Consider - considerations of nephrologists when suggesting dialysis in elderly patients with renal failure: a discrete choice experiment

Aim: Determine the relative influence of elderly patient characteristics on nephrologists' dialysis recommendations.

Background: Nephrologists often face difficult decisions in recommending dialysis or non‐dialysis (supportive) care for elderly patients, given uncertainty around survival and the heavy burden of dialysis treatment. Discrete choice experiments (DCEs) mimic real‐world decisions through simultaneous consideration of multiple variables.

Methods: We conducted a DCE among Australasian nephrologists to assess the influence of patient characteristics on preferences for recommending dialysis. The DCE consisted of 12 scenarios of two patients described in terms of age, gender, cognition, comorbidity, life expectancy, current quality of life (QOL), expected QOL with dialysis, social support, patient and family inclination. Nephrologists indicated which hypothetical patient they preferred recommending dialysis for, or whether they preferred “neither”. Mixed logit models determined the odds of recommending dialysis over no dialysis. Trade‐offs between QOL and survival were calculated.

Results: A total of 159 nephrologists participated, with 34% aged 40–49 years, 62% male and 69% Caucasian. All characteristics except gender significantly affected the likelihood of dialysis recommendation. Nephrologists were more likely to recommend dialysis for patients with preserved cognition (OR 68.3 (95%CI 33.4–140.0)), lower comorbidity (OR 2.1 (1.1–4.1)), increased life expectancy (OR 2.8 (2.1–3.7)), high current QOL (OR 2.8 (2.0–3.8)) and positive patient and family dialysis inclination ((OR 27.5 (16.2–46.8), (OR 2.0 (1.3–3.3)) respectively). Nephrologists aged >65 were more likely (OR 11.7 (1.8–77.2)) to recommend dialysis. Nephrologists were willing to forgo 12 months of survival to avoid substantial QOL decrease with dialysis initiation.

Conclusions: Nephrologists avoided dialysis recommendation if it was expected to considerably reduce QOL. To inform dialysis decisions for the elderly, systematic and longitudinal evaluations of cognition and QOL are needed and research to better understand patient preferences.