Survival among older adults with kidney failure is better in the first three years with chronic dialysis treatment than not.

Comparisons of survival between dialysis and nondialysis care for older adults with kidney failure have been limited to those managed by nephrologists, and are vulnerable to lead and immortal time biases. So we compared time to all-cause mortality among older adults with kidney failure treated vs. not treated with chronic dialysis. Our retrospective cohort study used linked administrative and laboratory data to identify adults aged 65 or more years of age in Alberta, Canada, with kidney failure (2002-2012), defined by two or more consecutive outpatient estimated glomerular filtration rates less than 10 mL/min/1.73m2, spanning 90 or more days. We used marginal structural Cox models to assess the association between receipt of dialysis and all-cause mortality by allowing control for both time-varying and baseline confounders. Overall, 838 patients met inclusion criteria (mean age 79.1; 48.6% male; mean estimated glomerular filtration rate 7.8 mL/min/1.73m2). Dialysis treatment (vs. no dialysis) was associated with a significantly lower risk of death for the first three years of follow-up (hazard ratio 0.59 [95% confidence interval 0.46-0.77]), but not thereafter (1.22 [0.69-2.17]). However, dialysis was associated with a significantly higher risk of hospitalization (1.40 [1.16-1.69]). Thus, among older adults with kidney failure, treatment with dialysis was associated with longer survival up to three years after reaching kidney failure, though with a higher risk of hospital admissions. These findings may assist shared decision-making about treatment of kidney failure.

Primary care physicians' perceived barriers, facilitators and strategies to enhance conservative care for older adults with chronic kidney disease: a qualitative descriptive study.

BACKGROUND: Although primary care physicians (PCPs) are often responsible for the routine care of older adults with chronic kidney disease (CKD), there is a paucity of evidence regarding their perspectives and practice of conservative (non-dialysis) care. We undertook a qualitative study to describe barriers, facilitators and strategies to enhance conservative, non-dialysis, CKD care by PCPs in the community. METHODS: Semi-structured telephone and face-to-face interviews were conducted with PCPs from Alberta, Canada. Participants were identified using a snowball sampling strategy and purposively sampled based on sex, age and rural/urban location of clinical practice. Eligible participants had managed at least one patient ≥75 years with Stage 5 CKD (estimated glomerular filtration rate <15 mL/min/1.73 m2, not on dialysis) in the prior year. Participant recruitment ceased when data saturation was reached. Transcripts were analyzed thematically using conventional content analysis. RESULTS: In total, 27 PCPs were interviewed. The majority were male (15/27), were aged 40-60 years (15/27) and had practiced in primary care for >20 years (14/27). Perceived barriers to conservative CKD care included: managing expectations of kidney failure for patients and their families; dealing with the complexity of medical management of patients requiring conservative care; and challenges associated with managing patients jointly with specialists. Factors that facilitated conservative CKD care included: establishing patient/family expectations early; preserving continuity of care; and utilizing a multidisciplinary team approach. Suggested strategies for improving conservative care included having: direct telephone access to clinicians familiar with conservative care; treatment decision aids for patients and their families; and a conservative care clinical pathway to guide management. CONCLUSIONS: PCPs identified important barriers and facilitators to conservative care for their older patients with Stage 5 CKD. Further investigation of potential strategies that address barriers and enable facilitators is required to improve the quality of conservative care for older adults in the community.

Primary care physicians' perceived barriers and facilitators to conservative care for older adults with chronic kidney disease: design of a mixed methods study.

BACKGROUND: Guideline committees have identified the need for research to inform the provision of conservative care for older adults with stage 5 chronic kidney disease (CKD) who have a high burden of comorbidity or functional impairment. We will use both qualitative and quantitative methodologies to provide a comprehensive understanding of barriers and facilitators to care for these patients in primary care. OBJECTIVES: Our objectives are to (1) interview primary care physicians to determine their perspectives of conservative care for older adults with stage 5 CKD and (2) survey primary care physicians to determine the prevalence of key barriers and facilitators to provision of conservative care for older adults with stage 5 CKD. DESIGN: A sequential exploratory mixed methods design was adopted for this study. The first phase of the study will involve fundamental qualitative description and the second phase will be a cross-sectional population-based survey. SETTING: The research is conducted in Alberta, Canada. PARTICIPANTS: The participants are primary care physicians with experience in providing care for older adults with stage 5 CKD not planning on initiating dialysis. METHODS: The first objective will be achieved by undertaking interviews with primary care physicians from southern Alberta. Participants will be selected purposively to include physicians with a range of characteristics (e.g., age, gender, and location of clinical practice). Interviews will be recorded, transcribed verbatim, and analyzed using conventional content analysis to generate themes. The second objective will be achieved by undertaking a population-based survey of primary care physicians in Alberta. The questionnaire will be developed based on the findings from the qualitative interviews and pilot tested for face and content validity. Physicians will be provided multiple options to complete the questionnaire including mail, fax, and online methods. Descriptive statistics and associations between demographic factors and barriers and facilitators to care will be analyzed using regression models. LIMITATIONS: A potential limitation of this mixed methods study is its cross-sectional nature. CONCLUSIONS: This work will inform development of clinical resources and tools for care of older adults with stage 5 CKD, to address barriers and enable facilitators to community-based conservative care.

MISE EN CONTEXTE: Les comités pour l'établissement de lignes directrices ont relevé la nécessité pour la recherche de faciliter la mise en place d'un traitement conservateur chez les adultes âgés atteints d'insuffisance rénale chronique (IRC) de stade 5, des patients présentant une incidence élevée de comorbidité et d'altération de la fonction rénale. Des méthodes qualitatives et quantitatives seront utilisées pour assurer une compréhension détaillée des obstacles aux soins de première ligne et en contrepartie, des éléments qui les facilitent. OBJECTIFS DE L'ÉTUDE: Cette étude vise deux objectifs principaux : 1) Interroger les médecins qui prodiguent des soins primaires afin de connaître leur point de vue sur l'administration d'un traitement conservateur chez les patients âgés atteints d'IRC de stade 5. 2) Sonder ces mêmes médecins pour établir la prévalence tant des obstacles à fournir des traitements conservateurs que des éléments la facilitant chez les patients âgés atteints d'IRC de stade 5. CADRE ET TYPE D'ÉTUDE: Il s'agit d'un modèle d'étude exploratoire à méthodes mixtes qui sera effectuée de façon séquentielle. Une première phase impliquera une description qualitative fondamentale tandis qu'une deuxième consistera en une enquête transversale menée dans la population. Les deux phases de l'étude se tiendront en Alberta, au Canada. PARTICIPANTS: Un groupe de médecins prodiguant des soins primaires à des patients âgés atteints d'IRC de stade 5, mais n'envisageant pas de commencer des traitements d'hémodialyse. MÉTHODOLOGIE: Le premier objectif sera atteint en menant une enquête auprès des médecins du sud de l'Alberta prodiguant des soins de première ligne. Les participants seront sélectionnés avec l'intention d'inclure des praticiens représentant un éventail de caractéristiques (âge, genre, lieu de pratique). Les entrevues seront enregistrées puis transcrites intégralement, et l'information recueillie sera traitée en utilisant une approche conventionnelle d'analyse du contenu pour en tirer les thématiques. Le second objectif sera également réalisé en procédant à une enquête dans la population de médecins prodiguant des soins de première ligne en Alberta. Le questionnaire sera mis au point suivant les résultats obtenus lors des entretiens qualificatifs et testés lors d'essais-pilotes visant à établir leur validité apparente et de contenu. Les praticiens disposeront de plusieurs moyens pour retourner le questionnaire une fois complété soit par la poste, par fax ou par d'autres méthodes en ligne. Les données statistiques descriptives ainsi que les associations établies entre les facteurs démographiques et les obstacles et facilitateurs de soins seront analysées à l'aide de modèles de régression. LIMITES DE L'ÉTUDE: Nous prévoyons une éventuelle limite à cette étude par méthodes mixtes compte tenu de sa nature transversale. CONCLUSIONS: À terme, ces travaux orienteront le développement de ressources cliniques et d'outils pour la prise en charge des patients âgés atteints d'IRC de stade 5. Ils contribueront également à rendre possible l'établissement de programmes de traitements conservateurs communautaires et à éliminer les obstacles rencontrés.

Prevalence of Barriers and Facilitators to Enhancing Conservative Kidney Management for Older Adults in the Primary Care Setting.

BACKGROUND AND OBJECTIVES: Conservative management of adults with stage 5 CKD (eGFR<15 ml/min per 1.73 m2) is increasingly being provided in the primary care setting. We aimed to examine perceived barriers and facilitators for conservative management of older adults by primary care physicians. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: In 2015, we conducted a cross-sectional, population-based survey of all primary care physicians in Alberta, Canada. Eligible participants had experience caring for adults ages ≥75 years old with stage 5 CKD not planning on initiating dialysis. Questionnaire items were on the basis of a qualitative descriptive study informed by the Behavior Change Wheel and tested for face and content validity. Physicians were contacted via postal mail and/or fax on the basis of a modified Dillman method. RESULTS: Four hundred nine eligible primary care physicians completed the questionnaire (9.6% response rate). The majority of respondents were men (61.6%), were ages 40-60 years old (62.6%), and practiced in a large/medium population center (68.0%). The most common barrier to providing conservative care in the primary care setting was the inability to access support to maintain patients in the home setting (39.1% of respondents; 95% confidence interval, 34.6% to 43.6%). The second most common barrier was working with nonphysician providers with limited kidney-specific clinical expertise (32.3%; 95% confidence interval, 28.0% to 36.7%). Primary care physicians indicated that the two most common strategies that would enhance their ability to provide conservative management would be the ability to use the telephone to contact a nephrologist or clinical staff from the conservative care clinic (86.9%; 95% confidence interval, 83.7% to 90.0% and 85.6%; 95% confidence interval, 82.4% to 88.9%, respectively). CONCLUSIONS: We identified important areas to inform clinical programs to reduce barriers and enhance facilitators to improve primary care physicians' provision of conservative kidney care. In particular, primary care physicians require additional resources for maintaining patients in their home and telephone access to nephrologists and conservative care specialists.

A controlled quality improvement trial to reduce the use of physical restraints in older hospitalized adults.

OBJECTIVES: To implement and evaluate an evidence-informed multicomponent strategy to reduce physical restraint use in older adults admitted to acute care medical units. DESIGN: Stepped-wedge trial. SETTING: Four acute care medical units in Calgary, Alberta, over a 4-month time period. PARTICIPANTS: Data were collected from individuals aged 65 and older present on the study units during monthly restraint audits. INTERVENTION: Development of opinion leaders among the nursing leadership, education and training of physicians and unit nurses, and implementation of least restraint rounds. MEASUREMENTS: The primary outcome was rate of restraint use as determined from walk-around audits. Secondary outcomes included number of physician orders for physical restraints on the electronic medical record and fall reports. RESULTS: Thirteen percent to 27% of individuals were being restrained on the medical units before the intervention, with the vast majority of restraints being bed rails. This decreased to 7% to 14% after the intervention. The intervention resulted in a statistically significant reduction in restraint use measured in the early mornings (P = .01), and this trend continued after adjusting for unit and month (P = .06). Similarly, the rate of restraint use trended down at all other measured time periods but was not statistically significant. A limited number of individuals had an order for physical restraint within their electronic medical record (3% before, 2% after the intervention). The median number of monthly fall reports did not change (three before, three after; P = .60). CONCLUSION: A multicomponent team-focused quality improvement intervention has the potential to decrease the use of physical restraints in older hospitalized adults.

Evaluation of older adults hospitalized with a diagnosis of failure to thrive.

BACKGROUND: older adults are sometimes hospitalized with the admission diagnosis of failure to thrive (FTT), often because they are not felt safe to be discharged back to their current living arrangement. It is unclear if this diagnosis indicates primarily a social admission or suggests an acute medical deterioration. The objective of this study was to explore the level of acuity and medical investigations commonly conducted among older hospitalized adults with a diagnosis of FTT. METHODS: We conducted a retrospective cohort study at three hospitals in Calgary, Alberta. Data were extracted from the electronic medical records of the 603 admissions of patients 65 years or older with a diagnosis of FTT between January 2010 and January 2011. Markers of medical acuity were evaluated. RESULTS: The vast majority of patients had short hospital stays. Specialist physicians were consulted for 323 cases (54%). Allied health-care professionals were consulted in 151 cases (25%). While in hospital, patients underwent extensive investigations, including CT scans, ultrasounds, and echo-cardiograms. Many patients received IV fluids (71%) and IV antibiotics (35%). CONCLUSIONS: The data suggest that acute illnesses, and not social factors, were the primary reason for admission among those given a diagnosis of FTT.