SP677IMPLEMENTING A PATIENT-REPORTED OUTCOME MEASURE FOR HEMODIALYSIS PATIENTS IN ROUTINE CLINICAL CARE: PERSPECTIVES OF PATIENTS AND CLINICIANS

INTRODUCTION: The Edmonton Symptom Assessment System Revised: Renal (ESAS-r:Renal) is a patient reported outcome measure (PROM) used to assess physical and psychological symptom burden in patients living with chronic kidney disease. The use of PROMs in clinical care is frequently recommended but there is little information on how to best implement their use. We studied patient and clinician perspectives of the implementation process and impact of using the ESAS-r:Renal during routine clinical care of hemodialysis patients in Ontario, Canada. METHODS: Eight in-facility hemodialysis units assessed 1,459 patients with the ESAS-r:Renal every 4 to 6 weeks from April 2017 to June 2018. Pre- and post-implementation surveys and semi-structured interviews were conducted with patients and clinicians from the participating units. The results were used to identify implementation enablers and barriers, and to examine the perceived influence of ESAS-r:Renal on symptom management, patient-clinician communication, and interdisciplinary teamwork. RESULTS: 727 of patients participated in the pre-implementation survey and 579 participated in teh post-implementation survey. 518 (71%) of clinicians participated in the pre- and 323 (54%) participated in the post-implementation survey. Nine patients from three units participated in an individual interview and 48 clinicians from the eight units participated in group interviews (e.g., nephrologists, nurses, allied health professionals). Both patients and clinicians highly valued ESAS-r:Renal for ensuring symptoms are acknowledged by the care team, particularly psychosocial symptoms such as anxiety and depression, and for standardizing the symptom assessment process. Eighty-six percent of clinicians agreed that ESAS-r:Renal ensures symptoms are not missed and serves as a useful starting point to assess patients’ symptoms. Seventy-seven percent of patients reported that completing ESAS-r:Renal helped them feel more satisfied with their visit. Key inter-related barriers to the routine use of ESAS-r:Renal among clinicians included time/workload, high screening frequency, a lack of confidence to manage select symptoms and limited awareness of or access to external services for referrals. Notably, only 55% of clinicians reported they are very or moderately confident managing anxiety or depression. The survey and interview data suggests that the implementation of ESAS-r:Renal had limited influence on patient-clinician communication and interdisciplinary teamwork. The lack of impact on patient-clinician communication may be explained by a ceiling effect due to relatively high ratings at baseline (i.e., on average 70% of patients provided positive ratings pre-implementation versus 68% post-implementation). CONCLUSIONS: It is feasible to incorporate a PROM into routine care for patients on hemodialysis with appropriate education, integration into existing clinical workflows, and strong clinical and administrative leadership support. Further evaluation is required to understand the impact of ESAS-r:Renal on clinical processes and outcomes.

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