DART decision aid allows for better treatment decisions and reduces conflict for renal patients, study finds

A web-based decision aid can improve the quality of treatment decisions made by patients over 70 with chronic kidney disease (CKD)—that is the conclusion of a new study in the Annals of Internal Medicine (AIM).

THE DECISION AID FOR RENAL THERAPY (DART) is an educational aid accessible online that looks to remedy the issues with existing renal patient education materials outlined by the study authors, led by Keren Ladin (Tufts University, Medford, USA), which included that they are “generally not tailored for older adults”. It does this by “allow[ing] patients to control the pace of information” and providing accessible multimedia content for those with “limited health literacy”.

Older adults are also often educated on renal disease in single-session group classes, Ladin et al noted, which can be challenging for them due to hearing impairments, and which may not address their specific concerns. “Although decision aids improve decisional quality,” they added, “none have been specifically designed to meet the unique needs of older patients facing dialysis decisions”.

Keren Ladin

DART was a pre-existing tool for informing renal patients that was adapted by the study authors for older adults. The DART trial also addresses another gap—existing research on decision-making in dialysis patients has mostly focused on decisions made by those receiving maintenance dialysis, they have said, rather than those with advanced CKD who were yet to decide on treatment.

In total, 400 patients were recruited across nephrology clinics in four US cities for the trial, of whom 37 dropped out. These were patients who had not yet received dialysis but had stage four or five CKD with an estimated glomerular filtration rate <30mL/min/1.73m 2 It was a “non-blinded, site-level, 1:1 randomised trial”. Designing the trial around multiple centres was intended to account for “potential differences in site culture and patient education about kidney failure treatment choices”. Patients were followed for up to 18 months, and 183 were asked to use the DART tool at three months, the results of which were passed on to their clinician. The remaining 180 received “usual care”. The primary outcome was “change in deci - menting care, and procedures were one way to attract future applicants. As ‘value-based care’ models gain wider acceptance across different payers, it is likely to add more disincentives for referring patients to other specialists for common procedures. The literature supports that nephrologists can competently perform common dialysis access procedures with outcomes comparable and in some cases better than those performed by their colleagues from other subspecialties. Being proficient and competent to do procedures will help the next generation of nephrologists survive and thrive in the evolving value-based healthcare ecosystem. We must continue to equip and train future nephrologists with proper procedural training, and American Society of Diagnostic and Interventional Nephrology (ASDIN) can play a major role, along with ASN, in helping to form our future nephrologists.

References:

1. Update on the Task Force on the Future of Nephrology. Reimagining nephrology fellowship training. Mark Rosenberg. Kidney News, Volume 14, Issue 7, Publication date: 01 July 2022, pp 10–11

2. The Nephrology Workforce 2016, ASN, 2016, Exhibit 1, p7. Available at https://www.asnonline. org/education/training/workforce/Nephrology_ Workforce_Study_Report_2016.pdf

3. The ASN Task Force on the Future of Nephrology: What have we been hearing? Kidney News, Volume 14: Issue 9, Publication Date: 01 Sep 2022 Page: 14 sional conflict from baseline to the three-month follow-up assessed using the decisional conflict scale (DCS)”.

4. Effectiveness and safety of dialysis vascular access procedures performed by interventional nephrologists. Gerald A. Beathard, Terry Litchfield. Kidney International, Volume 66, Issue 4, October 2004, Pages 1622-1632. https://doi.org/10.111 1/j.1523-1755.2004.00928.

DCS scores improved to a statistically significant degree for those patients in the DART-assigned group at three- and six-month assessments. At three months, the mean difference from the control group was -7.9 and at six it was -8.5 on the DCS scale. Those in the DART group were also found to “perform better with respect to implementing decisions” and were less likely to delay a decision.

Dialysis decisions

Patient knowledge increase within control group: 5.5%

Patient knowledge increase within DART group: 10.9%

Statistically significant change was also present in measures of patient knowledge. On mean test performance, the control group improved over the course of the study period from 57.0% to 62.5%, while those who used DART went from 59.4% to 70.3%.

The study authors dubbed DART “an effective, patient-centred intervention that can improve decisional quality and knowledge of prognosis”, while reducing the burden on clinicians by allowing patients to educate themselves at home. The effect of DART was particularly strong up to six months, they said, and was still positive but “attenuated” after 18 months. Most studies, they said, examine the effects of decision aids after one week or one month.

The authors noted a few limitations, including that “enrolment among Latinx patients was low”, which was “possibly because DART was only offered in English”. There was also no supervision over how DART was used by patients. Ladin et al neverthless called DART a “consistent and accessible” tool that cuts conflict and improves knowledge for older CKD patients. Their final note was constructive, suggesting patients should be encouraged to revisit DART to improve outcomes after 18 months.