Pharmacological treatment for mental health illnesses in adults receiving dialysis: A scoping review.

BACKGROUND: Pharmacologic management of mental health illnesses in patients receiving dialysis is complex and lacking data. OBJECTIVE: Our objective was to synthesize published data for the treatment of depression, bipolar and related disorders, schizophrenia or psychotic disorders, and anxiety disorders in adults receiving hemodialysis or peritoneal dialysis. METHODS: We undertook a scoping review, searching the following databases: Medline, Embase, CINAHL, PsycINFO, Cochrane Library, Scopus, and Web of Science. Data on patients who received only short-term dialysis, a kidney transplant, or non-pharmacologic treatments were excluded. RESULTS: Seventy-three articles were included: 41 focused on depression, 16 on bipolar disorder, 13 on schizophrenia and psychotic disorders, 1 on anxiety disorders, and 2 addressing multiple mental health illnesses. The majority of depression studies reported on selective serotonin reuptake inhibitors (SSRIs) as a treatment. Sertraline had the most supporting data with use of doses from 25 to 200 mg daily. Among the remaining SSRIs, escitalopram, citalopram, and fluoxetine were studied in controlled trials, whereas paroxetine and fluvoxamine were described in smaller reports and observational trials. There are limited published data on other classes of antidepressants and on pharmacological management of anxiety. Data on treatment for patients with bipolar disorder or schizophrenia and related disorders are limited to case reports. CONCLUSION: Over half of the studies included were case reports, thus limiting conclusions. More robust data are required to establish effect sizes of pharmacological treatments prior to providing specific recommendations for their use in treating mental health illnesses in patients receiving dialysis.

Self- and Proxy-Completion of Quality of Life Assessment in Dementia Care: A Review of Reviews.

Background and Purpose: Quality of life (QOL) assessment invites the perspectives of people living with dementia to be shared with family caregivers and healthcare providers. A review of reviews was conducted to describe synthesized evidence (i.e., from other reviews) regarding self- and proxy-reports of QOL for this population. Methods: Searches were conducted in four databases. The 25 included articles addressed self- or proxy-rated patient-reported outcome measures, focused on any type of dementia, and were a review or synthesis published in English. Results: Individuals with dementia are largely able to self-report QOL. Proxy-reports are incongruent with self-reports due to various factors, including the proxy-patient relationship and perspective of measurement. Conclusion: When assessing QOL for people with dementia, self-reports are preferred to proxy-reports; however, a combination is recommended.

Navigating Living Kidney Donation and Transplantation Among South Asian Canadians: The ACTION Project.

RATIONALE & OBJECTIVE: South Asian (SA) Canadians with kidney failure have a 50%-77% lower likelihood of kidney transplant and are less likely to identify potential living donors (LDs). This study aimed to identify health system-, patient-, and community-level barriers and facilitators for accessing LD kidney transplantation in the SA community to inform the development of health system- and community-level interventions to address barriers. STUDY DESIGN: Qualitative study. SETTING & PARTICIPANTS: 20 SA recipients of an LD or deceased-donor kidney transplant, 10 SA LDs, and 41 general SA community members. ANALYTICAL APPROACH: In-depth multilingual interviews were conducted with recipients and LDs. Gender-, language-, and age-stratified focus groups were conducted with general SA community members. Summative content analysis was used to analyze the data. RESULTS: Hesitancy in approaching potential donors, fear about the health of potential LDs, information gaps, language barriers, and challenges evaluating out-of-country donors were highlighted as significant barriers by recipients, and financial concerns and information gaps were identified by donors. Cultural barriers in the SA community were highlighted by donors, recipients, and community members as critical factors when considering donation and transplant; women and elderly SA Canadians highlighted nuanced challenges. Participants reported generally a favorable perception of their health care teams, citing SA representation in the teams as important to providing culturally and linguistically sensitive care. LIMITATIONS: Limited geographic, race, and cultural representation and reliance on virtual data collection. CONCLUSIONS: This study highlights several culturally relevant barriers to donation and transplant that are potentially modifiable through patient-, health system-, and community-focused engagement and education.

Associations between hearing loss and clinical outcomes: population-based cohort study.

Background: Hearing loss (HL) is a leading cause of disability worldwide, but its clinical consequences and population burden have been incompletely studied. Methods: We did a retrospective population-based cohort study of 4,724,646 adults residing in Alberta between April 1, 2004 and March 31, 2019, of whom 152,766 (3.2%) had HL identified using administrative health data. We used administrative data to identify comorbidity and clinical outcomes, including death, myocardial infarction, stroke/transient ischemic attack, depression, dementia, placement in long-term care (LTC), hospitalization, emergency visits, pressure ulcers, adverse drug events and falls. We used Weibull survival models (binary outcomes) and negative binomial models (rate outcomes) to compare the likelihood of outcomes in those with vs without HL. We calculated population-attributable fractions to estimate the number of binary outcomes associated with HL. Findings: The age-sex-standardized prevalence of all 31 comorbidities at baseline was higher among participants with HL than those without. Over median follow-up of 14.4 y and after adjustment for potential confounders at baseline, participants with HL had higher rates of days in hospital (rate ratio 1.65, 95% CI 1.39, 1.97), falls (RR 1.72, 95% CI 1.59, 1.86), adverse drug events (RR 1.40, 95% CI 1.35, 1.45), and emergency visits (RR 1.21, 95% CI 1.14, 1.28) compared to those without, and higher adjusted hazards of death, myocardial infarction, stroke/transient ischemic attack, depression, heart failure, dementia, pressure ulcers and LTC placement. The estimated number of people with HL who required new LTC placement annually in Canada was 15,631, of which 1023 were attributable to HL. Corresponding estimates for new dementia among people with HL were 14,959 and 4350, and for stroke/TIA the estimates were 11,582 and 2242. Interpretation: HL is common, is often accompanied by substantial comorbidity, and is associated with significant increases in risk for a broad range of adverse clinical outcomes, some of which are potentially preventable. This high population health burden suggests that increased and coordinated investment is needed to improve the care of people with HL. Funding: Canadian Institutes of Health Research; David Freeze chair in health services research.

Electronic patient-reported outcomes in clinical kidney practice (ePRO Kidney): a process evaluation of educational support for clinicians.

Background: Patient-reported outcomes (PROs) are increasingly mandated in kidney care to incorporate patients' perspectives. Objectives: We assessed whether educational support for clinicians using electronic (e)PROs could enhance person-centered care. Design: A process evaluation, using a mixed methods longitudinal comparative concurrent design was undertaken of educational support to clinicians on routine use of ePROs. In two urban home dialysis clinics in Alberta, Canada, patients completed ePROs. At the implementation site, clinicians were provided with ePROs and clinician-oriented education via voluntary workshops. At the non-implementation site, neither were provided. Person-centered care was measured using the Patient Assessment of Chronic Illness Care-20 (PACIC-20). Methods: Longitudinal structural equation models (SEMs) compared change in overall PACIC scores. The interpretive description approach, using thematic analysis of qualitative data, further evaluated processes of implementation. Results: Data were collected from questionnaires completed by 543 patients, 4 workshops, 15 focus groups, and 37 interviews. There was no overall difference in person-centered care throughout the study, including after delivery of workshops. The longitudinal SEMs revealed substantial individual-level variability in overall PACIC trajectories. However, there was no improvement at the implementation site and no difference between the sites during both the pre- and post-workshop periods. Similar results were obtained for each PACIC domain. Qualitative analysis provided insights into why there was no substantial difference between sites: (1) clinicians wanted to see kidney symptoms, not quality of life, (2) workshops were tailored to clinicians' educational needs, not patients' needs, and (3) variable use of ePRO data by clinicians. Conclusion: Training clinicians on use of ePROs is complex and likely only part of what is required to enhance person-centered care. Registration: NCT03149328. https://clinicaltrials.gov/ct2/show/NCT03149328.

Lessons from professional nursing associations' policy advocacy responses to the COVID-19 pandemic: An interpretive description.

BACKGROUND: Professional nursing associations across jurisdictions engaged in significant policy advocacy during the COVID-19 pandemic to support nurses, the public and health systems. While professional nursing associations have a long history of engaging in policy advocacy, scholars have rarely critically examined this important function. PURPOSE: The purpose of this study was twofold: (a) to examine how professional nursing associations engage in the process of policy advocacy and (b) to develop knowledge specific to policy advocacy in the context of a global pandemic. METHODS: This study was conducted using interpretive description. A total of eight individuals from four professional nursing associations (two local, one national and one international) participated. Data sources included semi-structured interviews conducted between October 2021 and December 2021 and internal and external documents produced by organizations. Data collection and analysis occurred concurrently. Within-case analysis was conducted prior to cross-case comparisons. FINDINGS: Six key themes were developed to illustrate the lessons learned from these organizations including their organization's role in supporting a wide audience (professional nursing associations as a compass); the scope of their policy priorities (bridging the gaps between issues and solutions), the breadth of their advocacy strategies (top down, bottom up and everything in between), the factors influencing their decision-making (looking in and looking out), their evaluation practices (focus on contribution, not attribution) and the importance of capitalizing on windows of opportunity. CONCLUSIONS: This study provides insight into the nature of policy advocacy carried out by professional nursing associations. IMPACT: The findings suggest the need for those leading this important function to think critically about their role in supporting a wide range of audiences, the breadth and depth of their policy priorities and advocacy strategies, the factors that influence their decision-making, and the ways in which their policy advocacy work can be evaluated to move towards greater influence and impact.

The dynamic nature of patient engagement within a Canadian patient-oriented kidney health research network: Perspectives of researchers and patient partners.

INTRODUCTION: Canadians Seeking Solutions and Innovations to Overcome Chronic Kidney Disease (Can-SOLVE CKD) is a pan-Canadian health research network that engages patients as partners across 18 unique projects and core infrastructure. In this qualitative study, we explored how research teams integrated patient partners into network research activities to inform our patient engagement approach. METHODS: To capture a breadth of perspectives, this qualitative descriptive study purposively sampled researchers and patient partners across 18 network research teams. We conducted 4 focus groups (2 patients and 2 researchers; n = 26) and 28 individual telephone interviews (n = 12 patient partners; n = 16 researchers). Transcripts were coded in duplicate, and themes were developed through an inductive, thematic analysis approach. RESULTS: We included 24 patient partners and 24 researchers from 17 of the 18 projects and all core committees within the network. Overarching concepts relate participants' initial impressions and uncertainty about patient engagement to an evolving appreciation of its value, impact and sustainability. We identified four themes with subthemes that characterized the dynamic nature of patient engagement and how participants integrated patients across network initiatives: (1) Reinforcing a shared purpose (learning together, collective commitment, evolving attitudes); (2) Fostering a culture of responsive and innovative research (accessible supports, strengthened process and product); (3) Aligning priorities, goals and needs (amenability to patient involvement, mutually productive relationships, harmonizing expectations); (4) Building a path to sustainability (value creation, capacity building, sustaining knowledge use). CONCLUSIONS: Our findings demonstrate the dynamic and adaptive processes related to patient engagement within a national, patient-oriented kidney health research network. Optimization of support structures and capacity are key factors to promote sustainability of engagement processes within and beyond the network. PATIENT OR PUBLIC CONTRIBUTION: This project was conceived in collaboration with a Can-SOLVE CKD patient partner (N. F.), with lived experience of kidney failure. He also co-designed the study's protocol, led focus groups and researcher interviews, and contributed to data analysis. L. G. has lived experience as a caregiver for a person with CKD and facilitated patient partner focus groups. The patient partners, both of whom are listed authors, provided important insights that shaped our interpretation and presentation of study findings.

"You need a team": perspectives on interdisciplinary symptom management using patient-reported outcome measures in hemodialysis care-a qualitative study.

BACKGROUND: Patient-reported outcome measures (PROMs) are standardized instruments used for assessing patients' perspectives on their health status at a point in time, including their health-related quality of life, symptoms, functionality, and physical, mental, and social wellbeing. For people with kidney failure receiving hemodialysis, addressing high symptom burden and complexity relies on care team members integrating their expertise to achieve common management goals. In the context of a program-wide initiative integrating PROMs into routine hemodialysis care, we aimed to explore patients' and clinicians' perspectives on the role of PROMs in supporting interdisciplinary symptom management. METHODS: We employed a qualitative descriptive approach using semi-structured interviews and observations. Eligible participants included adult patients receiving intermittent, outpatient hemodialysis for > 3 months, their informal caregivers, and hemodialysis clinicians (i.e., nurses, nephrologists, and allied health professionals) in Southern Alberta, Canada. Guided by thematic analysis, team members coded transcripts in duplicate and developed themes iteratively through review, refinement, and discussion. RESULTS: Thirty-three clinicians (22 nurses, 6 nephrologists, 5 allied health professionals), 20 patients, and one caregiver participated in this study. Clinicians described using PROMs to coordinate care across provider types using the resources available in their units, whereas patients tended to focus on the perceived impact of this concerted care on symptom trajectory and care experience. We identified 3 overarching themes with subthemes related to the role of PROMs in interdisciplinary symptom management in this setting: (1) Integrating care for interrelated symptoms ("You need a team", conducive setting, role clarity and collaboration); (2) Streamlining information sharing and access (symptom data repository, common language for coordinated care); (3) Reshaping expectations (expectations for follow-up, managing symptom persistence). CONCLUSIONS: We found that use of PROMs in routine hemodialysis care highlighted symptom interrelatedness and complexity and helped to streamline involvement of the interdisciplinary care team. Issues such as role flexibility and resource constraints may influence sustainability of routine PROM use in the outpatient hemodialysis setting.

People with kidney failure receiving hemodialysis are faced with complex symptoms that impact their day-to-day functioning and quality of life. Patient-reported outcome measures (PROMs) are tools used by patients to directly communicate symptoms to their care team and guide symptom-focused care. Little is known about how PROMs could be integrated into the team-based care models of outpatient hemodialysis centres. In this study, we conducted interviews with people receiving hemodialysis and their clinicians about their perspectives on how PROMs could support interdisciplinary symptom management (i.e., integration of expertise to achieve common management goals). Participants described how the interrelatedness of symptoms was well suited to an integrated care approach and how PROMs enhanced communication and access to information across team members. In cases where symptoms persisted despite appropriate treatment, patients and clinicians explained how PROMs served as a tool to set realistic goals and reshape illness perception. Findings from this study suggest that access to resources, role flexibility, and established relationships within hemodialysis centres are important for sustaining PROM use in this setting.

Nigerian Health Care Providers and Diabetes Self-Management Support: Their Perspectives and Practices.

Nigeria struggles to reframe its traditional acute-care disease approach to health care to accommodate rising needs for chronic disease care. This interpretive descriptive study explored Nigerian healthcare providers' (HCPs) perspectives, experiences, and practices related to self-management support (SMS). Observational and experiential data were gathered from 19 HCPs at two urban hospitals in Southeastern Nigeria (seven physicians, four nurses, five dietitians/nutritionists, and three health educators). There were four themes: (a) compliance-oriented medical model, (b) SMS as advice, informal counseling, and education, (c) navigating the sociocultural terrain, and (d) workarounds. Nigerian HCPs perspectives and SMS practices were characterized by attempts to foster compliance with healthcare instructions within a traditional biomedical model. Participants enhanced patient support using specific strategies to bypass structural system obstacles. These findings demonstrate the need to reevaluate the current understanding of SMS in Nigeria and its practice.

Theory utilization in applied qualitative nursing research.

AIMS: To explore the nuances of theory utilization in qualitative methodologies, discuss the different relationships that applied qualitative methodologies have with theory and use the foundational underpinnings of interpretive description to challenge strongly entrenched ideas of theory that have extended into applied qualitative nursing research. DESIGN: Methodology discussion paper. DATA SOURCES: Narrative literature review and personal observations. CONCLUSION: Many qualitative research traditions have viewed the use of an explicit theoretical framework as an integral grounding for qualitative research studies. Much of the discussion of theory in extant qualitative methodological literature focuses on its use in the context of traditional methodologies such as ethnography, phenomenology and grounded theory, with less attention on methodological approaches developed for applied and practice disciplines such as nursing. Uncritical adoption of ideas about theory based on traditional qualitative methodological conventions can result in findings with little utility for application to the practice context. IMPACT: Nursing researchers should think critically about how theory is used in research endeavours geared towards applied practice and ensure that their methodological choices are in alignment with their philosophical and disciplinary epistemological positionings.

How the Routine Use of Patient-Reported Outcome Measures for Hemodialysis Care Influences Patient-Clinician Communication: A Mixed-Methods Study.

BACKGROUND AND OBJECTIVES: Patient-reported outcome measures invite patients to self-report aspects of their quality of life and have been reported to enhance communication with clinicians. We aimed to examine how routine use of patient-reported outcome measures in in-center hemodialysis units influenced patient-clinician communication. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: A concurrent, longitudinal, mixed-methods approach was used. We used data from a cluster randomized controlled trial of 17 hemodialysis units in northern Alberta that introduced a patient-reported outcome measures intervention. Patient-clinician communication was assessed using a modified Communication Assessment Tool. Using interpretive description, we explored patients' and nurses' perceptions of communication pertaining to routine patient-reported outcome measure use. Through purposeful sampling, we interviewed ten patients and eight nurses and conducted six observations in the dialysis units, which were documented in field notes. We reviewed 779 patient responses to open-ended survey questions from randomized controlled trial data. Qualitative data were thematically analyzed. RESULTS: Overall, patient-reported outcome measure use did not substantively improve patient-clinician communication. There was a small positive change in mean total Communication Assessment Tool scores (range, 1-5) from baseline to 12 months in patient-reported outcome measure use units (0.25) but little difference from control group units that did not use patient-reported outcome measures (0.21). The qualitative findings provide in-depth insights into why patient-reported outcome measure use did not improve patient-clinician communication. The purpose of patient-reported outcome measure use was not always understood by patients and clinicians; patient-reported outcome measures were not implemented as originally intended in the trial, despite clinician training; there were challenges using patient-reported outcome measures as a means to communicate; and patient-reported outcome measure use was perceived to have limited value. CONCLUSIONS: While patient-reported outcome measures use did not improve patient-clinician communication, qualitative data suggest implementation challenges, including limited clarity of purpose and perceived limited value, that may have limited the effectiveness of the intervention.

How Are Albertans "Adjusting to and Coping With" Dialysis? A Cross-Sectional Survey.

Background: Depression and anxiety are commonly reported (40% and 11%-52%) among adults receiving dialysis, compared with ~10% among all Canadians. Mental health in dialysis care is underrecognized and undertreated. Objective: (1) To describe preferences for mental health support reported by Albertans receiving dialysis; (2) to compare depression, anxiety, and quality-of-life (QOL) domains for people who would or would not engage in support for mental health; and (3) to explore sociodemographic, mental health, and QOL domains that explain whether people would or would not engage in support for mental health. Design: A cross-sectional survey. Setting: Alberta, Canada. Patients: Adults receiving all modalities of dialysis (N = 2972). Measurements: An online survey with questions about preferences for mental health support and patient-reported outcome measures (Patient Health Questionnaire-9 [PHQ-9], Generalized Anxiety Disorder-7 [GAD-7], and Kidney Disease QOL Instrument-36 [KDQOL-36]). Methods: To address objectives 1 and 2, we conducted chi-square tests (for discrete variables) and t tests (for continuous variables) to compare the distributions of the above measures for two groups: Albertans receiving dialysis who would engage or would not engage in support for mental health. We subsequently conducted a series of binary logistic regressions guided by the purposeful variable selection approach to identify a subset of the most relevant explanatory variables for determining whether or not people are more likely to engage in support for mental health (objective 3). To further explain differences between the two groups, we analyzed open-text comments following a summative content analysis approach. Results: Among 384 respondents, 72 did not provide a dialysis modality or answer the PHQ-9. The final data set included responses from 312 participants. Of these, 59.6% would consider engaging in support, including discussing medication with a family doctor (72.1%) or nephrologist (62.9%), peer support groups (64.9%), and talk therapy (60%). Phone was slightly favored (73%) over in person at dialysis (67.6%), outpatient (67.2%), or video (59.4%). Moderate to severe depressive symptoms (PHQ-9 score ≥10) was reported by 33.4%, and most respondents (63.9%) reported minimal anxiety symptoms; 36.1% reported mild to severe anxiety symptoms (GAD-7 score ≥5). The mean (SD) PHQ-9 score was 8.9 (6.4) for those who would engage in support, and lower at 5.8 (4.8) for those who would not. The mean (SD) GAD-7 score was 5.2 (5.6) for those who would engage in support and 2.8 (4.1) for those who would not. In the final logistic regression model, people who were unable to work had 2 times the odds of engaging in support than people who are able to work. People were also more likely to engage in support if they had been on dialysis for fewer years and had lower (worse) mental health scores (odds ratios = 1.06 and 1.38, respectively). The final model explained 15.5% (Nagelkerke R2) of the variance and with 66.6% correct classification. We analyzed 146 comments in response to the question, "Is there anything else you like to tell us." The top 2 categories for both groups were QOL and impact of dialysis environment. The third category differed: those who would engage wrote about support, whereas those who would not engage wrote about "dialysis is the least of my worries." Limitations: A low response rate of 12.9% limits representativeness; people who chose not to participate may have different experiences of mental health. Conclusions: Incorporating patients' preferences and willingness to engage in support for mental health will inform future visioning for person-centered mental health care in dialysis.

Contexte: La dépression et l'anxiété sont plus fréquemment signalées chez les adultes traités par dialyse (dépression: 40 %; anxiété: 11 à 52 %) comparativement à la population canadienne (environ 10 %). Les problèmes de santé mentale sont insuffisamment reconnus et traités dans les soins de dialyse. Objectifs: (1) décrire les préférences en matière de soutien en santé mentale des Albertains traités par dialyse; (2) comparer les domaines de la dépression, de l'anxiété et de la qualité de vie (QV) pour les personnes désirant obtenir ou non du soutien en santé mentale; (3) explorer les domaines sociodémographiques, de santé mentale et de QV qui expliquent pourquoi une personne désirerait obtenir ou non du soutien en santé mentale. Conception: Sondage transversal. Cadre: Alberta, Canada. Sujets: Adultes recevant toutes les modalités de dialyse (N=2972). Mesures: Un sondage en ligne comportant des questions sur les préférences en matière de soutien en santé mentale. Les mesures des résultats rapportés par les patients à trois questionnaires (questionnaire-9 sur la santé des patients [PHQ-9], questionnaire-7 sur les troubles anxieux généralisés [GAD-7] et l'instrument QOL-36 pour l'insuffisance rénale [KDQOL-36]). Méthodologie: Pour répondre aux objectifs 1 et 2, nous avons effectué des tests chi-carrés (pour les variables discrètes) et des tests t (pour les variables continues) pour comparer les distributions des mesures ci-dessus pour deux groupes: les Albertains sous dialyse désirant obtenir ou non du soutien en santé mentale. Une série de régressions logistiques binaires guidées par une approche de sélection ciblée des variables a ensuite été effectuée pour identifier un sous-ensemble des plus pertinentes variables explicatives permettant de déterminer si les gens sont plus susceptibles de vouloir obtenir du soutien en santé mentale (objectif 3). Pour expliquer plus précisément les différences entre les deux groupes, nous avons analysé les commentaires en texte ouvert en suivant une approche d'analyse de contenu sommative. Résultats: Des 384 répondants, 72 n'ont pas indiqué de modalité de dialyse ni répondu au questionnaire PHQ-9. L'ensemble de données final comprend les réponses de 312 patients. De ce nombre, 59,6 % envisageraient d'obtenir du soutien, notamment une discussion sur les médicaments avec un médecin de famille (72,1 %) ou un néphrologue (62,9 %), une participation à des groupes de soutien par les pairs (64,9 %) ou une psychothérapie (60 %). Les répondants préféraient le téléphone (73 %) plutôt qu'une visite en personne pendant la dialyse (67,6 %), qu'une consultation externe (67,2 %) ou qu'une consultation vidéo (59,4 %). Des symptômes dépressifs modérés à graves (score PHQ-9 ≥10) ont été rapportés par 33,4 % des répondants. La plupart des répondants (63,9 %) a signalé des symptômes minimes d'anxiété et 36,1 % ont signalé des symptômes d'anxiété légers à graves (score GAD-7 ≥5). Le score moyen (É-T) au PHQ-9 était de 8,9 (6,4) pour les sujets qui désiraient obtenir du soutien et de 5,8 (4,8) pour ceux qui n'en désiraient pas. Le score moyen (É-T) au GAD-7 était de 5,2 (5,6) pour les sujets qui désiraient obtenir du soutien et de 2,8 (4,1) pour ceux qui n'en désiraient pas. Dans le modèle final de régression logistique, les personnes qui ne pouvaient pas travailler étaient deux fois plus susceptibles de vouloir chercher du soutien que celles qui pouvaient travailler. Les répondants étaient également plus susceptibles de se faire aider s'ils étaient sous dialyse depuis moins longtemps et avaient des scores de santé mentale inférieurs (les plus faibles) (rapports de cotes respectifs: 1,06 et 1,38). Le modèle final expliquait 15,5 % (Nagelkerke R2) de la variance avec 66,6 % de classification correcte. Nous avons analysé 146 réponses à la question: « Y a-t-il autre chose que vous souhaiteriez nous dire? ¼ Dans les deux groupes, les deux principales catégories étaient la QV et l'impact de l'environnement de dialyse. La troisième catégorie différait: ceux qui en obtenaient écrivaient sur le soutien, alors que ceux qui n'en obtenaient pas ont indiqué que la « dialyse était le moindre de leurs soucis ¼. Limites: Le faible taux de réponse (12,9 %) limite la représentativité; les personnes qui ont choisi de ne pas participer pourraient avoir des expériences différentes en matière de santé mentale. Conclusion: L'intégration des préférences des patients et de leur volonté d'obtenir du soutien en santé mentale permettra d'éclairer la vision future des soins de santé mentale axés sur les patients traités par dialyse.

Patient-Reported Outcomes Measurement in Radiation Oncology: Interpretation of Individual Scores and Change over Time in Clinical Practice.

Tools for measuring patients' perceived health and quality of life, such as patient-reported outcome measures (PROMs), inform clinical decisions for patients requiring radiation therapy. However, there may be inconsistencies in how patients interpret and respond to PROMs due to cultural, environmental, personal, or experiential factors. Differential item functioning (DIF) and response shift (RS) refer to differences in the meaning of PROMs between patients or over time (respectively). DIF and RS can threaten the accurate interpretation and use of PROMs, potentially resulting in erroneous conclusions about effectiveness, and flawed individual-level clinical decision-making. Given the empirical evidence of DIF and RS, we aim to review clinical implications and solutions for addressing DIF and RS by providing vignettes from collaborative examinations with workshop participants, as well as the literature. By making these methodological concepts accessible and relevant, for practice, clinicians may feel more confident to ask clarifying questions of patients when PROM scores and the contextual patient information do not align. PROM scores need to be interpreted via dialogue with the patient to avoid misinterpretation due to DIF and RS, which could diminish patient-clinician communication and impede shared decision-making. This work is part of an interdisciplinary knowledge translation initiative focused on the interpretation of PROM scores by clinically-oriented audiences.

Mental Health Care for Adults Treated With Dialysis in Canada: A Scoping Review.

Purpose of review: Mental illnesses, especially depression and anxiety, are common conditions frequently underrecognized and untreated among individuals with end-stage kidney disease. Existing tools/interventions, approaches to care, and resources to support mental health for people treated with dialysis in Canada are not well known. The aim of this scoping review was to systematically describe how mental health care is provided to adults treated with dialysis in Canada. The research questions we sought to answer were the following: (1) What mental health assessment tools and interventions for adults treated with dialysis have been investigated and utilized in Canada? (2) what is the structure and process of mental health care delivered by kidney care to adults treated with dialysis in Canada? and (3) what is the availability of mental health care resources developed for adults treated with dialysis in Canada? Sources of information: Electronic databases included Medline, Embase, CINAHL, PsycINFO, Cochrane Library, Scopus, and Web of Science for peer-reviewed literature, and Google search engine for gray literature. Methods: Systematic searches were conducted to identify peer-reviewed and gray literature that focused on mental health care or support offered to adults receiving any form of dialysis in Canadian kidney care settings and/or community organizations. Mental health care and support was defined to include mental health assessment tools, interventions, resources, guidelines, and/or pathways used in dialysis in Canada. Title, abstracts, and full texts were screened independently by 2 reviewers with discrepancies resolved by additional team members. Web sites were screened by individual members. Data from included studies and Web sites were extracted based on the abovementioned research questions. Key findings: We identified 8 peer-reviewed articles from electronic databases, and 28 separate Web site addresses. Of the 8 articles, 4 investigated mental health assessment tools and 4 examined mental health interventions for individuals treated with dialysis in Canada. The mental health assessment tools that have been used are Beck Depression Inventory-II (BDI-II), Edmonton System Assessment Scale (ESAS), Edmonton System Assessment Scale revised (ESAS-r): Renal, Hospital Anxiety and Depression Scale (HADS), and Distress Assessment and Response Tool (DART), and the nonpharmacological interventions that have been investigated are intradialytic exercise, tai chi exercise program, medical music therapy, and brief mindfulness meditation. Of the 28 Web site addresses, 2 contained clinical tools for kidney care providers for the management of depression and anxiety in individuals treated with dialysis. The 26 remaining Web sites contained mental health resources for individuals with kidney disease, which presented different types of resources, including psychoeducation, peer support, and linkage to other services. Conclusion: In conclusion, we found only a limited number of studies investigating mental health assessment tools and interventions in Canada; there was a paucity of randomized controlled trials. Clinical pathways for the assessment and management of mental illness or symptoms in individuals treated with dialysis in Canada are also limited, and no clinical practice guidelines exist. Several mental health resources for people living with dialysis are available, predominantly focused on psychoeducation and peer support. Despite increasing prevalence of mental health concerns by people treated with dialysis, mental health care remains underaddressed. Limitations: It is plausible that additional literature related to mental health assessment tools, interventions, resources, guidelines, and pathways exists that we did not find during our systematic search, especially in gray literature that was limited to one search engine. In addition, health care agencies or organizations may have developed other mental health resources, which may not be available on the Internet.

Justification: Les troubles de santé mentale, la dépression et l'anxiété particulièrement, sont des affections courantes, mais souvent non reconnues et non traitées chez les personnes atteintes d'insuffisance rénale terminale. Les outils, interventions, approches de soins et ressources qui existent pour soutenir la santé mentale des personnes traitées par dialyse au Canada sont eux aussi mal connus. Cette revue de littérature vise à décrire systématiquement la façon dont les soins de santé mentale sont prodigués aux adultes dialysés au Canada. Pour ce faire, nous avons tenté de répondre aux questions de recherche suivantes: (1) Quels outils d'évaluation de la santé mentale et interventions auprès des adultes dialysés ont été étudiés et sont utilisés au Canada? (2) Quelle est la structure des soins de santé mentale dispensés par l'équipe des soins rénaux aux adultes dialysés au Canada, et quel en est le processus? (3) Les ressources en santé mentale mises au point pour les adultes dialysés au Canada sont-elles disponibles? Sources: Les bases de données électroniques Medline, Embase, CINAHL, PsycINFO, Cochrane Library, Scopus et Web of Science ont été consultées à la recherche de littérature évaluée par des pairs. Le moteur de recherche Google a été utilisé pour la littérature grise. Méthodologie: Des recherches systématiques ont été effectuées pour répertorier la littérature grise et la littérature évaluée par les pairs portant sur le soutien ou les soins de santé mentale offerts aux adultes recevant une forme quelconque de dialyse dans les établissements de santé rénale et/ou organismes communautaires canadiens. Le soutien et les soins en santé mentale ont été définis de façon à inclure les outils d'évaluation, interventions, ressources, lignes directrices ou schémas utilisés en contexte de dialyse au Canada. Les titres, résumés et articles complets ont été examinés de façon indépendante par deux auteurs; les désaccords ayant été résolus par d'autres membres de l'équipe. Les sites Web ont été examinés par des membres individuels. Les questions susmentionnées ont servi à l'extraction des données d'intérêt des études et sites inclus. Principaux résultats: Les bases de données électroniques ont permis de répertorier huit articles évalués par des pairs et 28 adresses de sites Web différentes. Des huit articles inclus, quatre avaient examiné des outils d'évaluation et quatre avaient examiné des interventions en santé mentale pour les personnes dialysées au Canada. Les outils d'évaluation de la santé mentale utilisés étaient BDI-II, ESAS, ESAS-r: Renal, HADS et DART. Les interventions non pharmacologiques incluaient des exercices intradialytiques, un programme de tai-chi, la musicothérapie médicale et une courte séance de méditation de pleine conscience. Sur les 28 adresses de site Web retenues, deux contenaient des outils cliniques destinés aux professionnels de la santé rénale pour la prise en charge de la dépression et de l'anxiété chez les personnes dialysées. Les 26 autres contenaient des ressources en santé mentale destinées aux personnes atteintes d'une néphropathie, soit différents types de ressources incluant notamment de la psychoéducation, du soutien par les pairs et des liens vers d'autres services.Pour résumer, nous n'avons trouvé qu'un nombre limité d'études portant sur les outils d'évaluation et les interventions pour la santé mentale au Canada, dont aucun essai randomisé contrôlé. Les cheminements cliniques pour évaluer et prendre en charge les troubles de santé mentale et leurs symptômes chez les personnes traitées par dialyse au Canada sont également limités, et il n'existe aucune ligne directrice en matière de pratique clinique. Plusieurs ressources en santé mentale sont disponibles pour cette population, elles sont principalement axées sur la psychoéducation et le soutien par les pairs. Malgré la prévalence croissante des troubles de santé mentale chez les personnes dialysées, les soins demeurent rarement abordés. Limites: Il est possible que d'autres documents existent sur les outils d'évaluation de la santé mentale, les interventions, les ressources, les lignes directrices ou les voies d'accès, et que nous les ayons manqués lors de la recherche systématique, particulièrement dans la littérature grise puisque celle-ci était limitée à un seul moteur de recherche. Il est également possible que des agences ou organismes de soins de santé aient mis au point d'autres ressources en santé mentale qui ne sont pas disponibles sur Internet.

Telemonitoring and Case Management for Hypertensive and Remote-Dwelling Patients With Chronic Kidney Disease-The Telemonitoring for Improved Kidney Outcomes Study (TIKO): A Clinical Research Protocol.

BACKGROUND: Hypertension, together with poorly controlled blood pressure (BP) are known risk factors for kidney disease and progression to kidney failure as well as increased cardiovascular (CV) morbidity and mortality. Several studies in patients without kidney disease have demonstrated the efficacy of home BP telemonitoring (HBPT) for BP control. OBJECTIVE: The primary aim of this study is to assess the mean difference in systolic BP (SBP) at 12 months, from baseline in remote dwelling patients with hypertension and chronic kidney disease (CKD) in Northern Alberta, Canada, comparing HBPT + usual care versus HBPT + a case manager. Other secondary objectives, including cost-effectiveness and acceptability of HBPT as well as occurrence of adverse events will also be assessed. DESIGN: This study is designed as a pragmatic randomized controlled trial (RCT) of HBPT plus clinical case management compared to HBPT with usual care. SETTING: Peace River region in Northern Alberta Region, Canada. PATIENTS: Primary care patients with CKD and hypertension. MEASUREMENTS: Eligible patients will be randomized 1:1 to HBPT + BP case management versus HBPT + usual care. In the intervention arm, BP will be measured 4 times daily for 1 week, with medications titrated up or down by the study case manager until guideline targets (systolic BP [SBP]: <130 mmHg) are achieved. Once BP is controlled, (ie, to guideline-concordant targets), this 1-week protocol will be repeated every 3 months for 1 year. Patients in the control arm will also follow the same BP measurement protocol; however, there will be no interactions with the case manager; they will share their BP readings with their primary care physicians or nurse practitioners at scheduled visits. LIMITATIONS: Potential limitations of this study include the relatively short duration of follow-up, possible technological pitfalls, and need for patients to own a smartphone and have access to the internet to participate. CONCLUSIONS: As this study will focus on a high-risk population that has been characterized by a large care gap, it will generate important evidence that would allow targeted and effective population-level strategies to be implemented to improve health outcomes for high-risk hypertensive CKD patients in Canada's remote communities. TRIAL REGISTRATION: www.clinicaltrials.gov (NCT number: NCT04098354).

CONTEXTE: L'hypertension et la pression artérielle (PA) mal contrôlée sont des facteurs de risque reconnus pour la néphropathie et la progression vers l'insuffisance rénale, en plus de poser un risque accru de morbidité et de mortalité cardiovasculaires. Plusieurs études chez des patients sans néphropathie ont démontré l'efficacité de la télésurveillance de la PA à domicile (TSPA) pour le contrôle de la PA. OBJECTIFS: Le principal objectif est d'évaluer la différence moyenne de pression artérielle systolique (PAS) après 12 mois par rapport à sa valeur initiale chez des patients atteints d'hypertension et d'insuffisance rénale chronique (IRC) habitant les communautés éloignées du nord de l'Alberta (Canada). Cet objectif sera atteint en comparant la TSPA + soins habituels à la TSPA + gestionnaire de cas. D'autres objectifs secondaires, notamment le rapport coût/efficacité de la TSPA, son acceptation et la survenue d'événements indésirables seront également évalués. TYPE D'ÉTUDE: Cette étude est conçue comme un essai randomisé contrôlé (ERC) pragmatique comparant la TSPA + prise en charge clinique des cas à la TSPA + soins habituels. CADRE: Région de Peace River dans le nord de l'Alberta (Canada). SUJETS: Patients atteints d'IRC et d'hypertension recevant des soins de santé primaires. MESURES: Les patients admissibles seront répartis 1:1 dans le groupe TSPA + prise en charge du cas d'hypertension ou dans le groupe témoin (TSPA + soins habituels). Dans le groupe d'intervention, la PA sera mesurée quatre fois par jour pendant une semaine, avec augmentation ou réduction de la médication par le gestionnaire de cas de l'étude jusqu'à ce que la cible de référence (PAS : <130 mmHg) soit atteinte. Une fois la PA contrôlée (c.-à-d. conforme aux cibles recommandées), ce protocole sur une semaine sera répété tous les trois mois pendant un an. Les patients du groupe témoin suivront le même protocole de mesure de la PA, mais sans interactions avec le gestionnaire de cas, ils transmettront plutôt leurs mesures de PA à leur médecin de soins primaires ou aux infirmières praticiennes lors de visites prévues. LIMITES: Cette étude est notamment limitée par la durée relativement courte du suivi, de possibles difficultés technologiques et la nécessité pour les participants de posséder un téléphone intelligent et d'avoir accès à l'Internet. CONCLUSION: Puisque cette étude se penchera sur une population à risque élevé et marquée par d'importantes lacunes en matière de soins, elle générera des données importantes qui aideront à mettre en œuvre des stratégies ciblées et efficaces au niveau de la population afin d'améliorer les évènements cliniques des patients hypertendus et atteints d'IRC à haut risque habitant les communautés éloignées au Canada.

Designing an App for Immunosuppression Adherence and Communication: A Qualitative Approach.

BACKGROUND: Immunosuppression nonadherence may be the most important factor limiting long-term allograft survival. OBJECTIVE: Following user-centered design, we explored the essential priorities and preferences of kidney transplant recipients and healthcare providers (HCP) to inform development of a smartphone app to improve immunosuppression adherence and communication. DESIGN: A qualitative descriptive research design was used. SETTING: The University of Alberta Hospital adult kidney transplant program in Edmonton, Canada. PARTICIPANTS: Participants were recruited by convenience sampling and included 32 kidney transplant recipients and 11 HCPs. METHODS: Seven focus groups (5 with recipients and 2 with HCPs) were conducted to inform app development. Sessions were recorded, and transcripts were coded to elucidate themes. RESULTS: App development to improve adherence was not a priority for HCP. Recipients prioritized choice: that all features be optional. Recipients preferred support while traveling; access to laboratory results; and use by younger or newly transplanted recipients. Both recipients and HCP preferred linkage to pharmacy; and self-management and accountability.For the app to improve communication, HCPs believed the priorities to be addressed included: clarity on scope of app; legal, ethical, and professional obligations; and charting. Both recipients and HCP prioritized HCP workload, and broader medication and health concerns. Healthcare providers preferred tech support; both recipients and HCPs preferred app access for nontransplant HCP. LIMITATIONS: Limitations include underrepresentation of physicians, recipients with racial/ethnic diversity, and potential selection bias of transplant recipients who perceived themselves to be adhering to immunosuppression medications. CONCLUSION: Future research is needed for the app to become a comprehensive, secure platform for broader communication between recipients and HCP, pharmacies, and nontransplant clinicians while streamlining HCP workload.

CONTEXTE: La non-observance du traitement immunosuppresseur pourrait s'avérer le facteur limitant ayant la plus grande incidence sur la survie à long terme de l'allogreffe. OBJECTIFS: Suivant une conception centrée sur l'utilisateur, nous avons exploré les préférences et les priorités essentielles des receveurs d'une greffe rénale et des fournisseurs de soins de santé (FSS) afin d'orienter le développement d'une application pour téléphones intelligents visant à améliorer les communications et l'observance du traitement immunosuppresseur. TYPE D'ÉTUDE: Un plan de recherche qualitatif et descriptif a été utilisé. CADRE: Le program de transplantation rénale pour adultes du University of Alberta Hospital à Edmonton (Canada). PARTICIPANTS: Les participants ont été recrutés par échantillonnage de commodité. L'étude a inclus 32 receveurs d'une greffe rénale et 11 FSS. MÉTHODOLOGIE: Sept groupes de discussion (5 avec les receveurs, 2 avec les FSS) ont été organisés pour guider le développement de l'application. Les séances ont été enregistrées et les transcriptions ont été codées afin de préciser les thèmes. RÉSULTATS: Le développement d'une application pour améliorer l'observance au traitement n'était pas une priorité pour les FSS. Les receveurs d'une greffe priorisaient d'avoir le choix : ils souhaitaient que toutes les fonctionnalités soient facultatives. Les receveurs d'une greffe avaient une préférence pour une application qui offrirait du soutien lors de leurs déplacements, qui permettrait un accès aux résultats de laboratoire et qui soit utilisée par les nouveaux greffés et les receveurs plus jeunes. Tous les participants préféraient que l'application propose un lien vers la pharmacie et qu'elle favorise l'autogestion et la responsabilisation.Pour que l'application améliore la communication, les FSS étaient d'avis qu'il fallait s'attarder aux priorités suivantes : la clarté de la portée de l'application; les obligations juridiques, éthiques et professionnelles; et la tenue des dossiers. Tant les receveurs d'une greffe que les FSS accordaient une priorité à la charge de travail des professionnels de la santé et aux préoccupations plus générales en matière de santé et de médicaments. Les FSS préféraient une assistance technique; et tous les participants avaient une préférence pour que l'application soit accessible aux FSS ne travaillant pas en transplantation. LIMITES: Parmi les limites figurent la sous-représentation des médecins, l'absence de receveurs issus de la diversité raciale/ethnique et un possible biais de sélection des receveurs d'une greffe qui se perçoivent comme adhérant à leur traitement immunosuppresseur. CONCLUSION: D'autres recherches sont nécessaires pour que l'application devienne une plateforme complète et sécurisée qui facilite la communication entre les patients, les professionnels de la santé, les pharmacies et les cliniciens ne travaillant pas en transplantation, tout en allégeant la charge de travail des fournisseurs de soins.

Knowledge translation resources to support the use of quality of life assessment tools for the care of older adults living at home and their family caregivers.

PURPOSE: To support the use of quality of life (QOL) assessment tools for older adults, we developed knowledge translation (KT) resources tailored for four audiences: (1) older adults and their family caregivers (micro), (2) healthcare providers (micro), (3) healthcare managers and leaders (meso), and (4) government leaders and decision-makers (macro). Our objectives were to (1) describe knowledge gaps and resources and (2) develop corresponding tailored KT resources to support use of QOL assessment tools by each of the micro-, meso-, and macro-audiences. METHODS: Data were collected in two phases through semi-structured interviews/focus groups with the four audiences in Canada. Data were analyzed using qualitative description analysis. KT resources were iteratively refined through formative evaluation. RESULTS: Older adults and family caregivers (N = 12) wanted basic knowledge about what "QOL assessment" meant and how it could improve their care. Healthcare providers (N = 13) needed practical solutions on how to integrate QOL assessment tools in their practice. Healthcare managers and leaders (N = 14) desired information about using patient-reported outcome measures (PROMs) and patient-reported experience measures (PREMs) in healthcare programs and quality improvement. Government leaders and decision-makers (N = 11) needed to know how to access, use, and interpret PROM and PREM information for decision-making purposes. Based on these insights and evidence-based sources, we developed KT resources to introduce QOL assessment through 8 infographic brochures, 1 whiteboard animation, 1 live-action video, and a webpage. CONCLUSION: Our study affirms the need to tailor KT resources on QOL assessment for different audiences. Our KT resources are available: www.healthyqol.com/older-adults .

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.

Furthering Cultural Safety in Kidney Care Within Indigenous Communities: A Systematic and Narrative Review.

RATIONALE & OBJECTIVE: Cultural Safety is being prioritized within health care around the world. As a concept, Cultural Safety centers upon power relations between health providers and indigenous recipients of care, ensuring that all people feel safe and respected in the health care system. In this article, we explored the breadth of the literature regarding Cultural Safety within the context of indigenous kidney health care. STUDY DESIGN & POPULATIONS: As a systematic narrative review, this work engaged widely across a diverse range of the available literature to broaden understanding of Cultural Safety within indigenous kidney health care and indigenous populations from Australia, New Zealand, Canada, and the United States. SEARCH STRATEGY & ANALYTICAL APPROACH: Guided by the research question focused on how Cultural Safety occurs within care for indigenous people with kidney disease, an initial database search by the university librarian resulted in retrieval of 2,232 articles, of which 96 potential articles were screened by the research team. RESULTS: 15 articles relevant to the research question were identified and study findings were assembled within 3 broad clusters: relationality, engagement, and health care self-determination; systemic issues, barriers, and access; and addressing legacies of colonialism for health care providers. LIMITATIONS: The review summarizes mainly qualitative articles given the paucity of articles found specific to Cultural Safety within indigenous contexts. CONCLUSIONS: Of particular interest to health care providers are the collation of solutions by cluster and the findings of this review that contribute to further understanding of the concept of Cultural Safety in health care for indigenous people with kidney disease. Also, findings address the importance of community-driven kidney care in which language, ways of knowing and being, and traditional ways of healing are prioritized.

Knowledge and Practice of Incremental Hemodialysis: A Survey of Canadian Nephrologists.

BACKGROUND: Incremental hemodialysis, a strategy to individualize dialysis prescription based on residual kidney function, may be associated with enhanced quality of life and decreased health care costs compared with conventional hemodialysis. OBJECTIVE: We surveyed practicing Canadian nephrologists to assess knowledge, perceptions, and practice pattern on the use of incremental hemodialysis. DESIGN/SETTING: We distributed a cross-sectional, web-based survey. We asked about incremental hemodialysis prescribing practices, including frequency of prescription, clinical factors used to determine suitability for treatment, and barriers to implementation. The survey was conducted from September 21 to October 30, 2020. PARTICIPANTS: We distributed the survey to practicing Canadian nephrologists identified from a private membership list of the Canadian Society of Nephrology (CSN), as well as to nephrologists named on a publicly available national list of practicing Canadian nephrologists created from provincial College of Physician registries. These were samples of convenience. METHODS: We conducted descriptive analysis of categorical data including frequencies for nominal variables and measures of central tendency (mean) and dispersion (standard deviation) for ordinal variables. We used chi-square analysis to identify association between participant and practice characteristics and their opinions and attitudes toward incremental dialysis. We used simple thematic analysis on free-text responses on questions regarding the prescription of incremental hemodialysis, focusing on age and baseline management of cardiac and noncardiac comorbidities. RESULTS: The response rate was 35% (243/691). Most (138/211, 65%) of the participants prescribed incremental hemodialysis using an individualized approach at the nephrologist's discretion. Most participants (200/203, 98%) did not report any policy for implementation. Residual urine output was identified as the most important factor for eligibility (112/172, 65%), followed by electrolyte stability (76/172, 44%) and patient goals of care (69/117, 40%). Most participants agreed that dialysis prescriptions should take residual kidney function into consideration; however, 74% of the participants disagreed with a statement that there was strong evidence supporting incremental hemodialysis. Barriers identified included patient safety, patient acceptance of dose escalation, and logistics of scheduling. Despite these barriers, 82% of participants felt that that incremental hemodialysis is feasible with their current resources and 78% agreed that with specific criteria, it is a safe option. LIMITATIONS: The generalizability of our study is limited by its response rate of 35%; however, this is comparable with typical response rates seen in electronic surveys. Most participants practice in an academic setting, which may have introduced bias to the results. CONCLUSIONS: Despite the perception of limited evidence and a lack of guidance on implementation, incremental hemodialysis is frequently practiced by Canadian nephrologists. Barriers to implementation were identified, highlighting the need for research to guide practice.

CONTEXTE: L'hémodialyse incrémentale est une stratégie tenant compte de la fonction rénale résiduelle pour individualiser la prescription de dialyse. Comparée à l'hémodialyse conventionnelle, cette modalité pourrait être associée à une amélioration de la qualité de vie des patients et à une réduction des coûts de santé. OBJECTIF: Nous avons interrogé des néphrologues canadiens en exercice afin d'évaluer leurs connaissances, leurs perceptions et leurs habitudes de pratique relativement à l'hémodialyse incrémentale. CONCEPTION DE L'ÉTUDE: Une enquête transversale en ligne a été distribuée. Les questions portaient sur les pratiques de prescription de l'hémodialyse incrémentale, notamment sur la fréquence de prescription, les facteurs cliniques utilisés pour déterminer l'adéquation du traitement, et les obstacles à la mise en œuvre. Le sondage a été réalisé entre le 21 septembre et le 30 octobre 2020. PARTICIPANTS: Nous avons distribué le sondage aux néphrologues canadiens en exercice figurant sur une liste privée des membres de la Société canadienne de néphrologie (SCN), ainsi qu'aux néphrologues figurant sur une liste nationale publique des néphrologues canadiens en exercice, créée à partir des registres des Collèges des médecins provinciaux. Il s'agit d'échantillons de commodité. MÉTHODOLOGIE: Nous avons procédé à une analyse descriptive des données catégoriques, notamment des fréquences pour les variables nominales et des mesures de tendance centrale (moyenne) et de dispersion (écart-type) pour les variables ordinales. Nous avons utilisé l'analyse du chi-carré pour établir l'association des caractéristiques des répondants et de leurs pratiques avec leurs opinions et comportements à l'égard de la dialyse incrémentale. Nous avons procédé à une analyse thématique simple des réponses en texte libre aux questions portant sur la prescription de l'hémodialyse incrémentale, en se concentrant sur l'âge et la prise en charge initiale des comorbidités cardiaques et non cardiaques. RÉSULTATS: Le taux de réponse était de 35 % (243/691). Une majorité de répondants (138/211 [65 %]) prescrivaient l'hémodialyse incrémentale selon une approche individualisée à la discrétion du néphrologue. La quasi-totalité des répondants (200/203 [98 %]) n'a pas fait état d'une politique de mise en œuvre. La diurèse résiduelle a été désignée comme le principal facteur d'admissibilité (112/172 [65 %]), suivie de la stabilité électrolytique (76/172 [44 %]) et des objectifs de soins du patient (69/117 [40 %]). La plupart des répondants ont convenu que la prescription de dialyse devrait tenir compte de la fonction rénale résiduelle; 74 % d'entre eux se sont toutefois dits en désaccord avec une affirmation selon laquelle il existe de solides preuves appuyant l'hémodialyse incrémentale. La sécurité du patient, l'acceptation par le patient d'une augmentation de la dose et la logistique de la planification figurent parmi les obstacles à la mise en œuvre mentionnés par les répondants. Malgré ces obstacles, 82 % des répondants étaient d'avis que l'hémodialyse incrémentale est possible avec les ressources actuelles, et 78 % étaient d'accord pour dire qu'avec des critères précis, cette modalité est une option sûre. LIMITES: La généralisabilité de notre étude est limitée par son faible taux de réponse (35 %), bien que celui-ci soit comparable à ceux qu'on observe généralement pour les enquêtes électroniques. La plupart des répondants exerçaient dans un cadre académique, ce qui peut avoir introduit un biais dans les résultats. CONCLUSION: L'hémodialyse incrémentale est fréquemment prescrite par les néphrologues canadiens, malgré une perception de preuves limitées et un manque d'orientation pour sa mise en œuvre. Les répondants ont mentionné quelques obstacles à sa mise en œuvre, soulignant ainsi la nécessité de mener des recherches afin de mieux orienter la pratique.