Prevalence and associations of limited health literacy in chronic kidney disease: a systematic review

"I just have to take it" - patient safety in acute care: perspectives and experiences of patients with chronic kidney disease

BACKGROUND

Frequent hospitalizations and dependency on technology and providers place individuals with chronic kidney disease (CKD) at high risk for multiple safety events. Threats to their safety may be physical, emotional, or psychological. This study sought to explore patient safety from the perspectives and experiences of patients with CKD in acute care settings, and to describe willingness to report incidents utilizing an existing safety reporting system.

METHODS

This study was conducted using a qualitative interpretive descriptive approach. Face to face interviews were conducted with 30 participants at their bedside during their current hospital admission. The majority of the participants were 50 years or older, of which 75% had a confirmed diagnosis of end stage renal disease with the remainder at stages 3 or 4 of CKD. Eighty percent of the participants were either on hemo- or peritoneal dialysis.

RESULTS

Participants expected to receive safe care, to be taken care of, and to be cared for. Safety threats included: sharing a room with patients who were on precautions; lack of cleanliness; and roommates perceived to be threatening. The concepts of being taken care of and being cared for constituted the safety threats identified within the interpersonal environment. Participants felt taken care of when their physical needs are met and cared for when their psychological and emotional needs are met. There was a general lack of awareness of the presence of a safety reporting system that was to be accessible to patients and families by telephone. There was also an overall unwillingness to report perceived safety incidents, although participants did distinguish between speaking up and reporting.

CONCLUSIONS

A key finding was the unwillingness to report incidents using the safety reporting system. Fear of reprisals was the most significant reporting impediment expressed. Actively inviting patients to speak up may be more effective when combined with a psychologically safe environment in order to encourage the involvement of patients in patient safety. System-wide organizational changes may be necessary to mitigate emotional and physical harm for this client population.

Feasibility and acceptability of telehealth coaching to promote healthy eating in chronic kidney disease: a mixed-methods process evaluation

OBJECTIVE

To evaluate the feasibility and acceptability of a personalised telehealth intervention to support dietary self-management in adults with stage 3-4 chronic kidney disease (CKD).

DESIGN

Mixed-methods process evaluation embedded in a randomised controlled trial.

PARTICIPANTS

People with stage 3-4 CKD (estimated glomerular filtration rate [eGFR]15-60 mL/min/1.73 m²).

SETTING

Participants were recruited from three hospitals in Australia and completed the intervention in ambulatory community settings.

INTERVENTION

The intervention group received one telephone call per fortnight and 2-8 tailored text messages for 3 months, and then 4-12 tailored text messages for 3 months without telephone calls. The control group received usual care for 3 months then non-tailored education-only text messages for 3 months.

MAIN OUTCOME MEASURES

Feasibility (recruitment, non-participation and retention rates, intervention fidelity and participant adherence) and acceptability (questionnaire and semistructured interviews).

STATISTICAL ANALYSES PERFORMED

Descriptive statistics and qualitative content analysis.

RESULTS

Overall, 80/230 (35%) eligible patients who were approached consented to participate (mean±SD age 61.5±12.6 years). Retention was 93% and 98% in the intervention and control groups, respectively, and 96% of all planned intervention calls were completed. All participants in the intervention arm identified the tailored text messages as useful in supporting dietary self-management. In the control group, 27 (69%) reported the non-tailored text messages were useful in supporting change. Intervention group participants reported that the telehealth programme delivery methods were practical and able to be integrated into their lifestyle. Participants viewed the intervention as an acceptable, personalised alternative to face-face clinic consultations, and were satisfied with the frequency of contact.

CONCLUSIONS

This telehealth-delivered dietary coaching programme is an acceptable intervention which appears feasible for supporting dietary self-management in stage 3-4 CKD. A larger-scale randomised controlled trial is needed to evaluate the efficacy of the coaching programme on clinical and patient-reported outcomes.

TRIAL REGISTRATION NUMBER

ACTRN12616001212448; Results.

Patients prioritize waitlist over posttransplant outcomes when evaluating kidney transplant centers

Factors that patients value when choosing a transplant center have not been well studied. In order to guide the improvement of patient-facing materials, we conducted an anonymous electronic survey of patients that assessed the relative importance of patient experience, practical considerations, transplant center reputation, center experience, and waitlist when selecting a transplant center. A total of 409 respondents completed the survey, of whom 68% were kidney transplant recipients and 32% had chronic kidney disease or were on dialysis. Participants had mean age 56 ± 12 years and were predominantly female (61%), white (79%), and had an associate's degree or higher (68%). Participants most often prioritized waitlist when evaluating transplant centers (transplanted 26%, chronic kidney disease 40%), and waitlist was almost twice as likely as outcomes to be ranked most important (30% vs 17%). Education level and transplant status were significantly associated with factors used for center prioritization. Waitlisted respondents most commonly (48%) relied on physicians for information when selecting a center, while a minority cited transplant-specific organizations. In order to improve shared decision-making, materials outlining center-specific waitlist features should be prioritized. Novel patient-oriented metrics for measuring transplant center quality that align with patient priorities must be explored.

Evaluating the European Health Literacy Survey Questionnaire in Patients with Stroke: A Latent Trait Analysis Using Rasch Modeling

BACKGROUND

The effective self-management and treatment of long-term disability after stroke depends greatly on the health literacy of patients. The European Health Literacy Survey Questionnaire (HLS-EU-Q) is a comprehensive and theory-based measure that captures multiple self-perceived competencies of health literacy and covers a diverse range of health contexts. However, there is no psychometric evidence on the HLS-EU-Q in the stroke population.

OBJECTIVE

The aim of this study was to examine the validity of the HLS-EU-Q in patients with stroke using Rasch analysis.

METHODS

We compared the model deviance among the one-domain, three-domain, four-domain, and 12-domain structures using likelihood ratio tests to determine the dimensionality of the HLS-EU-Q. Thereafter, we examined the unidimensionality of each domain, local independence, item fit, response categories, and differential item functioning (DIF) for the best fitting structure.

RESULTS

A total of 311 patients with stroke participated in this study. Rasch analysis revealed that the 12-domain HLS-EU-Q demonstrated the best data-model fit. The original 4-point scales showed disordering, which can be corrected by rescaling them as 3-point scales with the two middle categories collapsed. All 47 items in the rescaled HLS-EU-Q fit the 12-domain Rasch model, demonstrated local independence, assessed the 12 unidimensional domains respectively, and had invariant difficulties between different age or education groups of the patients with stroke.

CONCLUSION

We recommend using the 12-domain scores of the rescaled HLS-EU-Q to comprehensively and accurately capture the competencies to access, understand, appraise, and apply health information within the three health contexts of healthcare, disease prevention, and health promotion for patients with stroke.

Educational Support Around Dialysis Modality Decision Making in Patients With Chronic Kidney Disease: Qualitative Study

BACKGROUND

Patients with chronic kidney disease (CKD) are asked to choose a renal replacement therapy or conservative management. Education and knowledge transfer play key roles in this decision-making process, yet they remain a partially met need.

OBJECTIVE

We sought to understand the dialysis modality decision-making process through exploration of the predialysis patient experience to better inform the educational process.

DESIGN

Qualitative descriptive study.

SETTING

Kidney Care Centre of London Health Sciences Centre in London, Ontario, Canada.

PATIENTS

Twelve patients with CKD, with 4 patients on in-center hemodialysis, home hemodialysis, and peritoneal dialysis, respectively.

MEASUREMENTS

Not applicable.

METHODS

We conducted semistructured interviews with each participant, along with any family members who were present. Interviews were transcribed verbatim. Conventional content analysis was used to analyze the transcripts for common themes. Representative quotes were decided via team consensus. A patient collaborator was part of the research team.

RESULTS

Three themes influenced dialysis modality decision making: (i) Patient Factors: individualization, autonomy, and emotions; (ii) Educational Factors: tailored education, time and preparation, and available resources; and (iii) Support Systems: partnership with health care team, and family and friends.

LIMITATIONS

Sample not representative of wider CKD population. Limited number of eligible patients. Poor recall may affect findings.

CONCLUSIONS

Modality decision making is a complex process, influenced by the patient's health literacy, willingness to accept information, predialysis lifestyle, support systems, and values. Patient education requires the flexibility to individualize the delivery of a standardized CKD curriculum in partnership with a patient-health care team, to fulfill the goal of informed, shared decision making.

Association between health literacy and self-care behaviors among patients with chronic kidney disease

BACKGROUND

We explored the association between health literacy and self-care behaviors among low-income patients with chronic kidney disease (CKD).

METHODS

We used baseline data from the Kidney Awareness Registry and Education trial (n = 137 patients with CKD) and multivariable logistic regressions to cross-sectionally examine the association between health literacy, defined by a validated questionnaire, and healthy behaviors.

RESULTS

Study participants had a mean age of 55 years, were racially diverse (6% White, 36% Hispanic, 43% Black, 15% Asian) and 26% had low health literacy. Over one-third (38%) had hypertension, 51% had diabetes, and 67% had CKD stage 3 or 4. Compared to individuals with adequate health literacy, those with low health literacy had non-statistically significant higher tobacco use (adjusted odds ratio [aOR] = 2.33; 95% CI 0.90-6.06) and lower consumption of sugary beverages (aOR = 0.50; 0.20-1.23) and statistically significant decreased fast food intake (aOR = 0.38; 0.16-0.93). Health literacy was not associated with differences in medication adherence (0.84; 0.38-1.89) or physical activity (aOR = 2.39; 0.54-10.53).

CONCLUSIONS

Health literacy was not uniformly associated with all self-care behaviors important for CKD management. A more nuanced understanding of the association of health literacy and self-care may be necessary to promote participation in behaviors known to slow CKD progression.

Should We Recommend Renal Diet-Related Apps to Our Patients? An Evaluation of the Quality and Health Literacy Demand of Renal Diet-Related Mobile Applications

OBJECTIVE

Mobile phone applications (apps) are increasingly being used by patients with chronic kidney disease (CKD). We sought to describe the main purpose of commonly available renal diet apps and to quantify the accuracy of information, technical quality, and health literacy demand of renal diet apps.

DESIGN

The design was content analysis. All eligible renal diet apps in the Australian Apple App Store, Google Play, Windows Phone, and Blackberry App World were evaluated.

SUBJECTS

Eligible apps were in English and were related to kidney disease in humans (of any type or stage). Exclusion criteria included apps which were prohibited because of password protection.

MAIN OUTCOME MEASURE

Renal diet information in the apps was compared with evidence-based guidelines for the management of kidney disease to quantify information accuracy. App information was evaluated using the Silberg Scale. Technical quality and health literacy demand were evaluated using the Mobile Application Rating Scale.

RESULTS

A total of 21 apps were eligible for evaluation. The main purpose of these apps was to provide food and nutrition information (57.1%) or for educative purposes for CKD patients (38.1%). Only 47.6% (10/21) of apps contained accurate evidence-based information. Overall, app technical quality was considered acceptable (mean Mobile Application Rating Scale score 3.19 ± 0.35 out of 5), with 80.9% of apps scoring acceptable or greater for app technical quality. Scores for health literacy demand also indicated that most apps (15/21, 71.4%) were acceptable.

CONCLUSIONS

A range of apps currently exist that may provide individuals with CKD with useful food and nutrition information or increase their knowledge of the renal diet. These apps are also mainly of acceptable technical quality and health literacy demand. However, caution is required when using renal diet apps because more than half of the apps evaluated were not accurate and evidence based.

Assessing the ability of the Drug-Associated Risk Tool (DART) questionnaire to stratify hospitalised older patients according to their risk of drug-related problems: a cross-sectional validation study

OBJECTIVES

The Drug-Associated Risk Tool (DART) has been developed as a self-administered questionnaire for patients with the aim of stratifying patients according to their risk of drug-related problems (DRPs). We aimed to validate the ability of the questionnaire to distinguish between hospitalised patients showing lower and higher numbers of DRPs.

DESIGN

Cross-sectional study assessing the questionnaire's concurrent criterion validity.

SETTING

Five geriatric and the associated physical and neurological rehabilitation wards of a Swiss regional secondary care hospital with 617 beds.

PARTICIPANTS

We recruited 110 patients from a total of 437 admissions. Exclusion criteria were insufficient knowledge in spoken or written German, medical conditions preventing meaningful conversations and already receiving pharmacy services.

INTERVENTIONS

Comprehensive pharmacist-led clinical medication reviews were performed, including patient interviews, to identify potential and manifest DRPs. A cluster analysis was conducted to assess the discriminatory potential of the DART to group patients according to number (low and high) of identified DRPs. A subsequent discriminatory function analysis was performed to reduce the number of items. We determined which DART items may be used to trigger what type of medication review.

RESULTS

Recruited patients had a median age of 79 years and were prescribed a median of 11 drugs. Patients with a median DART score of 10 and a median of 3 DRPs represented one cluster, whereas patients with a median DART score of 15 and a median of 8 DRPs represented another cluster. Discriminatory function analysis reduced the questionnaire to five items with a moderate to strong correlation with the number of DRPs per patient (Spearman's rank correlation ρ=0.44). Additional items were associated with patients benefiting from interviews.

CONCLUSIONS

As a self-administered questionnaire for patients, the DART may be used to stratify hospitalised non-acute older patients in groups of having low and high likelihood of DRPs. The analyses showed that a short form of the DART can be used instead of the full tool to identify older inpatients at risk for DRPs. Additional eight items from the DART may be used to initiate additional clinical pharmacy services. The linkage between certain DART questions and type of medication review enables pharmacist resource allocation.

Contribution of Patient Interviews as Part of a Comprehensive Approach to the Identification of Drug-Related Problems on Geriatric Wards

BACKGROUND

Inappropriate prescribing is linked to increased risks for adverse drug reactions and hospitalisation. Combining explicit and implicit criteria of inappropriate prescribing with the information obtained in patient interviews seems beneficial with regard to the identification of drug-related problems (DRPs) in hospitalised patients.

OBJECTIVE

We aimed to investigate the inclusion of pharmacist interviews as part of medication reviews (including the use of explicit and implicit criteria of inappropriate prescribing) to identify DRPs in older inpatients.

METHODS

Clinical medication reviews were performed on geriatric and associated physical and neurological rehabilitation wards in a regional secondary care hospital. Data from electronic medical records, laboratory data, and current treatment regimens were complemented with a novel structured patient interview performed by a clinical pharmacist. The structured interview questioned patients on administration issues, prescribed medication, self-medication, and allergies. The reviews included the use of current treatment guidelines, the Medication Appropriateness Index, the Screening Tool of Older People's Prescriptions (STOPP, v2), and the Screening Tool to Alert to Right Treatment (START, v2). The potential relevance of the DRPs was estimated using the German version of the CLEO tool.

RESULTS

In 110 patients, 595 DRPs were identified, averaging 5.4 per patient (range 0-17). The structured interviews identified 249 DRPs (41.8%), of which 227 were not identified by any other source of information. The majority of DRPs (213/249, i.e. 85.5%) identified by patient interview were estimated to be of minor clinical relevance (i.e. limited adherence, knowledge, quality of life, or satisfaction).

CONCLUSION

We demonstrated that structured patient interviews identified additional DRPs that other sources did not identify. Embedded within a comprehensive approach, the structured patient interviews were needed as data resource for over one-third of all DRPs.

Drug-Associated Risk Tool: development and validation of a self-assessment questionnaire to screen for hospitalised patients at risk for drug-related problems

INTRODUCTION

Identifying patients with a high risk for drug-related problems (DRPs) might optimise the allocation of targeted pharmaceutical care during the hospital stay and on discharge.

OBJECTIVE

To develop a self-assessment screening tool to identify patients at risk for DRPs and validate the tool regarding feasibility, acceptability and the reliability of the patients' answers.

DESIGN

Prospective validation study.

SETTING

Two mid-sized hospitals (300-400 beds).

PARTICIPANTS

195 patients, exclusion criteria: under 18 years old, patients with a health status not allowing a meaningful communication (eg, delirium, acute psychosis, advanced dementia, aphasia, clouded consciousness state), palliative or terminally ill patients.

METHODS

Twenty-seven risk factors for the development of DRPs, identified in a previous study, provided the basis of the self-assessment questionnaire, the Drug-Associated Risk Tool (DART). Consenting patients filled in DART, and we compared their answers with objective patient data from medical records and laboratory data.

RESULTS

One hundred and sixty-four patients filled in DART V.1.0 in an average time of 7 min. After a first validation, we identified statements with a low sensitivity and revised the wording of the questions related to heart insufficiency, renal impairment or liver impairment. The revised DART (V.2.0) was validated in 31 patients presenting heart insufficiency, renal impairment or liver impairment as comorbidity and reached an average specificity of 88% (range 27-100) and an average sensitivity of 67% (range 21-100).

CONCLUSIONS

DART showed a satisfying feasibility and reliability. The specificity of the statements was mostly high. The sensitivity varied and was higher in statements concerning diseases that require regular disease control and attention to self-care and drug management. Asking patients about their conditions, medications and related problems can facilitate getting a first, broad picture of the risk for DRPs and possible pharmaceutical needs.

Multimorbidity in people with chronic kidney disease: implications for outcomes and treatment

PURPOSE OF REVIEW

With ageing populations, the prevalence of multimorbidity is increasing. This review discusses recent developments in the understanding of multimorbidity in the context of chronic kidney disease (CKD). It explores the associated treatment burden and the implications for key outcomes and patient care.

RECENT FINDINGS

Comorbidity and polypharmacy are common in CKD, even at early stages, and are associated with significant treatment burden. Both 'concordant' and 'discordant' comorbidities have a negative impact on mortality, cardiovascular disease, hospitalisation and length of stay. In addition, quality of life is influenced by many factors beyond CKD, including comorbidities and certain medications. Several factors may reduce treatment burden for people with CKD, though research on this is at an early stage. Although patient activation is desirable to support self-management amongst people with multimorbidity, there are significant challenges that impact patient capacity amongst elderly populations with complex needs.

SUMMARY

Comorbidities are common in CKD and have important implications for patients, clinicians and health services.

A Linguistic Analysis of Health Literacy Demands of Chronic Kidney Disease Patient Education Materials

Background:

Instruments to assess the quality and comprehensibility of printed patient education materials may lack proper consideration of how readers derive meaning from text. The Evaluative Linguistic Framework (ELF) considers how factors that influence readers' expectations about health care texts also affect their ability to understand them. The ELF has demonstrated value in improving the quality of patient materials about medication, consent, and self-reported questionnaires, but has not yet been used to evaluate a corpus of patient education materials about chronic disease self-management.

Objective:

This study sought to apply the ELF to examine specific elements of printed self-management patient education materials for chronic kidney disease (CKD) not captured by other tools.

Methods:

From a previously published systematic review, we identified 14 patient education materials (eight self-management, six diet and nutrition) for people with CKD. We used the ELF to identify the different ways the text could be structured, its intended purpose, the relationship established between reader and writer, presence of signposting, its complexity and technicality of language, and factual content.

Key Results:

Our analysis identified nine possible structural units, of which “introducing the problem” and “instructing the reader to self-manage” were common to all materials. However, there was no consistency or common sequence to these units of text. The intended readership and aims of the author(s) were not always clear; many materials made assumptions about what the reader knew, the language was often complex and dense, and the meta-discourse was sometimes distracting.

Conclusions:

Our analysis suggests CKD document developers can benefit from a theoretically grounded linguistic tool that focuses on the intended audience and their specific needs. The ELF identified structural units of text, aligned with rhetorical elements that can be uniformly applied for developing self-management education materials for CKD, and provided checks for language complexity. Further work can determine its usefulness for other (e.g., electronic) formats and other chronic diseases. [HLRP: Health Literacy Research and Practice. 2018;2(1):e1–e14.]

Plain Language Summary:

Helping patients make meaning from information about their condition is a key goal of health care organizations. We analyzed chronic kidney disease patient education materials on self-management using the Evaluative Linguistic Framework. The purpose and intended audience were frequently unclear. We identified nine structural units of text that may assist information providers to plan and structure content.

End-stage renal disease treatment options education: What matters most to patients and families

Treatment modality education can offer many important benefits to patients and their families. Evidence suggests such education can increase use of home dialysis, reduce catheter use, decrease 90-day mortality, and increase transplantation. While these benefits are encouraging, not all patients are offered options education and when they are, it may not be presented in a way that is immediately applicable to them and their lives. Furthermore, little is known regarding specific characteristics (e.g. format such as group or individual or in-person or online, duration, teaching methods, location, content) of educational programs that are most successful. No single approach has emerged as a best practice. In the absence of such evidence, adult learning principles, such as involving patients and families in the development programs and materials, can serve as a guide for educational development. Adult learning principles can enhance options education, evolving them from information delivery to a person-centered, values-based endeavor that helps match treatment to values and lifestyle.

Awareness, self-management behaviors, health literacy and kidney function relationships in specialty practice

AIM

To determine the relationship between chronic kidney disease (CKD) awareness (CKD-A), self-management behaviors (CKD-SMB) knowledge, performance of CKD-SMBs, health literacy (HL) and kidney function.

METHODS

Participants were eligible patients attending an outpatient nephrology clinic. Participants were administered: Newest Vital Sign to measure HL, CKD self-management knowledge tool (CKD-SMKT) to assess knowledge, past performance of CKD-SMB, CKD-A. Estimated GFR (eGFR) was determined using the MDRD-4 equation. Duration of clinic participation and CKD cause were extracted from medical charts.

RESULTS

One-hundred-fifty patients participated in the study. eGFRs ranged from 17-152 mL/min per 1.73 m². Majority (83%) of respondents had stage 3 or 4 CKD, low HL (63%), and were CKD aware (88%). Approximately 40% (10/25) of patients in stages 1 and 2 and 6.4% (8/125) in stages 3 and 4 were unaware of their CKD. CKD-A differed with stage (P < 0.001) but not by HL level, duration of clinic participation, or CKD cause. Majority of respondents (≥ 90%) correctly answered one or more CKD-SMKT items. Knowledge of one behavior, “controlling blood pressure” differed significantly by CKD-A. CKD-A was associated with past performance of two CKD-SMBs, “controlling blood pressure” (P = 0.02), and “keeping healthy body weight” (P = 0.01). Adjusted multivariate analyses between CKD-A and: (1) HL; and (2) CKD-SMB knowledge were non-significant. However, there was a significant relationship between CKD-A and kidney function after controlling for demographics, HL, and CKD-SMB (P < 0.05).

CONCLUSION

CKD-A is not associated with HL, or better CKD-SMBs. CKD-A is significantly associated with kidney function and substantially lower eGFR, suggesting the need for focused patient education in CKD stages 1.

Disparities in Health Literacy and Healthcare Utilization among Adolescents and Young Adults with Chronic or End-stage Kidney Disease

PURPOSE

Low health literacy adversely affects health outcomes in adults with chronic kidney disease. The current study examined associations between limited/inadequate health literacy and health services utilization among adolescents and young adults (AYA) with chronic or end-stage kidney disease (CKD or ESKD).

DESIGN AND METHODS

This was a retrospective cohort study that enrolled patients from both the pediatric- and adult-focused nephrology clinics of a major university hospital. Demographic information, patients' health literacy and numeracy skills (Newest Vital Sign), and health services utilization (emergency department visits, preventable hospitalizations, total hospitalizations, and length of stay in the hospital) were evaluated. A negative binomial regression model for counts tested the association between AYA patients' literacy/numeracy skills and health services utilization.

RESULTS

The study enrolled 142 participants, 66 (46.5%) patients from adult nephrology and 76 (53.5%) from pediatric nephrology clinics, with a mean age of 20.8±5.60years (range 12-31). Half of the sample (n=72, 51%) had limited health literacy skills. Health literacy/numeracy level was not significantly associated with total hospitalizations, preventable hospitalizations, emergency department (ED) visits, or length of hospital stay. However, public insurance/self-pay, minority race, and kidney transplant/dialysis diagnoses were associated with more preventable hospitalizations.

CONCLUSIONS

Among AYA with CKD/ESKD, there were no differences between the low and adequate health literacy groups on health care utilization outcomes when modeling clinical outcomes (total hospitalizations, preventable hospitalizations, ED visits, and length of hospital stay) after adjusting for demographics and disease type. This suggests that other factors warrant consideration in healthcare utilization rates.

Clinician views of patient decisional conflict when deciding between dialysis and conservative management: Qualitative findings from the PAlliative Care in chronic Kidney diSease (PACKS) study

BACKGROUND

Only a paucity of studies have addressed clinician perspectives on patient decisional conflict, in making complex decisions between dialysis and conservative management (renal supportive and palliative care).

AIM

To explore clinician views on decisional conflict in patients with end-stage kidney disease.

DESIGN

Interpretive, qualitative study.

SETTING AND PARTICIPANTS

As part of the wider National Institute for Health Research, PAlliative Care in chronic Kidney diSease study, semi-structured interviews were conducted with clinicians (nephrologists n = 12; 7 female and clinical nurse specialists n = 15; 15 female) across 10 renal centres in the United Kingdom. Interviews took place between April 2015 and October 2016 and a thematic analysis of the interview data was undertaken.

RESULTS

Three major themes with associated subthemes were identified. The first, 'Frequent changing of mind regarding treatment options', revealed how patients frequently altered their treatment decisions, some refusing to make a decision until deterioration occurred. The second theme, 'Obligatory beneficence', included clinicians helping patients to make informed decisions where outcomes were uncertain. In weighing up risks and benefits, and the impact on patients, clinicians sometimes withheld information they thought might cause concern. Finally, 'Intricacy of the decision' uncovered clinicians' views on the momentous and brave decision to be made. They also acknowledged the risks associated with this complex decision in giving prognostic information which might be inaccurate.

LIMITATIONS

Relies on interpretative description which uncovers constructed truths and does not include interviews with patients.

CONCLUSION

Findings identify decisional conflict in patient decision-making and a tension between the prerequisite for shared decision-making and current clinical practice. Clinicians also face conflict when discussing treatment options due to uncertainty in equipoise between treatments and how much information should be shared. The findings are likely to resonate across countries outside the United Kingdom.

An integrative review of the methodology and findings regarding dietary adherence in end stage kidney disease

BACKGROUND

Dietary modification is an important component of the management of end stage kidney disease (ESKD). The diet for ESKD involves modifying energy and protein intake, and altering sodium, phosphate, potassium and fluid intake. There have been no comprehensive reviews to date on this topic. The aims of this integrative review were to (i) describe the methods used to measure dietary adherence (ii) determine the rate of dietary adherence and (iii) describe factors associated with dietary adherence in ESKD.

METHODS

The Web of Science and Scopus databases were searched using the search terms 'adherence' and 'end stage kidney disease'. Of the 787 potentially eligible papers retrieved, 60 papers of 24,743 patients were included in this review. Of these papers, 44 reported the rate of dietary adherence and 44 papers described factors associated with adherence.

RESULTS

Most of the evidence regarding dietary adherence is derived from studies of hemodialysis patients (72% of patients). The most common method of measuring dietary adherence in ESKD was subjective techniques (e.g. food diaries or adherence questionnaires). This was followed by indirect methods (e.g. serum potassium, phosphate or interdialytic weight gain). The weighted mean adherence rate to ESKD dietary recommendations was 31.5% and 68.5% for fluid recommendations. Adherence to protein, sodium, phosphate, and potassium recommendations were highly variable due to differences in measurement methods used, and were often derived from a limited evidence base. Socioeconomic status, age, social support and self-efficacy were associated with dietary adherence. However, factors such as taste, the impact of the diet on social eating occasions; and dietetic staffing also appear to play a role in dietary adherence.

CONCLUSION

Dietary adherence rates in people with ESKD are suboptimal. Further research is required on dietary adherence in patients with ESKD from different social, educational, economic and ethnic groups. This research may identify other factors which may impact upon adherence, and could be used to inform the design of future strategies to improve dietary adherence. Future research that reports not just the rate of adherence to individual components of the nutrient prescription but also the overall quality of the diet would be useful.

Limited health literacy in advanced kidney disease

Limited health literacy may reduce the ability of patients with advanced kidney disease to understand their disease and treatment and take part in shared decision making. In dialysis and transplant patients, limited health literacy has been associated with low socioeconomic status, comorbidity, and mortality. Here, we investigated the prevalence and associations of limited health literacy using data from the United Kingdom-wide Access to Transplantation and Transplant Outcome Measures (ATTOM) program. Incident dialysis, incident transplant, and transplant wait-listed patients ages 18 to 75 were recruited from 2011 to 2013 and data were collected from patient questionnaires and case notes. A score >2 in the Single-Item Literacy Screener was used to define limited health literacy. Univariate and multivariate analyses were performed to identify patient factors associated with limited health literacy. We studied 6842 patients, 2621 were incident dialysis, 1959 were wait-listed, and 2262 were incident transplant. Limited health literacy prevalence was 20%, 15%, and 12% in each group, respectively. Limited health literacy was independently associated with low socioeconomic status, poor English fluency, and comorbidity. However, transplant wait-listing, preemptive transplantation, and live-donor transplantation were associated with increasing health literacy.

Social relevance assessments for virtual worlds

Purpose

The purpose of this paper is to introduce the concept of social relevance assessments, which are judgments made by individuals when they seek out information within virtual social worlds such as online support groups (OSGs).

Design/methodology/approach

Constructivist grounded theory was employed to examine the phenomenon of information exchange in OSGs for chronic kidney disease. In-depth interviews were conducted with 12 participants, and their posts in three OSGs were also harvested. Data were analyzed using inductive content analysis and the constant comparative method. Theoretical sampling was conducted until saturation was reached. Member checking, peer debriefing, and triangulation were used to verify results.

Findings

There are two levels of relevance assessment that occur when people seek out information in OSGs. First, participants evaluate the OSG to determine whether or not the group is an appropriate place for information exchange about kidney disease. Second, participants evaluate individual users on the OSG to see if they are appropriate people with whom to exchange information. This often takes the form of similarity assessment, whereby people try to determine whether or not they are similar to specific individuals on the forums. They use a variety of heuristics to assess similarity as part of this process.

Originality/value

This paper extends the author’s understanding of relevance in information science in two fundamental ways. Within the context of social information exchange, relevance is socially constructed and is based on social characteristics, such as age, shared beliefs, and experience. Moreover, relevance is assessed both when participants seek out information and when they disclose information, suggesting that the conception of relevance as a process that occurs primarily during information seeking is limited.

A Systematic Review of the Prevalence and Associations of Limited Health Literacy in CKD

BACKGROUND AND OBJECTIVES

The self-management and decision-making skills required to manage CKD successfully may be diminished in those with low health literacy. A 2012 review identified five papers reporting the prevalence of limited health literacy in CKD, largely from United States dialysis populations. The literature has expanded considerably since.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

We used systematic review, pooled prevalence analysis, metaregression, and exploration of heterogeneity in studies of patients with CKD (all stages).

RESULTS

From 433 studies, 15 new studies met the inclusion criteria and were analyzed together with five studies from the 2012 review. These included 13 cross-sectional surveys, five cohort studies (using baseline data), and two using baseline clinical trial data. Most (19 of 20) were from the United States. In total, 12,324 patients were studied (3529 nondialysis CKD, 5289 dialysis, 2560 transplant, and 946 with unspecified CKD; median =198.5; IQR, 128.5-260 per study). Median prevalence of limited health literacy within studies was 23% (IQR, 16%-33%), and pooled prevalence was 25% (95% confidence interval, 20% to 30%) with significant between-study heterogeneity (I2=97%). Pooled prevalence of limited health literacy was 25% (95% confidence interval, 16% to 33%; I2=97%) among patients with CKD not on dialysis, 27% (95% confidence interval, 19% to 35%; I2=96%) among patients on dialysis, and 14% (95% confidence interval, 7% to 21%; I2=97%) among patients with transplants. A higher proportion of nonwhite participants was associated with increased limited health literacy prevalence (P=0.04), but participant age was not (P=0.40). Within studies, nonwhite ethnicity and low socioeconomic status were consistently and independently associated with limited health literacy. Studies were of low or moderate quality. Within-study participant selection criteria had potential to introduce bias.

CONCLUSIONS

Limited health literacy is common in CKD, especially among individuals with low socioeconomic status and nonwhite ethnicity. This has implications for the design of self-management and decision-making initiatives to promote equity of care and improve quality. Lower prevalence among patients with transplants may reflect selection of patients with higher health literacy for transplantation either because of less comorbidity in this group or as a direct effect of health literacy on access to transplantation.

Hemodialysis Access Choice: Impact of Health Literacy

BACKGROUND

Hemodialysis patients need to make decisions about vascular access and diet that they may not fully understand. In this study, we hypothesized that patients with low health literacy are likely to choose a central venous catheter (CVC) and have higher serum potassium (K), serum phosphate (P), and inter-dialysis weight gains (IDWG).

OBJECTIVE

Primarily, the study sought to describe the health literacy of patients treated with hemodialysis in a Canadian tertiary care center. The secondary objective was to describe the association between health literacy and permanent vascular access choice, hyperkalemia, hyperphosphatemia, and IDWG.

METHODS

Adult patients receiving hemodialysis for more than 6 months were included. Health literacy was assessed with the Newest Vital Sign (NVS) test. Vascular access type and reasons for CVC use were determined. Serum K, P, and IDWG were collected retrospectively for 6 months. Student's t test and logistic regression were used to determine the association between health literacy (NVS score < 4 versus ≥ 4) and CVC choice, hyperkalemia, hyperphosphatemia, and high IDWG.

KEY RESULTS

Fifty-six patients were involved. The average NVS score was 2.9. Overall, 66% of the patients had a CVC; one-third had chosen this access themselves. Poor control of K, P, and IDWG was experienced by 27%, 55%, and 36% of patients, respectively. The average NVS score was lower for patients choosing a CVC (p = .001), but not different for those with higher K, P, or IDWG. None of the patients who chose a CVC had adequate health literacy (NVS ≥ 4).

CONCLUSIONS

Patients with low health literacy, who are eligible for both surgically created vascular access (fistula or graft) and CVC, are more likely to refuse fistula/graft creation compared to patients with adequate health literacy. Different educational strategies for such patients may help in appropriate decision-making. [Health Literacy Research and Practice. 2017;1(3):e136-e144.].

PLAIN LANGUAGE SUMMARY

This study suggests that more than one-half of patients who receive hemodialysis may not understand all the information provided by their health care team. Despite a higher risk of complications with a central venous catheter, patients with lower health literacy prefer the catheter over fistula as their blood access for hemodialysis. We need to explore patient education to ensure that information is easy to understand.

Eating Like a Rainbow: The Development of a Visual Aid for Nutritional Treatment of CKD Patients. A South African Project

Providing nutritional education for chronic kidney disease (CKD) patients in South Africa is complicated by several conditions: the population is composed of diverse ethnic groups, each with its own culture and food preferences; eleven languages are spoken and illiteracy is common in the lower socio-economic groups. Food preparation and storage are affected by the lack of electricity and refrigeration, and this contributes to a monotonous diet. In traditional African culture, two meals per day are often shared "from the pot", making portion control difficult. There is both under- and over-nutrition; late referral of CKD is common. Good quality protein intake is often insufficient and there are several misconceptions about protein sources. There is a low intake of vegetables and fruit, while daily sodium intake is high, averaging 10 g/day, mostly from discretionary sources. On this background, we would like to describe the development of a simplified, visual approach to the "renal diet", principally addressed to illiterate/non-English speaking CKD patients in Southern Africa, using illustrations to replace writing. This tool "Five steps to improve renal diet compliance", also called "Eating like a Rainbow", was developed to try to increase patients' understanding, and has so far only been informally validated by feedback from users. The interest of this study is based on underlining the feasibility of dietary education even in difficult populations, focusing attention on this fundamental issue of CKD care in particular in countries with limited access to chronic dialysis.

Health Literacy and Awareness of Atrial Fibrillation

Background

Atrial fibrillation (AF) is the most common clinically significant arrhythmia in adults and a major risk factor for ischemic stroke. Nonetheless, previous research suggests that many individuals diagnosed with AF lack awareness about their diagnosis and inadequate health literacy may be an important contributing factor to this finding.

Methods and Results

We examined the association between health literacy and awareness of an AF diagnosis in a large, ethnically diverse cohort of Kaiser Permanente Northern and Southern California adults diagnosed with AF between January 1, 2006 and June 30, 2009. Using self‐reported questionnaire data completed between May 1, 2010 and September 30, 2010, awareness of an AF diagnosis was evaluated using the question “Have you ever been told by a doctor or other health professional that you have a heart rhythm problem called atrial fibrillation or atrial flutter?” and health literacy was assessed using a validated 3‐item instrument examining problems because of reading, understanding, and filling out medical forms. Of the 12 517 patients diagnosed with AF, 14.5% were not aware of their AF diagnosis and 20.4% had inadequate health literacy. Patients with inadequate health literacy were less likely to be aware of their AF diagnosis compared with patients with adequate health literacy (prevalence ratio=0.96; 95% CI [0.94, 0.98]), adjusting for sociodemographics, health behaviors, and clinical characteristics.

Conclusions

Lower health literacy is independently associated with less awareness of AF diagnosis. Strategies designed to increase patient awareness of AF and its complications are warranted among individuals with limited health literacy.

Chronic Kidney Disease

The definition and classification of chronic kidney disease (CKD) have evolved over time, but current international guidelines define this condition as decreased kidney function shown by glomerular filtration rate (GFR) of less than 60 mL/min per 1·73 m², or markers of kidney damage, or both, of at least 3 months duration, regardless of the underlying cause. Diabetes and hypertension are the main causes of CKD in all high-income and middle-income countries, and also in many low-income countries. Incidence, prevalence, and progression of CKD also vary within countries by ethnicity and social determinants of health, possibly through epigenetic influence. Many people are asymptomatic or have non-specific symptoms such as lethargy, itch, or loss of appetite. Diagnosis is commonly made after chance findings from screening tests (urinary dipstick or blood tests), or when symptoms become severe. The best available indicator of overall kidney function is GFR, which is measured either via exogenous markers (eg, DTPA, iohexol), or estimated using equations. Presence of proteinuria is associated with increased risk of progression of CKD and death. Kidney biopsy samples can show definitive evidence of CKD, through common changes such as glomerular sclerosis, tubular atrophy, and interstitial fibrosis. Complications include anaemia due to reduced production of erythropoietin by the kidney; reduced red blood cell survival and iron deficiency; and mineral bone disease caused by disturbed vitamin D, calcium, and phosphate metabolism. People with CKD are five to ten times more likely to die prematurely than they are to progress to end stage kidney disease. This increased risk of death rises exponentially as kidney function worsens and is largely attributable to death from cardiovascular disease, although cancer incidence and mortality are also increased. Health-related quality of life is substantially lower for people with CKD than for the general population, and falls as GFR declines. Interventions targeting specific symptoms, or aimed at supporting educational or lifestyle considerations, make a positive difference to people living with CKD. Inequity in access to services for this disease disproportionally affects disadvantaged populations, and health service provision to incentivise early intervention over provision of care only for advanced CKD is still evolving in many countries.

Health Literacy Demand of Printed Lifestyle Patient Information Materials Aimed at People With Chronic Kidney Disease: Are Materials Easy to Understand and Act On and Do They Use Meaningful Visual Aids?

People with chronic kidney disease (CKD) need usable information on how to live well and slow disease progression. This information is complex, difficult to communicate, and changes during the course of the disease. We examined lifestyle-related printed CKD patient education materials focusing on actionability and visual aids. From a previous systematic review assessing readability of CKD patient information, we identified materials targeting nutrition, exercise, and self-management. We applied the Suitability Assessment of Materials (SAM) and Patient Education Materials Assessment Tool (PEMAT) to evaluate how easy materials were to understand (understandability) and act on (actionability). We created the 5C image checklist and systematically examined all visual aids for clarity, contribution, contradiction, and caption. Of the 26 materials included, one fifth (n = 5, 19%) were rated "not suitable" on SAM and fewer than half (n = 11, 42%) were rated "superior." PEMAT mean subdomain scores were suboptimal for actionability (52) and visuals (37). Overall, more than half of all 223 graphics (n = 127, 57%) contributed no meaning to the text. Images in three documents (12%) directly contradicted messaging in the text. CKD lifestyle information materials require focused improvements in both actionability of advice given and use of visual aids to support people with CKD to self-manage their condition. The fifth C is culture and is best evaluated by user-testing.

Patient preferences, knowledge and beliefs about kidney allocation: qualitative findings from the UK-wide ATTOM programme

OBJECTIVE

To explore how patients who are wait-listed for or who have received a kidney transplant understand the current UK kidney allocation system, and their views on ways to allocate kidneys in the future.

DESIGN

Qualitative study using semistructured interviews and thematic analysis based on a pragmatic approach.

PARTICIPANTS

10 deceased-donor kidney transplant recipients, 10 live-donor kidney transplant recipients, 12 participants currently wait-listed for a kidney transplant and 4 participants whose kidney transplant failed.

SETTING

Semistructured telephone interviews conducted with participants in their own homes across the UK.

RESULTS

Three main themes were identified: uncertainty of knowledge of the allocation scheme; evaluation of the system and participant suggestions for future allocation schemes. Most participants identified human leucocyte anitgen matching as a factor in determining kidney allocation, but were often uncertain of the accuracy of their knowledge. In the absence of information that would allow a full assessment, the majority of participants consider that the current system is effective. A minority of participants were concerned about the perceived lack of transparency of the general decision-making processes within the scheme. Most participants felt that people who are younger and those better matched to the donor kidney should be prioritised for kidney allocation, but in contrast to the current scheme, less priority was considered appropriate for longer waiting patients. Some non-medical themes were also discussed, such as whether parents of dependent children should be prioritised for allocation, and whether patients with substance abuse problems be deprioritised.

CONCLUSIONS

Our participants held differing views about the most important factors for kidney allocation, some of which were in contrast to the current scheme. Patient participation in reviewing future allocation policies will provide insight as to what is considered acceptable to patients and inform healthcare staff of the kinds of information patients would find most useful.

Targeting Access to Kidney Care Via Telehealth: The VA Experience

The Veterans Affairs (VA) is the largest integrated health care system in the United States and is responsible for the care of a population with a disproportionately high rate of CKD. As such, ensuring access to kidney health services is a VA imperative. One facet of the VA's strategy to reduce CKD is to leverage the use of teletechnology to expand the VA's outreach to Veterans with kidney disease. A wide array of teletechnology services have been deployed to both pull in Veterans and push out kidney health services to Veterans in their preferred health care venue. Teletechnology, thus, expands Veteran choice, facilitates their access to care, and furthers the goal of delivering patient-centered kidney specialty care. The VA has demonstrated the feasibility of virtual delivery of kidney specialty care services and education via synchronous and asynchronous approaches. The challenges ahead include determining the relative health care value of kidney telehealth services, identifying Veterans most likely to benefit from specific technologies and optimizing the adoption of effective kidney telehealth services by both providers and patients alike to ensure optimal and timely kidney health care delivery.

An Evidence-Based Approach to Conducting Systematic Reviews on CKD

With the growing need to integrate best evidence to inform clinical care, systematic reviews have continued to flourish. Although this type of review is integral to the synthesis of evidence-based information, systematic reviews are often conducted omitting well-established processes that ensure the validity and replicability of the study; elements of which are integral based on standards developed by the Cochrane Collaboration and the National Academy of Medicine. This review article will share best practices associated with conducting systematic reviews on the topic of CKD using an 8-step process and an evidence-based approach to retrieving and abstracting data. Optimal methods for conducting systematic review searching will be described, including development of appropriate search strategies and utilization of varied resources including databases, grey literature, primary journals, and handsearching. Processes and tools to improve research teams' coordination and efficiency, including integration of systematic review protocols and sophisticated software to streamline data management, will be investigated. In addition to recommended strategies for surveying and synthesizing CKD literature, techniques for maneuvering the complex field of Nephrology will also be explored.

A question prompt sheet for adult patients with chronic kidney disease

Background

Patients with chronic kidney disease (CKD) commonly have unmet information needs. Greater patient participation in healthcare discussions can address these needs and improve health outcomes. We developed a patient-centered question prompt sheet (QPS) to engage CKD patients in healthcare conversations.

Methods

We conducted a two phase, mixed-methods, cross-sectional study involving semi-structured telephone interviews. Patients with an estimated glomerular filtration rate (eGFR) <60 ml/min/1.73 m², on dialysis, or with a kidney transplant were recruited from one Veterans Affairs (VA) nephrology clinic. Phase 1 interviews included open-ended questions assessing patients’ CKD-related information needs and generated a preliminary 67-item QPS. Phase 2 interview participants rated the importance of asking each question on a 5-point Likert scale and provided open-ended feedback. All participants rated their willingness to use a CKD-QPS. Input from patient ratings, a multidisciplinary team, and from members of the National Kidney Disease Education Program (NKDEP) Coordinating Panel helped to shorten and refine the QPS. A qualitative thematic approach was used to analyze open-ended responses. Quantitative data were analyzed for means and proportions.

Results

Eighty-five patients participated. Most were male (97 %), non-Hispanic white (71 %), and mean age was 67 years. Patients desired more information about CKD, particularly dialysis/transplant, and the relationship between CKD and comorbid medical conditions. The final QPS included 31-questions divided into 7 CKD subtopics. Most patients (88 %) reported being ‘completely’ or ‘very’ willing to use a CKD-QPS in future doctor visits.

Conclusions

CKD patients have unmet information needs. We developed a QPS to engage CKD patients in healthcare discussions and to facilitate patient-centered care. Future research should assess whether the CKD-QPS addresses patients’ information needs, enhances doctor-patient communication, and improves health outcomes.

Electronic supplementary material

The online version of this article (doi:10.1186/s12882-016-0362-z) contains supplementary material, which is available to authorized users.

Multifaceted Assessment of Health Literacy in People Receiving Dialysis: Associations With Psychological Stress and Quality of Life

Health literacy (HL) refers to a person's ability to engage effectively with health information and services. We aimed to describe the HL of people receiving dialysis and the factors associated with it. A cross-sectional design was used, with demographic and clinical data as predictors. Participants were people receiving dialysis at a metropolitan health service in Melbourne, Australia. Health consumers with conditions not requiring dialysis were included for comparison. The Health Literacy Questionnaire, Kidney Disease Quality of Life-36, and Depression Anxiety Stress Scales-21 were administered. Participants (M age = 68.2 ± 13.7 years; n = 57 males) were 76 people receiving hemodialysis within a dialysis unit, 16 people receiving home peritoneal dialysis, and 8 people receiving home hemodialysis. Participants scored higher on the HL domains social support for health and engagement with health care providers but lower on active management of health than the comparison group (n = 813). Hierarchical cluster analysis revealed 2 clusters within the dialysis sample representing higher (n = 43) and lower (n = 57) profiles of HL. The higher HL cluster reported better quality of life across 4 of 5 domains of the Kidney Disease Quality of Life-36, fewer symptoms of depression and anxiety, and higher serum albumin (mean difference = 2.06 g/L, p = .04) than the lower HL cluster. These results show that people receiving dialysis feel better supported and informed about their health than other health consumers but are less active in managing it. Higher HL is associated with better mental health and quality of life. Identifying HL characteristics may help direct specific interventions to improve patient education and support.

Medication Adherence After Renal Transplantation-a Review of the Literature

BACKGROUND

Whether or not patients follow the advice given by their healthcare professional is commonly referred to as adherence. In the case of kidney transplantation, transplant recipients need to take immunosuppressive drugs on a regular basis to prevent rejection of their transplant. However, medication adherence can be problematic for many patients.

OBJECTIVES

This critical appraisal of evidence aimed to gain insights into factors contributing to adherence and non-adherence in recipients of kidney transplants, and to explore patients' perceptions regarding adherence to immunosuppression.

METHODS

A comprehensive literature search was performed using Medline, PsycInfo, the Joanna Briggs Institute, CINAHL and the Cochrane Library. Included were primary research studies or reviews of primary research, independent of their research paradigms, on adult kidney or kidney/pancreas transplant recipients published in English or German. Children or adolescents were not considered. No time-frame was applied RESULTS: Fifty-two papers were included in the review. All extracted findings of included papers were organised according to the five factors influencing medication-taking behaviour as defined by the World Health Organisation: social and economic factors; therapy-related factors; patient-related factors; condition-related factors; healthcare team and system-related factors.

CONCLUSION

Reasons for non-adherence after kidney transplantations are diverse. Attention is attracted by the fact that potentially modifiable factors such as social support, experiences on dialysis, side effects, features of the treatment regimen, intentions and beliefs, forgetfulness and mental health issues play a greater role than other factors in the development of medication non-adherence. Factors not related to patient characteristics seem to be under researched.

Introduction of Biosimilar Therapeutics Into Nephrology Practice in the United States: Report of a Scientific Workshop Sponsored by the National Kidney Foundation

Biosimilars are biologic medicines highly similar to the reference product with no meaningful clinical differences in terms of safety, purity, and potency. All biologic medicines are produced by living cells, resulting in an inherent heterogeneity in their higher order structures and post-translational modifications. In 2010, the US Congress enacted legislation to streamline the approval process for biosimilars of products losing patent protection, with the goal of decreasing costs and improving patient access to therapeutically important but expensive biologic agents. In 2015, the US Food and Drug Administration approved the first biosimilar agent through this pathway. Approval of additional biosimilar agents in the United States, including those used by nephrologists, is anticipated. Given the relative lack of knowledge regarding biosimilars and their approval process and a lack of trust by the nephrology community regarding their safety and efficacy, the National Kidney Foundation conducted a symposium, Introduction of Biosimilar Therapeutics Into Nephrology Practice in the U.S., September 17 to 18, 2015. Issues related to manufacturing, the regulatory approval process, interchangeability, substitution/switching, nomenclature, and clinician and patient awareness and acceptance were examined. This report summarizes the main discussions at the symposium, highlights several controversies, and makes recommendations related to public policy, professional and patient education, and research needs.

Chronic kidney disease: identification and management in primary care

Chronic kidney disease (CKD) is an important and common noncommunicable condition globally. In national and international guidelines, CKD is defined and staged according to measures of kidney function that allow for a degree of risk stratification using commonly available markers. It is often asymptomatic in its early stages, and early detection is important to reduce future risk. The risk of cardiovascular outcomes is greater than the risk of progression to end-stage kidney disease for most people with CKD. CKD also predisposes to acute kidney injury - a major cause of morbidity and mortality worldwide. Although only a small proportion of people with CKD progress to end-stage kidney disease, renal replacement therapy (dialysis or transplantation) represents major costs for health care systems and burden for patients. Efforts in primary care to reduce the risks of cardiovascular disease, acute kidney injury, and progression are therefore required. Monitoring renal function is an important task, and primary care clinicians are well placed to oversee this aspect of care along with the management of modifiable risk factors, particularly blood pressure and proteinuria. Good primary care judgment is also essential in making decisions about referral for specialist nephrology opinion. As CKD commonly occurs alongside other conditions, consideration of comorbidities and patient wishes is important, and primary care clinicians have a key role in coordinating care while adopting a holistic, patient-centered approach and providing continuity. This review aims to summarize the vital role that primary care plays in predialysis CKD care and to outline the main considerations in its identification, monitoring, and clinical management in this context.

Technique failure in Korean incident peritoneal dialysis patients: a national population-based study

Background

Technique failure is an important issue for peritoneal dialysis (PD) patients. In this study, we aimed to analyze technique failure rate in detail and to determine the predictors for technique failure in Korea.

Methods

We identified all patients who had started dialysis between January 1, 2005, and December 31, 2008, in Korea, using the Korean Health Insurance Review and Assessment Service database. A total of 7,614 PD patients were included, and the median follow-up was 24.9 months.

Results

The crude incidence rates of technique failure in PD patients were 54.1 per 1,000 patient-years. The cumulative 1-, 2-, and 3-year technique failure rates of PD patients were 4.9%, 10.3%, and 15.6%, respectively. However, those technique failure rates by Kaplan–Meier analysis were overestimated compared with the values by competing risks analysis, and the differences increased with the follow-up period. In multivariate analyses, diabetes mellitus and Medical Aid as a crude reflection of low socioeconomic status were independent risk factors in both the Cox proportional hazard model and Fine and Gray subdistribution model. In addition, cancer was independently associated with a lower risk of technique failure in the Fine and Gray model.

Conclusion

Technique failure was a major concern in patients initiating PD in Korea, especially in diabetic patients and Medical Aid beneficiaries. The results of our study offer a basis for risk stratification for technique failure.

Development of a health literacy questionnaire for Taiwanese hemodialysis patients

Background

Dialysis has long been a critical issue in the field of nephrology, though the burden this lifesaving technology places on society can be immense. Effectively increasing the health literacy of hemodialysis patients can be beneficial for their health outcomes and self-care abilities. Thus, the aims of this study are to: (1) develop a health literacy assessment tool in Chinese for patients receiving hemodialysis treatment; (2) assess the health literacy level of the Taiwanese hemodialysis population using the tool developed.

Methods

The questionnaire was developed based on Nutbeam’s three constructs of health literacy and seven sub-constructs identified for the purposes of this study. Experts were consulted for content validity assessment. The questionnaire then was used to conduct a census study at six hospitals and one dialysis clinic that provide hemodialysis treatment in the Taipei area (urban northern Taiwan). To be included, patients must have been at least 18 years old and receiving hemodialysis treatment at the time of the study. 468 eligible respondents were included in the analysis.

Results

The reliability of the tool was 0.81 and the confirmatory factor analysis indicated good construct validity. The mean literacy score for the sample was 19.7 (SD = 4.61) out of a maximum of 26 points, and the median was 21 (range from 6 to 26). Age, education level, primary language, primary caregiver identity, and willingness to receive a transplant were all factors that showed significant association to health literacy level in multiple categories.

Conclusions

The health literacy assessment tool developed in this study is the first health literacy assessment instrument to be made available for a specific patient group in Taiwan. Hemodialysis patients’ knowledge of day-to-day care practices is satisfactory, while their critical literacy is weak.

Perspectives on optimizing care of patients in multidisciplinary chronic kidney disease clinics

Purpose of review

To summarize a jointly held symposium by the Canadian Society of Nephrology (CSN), the Canadian Association of Nephrology Administrators (CANA), and the Canadian Kidney Knowledge Translation and Generation Network (CANN-NET) entitled “Perspectives on Optimizing Care of Patients in Multidisciplinary Chronic Kidney Disease (CKD) Clinics” that was held on April 24, 2015, in Montreal, Quebec.

Sources of information

The panel consisted of a variety of members from across Canada including a multidisciplinary CKD clinic patient (Randall Russell), nephrology fellow (Dr. David Collister), geriatrician (Dr. Josee Verdon), and nephrologists (Dr. Monica Beaulieu, Dr. Adeera Levin).

Findings

The objectives of the symposium were (1) to gain an understanding of the goals of care for CKD patients, (2) to gain an appreciation of different perspectives regarding optimal care for patients with CKD, (3) to examine the components required for optimal care including education strategies, structures, and tools, and (4) to describe a framework and metrics for CKD care which respect patient and system needs. This article summarizes the key concepts discussed at the symposium from a patient and physician perspectives. Key messages include (1) understanding patient values and preferences is important as it provides a framework as to what to prioritize in multidisciplinary CKD clinic and provincial renal program models, (2) barriers to effective communication and education are common in the elderly, and adaptive strategies to limit their influence are critical to improve adherence and facilitate shared decision-making, (3) the use of standardized operating procedures (SOPs) improves efficiency and minimizes practice variability among health care practitioners, and (4) CKD scorecards with standardized system processes are useful in approaching variability as well as measuring and improving patient outcomes.

Limitations

The perspectives provided may not be applicable across centers given the differences in patient populations including age, ethnicity, culture, language, socioeconomic status, education, and multidisciplinary CKD clinic structure and function.

Implications

Knowledge transmission by collaborative interprovincial and interprofessional networks may play a role in facilitating optimal CKD care. Validation of system and clinic models that improve outcomes is needed prior to disseminating these best practices.

Relationship between Health Literacy and Kidney Function

AIM

Low health literacy (HL) may contribute to poor self-management of chronic kidney disease (CKD) and poor kidney function. This study aimed to assess the relationship between HL and estimated glomerular filtration rate (eGFR).

METHODS

A cross-sectional observational study was conducted among consecutive eligible adult patients with CKD stages 1-4 attending an outpatient nephrology clinic. HL was assessed using Newest Vital Sign (NVS). eGFR was estimated using the Modification of Diet in Renal Disease equation. CKD self-management behaviour knowledge was assessed using a study instrument (CKD self-management knowledge (SMKT)).

RESULTS

One hundred fifty patients participated in the study (83% participation rate). The prevalence of high likelihood of limited HL was 32.7%. Participants' eGFRs ranged from 17 to 152 mL/min / 1.73 m(2) , with over 80% of the eGFRs below 60 mL/min / 1.73 m(2) . HL was associated with eGFR after controlling for all demographics except age, race and gender (which are included in eGFR equation) (P = 0.05). Every unit increase in NVS score was associated with a 1.9% increase (95% confidence interval = 0 to 3.86%) in eGFR (model R square = 0.23, P = 0.002), which remained significant after controlling for CKD-SMKT (P = 0.05; model R square = 0.28, P < 0.001). The relationship was non-significant after controlling for age, although it remained significant after controlling for other demographics including gender and race.

CONCLUSIONS

There is a small but significant association between HL and eGFR. Providers should use HL-tailored communication strategies in CKD patients. Larger multicentre studies are needed to substantiate this relationship.

The burden of comorbidity in people with chronic kidney disease stage 3: a cohort study

BACKGROUND

Multimorbidity is a growing concern for healthcare systems, with many countries experiencing demographic transition to older population profiles. Chronic kidney disease (CKD) is common but often considered in isolation. The extent and prognostic significance of its comorbidities is not well understood. This study aimed to assess the extent and prognostic significance of 11 comorbidities in people with CKD stage 3.

METHODS

A prospective cohort of 1741 people with CKD stage 3 was recruited from primary care between August 2008 and March 2010. Participants underwent medical history, clinical assessment, blood and urine sampling. Comorbidity was defined by self-reported doctor-diagnosed condition, disease-specific medication or blood results (hemoglobin), and treatment burden as number of ongoing medications. Logistic regression was used to identify associations with greater treatment burden (taking >5 medications) and greater multimorbidity (3 or more comorbidities). Kaplan Meier plots and multivariate Cox proportional hazards models were used to investigate associations between multimorbidity and all-cause mortality.

RESULTS

One thousand seven hundred forty-one people were recruited, mean age 72.9 +/-9 years. Mean baseline eGFR was 52 ml/min/1.73 m(2). Only 78/1741 (4 %) had no comorbidities, 453/1741 (26 %) had one, 508/1741 (29 %) had two and 702/1741 (40 %) had >2. Hypertension was common (88 %), 30 % had 'painful condition', 24 % anemia, 23 %, ischaemic heart disease, 17 % diabetes and 12 % thyroid disorders. Median medication use was 5 medications (interquartile range 3-8) and increased with degree of comorbidity. Greater treatment burden and multimorbidity were independently associated with age, smoking, increasing body mass index and decreasing eGFR. Treatment burden was also independently associated with lower education status. After median 3.6 years follow-up, 175/1741 (10 %) died. Greater multimorbidity was independently associated with mortality (hazard ratio 2.81 (95 % confidence intervals 1.72-4.58), p < 0.001) for 3 or more comorbidities vs 0 or 1).

CONCLUSIONS

Isolated CKD was rare and multimorbidity the norm in this cohort of people with moderate CKD. Increasing multimorbidity was associated with greater medication burden and poorer survival. CKD management should include consideration of comorbidities.