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。虽然透析可以延长生命，但它会带来深刻的、有时甚至是繁重的变化。 在生活方式上，并发症的风险很大，而对于老年人来说，永久残疾的可能性很高。 透析决策的质量往往很差；很少有患者收到预后信息或讨论 无需透析即可选择接受医疗管理。相反，患者将这些决定视为一种选择 在透析和死亡之间。 意义/影响：我们的首要目标是支持知情、目标一致的透析决策 开发决策支持工具，解决HSRD优先领域“医疗信息学”。这个项目将 通过生成支持明智决策的新工具来满足患者和临床医生的信息需求- 制定和目标一致的护理对晚期慢性肾病退伍军人和终末期肾病患者的护理 疾病。 创新：该项目在几个方面都是创新的。首先，它应用因果推理模型来估计 透析的治疗效果，以解决一个重要的临床问题，对其进行临床试验是不可行的。 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，它使用 新的情景规划框架，通过决策支持解决不确定性。 具体目标和方法：为了实现这一目标，我们将(1)比较存活率、无住院存活率、时间 使用因果推理模型对疗养院的安置和透析准入程序的数量进行 说明患有终末期肾病的老年退伍军人在透析和医疗管理方面的权衡 开发了基于情景框架的基于Web的风险收益计算器和辅助决策工具 计划结合了与透析开始时的存活率和治疗并发症的估计相比较 医疗管理；以及(3)使用混合方法，评估工具的可用性、可接受性和对 耐心的知识和决策的冲突。 实施/下一步：我们将与运营合作伙伴合作，确保工具满足 最终用户，并制定更广泛的测试和传播计划。到项目期结束时，我们 预计将提交一份提案，以测试将这些工具纳入较老版本的透析决策支持干预 退伍军人。

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.