Education, increasing social support may improve PD uptake among underrepresented groups

Key takeaways:

• Scheduling education for dialysis modalities can improve racial disparities in peritoneal dialysis uptake.
• Increasing social support can also improve uptake.

AUSTIN, Texas — Patients of underrepresented groups may choose peritoneal dialysis more often as an initial modality if nephrologists prioritize modality education and social support, according to data presented here.

“End-stage kidney disease is prevalent in our patient population in the Bronx and, although peritoneal dialysis has similar clinical outcomes as hemodialysis (HD), PD is underutilized in our predominantly Hispanic and Black patient population,” Clara Wilson, MD, MPH, from the division of nephrology at the Albert Einstein school of medicine at Montefiore Medical Center in New York, told Healio. “Not much is known about the demographic, clinical or psychosocial factors that influence patient preference toward PD. Understanding these factors and barriers can better inform dialysis modality education interventions that reflect the psychosocial and cultural values of our patients, help us better understand our patients' perspectives on dialysis modality education and ultimately empower our patients to choose a modality that preserves their independence and quality of life.”

Study

Wilson and colleagues examined 54 patients on dialysis between September 2021 and 2022 (50% were women; 46.3% were Black; the mean age was 62.8 years). Patients were referred to modality education by nephrologists at Montefiore Medical Center. Sociodemographic, clinical and qualitative data were derived from chart reviews. Researchers identified any changes between the initial modality a patient chose and what they ultimately used during the study. Using chi-square tests, t-tests and Wilcoxon rank sum tests, researchers checked the correlation between modality and relevant clinical and sociodemographic variables.

Overall, 38 patients chose a modality, with 19 who chose PD and 19 who chose HD. Of those who chose PD, only 36.8% started the modality they initially chose, while 15.8% started HD instead. In contrast, 61.1% of those who chose HD started it and the rest “are awaiting starting dialysis.”

Of the 19 patients utilizing PD, they were younger (59 vs. 66.5 years of age), less likely to be Hispanic (36.8% vs. 63.1%), more likely to be married or with a partner (44.5% vs. 37.2%) to have a high school education or higher (57.9% vs. 44.5%) and to be employed (26.3% vs. 11.1%) than patients using HD. Further, patients using PD had a mean eGFR of 15.4 mL/min/1.73 m² compared with the 13.4 mL/min/1.73 m² eGFR of patients on HD at baseline.

“What surprised me about our findings is that although many patients were plugged into nephrology care and referred for dialysis modality education, a lot of patients had difficulty scheduling PD modality education, referrals occurred in later stages of CKD and several patients who chose PD ended up on HD, while all who chose HD ended up on the dialysis modality of their choice,” Wilson told Healio. “Common barriers to choosing PD cited by patients were ‘not having support’ or ‘feeling overwhelmed by doing dialysis on their own.’ This further highlights gaps at each phase of the dialysis modality education pathway that can be intervened on to allow patients to receive education in a timely manner, including getting patients to education sessions earlier so that they have more time to have concerns addressed and to incorporate their support systems, and build confidence in their modality decision before having to urgently make a decision at initiation.”

Moving forward

To improve education and social support among patients, Wilson suggests nephrologists consider timely referrals and scheduling dialysis modality education. When it comes to the curriculum, Wilson said the education structure should be sensitive to financial, psychosocial and cultural values of patients and include peer-to-peer support from current patients on PD.

In the future, Wilson hopes to conduct semi-structured interviews to identify the themes of barriers influencing PD preference among patients.

“These results will not only inform improvements in PD modality education interventions, but we also hope these interviews can be replicated as a structure for patient focus groups to provide regular feedback to PD modality education programs,” Wilson said. “Further research in peer-to-peer PD programs involving peers from the same communities and with similar psychosocial and cultural values could also be revealing and may be a means of increasing patients' sense of empowerment and self-efficacy in choosing PD.”

Editor's Note: Corrections were made on April 27, 2023, for clarity. The editors regret the error.