Survival, symptoms and hospitalization of older patients with advanced chronic kidney disease managed without dialysis.

BACKGROUND: Shared decision-making (SDM) is important when considering whether an older patient with advanced chronic kidney disease (CKD) should be managed with dialysis or conservative kidney management (CKM). Physicians may find these conversations difficult because of the relative paucity of data on patients managed without dialysis. METHODS: This prospective observational study was conducted in a unit supported by a multidisciplinary Kidney Supportive Care (KSC) programme, in a cohort of 510 patients (280 CKM and 230 dialysis) ≥65 years of age with CKD stages 4 and 5. Survival was evaluated using logistic regression and Cox proportional hazards models. Linear mixed models were utilized to assess symptoms over time. RESULTS: CKM patients were older (mean 84 versus 74 years; P < .001) and almost 2-fold more likely to have three or more comorbidities (P < .001). The median survival of CKM patients was lower compared with dialysis from all time points: 14 months [interquartile range (IQR) 6-32] versus 53 (IQR 28-103) from decision of treatment modality or dialysis start date (P < .001); 15 months (IQR 7-34) versus 64 (IQR 30-103) from the time the estimated glomerular filtration rate (eGFR) was ≤15 mL/min/1.73 m2 (P < .001); and 8 months (IQR 3-18) versus 49 (19-101) from eGFR ≤10 mL/min/1.73 m2. A total of 59% of CKM patients reported an improvement in symptoms by their third KSC clinic visit (P < .001). The rate of unplanned hospitalization was 2-fold higher in the dialysis cohort. CONCLUSIONS: CKM patients survive a median of 14 months from the time of modality choice and have a lower rate of hospitalization than dialysis patients. Although the symptom burden in advanced CKD is high, most elderly CKM patients managed through an integrated KSC programme and can achieve improvement in their symptoms over time. These data might help with SDM.

Comparison of the cohort selection performance of Australian Medicines Terminology to Anatomical Therapeutic Chemical mappings.

OBJECTIVE: Electronic health records are increasingly utilized for observational and clinical research. Identification of cohorts using electronic health records is an important step in this process. Previous studies largely focused on the methods of cohort selection, but there is little evidence on the impact of underlying vocabularies and mappings between vocabularies used for cohort selection. We aim to compare the cohort selection performance using Australian Medicines Terminology to Anatomical Therapeutic Chemical (ATC) mappings from 2 different sources. These mappings were taken from the Observational Medical Outcomes Partnership Common Data Model (OMOP-CDM) and the Pharmaceutical Benefits Scheme (PBS) schedule. MATERIALS AND METHODS: We retrieved patients from the electronic Practice Based Research Network data repository using 3 ATC classification groups (A10, N02A, N06A). The retrieved patients were further verified manually and pooled to form a reference standard which was used to assess the accuracy of mappings using precision, recall, and F measure metrics. RESULTS: The OMOP-CDM mappings identified 2.6%, 15.2%, and 24.4% more drugs than the PBS mappings in the A10, N02A and N06A groups respectively. Despite this, the PBS mappings generally performed the same in cohort selection as OMOP-CDM mappings except for the N02A Opioids group, where a significantly greater number of patients were retrieved. Both mappings exhibited variable recall, but perfect precision, with all drugs found to be correctly identified. CONCLUSION: We found that 1 of the 3 ATC groups had a significant difference and this affected cohort selection performance. Our findings highlighted that underlying terminology mappings can greatly impact cohort selection accuracy. Clinical researchers should carefully evaluate vocabulary mapping sources including methodologies used to develop those mappings.