Survey: Nephrology providers have ‘limited experience’ discussing conservative care
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Key takeaways
- A survey of nephrology providers showed that most are unprepared to talk to patients about conservative kidney management.
- Researchers cited a need to increase training and surveillance of practices.
Nephrology providers have limited knowledge and experience in offering conservative kidney management to patients who decide to forgo renal replacement therapy, recently published survey results show.
“ ... [M]ost reported limited experience with [conservative kidney management] CKM and varied approaches and local resources to provide CKM,” Julie Chotivatanapong, BS, research study coordinator at the University of Washington Medicine Kidney Research Institute, and colleagues wrote. “There is a need to enhance provider training and surveillance of CKM practices and to develop models of CKM that optimize care delivery and outcomes for these patients.”
Access to resources
Susan P. Y. Wong, MD, MS, an associate professor in the division of nephrology at the University of Washington VA Puget Sound Health Care System and a co-author of the paper, told Healio that access to resources may play a role in the inability of nephrology providers to adequately offer CKM.
“Part of this may be due to differences in what kind of support individual patients need or prefer,” Wong said. “Part of this may be due to poor access to these resources. Another reason may be that nephrology providers are unsure about how to rally these resources in a coordinated and cohesive fashion in service of CKM,” Wong said.
The researchers conducted a survey of a national sample of nephrology providers recruited through U.S.-based professional societies and who were attendees at the National Kidney Foundation Spring Clinical Meetings in 2022. Respondents were asked about experiences with caring for patients who forgo RRT and their capacity to provide CKM.
Overall, 203 nephrology providers (aged 47 ±12 years, 53.2% were white, 66% were women), participated in the survey, of which 49.8% were nephrologists and 50.2% were advanced practice providers.
“Most indicated that they always or often provided symptom management (81.8%), multidisciplinary care (68%), tools to support shared decision-making about treatment of advanced kidney disease (66.3%), and psychological support (52.2%) to patients who forgo RRT, while less than half reported that they always or often provided staff training on the care of these patients (47.8%) and spiritual support (41.4%),” the researchers wrote. “Most providers reported always or often working with primary care (72.9%), palliative medicine (68.8%), hospice (62.6%), social work (58.1%) and dietitian (50.7%) services to support these patients, while only a minority indicated that they always or often offered chaplaincy (23.2%), physical and/or occupational therapy (22.8%), psychology or psychiatry (31.5%), and geriatric medicine (28.1%),” the authors wrote.
Limited data
Data on CKM practices in the U.S. are limited, the authors wrote. “The U.S. national registry on kidney failure focuses predominantly on patients who receive [renal replacement therapy] RRT and misses those who forgo this treatment,” the authors wrote. “The United States has also lagged considerably behind other developed countries in establishing CKM pathways, and available data indicate that services and quality of care provided to people who forgo RRT are highly variable across the country.”
Part of the reason for the lack of expertise in conservative kidney management is limited training, the researchers wrote. “Previous studies have shown that nephrology providers receive very little training on CKM and the whole-person approach to care necessary to successfully provide CKM,” they wrote. “Providers are often doubtful of patients who express that they do not wish to pursue RRT and manage their patients with the expectation that patients will change their minds.
“Even when providers are proactive in honoring patients’ wishes for CKM, their colleagues often make them feel as though they are practicing outside of norms or the scope of nephrology,” the authors wrote. “There is also the perception that caring for patients who do not pursue RRT falls outside the field of nephrology and might be better suited to other medical specialties, such as primary or palliative care.”
Wong outlined several steps that could be taken to ensure patients who decide to forgo RRT get adequate care. “More can be done to ‘normalize’ CKM as an option for kidney failure and ease its delivery,” Wong said. “First, providers need more education and training on CKM. Second, changing norms around dialysis and longevity-oriented care (eg, full code) as ‘standard of care’ would ease providers' (and patients’ and families’) discomfort with pursuing CKM. There is reluctance, fear and moral distress with forgoing a treatment (ie, dialysis) that is framed as the norm.
“Last, but not least, there needs to be more research on CKM to develop the evidence to guide practices,” Wong told Healio.
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