Education of patients with chronic kidney disease at the interface of primary care providers and nephrologists

Association between English Proficiency and Kidney Disease Knowledge and Communication Quality among Patients with ESKD

Key Points

In one hospital-based safety-net dialysis unit, only one half of patients with ESKD knew their cause of kidney failure, which did not differ by English proficiency status. Patients with limited English proficiency (versus English-proficient patients) reported poorer communication with the dialysis care team (less listening, fewer clear explanations, less time spent). We highlight the need for tailored, patient-centered communication between limited English-proficient patients and dialysis care team members.

Background

ESKD is a chronic health condition for which communication between health care teams and patients is important to guide patient self-management activities. Yet, little is known about the quality of communication among patients with ESKD and their care team members. We examined the influence of patient's limited English proficiency (LEP) status on communication experiences at one dialysis center.

Methods

A survey was administered to adults receiving ESKD care at a dialysis unit within a public health care delivery system between July 2022 and February 2023, to ascertain kidney disease knowledge and perceptions of communication quality with the dialysis care team. Multivariable logistic and ordinal logistic regression models adjusted for age and sex were used to determine associations between LEP status and CKD knowledge.

Results

Among 93 eligible patients, 88.2% (n =82) completed the survey. Approximately 37.8% (n =31) had LEP, mean age was 58.8 years, 68.3% were men, mean dialysis vintage was 3.9 years, and 25% had a positive depression screen (LEP 30%; English-proficient 22%). A higher proportion of English-proficient patients screened positive for limited health literacy compared to those with LEP (74.5% versus 38.7%, P = 0.002). Overall, knowledge of assigned cause of ESKD (53.4%) and CKD/transplant knowledge (57.3%) was suboptimal. After adjustment, LEP status was not significantly associated with knowing the correct cause of kidney failure (odds ratio, 0.49; 95% confidence interval, 0.19 to 1.27) but was significantly associated with having a higher score on a CKD/transplant knowledge scale (odds ratio, 3.99; 95% confidence interval, 1.66 to 9.58). Patients with LEP reported poorer communication quality with dialysis providers and staff (less listening, fewer clear explanations, less time spent with patients) compared with English-proficient patients, although differences were not statistically significant.

Conclusions

Overall communication between patients with ESKD and members of the dialysis care team was suboptimal, regardless of English proficiency. Interventions to enhance communication for ESKD patients are needed.

Outpatient clinic specific for end-stage renal disease improves patient survival rate after initiating dialysis

The importance of a shared decision-making (SDM) approach is widely recognized worldwide. In Japan, hospital accreditation involves the promotion of SDM for patients with end-stage renal disease (ESRD) when considering renal replacement therapy (RRT). This study aimed to clarify the effectiveness and long-term medical benefits of SDM in RRT. Patients with ESRD who underwent dialysis therapy were retrospectively divided into those who visited outpatient clinics specific for ESRD (ESRD clinic) supporting RRT selection with an SDM approach (visited group) and those who did not visit the ESRD clinic (non-visited group). Data of 250 patients (129 in the non-visited group and 121 in the visited group) were analyzed. Mortality was significantly higher in the non-visited group than in the visited group. Not seeing an ESRD specialist was associated with emergent initiation of dialysis and subsequent 1 year mortality. The number of patients who chose peritoneal dialysis as a modality of RRT was significantly larger in the visited group. These findings demonstrate the association between the ESRD clinic, 1 year survival in patients with ESRD after initiating dialysis, and the different RRT modalities. This specific approach in the ESRD clinic may improve the management of patients with ESRD.

Provision of renal-specific nutrition knowledge for changing dietary practice in Bangladeshi hemodialysis patients

Objective

Studies show that provision of nutrition knowledge help renal patients make informed food choices. This study aimed to evaluate the impact of nutrition knowledge for changing dietary practice among Bangladeshi dialysis patients.

Methods

Following development of a renal-specific nutrition booklet, a pilot study was conducted among 50 hemodialysis patients from a single dialysis setting. Demographic, anthropometric, clinical, biochemical, dietary data, and a 10-item MCQ on renal-specific nutrition information were collected before and 3 months after the provision of the booklet.

Results

52% of the participants were male, 54% had twice weekly dialysis, age 53 ± 12 years, and dialysis vintage was 46 ± 25 months. Serum potassium and phosphorous, dietary potassium, phosphorous, and phosphorous to protein ratio were significantly reduced after the provision of the booklet. Additionally, patients consuming >3 meals/day increased to 66% while adherence to renal-specific cooking method and vegetable preference were significantly increased to 70% and 62%, respectively.

Conclusion

Provision of knowledge via renal-specific nutrition booklet was able to improve patients' dietary practice and enhance their dietary adherence to renal specific recommendations.

Innovation

The booklet was developed using locally available food items in local language and was found beneficial in low-resource settings where overall health care facilities, including nutrition support are limited.

Features of patient-education websites for patients with chronic kidney disease: an analysis of recommended websites

BACKGROUND

Chronic kidney disease (CKD) requires lifelong self-management. With the rise in access to the Internet, many CKD patients and their caregivers increasingly use the internet for information on CKD self-management. A recent environmental scan by Smekal et al. identified 11 CKD-related websites that covered the greatest number of content areas. This paper aims to evaluate these 11 selected websites in order to identify those that most effectively address content areas relevant to patients with CKD.

METHODS

Each website was assessed for information to 6 content areas: diet, physical activity, financial information, emotional support, general CKD information, and medication adherence. A three-tiered scoring metric was used in which a 0 was given if a content area was completely unaddressed, a (+) was given for a category that was generally addressed, and a (++) was given for a category that was addressed with actionable guidance.

RESULTS

While CKD information and diet were very comprehensively covered with scores of 11 (++) and 8 (++), respectively; physical activity, emotional support and medication adherence received the fewest (++) scores (3 for physical activity and five for both emotional support and medication adherence). For each content area, recommendations are made for websites that are particularly useful. Common themes for these highlighted websites include specific instructions, multiple modalities of information, downloadable and printable resources, and contact references for personal inquiries.

CONCLUSION

The recommended websites can help CKD patients and caregivers utilize the most applicable information for their specific self-management needs. Website improvements related to physical activity, emotional support, and financial information for persons with CKD are warranted.

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.

Health Literacy Not Associated with Chronic Kidney Disease Awareness

Background:

Patient awareness of their chronic kidney disease (CKD) and health literacy (HL) are both important for adherence to therapies that slow CKD progression and to reduce risk of complications. Little is known about the association between HL and CKD awareness.

Objective:

We sought to determine if patient HL is associated with CKD awareness.

Methods:

We conducted a cross-sectional study of general medicine inpatients at an urban academic medical center discharged between June 2011 and July 2013 with CKD, defined as having at least one CKD International Classification of Diseases, ninth revision code (585.0–585.9), among their first 20 admission diagnoses. Logistic regression was used to analyze the influence of HL, demographic, clinical, and health care use covariates on the likelihood of patients' CKD awareness. Our primary outcome was patient awareness of their CKD, defined as correct patient self-report of “kidney problems.” We used the Brief Health Literacy Screen, a three-item verbal questionnaire, to assess HL.

Key Results:

Among 1,308 patients with CKD, awareness of CKD was 33%, and 48% had adequate HL. However, CKD awareness was not associated with HL even among patients with stage 4 or 5 CKD. In multivariable logistic regression, greater awareness was associated with being a woman, younger than age 50 years, married, White, having hypertension, and having a higher CKD stage (all p < .05). In stratified analyses, patients with hypertension had greater CKD awareness, regardless of HL or diabetes status (p < .05).

Conclusions:

Among hospitalized patients with CKD, both CKD awareness and HL are low and inadequate. Surprisingly, patients' knowledge of their CKD diagnosis was not related to patients' HL. Patients with hypertension who young, white, or married may be receiving or retaining more education related to CKD. More work is needed on how to effectively communicate CKD diagnosis to prevent widening health disparities. [Health Literacy Research and Practice. 2017;1(3):e117–e127.]

Plain Language Summary:

We studied whether patients with low health literacy also had low awareness of their chronic kidney disease (CKD). Hospitalized patients with CKD were asked three questions about their health literacy and whether they had “kidney problems.” Overall CKD awareness and health literacy were low, but a low score on one did not predict a low score on the other.

Barriers to effective communication between veterans with chronic kidney disease and their healthcare providers

BACKGROUND

Many patients with chronic kidney disease (CKD) have insufficient knowledge about CKD, which is associated with poorer health outcomes. Effective patient-provider communication can improve CKD patients' knowledge, thereby augmenting their participation in self-care practices. However, barriers to addressing CKD patients' information needs have not been previously characterized.

METHODS

Adults with an estimated glomerular filtration rate (eGFR) of <60 mL/min/1.73 m(2) or on chronic dialysis or with a kidney transplant were recruited from a Department of Veterans Affairs (VA) nephrology clinic. Semi-structured telephone interviews were conducted to assess patients' CKD information needs and demographic characteristics. A qualitative approach was used to analyze interview transcripts and identify themes pertaining to communication dynamics.

RESULTS

Thirty-two patients participated. The mean age of participants was 63 years; most were male (94%) and non-Hispanic white (53%). CKD severity groups represented included CKD-3 (eGFR 30-59 mL/min/1.73 m(2); 34%), CKD-4 (eGFR 15-29 mL/min/1.73 m(2); 25%), CKD-5 (eGFR <15 mL/min/1.73 m(2); 16%), end-stage kidney disease on dialysis (13%) and kidney transplant recipients (12%). Several key themes emerged about barriers to patient-provider communication based on patients' reported care at both VA and non-VA facilities, including patients perceived their role as a 'listener', reported limited CKD knowledge, did not understand physicians' explanations and were dissatisfied with the patient-provider relationship.

CONCLUSIONS

Several barriers to patient-provider communication prevent patients from meeting their information needs and perpetuate patient passivity. Future research should evaluate whether interventions that empower CKD patients to actively participate in their care increase knowledge and improve health outcomes.

Specialist and primary care physicians' views on barriers to adequate preparation of patients for renal replacement therapy: a qualitative study

Background

Early preparation for renal replacement therapy (RRT) is recommended for patients with advanced chronic kidney disease (CKD), yet many patients initiate RRT urgently and/or are inadequately prepared.

Methods

We conducted audio-recorded, qualitative, directed telephone interviews of nephrology health care providers (n = 10, nephrologists, physician assistants, and nurses) and primary care physicians (PCPs, n = 4) to identify modifiable challenges to optimal RRT preparation to inform future interventions. We recruited providers from public safety-net hospital-based and community-based nephrology and primary care practices. We asked providers open-ended questions to assess their perceived challenges and their views on the role of PCPs and nephrologist-PCP collaboration in patients’ RRT preparation. Two independent and trained abstractors coded transcribed audio-recorded interviews and identified major themes.

Results

Nephrology providers identified several factors contributing to patients’ suboptimal RRT preparation, including health system resources (e.g., limited time for preparation, referral process delays, and poorly integrated nephrology and primary care), provider skills (e.g., their difficulty explaining CKD to patients), and patient attitudes and cultural differences (e.g., their poor understanding and acceptance of their CKD and its treatment options, their low perceived urgency for RRT preparation; their negative perceptions about RRT, lack of trust, or language differences). PCPs desired more involvement in preparation to ensure RRT transitions could be as “smooth as possible”, including providing patients with emotional support, helping patients weigh RRT options, and affirming nephrologist recommendations. Both nephrology providers and PCPs desired improved collaboration, including better information exchange and delineation of roles during the RRT preparation process.

Conclusions

Nephrology and primary care providers identified health system resources, provider skills, and patient attitudes and cultural differences as challenges to patients’ optimal RRT preparation. Interventions to improve these factors may improve patients’ preparation and initiation of optimal RRTs.

Readability of Written Materials for CKD Patients: A Systematic Review

BACKGROUND

The "average" patient has a literacy level of US grade 8 (age 13-14 years), but this may be lower for people with chronic kidney disease (CKD). Current guidelines suggest that patient education materials should be pitched at a literacy level of around 5th grade (age 10-11 years). This study aims to evaluate the readability of written materials targeted at patients with CKD.

STUDY DESIGN

Systematic review.

SETTING & POPULATION

Patient information materials aimed at adults with CKD and written in English.

SEARCH STRATEGY & SOURCES

Patient education materials designed to be printed and read, sourced from practices in Australia and online at all known websites run by relevant international CKD organizations during March 2014.

ANALYTICAL APPROACH

Quantitative analysis of readability using Lexile Analyzer and Flesch-Kincaid tools.

RESULTS

We analyzed 80 materials. Both Lexile Analyzer and Flesch-Kincaid analyses suggested that most materials required a minimum of grade 9 (age 14-15 years) schooling to read them. Only 5% of materials were pitched at the recommended level (grade 5).

LIMITATIONS

Readability formulas have inherent limitations and do not account for visual information. We did not consider other media through which patients with CKD may access information. Although the study covered materials from the United States, United Kingdom, and Australia, all non-Internet materials were sourced locally, and it is possible that some international paper-based materials were missed. Generalizability may be limited due to exclusion of non-English materials.

CONCLUSIONS

These findings suggest that patient information materials aimed at patients with CKD are pitched above the average patient's literacy level. This issue is compounded by cognitive decline in patients with CKD, who may have lower literacy than the average patient. It suggests that information providers need to consider their audience more carefully when preparing patient information materials, including user testing with a low-literacy patient population.

NSAID-avoidance education in community pharmacies for patients at high risk for acute kidney injury, upstate New York, 2011

INTRODUCTION

Nonsteroidal anti-inflammatory drugs (NSAIDs) are frequently associated with community-acquired acute kidney injury (AKI), a strong risk factor for development and progression of chronic kidney disease. Using access to prescription medication profiles, pharmacists can identify patients at high risk for NSAID-induced AKI. The primary objective of this analysis was to evaluate the effectiveness of a community pharmacy-based patient education program on patient knowledge of NSAID-associated renal safety concerns.

METHODS

Patients receiving prescription medications for hypertension or diabetes mellitus were invited to participate in an educational program on the risks of NSAID use. A patient knowledge questionnaire (PKQ) consisting of 5 questions scored from 1 to 5 was completed before and after the intervention. Information was collected on age, race, sex, and frequency of NSAID use.

RESULTS

A total of 152 participants (60% women) completed both the pre- and post-intervention questionnaire; average age was 54.6 (standard deviation [SD], 17.5). Mean pre-intervention PKQ score was 3.3 (SD, 1.4), and post-intervention score was 4.6 (SD, 0.9) (P = .002). Participants rated program usefulness (1 = not useful to 5 = extremely useful) as 4.2 (SD, 1.0). In addition, 48% reported current NSAID use and 67% reported that the program encouraged them to limit their use.

CONCLUSION

NSAID use was common among patients at high risk for AKI. A brief educational intervention in a community pharmacy improved patient knowledge on NSAID-associated risks. Pharmacists practicing in the community can partner with primary care providers in the medical home model to educate patients at risk for AKI.

Effective CKD care in European countries: challenges and opportunities for health policy

Chronic kidney disease (CKD) is an important global public health problem that is associated with adverse health outcomes and high health care costs. Effective and cost-effective treatments are available for slowing the progression of CKD and preventing its complications, including cardiovascular disease. Although wealthy nations have highly structured schemes in place to support the care of people with kidney failure, less consideration has been given to health systems and policy for the much larger population of people with non-dialysis-dependent CKD. Further, how to integrate such strategies with national and international initiatives for control of other chronic noncommunicable diseases (NCDs) merits attention. We synthesized the various approaches to CKD control across 17 European countries and present our findings according to the key domains suggested by the World Health Organization framework for NCD control. This report identifies opportunities to strengthen CKD-relevant health systems and explores potential mechanisms to capitalize on these opportunities. Across the 17 countries studied, we found a number of common barriers to the care of people with non-dialysis-dependent CKD: limited work force capacity, the nearly complete absence of mechanisms for disease surveillance, lack of a coordinated CKD care strategy, poor integration of CKD care with other NCD control initiatives, and low awareness of the significance of CKD. These common challenges faced by diverse health systems reflect the need for international cooperation to strengthen health systems and policies for CKD care.

The nephrology interdisciplinary team: an education synergism

Patients with kidney disease often have a poor understanding of their condition. The interdisciplinary team can effectively educate these patients to slow disease progression and enhance self-management. The kidney community needs large, well-designed studies to determine the best way to educate patients and hopefully stem the tide of a rapidly increasing population of kidney patients. Congress authorized payment to eligible providers for kidney disease education for Medicare beneficiaries. However, this benefit is not being optimally used. In addition, reimbursement denials were 14-17% in 2011 and 20-23% in 2012. This is more than 4 times the usual Medicare denial rate for current procedural terminology (CPT) codes.