Why Is Dialysis Starting Earlier? Are Patients Being Heard?

Health plans and researchers have quantified the trend toward starting maintenance dialysis at an earlier point in end-stage renal disease (ESRD) than in years past. Until now, the question of why this is happening remains unanswered.

Researchers reporting today in JAMA Internal Medicine, using records from 1691 cases at the Veterans Administration, have tried to come up with answers, and they aren’t comforting to those seeking a more patient-centered healthcare system. This qualitative study, which reviewed records from 2000 to 2009, found the following:

· Physician practices tended to drive decisions to start dialysis more than patient wishes, although many practices were designed to forestall dialysis

· The start of dialysis often accompanied acute illness or other medical procedures; physicians seized the “opportunity” when the patient was already hospitalized

· Physician-patient relations over the decision to start dialysis were sometimes adversarial, and physician recommendations sometimes conflicted with patient priorities.¹

Authors of the study, led by Susan P.Y. Wong, MD, said their findings “suggest opportunities to improve communication between patients and physicians and to better align these processes with patients’ values, goals, and preferences.”

An accompanying editorial led by Vishnu S. Potluri, MD, MPH, went further, saying the quotes in patient records uncovered in the study revealed a level of “paternalism,” and that “some clincians considered their patients to be in denial when they expressed reluctance about dialysis, or to be non-compliant when they missed appointments intended to prepare for dialysis.”²

Is it so unusual that patients with chronic kidney disease (CKD) would avoid dialysis for as long as possible? Of course not, say the authors of both the article and the editorial. Being on dialysis represents a lower quality of life, even though some manage to adapt and to enjoy family life and work, as the writers of the editorial note.

The study’s authors note that many of the physicians went to great lengths to avoid it; dialysis began only after “physicians had attempted a series of medical interventions intended to reverse or halt the loss of kidney function and/or treat the signs and symptoms of advanced CKD.”

What troubled researchers were cases in which there was no acute illness or apparent urgency. “Simply being in the hospital seemed to increase the likelihood of initiation of dialysis,” they wrote.

Admitted patients were labeled “predialysis” and the question of when to start was part of the care plan. This was especially true for patients who had mental illness or other obstacles to receiving routine care. “We … found examples in which physicians seemed to seize the ‘opportunity’ to initiate dialysis during a hospital admission in patients who had been reluctant to start dialysis,” the authors wrote.

Writers of the editorial encouraged payers to examine this phenomenon closely, as well as the dynamic of patients being presented with the options of “dialysis or death.”

Payers should require patient satisfaction measures, along with other measurements of kidney function, when evaluating decision-making in ESRD care, according to the editorial. They do caution that “the consequences of such a reimbursement structure would require careful assessment.”

While physicians may press for dialysis due to legitimate “fear of failing a patient who has medical complications,” Potluri et al write, “unfortunately, some nephrologists also may be influenced by their financial benefit of filling a dialysis chair with another patient.”

References

1. Wong SPY, Vig EK, Taylor JS, et al. Timing of initiation of maintenance dialysis: a quantitative analysis of the electronic medical records of a national cohort of patients from the Department of Veterans Affairs [published online January 25, 2016]. JAMA Intern Med. 2016; 10:1001/jamainternmed.2015.7412.

2. Potluri VS, Dember LM, Reese PP. Honoring patient preferences in initiation of dialysis: problems, proposals and a path forward [published online January 25, 2016]. JAMA Intern Med.