To the Editor:
Chronic kidney disease (CKD) affects approximately 1 in 7 US adults and is associated with premature morbidity, mortality, and reduced quality of life. Avoiding negative outcomes of CKD progression, such as cardiovascular events and kidney failure,1 requires patients to achieve aggressive lifestyle and medical management.2 However, many patients lack understanding of the tasks required to prevent CKD progression.3,4 This knowledge gap, the complexity of kidney disease information, and the challenge of CKD self-management demand effective communication between physicians and their patients.5
Wright Nunes et al6 found that use of a physician-delivered educational worksheet was associated with increased patient CKD knowledge in a predominately white population. This work, although important, was physician led, required physician training and acceptance, and included few racial minorities. The CKD Report Card, an investigator-developed 2-sided educational worksheet modified from National Kidney Disease Education Program materials,7 was designed to increase CKD knowledge and encourage patient-centered communication by facilitating discussion of clinical status (eg, laboratory values and CKD stage) and patient-led goal setting. We assessed the effects of the CKD Report Card at an urban predominantly African American nephrology clinic.
We recruited adult patients from the University of Chicago Nephrology Clinic. Patients enrolled during the first 4 weeks formed the control group; those during the second 4 weeks formed the intervention group. The intervention group was provided the CKD Report Card (Fig 1) immediately before the clinic visit. Patient knowledge was assessed before and after the clinic visit using a 30-item CKD Knowledge Tool, modified from the Kidney Disease Knowledge Survey.8 Paired-sample t tests were performed to analyze the change in CKD knowledge scores from pre- to postvisit. Difference-in-difference analysis was performed to examine the relative magnitude of improvement for the intervention group compared with controls. Intervention group and control group postvisit scores were compared using multivariable regression analysis adjusting for previsit scores and patients’ age, race, sex, education level, visit status (ie, new vs returning patient), CKD stage, years seeing nephrology, and physician status (ie, fellow vs attending). All statistical calculations were performed using Stata Statistical Software, version 14 (StataCorp). Additional methods are included in Item S1.
Figure 1.
The Chronic Kidney Disease (CKD) Report Card (sides 1 and 2). Abbreviation: PTH, parathyroid hormone. Modified with permission from the National Kidney Disease Education Program clinical and educational tools.7
Twenty-five patients were enrolled in each study group (intervention and control), with at least 3 patients per physician per phase of the study. Mean age of the study population (N = 50) was 63 ± 15 years, and 50% were 65 years or older. Fifty-eight percent were women, 76% were African American, 88% had CKD stages 3-5, 50% had diabetes, and 86% had hypertension. There were no significant differences between the control and intervention groups in age, race, sex, education level, CKD stage, or comorbid conditions (Table S1).
Compared with controls, the CKD Report Card group had greater postvisit knowledge gain for topics of kidney function, causes of CKD, and general CKD knowledge (Tables 1 and S2). Mean CKD knowledge score in the control group was 60.3% ± 15.4% for previsit scores and 64.1% ± 18.7% for postvisit scores. Mean CKD knowledge score in the CKD Report Card group was 62.9% ± 13.8% for previsit scores and 73.1% ± 14.7% for postvisit scores. Using paired-sample t tests, the mean difference (post-previsit CKD knowledge) in the control group was +3.9% (P = 0.12) compared with +10.1% (P = 0.004) in the intervention group (Table 1). Multivariable regression analysis controlling for previsit score, age, race, sex, education level, visit status, CKD stage, years seeing nephrology, and physician status showed a 7.1% increase in intervention group knowledge scores compared with the control group (95% confidence interval, 0.22-14.1; P = 0.05).
Table 1.
Select CKD Knowledge Tool Results by Question (percent of individuals answering correctly) and Mean CKD Knowledge Score for Control and Intervention Groups
| Question Topic | Control Group (n = 25) |
Intervention Group (n = 25) |
Intervention Compared With Control |
||||
|---|---|---|---|---|---|---|---|
| Previsit | Postvisit | % Difference | Previsit | Postvisit | % Difference | Mean Difference (95% confidence interval) | |
| Functions of the kidney: The kidney… | |||||||
| filters and cleans the blood | 22 (88%) | 21 (84%) | −4% (−12% to 4%) | 23 (92%) | 23 (92%) | 0% (−12% to 12%) | +4 (−10 to 18) |
| helps keep bones healthy | 4 (16%) | 7 (28%) | +12% (−2% to 26%) | 10 (40%) | 15 (60%) | +20% (−4% to 43%) | +8 (−19 to 34) |
| helps keep red blood cell counts normal | 12 (48%) | 12 (48%) | 0% (−24% to 24%) | 13 (52%) | 20 (80%) | +28% (3% to 53%) | +28 (−6 to 62) |
| helps keep phosphorus levels in the blood normal | 7 (28%) | 10 (40%) | +12% (−6% to 30%) | 9 (36%) | 12 (48%) | +12% (−2% to 26%) | 0 (−22 to 22) |
| Causes of CKD: What can cause CKD? | |||||||
| High blood pressure | 21 (84%) | 22 (88%) | +4% (−4% to 12%) | 22 (88%) | 25 (100%) | +12% (−2% to 26%) | +8 (−8 to 23) |
| Diabetes | 23 (92%) | 23 (92%) | 0% (0% to 0%) | 23 (92%) | 25 (100%) | +8% (−3% to 19%) | +8 (−3 to 19) |
| General CKD knowledge | |||||||
| GFR = glomerular filtration rate | 16 (64%) | 14 (56%) | − 8% (−32% to 16%) | 18 (72%) | 22 (88%) | +16% (−4% to 35%) | +24 (−6 to 54) |
| There are 5 stages of CKD | 8 (32%) | 11 (44%) | +12% (−2% to 26%) | 7 (28%) | 15 (60%) | +32% (12% to 52%) | +20 (−3 to 43) |
| CKD patients should avoid ibuprofen | 14 (56%) | 14 (56%) | 0% (−12% to 12%) | 16 (64%) | 18 (72%) | +8% (−3% to 19%) | +8 (−8 to 24) |
| Mean score (SD) | 60 (15) | 64 (19) | +4% (−1% to 9%) | 63 (14%) | 73 (15%) | +10% (5% to 15%) | +6 (−0.6 to 13) |
Note: Values expressed as number (percent correct) unless otherwise noted.
Abbreviations: CKD, chronic kidney disease; SD, standard deviation.
In our pilot study, we found that patient-led use of the CKD Report Card was associated with increased patient knowledge in an urban predominately minority nephrology clinic. Implementation of our user-friendly and easily navigable tool may offer patients a simple method of learning more about their kidney disease, pertinent laboratory values, and tips for successful health management. Furthermore, our educational intervention may facilitate physician-patient communication by empowering patients to ask questions that pertain to their personal health goals.
There were several limitations to this study, including a small sample size and single-institution research design. Patients varied in both the method and extent of CKD Report Card use during the clinic visit. Additionally, because this was not a randomized study, residual confounding cannot be ruled out. Planned next steps are to test the CKD Report Card in a larger randomized intervention with longer follow-up and then, if findings are robust, incorporate the tool into routine clinical care.
Article Information
Authors’ Contributions
Research idea and study design: JT, TP, MRS; data access and acquisition: JT, KJ; data analysis and interpretation: JT, MRS; statistical analysis: JT, MRS; supervision and mentorship: TP, MRS. Each author contributed important intellectual content during manuscript drafting or revision and accepts accountability for the overall work by ensuring that questions pertaining to the accuracy or integrity of any portion of the work are appropriately investigated and resolved.
Support
Ms Tzeggai was supported by the National Kidney Foundation of Illinois Medical Student Award and The University of Chicago Pritzker School of Medicine Summer Research Program. Dr Saunders was supported by National Institute of Diabetes and Digestive and Kidney Diseases K23DK103111. The funder had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; or preparation, review, and approval of the manuscript.
Financial Disclosure
The authors declare that they have no relevant financial interests.
Prior Presentation
This work was presented in abstract form at the National Kidney Foundation Spring Clinical Meeting; Boston, MA; May 8-12, 2019.
Peer Review
Received June 18, 2019. Evaluated by 2 external peer reviewers, with direct editorial input from the Statistical Editor, an Associate Editor, and the Editor-in-Chief. Accepted in revised form January 12, 2020.
Footnotes
Item S1: Supplementary methods
Table S1: Overall Patient Characteristics Associated With Patient Chronic Kidney Disease
Table S2: Complete CKD Knowledge Tool Results by Question (percent of individuals answering correctly) for Control and Intervention Groups
Supplementary Material
Item S1;Tables S1-S2.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Item S1;Tables S1-S2.