Using patient-reported outcome measures (PROMs) to promote quality of care in the management of patients with established kidney disease requiring treatment with haemodialysis in the UK (PROM-HD): a qualitative study protocol

Capacity for the management of kidney failure in the International Society of Nephrology Eastern and Central Europe region: report from the 2023 ISN Global Kidney Health Atlas (ISN-GKHA)

Delivery of care for kidney failure (KF) globally has a significant disparity; even in some countries, it means end of life for the person. The International Society of Nephrology Global Kidney Health Atlas (ISN-GKHA) tries to address gaps in KF care and standardize global nephrology care. From the third iteration of the ISN-GKHA, we present data for countries in the ISN Eastern and Central Europe region. The median prevalences of chronic kidney disease (12.8%) and treated KF (873.5 pmp) were higher than the global rates, respectively. Hemodialysis was the most preferred modality for KF in adults, whereas kidney replacement therapy was more balanced in children. Although most of the countries in the region had lower-middle-income and upper-middle-income levels, health expenditures for kidney health care were almost generally covered publicly. Nephrologists were responsible for the medical kidney care of people with KF in all countries. There was adequate infrastructure to provide all kinds of treatment for kidney care in the region. Regional characteristics such as high levels of obesity, smoking, and Balkan nephropathy as an endemic disease coupled with a shortage of workforce and finance continued to affect kidney care in the region negatively. By making organizational and legislative arrangements, partnerships with national authorities and societies may accelerate the improvement of kidney health care in the region.

Patient-Reported Outcome Measures for Patients With CKD: The Case for Patient-Reported Outcomes Measurement Information System (PROMIS) Tools

Chronic kidney disease (CKD), kidney failure, and kidney replacement therapies are associated with high symptom burden and impaired health-related quality of life (HRQOL). Symptoms change with disease progression or transition between treatment modalities and frequently go unreported and unmanaged. Tools that reliably monitor symptoms may improve the management of patients with CKD. Patient-reported outcome measures (PROMs) assess symptom severity; physical, psychological, social, and cognitive functioning; treatment-related side effects; and HRQOL. Systematic use of PROMs can improve patient-provider communication, patient satisfaction, clinical outcomes, and HRQOL. Potential barriers to their use include a lack of engagement, response burden, and limited guidance about PROM collection, score interpretation, and workflow integration. Well-defined, acceptable, and effective clinical response pathways are essential for implementing PROMs. PROMs developed by the Patient-Reported Outcomes Measurement Information System (PROMIS) address some challenges and may be suitable for clinical use among patients with CKD. PROMIS tools assess multiple patient-valued, clinically actionable symptoms and functions. They can be administered as fixed-length, customized short forms or computer adaptive tests, offering precise measurement across a range of symptom severities or function levels, tailored questions to individuals, and reduced question burden. Here we provide an overview of the potential use of PROMs in CKD care, with a focus on PROMIS.

Patient Perspectives of Skeletal Muscle Cramping in Dialysis: A Focus Group Study

Key Points

This first step demonstrated content validity for a patient-reported outcome measure for skeletal muscle cramping in dialysis. This work lays the foundation for developing a patient-reported outcome measure for regulatory use to assess skeletal muscle cramping in people receiving dialysis.

Background

Skeletal muscle cramping is a common, painful, and debilitating symptom experienced by people receiving dialysis. Neither a standardized, patient-endorsed definition of skeletal muscle cramping nor full understanding of patients' perspectives of skeletal muscle cramping exist. We conducted focus groups, within a Kidney Health Initiative (KHI) project, to elicit skeletal muscle cramping experiences of people receiving dialysis as the basis for patient-reported outcome measure (PROM) development.

Methods

Eligible participants (English-speaking adults aged 18–85 years treated by dialysis and a skeletal muscle cramping episode within 30 days) were purposively recruited from a panel (L&E Research) of people receiving dialysis at home or in-center. Standard qualitative methods were used to conduct virtual 90-minute sessions discussing the following: skeletal muscle cramping clinical characteristics, participants' skeletal muscle cramping experiences, and feedback on a draft skeletal muscle cramping definition and a patient-facing conceptual model developed by the KHI project workgroup. We used qualitative thematic analysis.

Results

There were 20 diverse participants in three focus groups. Universally experienced skeletal muscle cramping attributes differed by dialysis setting in onset, worst pain rating, duration, and timing. Variably experienced attributes (applied to home and in-center dialysis) were gross and fine motor effect, sleep disruption, mood-related themes of fear, and annoyance/frustration/irritability. Avoidance/adaptive behaviors included reluctance or avoiding movement, adjusting what they ate or drink (e.g. , yellow mustard, pickles, pickle juice, and tonic water), heat application, massage, and cannabidiol use. The skeletal muscle cramping definition was endorsed, and insightful suggestions for conceptual model were collected.

Conclusions

This qualitative study of in-center and home patients' skeletal muscle cramping experiences identified universally and variably experienced attributes. The patient-endorsed skeletal muscle cramping definition can serve as a standard for assessment. These results provide the foundation to develop a PROM for regulatory use with people receiving maintenance dialysis who experience skeletal muscle cramping.

'Why should I fill out this questionnaire?' A qualitative study of cancer patients' perspectives on the integration of e-PROMs in routine clinical care

PURPOSE

There is increasing interest in integrating electronic patient-reported outcomes (e-PROs) into clinical routines in cancer settings. However, little is known about patients' experiences with and perceptions of e-PRO measures (e-PROMs). This study examines patients' experiences with e-PROMS, particularly their perspectives about its usefulness and its implications for the clinical encounter with their doctors.

METHOD

A total of 19 individual in-person interviews with cancer patients at a Comprehensive Cancer Center in northern Italy conducted in 2021 inform this study.

RESULTS

The findings suggested that, overall, patients had positive attitudes towards data collection using e-PROMs. On the one hand, most patients found the integration of e-PROMs into routine clinical practice as beneficial in treating patients with cancer. The main benefits of e-PROMs according to this group of patients were that: they promoted patient-centred care; could be used to tailor and improve the quality of care through a holistic approach; supported early detection of problematic symptoms; increased patient self-awareness; and contributed to clinical research. On the other hand, many patients did not fully understand the purpose of e-PROMs and some patients were also sceptical about their usefulness in routine clinical practice.

CONCLUSIONS

These findings have several practical implications for ensuring the successful implementation of e-PROMs in routine clinical practice. These include the following preconditions: patients are informed about the purposes of data collection; physicians provide feedback to patients about the e-PROMs' results; and that hospital administrators allocate sufficient time for clinical interactions to integrate e-PROMs into routine clinical practice.

"You need a team": perspectives on interdisciplinary symptom management using patient-reported outcome measures in hemodialysis care-a qualitative study

BACKGROUND

Patient-reported outcome measures (PROMs) are standardized instruments used for assessing patients' perspectives on their health status at a point in time, including their health-related quality of life, symptoms, functionality, and physical, mental, and social wellbeing. For people with kidney failure receiving hemodialysis, addressing high symptom burden and complexity relies on care team members integrating their expertise to achieve common management goals. In the context of a program-wide initiative integrating PROMs into routine hemodialysis care, we aimed to explore patients' and clinicians' perspectives on the role of PROMs in supporting interdisciplinary symptom management.

METHODS

We employed a qualitative descriptive approach using semi-structured interviews and observations. Eligible participants included adult patients receiving intermittent, outpatient hemodialysis for > 3 months, their informal caregivers, and hemodialysis clinicians (i.e., nurses, nephrologists, and allied health professionals) in Southern Alberta, Canada. Guided by thematic analysis, team members coded transcripts in duplicate and developed themes iteratively through review, refinement, and discussion.

RESULTS

Thirty-three clinicians (22 nurses, 6 nephrologists, 5 allied health professionals), 20 patients, and one caregiver participated in this study. Clinicians described using PROMs to coordinate care across provider types using the resources available in their units, whereas patients tended to focus on the perceived impact of this concerted care on symptom trajectory and care experience. We identified 3 overarching themes with subthemes related to the role of PROMs in interdisciplinary symptom management in this setting: (1) Integrating care for interrelated symptoms ("You need a team", conducive setting, role clarity and collaboration); (2) Streamlining information sharing and access (symptom data repository, common language for coordinated care); (3) Reshaping expectations (expectations for follow-up, managing symptom persistence).

CONCLUSIONS

We found that use of PROMs in routine hemodialysis care highlighted symptom interrelatedness and complexity and helped to streamline involvement of the interdisciplinary care team. Issues such as role flexibility and resource constraints may influence sustainability of routine PROM use in the outpatient hemodialysis setting.

Adoption of Patient-Reported Outcomes by Health Systems and Physician Practices in the USA

BACKGROUND

Patient-reported outcome measures (PROs) can help clinicians adjust treatments and deliver patient-centered care, but organizational adoption of PROs remains low.

OBJECTIVE

This study examines the extent of PRO adoption among health systems and physician practices nationally and examines the organizational capabilities associated with more extensive PRO adoption.

DESIGN

Two nationally representative surveys were analyzed in parallel to assess health system and physician practice capabilities associated with adoption of PROs of disability, pain, and depression.

PARTICIPANTS

A total of 323 US health system and 2,190 physician practice respondents METHODS: Multivariable regression models separately estimated the association of health system and physician practice capabilities associated with system-level and practice-level adoption of PROs.

MAIN MEASURES

Health system and physician practice adoption of PROs for depression, pain, and disability.

KEY RESULTS

Pain (50.6%) and depression (43.8%) PROs were more commonly adopted by all hospitals and medical groups within health systems compared to disability PROs (26.5%). In adjusted analyses, systems with more advanced health IT functions were more likely to use disability (p<0.05) and depression (p<0.01) PROs than systems with less advanced health IT. Practice-level advanced health IT was positively associated with use of depression PRO (p<0.05), but not disability or pain PRO use. Practices with more chronic care management processes, broader medical and social risk screening, and more processes to support patient responsiveness were more likely to adopt each of the three PROs. Compared to independent physician practices, system-owned practices and community health centers were less likely to adopt PROs.

CONCLUSIONS

Chronic care management programs, routine screening, and patient-centered care initiatives can enable PRO adoption at the practice level. Developing these practice-level capabilities may improve PRO adoption more than solely expanding health IT functions.

Use of Patient-Reported Data within the Acute Healthcare Context: A Scoping Review

Patient-reported outcome measures (PROMs), patient-reported experience measures (PREMs) and patient satisfaction surveys provide important information on how care can be improved. However, data collection does not always translate to changes in practice or service delivery. This scoping review aimed to collect, map and report on the use of collected patient-reported data used within acute healthcare contexts for improvement to care or processes. Using JBI methods, an extensive search was undertaken of multiple health databases and trial registries for published and unpublished studies. The concepts of interest included the types and characteristics of published patient experience and PROMs research, with a specific focus on the ways in which data have been applied to clinical practice. Barriers and facilitators to the use of collected data were also explored. From 4057 records, 86 papers were included. Most research was undertaken in North America, Canada or the UK. The Hospital Consumer Assessment of Healthcare Providers and Systems tool (HCAHPS) was used most frequently for measuring patient satisfaction. Where reported, data were applied to improve patient-centred care and utilization of health resources. Gaps in the use of patient data within hospital services are noticeable. Engaging management and improving staff capability are needed to overcome barriers to implementation.

Perspectives of Patients, Nurses, and Nephrologists About Electronic Symptom Monitoring With Feedback in Hemodialysis Care

RATIONALE & OBJECTIVE

Patients receiving hemodialysis experience high symptom burden and low quality of life (QOL). Electronic patient-reported outcome measures (e-PROMs) monitoring with feedback to clinicians may be an acceptable intervention to improve health-related QOL for patients receiving hemodialysis. This study explored patient and clinician perspectives on e-PROMs monitoring with feedback to clinicians.

STUDY DESIGN

Qualitative study.

SETTING & PARTICIPANTS

41 participants (12 patients, 13 nephrologists, 16 dialysis nurses) who participated in a 6-month feasibility pilot study of adults receiving facility-based hemodialysis across 4 Australian units. The intervention consisted of electronic symptom monitoring with feedback to clinicians, who also received evidence-based symptom management recommendations to improve health-related QOL.

ANALYTICAL APPROACH

Semistructured interviews and focus group discussions explored the feasibility and acceptability of e-PROMs monitoring with feedback to clinicians. We conducted a thematic analysis of transcripts.

RESULTS

We identified 4 themes: enabling efficient, systematic, and multidisciplinary patient-centered care; experiencing limited data and options for symptom management; requiring familiarity with technology and processes; and identifying barriers and competing priorities. While insufficient patient engagement, logistic/technical challenges, and delayed symptom feedback emerged as barriers to implementation, active engagement by nurses in encouraging and supporting patients during survey completion and clinicians' prompt action after symptom feedback were considered to be facilitators to implementation.

LIMITATIONS

Limited generalizability due to inclusion of English-speaking participants only.

CONCLUSIONS

Patients, nurses, and nephrologists considered e-PROMs monitoring with feedback to clinicians feasible for symptom management in hemodialysis. Clinician engagement, patient support, reliable technology, timely symptom feedback, and interventions to address symptom burden are likely to improve its implementation within research and clinical settings.

Hemodialysis and Peritoneal Dialysis Patients’ Problems: Patients’ Perspective

Background: End-stage renal disease (ESRD) can be fatal without hemodialysis, peritoneal dialysis, or kidney transplantation. Hemodialysis and peritoneal dialysis participants confront many adverse effects due to both the disease course and the treatment program. Objectives: This study was done to analyze hemodialysis and peritoneal dialysis patients’ problems. Methods: A qualitative exploratory study was used, and a purposeful sample of 55 hemodialysis and 47 peritoneal dialysis patients were interviewed. The data were collected through interviews. Initially, 12 open-ended questions were developed and used to stimulate discussions in interview sessions. Directed content analysis was used for the analysis of the transcribed data. After giving a code to each line or incidence, codes were then compared for similarity and differences, merged, and categorized. Results: Themes of fatigue, diminished ability, sleeplessness, wasting time, body impairments, travel, and free-time activities limitations, low blood pressure, displeasure and gratification with hemodialysis if peritoneal dialysis patients compliant of peritoneal catheter problems, peritoneal dialysis difficulties and limitations, and gratification with peritoneal dialysis emerged. Conclusions: Hemodialysis problems and patients' dependency on the hemodialysis machine and ward are at a high level, and patients’ gratification is at a low level. Peritoneal dialysis patients, who do not get the infection, are satisfied with the dialysis method, and the patients' limitations and problems are fewer, and they are relaxed and have more freedom.

Implementation of telemedicine in cancer clinical trials: Connectpatienttodoctor study

Background

Telemedicine is currently being adopted for the management of patients in routine care. However, its use remains limited in the context of clinical trials.

Objective

This study aimed to demonstrate the feasibility of telemonitoring and patient-reported outcomes collection in the context of clinical trials.

Methods

The patients who were included in an interventional oncology clinical trial were eligible. The patients were registered with a digital tool to respond to a patient-reported outcomes questionnaire (ePRO) based on CTCAE (The Common Terminology Criteria for Adverse Events, National Cancer Institute), version 5.0, personalized to their pathology and treatment. An algorithm evaluated the health status of the patient based on the reported adverse events, with a classification in 4 different states (correct, compromise, state to be monitored, or critical state). The main objective was to evaluate the feasibility of remote monitoring via a connected platform of patients included in a clinical trial.

Results

From July 1, 2020, to March 31, 2021, 39 patients were included. The median age was 71 years (range 41-94); 74% (n=29) were male, and 59% (n=23) had metastatic disease. Out of the 969 ePRO questionnaires completed over the course of the study, 77.0% (n=746) were classified as “correct,” 10.9% (n=106) as “compromised,” and 12.1% (n=117) as “to be monitored” or “critical.” The median response time was 7 days (IQR 7-15.5), and 76% (25/33) of the patients were compliant. Out of the 35 patients who answered a satisfaction questionnaire, 95% (n=33) were satisfied or very satisfied with the tool, and 85% (n=30) were satisfied with their relationship with the health care team. There were 5 unscheduled hospitalizations during the study period.

Conclusions

Remote monitoring in clinical trials is feasible, with a high level of patient participation and satisfaction. It benefits patients, but it also ensures the high quality of the trial through the early management of adverse events and better knowledge of the tolerance profile of experimental treatments. This e-technology will likely be deployed more widely in our clinical trials.

Patient-Reported Outcome Measures in Endometriosis

Patient Reported Outcome Measures (PROM) evoke measurements that allow capturing patients’ perspectives on their condition. In endometriosis care, physicians’ understanding of the effect of the disease and the treatment on patients is often poor. The use of PROMs in endometriosis clinical practice can facilitate patient-provider communication and the implementation of patient-centered care, improve patients’ quality of life, as well as provide a tool for patients’ self-management of the disease. Today, PROMs are extensively used in research and clinical trials, however they are barely used in clinical practice. The development of digital tools facilitating capturing PROMs can contribute to their use by physicians in routine endometriosis care. However, all PROMs are not adapted to be used in routine care in the context of endometriosis. The objective of this study was to present a catalogue of available PROMs for routine endometriosis care and evaluate them according to selected criteria. To do so, we explored the different PROMs currently in the literature. Consequently, 48 PROM were identified as tools used to evaluate various dimensions of the impact of endometriosis on patients. The selected PROMs were evaluated for their potential to be used as a standard in clinical practice in endometriosis. The selected catalogue of PROMs is the starting point for the integration of digital tools to capture PROMs and the development of patient-centered dashboards to be used by patients and clinicians in endometriosis care and self-management to improve care processes, patient satisfaction, quality of life, and outcomes.

Patient-reported outcome measures in hemodialysis patients: results of the first multicenter cross-sectional ePROMs study in France

Background

Kidney failure with replacement therapy and hemodialysis are associated with a decrease in quality of life (QOL). Self-reported QOL symptoms are not always prioritized by the medical team, potentially leading to conflicting priorities with patients. Electronic patient-reported outcome measures (ePROMs) allow physicians to better identify these symptoms. The objective was to describe the prevalence of symptoms self-reported by hemodialysis (HD) patients.

Methods

A multicenter cross-sectional study was conducted in three HD centers. Patients were included if they were 18 years old or over treated with HD for at least 3 months in a center. Data were collected by the patient via a self-administered ePROMs questionnaire. Data included patient characteristics, post-dialysis fatigue and intensity, recovery time after a session, perceived stress, impaired sleep the day before the dialysis session, current state of health and the change from the past year. A multivariate analysis was conducted to identify relations between symptoms.

Results

In total, we included 173 patients with a mean age of 66.2 years, a mean ± SD hemodialysis duration of 48.9 ± 58.02 months. The prevalence of fatigue was 72%. 66% had a high level of stress (level B or C). Recovery time was more than 6 h after a HD session for 25% of patients and 78% declared they had a better or unchanged health status than the previous year. Sleep disturbance was associated with cardiovascular comorbidities (OR 5.08 [95% CI, 1.56 to 16.59], p = 0.007).

Conclusions

Fatigue and stress were the main symptoms reported by HD patients. The patient’s care teams should better consider these symptoms.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12882-021-02551-3.

Using patient-reported outcome measures during the management of patients with end-stage kidney disease requiring treatment with haemodialysis (PROM-HD): a qualitative study

OBJECTIVES

Patients undergoing haemodialysis report elevated symptoms and reduced health-related quality of life, and often prioritise improvements in psychosocial well-being over long-term survival. Systematic collection and use of patient-reported outcomes (PROs) may help support tailored healthcare and improve outcomes. This study investigates the methodological basis for routine PRO assessment, particularly using electronic formats (ePROs), to maximise the potential of PRO use, through exploration of the experiences, views and perceptions of patients and healthcare professionals (HCPs) on implementation and use of PROs in haemodialysis settings.

STUDY DESIGN

Qualitative study.

SETTING AND PARTICIPANTS

Semistructured interviews with 22 patients undergoing haemodialysis, and 17 HCPs in the UK.

ANALYTICAL APPROACH

Transcripts were analysed deductively using the Consolidated Framework for Implementation Research (CFIR) and inductively using thematic analysis.

RESULTS

For effective implementation, the potential value of PROs needs to be demonstrated empirically to stakeholders. Any intervention must remain flexible enough for individual and aggregate use, measuring outcomes that matter to patients and clinicians, while maintaining operational simplicity. Any implementation must sit within a wider framework of education and support for both patients and clinicians who demonstrate varying previous experience of using PROs and often confuse related concepts. Implementation plans must recognise the multidimensionality of end-stage kidney disease and treatment by haemodialysis, while acknowledging the associated challenges of delivering care in a highly specialised environment. To support implementation, careful consideration needs to be given to barriers and facilitators including effective leadership, the role of champions, effective launch and ongoing evaluation.

CONCLUSIONS

Using the CFIR to explore the experiences, views and perceptions of key stakeholders, this study identified key factors at organisational and individual levels which could assist effective implementation of ePROs in haemodialysis settings. Further research will be required to evaluate subsequent ePRO interventions to demonstrate the impact and benefit to the dialysis community.

An Evidence-Based Theory About PRO Use in Kidney Care: A Realist Synthesis

BACKGROUND

There is international interest on the use of patient-reported outcomes (PROs) in nephrology.

OBJECTIVES

Our objectives were to develop a kidney-specific program theory about use of PROs in nephrology that may enhance person-centered care, both at individual and aggregated levels of care, and to test and refine this theory through a systematic review of the empirical literature. Together, these objectives articulate what works or does not work, for whom, and why.

METHODS

Realist synthesis methodology guided the electronic database and gray literature searches (in January 2017 and October 2018), screening, and extraction conducted independently by three reviewers. Sources included all nephrology patients and/or practitioners. Through a process of extraction and synthesis, each included source was examined to assess how contexts may trigger mechanisms to influence specific outcomes.

RESULTS

After screening 19,961 references, 84 theoretical and 34 empirical sources were used. PROs are proposed to be useful for providing nephrology care through three types of use. The first type is use of individual-level PRO data at point of care, receiving the majority of theoretical and empirical explorations. Clinician use to support person-centered care, and patient use to support patient engagement, are purported to improve satisfaction, health, and quality of life. Contextual factors specific to the kidney care setting that may influence the use of PRO data include the complexity of kidney disease symptom burden, symptoms that may be stigmatized, comorbidities, and time or administrative constraints in dialysis settings. Electronic collection of PROs may facilitate PRO use given these contexts. The second type is use of aggregated PRO data at point of care, including public reporting of PROs to inform decisions at point of care and improve quality of care, and use of PROs for treatment decisions. The third type is use of aggregated PRO data by organizations, including publicly available PRO data to compare centers. In single-payer systems, regular collection of PROs by dialysis centers can be achieved through economic incentives. Both the second and third types of PRO use include pressures that may trigger quality improvement processes.

CONCLUSION

The current state of the evidence is primarily theoretical. There is pressing need for empirical research to improve the evidence-base of PRO use at individual and aggregated levels of nephrology care.

Using Patient-Reported Measures to Improve Outcomes in Kidney Disease

Patients with CKD and ESRD are vulnerable to increased mortality rates and other poor outcomes. Among those with ESRD, their health-related quality of life (HRQOL) is shown little to no improvement as they undergo treatments such as dialysis and providers concurrently manage other health issues that complicate their already vulnerable state. This review synthesizes evidence demonstrating that a focus on measuring and monitoring patient-reported outcomes (PRO) such as pain and depression can improve HRQOL. Patient-centered care has the potential to create an efficient way for clinicians to address specific challenges facing patients. While there is an emerging literature assessing the use of PROs in kidney research, by examining relevant research in other disciplines it is possible to generate better ways to use PROs in this high-risk population. Electronic health records as well as various other electronic methods of communication between the clinician and patient may serve to accelerate the trajectory toward patient-centered care using PROs.

The Association Between Estimated Glomerular Filtration Rate and Hospitalization for Fatigue: A Population-Based Cohort Study

Background:

Fatigue is a pervasive symptom among patients with chronic kidney disease (CKD) that is associated with several adverse outcomes, but the incidence of hospitalization for fatigue is unknown.

Objective:

To explore the association between estimated glomerular filtration rate (eGFR) and incidence of hospitalization for fatigue.

Design:

Population-based retrospective cohort study using a provincial administrative dataset.

Setting:

Alberta, Canada.

Patients:

People above age 18 who had at least 1 outpatient serum creatinine measurement taken in Alberta between January 1, 2009, and December 31, 2016.

Measurements:

The first outpatient serum creatinine was used to estimate GFR. Hospitalization for fatigue was identified using International Classification of Diseases, Tenth Revision (ICD-10) code R53.x.

Methods:

Patients were stratified by CKD category based on their index eGFR. We used negative binomial regression to determine if there was an increased incidence of hospitalization for fatigue by declining kidney function (reference eGFR ≥ 60 mL/min/1.73m²). Estimates were stratified by age, and adjusted for age, sex, socioeconomic status, and comorbidity.

Results:

The study cohort consisted of 2 823 270 adults, with a mean age of 46.1 years and median follow-up duration of 6.0 years; 5 422 hospitalizations for fatigue occurred over 14 703 914 person-years of follow-up. Adjusted rates of hospitalization for fatigue increased with decreasing kidney function, across all age strata. The highest rates were seen in adults on dialysis (adjusted incident rate ratios 24.47, 6.66, and 3.13 for those aged 18 to 64, 65 to 74, and 75+, respectively, compared with eGFR ≥ 60 mL/min/1.73m²).

Limitations:

Fatigue hospitalization codes have not been validated; reference group limited to adults with at least 1 outpatient serum creatinine measurement; remaining potential for residual confounding.

Conclusions:

Declining kidney function was associated with increased incidence of hospitalization for fatigue. Further research into ways to address fatigue in the CKD population is warranted.

Trial Registration:

Not applicable (not a clinical trial).

Feasibility and acceptability of e-PROMs data capture and feedback among patients receiving haemodialysis in the Symptom monitoring WIth Feedback Trial (SWIFT) pilot: protocol for a qualitative study in Australia

INTRODUCTION

People receiving haemodialysis experience a high symptom burden and impaired quality of life. The use of patient-reported outcome measures (PROMs) is increasing in nephrology care, however their acceptability, utility and impacts are not well understood.

METHODS AND ANALYSIS

We describe a protocol for a qualitative study to evaluate the feasibility and acceptability of electronic-PROMs (e-PROMs) data capture and feedback in haemodialysis following the pilot Symptom monitoring WIth Feedback Trial (SWIFT). SWIFT involves linkage of e-PROMs data, including symptoms and health-related quality of life, to the Australia and New Zealand Dialysis and Transplant Registry with feedback to patients' treating nephrologists and nurse unit managers. Focus groups and semistructured interviews will be conducted with nephrologists (n=15), dialysis nurses (n=24) and patients receiving haemodialysis (n=24) from six dialysis units in Australia. Question topics will include the technical and clinical feasibility and acceptability of e-PROMs reporting and feedback (including the barriers and enablers to uptake) and perceived impact on patient care and outcomes. Transcripts will be analysed thematically and guided by Normalisation Process Theory.

ETHICS AND DISSEMINATION

Ethics approval was obtained from the relevant hospital Human Research Ethics Committees (HREC/18/CALHN/481; HREC/MML/54599). The findings from the SWIFT pilot and qualitative evaluation will inform the implementation of the SWIFT main trial, and more broadly, the use of e-PROMs in clinical settings and registries.

TRIAL REGISTRATION NUMBER

ANZCTRN12618001976279.

Rapid Electronic Capturing of Patient-Reported Outcome Measures in Older Adults With End-Stage Renal Disease: A Feasibility Study

BACKGROUND

Patients with end-stage renal disease (ESRD) have a high burden of physical and psychological symptoms. Many remain unrecognized for long periods of time, particularly in older adults. The best strategy to monitor patient-reported outcome measures (PROMs) has not been identified.

OBJECTIVE

To assess the feasibility of implementing an iPad-based symptom assessment tool in older adults with ESRD on hemodialysis (HD).

METHODS

We designed an iPad application-delivery system for collecting electronic PROMs (ePROMs). Patient's ≥60 years of age with ESRD on HD were recruited from a single outpatient dialysis unit. Feasibility was evaluated based on recruitment, retention, and the system usability score (SUS). Assessments were completed at baseline, 3 months, and 6 months after enrollment. ANOVA was used to assess longitudinal symptom variability.

RESULTS

Twenty-two patients (49% recruitment rate) were enrolled, with an 82% retention at 6 months. Mean age was 69.4 years (SD 6.6), 63.6% were female, and 81.8% were African American. Participants reported minimal difficulty in using the app, with an overall SUS score of 77.6. There were no significant relationships between demographic characteristics (age, race, or education) and SUS. Baseline SF-12 physical score and SF-12 mental score were 40.4 (SD 9.1) and 33.9 (SD 6.7), respectively. No significant changes were seen in longitudinal ePROMs of pain, depression, or anxiety; but was seen in the dialysis symptom index.

CONCLUSION

In older patients with ESRD, collection of iPad-based ePROMs is feasible. This process can overcome inefficiencies associated with paper questionnaires and enable systematic monitoring of symptom burden.

Patients' experiences of transitioning between different renal replacement therapy modalities: A qualitative study

BACKGROUND

Different kidney replacement therapy modalities are available to manage end-stage kidney disease, such as home-based dialysis, in-center hemodialysis, and kidney transplantation. Although transitioning between modalities is common, data on how patients experience these transitions are scarce. This study explores patients' perspectives of transitioning from a home-based to an in-center modality.

METHODS

Patients transitioning from peritoneal dialysis to in-center hemodialysis were purposively selected. Semi-structured interviews were performed, digitally recorded, and transcribed verbatim. Data analysis, consistent with Charmaz' constructivist approach of grounded theory was performed.

RESULTS

Fifteen patients (10 males; mean age 62 years) participated. The conditions of the transitioning process impacted the participants' experiences, resulting in divergent experiences and associated emotions. Some participants experienced a loss of control due to the therapy-related changes. Some felt tied down and having lost independence, whereas others stated they regained control as they felt relieved from responsibility. This paradox of control was related to the patient having or not having (1) experienced a fit of hemodialysis with their personal lifestyle, (2) a frame of reference, (3) higher care requirements, (4) insight into the underlying reasons for transitioning, and (5) trust in the healthcare providers.

CONCLUSIONS

Care teams need to offer opportunities to elicit patients' knowledge and fears, dispel myths, forge connections with other patients, and visit the dialysis unit before transition to alleviate anxiety. Interventions that facilitate a sense of control should be grounded in the meaning that the disorder has for the person and how it impacts their sense of self.

Incorporating patient-reported outcomes (PROs) into dialysis policy: Current initiatives, challenges, and opportunities

Governments at national and state levels regulate dialysis care in the United States to ensure safe practices, and continually elevate the quality of care. An objective of these regulatory policies is the independent evaluation of dialysis unit outcomes by patients, caregivers, and the community to facilitate choices as well as to advance equal access to high quality dialysis care. These polices recognized decades ago that it was fundamental to include the patient perspective in the assessment and evaluation of dialysis care quality by requiring both individual and aggregate patient reported outcomes (PROs). Although there is support for integrating the patient perspective, concerns persist about the implementation of these polices including selection of PRO measures, administration timing and reach, as well as interpretation of results including benchmarking to permit comparisons across organizations. The experience from the early adoption of PROs into dialysis policies in conjunction with advances in electronic health records, personal data capture and monitoring, and analytics is poised to address these concerns. The dialysis community has the opportunity to lead the way in innovation related to PRO implementation not only in kidney disease care, but also for other healthcare conditions or contexts such as oncology, surgical, and acute care.

The Use of Patient-Reported Outcomes in Patients Treated With Maintenance Hemodialysis: A Perspective

There is increasing interest in the integration of patient-reported outcomes (PROs) into health care research and clinical practice for the benefit of patients with end-stage kidney disease receiving hemodialysis. In a research setting, PROs can be used as a patient-centered primary or secondary outcome in clinical studies. In routine care, PRO data may be used to support service delivery through benchmarking and audit or inform and enhance the care of the individual patient by improving patient-clinician communication. Despite evidence demonstrating the potential benefits of PROs and prioritization of these outcomes by patients, their use in kidney disease remains limited. Although there are significant methodological and operational challenges for the widespread integration of PROs, there is now consensus that this area should be at the forefront of clinical research and implementation science. We discuss the current use of PROs for patients with end-stage kidney disease receiving hemodialysis and identify a roadmap for increasing the evidence base and introducing PROs into mainstream clinical practice.