title: Association of patient autonomy with increased transplantation and survival among new dialysis patients in the United States.
abstract: BACKGROUND
  It is unclear whether patients with chronic kidney disease who are more autonomous in medical decision making have better outcomes than those who are not. We examined the contribution of patient autonomy to treatment selection (peritoneal dialysis versus hemodialysis) and subsequent association with transplantation and survival.
  
  
  METHODS
  Data were obtained from the Dialysis Morbidity and Mortality Study Wave 2, a national random sample of 4,025 new dialysis patients enrolled during 1996 and 1997 and followed up until October 31, 2001. Responders were asked to quantify their contribution to treatment selection and were grouped based on perceived degree of participation as patient led, team led, or patient and team led. Groups were compared and subsequent outcomes were evaluated by using Cox regression.
  
  
  RESULTS
  Six hundred thirty-six patients (26.3%) reported a patient-led decision, 860 patients (35.6%) reported a team-led decision, and 922 patients (38.1%) reported a patient-and-team-led decision in treatment assignment. Unadjusted death rates were significantly lower (127 versus 159 versus 207 deaths/1,000 patient-years at risk; P < 0.0001), and transplantation rates were significantly higher (103 versus 88 versus 41 transplantations/1,000 patient-years at risk; P < 0.0001) for patients reporting the greatest contribution to modality selection. With adjustment for case mix, mortality risks were lowest (relative risk [RR], 0.84; 95% confidence interval [CI], 0.71 to 0.99) and transplantation rates were highest (RR, 1.44; 95% CI, 1.07 to 1.93) for the patient-led group.
  
  
  CONCLUSIONS
  Although the contribution of patient selection factors cannot be completely ignored, this analysis supports an association of patient autonomy with transplantation and survival. Greater efforts to empower patients with chronic kidney disease during the period before end-stage renal disease may improve clinical outcomes.
authors.affiliation: Department of Internal Medicine, Regional Kidney Center, Letterkenny General Hospital, North Western Health Board, Letterkenny, Ireland. austin.stack@uth.tmc.edu
authors.forename: Austin G
authors.initials: AG
authors.lastname: Stack
authors.forename: David R
authors.initials: DR
authors.lastname: Martin
mesh_terms: D000328:Adult; D000368:Aged; D019090:Case Management; D015331:Cohort Studies; D015897:Comorbidity; D003644:Death Certificates; D003953:Diagnosis-Related Groups; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D007676:Kidney Failure, Chronic / Q000401:mortality / Q000523:psychology* / Q000601:surgery / Q000628:therapy; D016030:Kidney Transplantation / Q000706:statistics & numerical data*; D008297:Male; D008875:Middle Aged; D010348:Patient Care Team; D010358:Patient Participation / Q000706:statistics & numerical data*; D017060:Patient Satisfaction / Q000706:statistics & numerical data*; D026684:Personal Autonomy; D016016:Proportional Hazards Models; D011446:Prospective Studies; D011788:Quality of Life; D006435:Renal Dialysis / Q000706:statistics & numerical data*; D012306:Risk; D012494:Sampling Studies; D015983:Selection Bias; D011795:Surveys and Questionnaires; D016019:Survival Analysis; D016896:Treatment Outcome; D014481:United States / Q000453:epidemiology