Use of focus groups to identify concerns about dialysis. Choice Study

Psychometric properties of the kidney disease quality of life-36 (KDQOL-36) in Ethiopian patients undergoing hemodialysis

Background

Health-related quality of life (HRQOL) has a direct association with increased morbidity and mortality among end stage renal disease patients. Valid and reliable instruments to measure the HRQOL of patients with end stage renal disease are therefore required. This study aimed to translate, culturally adapt and evaluate the psychometric properties of the Amharic version of the Kidney Disease Quality of Life-36 (KDQOL-36) instrument in Ethiopian patients with end stage renal disease undergoing hemodialysis.

Methods

The KDQOL-36 instrument was developed for individuals with kidney disease who are being treated with dialysis and includes both generic and disease-specific components. The KDQOL-36 was translated to Amharic language and distributed to a cross-sectional sample of 292 hemodialysis patients. The psychometric evaluation included construct validity through corrected item-total correlation, confirmatory factor analysis and known group analysis. Convergent validity was evaluated by correlations between each of the three kidney disease targeted scales (symptoms/problems list, burden of kidney disease and effects of kidney diseases) and the European Quality of Life 5D-5L and Visual Analog Scales. Regarding reliability, internal consistency and test–retest reliability were assessed.

Results

Two hundred ninety-two patients with a mean age of 48 (SD ± 14.7) completed the questionnaire. Corrected item- total correlation scores were > 0.4 for all items. Confirmatory factor analysis revealed a two χ² /df was 4.4, Root Mean Square Error of Approximation (RMSEA) = 0.108 (90% CI 0.064–0.095), Comparative Fit Index (CFI) = 0.922, Tucker Lewis Index (TLI) = 0.948 and Standardized Root mean-squared residual (SRMR) = 0.058) and three χ² /df = 3.1, RMSEA = 0.085 (90% CI 0.064–0.095), CFI = 0.854, TLI = 0.838 and SRMR = 0.067) factor models for the generic and disease specific components respectively. The mean scores of the three kidney disease targeted domains were correlated to the EQ-5D-5L & VAS with correlation coefficients of large magnitude (0.55–0.81). The reliability of the instrument was satisfactory (Cronbach’s alpha = 0.81–0.91) and Intra-class correlation (ICC) = 0.90–0.96).

Conclusion

The Amharic version of the KDQOL-36 is a reliable and valid instrument recommended for assessment of HRQOL of Ethiopian patients on hemodialysis.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12955-022-01932-y.

Improving Caregiver Burden by a Peer-Led Mentoring Program for Caregivers of Patients With Chronic Kidney Disease: Randomized Controlled Trial

Chronic kidney disease (CKD) is associated with substantial morbidity, mortality, cost, and increased caregiver burden. Peer mentoring (PM) improves multiple outcomes in various chronic diseases. The effect of PM on caregiver burden among caregivers of patients with CKD has not been studied. We conducted a randomized clinical trial to test the effectiveness of a structured PM program on burden of care among caregivers of patients with CKD. We randomized 86 caregivers to receive 6 months of intervention in 1 of 3 groups: (1) face-to-face PM (n = 29); (2) online PM (n = 29); and (3) usual care: textbook-only (n = 28). Peer mentors were caregivers of patients with CKD, who received 16 h of instruction. All participants received a copy of a textbook, which contains detailed information about kidney disease. Participants in the PM groups received FTF or online PM for 6 months. The outcome was time-related change in the Zarit Burden Interview (ZBI) score. There was a statistically significant decrease in the ZBI score (SE: −3.44; CI: −6.31, −0.57 [p = 0.002]) compared with baseline, among the online PM group. Online PM led to decreased caregiver burden among caregivers of patients with CKD. The study was limited to English-speaking subjects with computer literacy.

Patient experiences of sleep in dialysis: systematic review of qualitative studies

RATIONALE AND OBJECTIVE

Sleep problems affect more than half of patients receiving dialysis and are associated with increased risk of mortality, cardiovascular events, depression and impaired functioning and quality of life. Symptoms such as fatigue and exhaustion may be attributed to sleep problems or sleep disorders, as well as the burden of kidney disease and treatment. This study aims to describe the patient perspectives on the reasons, impact and management of sleep problems in dialysis.

STUDY DESIGN

Systematic review and thematic synthesis of qualitative studies that report patient experience and perspectives on sleep in dialysis.

SETTING AND POPULATION

Patients receiving dialysis.

SEARCH STRATEGY AND SOURCES

MEDLINE, Embase, PsycINFO, CINAHL, reference lists and PhD dissertations were searched from inception to August 2019.

DATA EXTRACTION

All text from the results/conclusion of the primary studies.

ANALYTICAL APPROACH

Thematic synthesis.

RESULTS

We included 48 studies involving 1156 participants from 16 countries. We identified six themes: dominating demands of treatment (with subthemes of: demanding and relentless schedule, regret for wasted time); scheduling and control (managing sleep routines, napping and nocturnal sleep disruption, meditative aids); disruptions due to dialysis (unsettled sleep, hypervigilance and worry); symptoms depriving sleep (difficulty falling asleep, constant waking); overwhelmed and without choice (futility of sleep, uncontrollable exhaustion, restlessness is irrepressible); and as a coping mechanism (avoiding anxiety, alleviating symptoms, combating boredom).

LIMITATIONS

Most studies were conducted in high-income, English-speaking countries.

CONCLUSION

The treatment and symptom burden of dialysis disrupts and deprives patients of sleep, which leads to overwhelming and uncontrollable exhaustion. Better management of symptoms and effective strategies to manage sleep routines may improve sleep quality for better overall health in patients receiving dialysis.

The challenge of managing mild to moderate distress in patients with end stage renal disease: results from a multi-centre, mixed methods research study and the implications for renal service organisation

BACKGROUND

Lower-level emotional and psychological difficulties ('distress') in patients with end stage renal disease (ESRD), can lead to reduced quality of life and poor clinical outcomes. National guidelines mandate provision of emotional and psychological support for renal patients yet little is known about the support that patients may require, or the challenges that staff experience in identifying and responding to patient distress.

METHODS

Mixed methods study in renal units at four NHS Trusts in the West Midlands, UK involving cross-sectional surveys of ESRD patients and renal unit staff and semi-structured interviews with 46 purposively-sampled patients and 31 renal unit staff. Interviews explored patients' experience of distress and personal coping strategies, staff attitudes towards patient distress and perceptions of their role, responsibility and capacity.

RESULTS

Patient distress was widespread (346/1040; 33.3%), and emotional problems were frequently reported. Younger patients, females, those from black and minority ethnic (BME) groups and patients recently initiating dialysis reported particular support needs. Staff recognised the value of supporting distressed patients, yet support often depended on individual staff members' skills and personal approach. Staff reported difficulties with onward referral to formal counselling and psychology services and a lack of immediate access to less formalised options. There was also a substantial training/skills gap whereby many staff reported lacking the confidence to recognise and respond to patient distress. Staff fell broadly into three groups: 'Enthusiasts' who considered identifying and responding to patient distress as integral to their role; 'Equivocators' who thought that managing distress was part of their role, but who lacked skills and confidence to do this effectively, and 'Avoiders' who did not see managing distress as part of their role and actively avoided the issue with patients.

CONCLUSIONS

Embedding the value of emotional support provision into renal unit culture is the key to 'normalising' discussions about distress. Immediately accessible, informal support options should be available, and all renal staff should be offered training to proactively identify and reactively manage patient distress. Emotional support for staff is important to ensure that a greater emphasis on managing patient distress is not associated with an increased incidence of staff burnout.

Distress in patients with end-stage renal disease: Staff perceptions of barriers to the identification of mild-moderate distress and the provision of emotional support

OBJECTIVES

To explore staff perceptions of barriers to the identification of mild to moderate distress and the provision of emotional support in patients with end-stage renal disease.

METHODS

Qualitative semi-structured interviews with staff in two hospitals (n = 31), with data analysed using a hybrid approach combining thematic analysis with aspects of grounded theory.

RESULTS

Staff appeared very aware that many patients with end-stage renal disease experience distress, and most thought distressed patients should be helped as part of routine care. However, practice was variable and looking for and addressing distress was not embedded in care pathways. Interviews identified six themes: i) staff perceptions about how distress is manifested and what causes distress were variable; ii) staff perceptions of patients could lead to distress being overlooked because patients were thought to hide their distress whilst some groups were assumed to be more prone to distress than others; iii) role perceptions varied, with many staff believing it to be their role but not feeling comfortable with it, with doctors being particularly ambivalent; iv) fears held back some staff, who were concerned about what might happen when talking about distress, or who found the emotional load for themselves to be too high; v) staff felt they lacked skills, confidence and training, vi) capacity to respond may be limited, as staff perceive there to be insufficient time, with little or no specialist support services to refer patients to.

CONCLUSIONS

Staff perceived significant barriers in identifying and responding to patient distress. Barriers related to skills and knowledge could be addressed through training, with training ideally targeted at staff with positive attitudes, but who currently lack skills and confidence. Barriers related to role perceptions would be harder to address. The study is relevant internationally as part of improving long-term condition pathways.

Measuring health-related quality of life in patients with conservatively managed stage 5 chronic kidney disease: limitations of the Medical Outcomes Study Short Form 36: SF-36

PURPOSE

Chronic kidney disease (CKD) negatively affects health-related quality of life (HRQoL), which is often measured using the Medical Outcomes Study Short Form 36 (SF-36) questionnaire. However, the adequacy of SF-36 in this population has not been reported. We aimed to determine floor and ceiling effects and responsiveness to change of SF-36 in patients with conservatively managed stage 5 CKD.

METHODS

SF-36 data were collected prospectively. Floor and ceiling effects were estimated for each SF-36 scale and summary measure based on raw scores. The minimal clinically important difference (MCID) was estimated using a combination of anchor-based and distribution-based methods. Responsiveness to change was assessed by comparing MCID for each scale and summary measure to its smallest detectable change.

RESULTS

SF-36 data were available for 73 of the 74 study participants. Using baseline data, floor and/or ceiling effects were detected for 3 of the 8 SF-36 scales. The anchor-based estimation of MCID based on differences in baseline functional status yielded the most reliable results. For the physical component summary, MCID was estimated at 5.7 points. Whilst the two SF-36 summary measures were responsive to change and free of floor and/or ceiling effects, six of the eight scales were not.

CONCLUSIONS

This small study of patients with conservatively managed stage 5 CKD found that only the summary measures of SF-36 and 2 of its 8 scales can be used to assess changes in HRQoL over time. These findings suggest that in this population, alternative HRQoL assessment tools should be considered for future studies.

Patient Perspectives on the Choice of Dialysis Modality: Results From the Empowering Patients on Choices for Renal Replacement Therapy (EPOCH-RRT) Study

BACKGROUND

Little is known about factors that are important to patients with advanced kidney disease and their perspectives at the time they choose a dialysis modality. EPOCH-RRT, a study supported in part by the Patient-Centered Outcomes Research Institute (PCORI), was designed to assist patients with this choice by identifying such factors and effectively provide relevant information.

STUDY DESIGN

Cross-sectional study, designed and conducted in collaboration with a multistakeholder advisory panel that included patients, caregivers, and health care professionals.

SETTING & PARTICIPANTS

180 patients with advanced chronic kidney disease (CKD; estimated glomerular filtration rate < 25mL/min/1.73m²), either non-dialysis-dependent (NDD-CKD; n=65) or on dialysis therapy (hemodialysis [HD], n=77; or peritoneal dialysis, n=38), recruited across the United States through social media and in-person contacts.

METHODOLOGY

Semistructured telephone interviews including open- and closed-ended questions.

ANALYTICAL APPROACH

Mixed methods, integrating quantitative and qualitative approaches; themes identified through content analysis of interview transcripts by 2 independent coders.

RESULTS

Themes most often reported as important were keeping as much independence as possible, quality and quantity of life, and flexibility in daily schedule. Other factors (eg, concern about the way they look) differed across patient subgroups based on age, sex, and NDD-CKD/dialysis modality. Among patients who had initiated dialysis therapy, almost half (47%) the HD patients believed that the decision to be treated by HD had largely not been their choice; this was only reported by 3% of peritoneal dialysis patients.

LIMITATIONS

Recruitment through social media and willingness to participate in lengthy telephone interviews resulted in a select sample that may not be representative of the broader advanced CKD population; therefore, generalizability of findings cannot be determined.

CONCLUSIONS

Incorporation of patient priorities in care improves health outcomes. Given the perceived limited role in the choice of dialysis treatment, our findings support the need for interventions to improve shared decision making on dialysis treatment options, targeting both patients and clinicians.

Improving clinical skills to support the emotional and psychological well-being of patients with end-stage renal disease: a qualitative evaluation of two interventions

Background

Many patients with end-stage renal disease (ESRD) need and want improved emotional and psychological support. Explicit attention to patients' emotional issues during consultations can help, yet renal consultants rarely address emotional problems. This qualitative study aimed to evaluate whether two different low-cost interventions could individually enable consultants to talk with patients about their emotional concerns during routine outpatient consultations.

Method

One intervention involved patients using a Patient Issues Sheet to identify two to three issues they would like to talk about in their consultation and the second involved consultants asking patients a direct question about their emotional feelings. Consultants were trained to handle any emotional issues raised. Semi-structured interviews were conducted with five consultants and 36 ESRD patients from two UK renal units. Interviews were transcribed verbatim and analysed using the constant comparative method.

Results

Although consultants and patients tended to use the two interventions in different ways, they expressed generally positive views about how helpful the interventions were in promoting discussion of emotional issues. Consultants appreciated the training for facilitating empathetic handling of patients' emotional disclosures and containment of discussion. Most patients who raised emotional concerns were satisfied with their consultant's responses, while others were dissuaded from more explicit discussion by their consultant's concentration on physical considerations.

Conclusions

These qualitative study findings suggest that both interventions are feasible and acceptable and have the potential to help consultants improve emotional and psychological patient care, providing cognitive and behavioural tools to enable discussion of emotional issues during routine outpatient consultations.

Taking hospital treatments home: a mixed methods case study looking at the barriers and success factors for home dialysis treatment and the influence of a target on uptake rates

Background

Despite healthcare policies and evidence which promote home dialysis, uptake rates have been falling for over 10 years in England. A target introduced by commissioners in the West Midlands provided a unique opportunity to study how hospitals can increase home-based treatment for a group of patients with complex life-threatening conditions.

Methods

Quantitative changes in home treatment uptake rates in seven hospitals in the West Midlands were compared with the rest of England for 3 years pre and post the introduction of the target in 2010, using a logistic regression model. Qualitative interviews in four hospitals with 96 clinical and managerial staff and 93 dialysis patients explored the barriers and facilitators to increasing the uptake of home treatment and the impact of the target.

Results

Home treatment uptake rates increased significantly in the seven study hospitals compared with the 3 years prior to the introduction of the target and compared with the rest of England where rates remained static. The four main factors facilitating increased uptake were as follows: the commissioner’s target, linked to financial penalties; additional funding for specialist staff and equipment; committed, visible clinical champions and good systems for patient training and ongoing healthcare support at home. The three main barriers were as follows: lack of training for non-specialist staff, poorly developed patient education and considerable unrecognised and unmet emotional and psychological patient needs.

Conclusions

This study shows the impact of using targets with financial penalties to achieve change and how hospitals can increase significantly the uptake of home-based self-care for a group of patients with complex medical needs. It provides useful pointers to the main barriers and facilitators, which are likely to be relevant to other groups of patients who could be treated at home. It also highlights two neglected areas which need to improve if patients with life-threatening long-term conditions are to be encouraged to take up home treatment: individualised patient education which allows exploration of the impacts of treatment options and the provision of ongoing emotional support.

Choosing dialysis modality: decision making in a chronic illness context

BACKGROUND

Patients with chronic kidney disease (CKD) are encouraged to make an informed decision about dialysis. Survival rates for dialysis are equivalent yet there is wide variation in peritoneal dialysis uptake in the adult UK population. It is unclear how much is attributable to variations in patients' preferences. Kidney function usually declines over months and years; few studies have addressed how a chronic illness context affects choice. This study describes patients' decision making about dialysis and understands how the experience of CKD is associated with treatment choice.

METHOD

Survey employing interview methods explored 20 patients' views and experiences of making their dialysis choice. Data were analysed using thematic framework analysis to provide descriptive accounts of how patients experienced their illness and made treatment decisions.

RESULTS

Patients talked about challenges of living with CKD. Patients were provided with lots of information about treatment options in different formats. Patients did not distinguish between different types of dialysis and/or have an in-depth knowledge about options. Patients did not talk about dialysis options as a choice but rather as a treatment they were going to have.

CONCLUSION

Most patients perceived their choice as between 'dialysis' and 'no dialysis'. They did not perceive themselves to be making an active choice. Possibly, patients feel they do not need to engage with the decision until symptomatic. Despite lots of patient information, there were more opportunities to encounter positive information about haemodialysis. A more proactive approach is required to enable patients to engage fully with the dialysis treatment options.

Patients' perspectives on hemodialysis vascular access: a systematic review of qualitative studies

BACKGROUND

Delayed creation of vascular access may be due in part to patient refusal and is associated with adverse outcomes. Concerns about vascular access are prevailing treatment-related stressors for patients on hemodialysis therapy. This study aims to describe patients' perspectives on vascular access initiation and maintenance in hemodialysis.

STUDY DESIGN

Systematic review and thematic synthesis of qualitative studies.

SETTING & POPULATION

Patients with chronic kidney disease who express opinions about vascular access for hemodialysis.

SEARCH STRATEGY & SOURCES

MEDLINE, EMBASE, PsycINFO, CINAHL, reference lists, and PhD dissertations were searched to October 2013.

ANALYTICAL APPROACH

Thematic synthesis was used to analyze the findings.

RESULTS

From 46 studies involving 1,034 patients, we identified 6 themes: heightened vulnerability (bodily intrusion, fear of cannulation, threat of complications and failure, unpreparedness, dependence on a lifeline, and wary of unfamiliar providers), disfigurement (preserving normal appearance, visual reminder of disease, and avoiding stigma), mechanization of the body (bonded to a machine, internal abnormality, and constant maintenance), impinging on way of life (physical incapacitation, instigating family tension, wasting time, and added expense), self-preservation and ownership (task-focused control, advocating for protection, and acceptance), and confronting decisions and consequences (imminence of dialysis therapy and existential thoughts).

LIMITATIONS

Non-English articles were excluded.

CONCLUSIONS

Vascular access is more than a surgical intervention. Initiation of vascular access signifies kidney failure and imminent dialysis, which is emotionally confronting. Patients strive to preserve their vascular access for survival, but at the same time describe it as an agonizing reminder of their body's failings and "abnormality" of being amalgamated with a machine disrupting their identity and lifestyle. Timely education and counseling about vascular access and building patients' trust in health care providers may improve the quality of dialysis and lead to better outcomes for patients with chronic kidney disease requiring hemodialysis.

Qualitative research in CKD: an overview of methods and applications

There recently has been a paradigm shift in health care policies and research toward greater patient centeredness. A core tenet of patient-centered care is that patients' needs, values, and preferences are respected in clinical decision making. Qualitative research methods are designed to generate insights about patients' priorities, values, and beliefs. However, in the past 5 years (2008-2013), only 23 (0.4%) of the 6,043 original articles published in the top 5 nephrology journals (assessed by impact factor) were qualitative studies. Given this observation, it seems important to promote awareness and better understanding within the nephrology community about qualitative research and how the findings can contribute to improving the quality and outcomes of care for patients with chronic kidney disease. This article outlines examples of how qualitative research can generate insight into the values and preferences of patients with chronic kidney disease, provides an overview of qualitative health research methods, and discusses practical applications for research, practice, and policy.

A patient perspective on the barriers to home dialysis

INTRODUCTION

People with End Stage Renal Disease rarely choose home dialysis therapies even though they can offer a range of Quality-of-Life (QOL) benefits such as improved convenience, mental health well-being, employment, reduced mortality and cost effectiveness. Attempts to increase usage of such self-caring modalities, have met with limited success, in part due to a lack of understanding of patient decision making and patient perceived barriers to such therapies.

OBJECTIVE

To explore the patient perspective on the main barriers to a range of self-care or home dialysis therapies, including Continuous Ambulatory Peritoneal Dialysis, Home Haemodialysis and Extended Home Haemodialysis.

MATERIALS AND METHODS

A longitudinal patient narrative approach is adopted.

RESULTS

There are significant barriers to all aspects of informed decision making around home therapies, but many are based on perception. Creating decision aids and education programmes to tackle these perceived barriers, actively encouraging home therapy take up, focusing on QOL in clinical decision making, offering peer support and expanded in-centre self-care treatment options may increase awareness and uptake of self-care therapies.

Comparison of life participation activities among adults treated by hemodialysis, peritoneal dialysis, and kidney transplantation: a systematic review

BACKGROUND

A comprehensive assessment of the association of patients' renal replacement therapy (RRT) modality with their participation in life activities (physical function, travel, recreation, freedom, and work) is needed.

STUDY DESIGN

Systematic review of peer-reviewed published studies.

SETTING & POPULATION

Adults undergoing RRT (hemodialysis, peritoneal dialysis, or transplantation).

SELECTION CRITERIA FOR STUDIES

We searched PubMed, Cochrane Library, and EMBASE from January 1980 through April 2012 for English-language articles that compared participation in life activities among patients receiving: (1) hemodialysis compared with peritoneal dialysis, (2) hemodialysis compared with kidney transplantation, or (3) peritoneal dialysis compared with kidney transplantation.

PREDICTOR

RRT modality.

OUTCOMES

Reported rates of physical function, travel, recreation, freedom, and work-related activities by RRT modality.

RESULTS

46 studies (6 prospective cohort, 38 cross-sectional, and 2 pre-post transplantation) provided relevant comparisons of life participation activities among patients treated with hemodialysis, peritoneal dialysis, and kidney transplantation. Studies were conducted in 1985-2011 among diverse patient populations in 16 distinct locations. A majority of studies reported greater life participation rates for patients with kidney transplants compared with patients receiving either hemodialysis or peritoneal dialysis. In contrast, a majority of studies reported no differences in outcomes between patients receiving hemodialysis and patients receiving peritoneal dialysis. These results were consistent throughout the study period, across diverse populations, and among the subset of studies that performed appropriate adjustments for potential confounding factors.

LIMITATIONS

Many studies included in the review had significant design weaknesses.

CONCLUSIONS

Evidence suggests that patients with kidney transplants may experience better rates of life participation compared with patients receiving dialysis, whereas patients receiving hemodialysis and patients receiving peritoneal dialysis may experience similar rates of life participation. Rigorously performed studies are needed to better inform patients about the association of RRT with these important patient-reported outcomes.

[Taking into consideration patient concerns for the elaboration of educational programs for chronic renal failure patients]

The objective was to take into consideration patient concerns for an original qualitative approach to the elaboration of three therapeutic education programs (TEP) designed for chronic renal failure patients, transplantation recipients, and dialysis patients. Four discussion groups involved patients with non-terminal chronic renal failure (one group), transplantation recipients (one group), and dialysis patients (two groups). Topics discussed were patients' knowledge of the TEP and their disease and treatment, patients' expectations concerning the educative content and the organisation of the TEP. For all levels of chronic renal failure, patient expectations focused on nutrition, treatments, and the social and occupational supportive network. Patients with non-terminal renal failure also expressed their expectations concerning the comprehension of laboratory tests and the course of their renal disease. Transplantation recipients wanted to strengthen their knowledge about graft evolution and immunosuppression. Dialysis patients expressed their concerns about disease announcement and the decision for dialysis. While certain topics were common, patients were preoccupied by different problems depending on their degree of renal insufficiency. Nephrolor thus integrated these different levels of concern into the elaboration of E'Dire programs designed for non-terminal renal failure patients and EDUGREFFE for transplant recipients. The third program designed for dialysis patients is currently in the development phase.

Selecting renal replacement therapies: what do African American and non-African American patients and their families think others should know? A mixed methods study

Background

Little is known regarding the types of information African American and non-African American patients with chronic kidney disease (CKD) and their families need to inform renal replacement therapy (RRT) decisions.

Methods

In 20 structured group interviews, we elicited views of African American and non-African American patients with CKD and their families about factors that should be addressed in educational materials informing patients’ RRT selection decisions. We asked participants to select factors from a list and obtained their open-ended feedback.

Results

Ten groups of patients (5 African American, 5 non-African American; total 68 individuals) and ten groups of family members (5 African American, 5 non-African American; total 62 individuals) participated. Patients and families had a range (none to extensive) of experiences with various RRTs. Patients identified morbidity or mortality, autonomy, treatment delivery, and symptoms as important factors to address. Family members identified similar factors but also cited the effects of RRT decisions on patients’ psychological well-being and finances. Views of African American and non-African American participants were largely similar.

Conclusions

Educational resources addressing the influence of RRT selection on patients’ morbidity and mortality, autonomy, treatment delivery, and symptoms could help patients and their families select RRT options closely aligned with their values. Including information about the influence of RRT selection on patients’ personal relationships and finances could enhance resources’ cultural relevance for African Americans.

Development of a decision aid to inform patients' and families' renal replacement therapy selection decisions

BACKGROUND

Few educational resources have been developed to inform patients' renal replacement therapy (RRT) selection decisions. Patients progressing toward end stage renal disease (ESRD) must decide among multiple treatment options with varying characteristics. Complex information about treatments must be adequately conveyed to patients with different educational backgrounds and informational needs. Decisions about treatment options also require family input, as families often participate in patients' treatment and support patients' decisions. We describe the development, design, and preliminary evaluation of an informational, evidence-based, and patient-and family-centered decision aid for patients with ESRD and varying levels of health literacy, health numeracy, and cognitive function.

METHODS

We designed a decision aid comprising a complementary video and informational handbook. We based our development process on data previously obtained from qualitative focus groups and systematic literature reviews. We simultaneously developed the video and handbook in "stages." For the video, stages included (1) directed interviews with culturally appropriate patients and families and preliminary script development, (2) video production, and (3) screening the video with patients and their families. For the handbook, stages comprised (1) preliminary content design, (2) a mixed-methods pilot study among diverse patients to assess comprehension of handbook material, and (3) screening the handbook with patients and their families.

RESULTS

The video and handbook both addressed potential benefits and trade-offs of treatment selections. The 50-minute video consisted of demographically diverse patients and their families describing their positive and negative experiences with selecting a treatment option. The video also incorporated health professionals' testimonials regarding various considerations that might influence patients' and families' treatment selections. The handbook was comprised of written words, pictures of patients and health care providers, and diagrams describing the findings and quality of scientific studies comparing treatments. The handbook text was written at a 4th to 6th grade reading level. Pilot study results demonstrated that a majority of patients could understand information presented in the handbook. Patient and families screening the nearly completed video and handbook reviewed the materials favorably.

CONCLUSIONS

This rigorously designed decision aid may help patients and families make informed decisions about their treatment options for RRT that are well aligned with their values.

The perspectives of adults living with peritoneal dialysis: thematic synthesis of qualitative studies

BACKGROUND

Most patients with end-stage renal disease require dialysis to survive because they are unable to access kidney transplantation. Peritoneal dialysis (PD) is recommended by some clinical practice guidelines as the dialysis treatment of choice for adults without significant comorbid conditions or those with residual kidney function. This study aims to synthesize published qualitative studies of patients' experiences, beliefs, and attitudes about PD.

METHODS

We conducted a systematic review and thematic synthesis of qualitative studies of adult perspectives of living with PD. Databases (MEDLINE, Embase, PsycINFO, and CINAHL), theses, and reference lists were searched to November 2011.

RESULTS

39 studies involving 387 participants were included. We identified 7 themes: resilience and confidence (determination and overcoming vicissitudes), support structures (strong family relationship, peer support, professional dedication, social abandonment, and desire for holistic care), overwhelming responsibility (disruptive intrusion, family burden, and onerous treatment regimen), control (gaining bodily awareness, achieving independence and self-efficacy, and information seeking), freedom (flexibility and autonomy, retaining social functioning, and ability to travel), sick identity (damage to self-esteem and invisible suffering), and disablement (physical incapacitation and social loss and devaluation).

CONCLUSIONS

PD can offer patients a sense of control, independence, self-efficacy, and freedom. However, holistic and multidisciplinary care is needed to mitigate the risks of impaired self-esteem, physical incapacitation, reduced social functioning, and poor sense of self-worth. Strategies that aim to strengthen social support and promote resilience and confidence in patients are integral to achieving positive adjustment, improved psychosocial outcomes, and treatment satisfaction.

Understanding and assessing the impact of end-stage renal disease on quality of life: a systematic review of the content validity of self-administered instruments used to assess health-related quality of life in end-stage renal disease

Advances in healthcare, combined with an increasing number of adults with end-stage renal disease (ESRD), mean that there is a growing number of people now surviving on renal replacement therapy. The issue of health-related quality of life (HR-QOL) is becoming increasingly important in this area. For this reason, the content validity of various instruments used to measure HR-QOL in an ESRD population were explored. Systematic searches of MEDLINE (1950-2009) were conducted using terms related to ESRD combined with terms associated with measuring HR-QOL. A total of 378 abstracts were identified, detailing the repeated use of six generic measures and four disease-specific measures. The generic HR-QOL measures discussed include the Medical Outcomes 36-Item Short Form Survey (SF-36), the EuroQOL 5 Dimension (EQ-5D), and the WHO QOL assessment (WHOQOL-BREF). The most frequently used disease-specific measure discussed is the Kidney Disease QOL instrument (KDQOL) and its derivative versions (KDQOL-SF, KDQOL-36). The appropriateness of using the SF-36 in this population is challenged and recommendations include using the WHOQOL-BREF in cases when a generic instrument is required and the KDQOL-SF when a more disease-specific measurement is called for.

Patient views about treatment of stage 5 CKD: a qualitative analysis of semistructured interviews

BACKGROUND

How patients choose between alternative treatments for kidney failure is poorly understood. Recent studies of chronic kidney disease report that clinical outcomes, such as life expectancy, are rarely reflected in a patient's decision for type of treatment compared with nonclinical outcomes, such as time on dialysis therapy, convenience, or impact on the family.

METHODS

A qualitative analysis using thematic synthesis of patient views about renal replacement therapy (RRT) was undertaken. As part of a national study of patients and renal health care providers, we interviewed 95 Australian dialysis and transplant patients to explore how they perceive these alternative treatments.

RESULTS

52 patients were on satellite hemodialysis therapy, 8 patients were on incenter hemodialysis therapy, 8 patients were on continuous ambulatory peritoneal dialysis therapy, 5 patients were on automated peritoneal dialysis therapy, 4 patients were on home hemodialysis therapy, and 18 patients had a functioning transplant at the time of interview. Freedom, convenience, self-care, effectiveness, and simplicity were commonly cited positive characteristics, whereas confinement, risk, family burden, pain, and time commitment were negative characteristics associated with RRTs. Characteristics were not specific to dialysis modalities, and some (eg, self-care) were seen as both positive and negative. A limitation of the study was that only 17 of 77 (22%) dialysis patients interviewed were on a home-based therapy.

CONCLUSIONS

Patients preferred RRTs that enhanced their freedom and autonomy and were convenient, effective, and simple. Treatments that minimized confinement and risk also were viewed positively. Our analysis suggests that patients might choose between therapies based on their perception regarding which therapy most embodies particular characteristics that minimize impact on their lifestyle. Presentation of information regarding RRTs should focus on these characteristics and the potential impact of alternative treatments on the patients and how they wish to lead their lives.

The views of patients and carers in treatment decision making for chronic kidney disease: systematic review and thematic synthesis of qualitative studies

OBJECTIVE

To synthesise the views of patients and carers in decision making regarding treatment for chronic kidney disease, and to determine which factors influence those decisions.

DESIGN

Systematic review of qualitative studies of decision making and choice for dialysis, transplantation, or palliative care, and thematic synthesis of qualitative studies.

DATA SOURCES

Medline, PsycINFO, CINAHL, Embase, social work abstracts, and digital theses (database inception to week 3 October 2008) to identify literature using qualitative methods (focus groups, interviews, or case studies). Review methods Thematic synthesis involved line by line coding of the findings of the primary studies and development of descriptive and analytical themes.

RESULTS

18 studies that reported the experiences of 375 patients and 87 carers were included. 14 studies focused on preferences for dialysis modality, three on transplantation, and one on palliative management. Four major themes were identified as being central to treatment choices: confronting mortality (choosing life or death, being a burden, living in limbo), lack of choice (medical decision, lack of information, constraints on resources), gaining knowledge of options (peer influence, timing of information), and weighing alternatives (maintaining lifestyle, family influences, maintaining the status quo).

CONCLUSIONS

The experiences of other patients greatly influenced the decision making of patients and carers. The problematic timing of information about treatment options and synchronous creation of vascular access seemed to predetermine haemodialysis and inhibit choice of other treatments, including palliative care. A preference to maintain the status quo may explain why patients often remain on their initial therapy.

Survival disparities in patients with lymphoma according to place of residence and treatment provider: a population-based study

PURPOSE

Health disparities exist according to an individual's place of residence. We evaluated the association between primary area of residence (urban v rural) according to treatment provider (university based v community based) and overall survival in patients with lymphoma and determined whether there are patient groups that could benefit from better coordination of care.

PATIENTS AND METHODS

Population-based, retrospective cohort study of 2,330 patients with centrally confirmed lymphoma from Nebraska and surrounding states and treated by university-based or community-based oncologists from 1982 to 2006.

RESULTS

Among urban residents, 321 (14%) were treated by university-based providers (UUB) and 816 (35%) were treated by community-based providers (UCB). Among rural residents, 332 (14%) were treated by university-based providers (RUB), and 861 (37%) were treated by community-based providers (RCB). The relative risk (RR) of death among UUB, UCB, and RUB were not statistically different. However, RCB had a higher risk of death (RR, 1.37; 95% CI, 1.14 to 1.65; P = .01; and RR, 1.26; 95% CI, 1.06 to 1.49; P = .01) when compared with UUB and RUB, respectively. This association was true in both low- and intermediate-risk patients. Among high-risk patients, UCB, RUB, and RCB were all at higher risk of death when compared with UUB.

CONCLUSION

Survival outcomes of patients with lymphoma may be associated with place of residence and treatment provider. High-risk patients from rural areas may benefit from better coordination of care.

Patients' experiences and perspectives of living with CKD

Explicit incorporation of patients' values and preferences is important in health care decision making. However, there are few data about this topic for patients with chronic kidney disease (CKD). We conducted 9 focus groups (3 each for CKD stages 1 to 5, CKD stage 5D, and CKD stages 1 to 5T). Five major themes were identified: (1) personal meaning of CKD, (2) managing and monitoring health, (3) lifestyle consequences, (4) family impact, and (5) informal support structures. Patients had to adjust to the disruptive and permanent implications of the illness on their physical health, identity, emotions, family, lifestyle, relationships, and employment. The overwhelming fatigue, complex treatment regimens, side effects, and liquid and diet restrictions constrained patients' lives. Patients appreciated specialist care, but described the health care system as nonintegrated and believed they received insufficient information and psychosocial support. Choice of treatments was based on lifestyle, family impact, and physical comfort, seldom on clinical outcomes. Time was needed to comprehend the diagnosis, cope with uncertainty, integrate their treatment regimen into their daily routine, and reestablish a sense of normality in their lives. Rather than focusing on clinical targets, greater attention may need to be given to providing information and psychosocial and practical support at a patient-level not organ-specific level, to maximize patient quality of life.

Information topics important to chronic kidney disease patients: a systematic review

It is essential to identify the information topics that are important to chronic kidney disease (CKD) patients to provide 'appropriate' information that will improve their knowledge, promote independence and encourage them to self-manage their illness. This paper, through a systematic review, explores the existing body of evidence on the information needs of CKD patients to identify information topic areas important to these patients and highlight factors that influence a patient's information needs.

Travel time to dialysis as a predictor of health-related quality of life, adherence, and mortality: the Dialysis Outcomes and Practice Patterns Study (DOPPS)

BACKGROUND

Longer travel time to the dialysis unit creates a substantial burden for many patients. This study evaluated the effect of self-reported 1-way travel time to hemodialysis on mortality, health-related quality of life (HR-QOL), adherence, withdrawal from dialysis therapy, hospitalization, and transplantation.

STUDY DESIGN

Prospective observational cohort.

SETTING & PARTICIPANTS

Patients enrolled in the Dialysis Outcomes and Practices Patterns Study who completed a patient questionnaire (n = 20,994).

PREDICTOR

One-way travel time to hemodialysis treatment, categorized as 15 or less, 16 to 30, 31 to 60, and longer than 60 minutes. Covariates included demographics, comorbid conditions, serum albumin level, time on dialysis therapy, and country.

OUTCOME & MEASUREMENT

HR-QOL was examined by using a linear mixed model. Cox proportional hazards regression was used to examine associations with mortality, withdrawal from dialysis therapy, hospitalization, and transplantation.

RESULTS

Longer travel time was associated with greater adjusted relative risk (RR) of death (P = 0.05 for overall trend). Adjusted HR-QOL subscales were significantly lower for those with longer travel times compared with those traveling 15 minutes or less. There were no associations of travel time with withdrawal from dialysis therapy (P = 0.6), hospitalization (P = 0.4), or transplantation (P = 0.7).

LIMITATIONS

The questionnaire nonresponse rate was substantial, and nonresponders were older, with more comorbid conditions. Travel time was assessed by using a single nonvalidated question.

CONCLUSIONS

Longer travel time is associated significantly with greater mortality risk and decreased HR-QOL. Exploring opportunities to decrease travel time should be incorporated into the dialysis clinical routine.

Sleep apnea and dialysis therapies: things that go bump in the night?

Sleep apnea has been linked to excessive daytime sleepiness, depressed mood, hypertension, and cardiovascular disease in the general population. The prevalence of severe sleep apnea in the conventional thrice-weekly hemodialysis population has been estimated to be more than 50%. Sleep apnea leads to repetitive episodes of hypoxemia, hypercapnia, sleep disruption, and activation of the sympathetic nervous system. The hypoxemia, arousals, and intrathoracic pressure changes associated with sleep apnea lead to sympathetic activation, endothelial dysfunction, oxidative stress, and inflammation. Because sleep apnea has been shown to be widespread in the conventional dialysis population, it may be that sleep apnea contributes substantially to the sleepiness, poor quality of life, and cardiovascular disease found in this population. The causal links between conventional dialysis and sleep apnea remain speculative, but there are likely multiple factors related to volume status and azotemia that contribute to the high rate of severe sleep apnea in dialysis patients. Both nocturnal automated peritoneal dialysis and nocturnal hemodialysis have been associated with reduced severity of sleep apnea. Nocturnal dialysis modalities may provide tools to increase our understanding of the uremic sleep apnea and may also provide therapeutic alternatives for end-stage renal disease patients with severe sleep apnea. In conclusion, sleep apnea is an important, but overlooked, public health problem for the dialysis population. The impact of sleep apnea treatment in this high-risk population may include reduced sleepiness, better mood and blood pressure, and lowered risk of cardiovascular disease.

Assessment of health-related quality of life among patients with chronic kidney disease

The health-related quality of life (HRQOL) of patients with chronic kidney disease influences the timing of the initiation of dialysis, whether they continue to work with progressive kidney failure and whether they maintain an active role in the home and community. The importance of HRQOL to the goals of therapy has been widely documented for dialysis patients who chose not to receive a kidney transplant and those with substantial comorbidities who are not candidates for kidney transplantation, patients who are confined to the chronic rigors of maintenance dialysis. The usual conceptualization of HRQOL has been based on the World Health Organization's definition of QOL as a complete state of physical, mental, and social well-being and not merely an absence of disease in infirmity. This conceptual model has limitations because few standard HRQOL questionnaires assess satisfaction with family despite being a critical domain to patients. Measuring and monitoring HRQOL in CKD patients can be achieved with the widespread implementation of facile HRQOL assessment. The importance of HRQOL has been increasingly recognized by health care payers, health care providers, regulatory agencies, and researchers, both within and outside the renal community. Despite the apparent need and potential benefits of HRQOL assessments in dialysis patients, there are limitations to the translation of such assessments from the research domain into the clinical arena such as the length of questionnaires and display of the information at the point of care. These limitations can be addressed through the development of computer-adaptive testing (CAT). CAT permits the response of the patient to inform the selection of the next question. In this way, the length of HRQOL questionnaires may be dramatically shortened while not sacrificing the sensitivity or reliability of a longer instrument. The routine use of HRQOL assessments in the care of patients with CKD represents an important opportunity for the nephrologist to better incorporate the values and concerns of the patient into their care.

Issues in conducting cross-cultural research: implementation of an agreed international protocol [corrected] designed by the WHOQOL Group for the conduct of focus groups eliciting the quality of life of older adults

Multi-centre and cross-cultural research require the use of common protocols if the results are to be either pooled or compared. All too often adherence to protocols is not discussed in reports and where it is reported poor adherence is frequently noted. This paper discusses the use of international guidelines developed by WHOQOL Field Centres to conduct and report focus groups aimed at eliciting key concepts of quality of life among older adults. This was the first step in the development of the WHOQOL-OLD instrument. Although there was overall adherence to the agreed guidelines, there were some differences in the level of reporting, even after participating Field Centres had the opportunity to explain their reports. The reasons for these discrepancies are reported. It is concluded that because of local situations, it is difficult to achieve identical implementation of multi-centre cross-cultural protocols and that the highest standards of auditing are required if findings are to be compared. Suggestions for how such protocols can be improved are given.

Health-related quality of life in nephrology research and clinical practice

Physical, psychosocial, and lifestyle disturbances, along with physical and emotional symptoms, have been shown to impact the health-related quality of life (HRQOL) of those dependent on renal replacement therapy. The value of HRQOL measurement as a tool to improve clinical care has been recognized by patients, clinical investigators, and health care providers. The potential importance of HRQOL assessment lies in the additional information it provides and the impact it has on the clinical decision-making process between a patient and a physician. There remain a multitude of challenges facing renal providers who wish to incorporate HRQOL measurement to improve patient care. These challenges include the clinician's understanding of the conceptual model of HRQOL, the quality of the scientific process that contributed to the current literature on HRQOL, a willingness of the clinician to incorporate HRQOL information into clinical practice, and the logistic difficulties of collecting and applying HRQOL data in a busy practice setting. Arguably, optimizing HRQOL may be the most substantial impact the health care team will have on the person with kidney failure. In order to implement HRQOL assessment at the point of care, providers may consider using computer adaptive testing and scoring algorithms using item response theory, which will allow adequate reliability for interpretation of change among individuals. Moreover, the effective assessment and interpretation of HRQOL will be aided by continued publication of norms, outcomes of randomized controlled trials, and continued experience of investigators and clinicians.

Renal replacement therapy choices for pre-dialysis renal patients

With the numbers of patients developing end-stage renal failure predicted to increase over the coming years, more patients than ever will be expected to choose their future form of renal replacement treatment. This study explored the decision-making processes of pre-dialysis patients to elucidate how these choices were made. Nine pre-dialysis patients were interviewed, transcripts of which were analysed using interpretative phenomenological analysis. Four main themes relating to the decision-making process emerged: maintaining one's integrity, forced adaptation, utilizing information, and support and experiencing illness. While making a decision was an individualized process, contextualized within participants' illness experiences, these core themes emerged for the whole group, irrespective of the chosen treatment modality. For renal services, there is a need to tailor information provided to pre-dialysis patients and to become cognizant of the contexts in which they live and operate.

Health Related Quality of Life in Patients with Chronic Kidney Disease

Monitoring a patient's functional status and the subjective state of well being as it related to health condition, together known as health related quality of life (HRQOL) measurements, is of particular importance in patients with chronic kidney disease (CKD) including those with end stage renal disease (ESRD). The concept of quality of life in dialysis has evolved since the inception of renal replacement therapy from simple survival to enjoying a certain level of well being. The measurement of dialysis outcomes have paralleled the improvement in the delivery of renal replacement therapy progressing from level of functioning, symptom checklists, multi dimensional well being, and moving perhaps to more patient centered quality of life. HRQOL domains have been strongly associated with objective patient outcomes. The self reported physical functioning and mental well being correlate with serum albumin and body composition measures. The ability of those on hemodialysis to self administer questionnaires is a barrier to the widespread use of multidimensional HRQOL assessment in clinical practice. However, new technologies using computer adaptive testing and item response theory may allow those questionnaires to be quickly and more efficiently administered by clinic staff. The finding of different HRQOL scores among CKD patients of different racial and ethnic backgrounds supports the need to individualize the concept of HRQOL, so that we can assess the crucial aspects of life in our patients and integrate these domains into a comprehensive plan of care. These recent findings underline the critical need to measure HRQOL and to expand the boundaries of our multidimensional tools with technology and a more patient centered concept of quality of life.

Sleep disturbances in dialysis patients

Sleep disturbances are extremely common in dialysis patients. Subjective sleep complaints are reported in up to 80% of those surveyed and sleep apnoea syndrome, restless legs syndrome, and periodic limb movement disorder are much more prevalent than in the general population. Excessive daytime sleepiness is also an important problem. These sleep abnormalities appear to have significant negative effects on quality of life and functional health status. Although long-term studies regarding other effects on health outcomes remain to be conducted, available data also suggest that sleep disturbances may have an important impact on morbidity and mortality. Achieving a more complete understanding of the sleep problems experienced by this group is absolutely imperative if improving health outcomes is the goal. Clinicians and researchers alike face numerous challenges in this regard, especially when considering the complex clinical presentation and treatment needs typical of these patients. Therefore, the purpose of this article is to present an up-to-date review of the literature regarding sleep disturbances in dialysis patients with special emphasis on the numerous factors potentially contributing to these problems and associated clinical and research implications.

Judgment analysis of prioritization decisions within a dialysis program in one United Kingdom region

BACKGROUND

Some previous research on rationed clinical services has confused the conceptual differences underpinning prioritization decisions on the one hand and assessments of individual need on the other. The balance of the clinical and nonclinical drivers of these decisions can be different. Our objective was to study the basis and extent of variation among nephrologists in one NHS region in their views concerning prioritization for dialysis.

DESIGN AND METHODS

In a clinical judgment analysis, multiple regression analysis was used to express the impact of clinical and nonclinical cues on nephrologists' decisions to offer dialysis and attribute priority to 50 "paper patients." Cues were selected for the decision-making models using stepwise (backward) elimination of variables. Further "policy" models for priority were derived by forcing in the doctors' views about the capacity of dialysis to extend life expectancy or improve its quality.

RESULTS

Comparison of "propensity to offer" and "prioritization" decision models showed a modest degree of correspondence. Among the nonrenal cues, the patient's mental state made the single greatest contribution to the priority decision models (mean contribution to R2 = 12.1, with temporary or permanent confusional states in patients changing the priority [1-50] by an average of 15 rank places). Although patient age significantly influenced the decision models of half of the doctors, the beta-coefficients were very modest, suggesting a change in rank order of no more than one place. There was a significant improvement in the overall explained variance (R2) of the models when varying perceptions of the capacity of dialysis to improve the quality or extend the duration of the patient's life were forced into the model. Although, in general, temporary or permanent confusion in the patient down-graded the priority for dialysis by between 10 and 20 places, this tendency was largely unchanged when the doctors' perceptions of benefit were forced into the priority model. Among renal cues, the presence of uremic symptoms had the greatest impact on priority (mean contribution to R2 = 49.1, mean beta-coefficient -17.1), whereas the presence of other comorbid disease had relatively little effect.

CONCLUSIONS

When forced to rank patients, the nonrenal factor that had the most significant bearing on perceived priority for dialysis was the patient's mental state. However, the impact of the patient's mental state on priority did not appear to be driven by its influence on the doctors' perceptions of how dialysis might improve quality of life.

Influence of self-efficacy and other factors on dietary behaviours in Japanese haemodialysis patients

In Japan, haemodialysis patients are required to adhere to a fairly rigid dietary regimen. Guided by Bandura's theory of self-efficacy, this study tested a prediction model of dietary behaviour. A total of 325 individuals completed a self-administered survey containing nine scales, which were used to measure the six constructs in the model. Using multiple regression analysis, 24% of the variance on the Dietary Behaviour Scale could be accounted for by three predictor scales, Dietary Management Self-efficacy, Support from Family, and Self-Repressive Behaviour Patterns. Multiple regression analysis identified that four scales, Character Image of Dialysis Staff, Support from Family, Dialysis Acceptance, and Somatic Symptoms, contributed to 13% of the variance of the Dietary Management Self-efficacy Scale. These results might provide direction to those who are involved in the support and care of haemodialysis patients, some of whom require life-long treatment, as is common in Japan.

Posttraumatic concerns: a patient-centered approach to outcome assessment after traumatic physical injury

BACKGROUND

Approximately 2.5 million Americans are admitted to the hospital after traumatic physical injury each year. Few investigations have elicited patients' perspectives regarding posttraumatic outcomes.

OBJECTIVE

To identify and categorize physically injured trauma survivors' posttraumatic concerns.

RESEARCH DESIGN

Prospective longitudinal investigation; trauma survivors were interviewed during the post-injury hospitalization and again 1, 4, and 12 months after the trauma.

SUBJECTS

Ninety-seven, randomly selected, English speaking, hospitalized survivors of motor vehicle-crashes or assaults.

MEASURES

At the end of each interview patients were asked, "Of all the things that have happened to you since you were injured, what concerns you the most?" Using an iterative process and working by consensus, investigators categorized patient concerns in content domains. Concern domains were then compared with established measures of posttraumatic stress disorder (PTSD) symptoms and limitations in physical functioning.

RESULTS

Seven categories of posttraumatic concerns were identified. During the course of the year, 73% of patients expressed physical health concerns, 58% psychological concerns, 53% work and finance concerns, 40% social concerns, 10% legal concerns, 10% medical concerns, and 20% uncodable concerns. Rater agreement on concern categorization was substantial (kappa = 0.72). The mean number of concerns expressed per patient gradually decreased over time (1 month mean = 1.51; 12 month mean = 1.26) and resembled the trajectories of PTSD symptoms and functional limitations.

CONCLUSIONS

The concerns of physically injured trauma survivors are readily elicited and followed up during the course of the year after injury. Open-ended inquiry regarding posttraumatic concerns may complement standardized outcome assessments by identifying and contextualizing the outcomes of greatest importance to patients.

Developing a health-related quality-of-life measure for end-stage renal disease: The CHOICE Health Experience Questionnaire

The Choices for Healthy Outcomes in Caring for End-Stage Renal Disease ([ESRD] CHOICE) Study was designed to evaluate the effectiveness of alternative dialysis prescriptions. As part of CHOICE, we developed an instrument for measuring health-related quality of life (HRQOL) for patients with ESRD that would complement the Medical Outcomes Study 36-Item Short-Form Survey (SF-36) and be sensitive to differences in dialysis modality (hemodialysis [HD] and peritoneal dialysis [PD]) and dialysis dose. The selection of HRQOL domains to be included was based on: (1) a structured literature review of 47 articles describing 53 different instruments; (2) content analysis of five focus groups with HD and PD patients, nephrologists, and other providers; (3) a survey of 110 dialysis providers about features of different modalities that affect patient HRQOL; and (4) a semistructured survey of 25 patients with ESRD on the effects of dialysis on functioning and HRQOL. To help prioritize domains and items identified by these methods, a representative sample of 136 dialysis patients rated each item for frequency and bother. A panel of nephrologists provided advice about the salience of items to modality or dose. Items and scales were selected with a preference for existing measures tested in patients with ESRD and were tested for reliability and validity. The first four steps yielded 22 HRQOL domains that included 96 items: 8 generic domains in the SF-36 (health perceptions, physical, social, physical and emotional role function, pain, mental health, and energy); 8 additional generic domains (cognitive functioning, sexual functioning, sleep, work, recreation, travel, finances, and general quality of life); and 6 ESRD-specific domains (diet, freedom, time, body image, dialysis access [catheters and/or vascular], and symptoms). New items were developed or adapted to assess ESRD-specific domains. Scales for these items showed adequate internal consistency (Cronbach's alpha > 0.70, except for time [alpha = 0.57] and quality of life [alpha = 0.68]), as well as convergent and discriminant construct validity in a sample of 928 patients. The final questionnaire included 21 domains (time was deleted) and 83 items. We have designed a patient-centered instrument, the CHOICE Health Experience Questionnaire, that addresses domains that may be sensitive to differences in dialysis modality and dose and shows evidence for reliability and validity as a measure of HRQOL in ESRD.

Formal literature review of quality-of-life instruments used in end-stage renal disease

Although quality-of-life assessment is an important complement to conventional clinical evaluation, there are limited opportunities for researchers in end-stage renal disease (ESRD) to examine evidence for a range of quality-of-life measures. To better understand how quality of life has been conceptualized, measured, and evaluated for ESRD, we conducted a structured literature review. Eligible articles were identified from a MEDLINE search, expert input, and review of references from eligible articles. A standardized instrument was created for article review and included type of measure, instrument development process, study sample characteristics, quality-of-life domains, and reliability and validity testing. From 436 citations, 78 articles were eligible for final review, and of those, 47 articles contained evidence of reliability or validity testing. Within this set, there were 113 uses of 53 different instruments: 82% were generic and 18% were disease specific. Only 32% defined quality of life. The most frequently assessed domains were depression (41%), social functioning (32%), positive affect (30%), and role functioning (27%). Testing was completed for test-retest reliability (20%), interrater reliability (13%), internal consistency (22%), content validity (24%), construct validity (41%), criterion validity (55%), and responsiveness (59%). Few articles measuring quality of life in ESRD defined quality-of-life domains or adequately described instrument development and testing. Generic measures, such as the Sickness Impact Profile, and disease-specific measures, such as the Kidney Disease Questionnaire, had been tested more thoroughly than others. Standardized reporting and more rigorous testing could help researchers make informed choices about instruments that would best serve their own and their patients' needs.