The Concordance between Patients’ Renal Replacement Therapy Choice and Definitive Modality: Is It a Utopia?

Abstract

IntroductionIt is desirable for patients to play active roles in the choice of renal replacement therapy (RRT). Patient decision aid tools (PDAs) have been developed to allow the patients to choose the option best suited to their individual needs.Material and MethodsAn observational, prospective registry was conducted in 26 Spanish hospitals between September 2010 and May 2012. The results of the patients’ choice and the definitive RRT modality were registered through the progressive implementation of an Education Process (EP) with PDAs designed to help Chronic Kidney Disease (CKD) patients choose RRT.ResultsPatients included in this study: 1044. Of these, 569 patients used PDAs and had made a definitive choice by the end of registration. A total of 88.4% of patients chose dialysis [43% hemodialysis (HD) and 45% peritoneal dialysis (PD)] 3.2% preemptive living-donor transplant (TX), and 8.4% conservative treatment (CT). A total of 399 patients began RRT during this period. The distribution was 93.4% dialysis (53.6% HD; 40% PD), 1.3% preemptive TX and 5.3% CT. The patients who followed the EP changed their mind significantly less often [kappa value of 0.91 (95% CI, 0.86–0.95)] than those who did not follow it, despite starting unplanned treatment [kappa value of 0.85 (95% CI, 0.75–0.95]. A higher agreement between the final choice and a definitive treatment was achieved by the EP and planned patients [kappa value of 0.93 (95% CI, 0.89–0.98)]. Those who did not go through the EP had a much lower index of choosing PD and changed their decision more frequently when starting definitive treatment [kappa value of 0.73 (95% CI, 0.55–0.91)].ConclusionsFree choice, assisted by PDAs, leads to a 50/50 distribution of PD and HD choice and an increase in TX choice. The use of PDAs, even with an unplanned start, achieved a high level of concordance between the chosen and definitive modality.

How a Bottom-Up Multi-Stakeholder Initiative Helped Transform the Renal Replacement Therapy Landscape in Spain

“…Overall, patients surveyed in 2015 and 2016 were very satisfied with the education process for RRT choice, with an average score of 8.5 out of 10, and differences between patients who opted for PD and those who chose HD were minimal (unpublished data) (see Table 1). This is in line with the previously mentioned research showing that free choice, assisted by PDAs, leads to an equal distribution of those choosing PD versus HD [20]. …”

“…Analysis of this registry showed a 50:50 split between patients choosing PD or HD plus an increase in pre-emptive transplantation choice. The use of PDAs, even with an unplanned start to RRT, achieved a high level of concordance between the chosen and final modality [20]. …”

“…However, although HD was still the starting option for most of the educated unplanned patients, their final method after recovering from the acute condition showed a more balanced dialysis distribution that was closer to that of the whole educated group [20]. …”

Developing and pilot testing a shared decision‐making intervention for dialysis choice

“…In a more recent study from France, 47.5% choose PD, although data regarding patient choosing HHD were not reported (Keating et al 2014). In an intervention study based on shared decision-making, 50% chose dialysis at home (Prieto-Velasco et al 2015). The high number of patients in our study choosing dialysis at home could be explained by the fact that decisions regarding dialysis mode are highly personal and strongly influenced by patient and family values, the context of their life and a desire for minimal intrusiveness (Harwood & Clark 2013).…”

Role of telehealth in renal replacement therapy education

“…Numerous international studies have demonstrated that pre‐ESRD education leads to greater patient selection of home dialysis modalities . For example, a multicenter study conducted in Spain between 2010 and 2012 noted a prevalence of peritoneal dialysis therapy up to 47.8% among ESRD patients who received pre‐ESRD education compared to 6.5% among patients who did not receive the same education . Analogously, preemptive kidney transplantation was 1.5% and 0%, respectively.…”