title: Effects of a nationwide predialysis educational program on modality choice, vascular access, and patient outcomes.
abstract: BACKGROUND
  Patients' education about transplant, hemodialysis (HD), peritoneal dialysis (PD), and conservative care often is provided by nephrologists as needed and occurs as time allows.
  
  
  METHODS
  Quality improvement report.
  
  
  METHODS
  Attendees of a national treatment options program (TOPs) who initiated long-term dialysis therapy (median, 3.4 months) at Fresenius Medical Care, North America facilities throughout 2008 were compared with period-prevalent incident patients receiving usual care.
  
  
  METHODS
  Standardized predialysis treatment options education.
  
  
  RESULTS
  Rates of opting for PD modality, arteriovenous HD access at initiation, and early (90-day) mortality risk.
  
  
  METHODS
  Logistic regression (for choice of PD and HD access type) and Cox models (for early mortality) were constructed, including a 1:1 matched cohort. A post hoc sensitivity analysis also compared a propensity score-matched cohort.
  
  
  RESULTS
  3,165 TOPs attendees (10.5% of 30,217 incident patients admitted between January 1 and December 31, 2008), were younger, more likely to be white, and had slightly larger body surface area. The unadjusted OR for TOPs attendees for selecting PD therapy was 8.45 (95% CI, 7.63-9.37) with a case-mix plus laboratory-adjusted OR of 5.13 (95% CI, 3.58-7.35). For patients who opted for in-center HD therapy, the OR was 2.14 (95% CI, 1.96-2.33) and adjusted OR was 2.06 (95% CI, 1.88-2.26) for starting with a fistula or graft. The unadjusted early mortality HR was 0.51 (95% CI, 0.43-0.60) and case-mix plus laboratory-adjusted adjusted HR was 0.61 (95% CI, 0.50-0.74) for TOPs attendees (all outcomes, P < 0.001). These results were consistent in the 1:1 matched analysis and propensity score-matched analysis.
  
  
  CONCLUSIONS
  It is possible that physicians who referred to these programs were more likely to prescribe PD therapy or place arteriovenous accesses. Motivated, treatment-adherent patients (who would have better outcomes) may have self-selected to attend education sessions.
  
  
  CONCLUSIONS
  Attending an options class predialysis was associated with more frequent selection of home dialysis, fewer tunneled HD catheters, and lower mortality risk during the first 90 days of dialysis therapy.
authors.affiliation: Fresenius Medical Care, North America, Waltham, MA 02451-1457, USA. elacsonj@fmc-na.com
authors.forename: Eduardo
authors.initials: E
authors.lastname: Lacson
authors.forename: Weiling
authors.initials: W
authors.lastname: Wang
authors.forename: Cari
authors.initials: C
authors.lastname: DeVries
authors.forename: Keith
authors.initials: K
authors.lastname: Leste
authors.forename: Raymond M
authors.initials: RM
authors.lastname: Hakim
authors.forename: Michael
authors.initials: M
authors.lastname: Lazarus
authors.forename: Joseph
authors.initials: J
authors.lastname: Pulliam
mesh_terms: D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D010353:Patient Education as Topic; D006435:Renal Dialysis; D051436:Renal Insufficiency, Chronic / Q000401:mortality / Q000628:therapy; D015996:Survival Rate; D016896:Treatment Outcome; D014481:United States