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NDT Advance Access originally published online on April 29, 2008
Nephrology Dialysis Transplantation 2008 23(10):3206-3214; doi:10.1093/ndt/gfn207
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© The Author [2008]. Published by Oxford University Press on behalf of ERA-EDTA. All rights reserved. For Permissions, please e-mail: journals.permissions@oxfordjournals.org


Patients’ priorities for health research: focus group study of patients with chronic kidney disease

Allison Tong1,2, Peter Sainsbury2,3, Stacy M. Carter2,4, Bronwyn Hall2, David C. Harris5, Rowan G. Walker6, Carmel M. Hawley7, Steven Chadban8 and Jonathan C. Craig1,2

1 NHMRC Centre for Clinical Research Excellence in Renal Medicine, Centre for Kidney Research, Children's Hospital at Westmead, Westmead, NSW 2145 2 School of Public Health, University of Sydney, Sydney, NSW 2006 3 Centre for Population Health, Sydney South West Area Health Service, NSW 2050 4 Centre for Values, Ethics and the Law in Medicine, University of Sydney, NSW 2006 5 Department of Renal Medicine, Western Clinical School, Westmead Hospital, NSW 2145 6 Department of Nephrology, Royal Melbourne Hospital, VIC 7 Department of Nephrology, School of Population Health, University of Queensland, Princess Alexandra Hospital, QLD 8 Royal Prince Alfred Hospital, University of Sydney, NSW, Australia

Allison Tong, NHMRC Centre for Clinical Research Excellence in Renal Medicine, Centre for Kidney Research, Children's Hospital at Westmead, Westmead, NSW 2145, Australia. Tel: +61-2-98451482; Email: AllisonT{at}health.usyd.edu.au



   Abstract
Top
 Abstract
Introduction
 Subjects and methods
 Results
 Reasons underpinning...
 Discussion
 Appendix. Ranking exercises
 References
 
Background. The inclusion of consumer preferences in prioritizing research topics is widely advocated, but prioritization is driven largely by professional agendas.

Methods. Patients with chronic kidney disease (CKD) were purposively sampled from four kidney dialysis and transplant centres in Australia to participate in nine focus groups (three each for pre-dialysis, dialysis and transplant patients), which were conducted from July 2006 to September 2006. Each involved 6–8 participants. Transcripts were coded and thematically analysed to identify recurrent research topics and the participants’ reasons for their choices.

Results. Participants suggested eight research priorities: prevention of kidney disease, better access to and improvement in kidney transplantation, reduction of symptoms of CKD and complications associated with treatment, new technological therapies, psychosocial aspects of living with CKD, whole body not organ-specialized care, and improvement in dialysis and caregiver support. Five major reasons for the selections were identified: normalization of life (developing therapies and regimens that fit into daily living), altruism (considering the welfare of others before personal needs), economic efficiency (channelling resources for maximum economic gain), personal needs (preferences based on feelings, values, personal needs) and clinical outcomes (improving health states and the physiological condition of patients with CKD).

Conclusions. A patient-focused research agenda is possible to elicit for CKD, and by inference for other healthcare issues. Unlike researchers who focus on specific interventions and questions, consumers think in terms of broad themes and quality of life outcomes. Effective methods for translating a patient-focused agenda into research priority setting and resource allocation are now needed.

Keywords: chronic kidney disease; decision making; patient involvement; qualitative research; research priorities



   Introduction
Top
 Abstract
 Introduction
Subjects and methods
 Results
 Reasons underpinning...
 Discussion
 Appendix. Ranking exercises
 References
 
Health research is largely community funded and ostensibly aims to improve outcomes for consumers. The inclusion of consumer perspectives in research priorities is widely advocated, yet research priorities are largely driven by professional agendas [1–3]. Consumers are rarely given a role in this decision-making process and the preferred mechanisms for consumer involvement remain unclear [4,5]. Consequently, the limited resources for health research may be directed towards research that consumers do not value as highly as researchers [2].

The experiences and knowledge of patients can complement those of clinicians, health professionals and researchers [6]. Patient involvement in identifying and prioritizing research topics may make practice and policy more relevant to consumers’ needs, leading to outcomes that include greater patient satisfaction, improvement in treatment adherence, better acceptance of research findings and reduced risk of litigation [3,7].

Research to identify patient priorities for health research is scarce [5]. According to a recent systematic review, most studies have not reported explicit and comprehensive details on how patient priorities were obtained [5]. Only three studies, involving osteoarthritis, asthma and spinal cord injury, have identified treatment-related research priorities of patients [8–10]. To our knowledge, no studies have explored the underlying rationales for patients’ decisions on research priorities and no studies on research priorities of chronic kidney disease (CKD) patients are available.

This study was conducted to elicit priorities for research topics from patients who have CKD and to explore the reasons underlying their selection of research topics.



   Subjects and methods
Top
 Abstract
 Introduction
 Subjects and methods
Results
 Reasons underpinning...
 Discussion
 Appendix. Ranking exercises
 References
 
We conducted nine focus groups from July to September 2006. Each focus group lasted 2 h and was facilitated by one of the authors (S.C. or A.T.) who had had no contact with the participants before the study. One observer (B.H.) recorded field notes on group dynamics and interactions, participant characteristics, body language and the context surrounding the discussion. Ethics approval was obtained from the four institutions involved in the study (Princess Alexandra Hospital, Brisbane; Royal Prince Alfred Hospital, Sydney; Westmead Hospital, Sydney; and Royal Melbourne Hospital).

Participant selection
Patients were eligible to participate if they were English-speaking, 18–80 years of age, able to give informed consent and were in one of three CKD stages [diagnosed with CKD, but not currently needing dialysis (pre-dialysis patients), undergoing haemodialysis or peritoneal dialysis, and kidney transplant recipients]. We conducted three focus groups for each of the three patient types.

Participants were purposively sampled for each focus group to achieve equal numbers of male and female participants from a wide age range and various cultural backgrounds. For each focus group, eight participants were approached either face-to-face or by telephone and invited to participate by the recruiting nephrologist or by the primary investigator (A.T.). Participants were offered reimbursement for their time and transport expenses; three declined reimbursement.

Setting
The focus groups were convened in neutral locations external to the hospitals to encourage openness during discussion [11].

Data collection
We developed a list of preliminary questions, to pose to the focus groups, from a literature review and discussion among the research team. After input from 11 multi-disciplinary collaborators (nephrology, public health, health economics, qualitative research, social work and consumer representative), the schedule was finalized. Each focus group had three phases, preliminary questions about the participants’ experiences of CKD, specific questions about the participants’ research priorities and an exercise for the participants to rank priorities for research.

To maximize participant engagement, an activity was developed [12] for the third phase of the focus group that enabled participants to allocate ‘money’ between competing research priorities. For each of five ranking exercises, participants were given a sheet of paper on which were listed several research topics (see the appendix). Ten counters (each representing one million dollars) were provided to each participant. The facilitator explained, ‘There is a limited amount of money and resources for research and decisions have to be made. Please distribute your money to the different research topics written on the sheet of paper, and think about how you are making those decisions. Also, please add topics that you think should be included but are not listed on the paper.’ We were not seeking consensus or a quantitative score for each list. Rather, we were aiming to understand how participants came to allocate resources, and to record their interactions around their allocations. For this reason, we encouraged debate and allowed participants to change their distribution of money during the discussion. All sessions were digitally audio-recorded and transcribed in full.

Analysis
The transcripts were entered into QSR Nvivo 7, a software program used to assist with storage, coding and searching of data. The transcripts were reviewed line-by-line by a single author (A.T.) who searched for concepts, themes and ideas, and developed a preliminary coding scheme. Transcripts were read and coded by three authors independently (A.T., B.H., P.S.) who compared and discussed their individual coding choices. Any disagreements were resolved by discussion. The coding scheme was revised based on these discussions to develop a final coding structure that adequately captured desired and relevant information. Through a process of careful analysis and comparisons (between individuals and groups), we inductively developed two categories of descriptive themes from the data. The first category of themes examined the research priorities expressed by the participants. The second category differentiated the ways in which participants explained their research prioritizations, i.e. the reasons for their choices.

A summary of our preliminary findings was mailed to the study participants in June 2007, to enhance the developing analytic framework and to ascertain whether the account made sense to participants with different perspectives. We received feedback from 18 out of 63 participants. Participants appreciated the summary and some commented further on their individual priorities, suggested that the summaries should be sent earlier and requested information on how the study would make an impact on the research agenda.



   Results
Top
 Abstract
 Introduction
 Subjects and methods
 Results
Reasons underpinning...
 Discussion
 Appendix. Ranking exercises
 References
 
The nine focus groups involved 63 participants (88% attendance rate), aged from 20 to 78 years (mean 52.3 years); 30 (48%) were male. Of the 63 participants, 50 (79%) were Caucasian and 13 were from nine different national backgrounds. Reasons for non-attendance included work commitments, illness-related problems and difficulty in arranging transport.

The participants valued the opportunity to engage with one another. Participants shared their experiences of coping with their illness, and the facilitators were careful to ensure that they were able to achieve this goal in the group. However, participants also engaged enthusiastically with the issue of research priorities. Participants suggested a wide range of topics and desired research outcomes based on their experiences, what was important to them and what they thought could be improved.

Research priorities
From the analysis of transcripts and field notes, we identified eight main research areas that participants nominated as priorities (Table 1). Additional quotes for each research topic are provided in Table 2.


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  		Table 1 Research priorities elicited from patients with chronic kidney disease

 

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  		Table 2 Quotations to illustrate the nine research topics identified

 
Prevention
Primary and secondary prevention of CKD were nominated frequently as the highest priority in all focus groups. The participants were averse to undergoing dialysis and transplantation and frequently stated that prevention was of higher priority than treatment or a cure. For prevention of CKD, participants suggested that research should focus on raising the public profile of CKD in the community, health promotion and discovering the causes of CKD.
I would like them to try and stop the renal disease becoming so prevalent. (Female, 50s, transplant)

Research on screening for detecting CKD and non-medical treatments of early CKD such as lifestyle factors, including dietary control and complementary medicines, and devising ways of putting the disease into remission were all identified as priority areas.

Complications and symptoms
Research to reduce complications and symptoms relating to CKD and the side effects of dialysis and transplant treatment were very important to the participants. They described a range of symptoms, complications and side effects that they experienced personally including cancer, heart disease, bone disease, fatigue, cramping and vomiting. All groups discussed the importance of research focused on eliminating the need for immunosuppressants and developing better treatments to reduce symptoms and complications.

Transplantation
While most participants perceived quality of life to be better after transplantation compared with dialysis treatment, some expressed a preference for dialysis. Rather than face the uncertainty and trauma of kidney rejection and immunosuppression, the minority favoured the predictability of the dialysis routine once they learned to integrate the regimen into their lifestyle. All participants recognised the current limitations and problems in transplantation (e.g. graft rejection, immunosuppression, lack of donors) and felt that research should aim to increase the availability of organs and donor numbers, reduce the time spent on the kidney transplant waiting list, improve matching between patients and donors, prolong graft survival and reduce post-transplantation drugs. Although xenotransplantation was discussed, it was considered of low priority due to the high risk of infection.

Technological solutions
Participants wanted current treatment to be revolutionized; they did not want to undergo dialysis, take immunosuppressants and depend on a donor for a kidney. Stem cell research, cloning and developing mechanical kidneys were considered important topics to include in the research agenda. Some participants wanted research to deliver an alternative to needles and the pain of dialysis.

Psychosocial needs and support
The need for more research on psychological and social support was discussed frequently. The participants felt that health professionals often overlooked the range of mental health and social problems prevalent in the CKD population. More specifically, the key issues they believed could be improved related to depression and poor coping, employment (how to re-enter the workforce, seek employment and improve employers’ understanding towards CKD patients), information needs and strengthening the family relationship.

Some patients who had received or were going to receive a transplant from a living donor faced tension within the donor–recipient relationship. For example, some felt obliged to accept a living donor kidney from their relative, at the same time feeling apprehensive about the health risks they felt they were imposing on that donor and about taking on the significant burden of being responsible for maintaining the donor's kidney. The following interaction highlights the anguish that occurs with the loss of a donated kidney.

But we were both incredibly sad [after the kidney was rejected], that was what hit the most, it's that dealing with losing that was harder for me than going on dialysis, because then I thought I did something wrong, and she gave me a gift. (Female, 40s, dialysis)

It's like you broke her present. (Female, 20s, dialysis)

Whole body care
Some participants felt that clinicians tended to narrow their focus to individual health issues, rather than broadly examining and managing the problem as a whole. They believed that health professionals needed to approach health research holistically and recognize the interdependence of health problems including heart disease, diabetes, obesity and lupus.

I think that's sometimes partly the problem, that they’re not actually looking at the whole picture...I don't think it's easy to separate research on blood pressure, diabetes and heart disease etcetera because they’re so inextricably linked. (Female, 40s, predialysis)

Dialysis
Dialysis was reported to be a time-consuming and sometimes painful process that interfered with lifestyle and reduced quality of life. The participants identified many areas for improvement in both haemodialysis and peritoneal dialysis treatment. They wanted machines to be less cumbersome and easier to operate and treatment to consume less time. Participants who had experienced dialysis believed it was important to improve vascular access into the bloodstream and the medication required while on dialysis.

There are lots of problems and lots of ways that [dialysis] could be improved like the big drama of getting access to the bloodstream. (Female, 60s, dialysis)

Caregiver support
As CKD patients, the participants experienced the personal effects of the disease but they were also aware that CKD had a devastating impact on caregivers. Some described the trauma, emotional stress, feelings of neglect and poor coping of their partners or other family members who had to take on care-giving responsibilities. The participants suggested that it was important for research to focus on addressing caregiver needs and support.



   Reasons underpinning participants’ research priorities
Top
 Abstract
 Introduction
 Subjects and methods
 Results
 Reasons underpinning...
Discussion
 Appendix. Ranking exercises
 References
 
We identified five reasons that participants used to explain their choice for research topics: normalization of life, altruism, economic efficiency, personal concerns and clinical outcomes (Table 3). The five reasons were not mutually exclusive; some choices for research topics were supported by more than one reason.


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  		Table 3 Reasons underpinning research theme prioritization with supporting quotations

 
Normalization of life
Developing therapies and treatment regimens that fit in with other aspects of daily living was important for participants. The diagnosis of CKD and the intensive, technically demanding regimen of dialysis disrupted participants’ lifestyles. The need for normality was more apparent in pre-dialysis and dialysis participants than transplant participants; transplantation allowed most participants a higher degree of normality and independence. A desire to reclaim a sense of normality frequently underpinned participants’ choices for research into better and more compact dialysis machines.
I think if they can sink money into improving the dialysis and making it so that it works better and frees you up then that's good enough for me. (Male, 50s, dialysis)

Altruism
We coded as ‘altruism’ any talk in which participants identified research topics based on the consideration of the welfare of others, over and above the participants’ individual needs as a patient. In making decisions on which research topic was of higher importance, the tension of wanting both personal and population benefit posed difficulties for the participants. However, altruism was consistently observed across all three types of participant groups. The participants agreed that the reason research on prevention should be highest priority was because it would benefit the community and future generations.

Even though I’m in the dialysis stage, I think it's more important to focus on the others. (Female, 20s, dialysis)

Also, participants considered the well-being of living donors and insisted that research focus on developing a cure or improving treatment so there would be no requirement for potential donors to jeopardize their own health by donating their kidney.

It isn't worth someone going through what they have to go through to give a kidney. (Female, 30s, predialysis)

Participants thought that research to understand the psychosocial issues faced by patients was important because it would benefit patients undergoing, or about to undergo, similar experiences.

I think we need to learn more about the experiences of people like ourselves who’ve gone through the same thing, and that information needs to be passed on and gathered, and put to better advantage so that we can help others. (Male, 50s, transplant)

Economic efficiency
We coded as ‘economic efficiency’ any talk about channelling the available resources for maximum effectiveness or getting the best value for the money. Participants considered the long-term economic benefits and cost of conducting research when prioritizing their choices for research. For example, they agreed that resources would be better channelled towards research on prevention and transplantation than dialysis, which was perceived to be a less cost-effective treatment.

I think the main aim is to keep people off dialysis so if you’ve got a transplant, the aim is to keep it operating for as long as you can ... dialysis is just so expensive. (Male, 60s, transplant)

Personal concerns
We coded as ‘personal concerns’ any talk in which preferences, feelings and values were given as reasons for participants’ decisions on research topics. The participants themselves recognized that their own individual experiences and emotions often influenced their choices in a range of research areas. Personal concerns were linked to a range of research topics including complications, transplantation, psychosocial needs and support, technological solutions and whole body research.

I wish there was a better alternative to what's currently available. In terms of research in the dialysis area, something that doesn't take a lot more time but something that is not as cumbersome as I expect it to be and probably a lot more comforting. I think comforting is the key issue I’m looking for right now. (Male, 50s, predialysis)

Participants diagnosed with CKD and who had not received dialysis treatment or transplantation felt that they were not being looked at holistically and emphasized the importance of the need for collaborative research across medical disciplines. During this earlier stage in the illness trajectory, the personal importance of other illnesses and problems (e.g. heart disease, diabetes, blood pressure, lupus) was comparable in magnitude to kidney disease. However, in the later stages, kidney disease became the dominant illness in the participants’ lives.

Clinical outcomes
We coded as ‘clinical outcomes’ any talk in which participants suggested research topics to improve clinical outcomes and the physiological condition of the people diagnosed with CKD. Participants’ knowledge of the clinical outcomes (e.g. risk of mortality, morbidity and adverse effects) influenced their choice of topics particularly within the area of complications and transplantation.

I think heart disease in chronic kidney disease is quite important because of the calcifications, because of the prednisolone (immunosuppressant) we were taking all those years ago, I think it's terribly important because it can cause the calcification in your valve, in your arteries etcetera and I do find that quite important. (Female, 60s, transplant)



   Discussion
Top
 Abstract
 Introduction
 Subjects and methods
 Results
 Reasons underpinning...
 Discussion
Appendix. Ranking exercises
 References
 
Patients with CKD had eight priority areas for research: preventing CKD, reducing complications and symptoms, improving access to and outcomes of kidney transplantation, developing better technological solutions, developing better understanding of psychosocial needs, improving whole body care, improving dialysis treatment and developing caregiver support. Some of these priorities were not unexpected and perhaps overlap with professionally driven priorities, but we were able to demonstrate that elicitation of patients’ research priorities was feasible, and a coherent and comprehensive list of research priorities could be obtained. Many differences between a clinician-researcher and patient-generated list of topics are apparent. Patients think more broadly, are more thematic and focus on outcomes. Clinician-researchers think more mechanistically and focus on specific questions and interventions. How healthcare should be delivered, both to the patient and the caregivers, in a holistic way matters to patients, but appears not to be a priority of research funders who promote discovery-type and pharmacological research preferentially. Specifically, participants did not identify understanding disease processes as a priority topic, which underpins much basic scientific research. Only basic science, which has a reasonable chance of contributing to better clinical outcomes, is implicitly valued. In contrast, the disciplines of health services research and qualitative research are implicitly needed if these priorities are to be realized.

A significant and novel contribution of this work is the identification of five reasons that patients used to develop their research priorities (normalization of life, altruism, economic efficiency, personal concerns and clinical outcomes). This aspect of patient's research prioritization has not been reported previously. It provides a framework for understanding the factors that influence patients’ decisions about research priorities, and is transferable to all healthcare topics and not limited to kidney disease. By generating these five reasons, participants in our study have explicitly demonstrated that they understand the inevitable tensions in research, such as between the good of the individual and the good of society. They have shown that they understand the values attached to good clinical outcomes that may vary across individuals. The recognition of economic efficiency in research is an important observation. Usually limited to allocation of competing interventions into clinical practice, our participants recognized that opportunity cost applied equally to research funding. Criteria for research funding, such as those specified in grant assessment criteria of major funding bodies [3–15], are typically weighted to the research productivity of the individual, which can be and is quantified. Our participants have advocated for a similar quantitative approach to the potential benefit of a study by trading off the cost of the study with the potential health gain. Usually this is captured under the domain of ‘significance’ but this is not explicitly quantitative nor does it have an economic perspective. Given the scarce resources of healthcare research, it should be.

Despite the policy of all major international research funding agencies to include consumers in the process of setting priorities for research [16–20], there are very sparse data on how this can be achieved. A recent bibliography identified 96 reports relating to patients’ priorities for research or health outcomes [21]. Almost all studies have focused on patient preferences for treatment, but we identified three that specifically explored the patients’ research priorities. Similar to these studies, patient priorities were expressed by patients in terms of general research areas, including better medication to reduce side effects, prevention and psychosocial interventions. However, these studies did not provide insights into patient's reasoning about research priorities.

The agenda for health research is influenced by factors beyond the patients' reasons we identified. Researcher and reviewer interests, study feasibility, innovation, quality of the methods and ethical considerations influence both government and non-government funding for research. Commercial interests also affect decisions about what research should be funded; a significant amount of health research is sponsored by industry who often have an investment strategy embedded in studies designed to maximized profits [22,23]. These considerations are not necessarily inappropriate, simply incomplete. Including patient perspectives can broaden the research agenda and help to ensure that the limited resources are channelled towards research that optimizes the mix of benefits.

Our study demonstrates that if the right research methods are employed, the patients’ priorities for research can be elicited. These participants provided a set of research priorities and ways of reasoning that run parallel to, complement and may be quite different from the research priorities and means of reasoning used by other stakeholders, including governments, industry, health professionals and researchers. Health professionals and researchers draw on their own unique cultural norms and expertise when they construct research questions. They are informed by medical knowledge and the conventions of scientific inquiry, including the need to specify, in technical language, particular problems regarding aetiology, disease progression or intervention and management to investigate [24–26]. In contrast, these participants spoke in general terms and related research to hoped-for improvement to their own and others’ quality of life. This is unsurprising as it resonates with other findings concerning lay knowledge of health issues. We all use personal experiences, views about ourselves and others, and an in-depth understanding of the circumstances and social context in which we live to produce sophisticated and idiosyncratic frameworks of knowledge about our health and other aspects of our lives [27–29]. What has been missing, and what this study aims to provide, is a conduit through which these different ways of setting research priorities can influence one another.

Innovative methods are needed to better engage patients in agenda setting, rather than involving them in the same way as health professionals. We have demonstrated that focus groups and mock funding allocation exercises are feasible and productive and we encourage others to use similar methods for identifying priorities across different health conditions. Citizen juries provide a more deliberative approach, which, despite their added cost, may produce more sophisticated results. More detailed exploration of the patients’ reasons for choosing particular research priorities may, however, require in-depth face-to-face interviews, perhaps following involvement in a focus group or citizens’ jury. To be provocative, however, we would also contend that the inclusion of consumers in grant review panels for health research is a tokenistic approach. This study has demonstrated the richness and range of understanding that can come from engagement with the patients’ personal experiences of a particular illness. It is unlikely that a single ‘consumer’ on a panel could ever be adequately equipped to offer this depth and breadth of insight. Well-designed and reported qualitative research about priorities across a range of research areas would provide a more methodologically sound route for incorporation of lay knowledge into funding allocation decisions. The principles of reasoning generated in this study—normalization of life, altruism, economic efficiency, personal concerns and clinical outcomes—have particular potential: secondary analytic work across a large number of qualitative studies such as this one may, in the future, produce principles of reasoning that could be applied across research areas.

Although this study was conducted with CKD patients from four centres, the findings are applicable and transferable across settings and health disciplines. A patient-focused research agenda was possible to develop, was thematic and the outcomes were focused and could be used to refine and prioritize specific topics proposed by health-related researchers. The five reasons underlying the patients’ research priorities demonstrate that they understand the tensions in prioritizing research, the variation in disease course and clinical outcomes between patients and recognize that opportunity cost applies to research funding. Decision-making processes for selecting research topics should be made explicit. This study presents a model by which these decisions can incorporate consumer values and perspectives, facilitate active and effective consumer participation and avoid tokenism.



   Appendix. Ranking exercises
Top
 Abstract
 Introduction
 Subjects and methods
 Results
 Reasons underpinning...
 Discussion
 Appendix. Ranking exercises
References
 
Research about the:
pre-dialysis stage of chronic kidney disease

dialysis stage of chronic kidney disease

transplant stage of chronic kidney disease

Research that aims to:
discover the causes of chronic kidney disease

help to prevent chronic kidney disease

lead to better diagnosis of chronic kidney disease

improve treatment for people with chronic kidney disease

understand the experiences and needs of people with

chronic kidney disease

Research that aims to:
understand how chronic kidney disease works in the body

discover more effective treatments for chronic kidney disease

prevent chronic kidney disease in the community

help clinicians and hospitals to provide better services to

people who have chronic kidney disease

Research about:
bone disease in chronic kidney disease

cancer in chronic kidney disease

blood pressure in chronic kidney disease

anaemia in chronic kidney disease

heart disease in chronic kidney disease

nutrition in chronic kidney disease

Research that aims to help:
children with chronic kidney disease

adolescents with chronic kidney disease

young adults with chronic kidney disease

middle-aged adults with chronic kidney disease

older adults with chronic kidney disease



   Acknowledgments
 
A.T. is supported by a NHMRC Postgraduate Scholarship (Public Health) and a Centre for Clinical Research Excellence in Renal Medicine scholarship. Kidney Health, Australia, provided funding for this study. We would like to thank all the nephrologists and patients from Westmead Hospital, Royal Prince Alfred Hospital, Princess Alexandra Hospital and Royal Melbourne Hospital, who participated in the study.

Conflict of interest statement. None declared.



   References
Top
 Abstract
 Introduction
 Subjects and methods
 Results
 Reasons underpinning...
 Discussion
 Appendix. Ranking exercises
 References
 

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Received for publication: 13. 2.08
Accepted in revised form: 20. 3.08


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