Implementation and Effectiveness of a Learning Collaborative to Improve Palliative Care for Seriously Ill Hemodialysis Patients

• Published in: Clinical journal of the American Society of Nephrology Vol. 17; no. 10; pp. 1495 - 1505
• Main Authors: Kurella Tamura, Manjula, Holdsworth, Laura, Stedman, Margaret, Aldous, Annette, Asch, Steven M, Han, Jialin, Harbert, Glenda, Lorenz, Karl A, Malcolm, Elizabeth, Nicklas, Amanda, Moss, Alvin H, Lupu, Dale E
• Format: Journal Article
• Language: English
• Published: United States American Society of Nephrology 01-10-2022
• Subjects: Advance Care Planning; COVID-19 - epidemiology; Humans; Original; Palliative Care - methods; Renal Dialysis - methods; Terminal Care - methods; renal dialysis; geriatric nephrology
• ISSN: 1555-9041; 1555-905X
• DOI: 10.2215/CJN.00090122

Limited implementation of palliative care practices in hemodialysis may contribute to end-of-life care that is intensive and not patient centered. We determined whether a learning collaborative for hemodialysis center providers improved delivery of palliative care best practices.
Ten US hemodialysis centers participated in a pre-post study targeting seriously ill patients between April 2019 and September 2020. Three practices were prioritized: screening for serious illness, goals of care discussions, and use of a palliative dialysis care pathway. The collaborative educational bundle consisted of learning sessions, communication skills training, and implementation support. The primary outcome was change in the probability of complete advance care planning documentation among seriously ill patients. Health care utilization was a secondary outcome, and implementation outcomes of acceptability, adoption, feasibility, and penetration were assessed using mixed methods.
One center dropped out due to the coronavirus disease 2019 pandemic. Among the remaining nine centers, 20% (273 of 1395) of patients were identified as seriously ill preimplementation, and 16% (203 of 1254) were identified as seriously ill postimplementation. From the preimplementation to postimplementation period, the adjusted probability of complete advance care planning documentation among seriously ill patients increased by 34.5 percentage points (95% confidence interval, 4.4 to 68.5). There was no difference in mortality or in utilization of palliative hemodialysis, hospice referral, or hemodialysis discontinuation. Screening for serious illness was widely adopted, and goals of care discussions were adopted with incomplete integration. There was limited adoption of a palliative dialysis care pathway.
A learning collaborative for hemodialysis centers spanning the coronavirus disease 2019 pandemic was associated with adoption of serious illness screening and goals of care discussions as well as improved documentation of advance care planning for seriously ill patients.
Pathways Project: Kidney Supportive Care, NCT04125537.