Julie A. Wright Nunes|Kerri L. Cavanaugh|Angela Fagerlin
An Informed and Activated Patient: Addressing Barriers in the Pathway From Education to Outcomes
University of Michigan–Ann Arbor|Vanderbilt Health|University of Michigan–Ann Arbor|VA Center for Clinical Management Research
related article p 31 related article p 31 need better job helping people manage complex health conditions data suggest important link health formal education patients chronic kidney disease ckd1ricardo ac yang w lora cm et allimited health literacy associated low glomerular filtration chronic renal insufficiency cohort cric studyclin nephrol 2014 81 3037crossref pubmed scopus 50 google scholar low literacy less formal education associated severe stages kidney disease less kidneyspecific knowledge increased morbidity1ricardo ac yang w lora cm et allimited health literacy associated low glomerular filtration chronic renal insufficiency cohort cric studyclin nephrol 2014 81 3037crossref pubmed scopus 50 google scholar 2cavanaugh kl wingard rl hakim rm et allow health literacy associates increased mortality esrdj soc nephrol 2010 21 19791985crossref pubmed scopus 188 google scholar 3wright ja wallston ka elasy ta ikizler ta cavanaugh kl development results kidney disease knowledge survey given patients ckdam j kidney dis 2011 57 387395abstract full text full text pdf pubmed scopus 128 google scholar however understanding causal mechanisms pathway educational attainment health limited observational crosssectional study designs critical unmet need identify causal mechanisms pathway education poor health determine whether mechanisms different ckd compared conditions understand causal mechanisms pathway focus addressing modifiable barriers prevent patients taking necessary steps stay healthy preserve kidney function issue ajkd morton et al4morton rl schlackow staplin n et alimpact educational attainment health outcomes moderate severe ckdam j kidney dis 2016 67 3139abstract full text full text pdf pubmed scopus 27 google scholar report post hoc analysis 6000 patients ckd participating sharp study heart renal protection5baigent c landray mj reith c et althe effects lowering ldl cholesterol simvastatin plus ezetimibe patients chronic kidney disease study heart renal protection randomised placebocontrolled triallancet 2011 377 21812192abstract full text full text pdf pubmed scopus 1886 google scholar authors identified significant differences vascular morbidity causespecific mortality 4 participants formal education referent group comprising 11 highest educational attainment tertiary education across study population progressive trend point estimates observed mortality differences neighboring educational attainment groups statistically significant despite large sample size also adjustment lifestyle factors smoking status comorbid conditions excess mortality risk associated lower educational attainment considerably reduced even eliminated interestingly researchers find difference ckd progression rates across education levels results suggest educational attainment may important vascular morbidity mortality extremes risk poorest health people formal education surprising low education associated unemployment lower income less access care6song w hsu economic noneconomic outcomes ged credential recipients ged testing service research studies american educational research association washington dc general educational development testing service program american council education 20082142google scholar 7adler ne newman k socioeconomic disparities health pathways policieshealth affairs 2002 21 6076crossref pubmed scopus 1329 google scholar 8winkleby jatulis de frank e fortmann sp socioeconomic status health education income occupation contribute risk factors cardiovascular diseaseam j public health 1992 82 816820crossref pubmed scopus 1414 google scholar importantly lifestyle factors attenuated observed differences suggesting less healthy behaviors essential components causal pathway educational attainment poor outcomes ckd consistent current models patient populations robert wood johnson commission build healthier america describes three major interrelated pathways including health knowledge behaviors employment income social psychological factors9the robert wood johnson foundation commission build healthier america education matters health issue brief 6 education health september 2009 httpwwwcommissiononhealthorgpdfc270deb3ba424fbdbaeb2cd65956f00eissue20brief20620sept20092020education20and20healthpdf accessed october 6 2015google scholar link formal education health outcomes fig 1 health knowledge specifically links educational attainment healthrelated behaviors including diet physical activity smoking chronic disease management findings morton et al support framework suggest interventions improve disease knowledge may improve behaviors reduce morbidity mortality dilemma deliver diseasespecific education context complex conditions ckd unclear morton et al found formal education related clinical outcomes ckd progression one possibility regardless individual education attainment specific risk factors already place largely determine fate persons kidney health genetic predisposition10hsu cy iribarren c mcculloch ce darbinian j go risk factors endstage renal disease 25year followuparch intern med 2009 169 342350crossref pubmed scopus 428 google scholar another consideration mean estimated glomerular filtration rate morton et al study 25 mlmin173 m2 suggesting advanced kidney disease may less amenable interventions targeting lifestyle behavioral changes finding confirmed future research would highlight importance early targeted efforts toward diseasespecific education health optimization individuals risk early evidence kidney disease one potential missed opportunity improve patient knowledge early kidney disease relates ongoing debate within nephrology community regarding definition ckd patients told ckd diagnosis11cavanaugh kl ikizler ta acknowledging kidney disease ignorance salubriousam j kidney dis 2013 61 536539abstract full text full text pdf pubmed scopus 8 google scholar suggested providers disclose patients clear terms diagnosis ckd based estimated glomerular filtration rate biomarkers12greer rc crews dc boulware le challenges perceived primary care providers educating patients chronic kidney diseasej renal care 2012 38 174181crossref pubmed scopus 47 google scholar despite patients wanting information13costantini l beanlands h mccay e cattran hladunewich francis selfmanagement experience people mild moderate chronic kidney diseasenephrol nurs j 2008 35 quiz 156 147155pubmed google scholar patient lack commitment may undermine strength recommendations follow healthy lifestyle furthermore always clear evidence regarding management strategies blood pressure goals across ages comorbid conditions14lewis jb blood pressure control chronic kidney disease less really morej soc nephrol 2010 21 10861092crossref pubmed scopus 83 google scholar given lack clear evidencedbased consensus diagnosis communication management within nephrology community perhaps surprising patients optimally primed information ckd diagnosis must preserve kidney function another reason education may linked ckd progression even educated patients simply may much know keep kidneys healthy possible kidney disease advances issue likely becomes even pronounced often ckd one entity rather culmination several underlying comorbid conditions thus patients ckd requires focus facets health instead singular evidencebased solution manage ckd patients often asked modify behavior nearly every aspect lives addition overall lifestyle changes patients ckd must adhere complex regimens affect eat drink take medications manage daytoday illness pain given situation wonder patients ckd equivalent risk progression regardless education level morton et al target may met critical threshold patients decide knowledge behavior changes required overwhelming matter much formal education life becomes fun present patients might choose keep certain aspects nonoptimal behaviors today expense best outcomes tomorrow real dilemma collective challenge remain help patients change multiple behaviors include diet restrictions complex medication regimens healthy lifestyle implementations without becoming overwhelmed perhaps best way reach destination start taking small steps forward first must try address diseasespecific knowledge gaps patients diseasespecific education one part motivation healthy behavior important part diabetesfocused education patients diabetes mellitus improves glycemic control15rothman rl malone r bryant b et ala randomized trial primary carebased disease management program improve cardiovascular risk factors glycated hemoglobin levels patients diabetesam j med 2005 118 276284abstract full text full text pdf pubmed scopus 219 google scholar kidney diseasespecific education patients nearing dialysis therapy initiation may decrease mortality16devins gm mendelssohn dc barre pe taub k binik ym predialysis psychoeducational intervention extends survival ckd 20year followupam j kidney dis 2005 46 10881098abstract full text full text pdf pubmed scopus 158 google scholar need research focused developing testing education interventions use early ckd stop progression disease opportunity nephrology community help improve care unifying around consistent message providers tell patients terms ckd terminology definition management implications patients understand diagnosis must keep kidneys healthy need support maintaining behaviors aligned preserving kidney function one way provide patientcentered counseling17schell jo holley jl opportunities improve endoflife care esrdclin j soc nephrol 2013 8 20282030crossref pubmed scopus 7 google scholar includes identifying patients values goals aligning health behaviors decision aids tools designed increase patient knowledge facilitate disease communication often include methods engage patients shared decision making18lin ga fagerlin shared decision making state sciencecirc cardiovasc qual outcomes 2014 7 328334crossref pubmed scopus 67 google scholar tested numerous health conditions shown increase patient disease knowledge selfcare well improve clinical outcomes large systematic cochrane review decision aids identified trials use chronic disease trials kidney disease19stacey legare f col nf et aldecision aids people facing health treatment screening decisionscochrane database syst rev 2014 1 cd001431crossref pubmed scopus 72 google scholar time explore tools like optimize ckd care also challenge conventional wisdom selling improved health benefits patients collaborating care motivate develop sustain healthy behaviors recent study examining core human goals attached exercise segar colleagues20segar ml eccles js richardson cr rebranding exercise closing gap values behaviorint j behav nutr phys act 2011 8 94crossref pubmed scopus 71 google scholar found distant benefits exercise strong motivators exercising goals improving health preventing disease living longer although important people compelling daily priorities deciding whether exercise researchers suggested shifting paradigm medicine marketing glean insights better market sell exercise pointing immediate payoffs motivate behavior better distant goals20segar ml eccles js richardson cr rebranding exercise closing gap values behaviorint j behav nutr phys act 2011 8 94crossref pubmed scopus 71 google scholar segar et al20segar ml eccles js richardson cr rebranding exercise closing gap values behaviorint j behav nutr phys act 2011 8 94crossref pubmed scopus 71 google scholar call rebranding close gap behavior values applying patients ckd interventions develop must incorporate emphasis benefits immediate aligned patients values immediate benefits would different depending behavior focusing emphasizing stress reduction increased energy motivate daily exercise another example would thinking fresh home meal preparation option save income otherwise spent convenient prepackaged dineout foods rebranding could give patients positive reinforcement needed sustain behaviors improve outcomes including progression ckd outcome might perceived distant nebulous merely presented terms health benefit clearly work needed define effective methods educating patients specifically ckd diagnosis close gap patients value day day subsequent behaviors potentially address barriers patients face regardless education attainment help become truly informed activated care support none financial disclosure authors declare relevant financial interests impact educational attainment health outcomes moderate severe ckdamerican journal kidney diseasesvol 67issue 1previewthe inverse association educational attainment mortality well established relevance vascular events renal progression population chronic kidney disease ckd less clear study aims determine association highest educational attainment risk vascular events causespecific mortality ckd progression fulltext pdf open access