Developing Tools for Dialysis Decision Support in Older Adults

背景：每年有超过25，000名75岁以上的患者开始维持性透析治疗， 美国的虽然透析可以延长生命，但它也带来了深刻的，有时是沉重的变化 在生活方式方面，并发症的风险很大，老年人永久残疾的可能性很大。 透析决策的质量通常很差;很少有患者获得预后信息或讨论 选择接受医疗管理而无需透析。相反，患者将这些决定视为一种选择， 透析和死亡之间的关系 意义/影响：我们的总体目标是通过以下方式支持知情、目标一致的透析决策： 开发决策支持工具，解决HSRD优先领域“医疗保健信息学”问题。该项目将 通过生成支持知情决策的新工具，满足患者和临床医生的信息需求- 为患有晚期慢性肾病和终末期肾病的退伍军人提供目标一致的护理 疾病 创新：该项目在几个方面具有创新性。首先，它应用因果推理模型来估计 透析的治疗效果，以解决临床试验不可行的重要临床问题。 其次，它结合了以患者为中心的结果来评估透析的有效性。第三，使用 新的情景规划框架，以解决决策支持的不确定性。 具体目的和方法：为了实现这一目标，我们将（1）比较生存率、无住院生存率、时间 使用因果推理模型， 说明在患有终末期肾病老年退伍军人中透析与医疗管理的权衡 疾病;（2）开发基于Web的风险效益计算器和基于情景框架的决策辅助工具 计划纳入了生存率和治疗并发症与透析开始的估计， （3）使用混合方法，评估工具的可用性、可接受性和对 患者知识和决策冲突。 实施/后续步骤：我们将与业务合作伙伴合作，确保这些工具满足 最终用户，并制定更广泛的测试和传播计划。在项目结束时，我们 我希望提交一份提案，在老年人中测试结合这些工具的透析决策支持干预措施。 老兵

Background: Each year, more than 25,000 patients over the age of 75 start maintenance dialysis treatment in the United States. Although dialysis may prolong life, it entails profound and sometimes burdensome changes in lifestyle, substantial risks for complications, and for older adults, a high likelihood of permanent disability. The quality of dialysis decision making is often poor; few patients receive prognostic information or discuss the option to receive medical management without dialysis. Rather, patients perceive these decisions as a choice between dialysis or death. Significance/Impact: Our overarching goal is to support informed, goal-concordant dialysis decisions by developing decision support tools, addressing HSRD Priority Domain `Healthcare Informatics'. This project will address the information needs of patients and clinicians by generating new tools to support informed decision- making and goal-concordant care for Veterans with advanced chronic kidney disease and end-stage renal disease. Innovation: The project is innovative in several ways. First, it applies causal inference models to estimate treatment effects of dialysis to address an important clinical question for which a clinical trial is not feasible. Second, it incorporates patient-centered outcomes to evaluate the effectiveness of dialysis. Third, it uses novel scenario planning frameworks to address uncertainty with decision support. Specific Aims and Methods: To accomplish this goal, we will (1) compare survival, hospital-free survival, time to nursing home placement and number of dialysis access procedures using causal inference models to illustrate trade-offs from dialysis versus medical management among older Veterans with end-stage renal disease; (2) develop a web-based risk benefit calculator and decision aid based on the framework of scenario planning that incorporates estimates of survival and treatment complications with dialysis initiation compared to medical management; and (3) using mixed methods, evaluate the tools' usability, acceptability and effects on patient knowledge and decisional conflict. Implementation/Next Steps: We will work with operational partners to ensure the tools meet the needs of the end-users, and develop plans for broader testing and dissemination. By the end of the project period, we expect to submit a proposal to test a dialysis decision support intervention incorporating these tools in older Veterans.