Decision readiness and determinants of KRT among Veterans with advanced CKD

Abstract: Background: Kidney disease stakeholders recommend a system-wide increase in home dialysis use. KRT decision readiness is associated with higher selection and use of home dialysis; however, KRT decision making is complex, and factors informing KRT decision readiness in patients with advanced CKD are unclear. Methods: Using the baseline data of the Trial to Evaluate and Assess the effects of Comprehensive KRT-directed patient education on home dialysis use among VETerans, we conducted a cross-sectional analysis to evaluate prevalent KRT decision readiness, defined as ability to choose any KRT modality among US Veterans with advanced CKD. We also evaluated Veterans' ability to achieve high-quality informed KRT decisions (more than 60% decisional confidence on a scale ranging from 1% to 100%) and selection of home dialysis as secondary outcomes. Univariate and multivariable logistic regressions were used to test associations between patient-level variables and outcomes. Results: Of the 468 enrollees with a complete baseline dataset, 282 (60%) could not pick any KRT modality; the rest were split between high (20%) versus low-quality (20%) decisions and home (21%) versus in-center (12%) dialysis. Younger age, higher CKD stage, history of receiving prior KRT-directed education, rural habitation, and objective disease knowledge were positively associated with KRT decision readiness. Only objective disease knowledge was associated with KRT decision readiness after adjustments, with participants in the highest tertile of CKD-specific knowledge having two-fold (odds ratio, 2.31; 95% confidence interval, 1.18 to 4.55) and KRT-specific knowledge having five-fold (odds ratio, 5.16; 95% confidence interval, 2.63 to 10.32) higher odds of selecting their KRT. Item-level analysis showed that difficult, specifically KRT knowledge-related, items had a high discriminatory capacity to predict KRT decision readiness. Conclusions: Veterans with advanced CKD are ill-prepared for KRT decision making. Although social determinants of health have a potential role in identifying high-risk populations, objective kidney failure and KRT-specific knowledge have a dominant effect on KRT decision readiness. Clinical Trial registry name and registration number: NCT04064086.