A web-based decision aid can improve the quality of treatment decisions made by patients over 70 with chronic kidney disease (CKD)—that is the conclusion of a new study in the Annals of Internal Medicine (AIM).
The Decision Aid for Renal Therapy (DART) is an educational aid accessible online that looks to remedy the issues with existing renal patient education materials outlined by the study authors, led by Karen Ladin (Tufts University School of Medicine, Medford, USA) and Daniel E Weiner (Tufts University School of Medicine, Medford, USA), which included that they are “generally not tailored for older adults”. It does this by “allow[ing] patients to control the pace of information” and providing accessible multimedia content for those with “limited health literacy”.
Older adults are also often educated on renal disease in single-session group classes, Ladin et al noted, which can be challenging for them due to hearing impairments, and which may not address their specific concerns. “Although decision aids improve decisional quality,” they added, “none have been specifically designed to meet the unique needs of older patients facing dialysis decisions”.
DART was a pre-existing tool for informing renal patients that was adapted by the study authors for older adults. The DART trial also addresses another gap—existing research on decision-making in dialysis patients has mostly focused on decisions made by those receiving maintenance dialysis, they have said, rather than those with advanced CKD who were yet to decide on treatment.
In total, 400 patients were recruited across nephrology clinics in four US cities for the trial, of whom 37 dropped out. These were patients who had not yet received dialysis but had stage four or five CKD with an estimated glomerular filtration rate <30 mL/min/1.73m2. It was a “non-blinded, site-level, 1:1 randomised trial”. Designing the trial around multiple centres was intended to account for “potential differences in site culture and patient education about kidney failure treatment choices”. Patients were followed for up to 18 months, and 183 were asked to use the DART tool at three months, the results of which were passed on to their clinician. The remaining 180 received “usual care”. The primary outcome was “change in decisional conflict from baseline to the three-month follow-up assessed using the decisional conflict scale (DCS)”.
DCS scores improved to a statistically significant degree for those patients in the DART-assigned group at three- and six-month assessments. At three months, the mean difference from the control group was -7.9 and at six it was -8.5 on the DCS scale. Those in the DART group were also found to “perform better with respect to implementing decisions” and were less likely to delay a decision.
Statistically significant change was not just seen on the DCS count—it was also present in measures of patient knowledge. On mean test performance, the control group improved over the course of the study period from 57.0% to 62.5%, while those who used DART went from 59.4% to 70.3%.
The study authors dubbed DART “an effective, patient-centred intervention that can improve decisional quality and knowledge of prognosis”. It reduces the burden on clinicians by allowing patients to educate themselves at home and also by reducing conflict. The effect of DART was particularly strong up to six months, they said, and was still positive but “attenuated” after 18 months. They argued that most studies examined the effects of decision aids after one week or one month—making theirs even more likely to be “clinically significant”.
Speaking exclusively to Renal Interventions, Ladin described the study as “one of the largest longitudinal studies of adults over 70 with advanced kidney disease and their decision-making process and preferences regarding dialysis.” She said that “we were pleased to see DART is an effective tool to improve knowledge and decision-making for older adults.
“Many nephrologists report delaying discussions about dialysis because they perceive patient preferences to be unstable, because there is little time in the clinical encounter, and because they want to avoid burdening patients with bad news,” she suggested. “Our study demonstrates that patient preferences, once informed, are fairly stable, and education can occur even outside of the clinical encounter.”
Finally, Ladin concluded that “although clinicians are understandably reluctant to deliver difficult news, our prior work and that of others demonstrates that most patients want to have a sense of their prognosis and the need for future medical decisions. More work is needed to better understand best strategies for implementation, as well as more work to improve access to DART for non-English speaking populations.” Weiner added that “anything that makes difficult discussions easier and more informed is very helpful when trying to engage in patient-centred medical care.”
The authors noted a few limitations, including that “enrolment among Latinx patients was low”, which was “possibly because DART was only offered in English”. There was also no supervision over how DART was used by patients. Despite these concessions, the authors were confident enough to assert that the tool is a “consistent and accessible” one that cuts conflict and improves knowledge for older CKD patients. Their final note was constructive, suggesting patients should be encouraged to revisit DART to improve outcomes after 18 months.
