Informed Dialysis Modality Selection Among Veterans With Advanced CKD: A Community-Level Needs Assessment

Abstract

Rationale & objective: The Advancing Americans Kidney Health Executive order has directed substantial increases in home dialysis use for incident kidney replacement therapy (KRT). Clinical guidelines recommend patients' self-selection of KRT modality through a shared decision-making process, which, at the minimum, requires predialysis nephrology care and KRT-directed comprehensive prekidney failure patient education (CoPE). The current state of these essential services among Americans with advanced (stages 4 and 5) chronic kidney disease (CKD) and their informed preferences for home dialysis are unknown.

Study design: We conducted a community-based, cross-sectional, observational cohort study across a large regional Veteran Healthcare System from October 1, 2020, to September 30, 2021.

Setting & participants: Of the 928 Veterans with advanced CKD, 287 (30.9%) were invited for needs assessment evaluations. Of the 218 (76% of invited cohort) responding, 178 (81.6%) were receiving nephrology care, with approximately half of those (43.6%) receiving such care from non-Veterans Affairs providers.

Outcomes: The study was targeted to assess the prevalent state of ongoing nephrology care and KRT-directed pre-kidney failure education among Veterans with advanced CKD. The secondary outcome included evaluation of dialysis decision-making state among Veterans with advanced CKD.

Analytical approach: Veterans with advanced CKD with 2 sustained estimated glomerular filtration rates <30 mL/min/1.73 m² were identified through an electronic database query, and a randomly selected cohort was invited for their current state of and outstanding needs for predialysis nephrology care and CoPE, essential for informed KRT selection.

Results: Basic awareness of kidney disease was high (92.2%) among Veterans with advanced CKD, although only 38.5% were aware of the severity of their CKD. KRT-directed education during clinical care was reported by 46.8% of Veterans, of which 21.1% reported having received targeted CoPE classes. Three-quarters (74.3%) of Veterans expressed interest in receiving CoPE services. Overall, awareness of CKD and its severity and receipt of KRT-directed education were significantly higher among Veterans with nephrology care than among those without. Of the 61 Veterans providing their KRT preferences, overall decision making was poor, with three-quarters (73.8%) of the cohort unable to choose any KRT modality, irrespective of ongoing nephrology care. Only 8 (13%) felt confident choosing home KRT modalities.

Limitations: The study results are primarily applicable to the Veterans with advanced CKD. Furthermore, a limited numbers of respondents provided data on their KRT decision-making state, prohibiting broad generalizations.

Conclusions: In a first-of-its-kind community-based needs assessment evaluation among Veterans with advanced CKD, we found that awareness of kidney disease is positively associated with nephrology care; however, the informed KRT selection capabilities are universally poor, irrespective of nephrology care. Our results demonstrate a critical gap between the recommended and prevalent nephrology practices such as KRT-directed education and targeted CoPE classes required for informed patient-centered home dialysis selection in advanced CKD.

Keywords: Comprehensive Pre-ESKD education (CoPE); Home dialysis; Needs assessment evaluation.

Figure 1

The conceptual models of advanced CKD care at patient and health care system levels. Panel A shows the parsimonious patient-level model highlights key steps for an individual to reach an informed KRT selection. Panel B shows the population-level model integrates the conceptual clinical model with health outcome data to create a system-level “Flame Model” in which the quality/intensity of prekidney failure clinical care is associated with progressively higher utilization of home dialysis therapies. Abbreviations: CKD, chronic kidney disease; CoPE, comprehensive prekidney failure education; eGFR, estimated glomerular filtration rate; ICD, International Classification of Diseases; KRT, kidney replacement therapy; NF/SG VHS, North Florida South Georgia Veteran Healthcare System.

Figure 2

Participant selection diagram. Abbreviations: CKD, chronic kidney disease; CoPE, comprehensive prekidney failure education; eGFR, estimated glomerular filtration rate; ICD, International Classification of Diseases; NF/SG VHS, North Florida South Georgia Veteran Healthcare System.