Digital decision aid may be useful for older adults with CKD

Older patients with chronic kidney disease (CKD) may be better able to make decisions about their care with the use of a digital decision aid, a recent trial found.

Researchers randomly assigned patients ages 70 years and older with CKD to use the Decision Aid for Renal Therapy (DART) (an interactive, web-based decision aid designed for this population) plus receive written education about treatment or to receive written education alone. All patients had stage 4 to 5 CKD but were not receiving dialysis and were recruited from eight nephrology clinics associated with four U.S. centers. The goal of the study was to assess whether the decision aid improved decisional quality compared with usual care according to change in decisional conflict scale (DCS) score from baseline to three, six, 12, and 18 months. Secondary outcomes included changes in prognostic and treatment knowledge and uncertainty. The study results were published Dec. 20 by Annals of Internal Medicine.

Of 400 participants, 363 were randomly assigned, 180 to usual care and 183 to DART. Most patients (78.1%) were White, 13.1% were Black or African American, and 5.0% were Asian; 4.1% were Hispanic or Latino. Mean DCS declined in the DART group versus control (mean difference at three and six months, −7.9 [95% CI, −12.0 to −3.8] and −8.5 [95% CI, −13.0 to −3.9]; P<0.001). This effect was attenuated at 12- and 18-month follow-up. At three months, knowledge of CKD as determined by a 12-item test improved more with DART than with usual care (mean difference, 9.0 [95% CI, 4.6 to 13.4]; P<0.001), with similar findings at six months that were modestly attenuated at 18 months (mean difference, 5.9 [95% CI, 1.4 to 10.3]; P=0.010). Fifty-eight percent of patients who were assigned to DART and 51% of those assigned to usual care reported that they were unsure of their treatment preferences at baseline. At three, six, 12, and 18 months of follow-up, this changed to 28%, 20%, 23%, and 14% in the DART group and 38%, 35%, 32%, and 18% in the usual care group.

Hispanic and Latino patients were underrepresented in the trial, and the instrument used to measure knowledge was new, among other limitations, the researchers said. “In conclusion, DART presents a consistent and accessible decision support tool that expedites higher-quality patient-centered decisions by reducing decisional conflict and improving knowledge in the short-term,” they wrote. “Effects may be attenuated by 12 months, and patients may benefit from reengagement with DART annually.”

An accompanying editorial called on clinicians to build an infrastructure and culture that supports shared decision making. “Equitable and person-centered kidney care requires clinicians, organizational leaders, and policymakers to shift clinical practices from the simplistic formula that ‘dialysis is better’ toward a shared decision-making approach that embraces and prioritizes person-centered, goal-concordant decision making,” the editorialists wrote.