Training Nephrologists to Use Best Case/Worst Case for Dialysis Decisions for a Multisite Randomized Clinical Trial with Older Adults with End-Stage Kidney Disease

INTRODUCTION: We adapted the best case/worst case (BC/WC) tool to fit outpatient clinic conversations between nephrologists and older adults. This new tool uses scenario planning and a graphic aid for dialysis decisions. Our research question is, “Can we train nephrologists to use BC/WC?” METHODS: As part of a multisite randomized clinical trial, we randomized nephrologists at 8 study sites to an intervention or control group. We trained nephrologists in the intervention group with a 2-hour one-on-one session including 2 simulated patient encounters. We used a fidelity checklist upon completion and required 14/19 elements for competency. We collected the BC/WC graphic aid used with study-enrolled patients to evaluate the performance of the intervention in vivo. We measured performance, scored by 2 raters, using a separate rubric scaled from “Not Done” to “Exceptional.” RESULTS: We enrolled 49 nephrologists with 24 randomized to the intervention arm. For this in-progress study, there are on average 2.8 patients enrolled per nephrologist, and 18 nephrologists have not had 1 study patient enrolled. We successfully trained 22 nephrologists to competence, with an average training score of 18.3/19 and no need for remediation (2 nephrologists withdrew). Of 32 BC/WC graphic aids received, the average score for performance was 18 of 28, where 15 indicated “most elements done.” Interrater reliability for this assessment was high; intraclass correlation coefficient = 0.924 (95% CI 0.845–0.963). CONCLUSION: BC/WC, a tool pioneered in acute care surgery, can be taught to clinicians in other settings and has potential to improve communication regarding upstream decisions that influence surgical care.