Embedding an Education Intervention about Shared Decision Making into an RCT: Ensuring competency and fidelity.

Objective: To describe the outcomes of training nephrology clinicians and clinical research participants, to use the Best Case/Worst Case Communication intervention, for discussions about dialysis initiation for patients with life-limiting illness, during a randomized clinical trial to ensure competency, fidelity to the intervention, and adherence to study protocols and the intervention throughout the trial. Methods: We enrolled 68 nephrologists at ten study sites and randomized them to receive training or wait-list control. We collected copies of completed graphic aids (component of the intervention), used with study-enrolled patients, to measure fidelity and adherence. Results: We trained 34 of 36 nephrologists to competence and 27 completed the entire program. We received 60 graphic aids for study-enrolled patients for a 73% return rate in the intervention arm. The intervention fidelity score for the graphic aid reflected completion of all elements throughout the study. Conclusion: We successfully taught the Best Case/Worst Case Communication intervention to clinicians as research participants within a randomized clinical trial. Innovation: Decisions about dialysis are an opportunity to discuss prognosis and uncertainty in relation to consideration of prolonged life supporting therapy. Our study reveals a strategy to evaluate adherence to a communication intervention in real time during a clinical study.

Lower Socioeconomic Status is Associated With Adverse Urinary Markers and Surgical Complexity in Kidney Stone Patients.

OBJECTIVE: To determine if socioeconomic status (SES) correlates with severity of kidney stone disease and 24-hour urine parameters. MATERIALS AND METHODS: An IRB approved prospectively maintained database for nephrolithiasis was retrospectively analyzed for both 24-hour urine results and surgical procedures performed from 2009 to 2019. Severely distressed communities (SDC) were categorized as those with a Distressed Communities Index (DCI), a composite measure of SES, score in the top quartile (lowest for SES). Univariate and multivariate analyses were performed to evaluate the strength of the association of DCI on: stone size at presentation, need for and type of surgical procedure, need for staged surgery and specific stone risk factors in 24-hour urine collections. RESULTS: Surgical procedures were performed on 3939 patients (1978 women) who were not from SDC and 200 (97 women) from SDC. Patients from SDC were older (57.1 years vs 54.2 years; P = .009). Patients from SDC were more likely to undergo proportionally more invasive procedures (17.5% vs 11.6%; P = .011) and require staged surgery at a higher rate (13.0% vs 8.5%; P = .028). Men from SDC had larger stones (12.5 mm vs 9.7 mm; P = .001). Among 24-hour urine results from 2454 patients (1187 women), DCI was not correlated with sodium, calcium, magnesium, volume, oxalate, phosphate, and pH levels. Higher DCI (lower SES) correlated with lower urine citrate (P = .001) and lower urine potassium (P = .002). CONCLUSION: SES correlates with larger stone burden at the time of urologic intervention, requires proportionally more invasive procedures and more staged procedures. Lower SES correlated with lower urine citrate and potassium.

Opportunities to Improve Shared Decision Making in Dialysis Decisions for Older Adults with Life-Limiting Kidney Disease: A Pilot Study.

Background: Lack of awareness about the life-limiting nature of renal failure is a significant barrier to palliative care for older adults with end-stage renal disease. Objective: To train nephrologists to use the best case/worst case (BC/WC) communication tool to improve shared decision making about dialysis initiation for older patients with limited life expectancy. Design: This is a pre-/postinterventional pilot study. Setting/Subjects: There were 16 nephrologists and 30 patients of age 70 years and older with estimated glomerular filtration rate (eGFR) <20 mL/min per 1.73 m2 in outpatient nephrology clinics, in Madison, WI. Measurements: Performance of tool elements, content of communication about dialysis, shared decision making, acceptability of the intervention, decisions to pursue dialysis, and palliative care referrals were measured. Results: Fifteen of 16 nephrologists achieved competence performing the BC/WC tool with standardized patients, executing at least 14 of 19 items. Nine nephrologists met with 30 patients who consented to audio record their clinic visit. Before training, clinic visits focused on laboratory results and preparation for dialysis. After training, nephrologists noted that declining kidney function was "bad news," presented dialysis and "no dialysis" as treatment options, and elicited patient preferences. Observer-measured shared decision-making (OPTION 5) scores improved from a median of 20/100 (interquartile range [IQR] 15-35) before training to 58/100 (IQR 55-65). Patients whose nephrologist used the BC/WC tool were less likely to make a decision to initiate dialysis and were more likely to be referred to palliative care. Conclusions: Nephrologists can learn to use the BC/WC tool with older patients to improve shared decision making about dialysis, which may increase access to palliative care.