Jamie A. Green

Problem-solving therapy to improve depression scores among older hemodialysis patients: a pilot randomized trial.

AIMS Depression is common among dialysis patients and is associated with adverse outcomes. Problem-solving therapy (PST) is effective for treating depression in older patients with chronic illness, but its effectiveness has never been reported in hemodialysis (HD) patients. We investigated the feasibility and satisfaction of PST and its impact on depression scores among older HD patients. METHODS Patients at least 60 years of age receiving maintenance HD at a single outpatient dialysis center were eligible for the study. Randomized patients received either 6 weeks of PST from a licensed renal social worker or usual care. This study modeled the staff-patient ratio standard of most dialysis clinics, and therefore only one social worker provided the interventions. Study outcomes included feasibility (successful completion of 6 weekly sessions) and patient satisfaction with PST as well as impact on depression scores (between-group comparison of mean Beck depression inventory (BDI) and Patient health questionnaire-9 (PHQ-9) scores at 6 weeks, and of mean change-from-baseline scores). RESULTS The recruitment rate was 92% (35/38). All subjects randomized to the intervention arm (n = 17) and who initiated PST (n = 15) completed the study, and all reported overall satisfaction with the intervention. 87% reported that PST helped them to better solve problems and improved their ability to cope with their medical condition. At 6 weeks, there were no significant differences in mean BDI and PHQ scores between the usual care and the intervention group (BDI 11.3 vs. 9.3, p = 0.6; PHQ 5.7 vs. 3.3, p = 0.1). Mean change-from-baseline depression scores were significantly improved in the intervention group relative to the control group (change in BDI 6.3 vs.- 0.6, p = 0.004; change in PHQ 7.2 vs. 0.3, p < 0.001). CONCLUSIONS The results demonstrate that PST is feasible in the dialysis unit setting, acceptable to patients, and may positively impact depression among maintenance hemodialysis patients.

Opening Residents' Notes to Patients: A Qualitative Study of Resident and Faculty Physician Attitudes on Open Notes Implementation in Graduate Medical Education.

Purpose OpenNotes is a growing national initiative inviting patients to read clinician progress notes (open notes) through a secure electronic portal. The goals of this study were to (1) identify resident and faculty preceptor attitudes about sharing notes with patients, and (2) assess specific educational needs, policy recommendations, and approaches to facilitate open notes implementation. Method This was a qualitative study using focus groups with residents and faculty physicians who supervise residents, representing primary care, general surgery, surgical and procedural specialties, and nonprocedural specialties, from Beth Israel Deaconess Medical Center and Geisinger Health System in spring 2013. Data were audio recorded and transcribed verbatim, then coded and organized into themes. Results Thirty-six clinicians (24 [66.7%] residents and 12 [33.3%] faculty physicians) participated. Four main themes emerged: (1) implications of full transparency, (2) note audiences and ideology, (3) trust between patients and doctors, and (4) time pressures. Residents and faculty discussed how open notes might yield more engaged patients and better notes but were concerned about the time needed to edit notes and respond to patient inquiries. Residents were uncertain how much detail they should share with patients and were concerned about the potential to harm the patient–doctor relationship. Residents and faculty offered several recommendations for open notes implementation. Conclusions Overall, participants were ambivalent about resident participation in open notes. Residents and faculty identified clinical and educational benefits to open notes but were concerned about potential effects on the patient–doctor relationship, requirements for oversight, and increased workload and burnout.

Understanding the Influence of Educational Attainment on Kidney Health and Opportunities for Improved Care

Educational attainment is an important but often overlooked contributor to health outcomes in patients with kidney disease. Those with lower levels of education have an increased risk of ESRD, complications of peritoneal dialysis, worse transplant outcomes, and mortality. Mediators of these associations are poorly understood but involve a complex interplay between health knowledge, behaviors, and socioeconomic and psychosocial factors. Interventions targeting these aspects of care have the potential to reduce disparities related to educational attainment; however, few programs have been described that specifically address this issue. Future research efforts should not only systematically assess level of educational attainment but also report the differential impact of interventions across educational strata. In addition, routine measurement of health literacy may be useful to identify high-risk patients independent of years of schooling. A better understanding of the influence of educational attainment on kidney health provides an opportunity to improve the care and outcomes of vulnerable patients with kidney disease.

The Perceived Medical Condition Self-Management Scale can be applied to patients with chronic kidney disease

Chronic Kidney Disease (CKD) is a major burden on patients and the health care system. Treatment of CKD requires dedicated involvement from both caretakers and patients. Self-efficacy, also known as perceived competence, contributes to successful maintenance of patients CKD self-management behaviors such as medication adherence and dietary regulations. Despite a clear association between self-efficacy and improved CKD outcomes, there remains a lack of validated self-report measures of CKD self-efficacy. To address this gap, the Perceived Kidney/Dialysis Self-Management Scale (PKDSMS) was adapted from the previously validated Perceived Medical Condition Self-Management Scale. We then sought to validate this using data from two separate cohorts: a cross-sectional investigation of 146 patients with end-stage renal disease receiving maintenance hemodialysis and a longitudinal study of 237 patients with CKD not receiving dialysis. The PKDSMS was found to be positively and significantly correlated with self-management behaviors and medication adherence in both patient cohorts. The PKDSMS had acceptable reliability, was internally consistent, and exhibited predictive validity between baseline PKDSMS scores and self-management behaviors across multiple time points. Thus, the PKDSMS is a valid and reliable measure of CKD patient self-efficacy and supports the development of interventions enhancing perceived competence to improve CKD self-management.