Decision aid for replacement therapy improves decisional quality in older adults with CKD
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An online and interactive decision aid about kidney replacement therapy improved decisional quality among older adults with advanced chronic kidney disease, according to data published in Annal Internal Medicine.
“Although decision aids improve decisional quality, none have been specifically designed to meet the unique needs of older patients facing dialysis decisions,” Keren Ladin, PhD, an associate professor of community health at Tufts, and colleagues wrote. They added, “Based on our formative work examining decisional needs among older patients facing dialysis decisions and following the International Patient Decision Aid Standards, we refined a preexisting decision aid to meet the specific needs of older adults.”
In a multicenter, randomized controlled trial, researchers examined 363 patients who were 70 years or older with stage 4 to 5 CKD and who were not on dialysis. Patients received care from eight different outpatient nephrology clinics between 2018 and 2020.
Researchers randomized patients 1:1 to receive Decision-Aid for Renal Therapy (DART) treatment and written education (n=183) or control treatment and written education (n=180). DART treatment is a decision aid available online that takes 30 to 60 minutes to complete and is designed for older adults. Broken into three parts, DART educates users about kidney disease, covers therapeutic options and allows users to identify their values interactively.
“The tool does not replace doctors; it supports them. Generally, we found that many clinicians are taxed on time,” Ladin said in the press release. “Also, physicians are not often trained in having serious illness conversations or in helping patients make decisions that best reflect their values.”
Researchers followed patients for up to 18 months and asked patients to complete DART by the 3-month follow-up. Upon completion, a form of patient preferences summaries and questions were generated from DART and submitted to patients’ nephrologists.
Researchers considered a change in the decisional conflict scale (DCS) from baseline to month 3, 6, 12 and 18 the primary outcome of the study.
Compared with the control group, patients randomized to DART treatment showed an improvement in decisional quality with mean DCS scores decreasing. Results were maintained at 6 months and attenuated after this time.
Researchers also observed an improvement in knowledge among patients randomized to DART treatment rather than the control group.
Among the DART group, 50% of patients reported being “unsure” about treatment preferences at baseline, and the percentage declined to 28% at month 3, 20% at month 6 23% at month 12 and 14% by the 18-month mark. Comparatively, 51% of the control group reported being “unsure,” which changed to 38%, 35%, 32% and 18%, respectively.
Overall, DART improved decision quality for older adults for 6 months after the treatment. Researchers noted that “Latinx” patients were underrepresented in this study, and further research may have to be conducted.
In a press release, Ladin said, “Our goal is for decision-making to improve quality of life for older patients with advanced CKD. That’s really the goal. It’s not meant to push any particular modality, but just to help patients think about which treatment option is best for them, given where they are in their life, what they want do, how much care they want receive at home, and how involved they want be in their own care. DART is a tool to support shared decision-making. Future research is needed to examine how to best use it in practice, including optimal timing and strategies to encourage its use within the clinical encounter.”
Reference:
Decision-making tool for older adults with chronic kidney disease improves choices. https://www.newswise.com/articles/decision-making-tool-for-older-adults-with-chronic-kidney-disease-improves-choices?sc=mwhr&xy=10021929. Published Feb. 10, 2023. Accessed, Feb. 14, 2023.
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