Treatment-related decisional conflict in pre-dialysis chronic kidney disease patients in Singapore: Prevalence and determinants

Feasibility and Acceptability of a Palliative Care Intervention among Older Adults with Advanced CKD and Their Caregivers

Background

In non-nephrology settings, specialty palliative care (PC) improves decision making, patient's quality of life (QoL), advance care planning, and certain indicators of the quality of end-of-life (EoL) care. This pilot randomized control trial (RCT) explored the feasibility and acceptability of a PC intervention, CKD-EDU, for adults aged 75 years and older with eGFR ≤25 ml/min and their caregivers.

Methods

Participants randomized to the control group received standard nephrology care and routine kidney therapy education, whereas those randomized to CKD-EDU received a decision aid and met with a PC clinician up to three times to discuss kidney therapy decisions and EoL planning. Patients were assessed at baseline, 4–6, 12–14, and 24–26 weeks. Main outcomes included intervention feasibility and acceptability, decision conflict, and patient QoL. The mediating effects of reduced decision conflict on improved QoL were explored, as were the effects of CKD-EDU on advance care planning, EoL treatment intensity, and 6-month hospitalization. Statistical analyses encompassed descriptive analyses, adjusted repeated-measure models, mediation analyses, and logistic regression models.

Results

Among the 127 eligible patients screened, 58 (46%) consented: 30 were randomized to CKD-EDU and 28 to the control arm. All patients completed baseline assessments and 89% completed at least 1 intervention session (n=26/29), underscoring intervention adherence and feasibility. Similarly, assessment completion rates at 4 (83%, n=45/54), 12 (93%, n=42/45), and 24 (95%, n=40/42) weeks were high. The intervention received over 85% acceptability ratings for all questions. Patients exposed to CKD-EDU exhibited significant improvement in Decisional Conflict Scale scores (P = 0.003) at 4–6 weeks and improvements in QoL at 24–26 weeks (P = 0.02). Exploratory analyses were not statistically significant in this pilot study, but all effect sizes were in the predicted direction.

Conclusions

This study demonstrates the feasibility and acceptability of CKD-EDU. A larger scale trial is warranted to assess its effectiveness in improving key outcomes important to patients and families.

People living with chronic pain in Canada face difficult decisions and decisional conflict concerning their care: data from the national DECIDE-PAIN survey

BACKGROUND

Shared decision-making is an imperative in chronic pain care. However, we know little about the decision-making process, especially in primary care where most chronic pain care is provided. We sought to understand decisional needs of people living with chronic pain in Canada.

METHODS

We conducted a population-based cross-sectional online survey of random samples of adults living in Canada with chronic noncancer pain and registered with the Leger Marketing panel. We followed the International Association for Study of Pain definition of chronic pain (i.e., persistent or recurrent pain lasting longer than three months). We used a stratified proportional random sampling based on the population and chronic pain prevalence of each province to achieve representativeness. Based on the Ottawa Decision Support Framework, we collected data on difficult decisions (i.e., decision with more than one option and no clear best option) related to their chronic pain condition, the level of decisional conflict associated with the most difficult decisions (i.e., Decisional Conflict Scale), the assumed and preferred role during the decision-making process (i.e., Control Preferences Scale), and respondents' characteristics. We used descriptive quantitative analyses of survey responses.

RESULTS

Of the 31,545 invited panellists, 2,666 met the eligibility criteria, and 1,649 respondents from the 10 Canadian provinces completed the survey. Respondents had diverse socio-demographic profiles. Mean age was 51.8 years (SD = 16.3). Half were men (51.4%), most lived in urban areas (87.8%), mean pain duration was 8.5 years (SD = 9.6), and respondents reported an average number of painful body regions of 2.3 (SD = 1.5). We observed that 96.7% of respondents faced at least one difficult decision across their care pathways. These difficult decisions were related to numerous issues from the medical consultation, diagnosis, treatment, and daily life. Almost half of respondents made their most difficult decision with a primary care physician. One third of respondents experienced a high level of clinically significant decisional conflict (Decisional Conflict Scale score ≥ 37.5). Two-thirds of respondents self-reported having a collaborative role during their decision while three-quarters wanted this role.

CONCLUSIONS

People living with chronic pain in Canada have unmet decisional needs and need support to make optimal decisions to manage their chronic pain. Our findings will guide future development of interventions to implement shared decision-making, especially to support primary care where discussions about difficult decisions often occur.

Structural equation modeling analysis of factors influencing decisional conflict between dialysis modality among end-stage kidney disease patients in Wuhan

OBJECTIVES

To explore the influencing factors and relationships associated with decisional conflict of dialysis modality in End-stage kidney disease (ESKD) patients.

METHODS

This study was a survey-based cross-sectional investigation conducted on 150 ESKD patients in a third-class hospital in Wuhan. The general information questionnaire, decisional conflict scale, Montreal cognitive assessment, frail scale, perceived social support scale, and brief health literacy screen were used for investigation. SPSS 25.0 was used to compare the differences between the decisional and non-decisional conflict groups, and AMOS 23.0 was used to construct a structural equation model to explore the influencing factors.

RESULTS

The incidence of decisional conflict in 150 ESKD patients was 33.3% (50/150). Binary logistic regression analysis showed that the independent risk factors for decisional conflict of dialysis modality in ESKD patients included monthly household income (OR = 0.184), cognitive function (OR = 7.0), social support (OR = 0.891), health literacy (OR = 0.608), the level of eGFR (OR = 1.488), and the level of cTnI (OR = 9.558). The constructed path analysis model had a good fit (x2/df = 1.499, GFI = 0.957, AGFI = 0.911, NFI = 0.906, CFI = 0.967, RMSEA = 0.055). The path analysis showed that health literacy (0.577) had the greatest impact on the decisional conflict, with a direct effect of 0.480 and an indirect effect of 0.097 through cognitive function and monthly household income. Next was social support, with an effect value of 0.434.

CONCLUSIONS

In clinical practice, it is important to enhance the health literacy of patients and their families and to provide advanced education on dialysis plans. Additionally, in managing and planning chronic kidney disease progression and dialysis, it is recommended to regularly and systematically assess cognitive function, particularly before the patient's cognitive impairment worsens or the severity of the disease progresses. Advanced care planning can be established through collaboration between healthcare professionals and patients to ensure appropriate decision-making and management.

IMPLICATIONS FOR THE PROFESSION AND PATIENT CARE

This paper finds that the factors that influence and relate to dialysis methods in end-stage renal disease patients help nurses exercise autonomy better, assist patients in reducing their decisional conflict, and improve clinical outcomes.

PATIENT OR PUBLIC CONTRIBUTION

Patients received a relevant questionnaire survey, and caregivers assisted in conducting the study.

Palliative Care Acceptability for Older Adults with Advanced CKD: A Qualitative Study of Patients and Nephrologists

Rationale & Objective

Older adults in the United States often receive kidney therapies that do not align with their goals. Palliative care (PC) specialists are experts in assisting patients with the goals of care discussions and decision support, yet views and experiences of older patients who have received PC while contemplating kidney therapy decisions and their nephrologists remain unexplored. We evaluated the acceptability of CKD-EDU, a PC-based kidney therapy decision support intervention for adults ≥75 years of age.

Study Design

Qualitative study.

Setting & Participants

Two trained research coordinators interviewed patients and nephrologists participating in the CKD-EDU study.

Analytical Approach

Three coders analyzed the qualitative data using a thematic analysis approach to identify salient themes pertaining to intervention acceptability.

Results

Patients (n = 19; mean age: 80 years) viewed the PC intervention favorably, noting PC physicians' excellent communication skills, whole-person care, and decision-making support, including comprehension of prognostic information. Nephrologists (n = 24; mean age) welcomed PC assistance in decision making, support for conservative kidney management, and symptom management; a minority voiced concerns about third-party involvement in their practice.

Limitations

Single-center study.

Conclusions

Overall, patients and nephrologists generally found the PC intervention to be acceptable. Future testing of the current PC-based decision support intervention in a larger randomized controlled trial for older people navigating kidney therapy decisions is needed.

Assessment Tools for Measuring Health Literacy and Digital Health Literacy in a Hospital Setting: A Scoping Review

Assessment of (digital) health literacy in the hospital can raise staff awareness and facilitate tailored communication, leading to improved health outcomes. Assessment tools should ideally address multiple domains of health literacy, fit to the complex hospital context and have a short administration time, to enable routine assessment. This review aims to create an overview of tools for measuring (digital) health literacy in hospitals. A search in Scopus, PubMed, WoS and CINAHL, following PRISMA guidelines, generated 7252 hits; 251 studies were included in which 44 assessment tools were used. Most tools (57%) were self-reported and 27% reported an administration time of <5 min. Almost all tools addressed the domain 'understanding' (98%), followed by 'access' (52%), 'apply' (50%), 'appraise' (32%), 'numeracy' (18%), and 'digital' (18%). Only four tools were frequently used: the Newest Vital Sign (NVS), the Short Test of Functional Health Literacy for Adults ((S)TOFHLA), the Brief Health Literacy Screener (BHLS), and the Health Literacy Questionnaire (HLQ). While the NVS and BHLS have a low administration time, they cover only two domains. HLQ covers the most domains: access, understanding, appraise, and apply. None of these four most frequently used tools measured digital skills. This review can guide health professionals in choosing an instrument that is feasible in their daily practice, and measures the required domains.

Patients’ perspectives of home and self-assist haemodialysis and factors influencing dialysis choices in Singapore

Background

The rise in end stage kidney disease (ESKD) prevalence globally calls for a need to deliver quality and cost-effective dialysis. While most are familiar with centre-based haemodialysis (HD), there is a move to increase uptake of home-based modalities (peritoneal dialysis (PD) or home haemodialysis (HHD)) and self-assist haemodialysis (SAHD) due to the economic, clinical and lifestyle advantages they confer. However, HHD and SAHD are not yet widely adopted in Singapore with majority of patients receiving in-centre HD. Although much research has examined patient decision-making around dialysis modality selection, there is limited literature evaluating patient’s perspectives of HHD and SAHD in Asia where the prevalence of these alternative modalities remained low. With this background, we aimed to evaluate patient’s perspectives of HHD and SAHD and the factors influencing their choice of dialysis modality in Singapore to determine the challenges and facilitators to establishing these modalities locally.

Methods

Semi-structured interviews were conducted with 17 patients on dialysis from a tertiary hospital in Singapore in this exploratory qualitative study. Data collected from one-to-one interviews were analysed via thematic content analysis and reported via an interpretative approach.

Results

The findings were segregated into: (1) factors influencing choices of dialysis modality; (2) perspectives of HHD; and (3) perspectives of SAHD. Modality choices were affected by environmental, personal, social, financial, information and family-related factors. Most perceived HHD as providing greater autonomy, convenience and flexibility while SAHD was perceived as a safer option than HHD. For both modalities, patients were concerned about self-care and burdening their family.

Conclusions

The findings provided a framework for healthcare providers to understand the determinants affecting patients’ dialysis modality decisions and uncovered the facilitators and challenges to be addressed to establish HHD and SAHD modalities in Singapore.

Decisional Conflict About Kidney Failure Treatment Modalities Among Adults With Advanced CKD

Rationale & Objective

Choosing from multiple kidney failure treatment modalities can create decisional conflict, but little is known about this experience before decision implementation. We explored decisional conflict about treatment for kidney failure and its associated patient characteristics in the context of advanced chronic kidney disease (CKD).

Study Design

Cross-sectional study.

Setting & Participants

Adults (N = 427) who had advanced CKD, received nephrology care in Pennsylvania-based clinics, and had no history of dialysis or transplantation.

Predictors

Participants' sociodemographic, physical health, nephrology care/knowledge, and psychosocial characteristics.

Outcomes

Participants' results on the Sure of myself; Understand information; Risk-benefit ratio; Encouragement (SURE) screening test for decisional conflict (no decisional conflict vs decisional conflict).

Analytical Approach

We used multivariable logistic regression to quantify associations between aforementioned participant characteristics and decisional conflict. We repeated analyses among a subgroup of participants at highest risk of kidney failure within 2 years.

Results

Most (76%) participants reported treatment-related decisional conflict. Participant characteristics associated with lower odds of decisional conflict included complete satisfaction with patient-kidney team treatment discussions (OR, 0.16; 95% CI, 0.03-0.88; P = 0.04), attendance of treatment education classes (OR, 0.38; 95% CI, 0.16-0.90; P = 0.03), and greater treatment-related decision self-efficacy (OR, 0.97; 95% CI, 0.94-0.99; P < 0.01). Sensitivity analyses showed a similarly high prevalence of decisional conflict (73%) and again demonstrated associations of class attendance (OR, 0.26; 95% CI, 0.07-0.96; P = 0.04) and decision self-efficacy (OR, 0.95; 95% CI, 0.91-0.99; P = 0.03) with decisional conflict.

Limitations

Single-health system study.

Conclusions

Decisional conflict was highly prevalent regardless of CKD progression risk. Findings suggest efforts to reduce decisional conflict should focus on minimizing the mismatch between clinical practice guidelines and patient-reported engagement in treatment preparation, facilitating patient-kidney team treatment discussions, and developing treatment education programs and decision support interventions that incorporate decision self-efficacy-enhancing strategies.