Abstract
Objectives
Unplanned 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).
Methods
The 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.
Results
The 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.
Conclusion
Education 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.
Acknowledgments
We thank all patients included in the study and all physicians, nurses, and other health care personnel who participated in the clinical care and data collection. This observational study, Offering Patients Therapy Options in Unplanned Start (OPTiONS), was supported by a grant from Baxter Healthcare Corporation. Anna Machowska was funded by the European Union Marie Curie Initial Training Network grant (number FP7-PEOPLE-2011-ITN) for the project European Training and Research in Peritoneal Dialysis (EuTRiPD). This study was also supported by a grant from Baxter Healthcare Corporation to Karolinska Institutet.
Disclosure
Bengt Lindholm and Anna Machowska are employed by Baxter Healthcare Corporation. Peter Rutherford was employed by Baxter Healthcare Corporation at the time of the study and is now employed by Quintiles. The authors report no other conflicts of interest in this work.