DART improves treatment decision-making for patients with chronic kidney disease

1. Patients with chronic kidney disease (CKD) who used Decision-Aid for Renal Therapy (DART) demonstrated improved decision quality compared to those receiving care as usual.

2. Patients who used DART had increased knowledge regarding treatment options compared to those who received care as usual. 

Evidence Rating Level: 1 (Excellent)

Study Rundown: Individuals with advanced CKD face decisions regarding kidney replacement therapy, which are often life-long interventions. Patients require knowledge about their prognosis and treatment options to make informed decisions that are aligned with their personal values. DART is an educational tool developed for patients with CKD. The present study evaluated decision-making in patients with CKD with and without the DART tool. Decisional conflict scores were significantly improved for individuals in the DART group at both three and six-month follow-ups. Improvements were also seen in the DART group across various subscales of the decisional conflict scale. These results were consistent across subgroups including site, sex, race, education, health literacy, diabetes status, and kidney function. Patient knowledge was improved for both control and DART groups and these improvements persisted at 6 and 18-month follow-ups. Fewer individuals were “unsure” about treatment preferences over time in the DART group as compared to the control group. Treatment preferences were stable in both groups once they were established. The strength of this study is that multiple domains of decisional conflict, knowledge, and treatment preferences were examined. A limitation is the generalizability of the results, as the materials may not be accessible or comprehensible to those who are not proficient in English or have lower levels of literacy.

Click to read the study in AIM

Relevant Reading: Effects of dapagliflozin on hospitalizations in patients with chronic kidney disease: A post hoc analysis of DAPA-CKD

In-Depth [randomized controlled trial]: This multicenter, randomized control trial compared the effectiveness of DART to standard educational materials for improving decisional quality in CKD patients. The DART content included education modules on kidney failure, peritoneal dialysis, hemodialysis, renal transplant, medical management, and decision-making. Questions and prompts were written at a grade six reading level. The comparator intervention was a pamphlet from the National Kidney Foundation titled “Choosing a Treatment for Kidney Failure”. A total of 363 participants were randomized (180 to control and 183 to DART) and baseline characteristics between the two groups were balanced. Decisional conflict scores improved in the DART group at three- and six-month follow-up with mean differences of -7.9 (95% Confidence Interval [CI], -12.0 to -3.8) and -8.5 (95% CI, -13.0 to -3.9), respectively. As compared to the placebo group, patients in the DART group had knowledge improvement at three months (mean difference 9.0; 95% CI, 4.6 to 13.4), six months (mean difference, 9.4; 95% CI, 5.1 to 13.8), and 18 months (mean difference, 5.9; 95%CI, 1.4 to 10.3). Treatment preferences in the DART group changed from 58.5% “unsure” at baseline to 27.5%, 19.9%, 23.1%, and 13.9% at 3, 6, 12, and 18- month follow-ups, respectively. Preference for conservative management was increased from baseline (11.5%) in the DART group to 16.9% at three months and 19.9% at six months. Conservative management preferences were largely unchanged in the control group. In participants who initiated dialysis during the trial, 98% had treatment concordant to their last expressed preference before the initiation of dialysis. In summary, this study demonstrated that the DART tool improves decision-making and knowledge for patients with CKD.

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