Structured pre-dialysis programs: more than just timely referral?

BACKGROUND: Patients who begin chronic dialysis within 3 months of seeing a nephrologist (late referral)have increased morbidity and mortality. However, it is not known whether formal pre-dialysis education programs (PEPs) are more advantageous, regarding early dialysis outcomes and resource use, than unstructured specialist follow-up. METHODS: We prospectively collected information on specialist care, unstructured or PEP, modality choice and hospitalizations in the 1st 3 months of dialysis for all consecutive patients who started dialysis between 1st January 1999 and 30th June 2002 in two Italian centers. RESULTS: The 229 patients who participated in this study (62% male, median age 70 yrs) had a high prevalence of diabetes (27.5%) and cardiovascular disease (60%). Of these, 22.7% received unstructured follow-up and 40.6% received PEP care. Peritoneal dialysis (PD) was the first choice modality for 41.5% of patients and 55% had a planned start. Excluding late referrals (36.7%), the likelihood of PD selection was similar between PEP and unstructured care (52.7% vs. 40.4%, p = NS), while that of a planned start was greater among PEP patients (91.4% vs. 38.5%, p < 0.001). Multivariate analysis showed that only PEP (but not unstructured care) vs. late referral had a significant association with reduced odds of hemodialysis (HD) selection (OR: 0.301, [95%CI 0.153, 0.594]), emergency start (0.031 [0.013, 0.075]), 1st hospitalization > 5 days (0.165 [0.081, 0.333]), and further hospitalizations (0.346 [0.174, 0.685]). Late referrals independently predicted the lack of modality selection (1.847 [1.007, 3.388]). CONCLUSIONS: A structured PEP seemed to improve early dialysis outcomes and resource usage beyond that gained by a timely referral, except for the opportunity to select modality.