Principles and strategies for involving patients in research in chronic kidney disease: report from national workshops

BACKGROUND

There is widespread recognition that research will be more impactful if it arises from partnerships between patients and researchers, but evidence on best practice for achieving this remains limited.

METHODS

We convened workshops in three Australian cities involving 105 patients/caregivers and 43 clinicians/researchers. In facilitated breakout groups, participants discussed principles and strategies for effective patient involvement in chronic kidney disease research. Transcripts were analysed thematically.

RESULTS

Five major themes emerged. 'Respecting consumer expertise and commitment' involved valuing unique and diverse experiential knowledge, clarifying expectations and responsibilities, equipping for meaningful involvement and keeping patients 'in the loop'. 'Attuning to individual context' required a preference-based multipronged approach to engagement, reducing the burden of involvement and being sensitive to the patient journey. 'Harnessing existing relationships and infrastructure' meant partnering with trusted clinicians, increasing research exposure in clinical settings, mentoring patient to patient and extending reach through established networks. 'Developing a coordinated approach' enabled power in the collective and united voice, a systematic approach for equitable inclusion and streamlining access to opportunities and trustworthy information. 'Fostering a patient-centred culture' encompassed building a community, facilitating knowledge exchange and translation, empowering health ownership, providing an opportunity to give back and cultivating trust through transparency.

CONCLUSIONS

Partnering with patients in research requires respect and recognition of their unique, diverse and complementary experiential expertise. Establishing a supportive, respectful research culture, responding to their individual context, coordinating existing infrastructure and centralizing the flow of information may facilitate patient involvement as active partners in research.

Identifying critically important cardiovascular outcomes for trials in hemodialysis: an international survey with patients, caregivers and health professionals

BACKGROUND

Cardiovascular disease (CVD) is a major contributor to morbidity and mortality in people on hemodialysis (HD). Cardiovascular outcomes are reported infrequently and inconsistently across trials in HD. This study aimed to identify the priorities of patients/caregivers and health professionals (HPs) for CVD outcomes to be incorporated into a core outcome set reported in all HD trials.

METHODS

In an international online survey, participants rated the absolute importance of 10 cardiovascular outcomes (derived from a systematic review) on a 9-point Likert scale, with 7-9 being critically important. The relative importance was determined using a best-worst scale. Likert means, medians and proportions and best-worst preference scores were calculated for each outcome. Comments were thematically analyzed.

RESULTS

Participants included 127 (19%) patients/caregivers and 549 (81%) HPs from 53 countries, of whom 530 (78%) completed the survey in English and 146 (22%) in Chinese. All but one cardiovascular outcome ('valve replacement') was rated as critically important (Likert 7-9) by all participants; 'sudden cardiac death', 'heart attack', 'stroke' and 'heart failure' were all rated at the top by patients/caregivers (median Likert score 9). Patients/caregivers ranked the same four outcomes as the most important outcomes with mean preference scores of 6.2 (95% confidence interval 4.8-7.5), 5.9 (4.6-7.2), 5.3 (4.0-6.6) and 4.9 (3.6-6.3), respectively. The same four outcomes were ranked most highly by HPs. We identified five themes underpinning the prioritization of outcomes: 'clinical equipoise and potential for intervention', 'specific or attributable to HD', 'severity or impact on the quality of life', 'strengthen knowledge and education', and 'inextricably linked burden and risk'.

CONCLUSIONS

Patients and HPs believe that all cardiovascular outcomes are of critical importance but consistently identify sudden cardiac death, myocardial infarction, stroke and heart failure as the most important outcomes to be measured in all HD trials.

Recruitment and retention in clinical trials in chronic kidney disease: report from national workshops with patients, caregivers and health professionals

BACKGROUND

Slow recruitment and poor retention jeopardize the reliability and statistical power of clinical trials, delaying access to effective interventions and increasing costs, as commonly observed in nephrology trials. Involving patients in trial design, recruitment and retention is infrequent but potentially transformational.

METHODS

We conducted three workshops involving 105 patients/caregivers and 43 health professionals discussing patient recruitment and retention in clinical trials in chronic kidney disease.

RESULTS

We identified four themes. 'Navigating the unknown'-patients described being unaware of the research question, confused by technical terms, sceptical about findings and feared the risk of harm. 'Wary of added burden'-patients voiced reluctance to attend additional appointments, were unsure of the commitment required or at times felt too unwell and without capacity to participate. 'Disillusioned and disconnected'-some patients felt they were taken for granted, particularly if they did not receive trial results. Participants believed there was no culture of trial participation in kidney disease and an overall lack of awareness about opportunities to participate. To improve recruitment and retention, participants addressed 'Building motivation and interest'.

CONCLUSIONS

Investigators should establish research consciousness from the time of diagnosis, consider optimal timing for approaching patients, provide comprehensive information in an accessible manner, emphasize current and future relevance to them and their illness, involve trusted clinicians in recruitment and minimize the burden of trial participation. Participation in clinical trials was seen as an opportunity for people to give back to the health system and for future people in their predicament.

Patient needs and priorities for patient navigator programmes in chronic kidney disease: a workshop report

BACKGROUND AND OBJECTIVE

Patients with early chronic kidney disease (CKD) face challenges in accessing healthcare, including delays in diagnosis, fragmented speciality care and lack of tailored education and psychosocial support. Patient navigator programmes have the potential to improve the process of care and outcomes. The objective of this study is to describe the experiences of patients on communication, access of care and self-management and their perspectives on patient navigator programmes in early CKD.

DESIGN, SETTING AND PARTICIPANTS

We convened a workshop in Australia with 19 patients with CKD (all stages including CKD Stage 1 to 5 not on dialysis, 5D (dialysis), and 5T (transplant)) and five caregivers. All of them were over 18 years and English-speaking. Transcripts from the workshop were analysed thematically.

RESULTS

Four themes that captured discussions were: lost in the ambiguity of symptoms and management, battling roadblocks while accessing care, emotionally isolated after diagnosis and re-establishing lifestyle and forward planning. Five themes that focussed on patient navigator programmes were: trust and credibility, respecting patient choices and readiness to accept the programme, using accessible language to promote the programme, offering multiple ways to engage and communicate and maintaining confidentiality and privacy. Of the 17 features identified as important for a patient navigator programme, the top five were delivery of education, psychosocial support, lifestyle modification, communication and decision-making support and facilitating care.

CONCLUSION

Patient navigator services can address gaps in services around health literacy, communication, psychosocial support and coordination across multiple healthcare settings. In comparison to the existing navigator programmes, and other services that are aimed at addressing these gaps, credible, accessible and flexible patient navigator programmes for patients with early CKD, that support education, decision-making, access to care and self-management designed in partnership with patients, may be more acceptable to patients.

International Survey to Establish Prioritized Outcomes for Trials in People With Coronavirus Disease 2019

OBJECTIVES

There are over 4,000 trials conducted in people with coronavirus disease 2019. However, the variability of outcomes and the omission of patient-centered outcomes may diminish the impact of these trials on decision-making. The aim of this study was to generate a consensus-based, prioritized list of outcomes for coronavirus disease 2019 trials.

DESIGN

In an online survey conducted in English, Chinese, Italian, Portuguese, and Spanish languages, adults with coronavirus disease 2019, their family members, health professionals, and the general public rated the importance of outcomes using a 9-point Likert scale (7-9, critical importance) and completed a Best-Worst Scale to estimate relative importance. Participant comments were analyzed thematically.

SETTING

International.

SUBJECTS

Adults 18 years old and over with confirmed or suspected coronavirus disease 2019, their family members, members of the general public, and health professionals (including clinicians, policy makers, regulators, funders, and researchers).

INTERVENTIONS

None.

MEASUREMENTS

None.

MAIN RESULTS

In total, 9,289 participants from 111 countries (776 people with coronavirus disease 2019 or family members, 4,882 health professionals, and 3,631 members of the public) completed the survey. The four outcomes of highest priority for all three groups were: mortality, respiratory failure, pneumonia, and organ failure. Lung function, lung scarring, sepsis, shortness of breath, and oxygen level in the blood were common to the top 10 outcomes across all three groups (mean > 7.5, median ≥ 8, and > 70% of respondents rated the outcome as critically important). Patients/family members rated fatigue, anxiety, chest pain, muscle pain, gastrointestinal problems, and cardiovascular disease higher than health professionals. Four themes underpinned prioritization: fear of life-threatening, debilitating, and permanent consequences; addressing knowledge gaps; enabling preparedness and planning; and tolerable or infrequent outcomes.

CONCLUSIONS

Life-threatening respiratory and other organ outcomes were consistently highly prioritized by all stakeholder groups. Patients/family members gave higher priority to many patient-reported outcomes compared with health professionals.

Core Outcomes Set for Trials in People With Coronavirus Disease 2019

OBJECTIVES

The outcomes reported in trials in coronavirus disease 2019 are extremely heterogeneous and of uncertain patient relevance, limiting their applicability for clinical decision-making. The aim of this workshop was to establish a core outcomes set for trials in people with suspected or confirmed coronavirus disease 2019.

DESIGN

Four international online multistakeholder consensus workshops were convened to discuss proposed core outcomes for trials in people with suspected or confirmed coronavirus disease 2019, informed by a survey involving 9,289 respondents from 111 countries. The transcripts were analyzed thematically. The workshop recommendations were used to finalize the core outcomes set.

SETTING

International.

SUBJECTS

Adults 18 years old and over with confirmed or suspected coronavirus disease 2019, their family members, members of the general public and health professionals (including clinicians, policy makers, regulators, funders, researchers).

INTERVENTIONS

None.

MEASUREMENTS

None.

MAIN RESULTS

Six themes were identified. "Responding to the critical and acute health crisis" reflected the immediate focus on saving lives and preventing life-threatening complications that underpinned the high prioritization of mortality, respiratory failure, and multiple organ failure. "Capturing different settings of care" highlighted the need to minimize the burden on hospitals and to acknowledge outcomes in community settings. "Encompassing the full trajectory and severity of disease" was addressing longer term impacts and the full spectrum of illness (e.g. shortness of breath and recovery). "Distinguishing overlap, correlation and collinearity" meant recognizing that symptoms such as shortness of breath had distinct value and minimizing overlap (e.g. lung function and pneumonia were on the continuum toward respiratory failure). "Recognizing adverse events" refers to the potential harms of new and evolving interventions. "Being cognizant of family and psychosocial wellbeing" reflected the pervasive impacts of coronavirus disease 2019.

CONCLUSIONS

Mortality, respiratory failure, multiple organ failure, shortness of breath, and recovery are critically important outcomes to be consistently reported in coronavirus disease 2019 trials.

Validation of a Core Patient-Reported Outcome Measure for Fatigue in Patients Receiving Hemodialysis: The SONG-HD Fatigue Instrument

BACKGROUND AND OBJECTIVES

Fatigue is a very common and debilitating symptom and identified by patients as a critically important core outcome to be included in all trials involving patients receiving hemodialysis. A valid, standardized measure for fatigue is needed to yield meaningful and relevant evidence about this outcome. This study validated a core patient-reported outcome measure for fatigue in hemodialysis.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

A longitudinal cohort study was conducted to assess the validity and reliability of a new fatigue measure (Standardized Outcomes in Nephrology-Hemodialysis Fatigue [SONG-HD Fatigue]). Eligible and consenting patients completed the measure at three time points: baseline, a week later, and 12 days following the second time point. Cronbach α and intraclass correlation coefficient were calculated to assess internal consistency, and Spearman rho was used to assess convergent validity. Confirmatory factor analysis was also conducted. Hemodialysis units in the United Kingdom, Australia, and Romania participated in this study. Adult patients aged 18 years and over who were English speaking and receiving maintenance hemodialysis were eligible to participate. Standardized Outcomes in Nephrology-Hemodialysis, the Visual Analog Scale for fatigue, the 12-Item Short Form Survey, and Functional Assessment of Chronic Illness Therapy-Fatigue were used.

RESULTS

In total, 485 participants completed the study across the United Kingdom, Australia, and Romania. Psychometric assessment demonstrated that Standardized Outcomes in Nephrology-Hemodialysis is internally consistent (Cronbach α =0.81-0.86) and stable over a 1-week period (intraclass correlation coefficient =0.68-0.74). The measure demonstrated convergence with Functional Assessment of Chronic Illness Therapy-Fatigue and had moderate correlations with other measures that assessed related but not the same concept (the 12-Item Short Form Survey and the Visual Analog Scale). Confirmatory factor analysis supported the one-factor model.

CONCLUSIONS

SONG-HD Fatigue seems to be a reliable and valid measure to be used in trials involving patients receiving hemodialysis.

'A sword of Damocles': patient and caregiver beliefs, attitudes and perspectives on presymptomatic testing for autosomal dominant polycystic kidney disease: a focus group study

BACKGROUND AND OBJECTIVES

Presymptomatic testing is available for early diagnosis of hereditary autosomal dominant polycystic kidney disease (ADPKD). However, the complex ethical and psychosocial implications can make decision-making challenging and require an understanding of patients' values, goals and priorities. This study aims to describe patient and caregiver beliefs and expectations regarding presymptomatic testing for ADPKD.

DESIGN, SETTING AND PARTICIPANTS

154 participants (120 patients and 34 caregivers) aged 18 years and over from eight centres in Australia, France and Korea participated in 17 focus groups. Transcripts were analysed thematically.

RESULTS

We identified five themes: avoiding financial disadvantage (insecurity in the inability to obtain life insurance, limited work opportunities, financial burden); futility in uncertainty (erratic and diverse manifestations of disease limiting utility, taking preventive actions in vain, daunted by perplexity of results, unaware of risk of inheriting ADPKD); lacking autonomy and support in decisions (overwhelmed by ambiguous information, medicalising family planning, family pressures); seizing control of well-being (gaining confidence in early detection, allowing preparation for the future, reassurance in family resilience); and anticipating impact on quality of life (reassured by lack of symptoms, judging value of life with ADPKD).

CONCLUSIONS

For patients with ADPKD, presymptomatic testing provides an opportunity to take ownership of their health through family planning and preventive measures. However, these decisions can be wrought with tensions and uncertainty about prognostic implications, and the psychosocial and financial burden of testing. Healthcare professionals should focus on genetic counselling, mental health and providing education to patients' families to support informed decision-making. Policymakers should consider the cost burden and risk of discrimination when informing government policies. Finally, patients are recommended to focus on self-care from an early age.

Executive summary of the 2020 KDIGO Diabetes Management in CKD Guideline: evidence-based advances in monitoring and treatment

THE KIDNEY DISEASE

Improving Global Outcomes (KDIGO) Clinical Practice Guideline for Diabetes Management in Chronic Kidney Disease represents the first KDIGO guideline on this subject. The guideline comes at a time when advances in diabetes technology and therapeutics offer new options to manage the large population of patients with diabetes and chronic kidney disease (CKD) at high risk of poor health outcomes. An enlarging base of high-quality evidence from randomized clinical trials is available to evaluate important new treatments offering organ protection, such as sodium-glucose cotransporter-2 inhibitors and glucagon-like peptide-1 receptor agonists. The goal of the new guideline is to provide evidence-based recommendations to optimize the clinical care of people with diabetes and CKD by integrating new options with existing management strategies. In addition, the guideline contains practice points to facilitate implementation when insufficient data are available to make well-justified recommendations or when additional guidance may be useful for clinical application. The guideline covers comprehensive care of patients with diabetes and CKD, glycemic monitoring and targets, lifestyle interventions, antihyperglycemic therapies, and self-management and health systems approaches to management of patients with diabetes and CKD.

Patients' and caregivers' perspectives on access to kidney replacement therapy in rural communities: systematic review of qualitative studies

OBJECTIVE

Patients with chronic kidney disease (CKD) requiring kidney replacement therapy (KRT) in rural communities encounter many barriers in accessing equitable care and have worse outcomes compared with patients in urban areas. This study aims to describe the perspectives of patients and caregivers on access to KRT in rural communities to inform strategies to maximise access to quality care, and thereby reduce disadvantage, inequity and improve health outcomes.

SETTING

18 studies (n=593 participants) conducted across eight countries (Australia, Canada, the UK, New Zealand, Ghana, the USA, Tanzania and India).

RESULTS

We identified five themes: uncertainty in navigating healthcare services (with subthemes of struggling to absorb information, without familiarity and exposure to options, grieving former roles and yearning for cultural safety); fearing separation from family and home (anguish of homesickness, unable to fulfil family roles and preserving sense of belonging in community); intense burden of travel and cost (poverty of time, exposure to risks and hazards, and taking a financial toll); making life-changing sacrifices; guilt and worry in receiving care (shame in taking resources from others, harbouring concerns for living donor, and coping and managing in isolation).

CONCLUSION

Patients with CKD in rural areas face profound and inequitable challenges of displacement, financial burden and separation from family in accessing KRT, which can have severe consequences on their well-being and outcomes. Strategies are needed to improve access and reduce the burden of obtaining appropriate KRT in rural communities.

eHealth Interventions for Solid Organ Transplant Recipients: A Systematic Review and Meta-analysis of Randomized Controlled Trials

BACKGROUND

Lack of support for self-management may contribute to adverse health outcomes. eHealth has the potential to support self-management, but evidence in solid organ transplantation remains unclear. This review aims to evaluate the benefits and harms of eHealth interventions to support self-management in solid organ transplant recipients.

METHODS

We searched Cochrane Central Register of Controlled Trials, MEDLINE, and Embase databases for randomized trials of eHealth interventions in solid organ transplant recipients. We calculated the risk ratios or standardized mean difference of outcomes, and summary estimates were determined using random-effects models. The Cochrane risk of bias tool and Grading of Recommendations, Assessment, Development, and Evaluations were used to assess trial quality.

RESULTS

Twenty-one trials from 6 countries involving 2114 participants were included. Compared with standard care, eHealth interventions improved medication adherence (risk ratio, 1.34; CI, 1.12-2.56; I = 75%) and self-monitoring behavior (risk ratio, 2.58; CI, 1.56-4.27; I = 0%) up to 12 mo posttransplant. The treatment effects were largely consistent across different subgroups except for intervention functionality and mode of delivery. The effects on other outcomes were uncertain. Nine trials reported harms. The overall risk of bias was considered high or unclear, and the quality of evidence was low to very low for all outcomes.

CONCLUSIONS

eHealth interventions may improve medication adherence and self-monitoring behavior in the short term, but high-quality intervention studies are needed to determine whether eHealth will improve long-term patient-relevant outcomes.

Developing Consensus-Based Outcome Domains for Trials in Children and Adolescents With CKD: An International Delphi Survey

RATIONALE & OBJECTIVE

The inconsistency in outcomes reported and lack of patient-reported outcomes across trials in children with chronic kidney disease (CKD) limits shared decision making. As part of the Standardized Outcomes in Nephrology (SONG)-Kids initiative, we aimed to generate a consensus-based prioritized list of critically important outcomes to be reported in all trials in children with CKD.

STUDY DESIGN

An online 2-round Delphi survey in English, French, and Hindi languages.

SETTINGS & PARTICIPANTS

Patients (aged 8-21 years), caregivers/family, and health care professionals (HCPs) rated the importance of outcomes using a 9-point Likert scale (7-9 indicating critical importance) and completed a Best-Worst Scale.

ANALYTICAL APPROACH

We assessed the absolute and relative importance of outcomes. Comments were analyzed thematically.

RESULTS

557 participants (72 [13%] patients, 132 [24%] caregivers, and 353 [63%] HCPs) from 48 countries completed round 1 and 312 (56%) participants (28 [40%] patients, 64 [46%] caregivers, and 220 [56%] HCPs) completed round 2. Five outcomes were common in the top 10 for each group: mortality, kidney function, life participation, blood pressure, and infection. Caregivers and HCPs rated cardiovascular disease higher than patients. Patients gave lower ratings to all outcomes compared with caregivers/HCPs except they rated life participation (round 2 mean difference, 0.1), academic performance (0.1), mobility (0.4), and ability to travel (0.4) higher than caregivers and rated ability to travel (0.4) higher than HCPs. We identified 3 themes: alleviating disease and treatment burden, focusing on the whole child, and resolving fluctuating and conflicting goals.

LIMITATIONS

Most participants completed the survey in English.

CONCLUSIONS

Mortality, life participation, kidney function, and blood pressure were consistently highly prioritized by patients, caregivers, and HCPs. Patients gave higher priority to some lifestyle-related outcomes compared with caregivers/HCPs. Establishing critically important outcomes for all trials in children with CKD may improve consistent reporting of survival, kidney health, and clinical and life impact outcomes that are meaningful for decision making.

MO027EVALUATING THE FEASIBILITY AND IMPACT OF A MOBILE PHONE TEXT MESSAGING INTERVENTION ON ADHERENCE TO DIETARY RECOMMENDATIONS IN PATIENTS ON HAEMODIALYSIS (KIDNEYTEXT)

Background and Aims

Nutritional management is an important, but complex, component of treatment for people on haemodialysis. Dietary recommendations are poorly adhered to, and novel strategies to improve self-management are needed. The aim of this study was to determine the feasibility and effectiveness of a mobile phone text message intervention to improve dietary behaviours in people on haemodialysis.

Method

We conducted a six-month, multi-centre randomised controlled trial (2:1) in patients on maintenance haemodialysis. Participants who were randomised to receive the KIDNEYTEXT intervention received three semi-tailored text messages per week for six months plus usual care. The control group received usual care. The primary outcome was a composite outcome to determine feasibility, using: recruitment rate, retention rate, adherence to dietary recommendations and acceptability. Adherence to dietary recommendations was defined as meeting 3 of 4 nutrition guidelines (potassium, phosphorus, sodium and protein). Acceptability was evaluated by semi-structured interviews to elicit perspectives regarding satisfaction, acceptability and change in behaviours. Secondary outcomes included serum electrolytes, interdialytic weight gain (IDWG) and dietary intake. Trial registration - ACTRN12617001084370.

Results

In total, 130 participants were recruited (87 intervention, 43 control) from six haemodialysis units in Sydney, Australia. 48% of eligible patients consented to participate and 114 participants (88%) completed the trial. Whilst there was no significant difference in adherence to dietary recommendations at 6 months (p=0.14), there were significant reductions in dietary intake of potassium (p=0.01), phosphorus (p=0.003), sodium (p=0.031) and protein (p=0.024) in intervention participants compared to control. Compared to control participants, intervention arm had a significant increase in the number of participants meeting IDWG guidelines (p=0.005) and significant reduction in average IDWG (p=0.024). There was a significant reduction in the number of phosphate binders prescribed in the intervention arm compared to control at 6 months (p=0.03). There was no significant difference in serum electrolytes between the 2 arms at 6 months. Semi-structured interviews explored acceptability, with 5 themes emerging: clear and comprehensive, engaging with consistent and relevant content, maintaining attention with timely reminders, sustaining interest through ongoing care and generic messages inadequate to prompt dietary change.

Conclusion

A mobile phone text message intervention targeting dietary behaviours in people on haemodialysis is feasible and has the potential to change dietary behaviours and improve clinical parameters, such as fluid management and pill burden. Future trials evaluating the effect of a mobile phone text message intervention on patient-centred and clinical outcomes in the haemodialysis population is warranted.

0454 Sleep Disruptive Cognitions in Deployment-Related Insomnia

Introduction

Sleep disturbance is common following military deployment, and insomnia is associated with many adverse psychiatric and medical outcomes. Deployment to a threatening environment can engender nocturnal vigilance, which may be a salient feature of sleep disturbance in formerly deployed Veterans. Cognitive behavioral therapy for insomnia (CBTI) is an effective treatment; however, CBTI emphasizes targeting dysfunctional beliefs about sleep (DBAS) and generalized worries rather than vigilance. The goal of the present study was to investigate the role of vigilance, in relation to other potential types of sleep-interfering cognitions in formerly deployed Veterans with sleep disturbance.

Methods

Thirty-nine formerly deployed Veterans with disturbed sleep completed measures prior to an intervention. Insomnia was measured with the Insomnia Severity Index (ISI) and measures derived from actigraphy and morning sleep diaries administered for one week. Measures for sleep interfering cognitions included Dysfunctional Beliefs about Sleep (DBAS), the Penn State Worry Questionnaire (PSWQ), a measure of generalized worry, and the Fear of Loss of Vigilance (FLV) subscale of the Fear of Sleep Inventory (FOSI).

Results

All of the measures of sleep-interfering cognitions were significantly associated with ISI score. Generalized worries (PSWQ scores) were strongly and significantly correlated with both FLV and DBAS, which were not significantly correlated with each other. FOSI FLV explained 7.1% more variance in ISI score than DBAS alone (p = .04) while DBAS explained 23.1% additional variance in ISI score over FOSI FLV alone (p < .001).

Conclusion

It may be important to target both nocturnal vigilance and dysfunctional beliefs about sleep in the treatment of insomnia in formerly deployed Veterans.

Support

Supported by W81XWH-14-1-0066 from the Congressionally Directed Peer-Reviewed Medical Research Program of the Department of Defense.

0490 Development and Preliminary Evaluation of a Brief Intervention for Post-Deployment Insomnia

Introduction

Sleep disturbances are common among previously deployed Veterans. Cognitive behavioral therapy for insomnia (CBT-I) has shown promise for Veterans but there are limitations and CBT-I may not optimally target the nocturnal vigilance conditioned by threatening environments. We developed and preliminarily evaluated a brief educational/behavioral intervention that combined established behavioral sleep principles with cognitive exercises intended to reduce the impact of vigilant thoughts and behaviors on sleep.

Methods

Participants were 40 Veterans recruited from the community and local VAMC who had been deployed to combat zones or hazardous duty areas. The mean age was 40, and the majority were male, African American, and screened positively for PTSD. They were assigned to the study intervention or an educational control that utilized a pamphlet promoting healthy sleep habits. Assignment at a 2:1 ratio was intended to allow for refinement of the study intervention during the early phase of the trial. Initial assessment was followed by a week of sleep diary collection, then two intervention sessions a week apart, followed by a repeat assessment. Participants of the study intervention were assessed again 3-months later.

Results

Improvements in sleep efficiency, ratings for feeling rested in the morning, and reduced Insomnia Severity Index scores were seen in the post-treatment week but did not differ between groups. At 3-months, these improvements were sustained in the 14 retained participants of the study intervention, engagement in vigilance reducing exercises remained high, and ratings of how rested one felt in the morning were significantly improved over ratings from the post-treatment week.

Conclusion

Brief behavioral intervention for post-deployment insomnia can provide benefits and cognitive exercises to reduce the impact of vigilant thoughts and behaviors warrant further evaluation.

Support

Supported by W81XWH-14-1-0066 from the Congressionally Directed Peer-Reviewed Medical Research Program of the Department of Defense

1169 Innovative Exposure to Sleep Medicine for Medical Students

Introduction

Lack of exposure to the field of Sleep Medicine at the medical student level hinders sleep training. Instead of the traditional didactic style, there is a need for innovative collaborative measures to spark interest in the younger generation of learners. The goal of this educational endeavor was to introduce medical students to the field of Sleep Medicine through the platform of Student Interest Group in Neurology (SIGN).

Methods

An interactive session was conducted for SIGN at the University of Minnesota. 24 second-year medical students were divided into 6 groups. The session consisted of introduction, videos of common sleep disorders and interactive briefing afterward. 5-point Likert scale pre and post-session surveys were administered to measure the level of knowledge regarding sleep, familiarity with diagnostic tools, available education, pathways to Sleep Medicine, learner’s interest and impact of the session. Wilcoxon matched-pairs signed-rank test was performed to compare pre- and post-surveys.

Results

There was a significant improvement in measures of students’ knowledge about sleep diagnostic modalities (p =7.8*10-5), education received (p= 3.2*10-5) and pathways to sleep medicine (p=4.1*10-5). Survey also showed improvement in students’ interest in pursuing a Sleep Medicine career (p=0.07). There was no difference in knowledge about the importance of sleep for health (p=0.69). All of the students found the session to be informative.

Conclusion

Early exposure to sleep disorders in interactive format was well received by the medical students with significant improvement in scores regarding sleep education, awareness of diagnostic modalities, career pathway and interest in sleep medicine (p=0.07). Integration of exposure to Sleep Medicine within the medical curriculum in an innovative format should be done to instigate interest in this field. Further larger studies are warranted to evaluate the changes in the students’ interest in the subspecialty with an introduction in the early stages of their career.

Support

 

Behavioural and pharmaceutical interventions for the prevention of skin cancers in solid organ transplant recipients: a systematic review of randomised controlled trials

OBJECTIVES

Solid organ transplant recipients are at increased risk of skin cancer, affecting more than 50% of recipients. We aimed to determine the effectiveness of interventions for behavioural change for sun protection or skin cancer prevention in solid organ transplant recipients.

DESIGN

Systematic review.

DATA SOURCES

We searched MEDLINE, Embase, the Cochrane Central Register of Controlled Trials (CENTRAL) and CINAHL from inception to November 2019.

ELIGIBILITY CRITERIA

We included randomised controlled trials that evaluated the effect of behavioural or pharmaceutical interventions on behavioural change or skin cancer prevention in solid organ transplant recipients.

DATA EXTRACTION AND SYNTHESIS

Risks of bias and evidence certainty were assessed using Cochrane and the Grading of Recommendations Assessment Development and Evaluation framework.

RESULTS

Twenty trials (n=2295 participants) were included. It is uncertain whether behavioural interventions improve sun protection behaviour (n=3, n=414, standardised mean difference (SMD) 0.89, 95% CI -0.84 to 2.62, I²=98%) and knowledge (n=4, n=489, SMD 0.50, 95% CI 0.12 to 0.87, I²⁼ 76%) as the quality of evidence is very low. We are uncertain of the effects of mammalian target of rapamaycin inhibitors on the incidence of non-melanocytic skin cancer (n=5, n=1080, relative risk 0.46, 95% CI 0.28 to 0.75, I^{2 =}72%) as the quality of evidence is very low.

CONCLUSIONS

Behavioural and pharmaceutical preventive interventions may improve sun protective behaviour and knowledge, and reduce the incidence of non-melanocytic skin cancer, but the overall quality of the evidence is very low and insufficient to guide decision-making and clinical practice.

PROSPERO REGISTRATION NUMBER

CRD42017063962.

Core Outcome Domains for Trials in Autosomal Dominant Polycystic Kidney Disease: An International Delphi Survey

RATIONALE & OBJECTIVE

Outcomes reported in trials involving patients with autosomal dominant polycystic kidney disease (ADPKD) are heterogeneous and rarely include patient-reported outcomes. We aimed to identify critically important consensus-based core outcome domains to be reported in trials in ADPKD.

STUDY DESIGN

An international 2-round online Delphi survey was conducted in English, French, and Korean languages.

SETTING & PARTICIPANTS

Patients/caregivers and health professionals completed a 9-point Likert scale (7-9 indicating critical importance) and a Best-Worst Scale.

ANALYTICAL APPROACH

The absolute and relative importance of outcomes were assessed. Comments were analyzed thematically.

RESULTS

1,014 participants (603 [60%] patients/caregivers, 411 [40%] health professionals) from 56 countries completed round 1, and 713 (70%) completed round 2. The prioritized outcomes were kidney function (importance score, 8.6), end-stage kidney disease (8.6), death (7.9), blood pressure (7.9), kidney cyst size/growth (7.8), and cerebral aneurysm (7.7). Kidney cyst-related pain was the highest rated patient-reported outcome by both stakeholder groups. Seven themes explained the prioritization of outcomes: protecting life and health, directly encountering life-threatening and debilitating consequences, specificity to ADPKD, optimizing and extending quality of life, hidden suffering, destroying self-confidence, and lost opportunities.

LIMITATIONS

Study design precluded involvement from those without access to internet or limited computer literacy.

CONCLUSIONS

Kidney function, end-stage kidney disease, and death were the most important outcomes to patients, caregivers, and health professionals. Kidney cyst-related pain was the highest rated patient-reported outcome. Consistent reporting of these top prioritized outcomes may strengthen the value of trials in ADPKD for decision making.