Caring for patients with kidney disease: shifting the paradigm from evidence-based medicine to patient-centered care

• Type of Material: Article
• Authors: Christopher Bowling, Emory University; Ann M. O'Hare, VA Puget Sound Health Care System; Rudolph A. Rodriguez, VA Puget Sound Health Care System
• Language: English
• Date: 2016-03-01
• Publisher: Oxford University Press (OUP): Policy B - Oxford Open Option B
• Publication Version: Final Published Version
• Copyright Statement: © Published by Oxford University Press on behalf of ERA-EDTA 2015. This work is written by (a) US Government employee(s) and is in the public domain in the US
• Final Published Version (URL): http://dx.doi.org/10.1093/ndt/gfv003
• Title of Journal or Parent Work: Nephrology Dialysis Transplantation
• ISSN: 0931-0509
• Volume: 31
• Issue: 3
• Start Page: 368
• End Page: 375
• Grant/Funding Information: A.M.O. receives research funding from the NIH (1U01DK102150-01), the US Department of Veterans Affairs (1I01HX000961-01) and the CDC (IAA 14FED1405094-0001).; She receives an honorarium from UpToDate. C.B.B. receives funding from the National Institute on Aging (R03AG042336-01) and the T. Franklin Williams Scholarship Award (funding provided by Atlantic Philanthropies, Inc., the John A. Hartford Foundation, the Association of Specialty Professors, the American Society of Nephrology and the American Geriatrics Society) and the US Department of Veterans Affairs (1IK2CX000856-01A1).
• Keywords: QUALITY-OF-CARE; STAGE RENAL-DISEASE; older adults; patient-centered care; HEALTH-CARE; TRIALS; UNITED-STATES; Transplantation; SHARED DECISION-MAKING; Life Sciences & Biomedicine; OLDER-ADULTS; MULTIPLE CHRONIC CONDITIONS; kidney disease; Science & Technology; paradigm; evidence-based medicine; BLOOD-PRESSURE; Urology & Nephrology; CLINICAL-PRACTICE GUIDELINES
• Research Categories: Health Sciences, Medicine and Surgery; Health Sciences, Health Care Management

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.