Patient preference often guides decisions about whether to undergo dialysis, precisely because of the procedure’s potential negative impact on quality of life, according to Rebecca Frazier, MD, and colleagues. As a result, shared decision making (SDM) in this setting is recommended by nephrology professional organizations. Results from a study by Dr. Frazier and colleagues, however, suggest that many older patients with CKD do not have an opportunity for SDM when contemplating dialysis, underscoring the need for more education in this population. Published in the American Journal of Kidney Disease, the cross-sectional survey-based analysis enrolled 350 patients aged 70 or older with non-dialysis advanced CKD. On a scale of 0 to 100 using the 9-item Shared Decision-Making Questionnaire (SDM-Q-9), the mean score was 52 and only
41% of patients agreed that “My doctor and I selected a treatment option together.”

“In our study, only 76 patients of 350 scored [80% or greater] on the SDM-Q-9, corresponding to strongly or completely agreeing with the SDM-Q-9 statements,” wrote Dr. Frazier and colleagues, “despite having advanced CKD and nephrology care. Our research highlights the need to improve SDM for older adults facing
dialysis decisions.” The authors add that “Increasing patient knowledge about the treatment options, adequate preparation for the discussion, and emphasizing the importance of patients’ input, especially about their personal values, may help patients engage in SDM.”

Study Methodology

The primary outcome of the study was patient perceived SDM, measured using the validated SDM-Q-9. The included nine statements assess agenda setting, information sharing, deliberation, and decision making with input from the clinician and patient; each response is graded on a 6-point Likert scale, from 0 (strongly disagree) to 5 (strongly agree). The higher the total score across all the questions, the greater the SDM.

Participants (13% Black; 48% with diabetes) were recruited from nephrology clinics in greater Boston, Portland (Maine), San Diego, and Chicago. Dr. Frazier and team noted that their results might be subject to selection bias because the population was exclusively English-speaking and composed of individuals who were about to be randomized in the Decision Aid for Renal Therapy (DART) Trial.

Multivariable linear regression models were used to analyze associations between SDM and predictors, controlling for demographic and health factors. Wrote the authors, “To assess decisional needs, we examined decisional readiness characteristics, defined as patients’ perceptions about their treatment options knowledge, their certainty about their decision, and the quality of their medical care.” Attendance at classes about kidney
treatment options, support from care partners, demographic and health factors—such as age, gender, race, marital status, educational background, disease severity, and comorbidities—also were considered.

Male Sex & Older Age Associated With SDM

Reviewing the SDM-Q-scores, Dr. Frazier and colleagues noted high agreement among participants with statements about agenda setting (Figure), such as “My doctor made clear a decision needs to be made” (57%), and information sharing, such as “My doctor helped me understand all the information” (62%). Agreement was lower, however, for items related to deliberation, such as “My doctor and I thoroughly weighed the different treatment options” (48%) and decision making, such as “My doctor and I reached an agreement on how to proceed” (50%).

“These low scores are likely due to both physician and patient factors,” wrote the authors. For example, they cited an association between higher eGFR and less likelihood of SDM, and possible reluctance among clinicians to discuss dialysis or other treatments with patients with stage 3 CKD or early stage 4 CKD and stable kidney function. Also, patients might feel a power imbalance in decision making with a clinician, and some clinicians might take a paternalistic approach to discussing a topic like dialysis with patients, Dr. Frazier and team suggested.

The study results showed that male sex (P=0.01) and older age (P=0.02) were statistically significantly associated with higher SDM-Q-9 score quartiles. Among clinical factors, lower eGFR (P=0.04) and better self-reported health (P=0.002) were associated with higher SDM-Q-9 scores. Other factors statistically significantly associated with the higher scores were being better informed about kidney disease treatment options, greater satisfaction with medical care, and previously attending a class on kidney disease treatment options (all P<0.001).

Dr. Frazier and colleagues noted that education is central to the decision-making process, writing that “continuing to teach SDM in nephrology training programs, using decision aids that support SDM in the clinic, and preparing clinicians to engage in SDM may improve decisional outcomes for patients with advanced CKD.” They also wrote that “decision aids may help clinicians and patients navigate the decision-making process. Patient-facing decision aids often use written materials or web-based formats, which support SDM and address decisional needs. Studies of decision aids in advanced kidney disease found that they improved patient knowledge, advanced decisional readiness, and increased value-based decisions by encouraging patients to consider their own preferences and values. Additionally, decision aids helped to engage patients in the decision-making process and assisted in patient–clinician communication.”