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IIR 18-246 – HSR Study

IIR 18-246
Developing Tools for Dialysis Decision Support in Older Adults
Manjula Kurella Tamura, MD MPH
VA Palo Alto Health Care System, Palo Alto, CA
Palo Alto, CA
Funding Period: July 2020 - September 2025


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.

External Links for this Project

NIH Reporter

Grant Number: I01HX002763-01A2

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Journal Articles

  1. Miller LM, Rifkin D, Lee AK, Kurella Tamura M, Pajewski NM, Weiner DE, Al-Rousan T, Shlipak M, Ix JH. Association of Urine Biomarkers of Kidney Tubule Injury and Dysfunction With Frailty Index and Cognitive Function in Persons With CKD in SPRINT. American journal of kidney diseases : the official journal of the National Kidney Foundation. 2021 Oct 1; 78(4):530-540.e1. [view]
  2. McCauley MD, Hsu JY, Ricardo AC, Darbar D, Kansal M, Kurella Tamura M, Feldman HI, Kusek JW, Taliercio JJ, Rao PS, Shafi T, He J, Wang X, Sha D, Lamar M, Go AS, Yaffe K, Lash JP, CRIC Study Investigators. Atrial Fibrillation and Longitudinal Change in Cognitive Function in CKD. Kidney international reports. 2021 Mar 1; 6(3):669-674. [view]
  3. Bradshaw C, Thomas IC, Montez-Rath ME, Lorenz KA, Asch SM, Leppert JT, Wang V, O'Hare AM, Kurella Tamura M. Facility-Level Variation in Dialysis Use and Mortality Among Older Veterans With Incident Kidney Failure. JAMA Network Open. 2021 Jan 4; 4(1):e2034084. [view]
  4. Cheung KL, Tamura MK, Stapleton RD, Rabinowitz T, LaMantia MA, Gramling R. Feasibility and Acceptability of Telemedicine-Facilitated Palliative Care Consultations in Rural Dialysis Units. Journal of palliative medicine. 2021 Sep 1; 24(9):1307-1313. [view]
  5. Johansen KL, Chertow GM, Foley RN, Gilbertson DT, Herzog CA, Ishani A, Israni AK, Ku E, Kurella Tamura M, Li S, Li S, Liu J, Obrador GT, O'Hare AM, Peng Y, Powe NR, Roetker NS, St Peter WL, Abbott KC, Chan KE, Schulman IH, Snyder J, Solid C, Weinhandl ED, Winkelmayer WC, Wetmore JB. US Renal Data System 2020 Annual Data Report: Epidemiology of Kidney Disease in the United States. American journal of kidney diseases : the official journal of the National Kidney Foundation. 2021 Apr 1; 77(4 Suppl 1):A7-A8. [view]
  6. Knight SJ, Haibach JP, Hamilton AB, Whittle J, Ono SS, Butler J, Flower M, Ray CD, Pugh MJ, Zickmund SL. Veteran Engagement in Health Services Research: a Conceptual Model. Journal of general internal medicine. 2022 Apr 1; 37(Suppl 1):94-98. [view]

DRA: Aging, Older Veterans' Health and Care, Kidney Disorders
DRE: TRL - Applied/Translational, Prognosis, Treatment - Implementation
Keywords: Decision Support, Decision-Making, Patient Preferences
MeSH Terms: None at this time.

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