Early Referral to Nephrological Care and the Uptake of Peritoneal Dialysis. An Analysis of German Claims Data

Abstract

Background: Hemodialysis (HD) and peritoneal dialysis (PD) are medically equivalent alternatives for symptomatic therapy of end-stage renal disease (ESRD). An early referral (ER) of patients with chronic kidney disease (CKD) to a nephrological specialist is associated with a higher proportion of patients choosing PD. Germany historically shows a low PD uptake. This article is the first investigation into the impact of ER on the uptake of PD, using a large German claims database. Methods: Claims data of 4727 incident dialysis patients in 2015 and 2016 were analyzed. Accounting codes for nephrological care and dialysis modalities were identified. Their first documentation was defined as their first encounter with a nephrologist and their first dialysis treatment (HD or PD). ER was determined as receiving nephrological care at least six months before the first dialysis. A multivariate logistic regression model with adjusted odds ratios (AOR) investigates the impact of ER, outpatient dialysis start, age, comorbidities, and sex on the chance for PD. Results: Forty-three percent were referred to the nephrologist six months before their first dialysis (ER). Single tests, as well as the adjusted multivariate logistic regression, highlighted that ER significantly increases the chance for PD. In the multivariate model, the uptake of PD was associated with ER (AOR = 3.05; p < 0.001; 95% CI = 2.16–4.32), outpatient dialysis start (AOR = 0.71; p = 0.044; 95% CI = 0.51–0.99), younger age (AOR = 0.96; p < 0.001; 95% CI = 0.95–0.97), and fewer comorbidities (AOR = 0.85; p < 0.001; 95% CI = 0.44–1.58). Conclusions: ER of patients with CKD to a nephrologist increases PD uptake. It gives both nephrologists and patients enough time for patient education about different treatment options and can contribute to informed decisions about the dialysis treatment.

Late Dialysis Modality Education Could Negatively Predict Peritoneal Dialysis Selection

“…In the present study, young age, and low CCI were also significant predictors of high rates of PD selection, which is consistent with previous reports [ 11 , 12 , 13 , 21 ]. Jager et al discovered a stronger preference for HD in patients with poor activities of daily living or physical weakness [ 22 ].…”

“…Young age, few concomitant diseases, good nutritional status, full-time employment, and high education level have been reported to be linked to a higher probability of PD selection in patients with ESRD [ 11 , 12 , 13 ]. Although the link between medical engagement and PD selection is yet unknown, previous research has shown that RRT education remarkably increases the rate of PD selection [ 14 ].…”

Center Hemodialysis Versus Peritoneal Dialysis: A Cost-Utility Analysis

“…However, patients are often referred to a nephrologist only very late in their CKD stage, leaving limited time for the educational process. Late referral has been shown to be an independent risk factor for the initiation of HD instead of PD [16]. Despite a legal obligation to inform patients about possible treatment options, only 56% of HD patients report being informed about other dialysis options by their healthcare provider [17].…”

Hemodialysis and Peritoneal Dialysis in Germany from a Health Economic View—A Propensity Score Matched Analysis

“…All medically indispensable services are reimbursed by the SHI and are therefore included in the claims data with EBM codes. This allows the use of claims data to analyse patient care and its impact, especially in the context of chronic diseases, such as many nephrological illnesses [ 1 , 29 , 30 ].…”