Perit Dial Int
29(2):
142-143
2009
© 2009 International Society for Peritoneal Dialysis
ABSOLUTE FREE CHOICE FOR DIALYSIS MODALITY SELECTION — IS IT POSSIBLE?
Wai Kei Lo
Department of Medicine Tung Wah Hospital The University of Hong Kong Hong
Kong
e-mail:
wkloc{at}hkucc.hku.hk
In his classical book A History of Civilizations, the French
historian Fernand Braudel introduced European civilization with these two
opening sentences: "The history of Europe has everywhere been marked by
the stubborn growth of private `liberties', franchises or privileges limited
to certain groups, big or small. Often, these liberties conflicted with each
other or were mutually exclusive"
(1). "Free choice"
is no doubt one of the most important values of the modern world. We want free
choice in our selection of job, schools, living areas, religions,
nationalities, etc. However, on the other hand, people in charge of
job recruitment, school admission, and immigration departments also have their
free choice in selecting the persons they want. The two parties do not
necessarily agree. A person may want to choose to live in a certain place but
the price may not be affordable; the real world is not ideal in fulfilling our
free choices. Furthermore, we may have been subjected to unnoticeable subtle
influences when we exercised our free choice. A free choice is not that
free.
In this issue of Peritoneal Dialysis International, based on a
prospective cohort of incident peritoneal dialysis (PD) patients, recruited
between 2003 and 2006 in central Spain, Portolés et al.
pointed out that patients that were forced to receive PD had markedly
increased mortality compared to those that started PD of their own choice,
even after adjusting for comorbidities
(2). Their higher peritonitis
rates suggest that patient involvement and cooperation are important to
outcomes. While it is logical to deduce that a lower level of patient
commitment likely happens in patients being "forced" to receive
PD, the conclusion that "lack of patient free choice of technique
predicts early mortality in PD" has to be interpreted with caution.
Does the conclusion of this article speak against the obligatory PD-first
model run in places such as Mexico and Hong Kong where free choice is not
readily provided? First, it has to be noted that patients "forced"
to receive PD in this cohort of Spanish patients were actually those that had
contraindications to hemodialysis (HD), namely unavailable vascular access,
ischemic cardiopathy, or poor HD tolerance. They were forced to receive PD not
because they were not given the free choice for HD but because PD was their
only possible option. They might have died much earlier if they had not been
"forced" to receive PD. It is therefore not surprising to find
higher mortality among these patients even after adjusting for Charlson
Comorbidity Index because, apart from ischemic heart disease, the index does
not include these specific contraindications. Their survival should be
compared to patients with similar conditions but that chose to stay on HD.
In Spain, the PD utilization rate was low. According to the USRDS, it was
only 8.8% in 2005. It is hard to imagine if there are any patients forced to
use PD for nonmedical reasons in countries with such a low PD utilization
rate. In contrast, in high PD utilization areas, such as Mexico and Hong Kong
where PD penetration rates are around 80%, it is true that patients are
generally not given free choice to select dialysis modality. This is possibly
due to the unavailability of HD in the past. Although HD is more readily
available now, PD has been well accepted as the dialysis therapy in
these places, just as HD is in many other countries. In Hong Kong, PD was
proven the more cost-effective dialysis therapy. The average annual cost of a
PD patient is only around 40% that of a HD patient. Hemodialysis is therefore
provided only to patients with PD failure or contraindications for PD.
Patients need to seek HD in the private healthcare system if they choose HD
for nonmedical reasons. The philosophy is that the public healthcare system
provides the most cost-effective therapy and patients should be responsible
for the more expensive therapy if it is chosen for lifestyle reasons. Such a
policy may be criticized for not allowing patients free choice, but when there
are limited resources to support the more expensive therapy for every patient,
it is obviously not practical for the public healthcare system to support free
choice without boundaries. Taking care of more patients is more important than
supporting free choice in this setting. It is a luxury to talk about free
choice when the health budget cannot afford to provide it.
Would the lack of free choice compromise patient outcome? Although patients
would commit better to a therapy through the process of choosing, commitment
can also be built up through education, encouragement, motivation, and
training.
It was reported from the United Kingdom that if patients were given
absolute free choice after sufficient education about the choice of HD and PD,
45% of patients would choose PD
(3). Given the reported
contraindications (medical and social) for PD in 17% and 28% of incident
patients in the United Kingdom and The Netherlands respectively
(3,4),
if all patients were given the absolute free-choice for PD, the utilization
rate of PD among incident patients should be around 30% – 40%, which is
far higher that the actual PD utilization rates in all European countries. The
low PD utilization rate in most countries indicates that many patients were
either not given true free choice for PD or they were not given unbiased
information and education before making a choice. It is well known that a low
PD utilization rate is due mainly to nonmedical factors such as an unfavorable
reimbursement system and inadequate training in PD during nephrology
fellowship
(5,6).
Thus, provision of unbiased information and absolute free choice to patients
is not easy.
Ideally, patients should be given free choice of the therapy that best
suits them, medically and psychosocially. It is meaningless to perform a
randomized control trial to demonstrate the superiority of having free choice.
Who would be willing to be randomized into being forced and not allowed to
choose? People like having the right to choose. Nevertheless, in the real
world, availability of unbiased free choice seems possible only when the
health economy system can support it, when the reimbursement system is fair to
patients and healthcare workers in their selection of either HD or PD, and
when nephrologists, renal nurses, and dialysis providers are unbiased toward
either HD or PD. Conflict between healthcare providers and patients in the
arena of free choice will exist until then.
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DISCLOSURE
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I declare that I have no direct relationships with pharmaceutical companies
or other entities such as employment contracts, consultancy, advisory boards,
speaker bureaus, membership of Board of Directors, stock ownership that could
be perceived to represent a financial conflict of interest, and that no
financial conflict of interest exists.
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REFERENCES
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- Braudel F. A History of Civilizations.
[Translated by Richard Mayne.] New York: Penguin Books; 1993:307
.
- Portolés J, del Peso G, Fernández-Reyes MJ, Bajo MA,
López-Sánchez P; on behalf of the GCDP. Previous comorbidity and
lack of patient free choice of technique predict early mortality in peritoneal
dialysis. Perit Dial Int 2009;29
: 150-7.[Abstract/Free Full Text]
- Little J, Irwin A, Marshall T, Rayner H, Smith S. Predicting a
patient's choice of dialysis modality: experience in a United Kingdom renal
department. Am J Kidney Dis 2001;37
: 981-6.[Medline]
- Jager KJ, Korevaar JC, Dekker FW, Krediet RT, Boeschoten EW;
Netherlands Cooperative Study on the Adequacy of Dialysis (NECOSAD) Study
Group. The effect of contraindications and patient preference on dialysis
modality selection in ESRD patients in The Netherlands. Am J Kidney
Dis 2004; 43:891
-9.[Medline]
- Lameire N, Peeters P, Vanholder R, Van Biesen W. Peritoneal
dialysis in Europe: an analysis of its rise and fall. Blood
Purif 2006; 24:107
-14.[Medline]
- Mehrotra R, Blake P, Berman N, Nolph KD. An analysis of dialysis
training in the United States and Canada. Am J Kidney
Dis 2002; 40:152
-60.[Medline]
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DISCLOSURE
REFERENCES
