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Advanced CKD Care and Decision Making: Which Health Care Professionals Do Patients Rely on for CKD Treatment and Advice?

ABSTRACT: Rationale & Objective:Chronic kidney disease (CKD) care is often fragmented across multiple health care providers. It is unclear whether patients rely mostly on their nephrologists or non-nephrologist providers for medical care, including CKD treatment and advice. Study Design:Cross-sectional study. Setting & Participants:Adults receiving nephrology care at CKD clinics in Pennsylvania. Predictors:Frequency, duration, and patient-centeredness (range, 1 [least] to 4 [most]) of participants' nephrology care. Outcome:Participants' reliance on nephrologists, primary care providers, or other specialists for medical care, including CKD treatment and advice. Analytical Approach:Multivariable logistic regression to quantify associations between participants' reliance on their nephrologists (vs other providers) and their demographics, comorbid conditions, kidney function, and nephrology care. Results:Among 1,412 patients in clinics targeted for the study, 676 (48%) participated. Among these, 453 (67%) were eligible for this analysis. Mean age was 71 (SD, 12) years, 59% were women, 97% were white, and 65% were retired. Participants were in nephrology care for a median of 3.8 (IQR, 2.0-6.6) years and completed a median of 4 (IQR, 3-5) nephrology appointments in the past 2 years. Half (56%) the participants relied primarily on their nephrologists, while 23% relied on primary care providers, 18% relied on all providers equally, and 3% relied on other specialists. Participants' adjusted odds of relying on their nephrologists were higher for those in nephrology care for longer (OR, 1.08 [95% CI, 1.02-1.15]; P = 0.02), those who completed more nephrology visits in the previous 2 years (OR, 1.16 [95% CI, 1.05-1.29]; P = 0.005), and those who perceived their last interaction with their nephrologists as more patient-centered (OR, 2.63 [95% CI, 1.70-4.09]; P < 0.001). Limitations:Single health system study. Conclusions:Many nephrology patients relied on non-nephrologist providers for medical care. Longitudinal patient-centered nephrology care may encourage more patients to follow nephrologists' recommendations.

SUBMITTER: Barrett TM

PROVIDER: S-EPMC7568072 | biostudies-literature | 2020 Sep-Oct

REPOSITORIES: biostudies-literature

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Advanced CKD Care and Decision Making: Which Health Care Professionals Do Patients Rely on for CKD Treatment and Advice?

Barrett Tyler M TM Green Jamie A JA Greer Raquel C RC Ephraim Patti L PL Peskoe Sarah S Pendergast Jane F JF Hauer Chelsie L CL Strigo Tara S TS Norfolk Evan E Bucaloiu Ion Dan ID Diamantidis Clarissa J CJ Hill-Briggs Felicia F FF Browne Teri T Jackson George L GL Boulware L Ebony LE

Kidney medicine 20200615 5

<h4>Rationale & objective</h4>Chronic kidney disease (CKD) care is often fragmented across multiple health care providers. It is unclear whether patients rely mostly on their nephrologists or non-nephrologist providers for medical care, including CKD treatment and advice.<h4>Study design</h4>Cross-sectional study.<h4>Setting & participants</h4>Adults receiving nephrology care at CKD clinics in Pennsylvania.<h4>Predictors</h4>Frequency, duration, and patient-centeredness (range, 1 [least] to 4 [m ...[more]

PMID: 33089136

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Project description:Rationale & objectiveGreater understanding of the challenges to shared decision making about treatment of advanced chronic kidney disease (CKD) is needed to support implementation of shared decision making in clinical practice.Study designQualitative study.Setting & participantsPatients aged≥65 years with advanced CKD and their clinicians recruited from 3 medical centers participated in semi-structured interviews. In-depth review of patients' electronic medical records was also performed.Analytical approachInterview transcripts and medical record notes were analyzed using inductive thematic analysis.ResultsTwenty-nine patients (age 73±6 years, 66% male, 59% White) and 10 of their clinicians (age 52±12 years, 30% male, 70% White) participated in interviews. Four themes emerged from qualitative analysis: (1) competing priorities-patients and their clinicians tended to differ on when to prioritize CKD and dialysis planning above other personal or medical problems; (2) focusing on present or future-patients were more focused on living well now while clinicians were more focused on preparing for dialysis and future adverse events; (3) standardized versus individualized approach to CKD-although clinicians tried to personalize care recommendations to their patients, the patients perceived their clinicians as taking a monolithic approach to CKD that was predicated on clinical practice guidelines and medical literature rather than the patients' lived experiences with CKD and personal values and goals; and (4) power dynamics-patients described cautiously navigating a power differential in their therapeutic relationship with their clinicians whereas clinicians seemed less attuned to these power dynamics.LimitationsThematic saturation was based on patient interviews. Themes presented might incompletely reflect clinicians' perspectives.ConclusionsEfforts to improve shared decision making for treatment of advanced CKD will likely need to explicitly address differences between patients and their clinicians in approaches to decision making about treatment of advanced CKD and perceived power imbalances in the therapeutic relationship.

Project description:Rationale & objectiveDigital health system tools to support shared decision making and preparation for kidney replacement treatments for patients with chronic kidney disease (CKD) are needed.Study designDescriptive study of the implementation of digital infrastructure to support a patient-centered health system intervention.Setting & participants4 CKD clinics within a large integrated health system.ExposureWe developed an integrated suite of digital engagement tools to support patients' shared decision making and preparation for kidney failure treatments. Tools included an automated CKD patient registry and risk prediction algorithm within the electronic health record (EHR) to identify and prioritize patients in need of nurse case management to facilitate shared decision making and preparation for kidney replacement treatments, an electronic patient-facing values clarification tool, a tracking application to document patients' preparation for treatments, and an EHR work flow to broadcast patients' treatment preferences to all health care providers.OutcomesUptake and acceptability.Analytic approachMixed methods.ResultsFrom July 1, 2017, through June 30, 2018, the CKD registry identified 1,032 patients in 4 nephrology clinics, of whom 243 (24%) were identified as high risk for progressing to kidney failure within 2 years. Kidney Transitions Specialists enrolled 117 (48%) high-risk patients by the end of year 1. The values tool was completed by 30/33 (91%) patients who attended kidney modality education. Nurse case managers used the tracking application for 100% of patients to document 287 planning steps for kidney replacement therapy. Most (87%) high-risk patients had their preferred kidney replacement modality documented and displayed in the EHR. Nurse case managers reported that the tools facilitated their identification of patients needing support and their navigation activities.LimitationsSingle institution, short duration.ConclusionsDigital health system tools facilitated rapid identification of patients needing shared and informed decision making and their preparation for kidney replacement treatments.FundingThis work was supported through a Patient-Centered Outcomes Research Institute (PCORI) Project Program Award (IHS-1409-20967).Trial registrationClinicalTrials.gov NCT02722382.

Project description:BackgroundPeople with prediabetes are at high risk of developing type 2 diabetes and its complications, such as cardiovascular diseases and premature mortality. Primary prevention and health maintenance are therefore imperative. Evidence has shown that prediabetes can be prevented or delayed with behavioural change, mainly in eating habits and physical activity. Interventions that use a person-centered approach can lead to improvements in self-management, quality of life, and health outcomes. Nevertheless, there is a need for further research that engages healthcare professionals and people with prediabetes in constructing and implementing preventive programs. The purpose of this study is to explore and describe how healthcare professionals perceive prediabetes, the current challenges in its detection and treatment, and what is needed to improve quality of care.MethodsThis qualitative study was conducted in Region Stockholm. A total of 26 primary health care professionals participated in individual interviews: 15 diabetes nurses and/or district nurses, five general practitioners, five dietitians, and one physiotherapist. Interview transcripts were analyzed with qualitative content analysis.ResultsThe analysis revealed two main themes that emphasize the need to make prediabetes more visible in primary health care. Despite the healthcare professionals' engagement and their motivation to improve prediabetes care, ad hoc practices and the absence of clear screening guidelines and referral pathways made it harder to focus on primary prevention. Supporting professionals in implementing structured care for people with prediabetes might encourage more efficient interprofessional collaboration and contribute to better strategies for promoting behavioural change.ConclusionsEstablishing prediabetes care guidelines, supporting health care professionals´ knowledge and skills in prediabetes care, and implementing interprofessional referral pathways are some steps to enhance prediabetes detection and care precedence in primary health care. These steps could lead to more preventive care and ensure patient safety and health care equity.

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Advanced CKD Care and Decision Making: Which Health Care Professionals Do Patients Rely on for CKD Treatment and Advice?

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Advanced CKD Care and Decision Making: Which Health Care Professionals Do Patients Rely on for CKD Treatment and Advice?

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