ESRD Modality Selection Into the 21st Century: The Importance of Non Medical Factors

Nissenson, Allen R.; Prichard, Sarah; Cheng, Ignatius K.P.; Gokal, Ram; Kubota, Minoru; Maiorca, R; Riella, Miguel C.; Rottembourg, Jacques; Stewart, John H.

doi:10.1097/00002480-199743030-00005

Cited by 39 publications

(60 citation statements)

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“…Prediction of choice of dialysis modality could be expected to be poor in the absence of information on factors known to be important for this decision, such as financial incentives for providers of RRT, educational deficits in the health care team, and/or patient, physician bias, resource availability, social mores, and cultural habits (34). However, it seemed reasonable that some of this predictive power could be captured by including information into the PS model that identified the individual dialysis facility.…”

Section: Discussionmentioning

confidence: 99%

Comparing Mortality of Elderly Patients on Hemodialysis versus Peritoneal Dialysis

Winkelmayer¹,

Glynn²,

Mittleman³

et al. 2002

Journal of the American Society of Nephrology

142

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Abstract. The objective of this study was to evaluate differences in mortality over the first year of renal replacement therapy (RRT) between elderly patients starting treatment on hemodialysis (HD) versus peritoneal dialysis (PD). For the period of 1991 to mid-1996, this study defined an inception cohort of all patients aged Ͼ65 yr with new-onset chronic RRT who were New Jersey Medicare and/or Medicaid beneficiaries in the year before RRT and who had been diagnosed with renal disease more than 1 yr before RRT. Propensity scores were calculated for first treatment assignment from a large number of baseline covariates. Mortality was then compared among patients initially assigned to HD versus PD using multivariate 90-d interval Cox models controlled for propensity scores and center stratification. Peritoneal dialysis starters had a 16% higher rate of death during the first 90 d of RRT compared with HD patients (hazard ratio [HR], 1.16; 95% confidence interval [CI], 0.96 to 1.42)]. Mortality did not differ between day 91 and 180 (HR, 1.03; 95% CI, 0.71 to 1.51). Thereafter, PD starters again died at a higher rate (HR, 1.45; 95% CI, 1.07 to 1.98). These findings were more pronounced among patients with diabetes. Sensitivity analyses using more stringent criteria to ensure that first treatment choice reflected long-term treatment choice confirmed the presence of an association between PD and mortality. In conclusion, compared with HD, peritoneal dialysis appears to be associated with higher mortality among older patients, particularly among those with diabetes, even after controlling for a large number of risk factors for mortality, propensity scores to control for nonrandom treatment assignment, and center stratification.Various studies have sought to answer the question of whether or not survival on peritoneal dialysis (PD) and hemodialysis (HD) differed. (1-22) These studies vary enormously with regard to population selection criteria, sample size, statistical methodology, definition of treatment, and availability of information on important potential confounders. The various results are conflicting: some studies have found a survival benefit for PD patients (12,16,18,20), others for those on HD (10,11,13), and still others have found mortality not to differ (2)(3)(4)(5)(6)(7)(8)14,15,19,21,22).Many of these previous studies, and all studies on US populations after 1983 have not adequately addressed a key methodologic issue: assessments that start at 4 or 6 mo after onset of RRT are likely to discard relevant events that occur between the first dialysis treatment and the chosen starting point of such studies, particularly modality switches and deaths. This omission can result in biased estimates of effect. Another important potential source of bias that frequently remained unaccounted for is uncontrolled center effects (23). Furthermore, potentially useful techniques developed to enhance control for nonrandom treatment assignment, such as propensity scores (PS) or g-estimation (24,25), have not been used in compa...

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Section: Discussionmentioning

confidence: 99%

Comparing Mortality of Elderly Patients on Hemodialysis versus Peritoneal Dialysis

Winkelmayer¹,

Glynn²,

Mittleman³

et al. 2002

Journal of the American Society of Nephrology

142

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“…3 Even though the determinants of modality selection are largely nonmedical, attention has been drawn to two medical issues and their potential relationship to modality selection. 4 First, it has been argued that increasing age, comorbidity, and body size among the incident ESRD population is responsible, at least in part, for the decrease in CPD take-on. With an aging, more obese, and sicker incident patient population, further decline in CPD use would be inevitable.…”

mentioning

confidence: 99%

Chronic Peritoneal Dialysis in the United States

Mehrotra

Kermah

Fried

et al. 2007

Journal of the American Society of Nephrology

134

119

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In the United States, chronic peritoneal dialysis take-on has declined among incident ESRD patients. Although increasing age, co-morbidity, and body size may explain part of this decline, other factors likely contribute. Among incident ESRD patients in the United States, we found that peritoneal dialysis take-on significantly decreased from 11% in 1996 to 1997 to 7% in 2002 to 2003 (P Ͻ 0.001 for the trend). This decrease remained after adjusting for patient demographics, case-mix, and laboratory data, suggesting the involvement of other factors. This decline in utilization occurred during a time of improving outcomes for incident peritoneal dialysis patients, measured as reduced hazards for death or for the need to transfer to hemodialysis. In contrast, among patients initially treated with hemodialysis, the 12-month adjusted hazards for death or transfer to peritoneal dialysis slightly worsened or were unchanged over this same period. Therefore, the decline in peritoneal dialysis take-on cannot be entirely explained by increasing age, co-morbidity and body size of incident ESRD patients. The decline in utilization has occurred at a time when the early outcomes of CPD patients have improved.

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“…Medical and nonmedical factors are reported to contribute to a decision to start a patient on home dialysis (13). Nonmedical factors can be patient or facility specific.…”

Section: Discussionmentioning

confidence: 99%

Dialysis Facility and Patient Characteristics Associated with Utilization of Home Dialysis

Walker

Inglese

Sloand

et al. 2010

Clinical Journal of the American Society of Nephrology

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Background and objectives: Nonmedical factors influencing utilization of home dialysis at the facility level are poorly quantified. Home dialysis is comparably effective and safe but less expensive to society and Medicare than in-center hemodialysis. Elimination of modifiable practice variation unrelated to medical factors could contribute to improvements in patient outcomes and use of scarce resources.Design, setting, participants, & measurements: Prevalent dialysis patient data by facility were collected from the 2007 ESRD Network's annual reports. Facility characteristic data were collected from Medicare's Dialysis Facility Compare file. A multivariate regression model was used to evaluate associations between the use of home dialysis and facility characteristics.Results: The utilization of home dialysis was positively associated with facility size, percent patients employed full-or part-time, younger population, and years a facility was Medicare certified. Variables negatively associated include an increased number of hemodialysis patients per hemodialysis station, chain association, rural location, more densely populated zip code, a late dialysis work shift, and greater percent of black patients within a zip code.Conclusions: Improved understanding of factors affecting the frequency of use of home dialysis may help explain practice variations across the United States that result in an imbalanced use of medical resources within the ESRD population. In turn, this may improve the delivery of healthcare and extend the ability of an increasingly overburdened medical financing system to survive.

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ESRD Modality Selection Into the 21st Century: The Importance of Non Medical Factors

Cited by 39 publications

References 0 publications

Comparing Mortality of Elderly Patients on Hemodialysis versus Peritoneal Dialysis

Comparing Mortality of Elderly Patients on Hemodialysis versus Peritoneal Dialysis

Chronic Peritoneal Dialysis in the United States

Dialysis Facility and Patient Characteristics Associated with Utilization of Home Dialysis

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