Geriatric Assessment in CKD Care: An Implementation Study

Abstract

Rationale & ObjectiveOlder people with progressive chronic kidney disease (CKD) have complex health care needs. Geriatric evaluation preceding decision-making for kidney replacement is recommended in guidelines, but implementation is lacking in routine care. We aimed to evaluate implementation of geriatric assessment in CKD care. Study DesignMixed-methods implementation study. Setting& Participants: Dutch nephrology centers were approached for implementation of geriatric assessment in patients aged ≥70 years and with an eGFR ≤20mL/min. Quality Improvement ActivitiesWe implementated a consensus-based nephrology-tailored geriatric assessment: a patient-questionnaire and professional-administered test set comprising 16 instruments covering functional, cognitive, psycho-social and somatic domains and patient-reported outcome measures. OutcomesWe aimed for implementation in 10 centers and 200 patients. Implementation was evaluated by (i) perceived enablers and barriers of implementation, including integration in work routines (Normalization MeAsure Development tool), and (ii) relevance of the instruments to routine care for the target population. Analytical ApproachVariations in implementation practices were described based on field notes. The post-implementation survey among healthcare professionals was analyzed descriptively, using an explanatory qualitative approach for open-ended questions. ResultsGeriatric assessment was implemented in 10 centers among n=191 patients. Survey respondents (n=71, 88% response rate) identified determinants that facilitated implementation: i.e. multidisciplinary collaboration (with geriatricians) -meetings and reports, and execution of assessments by nurses. Barriers to implementation were: patient illiteracy or language barrier, time constrains, and patient burden. Professionals considered geriatric assessment sufficiently integrated into work routines (mean 6.7/10, SD2.0), but also subject to improvement. Likewise, the relevance of geriatric assessment for routine care was scored as 7.8/10, SD1.2). The Clinical Frailty Score and Montreal Cognitive Assessment were perceived most relevant instruments. LimitationsSelection bias of interventions’ early adopters may limit generalizability. ConclusionsGeriatric assessment could successfully be integrated in CKD care, and was perceived relevant to healthcare professionals.