Variability in case mix and peritoneal dialysis selection in fifty-nine French districts

Abstract

In France, the use of peritoneal dialysis (PD) as the first-choice treatment varies greatly between districts, as it is already known to do between countries. Baseline clinical factors associated with choice of first modality were analyzed in 10 815 new end-stage renal disease patients in 59 districts. To describe practices at the district level, we used an agglomerative hierarchical classification, with proximity defined by a likelihood-ratio test that compared multivariate logistic regressions of the following factors: age, gender, diabetes, congestive heart failure, severe behavioral disorders, mobility, and employment. To propose a typology, each cluster of districts was described by a multivariate logistic regression. While populations starting PD in France, as elsewhere, are more likely to be young or employed, they are also more likely to be elderly or have congestive heart failure or severe behavioral disorders. Overall, 14% of patients start with PD, but this rate varies significantly across districts, from 0% to 45%. A specific combination of factors was associated with the first-choice modality in each group of districts. This study highlights the lack of consensual medical criteria for this choice and the likelihood that nonmedical factors may explain the observed differences. The high variability suggests that PD can be used in almost all clinical conditions. Accordingly, patient preference should play a more important role in the decision-making process.