Rationale & ObjectiveOlder adults with advanced chronic kidney disease (CKD) face difficult decisions about dialysis initiation. Although shared decision making (SDM) can help align patient preferences and values with treatment options, the extent to which older patients with CKD experience SDM remains unknown.Study DesignA cross-sectional analysis of patient surveys examining decisional readiness, treatment options education, care partner support, and SDM.Setting & ParticipantsAdults aged 70 years or older from Boston, Chicago, San Diego, or Portland (Maine) with nondialysis advanced CKD.PredictorsDecisional readiness factors, treatment options education, and care partner support.OutcomesPrimary: SDM measured by the 9-item Shared Decision Making Questionnaire (SDM-Q-9) instrument, with higher scores reflecting greater SDM. Exploratory: Factors associated with SDM.Analytical ApproachWe used multivariable linear regression models to examine the associations between SDM and predictors, controlling for demographic and health factors.ResultsAmong 350 participants, mean age was 78 ± 6 years, 58% were male, 13% identified as Black, and 48% had diabetes. Mean SDM-Q-9 score was 52 ± 28. SDM item agreement ranged from 41% of participants agreeing that "my doctor and I selected a treatment option together" to 73% agreeing that "my doctor told me that there are different options for treating my medical condition." In multivariable analysis adjusted for demographic characteristics, lower estimated glomerular filtration rate, and diabetes, being "well informed" and "very well informed" about kidney treatment options, having higher decisional certainty, and attendance at a kidney treatment options class were independently associated with higher SDM-Q-9 scores.LimitationsThe cross-sectional study design limits the ability to make temporal associations between SDM and the predictors.ConclusionsMany older patients with CKD do not experience SDM when making dialysis decisions, emphasizing the need for greater access to and delivery of education for individuals with advanced CKD. Older adults with advanced chronic kidney disease (CKD) face difficult decisions about dialysis initiation. Although shared decision making (SDM) can help align patient preferences and values with treatment options, the extent to which older patients with CKD experience SDM remains unknown. A cross-sectional analysis of patient surveys examining decisional readiness, treatment options education, care partner support, and SDM. Adults aged 70 years or older from Boston, Chicago, San Diego, or Portland (Maine) with nondialysis advanced CKD. Decisional readiness factors, treatment options education, and care partner support. Primary: SDM measured by the 9-item Shared Decision Making Questionnaire (SDM-Q-9) instrument, with higher scores reflecting greater SDM. Exploratory: Factors associated with SDM. We used multivariable linear regression models to examine the associations between SDM and predictors, controlling for demographic and health factors. Among 350 participants, mean age was 78 ± 6 years, 58% were male, 13% identified as Black, and 48% had diabetes. Mean SDM-Q-9 score was 52 ± 28. SDM item agreement ranged from 41% of participants agreeing that "my doctor and I selected a treatment option together" to 73% agreeing that "my doctor told me that there are different options for treating my medical condition." In multivariable analysis adjusted for demographic characteristics, lower estimated glomerular filtration rate, and diabetes, being "well informed" and "very well informed" about kidney treatment options, having higher decisional certainty, and attendance at a kidney treatment options class were independently associated with higher SDM-Q-9 scores. The cross-sectional study design limits the ability to make temporal associations between SDM and the predictors. Many older patients with CKD do not experience SDM when making dialysis decisions, emphasizing the need for greater access to and delivery of education for individuals with advanced CKD.
National health data reported for Asians in the aggregate present a picture of good health, but significant health disparities exist between Southeast Asian refugees, and Cambodians in particular, and the overall population of the U.S. To effectively address health disparities, ethnically specific data is needed. Data from a community survey of 381 Cambodian adults 25 years of age and older are presented. Overall, 44% of respondents reported fair or poor health. Using multivariate logistic regression, we examined the relationships between self-rated health and demographics, timing of immigration, language use and literacy, and access to health care. In our final model those most likely to report fair or poor health were female, older, unable to work due to disability, to have spent a smaller proportion of their life in the U.S., and to have wanted to see a doctor in the past year, but not been able to.
Health impact assessment (HIA) seeks to expand evaluation of policy and programmes in all sectors, both private and public, to include their impact on population health. While the idea that the public's health is affected by a broad array of social and economic policies is not new and dates back well over two centuries, what is new is the notion-increasingly adopted by major health institutions, such as the World Health Organisation (WHO) and the United Kingdom National Health Services (NHS)-that health should be an explicit consideration when evaluating all public policies. In this article, it is argued that while HIA has the potential to enhance recognition of societal determinants of health and of intersectoral responsibility for health, its pitfalls warrant critical attention. Greater clarity is required regarding criteria for initiating, conducting, and completing HIA, including rules pertaining to decision making, enforcement, compliance, plus paying for their conduct. Critical debate over the promise, process, and pitfalls of HIA needs to be informed by multiple disciplines and perspectives from diverse people and regions of the world.
Objective Knowledge Translation (KT) is the exchange, synthesis, and ethically-sound application of knowledge. A case study methodology is used to examine KT at the organizational level of the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) program.Method The study used purposeful sampling to select WIC informants from state WIC agencies to participate in semi-structured interviews about their individual experiences during the 2009 WIC regulation change process. Thematic coding of retrospective semi-structured interviews with key informants from WIC state agencies revealed key components of the state-level WIC regulation implementation process, and key constructs of Organizational Readiness for Knowledge Translation in the WIC program.Results WIC informants highlight that decisions made by WIC state agencies regarding how to appraise, synthesize, and adapt evidence or regulation change are constrained by the KT decisions made by federal agencies. WIC state agencies should assess their level of readiness for KT in terms of 1) innovation readiness; 2) personal readiness; and 3) institutional readiness.Conclusions This WIC case study can help decision-makers to understand the KT process of implementing evidence-informed regulation changes, identify factors that could influence states’ ability to be prepared for implementing changes, and gauge “practicality” of future WIC regulation changes.
Objective: Studies assessing awareness and knowledge of alcohol-attributable causes of death and disease have been conducted across the globe to develop and evaluate public information campaigns to increase alcohol health literacy. Because of variation in measurement, the results of these studies cannot be easily compared to determine relative rates of high versus low alcohol health literacy across countries or regions. This review catalogs the samples and survey items that have been used and presents recommendations for how to improve alcohol health literacy survey research. Method: Searches for studies surveying general populations for knowledge of the associations between alcohol and nine alcohol-related health harms—fetal alcohol syndrome, liver cirrhosis, cancer, pancreatitis, tuberculosis, epilepsy, cardiovascular disease, lower respiratory infections, and conduction disorders—were conducted in PubMed and Embase. Survey results published between January 2007 and April 2018 were reviewed for eligibility. Of 791 studies initially identified, 76 were included in the final analysis. Results: Survey items varied substantially in the types of response options used (e.g., yes/no, agree/disagree, Likert scales, multiple choice); terminology for drinking behavior (e.g., alcohol consumption vs. alcohol abuse), risk-factor framing (e.g., cause vs. association), and health harms (e.g., cardiovascular disease vs. stroke); and how their results were presented (e.g., numbers and/or percentages of respondents vs. odds ratios). Very few studies used probability samples. Conclusions: The current state of the research literature makes it impossible to identify patterns of alcohol health literacy globally or even to compare intra-country studies across time. We recommend that a database of standard, validated questions for assessing knowledge about the relationship between alcohol and several key health outcomes be assembled and made available to the research community.
Older patients with advanced chronic kidney disease (CKD) use intensive care at the end of life and die in a hospital more frequently than patients with cancer or heart disease. Advance care planning (ACP) can help align treatment with patient preferences and improve patient-centered care, yet ACP quality and experiences among older patients with CKD and their care partners remain incompletely understood, particularly among the non-dialysis-dependent population.In-person interviewer-administered surveys of patients 70 years and older with non-dialysis-dependent CKD stage 4 or 5 and their self-identified care partners.42 participants (31 patients, 11 care partners) at 2 clinical sites in greater Boston.Completion of advance directives and self-reported perceptions, preferences, and experiences of ACP.Descriptive analysis of patient and care partner surveys. McNemar test analysis to compare patient and care partner responses.Most patients had written advance directives (64%) and surrogate decision makers (81%). Although patients reported positive perceptions and high trust in their clinicians' judgment, few (16%) had actually discussed preferences for life-sustaining treatment with their nephrologists. Few ACP discussions included components reflective of high-quality ACP: 16% of patients had been asked about their values concerning end-of-life care and 7% had discussed issues of decision-making capacity and consent to care should their health decline. When presented with 2 hypothetical scenarios (stroke/heart attack or dementia), nearly all patients and care partners reported a preference for comfort care over delaying death. Care partners were more likely than patients to report that they had experienced discussion components reflective of high-quality ACP with the clinical team.Single metropolitan area; most patients did not identify a care partner; nonresponse bias and small sample size.Patients often believed that their clinicians understood their end-of-life wishes despite not having engaged in ACP conversations that would make those wishes known. Improving clinical ACP communication may result in end-of-life treatment that better aligns with patient goals.
