Title: Optimising Staff-patient Communication in Advanced Renal disease (The OSCAR study)
Funder: Department of Health and Social Care

Abstract: BackgroundAnnually in the UK, 3,500 adults over 65 with end-stage kidney disease (ESKD) start dialysis. They are the fastest growing group of recipients, and providing dialysis for them costs 312 million/year. Yet for older people, the survival benefits of dialysis are uncertain and its quality of life impact greatest. Conservative (non-dialytic) care is a benefical alternative to dialysis for older patients, particularly those with comorbidity or frailty, but there is huge unwarranted variation in rates of conservative care: from 5% to 95% across UK renal units. One reason for this is inconsistency in how clinicians communicate about treatment options, which strongly influences patients' decision-making.AimsTo understand communication, information provision and decision-making support in renal units with varying treatment rates for older patients To identify and describe interactional features of consultations between kidney clinicians and older people (80+ or 65+ with poor performance status/comorbidities) with advanced chronic kidney disease (eGFR To develop an evidence-based, acceptable intervention, incorporating clinician training, to enhance how clinicians support patients' decision-making To contribute to the evidence-base on how patient-centred decision-making is interactionally implemented MethodsMixed-methods, via four work packages, following MRC complex interventions guidelines and the person-based approach to enhancing intervention acceptability and feasibility. Data collection, analysis and intervention development informed by clinician behaviour change theory.Work Package 1: Understanding the contextAt five renal units with a range of CCC rates for older people, I will:Conduct ethnographic, non-participant observation of renal consultants', registrars' and nurses' consultations with eligible patients (and carers, if present), and qualitative interviews with clinicians; analyse data thematically. Evaluate the content and comprehensibility of information resources provided to patients (e.g. education sessions, decision aids). Work Package 2: Describing communication and its consequencesAcross these renal units, I will: Video-record 60-80 consultations between 20 clinicians and eligible patients (and carers); use Conversation Analysis to identify trainable elements. Collect patient-/carer- and clinician-reported questionnaire data regarding consultation communication and treatment decision-making; test for associations between clinicians' communication behaviours and patient/carer outcomes, and differences between patient/carer and clinician outcomes. Conduct qualitative interviews exploring patient/carer experiences of communication and decision-making; analyse thematically. Work Package 3: Intervention development Co-produce the intervention with the Stakeholder Panel (patients, carers, clinicians, educators and commissioners), integrating WP1&2 findings, evidence and theory. Refine intervention via iterative 'think aloud' interviews with 20 clinicians. Work Package 4: Pilot, refine Pilot the intervention in a renal unit not involved in WP1&2. Use pre-/post- questionnaires and qualitative interviews to determine clinician views/experiences. Video-record post-training consultations to determine whether and how training is put into practice. Further refine intervention and prepare for full evaluation. TimelinesFour-year study (2.5 years WP1&2, 1.5 years WP3&4), beginning 1.1.2019.Anticipated impact Patient-centred communication and decision-making support, across renal units Accurate, appropriate information provision Treatment/care concordant with patient preference Potential cost savings: reduced dialysis, hospitalisation Improved staff self-efficacy/ability and patient experience of decision-making Evidence to inform practice guidelines Dissemination will include open-access journal publications, linked blogs, conference presentations, policy/media briefings, freely available plain English summaries, and a short video.

Lay abstract: Aim To understand how kidney clinicians (doctors and nurses) communicate with older people with advanced kidney disease when they are deciding what treatment to have for kidney failure. To develop a package ('intervention') to enhance how kidney clinicians communicate, and ensure they provide person-centred support and accurate information to patients making this decision. I will focus on older adults with advanced, chronic kidney disease and other health problems, for whom there is currently no clear 'best option' when deciding between treatments.BackgroundEvery day, 10 UK citizens over 65 develop kidney failure and must decide what treatment to have. As most are too unwell for transplantation, their choice is between dialysis or non-dialysis 'comprehensive conservative care' (CCC). This is often a difficult decision: dialysis can prolong life, but this is not guaranteed for older patients, and it has a negative impact on quality of life. Patients rely on kidney clinicians for information and support to help them decide, but the way clinicians discuss treatment options and the information they provide varies widely. This means treatment decision-making is not consistently patient-centred, and there is huge variation in treatment rates, and therefore treatment costs, across the UK.Design and methods A Stakeholder Panel including at least five patients and family members/friends ('carers'), plus clinicians, educators and commissioners of kidney services, will give ongoing advice.The project involves four studies ('Work Packages'):Work Package 1: At five kidney units with a range of rates of CCC for older people, we will observe outpatient interactions about treatment options between staff and older patients and review the information resources provided. We will interview 20-25 clinicians about their experiences and views of supporting older people's treatment decision-making. Work package 2: At the five units, we will video-record 60-80 outpatient consultations between eligible patients (and any accompanying carers) and 20 clinicians (consultants, registrars, nurses). We will determine how clinicians talk about the different treatment options and support people deciding about treatment, and identify key 'trainable' elements of communication: ways of interacting and providing information that support patient-centred decision-making. We will ask patients, carers and clinicians to complete questionnaires about their views of the consultation and treatment decision. 20-25 patients/carers will also be interviewed about their experiences.Work Package 3: With the Stakeholder Panel, we will use findings from Work Packages 1&2 plus other evidence to design an intervention to improve communication, information provision and decision-making support in consultations. This will include staff training (incorporating examples of 'trainables' from the video-recordings) and written guidance for kidney units. We will interview clinicians about the intervention and refine it, so it is appropriate and acceptable.Work Package 4: Finally, we will deliver the intervention in a kidney unit, ask clinicians their views, and video-record their consultations after the training to see whether and how it is put into practice. If needed, we will refine the intervention further.Patient and Public Involvement This research has been developed with people with kidney disease and their carers, through group and one-to-one meetings, and with kidney clinicians. All agreed it was needed and likely to be beneficial. We will continue working closely with members of the public through the Stakeholder Panel. Two patients/carers from the Panel will join the Project Advisory Committee. Each group will meet eight times during the four-year study. Members of the public will be provided with training, support, travel expenses, and vouchers acknowledging their contribution.DisseminationFindings will be shared through freely available journal articles, conference presentations, and a short video for the public developed with the Stakeholder Panel. Plain English summaries will be published online and given to participants.

Research activity codes: 7.2 END OF LIFE CARE;7.3 MANAGEMENT AND DECISION MAKING
Health categories: RENAL AND UROGENITAL