Using Patient-Reported Measures in Dialysis Clinics

Dialysis Patient Experiences During the COVID-19 Pandemic: A Survey Study

Rationale & Objective

The coronavirus disease 2019 (COVID-19) pandemic imposed several changes in the care of patients with kidney failure receiving dialysis. We explored patient care experiences during the pandemic.

Study Design

The study team verbally administered surveys including Likert scale multiple-choice questions and open-ended questions and recorded responses.

Setting & Participants

Surveys were administered to adults receiving dialysis through an academic nephrology practice after the first wave of the COVID-19 pandemic.

Exposure

Outpatient dialysis treatment during the COVID-19 pandemic.

Outcomes

Perceptions of care and changes in health.

Analytical Approach

Multiple-choice responses were quantified using descriptive statistics. Thematic analysis was used to code open-ended responses and derive themes surrounding patient experiences.

Results

A total of 172 patients receiving dialysis were surveyed. Most patients reported feeling "very connected" to the care teams. Seventeen percent of participants reported transportation issues, 6% reported difficulty obtaining medications, and 9% reported difficulty getting groceries. Four themes emerged as influencing patient experiences during the pandemic: 1) the COVID-19 pandemic did not significantly affect participants' experience of dialysis care; 2) the COVID-19 pandemic significantly impacted other aspects of participants' lives, which in turn were felt to affect mental and physical health; 3) regarding dialysis care experience more generally, participants valued consistency, dependability, and personal connection to staff; and 4) the COVID-19 pandemic highlighted the importance of external social support.

Limitations

Surveys were administered early in the COVID-19 pandemic, and patient perspectives have not been reassessed. Further qualitative analysis using semi-structured interviews was not performed. Survey distribution in additional practice settings, using validated questionnaires, would increase generalizability of the study. The study was not powered for statistical analysis.

Conclusions

Early in the COVID-19 pandemic, perceptions of dialysis care were unchanged for most patients. Other aspects of participants' lives were impacted, which affected their health. Subpopulations of patients receiving dialysis may be more vulnerable during the pandemic: those with histories of mental health conditions, non-White patients, and patients treated by in-center hemodialysis.

Plain-language summary

Patients with kidney failure continue to receive life-sustaining dialysis treatments during the coronavirus disease 2019 (COVID-19) pandemic. We sought to understand perceived changes in care and mental health during this challenging time. We administered surveys to patients receiving dialysis after the initial wave of COVID-19, asking questions on topics including access to care, ability to reach care teams, and depression. Most participants did not feel that their dialysis care experiences had changed, but some reported difficulties in other aspects of living such as nutrition and social interactions. Participants highlighted the importance of consistent dialysis care teams and the availability of external support. We found that patients who are treated with in-center hemodialysis, are non-White, or have mental health conditions may have been more vulnerable during the pandemic.

Burden of mental health symptoms and perceptions of their management in in-centre hemodialysis care: a mixed methods study

Background

We aimed to describe (1) depressive and anxiety symptom burdens reported by adults on in-centre hemodialysis in Northern Alberta, Canada and (2) patients’ and nurses’ perceptions of managing such symptoms using routine patient-reported outcome measures (PROMs).

Methods

A longitudinal mixed methods approach was employed. Cluster randomized controlled trial data exposed the prevalence of positive screens (scores ≥ 3) for depressive (PHQ-2) and anxiety (GAD-2) symptoms. A descriptive qualitative approach was used to understand patients’ and nurses’ perceptions of managing these symptoms using the ESAS-r: Renal and EQ-5D-5L. Using purposeful sampling, patients and nurses were invited for interviews. Field notes were documented from 6 dialysis unit observations. Patients’ responses to open-ended survey questions and nurses’ electronic chart notes related to mental health were compiled. Thematic and content analyses were used.

Results

Average age of patients (n = 408) was 64.0 years (SD 15.4), 57% were male, and 87% were not working; 29% screened positive for depressive symptoms, 21% for anxiety symptoms, and 16% for both. From patient (n = 10) and nurse (n = 8) interviews, unit observations, patient survey responses (n = 779) and nurses’ chart notes (n = 84), we discerned that PROMs (ESAS-r: Renal/EQ-5D-5L) had the potential to identify and prompt management of mental health concerns. However, opinions differed about whether mental health was within kidney care scope. Nonetheless, participants agreed there was a lack of mental health resources.

Conclusions

Prevalence of depressive and anxiety symptoms aligned with existing literature. Tensions regarding mental health management highlight the need for systemic decisions about how routine PROM use, including mental health assessment, may be optimized to meet patients’ needs.

Supplementary Information

The online version contains supplementary material available at 10.1186/s41687-021-00385-z.

Mapping the Edmonton Symptom Assessment System-Revised: Renal to the EQ-5D-5L in patients with chronic kidney disease

PURPOSE

The Edmonton Symptom Assessment System-Revised: Renal (ESAS-r: Renal) is a disease-specific patient-reported outcome measure (PROM) that assesses symptoms common in chronic kidney disease (CKD). There is no preference-based scoring system for the ESAS-r: Renal or a mapping algorithm to predict health utility values. We aimed to develop a mapping algorithm from the ESAS-r: Renal to the Canadian EQ-5D-5L index scores.

METHODS

We used data from a multi-centre cluster randomized-controlled trial of the routine measurement and reporting of PROMs in hemodialysis units in Northern Alberta, Canada. In two arms of the trial, both the ESAS-r: Renal and the EQ-5D-5L were administered to CKD patients undergoing hemodialysis. We used data from one arm for model estimation, and data from the other for validation. We explored direct and indirect mapping models; model selection was based on statistical fit and predictive power.

RESULTS

Complete data were available for 506 patient records in the estimation sample and 242 in the validation sample. All models tended to perform better in patients with good health, and worse in those with poor health. Generalized estimating equations (GEE) and generalized linear model (GLM) on selected ESAS-r: Renal items were selected as final models as they fitted the best in estimation and validation sample.

CONCLUSION

When only ESAS-r: Renal data are available, one could use GEE and GLM to predict EQ-5D-5L index scores for use in economic evaluation. External validation on populations with different characteristics is warranted, especially where renal-specific symptoms are more prevalent.

Evaluation of PROMIS Preference Scoring System (PROPr) in Patients Undergoing Hemodialysis or Kidney Transplant

BACKGROUND AND OBJECTIVES

A preference-based health utility score (PROPr) can be calculated using Patient-Reported Outcomes Measurement Information System domain scores. We assessed the construct validity of PROPr among patients treated with KRT (hemodialysis or kidney transplant).

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

We performed a secondary analysis of data collected in multicenter, cross-sectional studies of adults treated with KRT, recruited between April 2016 to March 2020 in Toronto, Canada. All participants provided informed consent. The outcome was the PROPr score. Coadministered outcome variables included the Short-Form Six-Domain (SF-6D) and EuroQol Five-Domain Five-Level (EQ-5D-5L) scores. Socioeconomic and clinical variables included age, sex, diabetes, eGFR, serum albumin, hemoglobin, KRT, and Charlson Comorbidity Index. Construct validity was assessed through correlations between PROPr and SF-6D or EQ-5D-5L, and associations between PROPr and other exposure variables. Health-condition impact estimates (coefficients for health conditions compared with a referent category, e.g., dialysis versus kidney transplant) were calculated using multivariable linear regression.

RESULTS

The mean (SD) age of the 524 participants was 57 (17) years, 58% were male, and 45% were White. Median (interquartile range) score was 0.39 (0.24-0.58) for PROPr, 0.69 (0.58-0.86) for SF-6D, and 0.85 (0.70-0.91) for EQ-5D-5L. Large correlations were observed between PROPr versus SF-6D (0.79; 95% confidence interval [95% CI], 0.76 to 0.82) and EQ-5D-5L (0.71; 95% CI, 0.66 to 0.75). Both PROPr and the other utility indices demonstrated health-condition impact in the expected direction. For example, the estimate for PROPr was -0.17 (95% CI, -0.13 to -0.21) for dialysis (versus kidney transplant), -0.05 (95% CI, -0.11 to 0.01; P=0.08) for kidney transplant recipients with an eGFR of <45 versus ≥45 ml/min per 1.73 m², and -0.28 (95% CI, -0.22 to -0.33) for moderate/severe versus no/mild depressive symptoms.

CONCLUSIONS

Our results support the validity of PROPr among patients treated with KRT.

An Evidence-Based Theory About PRO Use in Kidney Care: A Realist Synthesis

BACKGROUND

There is international interest on the use of patient-reported outcomes (PROs) in nephrology.

OBJECTIVES

Our objectives were to develop a kidney-specific program theory about use of PROs in nephrology that may enhance person-centered care, both at individual and aggregated levels of care, and to test and refine this theory through a systematic review of the empirical literature. Together, these objectives articulate what works or does not work, for whom, and why.

METHODS

Realist synthesis methodology guided the electronic database and gray literature searches (in January 2017 and October 2018), screening, and extraction conducted independently by three reviewers. Sources included all nephrology patients and/or practitioners. Through a process of extraction and synthesis, each included source was examined to assess how contexts may trigger mechanisms to influence specific outcomes.

RESULTS

After screening 19,961 references, 84 theoretical and 34 empirical sources were used. PROs are proposed to be useful for providing nephrology care through three types of use. The first type is use of individual-level PRO data at point of care, receiving the majority of theoretical and empirical explorations. Clinician use to support person-centered care, and patient use to support patient engagement, are purported to improve satisfaction, health, and quality of life. Contextual factors specific to the kidney care setting that may influence the use of PRO data include the complexity of kidney disease symptom burden, symptoms that may be stigmatized, comorbidities, and time or administrative constraints in dialysis settings. Electronic collection of PROs may facilitate PRO use given these contexts. The second type is use of aggregated PRO data at point of care, including public reporting of PROs to inform decisions at point of care and improve quality of care, and use of PROs for treatment decisions. The third type is use of aggregated PRO data by organizations, including publicly available PRO data to compare centers. In single-payer systems, regular collection of PROs by dialysis centers can be achieved through economic incentives. Both the second and third types of PRO use include pressures that may trigger quality improvement processes.

CONCLUSION

The current state of the evidence is primarily theoretical. There is pressing need for empirical research to improve the evidence-base of PRO use at individual and aggregated levels of nephrology care.

Quality of Life and Health Status Among Patients Receiving Renal Replacement Therapy in Trinidad and Tobago, West Indies

PURPOSE

The determinants of quality of life for patients on renal replacement therapy vary across the world. The aim of this study is to determine the quality of life of patients on renal replacement therapy in Trinidad and Tobago and predictors thereof.

PATIENTS AND METHODS

This cross-sectional study took place over a 1-year period. Data were obtained from 530 out of 1383 patients meeting inclusion criteria (100 transplants, 80 peritoneal dialyses, 350 hemodialyses) using the survey instruments. Stratified random sampling with proportional allocation was used to select patients at hemodialysis centres. The Kidney Disease Quality of Life questionnaire (KDQOL-36), EuroQol and demographic questionnaires were administered via face-to-face interviews. SPSS24, STATA14 and MINITAB18 were used for descriptive and inferential data analysis.

RESULTS

Of the 530 patients, 52.5% were male, 37.5% were in the 56-65 years age group and 51.3% were of Indo-Trinbagonian descent. Hypertension (25.5%) and type 2 diabetes mellitus (62.0%) were reported as the main causes of kidney disease in the dialysis group. In the transplant category, chronic glomerulonephritis (45%) was the main aetiology of kidney disease. The KDQOL-36 domain scores and significantly associated variables included modality of renal replacement, Charlson's Comorbidity Index, ethnicity, income and employment status. Transplant patients had higher mean subcomponent Kidney Disease Quality of Life scores and performed better in the EuroQol than patients on dialysis. Patients on peritoneal dialysis had a better quality of life than hemodialysis patients. Among patients on hemodialysis, an arteriovenous fistula significantly impacted their quality of life.

CONCLUSION

Renal transplant recipients enjoy the best quality of life and health state among patients on renal replacement therapy in Trinidad and Tobago. Increasing patients' access to renal transplantation or peritoneal dialysis will markedly improve health status for the number of years of renal replacement therapy.

A study of quality of life among hemodialysis patients and its associated factors using kidney disease quality of life instrument-SF36 in Riyadh, Saudi Arabia

We aimed in this study to assess the quality of life for kidney-ill patients using Kidney Disease Quality of Life Instrument-SF36 (KDQOL-SF36) and the impact of other demographic, clinical, and social factors on patients' QOL. The quality of life was assessed using an Arabic version of KDQOL-36. The KDQOL-36 subscales Physical Component Summary (PCS), Mental Component Summary (MCS), Burden of Kidney Disease, and Effects of Kidney Disease were calculated. The effect of sex, diabetic status, diabetes mellitus, marital and status employment status, etc. on these subscales was evaluated. Reliability was determined by calculating Cronbach's alpha. A total of 254 patients were enrolled. The mean age was 58.2 (standard deviation 18.2) years; 61% were male, 56.7% diabetic and 20.1% were employed. The mean domain scores on the PCS, MCS, burden of kidney disease, and effects of kidney disease subscales were 49.4, 38.7, 52.6, and 37.2, respectively. Afternoon shift patients score highest among all shifts in MCS and PCS (P = 0.0001). The MCS score (38.7 ± 28.7) was significantly lower than PCS (49.4 ± 16.5) (P = 0.0001). The "effect of kidney disease" subscale was higher in males (P = 0.02), employed patients (P = 0.02), in the afternoon dialysis shift (0.0001). For PCS higher scores were seen in males (P = 0.0001), in non-diabetics (compared to diabetics) (P = 0,006), in the employed patients (P = 0.02). The highest score was seen in the "burden of kidney disease" subscale and the lowest in the "effects of kidney disease" subscale. Higher scores were seen in males, in nondiabetics, in the employed patients.

Implementing a Patient-Reported Outcome Measure for Hemodialysis Patients in Routine Clinical Care: Perspectives of Patients and Providers on ESAS-r:Renal

BACKGROUND AND OBJECTIVES

The Edmonton Symptom Assessment System Revised: Renal is a patient-reported outcome measure used to assess physical and psychosocial symptom burden in patients treated with maintenance dialysis. Studies of patient-reported outcome measures suggest the need for deeper understanding of how to optimize their implementation and use. This study examines patient and provider perspectives of the implementation process and the influence of the Edmonton Symptom Assessment System Revised: Renal on symptom management, patient-provider communication, and interdisciplinary communication.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

Eight in-facility hemodialysis programs in Ontario, Canada, assessed patients using the Edmonton Symptom Assessment System Revised: Renal every 4-6 weeks for 1 year. Screening and completion rates were tracked, and pre- and postimplementation surveys and midimplementation interviews were conducted with patients and providers. A chart audit was conducted 12 months postimplementation.

RESULTS

In total, 1459 patients completed the Edmonton Symptom Assessment System Revised: Renal; 58% of eligible patients completed the preimplementation survey (n=718), and 56% of patients who completed the Edmonton Symptom Assessment System Revised: Renal at least once completed the postimplementation survey (n=569). Provider survey response rates were 71% (n=514) and 54% (n=319), respectively. Nine patients/caregivers from three sites and 48 providers from all sites participated in interviews. A total of 1207 charts were audited. Seven of eight sites had mean screening rates over 80%, suggesting that routine use of the Edmonton Symptom Assessment System Revised: Renal in clinical practice is feasible. However, the multiple data sources painted an inconsistent picture of the value and effect of the Edmonton Symptom Assessment System Revised: Renal. The Edmonton Symptom Assessment System Revised: Renal standardized symptom screening processes across providers and sites; improved patient and provider symptom awareness, particularly for psychosocial symptoms; and empowered patients to raise issues with providers. Yet, there was little, if any, statistically significant improvement in the metrics used to assess symptom management, patient-provider communication, and interdisciplinary communication.

CONCLUSIONS

The Edmonton Symptom Assessment System Revised: Renal patient-reported outcome measure may be useful to standardize symptom screening, enhance awareness of psychosocial symptoms among patients and providers, and empower patients rather than to reduce symptom burden.

Association between Satisfaction with Dialysis Treatment and Quality of Life: A Cross-Sectional Study

INTRODUCTION

CKD is associated with a reduction of patients' health-related quality of life. Considering the time spent in dialysis, satisfaction with care is essential for patients QOL.

OBJECTIVE

Since the possible association between satisfaction with the dialysis care and QOL has never been studied, in this study, we explore this plausible link.

METHODS

One hundred three patients on hemodialysis (HD) and peritoneal dialysis (PD) filled-in patient-reported outcome measures (PROMs) and patient-reported experience measures (PREMs). QOL was assessed by Kidney Disease Quality of Life-36 and satisfaction by Choices for Healthy Outcomes in Caring for End-Stage Renal Disease (CHOICE) questionnaire. The analysis was conducted on patient-level, considering for single patient sociodemographic characteristics and presence of depression/anxiety. One-way ANOVA was used to compare QOL mean scores for patients who answered "excellent" and for those who answered "other ratings" in CHOICE questionnaire and the Pearson χ2 test to compare the patients' characteristics between these 2 groups of patients.

RESULTS

The analysis showed a significant positive association between PREM and PROM scores for 8 out of 23 CHOICE items. Six of them were related to the figure of nephrologist, 1 to dialysis access site, and 1 to the social worker support. Significant association (p < 0.05) were between frequency of seeing nephrologist and physical component plus mental component, accuracy of information from nephrologist and burden of disease, accuracy of instructions from nephrologist and burden of disease, coordination between nephrologist and other physicians plus mental component, attention to cleanliness of access site and mental component, amount of dialysis information from staff and burden of disease, information from staff when choosing between HD or PD and physical component plus burden of disease, and ease of seeing social worker and burden of disease.

CONCLUSIONS

The study provides support for the relationship between the care satisfaction and QOL, highlighting the central role of the nephrologist-patient communication in the QOL of dialysis patients.

The Relationship between Dialysis Metrics and Patient-Reported Cognition, Fatigue, and Physical Function

Introduction

The impact of achieving hemodialysis laboratory and hemodynamic quality metrics on patient-reported outcomes (PROs) is unknown.

Objective

To determine if meeting dialysis laboratory quality of care measures is associated with improved PROs.

Methods

In this cross-sectional study, we measured the relationship between dialysis patients' Patient Reported Outcome Measurement Information System (PROMIS) scores and commonly used dialysis quality of care measures.

Results

PROMIS surveys were administered to 92 dialysis patients. The mean ± SD scores demonstrated higher fatigue (55.0 ± 9.8) and lower physical function (37.9 ± 7.9) but similar cognition (50.3 ± 10.9) compared to general population normative scores of 50 ± 10. Dialysis patients meeting Kt/V goals had no better scores than those who did not. Meeting the hemoglobin (Hgb) value of ≥10 g/dL was associated with a lower fatigue score, but no difference in cognitive or physical function scores. Meeting the serum albumin goal of ≥4.0 mg/dL was associated with a higher physical function score but made no difference for cognitive function or fatigue score. As a continuous variable, a higher Hgb was associated with lower reported fatigue (HR -1.74 95%, CI [-3.09, -0.39]), but no other measures were associated with PRO scores when adjusted for demographics and comorbidities.

Conclusions

We found little association between measures currently used to assess the quality of dialysis care and PROs. Encouraging improved utilization of PROs and incorporating PROs into quality measurements might give a more robust assessment of quality of care. Future studies should assess the benefits of this approach.

Using Patient Experience Survey Data to Improve In-Center Hemodialysis Care: A Practical Review

Patient experience is an integral aspect of the care we deliver to our dialysis patients. Standardized evaluation of patient experience with in-center hemodialysis started in the United States in 2012 with the In-Center Hemodialysis Consumer Assessment of Healthcare Providers and Systems (ICH CAHPS) survey. Over time there have been a few changes to this survey, how it is administered, and how it fits within the Centers for Medicare & Medicaid Services End-Stage Renal Disease Quality Incentive Program. Although the importance of this survey has been growing, knowledge of this survey among nephrologists has lagged. We provide a review of the survey development and how its use has evolved since 2012. We discuss in detail research done on this survey to date, including survey psychometric evaluation. We highlight gaps in our knowledge that need further research and end with general recommendations to improve patient experience within hemodialysis facilities, which we believe is a worthy goal for all members of the dialysis team.

Dietary Patterns and Health Outcomes among African American Maintenance Hemodialysis Patients

The association between dietary patterns and health outcomes, such as quality of life (QOL), in maintenance hemodialysis (MHD) patients with certain racial backgrounds has not been studied in detail. QOL is a powerful outcome measure in which dietary patterns could be a modifying factor. This study is a secondary analysis examining the association between dietary patterns and health outcomes in 101 African American (AA) maintenance hemodialysis (MHD) patients participating in the Palm Tocotrienols in Chronic Hemodialysis (PATCH) study. Quality of life (QOL) was assessed using the Kidney Disease Quality of Life 36-item survey (KDQOL-36™). Blood samples were analyzed for lipids, lipoprotein subfractions, and inflammatory markers. Food intake was measured using six non-consecutive 24-h dietary recalls over 15 months. Implausible energy intake reports were screened out by comparing reported energy intake (rEI) with predicted total energy expenditure (pTEE). Cluster analysis, using the k-means algorithm, identified two distinct dietary patterns in the study population: a high "sugar sweetened beverage" pattern (hiSSB) and a low "sugar sweetened beverage pattern" (loSSB). In the hiSSB group, consumption of SSB accounted for ~28% of energy intake, while SSB represented only 9% of energy intake in the loSSB group. The hiSSB group was characterized by a higher intake of total calories, sugar and percentage of kilocalories from carbohydrates, whereas the percentage of kilocalories from protein and fat was lower. While additional micronutrient intakes differed between groups (vitamin C, zinc, chromium), these were significantly lower than recommended values in the entire cohort. Patients in the hiSSB group presented with lower high-density lipoprotein cholesterol (HDL-C), lower large HDL particles and smaller low density lipoprotein (LDL) particle diameters. Antidepressant usage was significantly higher in the hiSSB group. Patients in the hiSSB group scored lower across all five KDQOL domains and scored significantly lower in the mental composite domain. MHD patients following a hiSSB dietary pattern had smaller dense LDL particles, lower HDL-C, and a lower QOL. Suboptimal intakes of fruits, vegetables, and grains as well as key micronutrients were evident in both patterns.

Quality of life in older adults receiving hemodialysis: a qualitative study

PURPOSE

Patient priorities for quality of life change with age. We conducted a qualitative study to identify quality of life themes of importance to older adults receiving dialysis and the extent to which these are represented in existing quality of life instruments.

METHODS

We conducted semi-structured interviews with 12 adults aged ≥ 75 years receiving hemodialysis to elicit participant perspectives on what matters most to them in life. We used framework analysis methodology to process interview transcripts (coding, charting, and mapping), identify major themes, and compare these themes by participant frailty status. We examined for representation of our study's subthemes in the Kidney Disease Quality of Life (KDQOL-36) and the World Health Organization Quality of Life for Older Adults (WHOQOL-OLD) instruments.

RESULTS

Among the 12 participants, average age was 81 (4.2) years, 7 African-American, 6 women, and 6 met frailty criteria. We identified two major quality of life themes: (1) having physical well-being (subthemes: being able to do things independently, having symptom control, maintaining physical health, and being alive) and (2) having social support (subthemes: having practical social support, emotional social support, and socialization). Perspectives on the subthemes often varied by frailty status. For example, being alive meant surviving from day-to-day for frail participants, but included a desire for new life experiences for non-frail participants. The majority of the subthemes did not correspond with domains in the KDQOL-36 and WHOQOL-OLD instruments.

CONCLUSION

Novel instruments are likely needed to elicit the dominant themes of having physical well-being and having social support identified by older adults receiving dialysis.

Health-related quality of life and adequacy of dialysis for the individual maintained on peritoneal dialysis

The goal of care of the peritoneal dialysis (PD) patient should be directed at adjusting therapy to maximize the patient's health-related quality of life (HRQOL). Incorporating the routine assessments of HRQOL into the care of PD patients is important and should serve as an essential marker of the adequacy of dialysis and help the dialysis staff design the optimal treatment regimen for each patient. HRQOL is best assessed with patient-reported outcome measures (PROMs). How best to incorporate these PROMs into the routine care of the PD patient is not clear in terms of the best instruments to use, frequency of measurements, patient acceptability, and how to translate these assessments into improvements in patient care. Nevertheless, incorporating routine assessments of HRQOL into the care of PD patients is essential if the dialysis team is to provide optimal care; it is an area that is receiving increasing attention and is ripe for further study and investigation.

Incorporating patient-reported outcomes (PROs) into dialysis policy: Current initiatives, challenges, and opportunities

Governments at national and state levels regulate dialysis care in the United States to ensure safe practices, and continually elevate the quality of care. An objective of these regulatory policies is the independent evaluation of dialysis unit outcomes by patients, caregivers, and the community to facilitate choices as well as to advance equal access to high quality dialysis care. These polices recognized decades ago that it was fundamental to include the patient perspective in the assessment and evaluation of dialysis care quality by requiring both individual and aggregate patient reported outcomes (PROs). Although there is support for integrating the patient perspective, concerns persist about the implementation of these polices including selection of PRO measures, administration timing and reach, as well as interpretation of results including benchmarking to permit comparisons across organizations. The experience from the early adoption of PROs into dialysis policies in conjunction with advances in electronic health records, personal data capture and monitoring, and analytics is poised to address these concerns. The dialysis community has the opportunity to lead the way in innovation related to PRO implementation not only in kidney disease care, but also for other healthcare conditions or contexts such as oncology, surgical, and acute care.

Varying Association of Extended Hours Dialysis with Quality of Life

BACKGROUND AND OBJECTIVES

Little is known about the effect of changes in dialysis hours on patient-reported outcome measures. We report the effect of doubling dialysis hours on a range of patient-reported outcome measures in a randomized trial, overall and separately for important subgroups.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

The A Clinical Trial of IntensiVE Dialysis trial randomized 200 participants to extended or standard weekly hours hemodialysis for 12 months. Patient-reported outcome measures included two health utility scores (EuroQOL-5 Dimensions-3 Level, Short Form-6 Dimension) and their derived quality-adjusted life year estimates, two generic health scores (Short Form-36 Physical Component Summary, Mental Component Summary), and a disease-specific score (Kidney Disease Component Score). Outcomes were assessed as the mean difference from baseline using linear mixed effects models adjusted for time point and baseline score, with interaction terms added for subgroup analyses. Prespecified subgroups were dialysis location (home- versus institution-based), dialysis vintage (≤6 months versus >6 months), region (China versus Australia, New Zealand, Canada), and baseline score (lowest, middle, highest tertile). Multiplicity-adjusted P values (Holm-Bonferroni) were calculated for the main analyses.

RESULTS

Extended dialysis hours was associated with improvement in Short Form-6 Dimension (mean difference, 0.027; 95% confidence interval [95% CI], 0.00 to 0.05; P=0.03) which was not significant after adjustment for multiple comparisons (Padjusted =0.05). There were no significant differences in EuroQOL-5 Dimensions-3 Level health utility (mean difference, 0.036; 95% CI, -0.02 to 0.09; P=0.2; Padjusted =0.2) or in quality-adjusted life years. There were small positive differences in generic and disease-specific quality of life: Physical Component Summary (mean difference, 2.3; 95% CI, 0.6 to 4.1; P=0.01; Padjusted =0.04), Mental Component Summary (mean difference, 2.5; 95% CI, 0.5 to 4.6; P=0.02; Padjusted =0.05) and Kidney Disease Component Score (mean difference, 3.5; 95% CI, 1.5 to 5.5; P=0.001; Padjusted =0.005). The results did not differ among predefined subgroups or by baseline score.

CONCLUSIONS

The effect of extended hours hemodialysis on patient-reported outcome measures reached statistical significance in some but not all measures. Within each measure the effect was consistent across predefined subgroups. The clinical importance of these differences is unclear.

Problems with analyses and interpretation of data in "use of the KDQOL-36™ for assessment of health-related quality of life among dialysis patients in the United States"

A recent article in the journal reported analyses of KDQOL-36™ survey data collected from 240,343 adults (330,412 surveys) dialyzed at a large dialysis organization in the United States during 2014-2016. The authors concluded that the KDQOL-36™ Symptoms and Problems of Kidney Disease scale had the highest mean score of the KDQOL-36™ scales. We note that this inference was erroneous because the scales are not scored on the same numeric scale. In addition, the authors found that responses to a general health perceptions item ("In general, would you say your health is excellent, very good, good, fair, or poor") was not significantly associated with any of the 5 KDQOL-36 scale scores. In contrast, we find significant and noteworthy correlations in two other datasets. These analytic issues call into question the accuracy and validity of the conclusions of this paper.

The Impact of Race and Ethnicity Upon Health-Related Quality of Life and Mortality in Dialysis Patients

Rationale & Objective

Health-related quality of life (HRQoL) has been recognized as a strong predictor of mortality among hemodialysis patients. However, differences in the association of HRQoL with survival across diverse racial/ethnic groups have not been well studied in this population.

Study Design

Observational cohort study.

Setting & Participants

We examined the relationship between HRQoL and mortality in a prospective cohort of racially/ethnically diverse hemodialysis patients recruited from 18 outpatient dialysis units during 2011 to 2016.

Exposure

Using the 36-Item Short Form Health Survey (SF-36) administered every 6 months, HRQoL was ascertained by 36 questions summarized as 2 Physical and Mental Component and 8 subscale scores.

Outcome

All-cause mortality.

Analytical Approach

Associations of time-varying SF-36 scores with mortality were estimated using Cox models in the overall cohort and within racial/ethnic subgroups.

Results

Among 753 hemodialysis patients who met eligibility criteria, expanded case-mix analyses showed that the lowest quartiles of time-varying Physical and Mental Component scores were associated with higher mortality in the overall cohort (reference: highest quartile): adjusted HRs, 2.30 (95% CI, 1.53-3.47) and 1.54 (95% CI, 1.05-2.25), respectively. In analyses stratified by race/ethnicity, the lowest quartile of Physical Component scores was significantly associated with higher mortality across all groups: adjusted HRs, 2.64 (95% CI, 1.31-5.29), 1.84 (95% CI, 1.01-3.38), and 3.18 (95% CI, 1.13-8.91) for Hispanic, African American, and other race/ethnicity patients, respectively. The lowest quartile of time-varying physical functioning, role limitations due to physical health, role limitations due to emotional problems, social functioning, and pain subscale scores were associated with higher mortality in the overall cohort and particularly in Hispanics and blacks.

Limitations

Residual confounding cannot be excluded.

Conclusions

Lower SF-36 Physical Component and subscale scores were associated with higher mortality in hemodialysis patients, including those of minority background. Further studies are needed to determine whether interventions that augment physical health might improve the survival of these diverse populations.

Use of the KDQOL-36™ for assessment of health-related quality of life among dialysis patients in the United States

Background

Health-related quality of life (HRQOL) is a key outcome for dialysis patients, and its assessment is mandated by the Centers for Medicaid and Medicare Services. The Kidney Disease Quality of Life (KDQOL-36™) survey is widely used for this assessment. KDQOL-36™ completion rates, and the distributions of scores and item responses, have not been examined in a large, nationally representative cohort of dialysis patients.

Methods

This retrospective, observational study considered 413,951 survey opportunities contributed by adult patients who received dialysis at a large dialysis organization in the United States during calendar years 2014, 2015, and 2016 and were not Veterans Affairs beneficiaries.

Results

During the study period, 240,343 unique patients completed a total of 330,412 surveys (overall completion rate 79.8%). Mean domain scores on the physical component summary (PCS), mental component summary (MCS), burden of kidney disease (BKD), symptoms and problems of kidney disease (SPKD), and effects of kidney disease (EKD) subscales were 36.6, 49.0, 51.3, 78.1, and 73.0, respectively. Scores were similar across dialysis modalities. Patient perceptions of general health were not correlated (R < 0.05) with PCS or SPKD. The SPKD showed ceiling effects: among patients treated with in-center hemodialysis, for all 12 items, < 10% of patients were “extremely bothered,” while > 65% of patients reported being “not at all” or only “somewhat bothered;” for 3 items, > 85% of patients gave these latter two responses. Interdialytic weight gain was not correlated with patient-reported shortness of breath, PCS, or SPKD.

Conclusions

Survey completion rates for the KDQOL-36™ were high, and scores were similar across dialysis modalities. Ceiling effects were observed for SPKD. Revision of the KDQOL-36™ to address factors that are most important to contemporary dialysis patients may be warranted.

Electronic supplementary material

The online version of this article (10.1186/s12882-019-1295-0) contains supplementary material, which is available to authorized users.

Kidney Disease Quality of Life 36-Item Short Form Survey (KDQOL-36) Normative Values for the United States Dialysis Population and New Single Summary Score

BACKGROUND

The Kidney Disease Quality of Life 36-item short form survey (KDQOL-36) is a widely used, patient-reported outcome measure for patients on dialysis. Efforts to aid interpretation are needed.

METHODS

We used a sample of 58,851 dialysis patients participating in the Medical Education Institute (MEI) KDQOL Complete program, and 443,947 patients from the US Renal Data System (USRDS) to develop the KDQOL-36 Summary Score (KSS) for the kidney-targeted KDQOL-36 scales (Burdens of Kidney Disease [BKD], Symptoms and Problems of Kidney Disease [SPKD], and Effects of Kidney Disease [EKD]). We also used the MEI and USRDS data to calculate normative values for the Short Form-12 Health Survey's Physical Component Summary (PCS) and Mental Component Summary (MCS), and the KDQOL-36's BKD, SPKD, and EKD scales for the United States dialysis population. We used confirmatory factor analysis (CFA) models for KDQOL-36 kidney-targeted items, evaluated model fit with the comparative fit index (CFI; >0.95 indicates good fit) and root-mean-squared error of approximation (RMSEA; <0.06 indicates good fit), and estimated norms by matching the joint distribution of patient characteristics in the MEI sample to those of the USRDS sample.

RESULTS

A bifactor CFA model fit the data well (RMSEA=0.046, CFI=0.990), supporting the KSS (α=0.91). Mean dialysis normative scores were PCS=37.8 and MCS=50.9 (scored on a T-score metric); and KSS=73.0, BKD=52.8, SPKD=79.0, and EKD=74.1 (0-100 possible scores).

CONCLUSIONS

The KSS is a reliable summary of the KDQOL-36. The United States KDQOL-36 normative facilitate interpretation and incorporation of patient-related outcome measures into kidney disease care.

Strategies for incorporating patient-reported outcomes in the care of people with chronic kidney disease (PRO kidney): a protocol for a realist synthesis

BACKGROUND

Patient-reported outcomes and experience measures (jointly referred to here as PROs) are internationally recognized as a means for patients to provide information about their quality of life, symptoms, and experiences with care. Although increasingly recognized as key to improving the quality of healthcare at individual (e.g., patients, caregivers, and providers) and aggregate (e.g., government, policy/system-wide decision-making) levels, there are important knowledge gaps in our understanding of how PROs are, and can be, used across different settings, particularly in nephrology to enhance person-centered care. This knowledge is needed for developing strategies to guide optimal use of PROs in nephrology care. Currently, no strategies exist. The purpose of this review is to address this knowledge gap by answering the following realist question: How can PROs be used to enhance person-centered nephrology care, both at individual and aggregate levels?

METHODOLOGY

Realist synthesis is an explanatory approach to data synthesis that aims to explain how context and mechanisms influence the outcome of an intervention. An initial program theory will be developed through the systematic search of the published literature in bibliographic databases (Ovid MEDLINE, Ovid Embase, EBSCOhost CINAHL, Web of Science, and Scopus) on existing theories explaining how PROs are used in healthcare settings. This initial program theory will then be tested and refined through the process of realist synthesis, using context-mechanism-outcome configurations. A kidney-specific program theory will then be created to address the utilization of PROs in nephrology across individual and aggregate levels to augment person-centered care. Searching will be iterative and refined as data is extracted and analyzed using a pilot-tested context + mechanism = outcome heuristic. Throughout, we will consult methodological experts, research team practitioners, and the Patient Advisory Committee to help refine the theories. Last, we will develop and disseminate knowledge translation products widely to knowledge user groups.

DISCUSSION

The utilization of PROs remains a challenge in nephrology. The findings from this synthesis will provide a framework to guide both policy makers and practitioners on how to enhance person-centered care through successful utilization of PROs across individual and aggregate levels in nephrology.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42017056063.