Katharine L Cheung1, Maria E Montez-Rath2, Glenn M Chertow2, Wolfgang C Winkelmayer2, Vyjeyanthi S Periyakoil3, Manjula Kurella Tamura4. 1. Division of Nephrology, University of Vermont College of Medicine, Burlington. Katharine.L.Cheung@med.uvm.edu. 2. Division of Nephrology, Stanford University School of Medicine, Palo Alto, California. 3. Department of Medicine, Veterans Affairs Palo Alto Health Care System, California. Division of General Medical Disciplines, Stanford University School of Medicine, Palo Alto, California. 4. Division of Nephrology, Stanford University School of Medicine, Palo Alto, California. Geriatric Research and Education Clinical Center, Veterans Affairs Palo Alto Health Care System, California.
Abstract
BACKGROUND: Accurate prognostic models could inform treatment decisions for older adults with end-stage renal disease who are considering dialysis and might identify patients more appropriate for conservative care or hospice. METHODS: In a cohort of patients aged ≥ 67 years commencing dialysis in the United States between January 1, 2008 and June 30, 2009, we compared the discrimination of three existing instruments (the Liu index; the French Renal Epidemiology and Information Network score; and hospice eligibility criteria) for the prediction of 6-month mortality. We estimated the odds of death associated with each prognostic index using logistic regression with and without adjustment for age. Predictive indices were compared using the concordance ("c")-statistic. RESULTS: Of 44,109 eligible patients, 10,289 (23.3%) died within 6 months of dialysis initiation. The c-statistic for the Liu, Renal Epidemiology and Information Network, hospice eligibility criteria, and combined Liu/hospice eligibility criteria scores without and with age were 0.62/0.65, 0.63/0.66, 0.65/0.68, and 0.68/0.70, respectively. Discrimination was poorer at older ages, especially for the Liu and Renal Epidemiology and Information Network scores. Although sensitivity was poor, a Renal Epidemiology and Information Network score ≥ 9 or an hospice eligibility criteria ≥ 3 had relatively high specificity. CONCLUSIONS: Existing prognostic indices based on administrative data perform poorly with respect to prediction of 6-month mortality in older patients with end-stage renal disease commencing dialysis.
BACKGROUND: Accurate prognostic models could inform treatment decisions for older adults with end-stage renal disease who are considering dialysis and might identify patients more appropriate for conservative care or hospice. METHODS: In a cohort of patients aged ≥ 67 years commencing dialysis in the United States between January 1, 2008 and June 30, 2009, we compared the discrimination of three existing instruments (the Liu index; the French Renal Epidemiology and Information Network score; and hospice eligibility criteria) for the prediction of 6-month mortality. We estimated the odds of death associated with each prognostic index using logistic regression with and without adjustment for age. Predictive indices were compared using the concordance ("c")-statistic. RESULTS: Of 44,109 eligible patients, 10,289 (23.3%) died within 6 months of dialysis initiation. The c-statistic for the Liu, Renal Epidemiology and Information Network, hospice eligibility criteria, and combined Liu/hospice eligibility criteria scores without and with age were 0.62/0.65, 0.63/0.66, 0.65/0.68, and 0.68/0.70, respectively. Discrimination was poorer at older ages, especially for the Liu and Renal Epidemiology and Information Network scores. Although sensitivity was poor, a Renal Epidemiology and Information Network score ≥ 9 or an hospice eligibility criteria ≥ 3 had relatively high specificity. CONCLUSIONS: Existing prognostic indices based on administrative data perform poorly with respect to prediction of 6-month mortality in older patients with end-stage renal disease commencing dialysis.
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