Quality Improvement Project
Low PD Utilization in U.S.:
Result of Poor Patient Education
(2001-2002)
R. Mehrotra, J. Sayre, D. Marsh, V. Peters, J. Zamora, and A. Nissenson
ABSTRACT
Absolute/relative
contraindications for hemodialysis or peritoneal dialysis (PD) are present in
< 20% of all incident dialysis patients. To understand the process of
modality selection, end-stage renal disease (ESRD) Network 18 has undertaken a
continuous quality improvement project.
As an initial step, all incident ESRD patients admitted for chronic
dialysis during April and May 2002 were invited to complete a survey. Of the 1377 incident patients, 430 responded
(31%). Their mean (+SEM) age was 62.7+0.9 years; 53% males, 37%
Hispanic, 43% diabetic with an estimated GFR of 6.0+0.3 ml/min/1.73m2. Similar to all incident patients during the
study period, <6% of the respondents were being treated with PD. Over 30% of
the patients reported that options regarding dialysis modalities were not
presented to them up until the need for first dialysis; 8.4% were never presented with treatment
options. Despite the absence of
contraindications for PD, two-thirds of the respondents
reported PD was not offered as a
possible treatment method. Timing of referral to a nephrologist had a marginally
significant effect on the probability of being informed about PD as a treatment
option (p=0.06). The longer before the first dialysis that treatment options
were first presented to the patient, the more likely that PD was presented as a
choice: 46% of patients who were educated >12 months prior to first
dialysis, compared to 28% of those who were not presented with options until
after their first chronic dialysis (p <0.0001). Patients presented with PD as a treatment option were more likely
to be employed (p<0.0001) and have a higher pre-dialysis hematocrit
(p<0.0001). There was no relationship between age, gender, race/ethnicity,
insurance status, body weight or size, cause of renal failure, presence/absence
of co-morbidities, serum albumin, residual renal function, level of patient
education or health care personnel performing education on the probability of
patients being presented with PD as a possible treatment option. To conclude,
our data suggests that the relatively low PD utilization in ESRD Network 18 may
be largely because of the failure of health care providers to present PD as a
treatment option to the patients. Thus, our study identifies a great
opportunity to improve the process of modality selection. Steps need to be taken to ensure that all
ESRD patients, in the absence of medical contraindications, are presented with
a true choice regarding their options for dialysis therapy. Further intervention activities are
currently being planned by the Medical Review Board.
