International variation in dialysis discontinuation in patients with advanced kidney disease

Abstract

Background: Decisions about dialysis for advanced kidney disease are often strongly shaped by sociocultural and system-level factors rather than the priorities and values of individual patients. We examined international variation in the uptake of conservative approaches to the care of patients with advanced kidney disease, in particular discontinuation of dialysis.

Methods: We employed an observational cohort study design using data collected from patients maintained on long-term hemodialysis between 1996 and 2015 in facilities across 12 developed countries participating in the Dialysis Outcomes and Practice Patterns Study (DOPPS). The main outcome was discontinuation of dialysis therapy. We analyzed the association between several patient characteristics and time to dialysis discontinuation by country and phase of study entry.

Results: A total of 259 343 DOPPS patients contributed data to the study, of whom 48 519 (18.7%) died during the study period. Of the decedents, 5808 (12.0%) discontinued dialysis before death. Rates of discontinuation were higher within the first few months after initiation of dialysis, among older adults, among those with a greater number of comorbidities and among those living in an institution. After adjustment for age, sex, dialysis duration, diabetes and dialysis era, rates of discontinuation were highest in Canada, the United States and Australia/New Zealand (33.8, 31.4 and 21.5 per 1000/yr, respectively) and lowest in Japan and Italy (< 0.1 per 1000/yr). Crude discontinuation rates were highest in dialysis facilities that were more likely to offer comprehensive conservative renal care to older adults.

Interpretation: We found persistent international variation in average rates of dialysis discontinuation not explained by differences in patient case-mix. These differences may reflect physician-, facility- and society-level differences in clinical practice. There may be opportunities for international cross-collaboration to improve support for patients with end-stage renal disease who prefer a more conservative approach.

Figure 1:

Process chart showing Dialysis Outcomes and Practice Patterns Study (DOPPS) study design and data sources. Dotted box represents data used to determine dialysis discontinuation information. Note: R = randomization.

Figure 2:

Adjusted dialysis discontinuation (DD) rate by country (hazard log scale) in phases 1–5 of the Dialysis Outcomes and Practice Patterns Study, excluding 1 large US dialysis organization in phases 4 and 5. Cox model adjusted for country, age, duration of dialysis, gender and diabetes, censoring any death events. Note: Ref. = reference. Error bars represent 95% confidence intervals.

Figure 3:

Unadjusted discontinuation rate (raw data unmodelled) by country during the first 4 months after dialysis initiation and during subsequent follow-up in phases 1–5 of the Dialysis Outcomes and Practice Patterns Study, excluding 1 large US dialysis organization in phases 4 and 5. Each patient could contribute time to both categories.

Figure 4:

Facility hemodialysis discontinuation rate according to the medical director’s self-reported willingness to offer comprehensive conservative renal care instead of dialysis initiation for elderly patients approaching end-stage renal disease (unadjusted). Data from phases 4 and 5 medical director survey aligned with facilities’ corresponding discontinuation rate among all patients undergoing hemodialysis who received care during the study phase, excluding 1 large US dialysis organization in phases 4 and 5.