Effectiveness of an Intervention to Improve Decision Making for Older Patients With Advanced Chronic Kidney Disease : A Randomized Controlled Trial

Keren Ladin, Research on Ethics, Aging, and Community Health (REACH Lab), Medford, and Departments of Community Health and Occupational Therapy, Tufts University, Medford, Massachusetts (K.L.).
Hocine Tighiouart, Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, and Tufts Clinical and Translational Science Institute, Tufts University, Boston, Massachusetts (H.T.).
Olivia Bronzi, William B. Schwartz Division of Nephrology, Tufts Medical Center, Boston, Massachusetts (O.B., D.E.W.).
Susan Koch-Weser, Department of Public Health & Community Medicine, Tufts University School of Medicine, Boston, Massachusetts (S.K.).
John B. Wong, Division of Clinical Decision Making, Tufts Medical Center, Boston, Massachusetts (J.B.W.).
Sarah Levine, Cooper Medical School of Rowan University, Camden, New Jersey (S.L., A.A.).
Arushi Agarwal, Cooper Medical School of Rowan University, Camden, New Jersey (S.L., A.A.).
Lucy Ren, The University of North Texas Health Science Center at Fort Worth/Texas College of Osteopathic Medicine, Fort Worth, Texas (L.R.).
Jack Degnan, Division of Nephrology-Hypertension, UC San Diego, La Jolla, and Nephrology Section, VA San Diego Healthcare System, San Diego, California (J.D., D.R.).
Lexi N. Sewall, Maine Nephrology Associates, Maine Medical Center, Portland, Maine (L.N.S.).


BACKGROUND: Older patients with advanced chronic kidney disease (CKD) face difficult decisions about managing kidney failure, frequently experiencing decisional conflict, regret, and treatment misaligned with preferences. OBJECTIVE: To assess whether a decision aid about kidney replacement therapy improved decisional quality compared with usual care. DESIGN: Multicenter, randomized, controlled trial. (ClinicalTrials.gov: NCT03522740). SETTING: 8 outpatient nephrology clinics associated with 4 U.S. centers. PARTICIPANTS: English-fluent patients, 70 years and older with nondialysis CKD stages 4 to 5 recruited from 2018 to 2020. INTERVENTION: DART (Decision-Aid for Renal Therapy) is an interactive, web-based decision aid for older adults with CKD. Both groups received written education about treatments. MEASUREMENTS: Change in the decisional conflict scale (DCS) score from baseline to 3, 6, 12, and 18 months. Secondary outcomes included change in prognostic and treatment knowledge and change in uncertainty. RESULTS: Among 400 participants, 363 were randomly assigned: 180 to usual care, 183 to DART. Decisional quality improved with DART with mean DCS declining compared with control (mean difference, -8.5 [95% CI, -12.0 to -5.0]; < 0.001), with similar findings at 6 months, attenuating thereafter. At 3 months, knowledge improved with DART versus usual care (mean difference, 7.2 [CI, 3.7 to 10.7]; < 0.001); similar findings at 6 months were modestly attenuated at 18 months (mean difference, 5.9 [CI, 1.4 to 10.3]; = 0.010). Treatment preferences changed from 58% "unsure" at baseline to 28%, 20%, 23%, and 14% at 3, 6, 12, and 18 months, respectively, with DART, versus 51% to 38%, 35%, 32%, and 18% with usual care. LIMITATION: Latinx patients were underrepresented. CONCLUSION: DART improved decision quality and clarified treatment preferences among older adults with advanced CKD for 6 months after the DART intervention. PRIMARY FUNDING SOURCE: Patient-Centered Outcomes Research Institute (PCORI).