A first-of-its-kind patient satisfaction study
suggests that many patients tethered to a life-saving
artificial kidney machine that cleanses the bloodstream of
wastes might have preferred a second option —
home-based peritoneal dialysis, which uses the lining of
the patient's belly as a natural filter — if only
they had been given a truly informed choice.
The Johns Hopkins researchers found that after about
several weeks of treatment, kidney disease patients who
were given the option of peritoneal dialysis were 1.5 times
more likely than artificial kidney hemodialysis patients to
rate their overall care as excellent. Their study is
published in the Feb. 11 issue of Journal of the
American Medical Association. Neither treatment is
clearly superior to the other with regard to mortality and
overall complications.
The kidney normally cleans wastes from the
bloodstream. If the organ stops working, patients, to
survive, must undergo "kidney replacement treatment" with
either a kidney transplant or, more commonly, a lifetime of
dialysis. Peritoneal dialysis involves surgically and
permanently placing a soft plastic tube or catheter into
the lining of the belly. A sterile cleansing fluid flushed
through this catheter is allowed to dwell in the belly
until wastes pass across the lining into the fluid; the
fluid is then removed from the belly via the same tube.
Generally, peritoneal dialysis can be conducted in
several short daily sessions at home or work using portable
equipment, whereas hemodialysis requires visits to a
dialysis center multiple times each week for hours at a
time.
"Peritoneal dialysis may be a better option for more
patients than are receiving it in the U.S.," said Haya
Rubin, professor of medicine at the schools of
Medicine and Public
Health and director of Quality of Care Research at
Johns Hopkins. "Our study suggests that the vast majority
of patients who are undergoing hemodialysis could be making
a decision on dialysis treatment on the basis of very
inadequate information. Peritoneal dialysis patients are
far more happy with their care than hemodialysis patients."
Rubin added that pressure to fill large, growing numbers of
hemodialysis centers nationwide with patients who use the
more expensive personnel and equipment may be part of the
reason that more patients are undergoing hemodialysis.
The researchers undertook the study because they were
puzzled that the rate of using peritoneal dialysis
continued to fall in the United States, while anecdotal
evidence mounted that peritoneal patients were quite
satisfied with the treatment. Also, the treatment was
increasingly favored in other countries, among them
European nations, including the United Kingdom.
Currently, only 10 percent of the 100,000-plus
patients starting dialysis each year in the United States
use peritoneal dialysis.
For their study, the researchers surveyed 656 patients
at 37 dialysis centers in 14 states, asking them seven
weeks after they began dialysis about their care. While
patients who use peritoneal dialysis must visit a dialysis
center for a week or two to be trained, eventually they can
perform the 30-minute procedure four times a day outside
the center, offering them much more independence. They
typically return to the dialysis center for monthly
checkups. Hemodialysis patients, by contrast, must spend
three to four hours, three times a week, attached to a
blood-cleaning machine at a dialysis center.
The survey results showed that 85 percent of
peritoneal dialysis patients rated their care as
"excellent" compared to 56 percent of hemodialysis
patients. The ratings included variables such as care by
and access to the dialysis center staff, quality of
treatment, and pain control, but the largest differences
between the two groups of patients were "information given
to help choose modality" and "the amount of dialysis
information from staff."
Even when the results were adjusted to account for
age, race, gender, education and other demographic
differences between the two groups (peritoneal dialysis
patients tended to be better educated, married and
working), peritoneal patients still rated their quality of
care much higher than did hemodialysis patients.
"This really speaks to the issue of whether patients
are getting all the information they need up front, in a
thorough, comprehensive way, to choose the right treatment
for them," said principal investigator Neil R. Powe,
director of the
Welch Center for Prevention, Epidemiology and Clinical
Research and professor of medicine, epidemiology and
health policy and management at the schools of Medicine and
Public Health.
Rubin said, "Economic issues or lack of information on
peritoneal dialysis's benefits may promote referrals to
hemodialysis. Dialysis centers invest heavily in both
equipment and personnel and to remain financially solvent
must make sure both are used to receive reimbursement by
Medicare, the nation's largest payer of dialysis
services."
"Some patients may like the social aspects of spending
time in a hemodialysis center, and others may just not want
to bother with peritoneal dialysis," Powe said. "But I
think some hemodialysis patients would switch if they knew
more about peritoneal dialysis, because they would
appreciate being more satisfied with their care."
The study was supported by grants from the Agency for
Healthcare Research and Quality and the National Institute
of Diabetes and Digestive and Kidney Diseases. Researchers
who collaborated with Rubin and Powe include Nancy Fink and
Laura Plantinga, both of Hopkins; John Sadler, of the
Independent Dialysis Foundation in Baltimore; and Alan
Kliger, of Yale University and the Department of Medicine
at Hospital of St. Raphael, in New Haven, Conn.