Best–Worst Scaling as a Values Clarification Method within a Decision Aid for Kidney Treatment Decision Making

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Background: Best–worst scaling (BWS) has been increasingly used as a values clarification method to help patients make value-concordant decisions. However, evidence on its use remains limited. Objective: To examine 1) the association between BWS-derived treatment preference scores and patients’ stated and real-world treatment choices and 2) whether BWS-identified best-match treatments were concordant with treatment choices among older adults with end-stage kidney disease (ESKD). Methods: We conducted a prospective study among patients aged ≥70 y with incident ESKD in Singapore at the time of decision making. During a renal counseling session with a decision aid, participants completed 2 BWS exercises to clarify values related to treatment choices (dialysis vs kidney supportive care [KSC] and hemodialysis vs peritoneal dialysis). BWS responses were scored by assigning preference weights to treatment-related attributes and aggregating them into continuous treatment preference scores for each treatment option. Logistic regression assessed associations between dialysis preference scores and postcounseling preference for dialysis and dialysis initiation at 6 mo. Concordance was assessed by comparing the BWS-derived best-match treatment, postcounseling preferred treatment, and real-world treatment choice at 6 mo using the Stuart–Maxwell test. Results: Twenty-three patients were enrolled (mean age 77.9 ± 4.7 y; 65% male). Higher BWS scores favoring dialysis were associated with greater odds of preferring dialysis after counseling (odds ratio = 1.31; P = 0.018) and initiating dialysis at 6 mo (odds ratio = 1.41; P = 0.012). For the dialysis and vs decision, the Stuart–Maxwell test indicated no significant differences; 70% selected ( P = 0.70) and 65% initiated ( P = 0.26) a treatment concordant with the BWS-derived best-match option. Conclusions: This study provides preliminary evidence that BWS-based values clarification is associated with treatment preferences and subsequent real-world treatment initiation among older adults with ESKD.

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