title: Upstream discussion provided in the ambulatory setting to assist patients with chronic kidney disease considering dialysis.
abstract: OBJECTIVE
  Extensive discussion with renal patients about treatment intensity is not systematically integrated into their care and often occurs during an acute hospitalization. We conducted a "test-of-change" pilot study to assess the utility of providing an upstream discussion in the ambulatory setting as an additional nephrology consult to assist patients with chronic kidney disease considering treatment choices.
  
  
  METHODS
  We randomly assigned patients with Stage 4 or Stage 5 chronic kidney disease who had not yet begun renal dialysis to 1 of 2 groups. The test group received the additional nephrology consult and met with an interdisciplinary team composed of a nephrologist, social worker, and clinical ethicist, and the control group did not. Qualitative data were collected in 2012 and 2013 via oral questionnaire. Both groups received a 6-month follow-up assessment.
  
  
  RESULTS
  Patients who received the nephrology consult reported that they experienced help in forming a treatment plan, felt well understood, and had the opportunity to thoroughly discuss questions. The controls had a 26% increased probability of beginning dialysis and had a statistically significant increase in dialysis and clinic visits (p < 0.10 and p < 0.05). Controls also were likelier than the test group to be admitted to the hospital (0.5 vs 0.2 admissions per patient in the test group), spend more days hospitalized (2.8 vs 0.5 bed days per patient), and visit the emergency room (0.73 vs 0.66 visits per patient) and clinic (6.6 vs 3.6 visits per patient).
  
  
  CONCLUSIONS
  An additional nephrology consultation proved helpful both qualitatively and quantitatively.
authors.affiliation: Chief of Nephrology at the South Bay Medical Center in Harbor City, CA. tuan.k.le@kp.org.
authors.forename: Tuan K
authors.initials: TK
authors.lastname: Le
authors.affiliation: Nephrologist at the South Bay Medical Center in Harbor City, CA. mi.x.chang@kp.org.
authors.forename: Mi
authors.initials: M
authors.lastname: Chang
authors.affiliation: Director of Medical Bioethics at the South Bay Medical Center in Harbor City, CA. craig.m.nelson@kp.org.
authors.forename: Craig
authors.initials: C
authors.lastname: Nelson
authors.affiliation: Social Worker at the Los Angeles Medical Center in CA. julie.sortais@kp.org.
authors.forename: Julie Ann
authors.initials: JA
authors.lastname: Sortais
authors.affiliation: Physician and Director of the Inpatient Palliative Care Team at the South Bay Medical Center in Harbor City, CA. pushkar.chand@kp.org.
authors.forename: Pushkar
authors.initials: P
authors.lastname: Chand
authors.affiliation: Research Consultant for the Center for Care Experience, Care Management Institute and The Permanente Federation in Oakland, CA. karen.tallman@kp.org.
authors.forename: Karen
authors.initials: K
authors.lastname: Tallman
mesh_terms: D000328:Adult; D000554:Ambulatory Care Facilities; D003142:Communication; D003657:Decision Making; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D009398:Nephrology; D010358:Patient Participation; D017060:Patient Satisfaction; D010865:Pilot Projects; D012017:Referral and Consultation / Q000592:standards*; D006435:Renal Dialysis; D051436:Renal Insufficiency, Chronic / Q000628:therapy*