Value-based evaluation of dialysis versus conservative care in older patients with advanced chronic kidney disease: a cohort study

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Abstract

Background

Conservative care is argued to be a reasonable treatment alternative for dialysis in older patients with advanced chronic kidney disease (CKD). However, comparisons are scarce and generally focus on survival only. Comparative data on more patient-relevant outcomes are needed to truly foster shared decision-making on an individual level, and cost comparison is needed to assess value of care.

Methods

We conducted a retrospective observational single-center cohort study in 366 patients aged ≥70 years with advanced CKD, who chose dialysis ( n = 240) or conservative care ( n = 126) after careful counselling by a multidisciplinary team in a non-academic teaching hospital in The Netherlands. Using a value-based health care approach (value = outcomes/cost): survival, health-related quality of life—cross-sectionally assessed with the Kidney Disease Quality of Life Short Form™—treatment burden, and treatment costs were evaluated.

Results

The overall survival benefit of patients on a dialysis pathway compared with patients on conservative care diminished or lost significance in patients aged ≥80 years or with severe comorbidity. There were no differences between patients managed conservatively and dialysis patients on physical and mental health summary scores (all P > 0.1). Patients on conservative care had 352.7 hospital free days per year versus 282.7 in patients on a dialysis pathway, calculated from treatment decision (adjusted incidence rate ratio: 1.15, 95% confidence interval: 1.09 to 1.21, P < 0.001). Annual treatment costs were lower in patients on conservative care (adjusted cost ratio: 0.43, 95% confidence interval: 0.28 to 0.67, P < 0.001).

Conclusions

In this study, conservative care is shown to be a viable treatment option in older patients with advanced CKD, particularly in the oldest old and those with severe comorbidity. By achieving similar outcomes at lower treatment burden and treatment costs, value was generated for older patients choosing conservative care and society.

Electronic supplementary material

The online version of this article (10.1186/s12882-018-1004-4) contains supplementary material, which is available to authorized users.

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Most cited references 36

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Executive summary of the KDIGO Controversies Conference on Supportive Care in Chronic Kidney Disease: developing a roadmap to improving quality care.

Sara N Davison, Adeera Levin, Alvin H Moss … (2015)

Patients with advanced chronic kidney disease (CKD) have a high burden of physical and psychosocial symptoms, poor outcomes, and high costs of care. Current paradigms of care for this highly vulnerable population are variable, prognostic and assessment tools are limited, and quality of care, particularly regarding conservative and palliative care, is suboptimal. The KDIGO Controversies Conference on Supportive Care in CKD reviewed the current state of knowledge in order to define a roadmap to guide clinical and research activities focused on improving the outcomes of people living with advanced CKD, including those on dialysis. An international group of multidisciplinary experts in CKD, palliative care, methodology, economics, and education identified the key issues related to palliative care in this population. The conference led to a working plan to address outstanding issues in this arena, and this executive summary serves as an output to guide future work, including the development of globally applicable guidelines.

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The views of patients and carers in treatment decision making for chronic kidney disease: systematic review and thematic synthesis of qualitative studies

R Morton, A Tong, Mary Howard … (2010)

Objective To synthesise the views of patients and carers in decision making regarding treatment for chronic kidney disease, and to determine which factors influence those decisions. Design Systematic review of qualitative studies of decision making and choice for dialysis, transplantation, or palliative care, and thematic synthesis of qualitative studies. Data sources Medline, PsycINFO, CINAHL, Embase, social work abstracts, and digital theses (database inception to week 3 October 2008) to identify literature using qualitative methods (focus groups, interviews, or case studies). Review methods Thematic synthesis involved line by line coding of the findings of the primary studies and development of descriptive and analytical themes. Results 18 studies that reported the experiences of 375 patients and 87 carers were included. 14 studies focused on preferences for dialysis modality, three on transplantation, and one on palliative management. Four major themes were identified as being central to treatment choices: confronting mortality (choosing life or death, being a burden, living in limbo), lack of choice (medical decision, lack of information, constraints on resources), gaining knowledge of options (peer influence, timing of information), and weighing alternatives (maintaining lifestyle, family influences, maintaining the status quo). Conclusions The experiences of other patients greatly influenced the decision making of patients and carers. The problematic timing of information about treatment options and synchronous creation of vascular access seemed to predetermine haemodialysis and inhibit choice of other treatments, including palliative care. A preference to maintain the status quo may explain why patients often remain on their initial therapy.

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How should cost data in pragmatic randomised trials be analysed?

S. Thompson, Tracie Barber (2000)

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Author and article information

Contributors

Wouter R. Verberne:

ORCID: http://orcid.org/0000-0003-4262-7162

+31883204761 , w.verberne@antoniusziekenhuis.nl

Janneke Dijkers: jannekedijkers@gmail.com

Johannes C. Kelder: keld01@antoniusziekenhuis.nl

Anthonius B. M. Geers: a.geers@antoniusziekenhuis.nl

Wilbert T. Jellema: w.jellema@antoniusziekenhuis.nl

Hieronymus H. Vincent: hh.vincent@antoniusziekenhuis.nl

Johannes J. M. van Delden: j.j.m.vandelden@umcutrecht.nl

Willem Jan W. Bos: w.bos@antoniusziekenhuis.nl

Journal

Journal ID (nlm-ta): BMC Nephrol

Journal ID (iso-abbrev): BMC Nephrol

Title: BMC Nephrology

Publisher: BioMed Central (London )

ISSN (Electronic): 1471-2369

Publication date (Electronic): 16 August 2018

Publication date PMC-release: 16 August 2018

Publication date Collection: 2018

Volume: 19

Electronic Location Identifier: 205

Affiliations

[1 ]ISNI 0000 0004 0622 1269, GRID grid.415960.f, Department of Internal Medicine, , St Antonius Hospital, ; Koekoekslaan 1, 3435 CM, Utrecht Nieuwegein, The Netherlands

[2 ]ISNI 0000 0004 0622 1269, GRID grid.415960.f, Department of Clinical Epidemiology and Medical Statistics, , St Antonius Hospital, ; Nieuwegein, Utrecht The Netherlands

[3 ]ISNI 0000000090126352, GRID grid.7692.a, University Medical Centre Utrecht, Julius Centre for Health Sciences and Primary Care, ; Utrecht, The Netherlands

[4 ]ISNI 0000000089452978, GRID grid.10419.3d, Department of Internal Medicine, , Leiden University Medical Center, ; Leiden, Zuid-Holland The Netherlands

Author information

Wouter R. Verberne http://orcid.org/0000-0003-4262-7162

Article

Publisher ID: 1004

DOI: 10.1186/s12882-018-1004-4

PMC ID: 6097302

PubMed ID: 30115028

SO-VID: c5d243cf-a062-4176-889b-d0fc1ece71e1

License:

Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License ( http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

History

Date received : 6 June 2018

Date accepted : 6 August 2018

Funding

Funded by: St Antonius Research Fund

Funded by: Roche (NL)

Funded by: Zilveren Kruis (NL)

Custom metadata

ScienceOpen disciplines: Nephrology

Keywords: aged,chronic kidney failure,end-stage renal disease (esrd),renal dialysis,conservative treatment

Data availability:

ScienceOpen disciplines: Nephrology

Keywords: aged, chronic kidney failure, end-stage renal disease (esrd), renal dialysis, conservative treatment

Value-based evaluation of dialysis versus conservative care in older patients with advanced chronic kidney disease: a cohort study

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Most cited references 36

Executive summary of the KDIGO Controversies Conference on Supportive Care in Chronic Kidney Disease: developing a roadmap to improving quality care.

The views of patients and carers in treatment decision making for chronic kidney disease: systematic review and thematic synthesis of qualitative studies

How should cost data in pragmatic randomised trials be analysed?

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