Improving CKD Patient Knowledge and Patient-Physician Communication: A Pilot Study of a CKD Report Card.

To the Editor:

Chronic kidney disease (CKD) affects approximately 1 in 7 US adults and is associated with premature morbidity, mortality, and reduced quality of life. Avoiding negative outcomes of CKD progression, such as cardiovascular events and kidney failure, requires patients to achieve aggressive lifestyle and medical management. However, many patients lack understanding of the tasks required to prevent CKD progression., This knowledge gap, the complexity of kidney disease information, and the challenge of CKD self-management demand effective communication between physicians and their patients.

Wright Nunes et al found that use of a physician-delivered educational worksheet was associated with increased patient CKD knowledge in a predominately white population. This work, although important, was physician led, required physician training and acceptance, and included few racial minorities. The CKD Report Card, an investigator-developed 2-sided educational worksheet modified from National Kidney Disease Education Program materials, was designed to increase CKD knowledge and encourage patient-centered communication by facilitating discussion of clinical status (eg, laboratory values and CKD stage) and patient-led goal setting. We assessed the effects of the CKD Report Card at an urban predominantly African American nephrology clinic.

We recruited adult patients from the University of Chicago Nephrology Clinic. Patients enrolled during the first 4 weeks formed the control group; those during the second 4 weeks formed the intervention group. The intervention group was provided the CKD Report Card (Fig 1) immediately before the clinic visit. Patient knowledge was assessed before and after the clinic visit using a 30-item CKD Knowledge Tool, modified from the Kidney Disease Knowledge Survey. Paired-sample t tests were performed to analyze the change in CKD knowledge scores from pre- to postvisit. Difference-in-difference analysis was performed to examine the relative magnitude of improvement for the intervention group compared with controls. Intervention group and control group postvisit scores were compared using multivariable regression analysis adjusting for previsit scores and patients’ age, race, sex, education level, visit status (ie, new vs returning patient), CKD stage, years seeing nephrology, and physician status (ie, fellow vs attending). All statistical calculations were performed using Stata Statistical Software, version 14 (StataCorp). Additional methods are included in Item S1.

Figure 1

The Chronic Kidney Disease (CKD) Report Card (sides 1 and 2). Abbreviation: PTH, parathyroid hormone. Modified with permission from the National Kidney Disease Education Program clinical and educational tools.

Twenty-five patients were enrolled in each study group (intervention and control), with at least 3 patients per physician per phase of the study. Mean age of the study population (N = 50) was 63 ± 15 years, and 50% were 65 years or older. Fifty-eight percent were women, 76% were African American, 88% had CKD stages 3-5, 50% had diabetes, and 86% had hypertension. There were no significant differences between the control and intervention groups in age, race, sex, education level, CKD stage, or comorbid conditions (Table S1).

Compared with controls, the CKD Report Card group had greater postvisit knowledge gain for topics of kidney function, causes of CKD, and general CKD knowledge (Tables 1 and S2). Mean CKD knowledge score in the control group was 60.3% ± 15.4% for previsit scores and 64.1% ± 18.7% for postvisit scores. Mean CKD knowledge score in the CKD Report Card group was 62.9% ± 13.8% for previsit scores and 73.1% ± 14.7% for postvisit scores. Using paired-sample t tests, the mean difference (post-previsit CKD knowledge) in the control group was +3.9% (P = 0.12) compared with +10.1% (P = 0.004) in the intervention group (Table 1). Multivariable regression analysis controlling for previsit score, age, race, sex, education level, visit status, CKD stage, years seeing nephrology, and physician status showed a 7.1% increase in intervention group knowledge scores compared with the control group (95% confidence interval, 0.22-14.1; P = 0.05).

Table 1

Select CKD Knowledge Tool Results by Question (percent of individuals answering correctly) and Mean CKD Knowledge Score for Control and Intervention Groups

Question Topic	Control Group (n = 25)			Intervention Group (n = 25)			Intervention Compared With Control
	Previsit	Postvisit	% Difference	Previsit	Postvisit	% Difference	Mean Difference (95% confidence interval)
Functions of the kidney: The kidney…
filters and cleans the blood	22 (88%)	21 (84%)	−4% (−12% to 4%)	23 (92%)	23 (92%)	0% (−12% to 12%)	+4 (−10 to 18)
helps keep bones healthy	4 (16%)	7 (28%)	+12% (−2% to 26%)	10 (40%)	15 (60%)	+20% (−4% to 43%)	+8 (−19 to 34)
helps keep red blood cell counts normal	12 (48%)	12 (48%)	0% (−24% to 24%)	13 (52%)	20 (80%)	+28% (3% to 53%)	+28 (−6 to 62)
helps keep phosphorus levels in the blood normal	7 (28%)	10 (40%)	+12% (−6% to 30%)	9 (36%)	12 (48%)	+12% (−2% to 26%)	0 (−22 to 22)
Causes of CKD: What can cause CKD?
High blood pressure	21 (84%)	22 (88%)	+4% (−4% to 12%)	22 (88%)	25 (100%)	+12% (−2% to 26%)	+8 (−8 to 23)
Diabetes	23 (92%)	23 (92%)	0% (0% to 0%)	23 (92%)	25 (100%)	+8% (−3% to 19%)	+8 (−3 to 19)
General CKD knowledge
GFR = glomerular filtration rate	16 (64%)	14 (56%)	− 8% (−32% to 16%)	18 (72%)	22 (88%)	+16% (−4% to 35%)	+24 (−6 to 54)
There are 5 stages of CKD	8 (32%)	11 (44%)	+12% (−2% to 26%)	7 (28%)	15 (60%)	+32% (12% to 52%)	+20 (−3 to 43)
CKD patients should avoid ibuprofen	14 (56%)	14 (56%)	0% (−12% to 12%)	16 (64%)	18 (72%)	+8% (−3% to 19%)	+8 (−8 to 24)
Mean score (SD)	60 (15)	64 (19)	+4% (−1% to 9%)	63 (14%)	73 (15%)	+10% (5% to 15%)	+6 (−0.6 to 13)

Note: Values expressed as number (percent correct) unless otherwise noted.

Abbreviations: CKD, chronic kidney disease; SD, standard deviation.

In our pilot study, we found that patient-led use of the CKD Report Card was associated with increased patient knowledge in an urban predominately minority nephrology clinic. Implementation of our user-friendly and easily navigable tool may offer patients a simple method of learning more about their kidney disease, pertinent laboratory values, and tips for successful health management. Furthermore, our educational intervention may facilitate physician-patient communication by empowering patients to ask questions that pertain to their personal health goals.

There were several limitations to this study, including a small sample size and single-institution research design. Patients varied in both the method and extent of CKD Report Card use during the clinic visit. Additionally, because this was not a randomized study, residual confounding cannot be ruled out. Planned next steps are to test the CKD Report Card in a larger randomized intervention with longer follow-up and then, if findings are robust, incorporate the tool into routine clinical care.