What influences patient choice of treatment modality at the pre-dialysis stage?

BACKGROUND: There is little information on factors influencing patient choice of renal replacement modality (RRM) in the UK. Pre-dialysis education programmes have been associated with increased uptake of peritoneal dialysis (PD) in other countries but their relevance in informing patient choice within UK centres has not been extensively studied. In this study, we examined how patient choice of different treatment modalities [haemodialysis (HD), PD and conservative management (CM)] is influenced by personal and demographic parameters.
METHODS: Questionnaires were sent to 242 pre-dialysis patients from a single centre. Patients were asked to rate factors affecting their treatment choice. Demographics, functional status, educational day attendance and Charlson index (CI) scores were also collected.
RESULTS: One hundred and eighteen replies were received. Seventy per cent of patients had chosen HD, 20% PD and 10% had opted for CM. There was a clear association between age and modality choice. Mean age of patients choosing PD was 55 years compared to 68 years for HD and 84 years for CM (P<0.001). Similarly, the degree of co-morbidity was linked with treatment choice, with patients choosing PD having a mean CI score of 4.1 compared to 5.8 among HD patients and 7.7 for CM (P<0.001). Factors rated as important by all three groups were: the ability to cope, fitting modality with lifestyle, distance to centre and verbal and written information about modality. Conversely, factors rated as not important by all groups were: use of internet, religious beliefs and friends' views. Using analysis of variance, there was a statistically significant variance between the HD and the PD group responses in the following factors: provision of written information (P=0.048), fitting modality with lifestyle (P=0.025), family/home/work circumstances (P=0.003) and past medical history (P=0.018). Fifty per cent of patients who chose PD attended a formal education day compared to 32.9% that chose HD and 0% that chose CM (P=0.011). The following demographic factors were crucial in predicting RRM choice: being married (PD 95.7%, HD 53.8%, CM 41.7%; P<0.001), being employed (PD 33.3%, HD 11.5%, CM 0%; P=0.015) and having another person living at home (PD 100%, HD 69.5%, CM 50%; P=0.003). Patients who have had a social services assessment in the last 12 months or received private care services or disability allowance were more likely to choose CM.
CONCLUSIONS: This study highlights important factors influencing patient choice of end-stage renal disease treatment modality including CM. While some of these are non-modifiable, such as age and degree of co-morbidity, others draw attention to the importance of good information provision and pre-dialysis education in empowering socially able patients to choose self-care therapies. Furthermore, the overwhelming association of having a strong social support network and being functionally able with choosing PD emphasizes the need for assisted PD.