title: COnsiderations of Nephrologists when SuggestIng Dialysis in Elderly patients with Renal failure (CONSIDER): a discrete choice experiment.
abstract: BACKGROUND
  Nephrologists often face difficult decisions when recommending dialysis or non-dialysis (supportive) care for elderly patients, given the uncertainty around survival and the burden of dialysis. Discrete choice experiments (DCEs) mimic real-world decisions through simultaneous consideration of multiple variables. We aimed to determine the relative influence of patient characteristics on dialysis recommendations.
  
  
  METHODS
  We conducted a DCE among Australasian nephrologists consisting of 12 scenarios of two patients (described in terms of age, gender, cognition, comorbidity, life expectancy, current quality of life (QOL), expected QOL with dialysis, social support, patient and family inclination). Nephrologists indicated which patient they preferred recommending dialysis for, or whether they preferred 'neither'. Mixed logit models determined the odds of recommending dialysis over no dialysis. Trade-offs between QOL and survival were calculated.
  
  
  RESULTS
  A total of 159 nephrologists participated (34% aged 40-49 years, 62% male and 69% Caucasian). All patient characteristics except gender significantly affected the likelihood of dialysis recommendation. Nephrologists were more likely to recommend dialysis for patients with preserved cognition (odds ratio [OR]: 68.3; 95% confidence interval [CI]: 33.4-140.0), lower comorbidity (OR: 2.1; 95% CI: 1.1-4.1), increased life expectancy (OR: 2.8; 95% CI: 2.1-3.7), high current QOL (OR: 2.8; 95% CI: 2.0-3.8) and positive patient and family dialysis inclination (OR: 27.5; 95% CI: 16.2-46.8 and OR: 2.0; 95% CI: 1.3-3.3, respectively). Nephrologists aged >65 were more likely (OR: 11.7; 95% CI: 1.8-77.2) to recommend dialysis. Nephrologists were willing to forgo 12 months of patient survival to avoid substantial QOL decrease with dialysis.
  
  
  CONCLUSIONS
  Nephrologists avoided dialysis recommendation if it was expected to considerably reduce QOL. To inform elderly patients' dialysis decisions, systematic and longitudinal cognition and QOL evaluations are needed as well as better research into understanding patient preferences.
authors: The George Institute for Global Health, University of Sydney, Sydney, New South Wales, Australia Renal Department, Concord Repatriation General Hospital, Sydney, New South Wales, Australia.
authors: Celine
authors: C
authors: Foote
authors: School of Public Health, University of Sydney, Sydney, New South Wales, Australia Nuffield Department of Population Health, University of Oxford, Headington,Oxford, UK.
authors: Rachael L
authors: RL
authors: Morton
authors: The George Institute for Global Health, University of Sydney, Sydney, New South Wales, Australia Renal Department, Concord Repatriation General Hospital, Sydney, New South Wales, Australia.
authors: Meg
authors: M
authors: Jardine
authors: The George Institute for Global Health, University of Sydney, Sydney, New South Wales, Australia Concord Clinical School, University of Sydney, Sydney, New South Wales, Australia.
authors: Martin
authors: M
authors: Gallagher
authors: Renal Medicine Department, St George Hospital, Sydney, New South Wales, Australia Department of Medicine, University of New South Wales, Sydney, New South Wales, Australia.
authors: Mark
authors: M
authors: Brown
authors: School of Public Health, University of Sydney, Sydney, New South Wales, Australia.
authors: Kirsten
authors: K
authors: Howard
authors: The George Institute for Global Health, University of Sydney, Sydney, New South Wales, Australia Menzies School of Research, Charles Darwin University, Darwin, Northern Territory, Australia.
authors: Alan
authors: A
authors: Cass
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001315:Australia; D002755:Choice Behavior; D002983:Clinical Competence; D003657:Decision Making; D005260:Female; D006801:Humans; D007676:Kidney Failure, Chronic / Q000628:therapy*; D008297:Male; D008875:Middle Aged; D009398:Nephrology / Q000592:standards*; D057240:Patient Preference; D017410:Practice Guidelines as Topic; D011788:Quality of Life; D006435:Renal Dialysis
keywords: decision-making; dialysis; discrete choice; elderly; nephrologist