title: Caring for patients with kidney disease: shifting the paradigm from evidence-based medicine to patient-centered care.
abstract: The last several decades have witnessed the emergence of evidence-based medicine as the dominant paradigm for medical teaching, research and practice. Under an evidence-based approach, populations rather than individuals become the primary focus of investigation. Treatment priorities are largely shaped by the availability, relevance and quality of evidence and study outcomes and results are assumed to have more or less universal significance based on their implications at the population level. However, population-level treatment goals do not always align with what matters the most to individual patients-who may weigh the risks, benefits and harms of recommended treatments quite differently. In this article we describe the rise of evidence-based medicine in historical context. We discuss limitations of this approach for supporting real-world treatment decisions-especially in older adults with confluent comorbidity, functional impairment and/or limited life expectancy-and we describe the emergence of more patient-centered paradigms to address these limitations. We explain how the principles of evidence-based medicine have helped to shape contemporary approaches to defining, classifying and managing patients with chronic kidney disease. We discuss the limitations of this approach and the potential value of a more patient-centered paradigm, with a particular focus on the care of older adults with this condition. We conclude by outlining ways in which the evidence-base might be reconfigured to better support real-world treatment decisions in individual patients and summarize relevant ongoing initiatives.
authors: Hospital and Specialty Medicine Service, VA Puget Sound Health Care System, Seattle, WA, USA Health Services Research and Development Center of Innovation, VA Puget Sound Health Care System, Seattle, WA, USA Department of Medicine, University of Washington, Seattle, WA, USA.
authors: Ann M
authors: AM
authors: O'Hare
authors: Hospital and Specialty Medicine Service, VA Puget Sound Health Care System, Seattle, WA, USA Department of Medicine, University of Washington, Seattle, WA, USA.
authors: Rudolph A
authors: RA
authors: Rodriguez
authors: Birmingham/Atlanta Geriatric Research, Education, and Clinical Center, Atlanta VA Medical Center, Decatur, GA, USA Department of Medicine, Emory University, Atlanta, GA, USA.
authors: Christopher Barrett
authors: CB
authors: Bowling
mesh_terms: D019468:Disease Management; D019317:Evidence-Based Medicine / Q000379:methods*; D006801:Humans; D018802:Patient-Centered Care / Q000379:methods*; D051436:Renal Insufficiency, Chronic / Q000628:therapy*
keywords: evidence-based medicine; kidney disease; older adults; paradigm; patient-centered care
references: N Engl J Med. 2012 Mar 1;366(9):780-1
references: 22375967
references: JAMA. 2014 Jul 16;312(3):225-6
references: 25027134
references: Arch Intern Med. 2004 Mar 22;164(6):659-63
references: 15037495
references: Am J Kidney Dis. 2009 Mar;53(3 Suppl 3):S4-16
references: 19231760
references: JAMA. 2009 Oct 28;302(16):1805-6
references: 19861674
references: Arch Intern Med. 2005 Apr 25;165(8):936-46
references: 15851647
references: JAMA. 2007 Nov 7;298(17):2038-47
references: 17986697
references: Am J Med. 2004 Feb 1;116(3):179-85
references: 14749162
references: J Gen Intern Med. 2014 Apr;29(4):552-3
references: 24442331
references: N Engl J Med. 2004 Dec 30;351(27):2870-4
references: 15625341
references: JAMA. 2013 Dec 25;310(24):2609-10
references: 24322396
references: JAMA. 2013 Dec 18;310(23):2503-4
references: 24165826
references: Arch Intern Med. 2012 Aug 13;172(15):1162-8
references: 22801930
references: JAMA. 1992 Sep 16;268(11):1460-1
references: 1512916
references: Adv Chronic Kidney Dis. 2011 Nov;18(6):450-5
references: 22098665
references: JAMA. 1992 Sep 16;268(11):1417-22
references: 1512909
references: JAMA. 2012 Jan 11;307(2):199-200
references: 22235093
references: Arch Intern Med. 2002 Aug 12-26;162(15):1682-8
references: 12153370
references: Gerontologist. 2012 Oct;52(5):703-11
references: 22421916
references: J Eval Clin Pract. 2006 Jun;12(3):281-8
references: 16722909
references: J Am Soc Nephrol. 2009 Apr;20(4):681-2
references: 19297553
references: JAMA. 2001 Jun 6;285(21):2750-6
references: 11386931
references: JAMA. 2007 Sep 12;298(10):1209-12
references: 17848656
references: Ann Intern Med. 2012 Apr 17;156(8):570-81
references: 22508734
references: Am J Kidney Dis. 2012 Apr;59(4):504-12
references: 22284441
references: JAMA. 2012 Jun 20;307(23):2493-4
references: 22797447
references: Kidney Int. 2014 Jan;85(1):49-61
references: 24284513
references: JAMA. 1992 Nov 4;268(17):2420-5
references: 1404801
references: Curr Opin Nephrol Hypertens. 2013 May;22(3):316-24
references: 23518464
references: J Gen Intern Med. 2011 Jul;26(7):783-90
references: 21286840
references: N Engl J Med. 2004 Aug 5;351(6):543-51
references: 15295047
references: J Am Geriatr Soc. 2012 Dec;60(12):2333-41
references: 23194184
references: N Engl J Med. 2011 May 5;364(18):1685-7
references: 21542739
references: N Engl J Med. 2010 Aug 12;363(7):609-19
references: 20581422
references: JAMA. 2012 Dec 12;308(22):2349-60
references: 23111824
references: Ann Intern Med. 2010 Jul 6;153(1):51-2
references: 20621903
references: Arch Intern Med. 2010 Jun 14;170(11):930-6
references: 20548004
references: Trials. 2010 Aug 12;11:85
references: 20704705
references: Health Aff (Millwood). 2014 Jul;33(7):1212-9
references: 25006148
references: JAMA. 2010 Apr 28;303(16):1644-5
references: 20424256
references: Trials. 2008 May 22;9:30
references: 18498644
references: J Am Geriatr Soc. 2008 Oct;56(10):1839-44
references: 18771453
references: J Am Geriatr Soc. 2012 Oct;60(10):E1-E25
references: 22994865
references: J Gen Intern Med. 2014 Mar;29(3):529-37
references: 24081443
references: Perspect Biol Med. 2005 Autumn;48(4):477-89
references: 16227661
references: Can Fam Physician. 2013 Nov;59(11):1160-1
references: 24235185
references: JAMA Intern Med. 2014 Aug;174(8):1350-8
references: 25055197
references: Health Aff (Millwood). 2010 May;29(5):835-43
references: 20439869
references: Am J Kidney Dis. 2012 Apr;59(4):513-22
references: 22305760
references: JAMA. 2005 Aug 10;294(6):716-24
references: 16091574
references: Lancet. 2008 Aug 16;372(9638):547-53
references: 18707986
references: Perm J. 2010 Spring;14(1):64-9
references: 20740135
references: JAMA. 2007 Mar 21;297(11):1233-40
references: 17374817
references: Ann Fam Med. 2014 May-Jun;12(3):202-3
references: 24821890
references: Lancet. 2014 Jan 11;383(9912):166-75
references: 24411645
references: Health Aff (Millwood). 2013 Apr;32(4):797-806
references: 23514777
references: JAMA. 2007 Sep 12;298(10):1160-2
references: 17848649
references: Arch Intern Med. 2010 Jun 28;170(12):1037-44
references: 20585069
references: Arch Intern Med. 2011 Mar 28;171(6):557-8
references: 21444845
references: BMJ. 2004 Oct 16;329(7471):912-5
references: 15485978
references: Eur J Clin Invest. 2013 May;43(5):469-75
references: 23521369
references: Am J Kidney Dis. 2008 Apr;51(4 Suppl 2):S13-20
references: 18359403
references: Ann Intern Med. 2009 May 19;150(10):717-24
references: 19451579
references: Med Care. 2014 Mar;52 Suppl 3:S23-30
references: 24561754
references: Am J Epidemiol. 1969 Feb;89(2):125-8
references: 5765952
references: J Am Geriatr Soc. 2013 May;61(5):739-46
references: 23617688
references: N Engl J Med. 2013 Jun 27;368(26):2448-50
references: 23802514
references: Kidney Int. 2014 Apr;85(4):723-7
references: 24682115
references: JAMA Intern Med. 2014 Mar;174(3):391-7
references: 24424348
references: N Engl J Med. 2011 Jun 30;364(26):2478-81
references: 21696327
references: Am J Kidney Dis. 2014 Mar;63(3):429-36
references: 24074823
references: Ann Intern Med. 2006 Feb 7;144(3):213-5
references: 16461967
references: Can Fam Physician. 2008 Dec;54(12):1655-8
references: 19074692
references: JAMA. 2014 Apr 9;311(14):1403-5
references: 24682222
references: J Eval Clin Pract. 2006 Aug;12(4):405-9
references: 16907681
references: JAMA. 2009 Dec 23;302(24):2686-94
references: 20040557
references: Kidney Int. 2013 Sep;84(3):622-3
references: 23989362
references: Am J Kidney Dis. 2002 Feb;39(2 Suppl 1):S1-266
references: 11904577
references: JAMA. 2014 Oct 1;312(13):1295-6
references: 25268434
references: BMJ Qual Saf. 2013 Oct;22(10):855-63
references: 23748154
references: JAMA. 2014 Oct 15;312(15):1513-4
references: 25167382
references: Am J Med Sci. 2014 Aug;348(2):115-20
references: 24879531
references: JAMA. 2012 Jun 20;307(23):2507-15
references: 22797451
references: Kidney Int. 2011 Jul;80(1):17-28
references: 21150873
references: J Am Soc Nephrol. 2007 Oct;18(10):2758-65
references: 17855638
references: N Engl J Med. 2012 Mar 1;366(9):777-9
references: 22375966