Factors influencing access to education, decision making, and receipt of preferred dialysis modality in unplanned dialysis start patients

Abstract

ObjectivesUnplanned dialysis start (UPS) leads to worse clinical outcomes than planned start, and only a minority of patients ever receive education on this topic and are able to make a modality choice, particularly for home dialysis. This study aimed to determine the predictive factors for patients receiving education, making a decision, and receiving their preferred modality choice in UPS patients following a UPS educational program (UPS-EP).MethodsThe Offering Patients Therapy Options in Unplanned Start (OPTiONS) study examined the impact of the implementation of a specific UPS-EP, including decision support tools and pathway improvement on dialysis modality choice. Linear regression models were used to examine the factors predicting three key steps: referral and receipt of UPS-EP, modality decision making, and actual delivery of preferred modality choice. A simple economic assessment was performed to examine the potential benefit of implementing UPS-EP in terms of dialysis costs.ResultsThe majority of UPS patients could receive UPS-EP (214/270 patients) and were able to make a decision (177/214), although not all patients received their preferred choice (159/177). Regression analysis demonstrated that the initial dialysis modality was a predictive factor for referral and receipt of UPS-EP and modality decision making. In contrast, age was a predictor for referral and receipt of UPS-EP only, and comorbidity was not a predictor for any step, except for myocardial infarction, which was a weak predictor for lower likelihood of receiving preferred modality. Country practices predicted UPS-EP receipt and decision making. Economic analysis demonstrated the potential benefit of UPS-EP implementation because dialysis modality costs were associated with modality distribution driven by patient preference.ConclusionEducation and decision support can allow UPS patients to understand their options and choose dialysis modality, and attention needs to be focused on ensuring equity of access to educational programs, especially for the elderly. Physician practice and culture across units/countries is an important predictor of UPS patient management and modality choice independent of patient-related factors. Additional work is required to understand and improve patient pathways to ensure that modality preference is enacted. There appears to be a cost benefit of delivering education, supporting choice, and ensuring that the choice is enacted in UPS patients.

Impact of an in-Hospital Patient Education Program on Choice of Renal Replacement Modality in Unplanned Dialysis Initiation

“…A lack of a patient-centered, structured, education program seems to be a major obstacle regarding deployment of PD. Several studies support the central role of patient education in dialysis modality choice [17, 24, 25]. …”

Risk Factors for Unplanned Dialysis Initiation: A Systematic Review of the Literature

“…Eligible studies included incident chronic dialysis patients (n = 42) 2 - 4 , 6 , 8 , 9 , 13 - 48 and patients with CKD known to nephrology (n = 6). 5 , 49 - 53 Study designs included retrospective cohort studies (n = 27), 2 , 3 , 5 , 6 , 14 - 16 , 19 - 24 , 26 , 28 , 31 …”

“…13 No randomized control trials were found in the search. The majority of studies were conducted in Europe (n = 26; 22 unique cohorts) 2 , 8 , 9 , 15 - 19 , 22 - 25 , 29 , 30 , 33 , 36 , 40 - 43 , 45 - 48 , 50 , 51 ; 11 studies were conducted in North America 3 - 6 , 14 , 21 , 26 , 28 , 31 , 52 , 53 (Canada, n = 9; 8 unique cohorts). Study cohort sizes ranged from 43 to 45 785 persons.…”

Optimal start in dialysis shows increased survival in patients with chronic kidney disease

“…This definition integrates other requirements such as the coincidence in the registry of the treatment at 90 days. It would have been interesting to incorporate as a requirement the training and information of the patient on the available options for RRT [18–20]. Unfortunately, the database did not enable the identification or assessment of the training received by the patient.…”