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

Abstract

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.

Figure 1:

Treatment preferences (dialysis v. conservative care) of 105 patients with end-stage chronic kidney disease. For numeric variables (life expectancy, number of visits to hospital and number of hours of dialysis per treatment), odds ratios correspond to an increase of one unit (i.e., 1 year, 1 visit to hospital per week, 1 hour of dialysis). For ordinal qualitative attributes (travel restrictions, available subsidized transport and treatment flexibility), odds ratios correspond to an increase of one level (e.g., from no subsidized transport to partially subsidized transport, or from partially subsidized to fully subsidized). For the variable “time of day”, dialysis during the day was used as the reference group. CI = confidence interval, OR = odds ratio.