Implementation and Effectiveness of a Learning Collaborative to Improve Palliative Care for Seriously Ill Hemodialysis Patients

Nephrology providers' perspective and use of mortality prognostic tools in dialysis patients

BACKGROUND

Mortality prognostic tools exist to aid in shared decision making with kidney failure patients but are underutilized. This study aimed to elucidate nephrology providers' practice patterns and understand barriers to prognostic tool use.

METHODS

Nephrology providers (8 physicians and 2 nurse practitioners) at an academic medical center underwent semi-structured interviews regarding their experience and perspective on the utility of mortality prognostic tools. Common themes were identified independently by 2 reviewers using grounded theory. Three six-month mortality prognostic tools were applied to the 279 prevalent dialysis patients that the interviewed providers care for. The C statistic was calculated for each tool via logistic regression and subsequent ROC analysis. Nephrology providers reviewed the performance of the prognostication tools in their own patient population. A post interview reassessed perspectives and any change in attitudes regarding the tools.

RESULTS

Nephrology providers did not use these mortality prognostic tools in their practice. Key barriers identified were provider concern that the tools were not generalizable to their patients, providers' trust in their own clinical judgement over that of a prognostic tool, time constraints, and lack of knowledge about the data behind these tools. When re-interviewed with the results of the three prognostic tools in their patients, providers thought the tools performed as expected, but still did not intend to use the tools in their practice. They reported that these tools are good for populations, but not individual patients. The providers preferred to use clinical gestalt for prognostication.

CONCLUSION

Although several well validated prognostic tools are available for predicting mortality, the nephrology providers studied do not use them in routine practice, even after an educational intervention. Other approaches should be explored to help incorporate prognostication in shared-decision-making for patients receiving dialysis.

Improving age-friendly advance care planning in primary care: Outcomes from a Pacific Northwest learning collaborative

BACKGROUND

Advance care planning (ACP) is the process of having conversations with patients to ensure preferences are known and support patient healthcare goals. ACP and the Age-Friendly Health Systems (AFHS) Initiative's, "What Matters," are synergistic approaches to patient-centered conversations. Implementation and measurement of ACP in primary care (PC) are variables in quality and consistency. We examined whether participation in an ACP learning collaborative (LC) would improve knowledge and ability to conduct ACP discussions and increase the frequency of documented ACP in participating practices.

METHODS

The WWAMI (Washington, Wyoming, Alaska, Montana, and Idaho) region Practice and Research Network (WPRN) and the Northwest Geriatrics Workforce Enhancement Center collaboratively organized a 9-month virtual LC. It consisted of 4 synchronous, 1.5-h sessions, technical support, and a panel of ACP experts. A Wilcoxon rank sum test assessed differences in knowledge from a pre-post survey. Documentation of ACP in the EHR was collected after at least one plan-do-study-act cycle.

RESULTS

We enrolled 17 participants from 6 PC practices (3 hospital-affiliated; 3 Federally Qualified Health Centers) from the WPRN. Two practices did not complete all LC activities. There was a trend toward increased ACP knowledge and skills overall especially in having discussions patients and families (pre-mean 2.9 [SD = 0.7]/post-mean 4.0[SD = 1.1], p < 0.05). 4/6 practices observed an increase in EHR documentation post-collaborative (median 16.3%, IQR 1.3%-36.9%).

CONCLUSIONS

The LC increased PC providers knowledge and skills of ACP and AFHS's What Matters, reported ACP EHR documentation, and contributed to practice change.

"Diving in the deep-end and swimming": a mixed methods study using normalization process theory to evaluate a learning collaborative approach for the implementation of palliative care practices in hemodialysis centers

BACKGROUND

Normalization Process Theory (NPT) is an implementation theory that can be used to explain how and why implementation strategies work or not in particular circumstances. We used it to understand the mechanisms that lead to the adoption and routinization of palliative care within hemodialysis centers.

METHODS

We employed a longitudinal, mixed methods approach to comprehensively evaluate the implementation of palliative care practices among ten hemodialysis centers participating in an Institute for Healthcare Improvement Breakthrough- Series learning collaborative. Qualitative methods included longitudinal observations of collaborative activities, and interviews with implementers at the end of the study. We used an inductive and deductive approach to thematic analysis informed by NPT constructs (coherence, cognitive participation, collective action, reflexive monitoring) and implementation outcomes. The NoMAD survey, which measures NPT constructs, was completed by implementers at each hemodialysis center during early and late implementation.

RESULTS

The four mechanisms posited in NPT had a dynamic and layered relationship during the implementation process. Collaborative participants participated because they believed in the value and legitimacy of palliative care for patients receiving hemodialysis and thus had high levels of cognitive participation at the start. Didactic Learning Sessions were important for building practice coherence, and sense-making was solidified through testing new skills in practice and first-hand observation during coaching visits by an expert. Collective action was hampered by limited time among team members and practical issues such as arranging meetings with patients. Reflexive monitoring of the positive benefit to patient and family experiences was key in shifting mindsets from disease-centric towards a patient-centered model of care. NoMAD survey scores showed modest improvement over time, with collective action having the lowest scores.

CONCLUSIONS

NPT was a useful framework for understanding the implementation of palliative care practices within hemodialysis centers. We found a nonlinear relationship among the mechanisms which is reflected in our model of implementation of palliative care practices through a learning collaborative. These findings suggest that the implementation of complex practices such as palliative care may be more successful through iterative learning and practice opportunities as the mechanisms for change are layered and mutually reinforcing.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT04125537 . Registered 14 October 2019 - Retrospectively registered.

Pathways Project Pragmatic Lessons Learned: Integrating Supportive Care Best Practices into Real-World Kidney Care

Key Points

A multisite quality improvement project using the Institute for Healthcare Improvement learning collaborative structure helped kidney care teams identify seriously ill patients and implement supportive care best practices. Helpful approaches included needs assessment, Quality Assurance and Performance Improvement tools, peer exchange, clinician role modeling, data feedback, and technical assistance. Dialysis center teams tailored implementation of best practices into routine dialysis workflows with nephrologist prerogative to delegate goals of care conversations to nurse practitioners and social workers.

Background

Despite two decades of national and international guidelines urging greater availability of kidney supportive care (KSC), uptake in the United States has been slow. We conducted a multisite quality improvement project with ten US dialysis centers to foster implementation of three KSC best practices. This article shares pragmatic lessons learned by the project organizers.

Methods

The project team engaged in reflection to distill key lessons about what did or did not work in implementing KSC.

Results

The seven key lessons are (1 ) systematically assess KSC needs; (2 ) prioritize both the initial practices to be implemented and the patients who have the most urgent needs; (3 ) use a multifaceted approach to bolster communication skills, including in-person role modeling and mentoring; (4 ) empower nurse practitioners and social workers to conduct advance care planning through teamwork and warm handoffs; (5 ) provide tailored technical assistance to help sites improve documentation and electronic health record processes for storing advance care planning information; (6 ) coach dialysis centers in how to use required Quality Assurance and Performance Improvement processes to improve KSC; and (7 ) implement systematic approaches to support patients who choose active medical management without dialysis.

Conclusions

Treatment of patients with kidney disease is provided in a complex system, especially when considered across the continuum, from CKD to kidney failure on dialysis, and at the end of life. Even among enthusiastic early adopters of KSC, 18 months was insufficient time to implement the three prioritized KSC best practices. Concentrating on a few key practices helped teams focus and see progress in targeted areas. However, effect for patients was attenuated because federal policy and financial incentives are not aligned with KSC best practices and goals.

Clinical Trial registry name and registration number

Pathways Project: KSC, NCT04125537 .