February 2004 - Patients beginning dialysis are more likely to rate their overall care higher and be more satisfied if they receive peritoneal dialysis rather than hemodialysis, according to a study in the February 11, 2004 issue of The Journal of the American Medical Association (JAMA).
According to background information, nearly 100,000 patients with incident end-stage renal (kidney) disease (ESRD) in the United States must choose between hemodialysis and peritoneal dialysis. Hemodialysis is usually performed in an outpatient dialysis facility 3 times a week for 3 to 4 hours, where trained nurses and technicians carry out the prescribed treatment using a dialysis machine under the direction of a physician. With this technique, insertion of special catheters or placement of grafts in the blood vessels is needed. In contrast, peritoneal dialysis involves inserting a special catheter into the abdominal cavity, and dialysis fluid is inserted and removed in several cycles throughout the night or day.
Peritoneal dialysis is most commonly performed every day at home by the patient after receiving training by dialysis facility staff. Previous studies comparing the two methods have indicated either no difference in survival rate, or better survival with peritoneal dialysis, especially in the first two years after starting dialysis. An earlier study indicated that the prevalence of the use of peritoneal dialysis among all dialysis patients is approximately 8.4 percent.
Haya R. Rubin, M.D., Ph.D., of The Johns Hopkins School of Medicine, Baltimore, and colleagues conducted a study to compare evaluations of dialysis care by peritoneal and hemodialysis patients at the same dialysis centers after several weeks of initiating dialysis. The study included a survey at enrollment of 736 patients who started dialysis at 37 dialysis centers participating in the Choices for Healthy Outcomes in Caring for End-stage Renal Disease (CHOICE) study, a national multicenter study of dialysis outcomes, from October 1995 to June 1998. Of those initially enrolled, 656 (89 percent) returned a satisfaction questionnaire after an average of 7 weeks of dialysis. Information collected included 3 overall ratings and 20 items rating specific aspects of dialysis care.
The researchers found that patients receiving peritoneal dialysis were much more likely (nearly 1.5 times more likely) than those receiving hemodialysis to give excellent ratings of dialysis care overall (85 percent vs. 56 percent, respectively); and significantly more likely to give excellent ratings for each specific aspect of care rated. The 3 items with the greatest differences were in the domain of information provided (average of information items: peritoneal dialysis [69 percent excellent] vs. hemodialysis [30 percent excellent]). The smallest differences were in ratings of accuracy of information from the nephrologist (a physician who specializes in the treatment of kidney disease), response to pain, amount of fluid removed, and staff availability in an emergency.
"In conclusion, our results that peritoneal dialysis patients rate their care more highly than hemodialysis patients suggest that nephrologists and primary care physicians should give greater consideration to peritoneal dialysis when patients are eligible for either modality, especially in light of no clear superiority in survival. More thorough information about choice of modality prior to the start of renal replacement therapy may lead more patients to choose peritoneal dialysis and lead to better patient satisfaction," the authors write.
Supported in part by grants from the Agency for Healthcare Research and Quality, Rockville, Md., and the National Institutes of Diabetes and Digestive and Kidney Diseases (NIDDK), Bethesda, Md. Co-author Dr. Neil Powe is supported in part by a grant from the NIDDK.
EDITORIAL: UNDERUTILIZATION OF PERITONEAL DIALYSIS
In an accompanying editorial, James Heaf, M.D., of Herlev University Hospital, Herlev, Denmark, writes that peritoneal dialysis is not used as often as it should be and offers suggestions on how to increase its use.
"Given these findings [of Rubin et al], it is therefore surprising that the incidence and prevalence of peritoneal dialysis use in the United States continue to decline, reaching 7.5 percent (6,991 new peritoneal dialysis patients/93,280 new dialysis patients) and 8.4 percent (24,268 peritoneal dialysis patients/288,978 dialysis patients), respectively, in 2001 and already much lower than rates in countries with comparable economies, such as Canada, the Netherlands, Denmark, and Sweden."
Dr. Heaf writes that although peritoneal dialysis is underutilized, several approaches in combination may help to substantially increase its use, including improvements in dialysis training; early patient referral; early dialysis planning; efficient access procedures; and agencies that provide funding for ESRD care finding peritoneal dialysis attractive.
"Patient choice, trained physicians, early referral, early dialysis planning, increased patient education, short waiting times, and rational funding are all desirable goals and markers of a well-run ESRD program. Peritoneal dialysis prevalence rates could indeed be considered a useful marker of program quality," he concludes.