title: Factors influencing access to education, decision making, and receipt of preferred dialysis modality in unplanned dialysis start patients.
abstract: OBJECTIVE
  Unplanned dialysis start (UPS) leads to worse clinical outcomes than planned start, and only a minority of patients ever receive education on this topic and are able to make a modality choice, particularly for home dialysis. This study aimed to determine the predictive factors for patients receiving education, making a decision, and receiving their preferred modality choice in UPS patients following a UPS educational program (UPS-EP).
  
  
  METHODS
  The Offering Patients Therapy Options in Unplanned Start (OPTiONS) study examined the impact of the implementation of a specific UPS-EP, including decision support tools and pathway improvement on dialysis modality choice. Linear regression models were used to examine the factors predicting three key steps: referral and receipt of UPS-EP, modality decision making, and actual delivery of preferred modality choice. A simple economic assessment was performed to examine the potential benefit of implementing UPS-EP in terms of dialysis costs.
  
  
  RESULTS
  The majority of UPS patients could receive UPS-EP (214/270 patients) and were able to make a decision (177/214), although not all patients received their preferred choice (159/177). Regression analysis demonstrated that the initial dialysis modality was a predictive factor for referral and receipt of UPS-EP and modality decision making. In contrast, age was a predictor for referral and receipt of UPS-EP only, and comorbidity was not a predictor for any step, except for myocardial infarction, which was a weak predictor for lower likelihood of receiving preferred modality. Country practices predicted UPS-EP receipt and decision making. Economic analysis demonstrated the potential benefit of UPS-EP implementation because dialysis modality costs were associated with modality distribution driven by patient preference.
  
  
  CONCLUSIONS
  Education and decision support can allow UPS patients to understand their options and choose dialysis modality, and attention needs to be focused on ensuring equity of access to educational programs, especially for the elderly. Physician practice and culture across units/countries is an important predictor of UPS patient management and modality choice independent of patient-related factors. Additional work is required to understand and improve patient pathways to ensure that modality preference is enacted. There appears to be a cost benefit of delivering education, supporting choice, and ensuring that the choice is enacted in UPS patients.
authors.affiliation: Division of Renal Medicine and Baxter Novum, Department of Clinical Science, Intervention, and Technology, Karolinska Institutet, Stockholm, Sweden.
authors.forename: Anna
authors.initials: A
authors.lastname: Machowska
authors.affiliation: Division of Nephrology, Department of Internal Medicine, Robert-Bosch-Krankenhaus, Stuttgart, Germany.
authors.forename: Mark Dominik
authors.initials: MD
authors.lastname: Alscher
authors.affiliation: Department of Renal Medicine, University Hospital of North Staffordshire, Stoke-on-Trent, Staffordshire, UK.
authors.forename: Satyanarayana
authors.initials: S
authors.lastname: Reddy Vanga
authors.affiliation: Center of Nephrology, Nephrologisches Zentrum, Mettmann, Germany.
authors.forename: Michael
authors.initials: M
authors.lastname: Koch
authors.affiliation: Department of Nephrology, Odense University Hospital, Odense, Denmark.
authors.forename: Michael
authors.initials: M
authors.lastname: Aarup
authors.affiliation: Division of Renal Medicine and Baxter Novum, Department of Clinical Science, Intervention, and Technology, Karolinska Institutet, Stockholm, Sweden.
authors.forename: Abdul Rashid
authors.initials: AR
authors.lastname: Qureshi
authors.affiliation: Division of Renal Medicine and Baxter Novum, Department of Clinical Science, Intervention, and Technology, Karolinska Institutet, Stockholm, Sweden.
authors.forename: Bengt
authors.initials: B
authors.lastname: Lindholm
authors.affiliation: Baxter Healthcare SA, Zurich, Switzerland.
authors.forename: Peter A
authors.initials: PA
authors.lastname: Rutherford
keywords: chronic kidney disease; decision-making process; dialysis; patient education; unplanned dialysis start