Division of Nephrology, Department of Medicine, West Virginia University School of Medicine, 1 Medical Center Drive, PO Box 9165, Morgantown, WV, 26506, USA.
Division of Nephrology, Department of Medicine, The University of Vermont Medical Center, Burlington, VT, USA.
BMC Nephrol. 2024 Nov 26;25(1):425. doi: 10.1186/s12882-024-03861-y.
Mortality prognostic tools exist to aid in shared decision making with kidney failure patients but are underutilized. This study aimed to elucidate nephrology providers' practice patterns and understand barriers to prognostic tool use.
Nephrology providers (8 physicians and 2 nurse practitioners) at an academic medical center underwent semi-structured interviews regarding their experience and perspective on the utility of mortality prognostic tools. Common themes were identified independently by 2 reviewers using grounded theory. Three six-month mortality prognostic tools were applied to the 279 prevalent dialysis patients that the interviewed providers care for. The C statistic was calculated for each tool via logistic regression and subsequent ROC analysis. Nephrology providers reviewed the performance of the prognostication tools in their own patient population. A post interview reassessed perspectives and any change in attitudes regarding the tools.
Nephrology providers did not use these mortality prognostic tools in their practice. Key barriers identified were provider concern that the tools were not generalizable to their patients, providers' trust in their own clinical judgement over that of a prognostic tool, time constraints, and lack of knowledge about the data behind these tools. When re-interviewed with the results of the three prognostic tools in their patients, providers thought the tools performed as expected, but still did not intend to use the tools in their practice. They reported that these tools are good for populations, but not individual patients. The providers preferred to use clinical gestalt for prognostication.
Although several well validated prognostic tools are available for predicting mortality, the nephrology providers studied do not use them in routine practice, even after an educational intervention. Other approaches should be explored to help incorporate prognostication in shared-decision-making for patients receiving dialysis.
存在死亡率预后工具，以帮助与肾衰竭患者共同做出决策，但未得到充分利用。本研究旨在阐明肾病专家的实践模式，并了解使用预后工具的障碍。
对一家学术医疗中心的 8 名医生和 2 名护士从业者进行了半结构化访谈，了解他们对死亡率预后工具的使用经验和看法。两位审阅者使用扎根理论独立确定了共同主题。对接受采访的医生所照顾的 279 名现有透析患者应用了三种六个月死亡率预后工具。通过逻辑回归和随后的 ROC 分析，为每种工具计算 C 统计量。肾病专家对这些预后工具在其自身患者人群中的表现进行了回顾。在访谈后，重新评估了对工具的看法以及对工具的态度变化。
肾病专家在实践中未使用这些死亡率预后工具。确定的主要障碍是：提供者担心工具无法推广到其患者；提供者更信任自己的临床判断，而不是预后工具；时间限制；以及对这些工具背后的数据缺乏了解。当在患者中应用三种预后工具的结果重新进行访谈时，提供者认为这些工具的表现符合预期，但仍不打算在实践中使用这些工具。他们报告说，这些工具对人群有用，但对个体患者没有用。提供者更喜欢使用临床总体印象进行预后。
尽管有几种经过充分验证的预后工具可用于预测死亡率，但研究中涉及的肾病专家即使在接受教育干预后，也未在常规实践中使用这些工具。应探索其他方法，以帮助将预后纳入接受透析治疗的患者的共同决策中。
