Japanese Patients' Perceptions of Shared Decision-Making in Renal Replacement Therapy

Abstract

Introduction: Shared decision-making (SDM) is a key process in selecting renal replacement therapy (RRT). This study analyzed SDM perceptions, preferences, as well as patient- and facility-level factors influencing SDM perception among Japanese patients with chronic kidney disease (CKD) who selected RRT.

Methods: We conducted a cross-sectional survey of 475 adult patients with CKD from 49 medical facilities. SDM awareness and recognition, preferences for SDM timing and frequency, discussion content, and desired professional involvement were assessed. Patient- and facility-level factors associated with SDM perceptions were evaluated using multivariable analysis.

Results: The mean participant age was 67.4 years. Hemodialysis, peritoneal dialysis, and kidney transplantation were chosen by 71%, 24.4%, and 4.4% of patients, respectively. Although 81.2% recalled SDM occurring during RRT selection, only 4.7% were well aware of SDM before the survey. Patients prioritized discussions about daily life impact, financial burden, and family-related concerns. Most patients preferred SDM initiation when RRT was imminent, and to be conducted over multiple sessions. Many patients valued the involvement of medical social workers and their usual nonnephrologist physicians in addition to nephrologists. Multiple outpatient visits for RRT selection, involving nurse participation and extended consultation times, were significantly associated with SDM perceptions (prevalence ratio [PR]: 1.59, 95% confidence interval [CI]: 1.05-2.42).

Conclusion: Many Japanese patients with CKD retrospectively evaluated RRT selection as involving SDM; however, a few were familiar with the concept beforehand. This underscores the importance of establishing systems that facilitate repeated SDM discussions at critical moments for patients. These discussions should emphasize the impact of RRT on patients' lives and involve a multidisciplinary team.

Keywords: chronic kidney disease; health care professionals; patient preferences; renal replacement therapy; shared decision-making.

Graphical abstract

Figure 1

Sankey diagrams. (a) A Sankey diagram illustrating the combination (flow) of the timing and frequency of SDM implementation before RRT selection (n = 438). The height of the individual boxes (nodes) on the vertical axis represents relative proportions, whereas the thickness of the links connecting the boxes for timing and frequency reflects the relative proportions of each combination. Deep blue indicates “> 3 years before RRT,” medium blue indicates “1 to < 3 years before RRT,” light blue indicates “6 months to < 1 year before RRT,” and very light blue indicates “> 6 months before RRT.” Red indicates “every visit,” orange indicates “every few months,” light orange indicates “every 6 months or more,” green indicates “as needed,” and light yellow indicates “once." For example, 3.2% of patients reported timing of “> 3 years before” with a frequency of “every visit.” In contrast, 1.1% reported timing of “6 months to < 1 year before” with a frequency of “as needed,” and 22.8% reported timing of “< 6 months before” with a frequency of “once.” (b) A Sankey diagram illustrating the frequency of SDM implementation after RRT selection and preferences for SDM after RRT initiation (n = 440). The thickness of the links connecting the boxes for frequency of implementation and preferences after RRT initiation indicates the relative proportions of each combination. Red indicates “every visit,” orange indicates “every few months,” light orange indicates “every 6 months or more,” green indicates “as needed,” and light yellow indicates “not necessary." Blue indicates “want SDM,” orange indicates “no SDM,” and grey indicates “unsure.” RRT, renal replacement therapy; SDM, shared decision-making.