Value-based evaluation of dialysis versus conservative care in older patients with advanced chronic kidney disease: a cohort study

Verberne, Wouter R; Dijkers, Janneke; Kelder, Johannes C.; Geers, A. B. M.; Jellema, Wilbert T.; Vincent, H. H.; Delden, Johannes J. M. van; Bos, Willem Jan W.

doi:10.1186/s12882-018-1004-4

Cited by 52 publications

(97 citation statements)

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“…Those over the age of 75 make up 22% of all patients on dialysis in Australia [2], and figures are similar elsewhere (USA -20%, UK -16% and Japan -31%) [3][4][5]. Elderly patients on dialysis, particularly if they have comorbidities, may not survive for long periods or have a good quality of life [6,7]. This suggests that comprehensive conservative or supportive care, without dialysis, may be a valuable treatment pathway for such patients.…”

Section: Introductionmentioning

confidence: 99%

Enabling good outcomes in older adults on dialysis: a qualitative study

et al. 2020

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Background: Older patients on dialysis may not have optimal outcomes, particularly with regards to quality of life. Existing research is focused mainly on survival, with limited information about other outcomes. Such information can help in shared decision-making around dialysis initiation; it can also be used to improve outcomes in patients established on dialysis. We used qualitative research methods to explore patient perspectives regarding their experience and outcomes with dialysis. Methods: Semi-structured interviews with participants aged ≥70, receiving dialysis at a regional Australian hospital, were recorded and transcribed. From participants' responses, we identified descriptive themes using a phenomenological approach, with verification by two researchers. Factors affecting outcomes were derived reflexively from these themes. Results: Seventeen interviews were analysed prior to saturation of themes. Participants (12 on haemodialysis, 5 on peritoneal dialysis) had spent an average of 4.3 years on dialysis. There were 11 males and 6 females, with mean age 76.2 years (range 70 to 83). Experiences of dialysis were described across four domains-the self, the body, effects on daily life and the influences of others; yielding themes of (i) responses to loss (of time, autonomy, previous life), (ii) responses to uncertainty (variable symptoms; unpredictable future; dependence on others), (iii) acceptance / adaptation (to life on dialysis; to ageing) and (iv) the role of relationships / support (family, friends and clinicians). Conclusions: Older patients experience the effects of dialysis across multiple domains in their lives. They endure feelings of loss and persistent uncertainty, but may also adapt successfully to their new circumstances, aided by the support they receive from family, health professionals and institutions. From these insights, we have suggested practical measures to improve outcomes in older patients.

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Section: Introductionmentioning

confidence: 99%

Enabling good outcomes in older adults on dialysis: a qualitative study

et al. 2020

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“…These findings suggest that a conservative care pathway could reduce the treatment burden and hospital costs associated with resource-intensive care that may not be aligned with a patient's values and preferences. Value of care could therefore be generated in selected older patients with conservative care as alternative to dialysis considering its previously recognized potential to achieve reasonable patient-relevant outcomes, such as survival and healthrelated quality of life [8][9][10][11][12][13], in balance with treatment burden and costs. This emphasizes the need for a shared decision-making process on preferred treatment for endstage kidney disease that focuses on what matters to the patient.…”

Section: Discussionmentioning

confidence: 99%

“…We identified a retrospective cohort of all patients aged ≥70 years old with stage 4/5 chronic kidney disease who received nephrology care in a nonacademic teaching hospital between January 1, 2008, and May 1, 2016, based on a previous cohort [10,11]. Patients were included if they had made a decision to be treated with conservative care or dialysis after a shared decision-making process (original treatment decision).…”

Section: Study Populationmentioning

confidence: 99%

“…Emerging observational studies showed that dialysis may not prolong life or improve health-related quality of life compared to conservative care in selected older patients, particularly in the oldest patients and patients with multiple comorbidities [8][9][10][11][12][13]. Treatment pathways as conservative care that have the potential to achieve reasonable health outcomes could also reduce the treatment burden and costs associated with resource-intensive care that may not be aligned with a patient's values and preferences [14].…”

Section: Introductionmentioning

confidence: 99%

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Hospital Utilization and Costs in Older Patients with Advanced Chronic Kidney Disease Choosing Conservative Care or Dialysis: A Retrospective Cohort Study

et al. 2020

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Background: Nondialytic conservative care has been recognized as a viable alternative to chronic dialysis in older patients with end-stage kidney disease, but little is known about its consequences on hospital utilization and costs. Methods: We performed a retrospective cohort study to compare outpatient and inpatient hospital utilization, place of death, and hospital costs in patients aged ≥70 years old who chose conservative care (n = 100) or dialysis (n = 162) after shared decision making in a nonacademic teaching hospital between 2008 and 2016. Results: Patients who chose conservative care were older than patients who chose dialysis (82.5 vs. 76.3 years). Comorbidity did not differ between the 2 patient groups. The incidence rates of outpatient visits per year were 7.1 in patients who chose conservative care and 10.7 in patients who chose dialysis (incidence rate ratio 0.67, 95% CI 0.55-0.81). The incidence rates of inhospital days per year were, respectively, 6.0 and 9.8 (incidence rate ratio 0.50, 95% CI 0.29-0.88). Also in the final month of life, patients on conservative care had less outpatient visits, were less frequently hospitalized, and died less frequently in hospital than the dialysis patient group. The cost rates per year, measured from original treatment decision, were EUR 5,859 in conservative care patients and EUR 28,354 in patients who chose dialysis comprising both the predialysis and dialysis period (cost rate ratio 0.42, 95% CI 0.27-0.65). Patients who chose dialysis had higher costs on dialysis sessions, outpatient care, inpatient care, laboratory tests, and medical imaging. Conclusions: Patients who decided to forego dialysis and chose conservative care had less outpatient and inpatient hospital utilization than patients who chose dialysis, including less intensive hospital utilization near the end of life. Both overall and nondialysis-related costs were lower in patients on a conservative care pathway.

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“…When it comes to treatment modality decision-making in AKD, no papers present a thorough overview of existing SDM interventions with evidence on any of their outcomes or novel developments in this field. Systematic reviews, including meta-analyses, have been written on: the perspectives of living with kidney failure19; factors influencing the decision-making process regarding treatment modalities for patients with AKD20–25; the readability of written materials for patients with chronic kidney disease (CKD)26 27; the effects of education and cognition of patients on SDM28–30; the validity of prognostic algorithms for this decision-making process31; advanced care planning32 33 and treatment outcomes in the elderly 34–38. Furthermore, a preliminary search in the PubMed, Medline, Embase, Web of Science, Cochrane Library, Emcare, International Prospective Register of Systematic Reviews (PROSPERO), PsycINFO and Academic Search Premier databases did not identify any scoping reviews on this subject.…”

Section: Introductionmentioning

confidence: 99%

Shared decision-making in advanced kidney disease: a scoping review protocol

Engels¹,

Graav

Nat

et al. 2020

BMJ Open

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Protocol © Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.Strength and limitations of this study ► The proposed scoping review will be the first paper to systematically search and map shared decisionmaking (SDM) interventions for treatment modality decisions in advanced kidney disease, evaluate the evidence on their reported outcomes and report on new developments or ongoing studies in this field. ► It will provide a comprehensive overview by collecting information from both quantitative and qualitative research, as well as the grey literature and key experts on SDM. ► Research in SDM is heterogeneous in its methodology and the reporting of outcomes; therefore a scoping review will be better suited to map, summarise and present this information than traditional systematic reviews or meta-analyses. ► Included studies will not undergo a formal quality assessment as scoping reviews attempt to provide an overview of all the existing evidence, regardless of its quality. ► Potentially relevant findings from papers written in other languages will be missed, as this study will only include papers written in English. AbStrACtIntroduction Patients with advanced kidney disease (AKD) have to make difficult treatment modality decisions as their disease progresses towards end-stage kidney disease. International guidelines in nephrology suggest shared decision-making (SDM) to help patients make timely treatment modality decisions that align with their values and preferences. However, systematic reviews or scoping reviews on these SDM interventions and on their reported use or outcomes are lacking. This limits the adoption of SDM in clinical practice and hampers further research and development on the subject. Our aim is to provide a comprehensive and up-to-date overview of these SDM interventions by means of a scoping review of the literature. Scoping reviews can provide a broad overview of a topic, identify gaps in the research knowledge base and report on the types of evidence that address and inform practices. This paper presents our study protocol. Methods and analysis The proposed scoping review will be performed in accordance with the Joanna Briggs Institute's (JBI) methodology for scoping reviews. It will cover both qualitative and quantitative scientific literature, as well as the grey literature on SDM interventions for treatment modality decisions in AKD. Only literature written in English will be considered for inclusion. Two independent reviewers will participate in an iterative process of screening the literature, paper selection and data extraction. Disagreements between the reviewers will be resolved by discussion until consensus is reached or after consultation with the research team when needed. Results will be reported with descriptive statistics and diagrammatic or tabular displayed information, accompanied by narrative summaries as explained in the JBI guidelines. Ethics and dissemination Ethical approval for the cond...

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Value-based evaluation of dialysis versus conservative care in older patients with advanced chronic kidney disease: a cohort study

Cited by 52 publications

References 51 publications

Enabling good outcomes in older adults on dialysis: a qualitative study

Enabling good outcomes in older adults on dialysis: a qualitative study

Hospital Utilization and Costs in Older Patients with Advanced Chronic Kidney Disease Choosing Conservative Care or Dialysis: A Retrospective Cohort Study

Shared decision-making in advanced kidney disease: a scoping review protocol

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