Factors influencing patient choice of dialysis versus conservative care to treat end-stage kidney disease

Background:

For every patient with chronic kidney disease who undergoes renal-replacement therapy, there is one patient who undergoes conservative management of their disease. We aimed to determine the most important characteristics of dialysis and the trade-offs patients were willing to make in choosing dialysis instead of conservative care.

Methods:

We conducted a discrete choice experiment involving adults with stage 3–5 chronic kidney disease from eight renal clinics in Australia. We assessed the influence of treatment characteristics (life expectancy, number of visits to the hospital per week, ability to travel, time spent undergoing dialysis [i.e., time spent attached to a dialysis machine per treatment, measured in hours], time of day at which treatment occurred, availability of subsidized transport and flexibility of the treatment schedule) on patients’ preferences for dialysis versus conservative care.

Results:

Of 151 patients invited to participate, 105 completed our survey. Patients were more likely to choose dialysis than conservative care if dialysis involved an increased average life expectancy (odds ratio [OR] 1.84, 95% confidence interval [CI] 1.57–2.15), if they were able to dialyse during the day or evening rather than during the day only (OR 8.95, 95% CI 4.46–17.97), and if subsidized transport was available (OR 1.55, 95% CI 1.24–1.95). Patients were less likely to choose dialysis over conservative care if an increase in the number of visits to hospital was required (OR 0.70, 95% CI 0.56–0.88) and if there were more restrictions on their ability to travel (OR = 0.47, 95%CI 0.36–0.61). Patients were willing to forgo 7 months of life expectancy to reduce the number of required visits to hospital and 15 months of life expectancy to increase their ability to travel.

Interpretation:

Patients approaching end-stage kidney disease are willing to trade considerable life expectancy to reduce the burden and restrictions imposed by dialysis.Stage 5 chronic kidney disease is a major health issue worldwide and has a mortality that exceeds many cancers.^1,2 The treatment options for stage 5 (i.e., end-stage) kidney disease include dialysis, kidney transplantation and supportive nondialytic treatment (conservative care). A national report by the Australian Institute of Health and Welfare estimates that for every patient with chronic kidney disease who undergoes dialysis or transplantation, there is one other patient whose disease is managed conservatively.³Conservative care includes the multidisciplinary management of uremic symptoms through diet and medications, such as erythropoietin and diuretics, as well as psychosocial support and eventual palliative care. The reported median survival with conservative care for end-stage kidney disease is between 6 and 32 months. For some patients, particularly the elderly and those with ischemic heart disease, this period may be equal to or greater than their expected survival with dialysis.^4–7 Dialysis usually prolongs life, but it can impose a substantial burden on patients and their families and may be associated with a reduction in quality of life. The decision to start dialysis thus involves an assessment of both the evidence-based outcomes for the population in question and the preferences of the individual patient.Incorporating patient preferences for treatment of stage 5 chronic kidney disease is recommended in clinical guidelines;⁸ however, little is known about the trade-offs that patients are willing to consider when choosing between dialysis and conservative care. Discrete choice experiments are used to quantify patient preferences. These experiments are grounded in economic theory^9,10 and allow the measurement of patients’ strengths of preferences for different characteristics of treatment and the trade-offs involved. Real-world decisions are closely simulated through the simultaneous consideration of all treatment characteristics.¹¹ Discrete choice experiments are a valid and reliable approach to eliciting preferences for health care^12–14 and have been used to measure the preferences of patients with chronic kidney disease in terms of organ donation and allocation, and end-of-life care.¹⁵Knowing patients’ preferences for the treatment of stage 5 chronic kidney disease is necessary to plan appropriate health care services and enhance the quality of care. With this study, we aimed to quantify the extent to which the characteristics of dialysis influence patient preferences for treatment and to assess the trade-offs patients were willing to make between these characteristics.