Behavioral Stage of Change and Dialysis Decision-Making

Abstract

Background and objectives Behavioral stage of change (SoC) algorithms classify patients' readiness for medical treatment decision-making. In the precontemplation stage, patients have no intention to take action within 6 months. In the contemplation stage, action is intended within 6 months. In the preparation stage, patients intend to take action within 30 days. In the action stage, the change has been made. This study examines the influence of SoC on dialysis modality decision-making.Design, setting, participants, & measurements SoC and relevant covariates were measured, and associations with dialysis decision-making were determined. In-depth interviews were conducted with 16 patients on dialysis to elicit experiences. Qualitative interview data informed the survey design. Surveys were administered to adults with CKD (eGFR#25 ml/min/1.73 m 2 ) from August, 2012 to June, 2013. Multivariable logistic regression modeled dialysis decision-making with predictors: SoC, provider connection, and dialysis knowledge score.Results Fifty-five patients completed the survey (71% women, 39% white, and 59% black), and median annual income was $17,500. In total, 65% of patients were in the precontemplation/contemplation (thinking) and 35% of patients were in the preparation/maintenance (acting) SoC; 62% of patients had made dialysis modality decisions. Doctors explaining modality options, higher dialysis knowledge scores, and fewer lifestyle barriers were associated with acting versus thinking SoC (all P,0.02). Patients making modality decisions had doctors who explained dialysis options (76% versus 43%), were in the acting versus the thinking SoC (50% versus 10%), had higher dialysis knowledge scores (1.4 versus 0.5), and had lower eGFR (13.9 versus 16.8 ml/min/1.73 m 2 ; all P,0.05). In adjusted analyses, dialysis knowledge was significantly associated with decision-making (odds ratio, 4.2; 95% confidence interval, 1.4 to 12.9; P=0.01), and SoC was of borderline significance (odds ratio, 5.8; 95% confidence interval, 1.0 to 32.6; P=0.05). The model C statistic was 0.87.Conclusions Dialysis decision-making was associated with SoC, dialysis knowledge, and physicians discussing treatment options. Future studies determining ways to assist patients with CKD in making satisfying modality decisions are warranted.

Use of a Supportive Kidney Care Video Decision Aid in Older Patients: A Randomized Controlled Trial

“…We performed this prospective 2 parallel-arm RCT among patients with advanced CKD in Boston, MA, and Philadelphia, PA, USA. We calculated that 50 participants per arm would achieve 85% power to detect a 0.5 SD of change in supportive kidney care knowledge after receiving education [24,25]. Although the video featured older adults, study enrollment was initially open to include all adult patients (≥18 years) to achieve enrollment targets more rapidly.…”

Educating Prospective Kidney Transplant Recipients and Living Donors about Living Donation: Practical and Theoretical Recommendations for Increasing Living Donation Rates

“…Finally, though not a TTM construct, there is also some evidence that increasing knowledge of transplantation may also help increase patients’ readiness to pursue LDKT [15, 25]. Given the significant knowledge gaps faced by kidney patients, helping them learn more about the facts related to LDKT will better prepare them for undergoing evaluation, surgery, and recovering afterwards.…”

“…Among the highest priority recommendations were to insure that comprehensive LDKT education was available to patients at all stages of CKD as well as to their potential living donors, that LDKT education occur multiple times for individuals across the stages of CKD progression, and that distinct efforts be made to increase access to LDKT education for potential recipients and donors identifying as racial/ethnic minorities [11••]. Emerging evidence suggests that patients at lower levels of readiness for LDKT include those who are earlier in their CKD progression and racial/ethnic minorities [13–15]. Lessons from health education research across many behaviors indicate that when a patient is not ready to take a particular health behavior, like pursuing LDKT, educational messages strongly promoting taking that behavior in the near future often fall on deaf or resistant ears [16].…”

Patient perspectives on the optimal start of renal replacement therapy

“…Higher levels of dialysis knowledge as well as greater involvement in the discussion of treatment options by nephrologists have been shown to be associated with better decision‐making around initiating dialysis (Prakash et al . ). Such decisions must also take into account patients’ values and availability of support (Harwood & Clark ).…”

“…Additionally, there is evidence that despite their belief that initiating RRT should be the patient's decision, many patients perceive that the choice to begin dialysis was not their own (Ladin et al 2016). Higher levels of dialysis knowledge as well as greater involvement in the discussion of treatment options by nephrologists have been shown to be associated with better decision-making around initiating dialysis (Prakash et al 2015). Such decisions must also take into account patients' values and availability of support (Harwood & Clark 2013).…”