Browsing by Author "Greer, Raquel C"
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Item Open Access Development of a decision aid to inform patients' and families' renal replacement therapy selection decisions.(BMC Med Inform Decis Mak, 2012-12-01) Ameling, Jessica M; Auguste, Priscilla; Ephraim, Patti L; Lewis-Boyer, LaPricia; DePasquale, Nicole; Greer, Raquel C; Crews, Deidra C; Powe, Neil R; Rabb, Hamid; Boulware, L EbonyBACKGROUND: Few educational resources have been developed to inform patients' renal replacement therapy (RRT) selection decisions. Patients progressing toward end stage renal disease (ESRD) must decide among multiple treatment options with varying characteristics. Complex information about treatments must be adequately conveyed to patients with different educational backgrounds and informational needs. Decisions about treatment options also require family input, as families often participate in patients' treatment and support patients' decisions. We describe the development, design, and preliminary evaluation of an informational, evidence-based, and patient-and family-centered decision aid for patients with ESRD and varying levels of health literacy, health numeracy, and cognitive function. METHODS: We designed a decision aid comprising a complementary video and informational handbook. We based our development process on data previously obtained from qualitative focus groups and systematic literature reviews. We simultaneously developed the video and handbook in "stages." For the video, stages included (1) directed interviews with culturally appropriate patients and families and preliminary script development, (2) video production, and (3) screening the video with patients and their families. For the handbook, stages comprised (1) preliminary content design, (2) a mixed-methods pilot study among diverse patients to assess comprehension of handbook material, and (3) screening the handbook with patients and their families. RESULTS: The video and handbook both addressed potential benefits and trade-offs of treatment selections. The 50-minute video consisted of demographically diverse patients and their families describing their positive and negative experiences with selecting a treatment option. The video also incorporated health professionals' testimonials regarding various considerations that might influence patients' and families' treatment selections. The handbook was comprised of written words, pictures of patients and health care providers, and diagrams describing the findings and quality of scientific studies comparing treatments. The handbook text was written at a 4th to 6th grade reading level. Pilot study results demonstrated that a majority of patients could understand information presented in the handbook. Patient and families screening the nearly completed video and handbook reviewed the materials favorably. CONCLUSIONS: This rigorously designed decision aid may help patients and families make informed decisions about their treatment options for RRT that are well aligned with their values.Item Open Access Effect of primary care physicians' use of estimated glomerular filtration rate on the timing of their subspecialty referral decisions.(BMC Nephrol, 2011-01-14) Greer, Raquel C; Powe, Neil R; Jaar, Bernard G; Troll, Misty U; Boulware, L EbonyBACKGROUND: Primary care providers' suboptimal recognition of the severity of chronic kidney disease (CKD) may contribute to untimely referrals of patients with CKD to subspecialty care. It is unknown whether U.S. primary care physicians' use of estimated glomerular filtration rate (eGFR) rather than serum creatinine to estimate CKD severity could improve the timeliness of their subspecialty referral decisions. METHODS: We conducted a cross-sectional study of 154 United States primary care physicians to assess the effect of use of eGFR (versus creatinine) on the timing of their subspecialty referrals. Primary care physicians completed a questionnaire featuring questions regarding a hypothetical White or African American patient with progressing CKD. We asked primary care physicians to identify the serum creatinine and eGFR levels at which they would recommend patients like the hypothetical patient be referred for subspecialty evaluation. We assessed significant improvement in the timing [from eGFR < 30 to ≥ 30 mL/min/1.73m(2)) of their recommended referrals based on their use of creatinine versus eGFR. RESULTS: Primary care physicians recommended subspecialty referrals later (CKD more advanced) when using creatinine versus eGFR to assess kidney function [median eGFR 32 versus 55 mL/min/1.73m(2), p < 0.001]. Forty percent of primary care physicians significantly improved the timing of their referrals when basing their recommendations on eGFR. Improved timing occurred more frequently among primary care physicians practicing in academic (versus non-academic) practices or presented with White (versus African American) hypothetical patients [adjusted percentage(95% CI): 70% (45-87) versus 37% (reference) and 57% (39-73) versus 25% (reference), respectively, both p ≤ 0.01). CONCLUSIONS: Primary care physicians recommended subspecialty referrals earlier when using eGFR (versus creatinine) to assess kidney function. Enhanced use of eGFR by primary care physicians' could lead to more timely subspecialty care and improved clinical outcomes for patients with CKD.Item Open Access Hospital discharge communications during care transitions for patients with acute kidney injury: a cross-sectional study.(BMC Health Serv Res, 2016-08-30) Greer, Raquel C; Liu, Yang; Crews, Deidra C; Jaar, Bernard G; Rabb, Hamid; Boulware, L EbonyBACKGROUND: High quality hospital discharge communications about acute kidney injury (AKI) could facilitate continuity of care after hospital transitions and reduce patients' post-hospitalization health risks. METHODS: We characterized the presence and quality (10 elements) of written hospital discharge communications (physician discharge summaries and patient instructions) for patients hospitalized with AKI at a single institution in 2012 through medical record review. RESULTS: In 75 randomly selected hospitalized patients with AKI, fewer than half of physician discharge summaries and patient instructions documented the presence (n = 33, 44 % and n = 10, 13 %, respectively), cause (n = 32, 43 % and n = 1, 1 %, respectively), or course of AKI (n = 23, 31 %, discharge summary only) during hospitalization. Few provided recommendations for treatment and/or observation specific to AKI (n = 11, 15 and 6, 8 % respectively). In multivariable analyses, discharge communications containing information about AKI were most prevalent among patients with AKI Stage 3, followed by patients with Stage 2 and Stage 1 (adjusted percentages (AP) [95 % CI]: 84 % [39-98 %], 43 % [11-82 %], and 24 % [reference], respectively; p trend = 0.008). AKI discharge communications were also more prevalent among patients with known chronic kidney disease (CKD) versus those without (AP [95 % CI]: 92 % [51-99 %] versus 39 % [reference], respectively, p = 0.02) and among patients discharged from medical versus surgical services (AP [95 % CI]: 73 % [33-93 %] versus 23 % [reference], respectively, p = 0.01). Communications featured 4 median quality elements. Quality elements were greater in communications for patients with more severe AKI (Stage 3 (number of additional quality elements (β) [95 % CI]: 2.29 [0.87-3.72]), Stage 2 (β [95 % CI]: 0.62 [-0.65-1.90]) and Stage 1 (reference); p for trend = 0.002). CONCLUSIONS: Few hospital discharge communications in AKI patients described AKI or provided recommendations for AKI care. Improvements in the quality of hospital discharge communications to improve care transitions of patients with AKI are needed.Item Open Access Selecting renal replacement therapies: what do African American and non-African American patients and their families think others should know? A mixed methods study.(BMC Nephrol, 2013-01-14) DePasquale, Nicole; Ephraim, Patti L; Ameling, Jessica; Lewis-Boyér, Lapricia; Crews, Deidra C; Greer, Raquel C; Rabb, Hamid; Powe, Neil R; Jaar, Bernard G; Gimenez, Luis; Auguste, Priscilla; Jenckes, Mollie; Boulware, L EbonyBACKGROUND: Little is known regarding the types of information African American and non-African American patients with chronic kidney disease (CKD) and their families need to inform renal replacement therapy (RRT) decisions. METHODS: In 20 structured group interviews, we elicited views of African American and non-African American patients with CKD and their families about factors that should be addressed in educational materials informing patients' RRT selection decisions. We asked participants to select factors from a list and obtained their open-ended feedback. RESULTS: Ten groups of patients (5 African American, 5 non-African American; total 68 individuals) and ten groups of family members (5 African American, 5 non-African American; total 62 individuals) participated. Patients and families had a range (none to extensive) of experiences with various RRTs. Patients identified morbidity or mortality, autonomy, treatment delivery, and symptoms as important factors to address. Family members identified similar factors but also cited the effects of RRT decisions on patients' psychological well-being and finances. Views of African American and non-African American participants were largely similar. CONCLUSIONS: Educational resources addressing the influence of RRT selection on patients' morbidity and mortality, autonomy, treatment delivery, and symptoms could help patients and their families select RRT options closely aligned with their values. Including information about the influence of RRT selection on patients' personal relationships and finances could enhance resources' cultural relevance for African Americans.Item Open Access Setting an agenda for comparative effectiveness systematic reviews in CKD care.(BMC Nephrol, 2012-08-01) Crews, Deidra C; Greer, Raquel C; Fadrowski, Jeffrey J; Choi, Michael J; Doggett, David; Segal, Jodi B; Fawole, Kemi A; Crawford, Pammie R; Boulware, L EbonySystematic reviews comparing the effectiveness of strategies to prevent, detect, and treat chronic kidney disease are needed to inform patient care. We engaged stakeholders in the chronic kidney disease community to prioritize topics for future comparative effectiveness research systematic reviews. We developed a preliminary list of suggested topics and stakeholders refined and ranked topics based on their importance. Among 46 topics identified, stakeholders nominated 18 as 'high' priority. Most pertained to strategies to slow disease progression, including: (a) treat proteinuria, (b) improve access to care, (c) treat hypertension, (d) use health information technology, and (e) implement dietary strategies. Most (15 of 18) topics had been previously studied with two or more randomized controlled trials, indicating feasibility of rigorous systematic reviews. Chronic kidney disease topics rated by stakeholders as 'high priority' are varied in scope and may lead to quality systematic reviews impacting practice and policy.Item Open Access Specialist and primary care physicians' views on barriers to adequate preparation of patients for renal replacement therapy: a qualitative study.(BMC Nephrol, 2015-03-28) Greer, Raquel C; Ameling, Jessica M; Cavanaugh, Kerri L; Jaar, Bernard G; Grubbs, Vanessa; Andrews, Carrie E; Ephraim, Patti; Powe, Neil R; Lewis, Julia; Umeukeje, Ebele; Gimenez, Luis; James, Sam; Boulware, L EbonyBACKGROUND: Early preparation for renal replacement therapy (RRT) is recommended for patients with advanced chronic kidney disease (CKD), yet many patients initiate RRT urgently and/or are inadequately prepared. METHODS: We conducted audio-recorded, qualitative, directed telephone interviews of nephrology health care providers (n = 10, nephrologists, physician assistants, and nurses) and primary care physicians (PCPs, n = 4) to identify modifiable challenges to optimal RRT preparation to inform future interventions. We recruited providers from public safety-net hospital-based and community-based nephrology and primary care practices. We asked providers open-ended questions to assess their perceived challenges and their views on the role of PCPs and nephrologist-PCP collaboration in patients' RRT preparation. Two independent and trained abstractors coded transcribed audio-recorded interviews and identified major themes. RESULTS: Nephrology providers identified several factors contributing to patients' suboptimal RRT preparation, including health system resources (e.g., limited time for preparation, referral process delays, and poorly integrated nephrology and primary care), provider skills (e.g., their difficulty explaining CKD to patients), and patient attitudes and cultural differences (e.g., their poor understanding and acceptance of their CKD and its treatment options, their low perceived urgency for RRT preparation; their negative perceptions about RRT, lack of trust, or language differences). PCPs desired more involvement in preparation to ensure RRT transitions could be as "smooth as possible", including providing patients with emotional support, helping patients weigh RRT options, and affirming nephrologist recommendations. Both nephrology providers and PCPs desired improved collaboration, including better information exchange and delineation of roles during the RRT preparation process. CONCLUSIONS: Nephrology and primary care providers identified health system resources, provider skills, and patient attitudes and cultural differences as challenges to patients' optimal RRT preparation. Interventions to improve these factors may improve patients' preparation and initiation of optimal RRTs.Item Open Access The providing resources to enhance African American patients' readiness to make decisions about kidney disease (PREPARED) study: protocol of a randomized controlled trial.(BMC Nephrol, 2012-10-12) Ephraim, Patti L; Powe, Neil R; Rabb, Hamid; Ameling, Jessica; Auguste, Priscilla; Lewis-Boyer, LaPricia; Greer, Raquel C; Crews, Deidra C; Purnell, Tanjala S; Jaar, Bernard G; DePasquale, Nicole; Boulware, L EbonyBACKGROUND: Living related kidney transplantation (LRT) is underutilized, particularly among African Americans. The effectiveness of informational and financial interventions to enhance informed decision-making among African Americans with end stage renal disease (ESRD) and improve rates of LRT is unknown. METHODS/DESIGN: We report the protocol of the Providing Resources to Enhance African American Patients' Readiness to Make Decisions about Kidney Disease (PREPARED) Study, a two-phase study utilizing qualitative and quantitative research methods to design and test the effectiveness of informational (focused on shared decision-making) and financial interventions to overcome barriers to pursuit of LRT among African American patients and their families. Study Phase I involved the evidence-based development of informational materials as well as a financial intervention to enhance African American patients' and families' proficiency in shared decision-making regarding LRT. In Study Phase 2, we are currently conducting a randomized controlled trial in which patients with new-onset ESRD receive 1) usual dialysis care by their nephrologists, 2) the informational intervention (educational video and handbook), or 3) the informational intervention in addition to the option of participating in a live kidney donor financial assistance program. The primary outcome of the randomized controlled trial will include patients' self-reported rates of consideration of LRT (including family discussions of LRT, patient-physician discussions of LRT, and identification of a LRT donor). DISCUSSION: Results from the PREPARED study will provide needed evidence on ways to enhance the decision to pursue LRT among African American patients with ESRD.