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Optimizing renal replacement therapy in older adults: a framework for making individualized decisions.

ABSTRACT: It is often difficult to synthesize information about the risks and benefits of recommended management strategies in older patients with end-stage renal disease since they may have more comorbidity and lower life expectancy than patients described in clinical trials or practice guidelines. In this review, we outline a framework for individualizing end-stage renal disease management decisions in older patients. The framework considers three factors: life expectancy, the risks and benefits of competing treatment strategies, and patient preferences. We illustrate the use of this framework by applying it to three key end-stage renal disease decisions in older patients with varying life expectancy: choice of dialysis modality, choice of vascular access for hemodialysis, and referral for kidney transplantation. In several instances, this approach might provide support for treatment decisions that directly contradict available practice guidelines, illustrating circumstances when strict application of guidelines may be inappropriate for certain patients. By combining quantitative estimates of benefits and harms with qualitative assessments of patient preferences, clinicians may be better able to tailor treatment recommendations to individual older patients, thereby improving the overall quality of end-stage renal disease care.

SUBMITTER: Tamura MK

PROVIDER: S-EPMC3396777 | biostudies-literature | 2012 Aug

REPOSITORIES: biostudies-literature

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Optimizing renal replacement therapy in older adults: a framework for making individualized decisions.

Tamura Manjula Kurella MK Tan Jane C JC O'Hare Ann M AM

Kidney international 20111116 3

It is often difficult to synthesize information about the risks and benefits of recommended management strategies in older patients with end-stage renal disease since they may have more comorbidity and lower life expectancy than patients described in clinical trials or practice guidelines. In this review, we outline a framework for individualizing end-stage renal disease management decisions in older patients. The framework considers three factors: life expectancy, the risks and benefits of comp ...[more]

PMID: 22089945

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Project description:BackgroundFew educational resources have been developed to inform patients' renal replacement therapy (RRT) selection decisions. Patients progressing toward end stage renal disease (ESRD) must decide among multiple treatment options with varying characteristics. Complex information about treatments must be adequately conveyed to patients with different educational backgrounds and informational needs. Decisions about treatment options also require family input, as families often participate in patients' treatment and support patients' decisions. We describe the development, design, and preliminary evaluation of an informational, evidence-based, and patient-and family-centered decision aid for patients with ESRD and varying levels of health literacy, health numeracy, and cognitive function.MethodsWe designed a decision aid comprising a complementary video and informational handbook. We based our development process on data previously obtained from qualitative focus groups and systematic literature reviews. We simultaneously developed the video and handbook in "stages." For the video, stages included (1) directed interviews with culturally appropriate patients and families and preliminary script development, (2) video production, and (3) screening the video with patients and their families. For the handbook, stages comprised (1) preliminary content design, (2) a mixed-methods pilot study among diverse patients to assess comprehension of handbook material, and (3) screening the handbook with patients and their families.ResultsThe video and handbook both addressed potential benefits and trade-offs of treatment selections. The 50-minute video consisted of demographically diverse patients and their families describing their positive and negative experiences with selecting a treatment option. The video also incorporated health professionals' testimonials regarding various considerations that might influence patients' and families' treatment selections. The handbook was comprised of written words, pictures of patients and health care providers, and diagrams describing the findings and quality of scientific studies comparing treatments. The handbook text was written at a 4th to 6th grade reading level. Pilot study results demonstrated that a majority of patients could understand information presented in the handbook. Patient and families screening the nearly completed video and handbook reviewed the materials favorably.ConclusionsThis rigorously designed decision aid may help patients and families make informed decisions about their treatment options for RRT that are well aligned with their values.

Project description:Young adults receiving RRT face additional challenges in life. The effect of established kidney failure on young adulthood is uncertain. We aimed to establish the psychosocial and lifestyle status of young adults receiving RRT.Our study was a systematic review and meta-analysis of 16-30-year olds receiving RRT compared with the general population. We selected randomized, controlled trials; cohort studies; or cross-sectional studies without language restriction and extracted proportions of sociodemographic and lifestyle outcomes or validated psychologic health tests producing quality of life, wellbeing, and self-esteem scores. We undertook random effects meta-analysis.There were 60 studies with a total of 15,575 participants. Studies were largely single-center cross-sectional studies of those transplanted in childhood. Compared with healthy peers, young adults on RRT had lower quality of life, which was worse for patients on dialysis (seven studies: standardized mean difference, -1.01; 95% confidence interval [95% CI], -1.32 to -0.70) compared with patients with transplants (nine studies: standardized mean difference, -0.42; 95% CI, -0.64 to -0.20). They were more likely to be unemployed (seven studies: relative risk, 1.89; 95% CI, 1.47 to 2.44) and live in the family home (two studies: relative risk, 1.84; 95% CI, 1.40 to 2.43). They were less likely to be married or have a partner (four studies: relative risk, 0.71; 95% CI, 0.53 to 0.95). Higher education (three studies: relative risk, 1.05; 95% CI, 0.73 to 1.51), alcohol abstinence (three studies: relative risk, 1.96; 95% CI, 0.84 to 4.67), and smoking status (two studies: relative risk, 0.72; 95% CI, 0.36 to 1.44) did not differ. Results were limited by high heterogeneity and a small evidence base, biased toward surviving patients.Established kidney failure is associated with lower quality of life in young people and limited employment, independence, and relationships compared with healthy peers.This article contains a podcast at https://www.asn-online.org/media/podcast/CJASN/2017_10_19_CJASNPodcast_17_12_.mp3.

Project description:OBJECTIVES:This review summarises the information available for clinicians counselling older patients with kidney failure about treatment options, focusing on prognosis, quality of life, the lived experiences of treatment and the information needs of older adults. DESIGN:We followed the Joanna Briggs Institute Methodology for Scoping Reviews. The final report conforms to the PRISMA-ScR guidelines. DATA SOURCES:PubMed, PsycINFO, CINAHL, Embase, Scopus, Web of Science, TRIP and online repositories (for dissertations, guidelines and recommendations from national renal associations). ELIGIBILITY CRITERIA FOR INCLUSION:Articles in English studying older adults with advanced kidney disease (estimated glomerular filtration rate <30?mL/min/1.73?m2); published between January 2000 and August 2018. Articles not addressing older patients separately or those comparing between dialysis modalities were excluded. DATA EXTRACTION AND SYNTHESIS:Two independent reviewers screened articles for inclusion and grouped them by topic as per the objectives above. Quantitative data were presented as tables and charts; qualitative themes were identified and described. RESULTS:248 articles were included after screening 15?445 initial results. We summarised prognostic scores and compared dialysis and non-dialytic care. We highlighted potentially modifiable factors affecting quality of life. From reports of the lived experiences, we documented the effects of symptoms, of ageing, the feelings of disempowerment and the need for adaptation. Exploration of information needs suggested that patients want to participate in decision-making and need information, in simple terms, about survival and non-survival outcomes. CONCLUSION:When discussing treatment options, validated prognostic scores are useful. Older patients with multiple comorbidities do not do well with dialysis. The modifiable factors contributing to the low quality of life in this cohort deserve attention. Older patients suffer a high symptom burden and functional deterioration; they have to cope with significant life changes and feelings of disempowerment. They desire greater involvement and more information about illness, symptoms and what to expect with treatment.

Project description:IntroductionShared decision making is an interpersonal process whereby healthcare providers collaborate with and support patients in decision-making. Older adults receiving home care need support with decision-making. We will explore what older adults receiving home care and their caregivers need for making better health-related decisions.Methods and analysisThis two-phase sequential exploratory mixed methods study will be conducted in a pan-Canadian healthcare organisation, SE Health. First, we will create a participant advisory group to advise us throughout the research process. In phase 1 (qualitative), we will recruit a convenience sample of 15-30 older adults and caregivers receiving home care to participate in open-ended semi-structured interviews. Phase 1 participants will be invited to share what health-related decisions they face at home and what they need for making better decisions. In phase 2 (quantitative), interdisciplinary health and social care providers will be invited to answer a web-based survey to share their views on the decisional needs of older adults and their caregivers. The survey will include questions informed by findings from qualitative interviews in phase 1, and a workbook for assessing decisional needs based on the Ottawa Decision Support Framework. Finally, qualitative and quantitative results will be triangulated (by methods, investigator, theory and source) to develop a comprehensive understanding of decision-making needs from the perspective of older adults, caregivers and health and social care providers. We will use the quality of mixed methods studies in health services research guidelines and the Checklist for Reporting the Results of Internet E-Surveys checklist.Ethics and disseminationEthics approval was obtained from the research ethics boards at Southlake Regional Health Centre and Université Laval. This study will inform the design of decision support interventions. Further dissemination plans include summary briefs for study participants, tailored reports for home care decision makers and policy makers, and peer-reviewed publications.Trial registration numberNCT04327830.

Dataset Information

Optimizing renal replacement therapy in older adults: a framework for making individualized decisions.

Publications

Optimizing renal replacement therapy in older adults: a framework for making individualized decisions.

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