Decision Readiness and Determinants of Kidney Replacement Therapy among Veterans with Advanced Chronic Kidney Disease.

Abstract

INTRODUCTION Kidney disease stakeholders recommend a system-wide increase in home dialysis use. Kidney replacement therapy (KRT) decision readiness is associated with higher selection and use of home dialysis; however, KRT decision-making is complex, and factors informing KRT decision readiness in patients with advanced chronic kidney disease (CKD) are unclear. METHODS Using the baseline data of the Trial to Evaluate and Assess the effects of Comprehensive KRT-directed patient education on Home dialysis use among VETerans (TEACH-VET), we conducted a cross-sectional analysis to evaluate prevalent KRT decision readiness, defined as ability to choose any KRT modality among US Veterans with advanced CKD. We also evaluated Veterans' ability to achieve high-quality informed KRT decisions (more than 60% decisional confidence on a scale ranging from 1 to 100%) and selection of home dialysis as secondary outcomes. Univariate and multivariable logistic regression were used to test associations between patient-level variables and outcomes. RESULTS Of the 468 enrollees with a complete baseline dataset, 282 (60%) could not pick any KRT modality; the rest were split between high (20%) vs. low-quality (20%) decisions and home (21%) vs. in-center (19%) dialysis. Younger age, higher CKD stage, history of receiving prior KRT-directed education, rural habitation, and objective disease knowledge were positively associated with KRT decision readiness. Only objective disease knowledge was associated with KRT decision readiness after adjustments, with participants in the highest tertile of CKD-specific knowledge having two-fold (OR: 2.31, 95%CI: 1.18, 4.55) and KRT-specific knowledge having five-fold (OR: 5.16, 95%CI: 2.63, 10.32) higher odds of selecting their KRT. Item-level analysis showed that difficult, specifically KRT knowledge-related, items had a high discriminatory capacity to predict KRT decision readiness. CONCLUSION Veterans with advanced CKD are ill-prepared for KRT decision-making. While social determinants of health have a potential role in identifying high-risk populations, objective kidney failure and KRT-specific knowledge have a dominant impact on KRT decision readiness.