Does greater pediatric experience influence treatment choices in chronic disease management? Dialysis modality choice for children with end-stage renal disease
S. L. Furth, N. R. Powe, W. Hwang, A. M. Neu and B. A. Fivush
Department of Pediatrics, Johns Hopkins School of Hygiene and Public Health, Baltimore, Md, USA.
OBJECTIVE: To determine whether treatment choice for children with
end-stage renal disease varies with greater pediatric experience at the
dialysis facility. DESIGN: National cross-sectional study. SETTING:
Outpatient dialysis facilities throughout the United States. PATIENTS: All
children (age, < or = 19 years) undergoing dialysis in 1990, identified
using the Medicare End-stage Renal Disease registry (1990 facility survey
and quarterly dialysis records). OUTCOME MEASURES: The odds of receiving
peritoneal dialysis vs hemodialysis according to the pediatric experience
of the facility. "Pediatric experience" for dialysis facilities was defined
as the number of patients 19 years old or younger divided by the total
number of patients treated at that facility. Adjustment, using multiple
logistic regression, was made for differences in age, sex, cause and
duration of end-stage renal disease, income, education, and facility
characteristics. RESULTS: In 1990, there were 1256 patients 19 years old or
younger who underwent a single-treatment modality at a single facility for
most of the year. Sixty-three percent (790/ 1256) were treated at
facilities with fewer than 5% of patients younger than 19 years. Thirty-six
percent were treated at centers with less than 1% of pediatric patients. In
a multivariate analysis, pediatric experience in a facility was
independently associated with the use of peritoneal dialysis in children.
Children treated at facilities with more than 10% pediatric patients were
60% more likely to be treated with peritoneal dialysis rather than
hemodialysis compared with children treated at facilities with fewer than
1% of pediatric patients, even after controlling for patient age, race,
income, education, cause and duration of end-stage renal disease, and
facility characteristics such as hospital-based vs independent unit and
for-profit vs not-for-profit status (odds ratio, 1.6; 95% confidence
interval, 1.1-2.3). CONCLUSIONS: Children receiving care at dialysis
facilities that have greater experience with pediatric patients are more
likely to receive peritoneal dialysis than hemodialysis, a therapy with
recognized clinical benefits for children that is inherently less resource
intensive than is hemodialysis.
