Hemodialysis patient preference for type of vascular access: variation and predictors across countries in the DOPPS.

PURPOSE: Catheters are associated with worse clinical outcomes than fistulas and grafts in hemodialysis (HD) patients. One potential modifier of patient vascular access (VA) use is patient preference for a particular VA type. The purpose of this study is to identify predictors of patient VA preference that could be used to improve patient care. METHODS: This study uses a cross-sectional sample of data from the Dialysis Outcomes and Practice Patterns Study (DOPPS 3, 2005-09), that includes 3815 HD patients from 224 facilities in 12 countries. Using multivariable models we measured associations between patient demographic and clinical characteristics, previous catheter use and patient preference for a catheter. RESULTS: Patient preference for a catheter varied across countries, ranging from 1% of HD patients in Japan and 18% in the United States, to 42% to 44% in Belgium and Canada. Preference for a catheter was positively associated with age (adjusted odds ratio per 10 years=1.14; 95% CI=1.02-1.26), female sex (OR 1.49; 95% CI=1.15-1.93), and former (OR=2.61; 95% CI=1.66-4.12) or current catheter use (OR=60.3; 95% CI=36.5-99.8); catheter preference was inversely associated with time on dialysis (OR per three years=0.90; 95% CI=0.82-0.97). CONCLUSIONS: Considerable variation in patient VA preference was observed across countries, suggesting that patient VA preference may be influenced by sociocultural factors and thus could be modifiable. Catheter preference was greatest among current and former catheter users, suggesting that one way to influence patient VA preference may be to avoid catheter use whenever possible.

Factors affecting employment at initiation of dialysis.

BACKGROUND AND OBJECTIVES: Half the individuals who reach ESRD are working age (< 65 years old) and many are at risk for job loss. Factors that contribute to job retention among working-age patients with chronic kidney disease before ESRD are unknown. The purpose of the study is to understand factors associated with maintaining employment among working-age patients with advanced kidney failure. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: In this retrospective study we reviewed the United States Renal Data System database (1992 through 2003) and selected all patients (n = 102,104) who were working age and employed 6 months before dialysis initiation. Factors that were examined for an association with maintaining employment status included demographics, comorbid conditions, ESRD cause, insurance, predialysis erythropoietin use, and dialysis modality. RESULTS: Maintaining employment at the same level during the final 6 months before dialysis was more likely among (1) white men ages 30 to 49 years; (2) patients with either glomerulonephritis, cystic, or urologic causes of renal failure; (3) patients choosing peritoneal dialysis for their first treatment; (4) those with employer group or other health plans; and (5) erythropoietin usage before ESRD. Maintaining employment status was less likely among patients with congestive heart failure, cardiovascular disease, cancer, and other chronic illnesses. CONCLUSIONS: The rate of unemployment in working-age patients with chronic kidney disease and ESRD is high compared with that of the general population. Treating anemia with erythropoietin before kidney failure and educating patients about work-friendly home dialysis options might improve job retention.

The new Medicare PPS and home dialysis.

Overall, we believe that bundling of payments to dialysis facilities is positive for home dialysis. The incentive for higher utilization of home therapies comes down to the fact that, with treatments for all modalities being paid at the same rate, providers will see that home modalities cost less than facility-based treatments. The adjustment for home training treatments is certainly helpful, but it is not incentive enough on its own. From our perspective, one of the biggest financial incentives for home dialysis and more frequent dialysis therapies is that these patients are statistically known to spend less time in the hospital, over time costing taxpayers and the ESRD Program less money. We will continue to encourage CMS to consider the overall cost implications of more frequent dialysis. We are hopeful that when hospitalization costs are accounted for, CMS will do even more to encourage the use of these modalities.