Geriatric Assessment in CKD Care: An Implementation Study

Rationale & Objective Older people with progressive chronic kidney disease (CKD) have complex health care needs. Geriatric evaluation preceding decision making for kidney replacement is recommended in guidelines, but implementation is lacking in routine care. We aimed to evaluate implementation of geriatric assessment in CKD care. Study Design Mixed methods implementation study. Setting & Participants Dutch nephrology centers were approached for implementation of geriatric assessment in patients aged ≥70 years and with an estimated glomerular filtration rate of ≤20 mL/min/1.73 m2. Quality Improvement Activities/Exposure We implemented a consensus-based nephrology-tailored geriatric assessment: a patient questionnaire and professionally administered test set comprising 16 instruments covering functional, cognitive, psychosocial, and somatic domains and patient-reported outcome measures. Outcomes We aimed for implementation in 10 centers and 200 patients. Implementation was evaluated by (i) perceived enablers and barriers of implementation, including integration in work routines (Normalization Measure Development Tool) and (ii) relevance of the instruments to routine care for the target population. Analytical Approach Variations in implementation practices were described based on field notes. The postimplementation survey among health care professionals was analyzed descriptively, using an explanatory qualitative approach for open-ended questions. Results Geriatric assessment was implemented in 10 centers among 191 patients. Survey respondents (n = 71, 88% response rate) identified determinants that facilitated implementation, ie, multidisciplinary collaboration (with geriatricians) -meetings and reports and execution of assessments by nurses. Barriers to implementation were patient illiteracy or language barrier, time constraints, and patient burden. Professionals considered geriatric assessment sufficiently integrated into work routines (mean, 6.7/10 ± 2.0 [SD]) but also subject to improvement. Likewise, the relevance of geriatric assessment for routine care was scored as 7.8/10 ± 1.2. The Clinical Frailty Score and Montreal Cognitive Assessment were perceived as the most relevant instruments. Limitations Selection bias of interventions’ early adopters may limit generalizability. Conclusions Geriatric assessment could successfully be integrated in CKD care and was perceived relevant to health care professionals.

The petal charts presents the average score for each NPT subconstruct of normalization on a Likert scale of 1 (strongly disagree) to 5 (strongly agree).The boxes describe the determinants of NGA integration in routine work as derived from the qualitative analysis of open-ended questions.Supporting evidence (quotes) are presented in Supplemental Table S2.Abbreviations: HCP, health care professionals; NGA, nephrology-tailored geriatric assessment; KRT, kidney replacement therapy.

Mental functioning
Optimism (Life-orientation test) Not calculated due to missing items 0-24 (higher scores indicates higher optimism, average score general population: 16.2 3 )
The questionnaire consists of 6 parts: integration of NGA in routine care (using the validated NoMAD questionnaire), contribution of NGA to routine care, reasons for successful or limited implementation, evaluation of the specific instruments in the NGA, improvements for NGA practices, and general data.
It takes about 15 minutes to complete the multiple choice questions and scoring statements.Optionally, you can provide us additional explanations.We process your data in such a way that the answers cannot be traced back to you personally.This applies to both the report to the funder (Kidney Foundation) and the scientific article.Definition Nephro-Geriatric Assessment (NGA): he questionnaire is about 'embedding NGA in routine care'.This includes the patient questionnaire and the professional-administered test set of POLDER study, and using the results of these tests in CKDcare.
Assessment may have been done with interference of the geriatrician.Ideally, the results should be discussed with the patient in a multidisciplinary consultation.1. Evaluate the implementation of nephro-geriatric assessment (NGA) in routine care for patients with kidney failure 2. Improve the test set.

End of
The questionnaire consists of 6 parts: integration of NGA in routine care (using the validated NoMAD questionnaire), contribution of NGA to routine care, reasons for successful or limited implementation, evaluation of the specific instruments in the NGA, improvements for NGA practices, and general data.
It takes about 15 minutes to complete the multiple choice questions and scoring statements.Optionally, you can provide us additional explanations.We process your data in such a way that the answers cannot be traced back to you personally.This applies to both the report to the funder (Kidney Foundation) and the scientific article.
Would you like to have more information?Please see full information letter at our website: www.polderstudie.nl/nl/over-polder/evaluatieDo you give permission for the use of your answers for this research and their (scientific) publication?
oYes, I give permission oNo,I don't give permission < end of questionnaire> Definition Nephro-Geriatric Assessment (NGA): he questionnaire is about 'embedding NGA in routine care'.This includes the patient questionnaire and the professional-administered test set of POLDER study, and using the results of these tests in CKDcare.
Assessment may have been done with interference of the geriatrician.Ideally, the results should be discussed with the patient in a multidisciplinary consultation.1. Evaluate the implementation of nephro-geriatric assessment (NGA) in routine care for patients with kidney failure 2. Improve the test set.

End of Block: Consent
The questionnaire consists of 6 parts: integration of NGA in routine care (using the validated NoMAD questionnaire), contribution of NGA to routine care, reasons for successful or limited implementation, evaluation of the specific instruments in the NGA, improvements for NGA practices, and general data.
It takes about 15 minutes to complete the multiple choice questions and scoring statements.Optionally, you can provide us additional explanations.We process your data in such a way that the answers cannot be traced back to you personally.This applies to both the report to the funder (Kidney Foundation) and the scientific article.
Would you like to have more information?Please see full information letter at our website: www.polderstudie.nl/nl/over-polder/evaluatieDo you give permission for the use of your answers for this research and their (scientific) publication?
oYes, I give permission oNo,I don't give permission < end of questionnaire> Supplement File 2: Post-implementation survey amongst health care professionals Translated from Dutch.
[Voorend et al., Implementation of geriatric assessment in CKD care; a quality improvement initiative] Page 2 of 14 Explanation: Definition Nephro-Geriatric Assessment (NGA): he questionnaire is about 'embedding NGA in routine care'.This includes the patient questionnaire and the professional-administered test set of POLDER study, and using the results of these tests in CKDcare.
Assessment may have been done with interference of the geriatrician.Ideally, the results should be discussed with the patient in a multidisciplinary consultation.

End of
Q7 Do you feel the nephro-geriatric assessment is currently a normal part of your work in care for older CKD patients?
No, not at all Neutral Yes, completely Q8 Do you feel the nephro-geriatric assessment will become a normal part of your work in care older CKD patients?
No, not at all Neutral Yes, completely (0 Q10 For each statement please select an answer that best suits your experience.If the statement is not relevant to you please select 'not relevant to my role'.Not at all familiar Neutral Feels completely familiar Q7 Do you feel the nephro-geriatric assessment is currently a normal part of your work in care for older CKD patients?
No, not at all Neutral Yes, completely Q8 Do you feel the nephro-geriatric assessment will become a normal part of your work in care older CKD patients?
No, not at all Neutral Yes, completely (0 Q10 For each statement please select an answer that best suits your experience.If the statement is not relevant to you please select 'not relevant to my role'.Page 10 of 14 Q20 Starting from the 3 just mentioned objectives of the NGA (identifying and objectifying impairments, determining supportive treatment strategies, informing decision-making for choice of kidney replacement therapy).
How relevant are the specific tools of the patient-questionnaire for your role in kidney patient care?
(Please fill in your judgment and motivation) Page 10 of 14 Q20 Starting from the 3 just mentioned objectives of the NGA (identifying and objectifying impairments, determining supportive treatment strategies, informing decision-making for choice of kidney replacement therapy).
How relevant are the specific tools of the patient-questionnaire for your role in kidney patient care?
(Please fill in your judgment and motivation)   a Only for patients in whom there were doubts on physical and cognitive functioning.b Discipline not always present at multidisciplinary team meeting.c Either combined or in a separate visit, often in combination with educational-and/or doctors' consultation.d Initially separate visits but later these were combined.e Initially conducted by geriatric nurse, later by internist-geriatrician, in future disposition to be done by a nephrology nurse (practitioner).f Geriatric practices were conducted by a geriatric nurse who took over from the nephrology nurse.g During/subsequent to the study period a multidisciplinary team meeting was developed.
[Voorend et al., Implementation of geriatric assessment in CKD care; a quality improvement initiative.] 5 The extensiveness of the assessment and the applicability in daily practice needs adjusting.Some of the assessment domains are not suitable for everyone.(geriatrician) I have been given tools to start a patient conversation.Let's hope that a DIALOGICA [study] results in an abridged version of NGA.Quite often patients found the questions too difficult.Some questions were found to be too long and these comprised different parts.(nurse practitioner) A considerable number of patients experience hospital visits as very burdensome and therefore decline to participate in a study.
(geriatrician) I think that we can break the taboo of assessment and implement it more broadly, by giving it a different name or taking it out of the "geriatric" realm, and then patients will be more inclined to participate.(nurse practitioner) By less linking of it [NGA] to age you already take away the taboo, they don't want to be categorized as "geriatric patient" and are sometimes afraid of being tested for cognition.(nephrologist) a All selected illustrative quotes were translated from Dutch to English by a native speaker (NB) using back-translation.Abbreviations: 6-CIT, 6-item cognitive impairment test; HCW, health care worker; KRT, kidney replacement therapy; MoCA, Montreal cognitive assessment; NGA, nephrology-tailored geriatric assessment; PROMS, patient-reported outcome measure.

Figure S1 :
Figure S1: Integration of NGA in routine care: visualization of the mixed methods approach using of normalization construct scores and open-ended questions.The petal charts presents the average score for each NPT subconstruct of normalization on a Likert scale of 1 (strongly disagree) to 5 (strongly agree).The boxes describe the determinants of NGA integration in routine work as derived from the qualitative analysis of open-ended questions.Supporting evidence (quotes) are presented in Supplemental TableS2.Abbreviations: HCP, health care professionals; NGA, nephrology-tailored geriatric assessment; KRT, kidney replacement therapy.
(LOT-R): Hinz et al. (2017, J Clin Health Psychol) 4) PG-SGA-SF: Kosters et al. (2020, Nutrition) 5) SPICC-plus: De Boer et al.(2012, Tijdschr Gerontol Geriatr) Would you like to have more information?Please see full information letter at our website: www.polderstudie.nl/nl/over-polder/evaluatieDo you give permission for the use of your answers for this research and their (scientific) publication?o Yes, I give permission o No, I don't give permission < end of questionnaire> Supplement File 2: Post-implementation survey amongst health care professionals Translated from Dutch.[Voorend et al., Implementation of geriatric assessment in CKD care; a quality improvement initiative] Page 2 of 14 Explanation: Block: Consent Supplement File 2: Post-implementation survey amongst health care professionals Translated from Dutch.[Voorend et al., Implementation of geriatric assessment in CKD care; a quality improvement initiative] Page 1 of 14 POLDER Evaluation: implementation of NGA Start of Block: Consent Consent Form Thank you for participating in the evaluation of the nephro-geriatric assessment (NGA) in the POLDER study.Your opinion on this innovation in kidney failure care is essential!This POLDER sub-study aims to:

Item S2 :
Post-implementation survey amongst health care professionals Translated from Dutch.[Voorend et al., Implementation of geriatric assessment in CKD care; a quality improvement initiative] Page 2 of 14 Explanation:

Item S2 :
Post-implementation survey amongst health care professionals Translated from Dutch.[Voorend et al., Implementation of geriatric assessment in CKD care; a quality improvement initiative] Page 1 of 14 POLDER Evaluation: implementation of NGA Start of Block: Consent Consent Form Thank you for participating in the evaluation of the nephro-geriatric assessment (NGA) in the POLDER study.Your opinion on this innovation in kidney failure care is essential!This POLDER sub-study aims to:

Q2
How many years of work experience do you have in this position?________________________________________________________________ Q3 How many years have you been working for this department in this hospital?________________________________________________________________ Q4 Through which hospital are you connected to POLDER? <multiple choice answer option for all 10 hospitals> Q5 Have you been directly involved in the design and/or implementation of the NGA in your hospital?Yes / No End of Block A: General data Start of Block B: Integration in routine care (NoMAD questionnaire) Supplement File 2: Post-implementation survey amongst health care professionals Translated from Dutch.[Voorend et al., Implementation of geriatric assessment in CKD care; a quality improvement initiative] Page 4 of 14 Q6 When you use the nephro-geriatric assessment, how familiar does it feel?Not at all familiar Neutral Feels completely familiar can see how the NGA differs from usual ways of working in the kidney failure outpatient clinic.o o o o o □ 2. Staff in this organization have a shared understanding of the purpose of NGA.o o o o o □ 3. I understand how the nephro-geriatric assessment affects the nature of my work at the kidney failure outpatient clinic.oo o o o □ 4. I can see the potential value of the nephrogeriatric assessment for my work in older CKD patient care.o o o o o □ Q11 Could you briefly elaborate your answers?(optional) ________________________________________________________________ ________________________________________________________________ Supplement File 2: Post-implementation survey amongst health care professionals Translated from Dutch.[Voorend et al., Implementation of geriatric assessment in CKD care; a quality improvement initiative] Page 3 of 14 Start of Block A: General data Q1 What is your profession?oNephrol ogist oGeri atrician / internist-geriatrician oNurse practitioner, discipline: ________________________________________________ oNephrol ogy nurse oGeri atric nurse oDi etician oSoci al worker oResearchnurse oOt her, please specify: ________________________________________________ Q2 How many years of work experience do you have in this position?________________________________________________________________ Q3 How many years have you been working for this department in this hospital?________________________________________________________________ Q4 Through which hospital are you connected to POLDER? <multiple choice answer option for all 10 hospitals> Q5 Have you been directly involved in the design and/or implementation of the NGA in your hospital?Yes / No End of Block A: General data Start of Block B: Integration in routine care (NoMAD questionnaire) Item S2: Post-implementation survey amongst health care professionals Translated from Dutch.[Voorend et al., Implementation of geriatric assessment in CKD care; a quality improvement initiative] Page 4 of 14 Q6 When you use the nephro-geriatric assessment, how familiar does it feel?

Item S2 :
Post-implementation survey amongst health care professionals Translated from Dutch.[Voorend et al., Implementation of geriatric assessment in CKD care; a quality improvement initiative] Page 11 of 14 Start of Block E: Reasons for successful or limited implementation Q21 The reasons below may have been reason for good or limited implementation.Please indicate, from your experience, were these reasons present when the NGA was performed in your hospital?results of the tests were discussed in detail with the patient □ Patients were willing and available for the geriatric assessment □ The NGA is too much of a burden for many patients □ NGA was performed to a limited extent because many patients had low health literacy or due to a Nephrology department to involve geriatrics/elderly care in routine care □ Multidisciplinary consultation and reports in which NGA outcomes and treatment policy were discussed □ Support from other disciplines (e.g.dietitian, social worker) in the administration and interpretation of NGA □ Loss of geriatric knowledge and practical skills (for example due to team changes) □ Supplement File 2: Post-implementation survey amongst health care professionals Translated from Dutch.[Voorend et al., Implementation of geriatric assessment in CKD care; a quality improvement initiative] carrying out the NGA □ Lack of budget is a reason to carry out NGA less often or adequately.□ The sum-score forms in the dashboard (available from July 2020) were helpful □ Q22 Do you have any additional explanation about reasons for successful or limited implementation?Post-implementation survey amongst health care professionals Translated from Dutch.[Voorend et al., Implementation of geriatric assessment in CKD care; a quality improvement initiative] Page 11 of 14 Start of Block E: Reasons for successful or limited implementation Q21 The reasons below may have been reason for good or limited implementation.Please indicate, from your experience, were these reasons present when the NGA was performed in your hospital?purpose and results of the tests were discussed in detail with the patient □ Patients were willing and available for the geriatric assessment □ The NGA is too much of a burden for many patients □ NGA was performed to a limited extent because many patients had low health literacy or due to a Nephrology department to involve geriatrics/elderly care in routine care □ Multidisciplinary consultation and reports in which NGA outcomes and treatment policy were discussed □ Support from other disciplines (e.g.dietitian, social worker) in the administration and interpretation of NGA □ Loss of geriatric knowledge and practical skills (for example due to team changes) □ Item S2: Post-implementation survey amongst health care professionals Translated from Dutch.[Voorend et al., Implementation of geriatric assessment in CKD care; a quality improvement initiative] carrying out the NGA □ Lack of budget is a reason to carry out NGA less often or adequately.□ The sum-score forms in the dashboard (available from July 2020) were helpful □ Q22 Do you have any additional explanation about reasons for successful or limited implementation?(optional) ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ Item S2: Post-implementation survey amongst health care professionals Translated from Dutch.[Voorend et al., Implementation of geriatric assessment in CKD care; a quality improvement initiative] Page 13 of 14 Q23 What are the 3 most important for limited and successful implementation of NGA in your hospital?Choose from the above reasons or fill in yourself.Please drag the reasons to the boxes.
Perhaps adjustments to the test set is possible, depending on the patient and the hospital setting, e.g.targeting other languages, level of health literacy, or use of The 6-CIT versus The MoCA. (nurse practitioner)

Block: Consent Polder Evaluation: Implementation NGA
How relevant are the specific instruments from the test set for your role in kidney patient care?(Please fill in your judgment and motivation) ________________________________________________________________ ________________________________________________________________ Item S2: Post-implementation survey amongst health care professionals Translated from Dutch.[Voorend et al., Implementation of geriatric assessment in CKD care; a quality improvement initiative] □ Q13 Could you briefly elaborate your answers?(optional) Who are the key people?Why do you support the NGA, or not?What is your motivation for performing the NGA? [Voorend et al., Implementation of geriatric assessment in CKD care; a quality improvement initiative] Q15 Could you briefly elaborate your answers?(optional) If the nephro-geriatric assessment is not easy to integrate; Why not?Why does NGA disrupt working relationships?What do you run into?What additional support would you need to make NGA implementation feasible?How relevant, necessary and complete did you find the training?[Voorend et al., Implementation of geriatric assessment in CKD care; a quality improvement initiative] □ Q13 Could you briefly elaborate your answers?(optional) Who are the key people?Why do you support the NGA, or not?What is your motivation for performing the NGA? ________________________________________________________________ ________________________________________________________________ Item S2: Post-implementation survey amongst health care professionals Translated from Dutch.[Voorend et al., Implementation of geriatric assessment in CKD care; a quality improvement initiative] Q15 Could you briefly elaborate your answers?(optional) If the nephro-geriatric assessment is not easy to integrate; Why not?Why does NGA disrupt working relationships?What do you run into?What additional support would you need to make NGA implementation feasible?How relevant, necessary and complete did you find the training?________________________________________________________________ ________________________________________________________________ Item S2: Post-implementation survey amongst health care professionals Translated from Dutch.[Voorend et al., Implementation of geriatric assessment in CKD care; a quality improvement initiative] Q17 Could you briefly elaborate your answers?(optional) If colleagues do not agree with the NGA, where is the discussion?If NGA is worth it, what are the most important points of added value?What adjustments to the NGA would you like? ________________________________________________________________ ________________________________________________________________ End of Block B: integration in routine care (NoMAD questionnaire) [Voorend et al., Implementation of geriatric assessment in CKD care; a quality improvement initiative] [Voorend et al., Implementation of geriatric assessment in CKD care; a quality improvement initiative] Q17 Could you briefly elaborate your answers?(optional) If colleagues do not agree with the NGA, where is the discussion?If NGA is worth it, what are the most important points of added value?What adjustments to the NGA would you like? ________________________________________________________________ ________________________________________________________________ End of Block B: integration in routine care (NoMAD questionnaire) [Voorend et al., Implementation of geriatric assessment in CKD care; a quality improvement initiative] [Voorend et al., Implementation of geriatric assessment in CKD care; a quality improvement initiative] [Voorend et al., Implementation of geriatric assessment in CKD care; a quality improvement initiative]

File 2: Supplementary Tables and FiguresTable S1 :
Choose from the above reasons or fill in yourself.Please drag the reasons to the boxes.Constructs of integration in work routines, assessed with the NoMAD tool.
[Voorend et al., Implementation of geriatric assessment in CKD care; a quality improvement initiative] Page 14 of 14 [Voorend et al., Implementation of geriatric assessment in CKD care; a quality improvement initiative] [Voorend et al., Implementation of geriatric assessment in CKD care; a quality improvement initiative] [Voorend et al., Implementation of geriatric assessment in CKD care; a quality improvement initiative.] 1 Supplement a Refers to the questions as shown in Figure 2. b Refers to the questions as shown in Supplemental file 2. [Voorend et al., Implementation of geriatric assessment in CKD care; a quality improvement initiative.] 2

Table S2 :
Implementation outcomes per center

Table S4 :
Determinants of implementation identified in qualitative analysisDue to the POLDER study we recognize the importance[of NGA]for this older patient group and that is why we have set up a [nephrology]geriatric committee with a geriatrician and psychiatrist.(nursepractitioner)NGA is carried out for patients with kidney failure, not yet started on dialysis.I myself am not involved further and it doesn't impact my profession.Neither are my dialysis colleagues involved in the screening.Most of them don't even know about NGA.NGA] helps us to get a better picture of a patients activities of daily living.Sometimes it helps when making KRT decisions or to dispel doubts.(nursepractitioner)Due to NGA we have a more objective picture [of a patient], previously our point of departure was instinct our "gut feeling".As a social worker I can give support to issues which are relevant within my discipline such as burdened caregiver, social isolation.Importantly, the decision making process can be impacted by NGA outcomes (social worker) In critical cases it [NGA] plays a role in decision making about whether to start or not to start KRT.We don't really know as yet how the treatment is influenced, what is reversible and what is not.Key figures are the ones who perform the assessment.They are responsible for feedback to the multidisciplinary team.(socialworker)I was given enough time to perform NGA (particularly for the POLDER study).However I am alone and if we want to implement this [NGA] into daily practice then more colleagues are needed.The demand to carry out NGA is increasing.(nephrologynurse)Isupport the NGA and perform it too because firstly, it offers the patient and their family better support and coaching.Secondly, it gives a lot of information about the expected treatment, degree of frailty and expected care level and prognosis.(nursepractitioner)Inthemeantime,morefrequently geriatric assessment is requested for patients from the out-patients kidney failure clinic.We would like to see that it [NGA] becomes part of routine care.The nephrologists support the NGA and requests are becoming more frequent.(nurse)TheNGAisintegratedintothe outpatient clinic workflow and care pathway.(nursepractitioner)Over the past few years NGA has become more integrated into our workflow, including patients who do not participate in a study.Referral on to the geriatrician after NGA occurs regularly.The conversation with the patient and their family about KRT choice is more validated.(nursepractitioner)Thediscussion[amongstHCW]is due to the overlap [of tasks] with other disciplines, e.g.social worker: what is the difference between NGA and PROMS or a well-being measure?Can another discipline carry out NGA, e.g. a nurse.The initial training was certainly relevant, the intention was to repeat the training and the proficiency test because of the risk of faulty routine setting in.But also to carry out work visits to exchange experience with other hospitals.(nursepractitioner)Thekeyfiguresonthe nephrology plus outpatients clinic are the nurses, unfortunately they are given too little time to perform their work properly and this is a recurrent issue which is discussed at meetings with the unit coordinator.(geriatricnurse)Themostimportantmissingresources are time and manpower, and shortage of dialysis nurses is the most pressing because they are needed on the kidney failure outpatients clinic.(geriatrician)Q28Q29During the POLDER study it became clearer what the benefits of the questionnaires, the tests, the results and extra information meant.This was all discussed at the multidisciplinary meetings.And we experienced an increasing awareness of the added value of NGA and the improvements due to consultation with the geriatrician.(nursepractitioner)Therewashowever long term leave of absence of one HCW and that left us with only one other person who could do NGA which made things more complicated.(nursepractitioner)Reflexivemonitoring[Voorendet al., Implementation of geriatric assessment in CKD care; a quality improvement initiative.]notaware of any studies which compare the value of NGA versus the judgement/appraisal of an experienced nephrologist whether dialysis is beneficial for the individual patient.(nephrologist)Theimportance of performing CGA or NGA is no longer a under discussion at the geriatric out-patient clinic because we already have proof of its value, also its value in oncology.(geriatricnurse)Communal appraisal Some noticed more demand for NGA, and improvement of multidisciplinary cooperation due to NGA.But the value is not seen by everyone; mostly due to needed time-investments, burden for patients, or lack of concrete outcomes.Colleagues do not always regcognise the value [ofNGA] and only see the disadvantages: the extra time it costs for patients and family.(nephrologist) Colleagues are searching for more tangible outcomes and the effect on treatment choice [of NGA results] as it's not a straightforward choice, only in extreme outcomes.(nephrologist) Colleagues from geriatrics do see the added value [of NGA] because they have experienced it in other combinations e.g.orthopedicgeriatric care; some nephrology colleagues see the added value and some recognize the limitations and time investment.(geriatrician) Individual appraisal Most respondents value the effects of NGA; i.e. holistic view on frailty, improved patient-conversations and personalized care.But some noted to see no clear effect of NGA.There is no clear feedback and especially indisputable advice other than a summing-up of results.In practice this [NGA] contributes sporadically to decision making, whereby this information [decision about KRT] was already known prior to evaluation (nephrologist) I find it an important part of patient assessment and for individualized tailored care to support treatment choice.However it isn't as yet being performed with every patient who is eligible.(nephrology nurse) The added value is we have more insight than merely medical facts.(nephrologist) Reconfiguration Some parts of NGA may not fit all patients, need for adjustments for illiterate non-Dutch speaking persons.Further development of NGA is needed said some; e.g. through multidisciplinary team meetings, availability of geriatrics, potential use of shorter screening tool for full NGA.
[Voorend et al., Implementation of geriatric assessment in CKD care; a quality improvement initiative.] Q21 Q22 To a degree, it disrupts work relationships because other specialists (geriatrician) discusses nephrology related treatments with the patient.I don't know precisely how these discussions go, particularly if a patient has questions [about KRT], are they then referred to the nephrologist with their questions?(nephrologist)