title: Behavioral stage of change and dialysis decision-making.
abstract: OBJECTIVE
  Behavioral stage of change (SoC) algorithms classify patients' readiness for medical treatment decision-making. In the precontemplation stage, patients have no intention to take action within 6 months. In the contemplation stage, action is intended within 6 months. In the preparation stage, patients intend to take action within 30 days. In the action stage, the change has been made. This study examines the influence of SoC on dialysis modality decision-making.
  
  
  METHODS
  SoC and relevant covariates were measured, and associations with dialysis decision-making were determined. In-depth interviews were conducted with 16 patients on dialysis to elicit experiences. Qualitative interview data informed the survey design. Surveys were administered to adults with CKD (eGFR≤25 ml/min/1.73 m(2)) from August, 2012 to June, 2013. Multivariable logistic regression modeled dialysis decision-making with predictors: SoC, provider connection, and dialysis knowledge score.
  
  
  RESULTS
  Fifty-five patients completed the survey (71% women, 39% white, and 59% black), and median annual income was $17,500. In total, 65% of patients were in the precontemplation/contemplation (thinking) and 35% of patients were in the preparation/maintenance (acting) SoC; 62% of patients had made dialysis modality decisions. Doctors explaining modality options, higher dialysis knowledge scores, and fewer lifestyle barriers were associated with acting versus thinking SoC (all P<0.02). Patients making modality decisions had doctors who explained dialysis options (76% versus 43%), were in the acting versus the thinking SoC (50% versus 10%), had higher dialysis knowledge scores (1.4 versus 0.5), and had lower eGFR (13.9 versus 16.8 ml/min/1.73 m(2); all P<0.05). In adjusted analyses, dialysis knowledge was significantly associated with decision-making (odds ratio, 4.2; 95% confidence interval, 1.4 to 12.9; P=0.01), and SoC was of borderline significance (odds ratio, 5.8; 95% confidence interval, 1.0 to 32.6; P=0.05). The model C statistic was 0.87.
  
  
  CONCLUSIONS
  Dialysis decision-making was associated with SoC, dialysis knowledge, and physicians discussing treatment options. Future studies determining ways to assist patients with CKD in making satisfying modality decisions are warranted.
authors.affiliation: Division of Nephrology, Department of Medicine, MetroHealth Medical Center, Cleveland, Ohio; Division of Nephrology, Department of Medicine, Case Western Reserve University, Cleveland, Ohio; suma74@gmail.com suma.prakash@case.edu.
authors.forename: Suma
authors.initials: S
authors.lastname: Prakash
authors.affiliation: Research Institute, MetroHealth Medical Center, Cleveland, Ohio;
authors.forename: Anna
authors.initials: A
authors.lastname: McGrail
authors.affiliation: Center of Health Care Research and Policy, MetroHealth Medical Center, Cleveland, Ohio; Department of Medicine, MetroHealth Medical Center, Cleveland, Ohio;
authors.forename: Steven A
authors.initials: SA
authors.lastname: Lewis
authors.affiliation: Department of Quantitative Health Sciences, Cleveland Clinic Foundation, Cleveland, Ohio; and.
authors.forename: Jesse
authors.initials: J
authors.lastname: Schold
authors.affiliation: Department of Medicine, MetroHealth Medical Center, Cleveland, Ohio; Department of Medicine, Case Western Reserve University, Cleveland, Ohio.
authors.forename: Mary Ellen
authors.initials: ME
authors.lastname: Lawless
authors.affiliation: Division of Nephrology, Department of Medicine, MetroHealth Medical Center, Cleveland, Ohio; Division of Nephrology, Department of Medicine, Case Western Reserve University, Cleveland, Ohio;
authors.forename: Ashwini R
authors.initials: AR
authors.lastname: Sehgal
authors.affiliation: Department of Medicine, MetroHealth Medical Center, Cleveland, Ohio; Department of Medicine, Case Western Reserve University, Cleveland, Ohio.
authors.forename: Adam T
authors.initials: AT
authors.lastname: Perzynski
mesh_terms: D000328:Adult; D000368:Aged; D000465:Algorithms; D001291:Attitude of Health Personnel; D002755:Choice Behavior; D003142:Communication; D003430:Cross-Sectional Studies; D005260:Female; D015438:Health Behavior; D019538:Health Care Surveys; D007722:Health Knowledge, Attitudes, Practice; D057220:Health Literacy; D006801:Humans; D033182:Intention; D007407:Interviews as Topic; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D016017:Odds Ratio; D010358:Patient Participation; D010361:Patients / Q000523:psychology*; D010820:Physicians / Q000523:psychology; D036301:Qualitative Research; D006435:Renal Dialysis / Q000379:methods*; D051436:Renal Insufficiency, Chronic / Q000175:diagnosis / Q000523:psychology* / Q000628:therapy*; D011795:Surveys and Questionnaires
keywords: ESRD; chronic renal insufficiency; clinical nephrology; dialysis