiliation(s)
- Gill Combes
- Institute of Applied Health Research, University of Birmingham, Birmingham, B15 2TT, UK.
| | - Kim Sein
- Hull York Medical School, University of Hull, Hull, HU6 7RX, UK
| | - Kerry Allen
- Health Services Management Centre, University of Birmingham, Birmingham, B15 2TT, UK
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Prieto-Velasco M, Quiros P, Remon C. The Concordance between Patients' Renal Replacement Therapy Choice and Definitive Modality: Is It a Utopia? PLoS One 2015; 10:e0138811. [PMID: 26466387 PMCID: PMC4605797 DOI: 10.1371/journal.pone.0138811] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2015] [Accepted: 09/03/2015] [Indexed: 11/18/2022] Open
Abstract
INTRODUCTION It is desirable for patients to play active roles in the choice of renal replacement therapy (RRT). Patient decision aid tools (PDAs) have been developed to allow the patients to choose the option best suited to their individual needs. MATERIAL AND METHODS An observational, prospective registry was conducted in 26 Spanish hospitals between September 2010 and May 2012. The results of the patients' choice and the definitive RRT modality were registered through the progressive implementation of an Education Process (EP) with PDAs designed to help Chronic Kidney Disease (CKD) patients choose RRT. RESULTS Patients included in this study: 1044. Of these, 569 patients used PDAs and had made a definitive choice by the end of registration. A total of 88.4% of patients chose dialysis [43% hemodialysis (HD) and 45% peritoneal dialysis (PD)] 3.2% preemptive living-donor transplant (TX), and 8.4% conservative treatment (CT). A total of 399 patients began RRT during this period. The distribution was 93.4% dialysis (53.6% HD; 40% PD), 1.3% preemptive TX and 5.3% CT. The patients who followed the EP changed their mind significantly less often [kappa value of 0.91 (95% CI, 0.86-0.95)] than those who did not follow it, despite starting unplanned treatment [kappa value of 0.85 (95% CI, 0.75-0.95]. A higher agreement between the final choice and a definitive treatment was achieved by the EP and planned patients [kappa value of 0.93 (95% CI, 0.89-0.98)]. Those who did not go through the EP had a much lower index of choosing PD and changed their decision more frequently when starting definitive treatment [kappa value of 0.73 (95% CI, 0.55-0.91)]. CONCLUSIONS Free choice, assisted by PDAs, leads to a 50/50 distribution of PD and HD choice and an increase in TX choice. The use of PDAs, even with an unplanned start, achieved a high level of concordance between the chosen and definitive modality.
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Affiliation(s)
- Mario Prieto-Velasco
- Department of Nephrology, Complejo Asistencial Universitario de León, León, Spain
- * E-mail:
| | - Pedro Quiros
- Department of Nephrology, Hospital Universitario de Puerto Real, Puerto Real, Spain
| | - Cesar Remon
- Department of Nephrology, Hospital Universitario de Puerto Real, Puerto Real, Spain
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Isnard Bagnis C, Crepaldi C, Dean J, Goovaerts T, Melander S, Nilsson EL, Prieto-Velasco M, Trujillo C, Zambon R, Mooney A. Quality standards for predialysis education: results from a consensus conference. Nephrol Dial Transplant 2015; 30:1058-66. [PMID: 24957808 PMCID: PMC4479667 DOI: 10.1093/ndt/gfu225] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2013] [Accepted: 05/27/2014] [Indexed: 11/14/2022] Open
Abstract
This position statement was compiled following an expert meeting in March 2013, Zurich, Switzerland. Attendees were invited from a spread of European renal units with established and respected renal replacement therapy option education programmes. Discussions centred around optimal ways of creating an education team, setting realistic and meaningful objectives for patient education, and assessing the quality of education delivered.
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Affiliation(s)
- Corinne Isnard Bagnis
- Service de Néphrologie, Groupe Hospitalier Pitié-Salpêtrière et Chaire de Recherche en Education Thérapeutique, Université Pierre et Marie Curie, Paris, France
| | - Carlo Crepaldi
- Unità Operativa di Nefrologia, Dialisi e Trapianto, Ospedale San Bortolo, Vicenza, Italy
| | - Jessica Dean
- Department of Clinical Health Psychology, Salford Royal Hospital, Salford, UK
| | - Tony Goovaerts
- Cliniques Universitaires St. Luc, Service de Néphrologie, Brussels, Belgium
| | - Stefan Melander
- Department of Nephrology, University Hospital of Linköping, Linköping, Sweden
| | - Eva-Lena Nilsson
- Department of Nephrology, Skånes University Hospital, Malmö, Sweden
| | | | - Carmen Trujillo
- Unidad clínica de Gestión de Nefrología, Hospital Regional Carlos Haya, Malaga, Spain
| | - Roberto Zambon
- Unità Operativa di Nefrologia, Dialisi e Trapianto, Ospedale San Bortolo, Vicenza, Italy
| | - Andrew Mooney
- Renal Unit, St James's University Hospital, Leeds Teaching Hospitals NHS Trust, Leeds, UK
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Goovaerts T, Bagnis Isnard C, Crepaldi C, Dean J, Melander S, Mooney A, Prieto‐Velasco M, Trujillo C, Zambon R, Nilsson E. Continuing education: preparing patients to choose a renal replacement therapy. J Ren Care 2015; 41:62-75. [PMID: 25597792 PMCID: PMC7328707 DOI: 10.1111/jorc.12106] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Patients with progressive chronic kidney disease face a series of treatment decisions that will impact the quality of life of themselves and their family. Renal replacement therapy option education (RRTOE), generally provided by nurses, is recommended by international guidelines OBJECTIVES To provide nurses with advice and guidance on running RRTOE. DESIGN A consensus conference. PARTICIPANTS Four nurses, 5 nephrologists and 1 clinical psychologist (9 renal units; 6 European countries) from units that had extensive experience in RRTOE or were performing research in this field. APPROACH Experts brainstormed and discussed quality standards for the education team, processes, content/topics, media/material/funding and quality measurements for RRTOE. RESULTS Conclusions and recommendations from these discussions that are particularly pertinent to nurses are presented in this paper. CONCLUSIONS Through careful planning and smooth interdisciplinary cooperation, it is possible to implement an education and support programme that helps patients choose a form of RRT that is most suited to their needs. This may result in benefits in quality of life and clinical outcomes. APPLICATION TO PRACTICE There are large differences between renal units in terms of resources available and the demographics of the catchment area. Therefore, nurses should carefully consider how best to adapt the advice offered here to their own situation. Throughout this process, it is crucial to keep in mind the ultimate goal - providing patients with the knowledge and skill to make a modality choice that will enhance their quality of life to the greatest degree.
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Affiliation(s)
- Tony Goovaerts
- Cliniques Universitaires St LucService de NéphrologieBrusselsBelgium
| | - Corinne Bagnis Isnard
- Service de Néphrologie, Groupe Hospitalier Pitié‐Salpêtrière et Chaire de Recherche en Education ThérapeutiqueUniversité Pierre et Marie CurieParisFrance
| | - Carlo Crepaldi
- Unità Operativa di NefrologiaDialisi e TrapiantoOspedale San BortoloVicenzaItaly
| | - Jessica Dean
- Department of Clinical Health PsychologySalford Royal HospitalSalfordUK
| | - Stefan Melander
- Department of NephrologyUniversity Hospital of LinköpingLinköpingSweden
| | - Andrew Mooney
- Renal UnitSt James's University Hospital, Leeds Teaching Hospitals NHS TrustLeedsUK
| | | | - Carmen Trujillo
- Unidad clínica de Gestión de NefrologíaHospital Regional Carlos HayaMalagaSpain
| | - Roberto Zambon
- Unità Operativa di NefrologiaDialisi e TrapiantoOspedale San BortoloVicenzaItaly
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Prieto-Velasco M, Isnard Bagnis C, Dean J, Goovaerts T, Melander S, Mooney A, Nilsson EL, Rutherford P, Trujillo C, Zambon R, Crepaldi C. Predialysis education in practice: a questionnaire survey of centres with established programmes. BMC Res Notes 2014; 7:730. [PMID: 25326141 PMCID: PMC4210595 DOI: 10.1186/1756-0500-7-730] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2014] [Accepted: 10/09/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND There is growing evidence that renal replacement therapy option education (RRTOE) can result in enhanced quality of life, improved clinical outcomes, and reduced health care costs. However, there is still no detailed guidance on the optimal way to run such programmes. To help address this knowledge gap, an expert meeting was held in March 2013 to formulate a position statement on optimal ways to run RRTOE. Experts were selected from units that had extensive experience in RRTOE or were performing research in this field. Before the meeting, experts completed a pilot questionnaire on RRTOE in their own units. They also prepared feedback on how to modify this questionnaire for a large-scale study. METHODS A pilot, web-based questionnaire was used to obtain information on: the renal unit and patients, the education team, RRTOE processes and content, how quality is assessed, and funding. RESULTS Four nurses, 5 nephrologists and 1 clinical psychologist (9 renal units; 6 EU countries) participated. Nurses were almost always responsible for organising RRTOE. Nephrologists spent 7.5% (median) of their time on RRTOE. Education for the patient and family began several months before dialysis or according to disease progression. Key topics such as the 'impact of the disease' were covered by every unit, but only a few units described all dialysis modalities. Visits to the unit were almost always arranged. Materials came in a wide variety of forms and from a wide range of sources. Group education sessions were used in 3/9 centres. Expectations on the timing of patients' decisions on modality and permanent access differed substantially between centres. Common quality assurance measures were: patient satisfaction, course attendance, updated materials. Only 1 unit had a dedicated budget. CONCLUSIONS There were substantial variations in how RRTOE is run between the units. A modified version of this questionnaire will be used to assess RRTOE at a European level.
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Affiliation(s)
| | - Corinne Isnard Bagnis
- />Service de Néphrology, Groupe Hospitalier Pitié-Salpêtrière et Chaire de Recherche en Education Thérapeutique, Université Pierre et Marie Curie, Paris, France
| | - Jessica Dean
- />Department of Clinical Health Psychology, Salford Royal Hospital, Salford, M6 8HD UK
| | - Tony Goovaerts
- />Cliniques Universitaires St. Luc, Service de Néphrologie, Brussels, Belgium
| | - Stefan Melander
- />Department of Nephrology, University Hospital of Linköping, Linköping, Sweden
| | - Andrew Mooney
- />Renal Unit, St James’s University Hospital, Leeds Teaching Hospitals NHS Trust, Leeds, LS9 7TF UK
| | - Eva-Lena Nilsson
- />Department of Nephrology and Transplantation, Skånes University Hospital, Malmö, Sweden
| | | | - Carmen Trujillo
- />Unidad clínica de Gestión de Nefrología, Hospital Regional Carlos Haya, Malaga, Spain
| | - Roberto Zambon
- />Unità Operativa di Nefrologia, Dialisi e Trapianto, Ospedale San Bortolo, ULSS106 Vicenza, Italy
| | - Carlo Crepaldi
- />Unità Operativa di Nefrologia, Dialisi e Trapianto, Ospedale San Bortolo, ULSS106 Vicenza, Italy
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Bedeutung der Prädialysevorbereitung und Patienteninformation für die Wahl des Dialyseverfahrens. Wien Med Wochenschr 2013; 163:266-70. [DOI: 10.1007/s10354-013-0192-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2012] [Accepted: 03/13/2013] [Indexed: 10/26/2022]
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15
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Goovaerts T. Practical help for setting-up, implementing and evaluating home therapies in your unit. J Ren Care 2013; 39 Suppl 1:1. [PMID: 23464905 DOI: 10.1111/j.1755-6686.2013.12001.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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16
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Views of Japanese patients on the advantages and disadvantages of hemodialysis and peritoneal dialysis. Int Urol Nephrol 2012; 45:1145-58. [PMID: 23161376 DOI: 10.1007/s11255-012-0322-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2012] [Accepted: 10/22/2012] [Indexed: 01/15/2023]
Abstract
PURPOSE The preference for dialysis modalities is not well understood in Japan. This study explored the subjective views of Japanese patients undergoing dialysis regarding their treatments. METHODS The participants were receiving in-center hemodialysis (CHD) or continuous ambulatory peritoneal dialysis (CAPD). In Study 1, 34 participants (17 CHD and 17 CAPD) were interviewed about the advantages and disadvantages of dialysis modalities. In Study 2, 454 dialysis patients (437 CHD and 17 CAPD) rated the advantages and disadvantages of CHD and CAPD in a cross-sectional survey. RESULTS Interviews showed that professional care and dialysis-free days were considered as advantages of CHD, while independence, less hospital visits, and flexibility were considered as advantages of CAPD. Disadvantages of CHD included restriction of food and fluids and unpleasant symptoms after each dialysis session. Catheter care was an additional disadvantage of CAPD. Survey showed that the highly ranked advantages were professional care in CHD and less frequent hospital visits in CAPD, while the highly ranked disadvantages were concerns about emergency and time restrictions in CHD, and catheter care and difficulty in soaking in a bath in CAPD. The total scores of advantages and disadvantages showed that CHD patients subjectively rated their own modality better CHD over CAPD, while CAPD patients had the opposite opinion. CONCLUSIONS The results of this study indicate that the factors affecting the decision-making process of Japanese patients are unique to Japanese culture, namely considering the trouble caused to the people around patients (e.g., families, spouses, and/or caregivers).
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Coentrão L, Santos-Araújo C, Dias C, Neto R, Pestana M. Effects of starting hemodialysis with an arteriovenous fistula or central venous catheter compared with peritoneal dialysis: a retrospective cohort study. BMC Nephrol 2012; 13:88. [PMID: 22916962 PMCID: PMC3476986 DOI: 10.1186/1471-2369-13-88] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2011] [Accepted: 08/20/2012] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Although several studies have demonstrated early survival advantages with peritoneal dialysis (PD) over hemodialysis (HD), the reason for the excess mortality observed among incident HD patients remains to be established, to our knowledge. This study explores the relationship between mortality and dialysis modality, focusing on the role of HD vascular access type at the time of dialysis initiation. METHODS A retrospective cohort study was performed among local adult chronic kidney disease patients who consecutively initiated PD and HD with a tunneled cuffed venous catheter (HD-TCC) or a functional arteriovenous fistula (HD-AVF) in our institution in the year 2008. A total of 152 patients were included in the final analysis (HD-AVF, n = 59; HD-TCC, n = 51; PD, n = 42). All cause and dialysis access-related morbidity/mortality were evaluated at one year. Univariate and multivariate analysis were used to compare the survival of PD patients with those who initiated HD with an AVF or with a TCC. RESULTS Compared with PD patients, both HD-AVF and HD-TCC patients were more likely to be older (p<0.001) and to have a higher frequency of diabetes mellitus (p = 0.017) and cardiovascular disease (p = 0.020). Overall, HD-TCC patients were more likely to have clinical visits (p = 0.069), emergency room visits (p<0.001) and hospital admissions (p<0.001). At the end of follow-up, HD-TCC patients had a higher rate of dialysis access-related complications (1.53 vs. 0.93 vs. 0.64, per patient-year; p<0.001) and hospitalizations (0.47 vs. 0.07 vs. 0.14, per patient-year; p = 0.034) than HD-AVF and PD patients, respectively. The survival rates at one year were 96.6%, 74.5% and 97.6% for HD-AVF, HD-TCC and PD groups, respectively (p<0.001). In multivariate analysis, HD-TCC use at the time of dialysis initiation was the important factor associated with death (HR 16.128, 95%CI [1.431-181.778], p = 0.024). CONCLUSION Our results suggest that HD vascular access type at the time of renal replacement therapy initiation is an important modifier of the relationship between dialysis modality and survival among incident dialysis patients.
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Affiliation(s)
- Luis Coentrão
- Nephrology Research and Development Unit, Faculty of Medicine, University of Porto & São João Hospital Centre, Alameda Professor Hernani Monteiro, Porto, 4202-451, Portugal
| | - Carla Santos-Araújo
- Nephrology Research and Development Unit, Faculty of Medicine, University of Porto & São João Hospital Centre, Alameda Professor Hernani Monteiro, Porto, 4202-451, Portugal
| | - Claudia Dias
- Department of Health Information and Decision Sciences, Faculty of Medicine, University of Porto, Alameda Professor Hernani Monteiro, Porto, 4202-451, Portugal
| | - Ricardo Neto
- Nephrology Research and Development Unit, Faculty of Medicine, University of Porto & São João Hospital Centre, Alameda Professor Hernani Monteiro, Porto, 4202-451, Portugal
| | - Manuel Pestana
- Nephrology Research and Development Unit, Faculty of Medicine, University of Porto & São João Hospital Centre, Alameda Professor Hernani Monteiro, Porto, 4202-451, Portugal
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Winterbottom AE, Bekker HL, Conner M, Mooney AF. Patient stories about their dialysis experience biases others' choices regardless of doctor's advice: an experimental study. Nephrol Dial Transplant 2011; 27:325-31. [DOI: 10.1093/ndt/gfr266] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Covic A, Bammens B, Lobbedez T, Segall L, Heimburger O, Van Biesen W, Fouque D, Vanholder R. Reply. Nephrol Dial Transplant 2010. [DOI: 10.1093/ndt/gfq368] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Covic A, Bammens B, Lobbedez T, Segall L, Heimbürger O, van Biesen W, Fouque D, Vanholder R. Educating end-stage renal disease patients on dialysis modality selection: clinical advice from the European Renal Best Practice (ERBP) Advisory Board. Nephrol Dial Transplant 2010; 25:1757-9. [PMID: 20392704 DOI: 10.1093/ndt/gfq206] [Citation(s) in RCA: 73] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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