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BMC Nephrology
Published in: BMC Nephrology 1/2018

Open Access 01-12-2018 | Research article

Value-based evaluation of dialysis versus conservative care in older patients with advanced chronic kidney disease: a cohort study

Authors: Wouter R. Verberne, Janneke Dijkers, Johannes C. Kelder, Anthonius B. M. Geers, Wilbert T. Jellema, Hieronymus H. Vincent, Johannes J. M. van Delden, Willem Jan W. Bos

Published in: BMC Nephrology | Issue 1/2018

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Abstract

Background

Conservative care is argued to be a reasonable treatment alternative for dialysis in older patients with advanced chronic kidney disease (CKD). However, comparisons are scarce and generally focus on survival only. Comparative data on more patient-relevant outcomes are needed to truly foster shared decision-making on an individual level, and cost comparison is needed to assess value of care.

Methods

We conducted a retrospective observational single-center cohort study in 366 patients aged ≥70 years with advanced CKD, who chose dialysis (n = 240) or conservative care (n = 126) after careful counselling by a multidisciplinary team in a non-academic teaching hospital in The Netherlands. Using a value-based health care approach (value = outcomes/cost): survival, health-related quality of life—cross-sectionally assessed with the Kidney Disease Quality of Life Short Form™—treatment burden, and treatment costs were evaluated.

Results

The overall survival benefit of patients on a dialysis pathway compared with patients on conservative care diminished or lost significance in patients aged ≥80 years or with severe comorbidity. There were no differences between patients managed conservatively and dialysis patients on physical and mental health summary scores (all P > 0.1). Patients on conservative care had 352.7 hospital free days per year versus 282.7 in patients on a dialysis pathway, calculated from treatment decision (adjusted incidence rate ratio: 1.15, 95% confidence interval: 1.09 to 1.21, P <  0.001). Annual treatment costs were lower in patients on conservative care (adjusted cost ratio: 0.43, 95% confidence interval: 0.28 to 0.67, P <  0.001).

Conclusions

In this study, conservative care is shown to be a viable treatment option in older patients with advanced CKD, particularly in the oldest old and those with severe comorbidity. By achieving similar outcomes at lower treatment burden and treatment costs, value was generated for older patients choosing conservative care and society.
Appendix
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Literature
1.
Couser WG, Remuzzi G, Mendis S, Tonelli M. The contribution of chronic kidney disease to the global burden of major noncommunicable diseases. Kidney Int. 2011;80(12):1258–70.PubMed
2.
Saran R, Robinson B, Abbott KC, Agodoa LY, Ayanian J, Bragg-Gresham J, et al. US Renal Data System 2016 Annual Data Report: Epidemiology of Kidney Disease in the United States. Am J Kidney Dis. 2017;69(3S1):A7–8.PubMedPubMedCentral
3.
Gilg J, Caskey F, Fogarty D. UK renal registry 18th annual report: chapter 1 UK renal replacement therapy incidence in 2014: national and Centre-specific analyses. Nephron. 2016;132(Suppl 1):9–40.PubMed
4.
5.
Kallenberg MH, Kleinveld HA, Dekker FW, van Munster BC, Rabelink TJ, van Buren M, et al. Functional and cognitive impairment, frailty, and adverse health outcomes in older patients reaching ESRD-A systematic review. Clin J Am Soc Nephrol. 2016;11(9):1624–39.PubMedPubMedCentral
6.
O'Connor NR, Kumar P. Conservative management of end-stage renal disease without dialysis: a systematic review. J Palliat Med. 2012;15(2):228–35.PubMedPubMedCentral
7.
Murtagh FE, Burns A, Moranne O, Morton RL, Naicker S. Supportive care: comprehensive conservative Care in end-Stage Kidney Disease. Clin J Am Soc Nephrol. 2016;11(10):1909–14.PubMedPubMedCentral
8.
Hole B, Tonkin-Crine S, Caskey FJ, Roderick P. Treatment of end-stage kidney failure without renal replacement therapy. Semin Dial. 2016;29(6):491–506.PubMed
9.
Verberne WR, Geers AB, Jellema WT, Vincent HH, van Delden JJ, Bos WJ. Comparative survival among older adults with advanced kidney disease managed conservatively versus with Dialysis. Clin J Am Soc Nephrol. 2016;11(4):633–40.PubMedPubMedCentral
10.
Davison SN, Levin A, Moss AH, Jha V, Brown EA, Brennan F, et al. Executive summary of the KDIGO controversies conference on supportive Care in Chronic Kidney Disease: developing a roadmap to improving quality care. Kidney Int. 2015;88(3):447–59.PubMed
11.
van de Luijtgaarden MW, Noordzij M, van Biesen W, Couchoud C, Cancarini G, Bos WJ, et al. Conservative care in Europe--nephrologists' experience with the decision not to start renal replacement therapy. Nephrol Dial Transplant. 2013;28(10):2604–12.PubMed
12.
Morton RL, Turner RM, Howard K, Snelling P, Webster AC. Patients who plan for conservative care rather than dialysis: a national observational study in Australia. Am J Kidney Dis. 2012;59(3):419–27.PubMed
13.
Wong SP, Hebert PL, Laundry RJ, Hammond KW, Liu CF, Burrows NR, et al. Decisions about renal replacement therapy in patients with advanced kidney disease in the US Department of veterans affairs, 2000-2011. Clin J Am Soc Nephrol. 2016;11(10):1825–33.PubMedPubMedCentral
14.
Renal Physicians Association. Shared Decision-Making in the Appropriate Initiation of and Withdrawal from Dialysis (Clinical Practice Guideline). 2nd ed. Rockville; 2010.
15.
Parvez S, Abdel-Kader K, Pankratz VS, Song MK, Unruh M. Provider knowledge, attitudes, and practices surrounding conservative Management for Patients with advanced CKD. Clin J Am Soc Nephrol. 2016;11(5):812–20.PubMedPubMedCentral
16.
Morton RL, Tong A, Howard K, Snelling P, Webster AC. The views of patients and carers in treatment decision making for chronic kidney disease: systematic review and thematic synthesis of qualitative studies. BMJ. 2010;340:c112.PubMedPubMedCentral
17.
Evangelidis N, Tong A, Manns B, Hemmelgarn B, Wheeler DC, Tugwell P, et al. Developing a set of Core outcomes for trials in hemodialysis: an international Delphi survey. Am J Kidney Dis. 2017;70(4):464–75.PubMed
18.
Urquhart-Secord R, Craig JC, Hemmelgarn B, Tam-Tham H, Manns B, Howell M, et al. Patient and caregiver priorities for outcomes in hemodialysis: an international nominal group technique study. Am J Kidney Dis. 2016;68(3):444–54.PubMed
19.
Janssen IM, Gerhardus A, von Gersdorff GD, Baldamus CA, Schaller M, Barth C, et al. Preferences of patients undergoing hemodialysis - results from a questionnaire-based study with 4,518 patients. Patient Prefer Adherence. 2015;9:847–55.PubMedPubMedCentral
20.
Porter ME. What is value in health care? N Engl J Med. 2010;363(26):2477–81.PubMed
21.
Porter ME, Larsson S, Lee TH. Standardizing patient outcomes measurement. N Engl J Med. 2016;374(6):504–6.PubMed
22.
Davies SJ, Russell L, Bryan J, Phillips L, Russell GI. Comorbidity, urea kinetics, and appetite in continuous ambulatory peritoneal dialysis patients: their interrelationship and prediction of survival. Am J Kidney Dis. 1995;26(2):353–61.PubMed
23.
Levey AS, Coresh J, Greene T, Stevens LA, Zhang YL, Hendriksen S, et al. Using standardized serum creatinine values in the modification of diet in renal disease study equation for estimating glomerular filtration rate. Ann Intern Med. 2006;145(4):247–54.PubMed
24.
Hays RD, Kallich JD, Mapes DL, Coons SJ, Carter WB. Development of the kidney disease quality of life (KDQOL) instrument. Qual Life Res. 1994;3(5):329–38.
25.
Korevaar JC, Merkus MP, Jansen MA, Dekker FW, Boeschoten EW, Krediet RT, et al. Validation of the KDQOL-SF: a dialysis-targeted health measure. Qual Life Res. 2002;11(5):437–47.PubMed
26.
Sedgwick P. Incidence rate ratio. BMJ. 2010;341:c4804.
27.
Thompson SG, Barber JA. How should cost data in pragmatic randomised trials be analysed? BMJ. 2000;320(7243):1197–200.PubMedPubMedCentral
28.
Mihaylova B, Briggs A, O'Hagan A, Thompson SG. Review of statistical methods for analysing healthcare resources and costs. Health Econ. 2011;20(8):897–916.PubMed
29.
Wongrakpanich S, Susantitaphong P, Isaranuwatchai S, Chenbhanich J, Eiam-Ong S, Jaber BL. Dialysis therapy and conservative Management of Advanced Chronic Kidney Disease in the elderly: a systematic review. Nephron. 2017;137(3):178–89.PubMed
30.
Foote C, Kotwal S, Gallagher M, Cass A, Brown M, Jardine M. Survival outcomes of supportive care versus dialysis therapies for elderly patients with end-stage kidney disease: a systematic review and meta-analysis. Nephrology (Carlton). 2016;21(3):241–53.
31.
Brown MA, Collett GK, Josland EA, Foote C, Li Q, Brennan FP. CKD in elderly patients managed without dialysis: survival, symptoms, and quality of life. Clin J Am Soc Nephrol. 2015;10(2):260–8.PubMedPubMedCentral
32.
Hussain JA, Mooney A, Russon L. Comparison of survival analysis and palliative care involvement in patients aged over 70 years choosing conservative management or renal replacement therapy in advanced chronic kidney disease. Palliat Med. 2013;27(9):829–39.PubMed
33.
Murtagh FE, Marsh JE, Donohoe P, Ekbal NJ, Sheerin NS, Harris FE. Dialysis or not? A comparative survival study of patients over 75 years with chronic kidney disease stage 5. Nephrol Dial Transplant. 2007;22(7):1955–62.PubMed
34.
Chandna SM, Da Silva-Gane M, Marshall C, Warwicker P, Greenwood RN, Farrington K. Survival of elderly patients with stage 5 CKD: comparison of conservative management and renal replacement therapy. Nephrol Dial Transplant. 2011;26(5):1608–14.PubMed
35.
Hussain JA, Flemming K, Murtagh FE, Johnson MJ. Patient and health care professional decision-making to commence and withdraw from renal dialysis: a systematic review of qualitative research. Clin J Am Soc Nephrol. 2015;10(7):1201–15.PubMedPubMedCentral
36.
Tsai HB, Chao CT, Chang RE, Hung KY, COGENT Study Group. Conservative management and health-related quality of life in end-stage renal disease: a systematic review. Clin Invest Med. 2017;40(3):E127–E34.PubMed
37.
Da Silva-Gane M, Wellsted D, Greenshields H, Norton S, Chandna SM, Farrington K. Quality of life and survival in patients with advanced kidney failure managed conservatively or by dialysis. Clin J Am Soc Nephrol. 2012;7(12):2002–9.PubMedPubMedCentral
38.
Yong DS, Kwok AO, Wong DM, Suen MH, Chen WT, Tse DM. Symptom burden and quality of life in end-stage renal disease: a study of 179 patients on dialysis and palliative care. Palliat Med. 2009;23(2):111–9.PubMed
39.
De Biase V, Tobaldini O, Boaretti C, Abaterusso C, Pertica N, Loschiavo C, et al. Prolonged conservative treatment for frail elderly patients with end-stage renal disease: the Verona experience. Nephrol Dial Transplant. 2008;23(4):1313–7.PubMed
40.
Seow YY, Cheung YB, Qu LM, Yee AC. Trajectory of quality of life for poor prognosis stage 5D chronic kidney disease with and without dialysis. Am J Nephrol. 2013;37(3):231–8.PubMed
41.
Visser A, Dijkstra GJ, Kuiper D, de Jong PE, Franssen CF, Gansevoort RT, et al. Accepting or declining dialysis: considerations taken into account by elderly patients with end-stage renal disease. J Nephrol. 2009;22(6):794–9.PubMed
42.
Teo BW, Ma V, Xu H, Li J, Lee EJ. Profile of hospitalisation and death in the first year after diagnosis of end-stage renal disease in a multi-ethnic Asian population. Ann Acad Med Singap. 2010;39(2):79–87.PubMed
43.
Carson RC, Juszczak M, Davenport A, Burns A. Is maximum conservative management an equivalent treatment option to dialysis for elderly patients with significant comorbid disease? Clin J Am Soc Nephrol. 2009;4(10):1611–9.PubMedPubMedCentral
44.
Shum CK, Tam KF, Chak WL, Chan TC, Mak YF, Chau KF. Outcomes in older adults with stage 5 chronic kidney disease: comparison of peritoneal dialysis and conservative management. J Gerontol A Biol Sci Med Sci. 2014;69(3):308–14.PubMed
45.
Rodriguez Villarreal I, Ortega O, Hinostroza J, Cobo G, Gallar P, Mon C, et al. Geriatric assessment for therapeutic decision-making regarding renal replacement in elderly patients with advanced chronic kidney disease. Nephron Clin Pract. 2014;128(1-2):73–8.PubMed
46.
Morton RL, Snelling P, Webster AC, Rose J, Masterson R, Johnson DW, et al. Factors influencing patient choice of dialysis versus conservative care to treat end-stage kidney disease. CMAJ. 2012;184(5):E277–83.PubMedPubMedCentral
47.
Lee CP, Chertow GM, Zenios SA. A simulation model to estimate the cost and effectiveness of alternative dialysis initiation strategies. Med Decis Mak. 2006;26(5):535–49.
48.
Teerawattananon Y, Mugford M, Tangcharoensathien V. Economic evaluation of palliative management versus peritoneal dialysis and hemodialysis for end-stage renal disease: evidence for coverage decisions in Thailand. Value Health. 2007;10(1):61–72.PubMed
49.
Morton RL, Kurella Tamura M, Coast J, Davison SN. Supportive care: economic considerations in advanced kidney disease. Clin J Am Soc Nephrol. 2016;11(10):1915–20.PubMedPubMedCentral
50.
Joly D, Anglicheau D, Alberti C, Nguyen AT, Touam M, Grunfeld JP, et al. Octogenarians reaching end-stage renal disease: cohort study of decision-making and clinical outcomes. J Am Soc Nephrol. 2003;14(4):1012–21.PubMed
51.
Szeto CC, Kwan BC, Chow KM, Pang WF, Kwong VW, Leung CB, et al. Life expectancy of Chinese patients with chronic kidney disease without dialysis. Nephrology (Carlton). 2011;16(8):715–9.
52.
Wong CF, McCarthy M, Howse ML, Williams PS. Factors affecting survival in advanced chronic kidney disease patients who choose not to receive dialysis. Ren Fail. 2007;29(6):653–9.PubMed
Metadata
Title
Value-based evaluation of dialysis versus conservative care in older patients with advanced chronic kidney disease: a cohort study
Authors
Wouter R. Verberne
Janneke Dijkers
Johannes C. Kelder
Anthonius B. M. Geers
Wilbert T. Jellema
Hieronymus H. Vincent
Johannes J. M. van Delden
Willem Jan W. Bos
Publication date
01-12-2018
Publisher
BioMed Central
Published in
BMC Nephrology / Issue 1/2018
Electronic ISSN: 1471-2369
DOI
https://doi.org/10.1186/s12882-018-1004-4

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