Health Outcome Preferences and Trade-offs Among Older Adults With Advanced CKD: A Discrete Choice Experiment

Abstract

Rationale & objective: Decision making for the treatment of kidney failure in older adults should incorporate patient preferences. This discrete choice experiment (DCE) identified the health outcome preferences of older patients with chronic kidney disease (CKD) who are at elevated risk of kidney failure.

Study design: DCE questionnaire development and application.

Setting & participants: Persons aged 65 years and older with CKD stage 4 or 5 treated in an outpatient clinic.

Exposure: Five questionnaire attributes: fatigue, life expectancy, level of independence, hospital admissions, and hospital visits.

Outcome: Patients' health outcome priorities (relative importance of attributes) and the trade-offs they were willing to make (marginal rates of substitution).

Analytical approach: DCE design based on qualitative research, literature review, and pilot testing (n=14). Data were analyzed using a logistic regression analysis, and interactions between age subgroups were explored using logistic regression models.

Results: The questionnaire was completed by 85 patients (mean age 77 years; 65% male). Fatigue had the greatest influence on patients' choices (relative importance 26%), followed by life expectancy (23%), hospital admissions (20%), level of independence (16%), and hospital visits (15%). To avoid fatigue, patients were willing to accept a 46% decrease in 3-year survival probability, 5 extra hospital admissions per year, or 86 extra hospital visits per year. Among patients aged≥85 years, avoiding hospital admissions was the top health outcome priority; among patients aged 65-74 years, it was the lowest-ranked attribute.

Limitations: Participants were required to return the questionnaire independently. Subgroups may have been too small to detect all significant differences.

Conclusions: Fatigue and life expectancy were the top health outcome priorities of older people with advanced CKD. Avoiding hospital admissions was the top priority among the oldest patients. These findings inform the choice of patient-centered outcomes in research and clinical practice for older patients with CKD.

Plain-language summary: This study explored what matters most to older patients with kidney disease when making decisions about treatments. We asked patients to choose between treatment options that varied in terms of fatigue, life expectancy, independence, hospital admissions, and hospital visits. The findings revealed that fatigue and life expectancy were the most important factors for patients aged 65 years or older. The subgroup of patients aged 85 years or older cared most about avoiding hospital admissions. These findings help us understand what older patients with kidney disease may care about most when deciding on treatment options, which may inform their treatment decisions.

Keywords: Chronic kidney disease; decision making; end-stage kidney disease; fatigue; geriatric nephrology; health outcome preferences; health outcome priorities; kidney failure; life expectation; older patients; patient preferences; patient priorities; renal failure.