Advance Care Planning Coaching in CKD Clinics: A Pragmatic Randomized Clinical Trial,American Journal of Kidney Diseases

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Advance Care Planning Coaching in CKD Clinics: A Pragmatic Randomized Clinical Trial
American Journal of Kidney Diseases ( IF 9.4 ) Pub Date : 2021-10-12 , DOI: 10.1053/j.ajkd.2021.08.019
Dale E Lupu ₁ , Annette Aldous ₂ , Elizabeth Anderson ₃ , Jane O Schell ₄ , Hunter Groninger ₅ , Michael J Sherman ₆ , Joseph R Aiello ₇ , Samuel J Simmens ₂

Affiliation

Rationale & Objective

Although guidelines recommend more and earlier advance care planning (ACP) for patients with chronic kidney disease (CKD), scant evidence exists to guide incorporation of ACP into clinical practice for patients with stages of CKD prior to kidney failure. Involving nephrology team members in addition to primary care providers in this important patient-centered process may increase its accessibility. Our study examined the effect of coaching implemented in CKD clinics on patient engagement with ACP.

Study Design

Multicenter, pragmatic randomized controlled trial.

Setting & Participants

Three CKD clinics in different states participated: 273 patients consented to participate, 254 were included in analysis. Eligible patients were 55 years or older, had stage 3-5 CKD, and were English speaking.

Intervention

Nurses or social workers with experience in nephrology or palliative care delivered individualized in-person ACP sessions. The enhanced control group was given Make Your Wishes About You (MY WAY) education materials and was verbally encouraged to bring their completed advance directives to the clinic.

Outcome

Primary outcome measures were scores on a 45-point ACP engagement scale at 14 weeks and a documented advance directive or portable medical order at 16 weeks after enrollment.

Results

Among 254 participants analyzed, 46.5% were 65-74 years of age, and 54% had CKD stage 3. The coached patients scored 1.9 points higher at 14 weeks on the ACP engagement scale (β = 1.87 [95% CI, 0.13-3.64]) adjusted for baseline score and site. Overall, 32.8% of intervention patients (41 of 125) had an advance directive compared with 17.8% (23 of 129) of patients in the control group. In a site-adjusted multivariable model, coached patients were 79% more likely to have a documented advance directive or portable medical order (adjusted risk ratio, 1.79 [95% CI, 1.18-2.72]), with the impact principally evident at only 1 study site.

Limitations

Small number of study sites and possible unrepresentativeness of the broader CKD population by study participants.

Conclusions

Individualized coaching may be effective in enhancing ACP, but its impact may be influenced by the health care environment where it is delivered.

Funding

The Patrick and Catherine Weldon Donaghue Medical Research Foundation, via the Greater Value Portfolio.

Trial Registration

Registered at ClinicalTrials.gov with study number NCT03506087.

中文翻译：

CKD 诊所的预先护理计划指导：务实的随机临床试验

基本原理和目标

尽管指南建议对慢性肾脏病 (CKD) 患者进行更多和更早的预先护理计划 (ACP)，但缺乏证据来指导将 ACP 纳入肾衰竭前 CKD 阶段患者的临床实践。除了初级保健提供者之外，让肾脏病学团队成员参与这个以患者为中心的重要过程可能会增加其可及性。我们的研究检查了 CKD 诊所实施的辅导对患者参与 ACP 的影响。

学习规划

多中心、务实的随机对照试验。

设置与参与者

不同州的三个 CKD 诊所参与：273 名患者同意参与，254 名患者被纳入分析。符合条件的患者年龄在 55 岁或以上，患有 3-5 期 CKD，并且会说英语。

干涉

具有肾脏病学或姑息治疗经验的护士或社会工作者提供了个性化的面对面 ACP 课程。增强的控制组获得了关于你的愿望 (MY WAY) 教育材料，并被口头鼓励他们将完成的预先指示带到诊所。

结果

主要结果测量是在 14 周时 ACP 参与量表上的 45 分评分，以及在入组后 16 周时记录在案的预先指示或便携式医疗命令。

结果

在分析的 254 名参与者中，46.5% 为 65-74 岁，54% 患有 CKD 3 期。在 ACP 参与量表上，接受指导的患者在 14 周时得分高出 1.9 分（β = 1.87 [95% CI，0.13-3.64 ]）根据基线分数和站点进行了调整。总体而言，32.8% 的干预患者（125 名中的 41 名）有预先指示，而对照组的这一比例为 17.8%（129 名中的 23 名）。在现场调整的多变量模型中，接受指导的患者有 79% 的可能性有记录在案的预先指示或便携式医疗命令（调整后的风险比，1.79 [95% CI，1.18-2.72]），其影响主要是明显的，只有 1学习地点。