Pathways Project: Development of a Multimodal Innovation To Improve Kidney Supportive Care in Dialysis Centers

Abstract

Current care models for older patients with kidney failure in the United States do not incorporate supportive care approaches. The absence of supportive care contributes to poor symptom management and unwanted forms of care at the end of life. Using an Institute for Healthcare Improvement Collaborative Model for Achieving Breakthrough Improvement, we conducted a focused literature review, interviewed implementation experts, and convened a technical expert panel to distill existing evidence into an evidence-based supportive care change package. The change package consists of 14 best-practice recommendations for the care of patients seriously ill with kidney failure, emphasizing three key practices: systematic identification of patients who are seriously ill, goals-of-care conversations with identified patients, and care options to respond to patient wishes. Implementation will be supported through a collaborative consisting of three intensive learning sessions, monthly learning and collaboration calls, site data feedback, and quality-improvement technical assistance. To evaluate the change package's implementation and effectiveness, we designed a mixed-methods hybrid study involving the following: (1) effectiveness evaluation (including patient outcomes and staff perception of the effectiveness of the implementation of the change package); (2) quality-improvement monitoring via monthly tracking of a suite of quality-improvement indicators tied to the change package; and (3) implementation evaluation conducted by the external evaluator using mixed methods to assess implementation of the collaborative processes. Ten dialysis centers across the country, treating approximately 1550 patients, will participate. This article describes the process informing the intervention design, components of the intervention, evaluation design and measurements, and preliminary feasibility assessments.

Clinical trial registry name and registration number: Pathways Project: Kidney Supportive Care, NCT04125537.

Keywords: advance care planning; communication; end of life; geriatric and palliative nephrology; goals of care; implementation science; palliative care; shared decision-making; supportive care.

Conflict of interest statement

D.E. Lupu reports receiving funded time from the Coalition for Supportive Care of Kidney Patients, and grant support from the Gordon and Betty Moore Foundation for the Pathways Project and the Patrick and Catherine Weldon Donaghue Medical Research Foundation for the My Way Project. A.H. Moss reports receiving funding from the George Washington University School of Nursing, which has grant support from the Gordon and Betty Moore Foundation for the Pathways Project, and grant support from the National Institutes of Health. All remaining authors have nothing to disclose.

Copyright © 2021 by the American Society of Nephrology.

Figures

Figure 1.

Flow diagram of article selection process for development of the change package. Of 570 articles initially identified, 49 articles met criteria for inclusion.

Figure 2.

Baseline documentation of advance care planning in charts of seriously ill patients. Availability of complete information about different components of advance care planning varied, from high of 68% of patients with complete information about a surrogate, to low of 15% of information with a medical order such as DNR or POLST accessible in the chart. ACP, advance care planning; DNR, Do Not Resuscitate; MOLST, Medical Order for Life-Sustaining Treatment; POLST, Physician or Provider Order for Life-Sustaining Treatment.