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Original Investigation
February 2016

Timing of Initiation of Maintenance DialysisA Qualitative Analysis of the Electronic Medical Records of a National Cohort of Patients From the Department of Veterans Affairs

Author Affiliations
  • 1Department of Medicine, University of Washington, Seattle
  • 2Department of Medicine, VA Puget Sound Healthcare System, Seattle, Washington
  • 3Department of Anthropology, University of Washington, Seattle
  • 4Chronic Kidney Disease Initiative, Division of Diabetes Translation, Centers for Disease Control and Prevention, Atlanta, Georgia
  • 5Health Service Research and Development Center of Innovation, VA Puget Sound Healthcare System, Seattle, Washington
  • 6Department of Health Services, University of Washington, Seattle
  • 7Liberia Country Office, Division of Global Health Protection, Centers for Disease Control and Prevention, Atlanta, Georgia
JAMA Intern Med. 2016;176(2):228-235. doi:10.1001/jamainternmed.2015.7412

Importance  There is often considerable uncertainty about the optimal time to initiate maintenance dialysis in individual patients and little medical evidence to guide this decision.

Objective  To gain a better understanding of the factors influencing the timing of initiation of dialysis in clinical practice.

Design, Setting, and Participants  A qualitative analysis was conducted using the electronic medical records from the Department of Veterans Affairs (VA) of a national random sample of 1691 patients for whom the decision to initiate maintenance dialysis occurred in the VA between January 1, 2000, and December 31, 2009. Data analysis took place from June 1 to November 30, 2014.

Main Outcomes and Measures  Central themes related to the timing of initiation of dialysis as documented in patients’ electronic medical records.

Results  Of the 1691 patients, 1264 (74.7%) initiated dialysis as inpatients and 1228 (72.6%) initiated dialysis with a hemodialysis catheter. Cohort members met with a nephrologist during an outpatient clinic visit a median of 3 times (interquartile range, 0-6) in the year prior to initiation of dialysis. The mean (SD) estimated glomerular filtration rate at the time of initiation for cohort members was 10.4 (5.7) mL/min/1.73 m2. The timing of initiation of dialysis reflected the complex interplay of at least 3 interrelated and dynamic processes. The first was physician practices, which ranged from practices intended to prepare patients for dialysis to those intended to forestall the need for dialysis by managing the signs and symptoms of uremia with medical interventions. The second process was sources of momentum. Initiation of dialysis was often precipitated by clinical events involving acute illness or medical procedures. In these settings, the imperative to treat often seemed to override patient choice. The third process was patient-physician dynamics. Interactions between patients and physicians were sometimes adversarial, and physician recommendations to initiate dialysis sometimes seemed to conflict with patient priorities.

Conclusions and Relevance  The initiation of maintenance dialysis reflects the care practices of individual physicians, sources of momentum for initiation of dialysis, interactions between patients and physicians, and the complex interplay of these dynamic processes over time. Our findings suggest opportunities to improve communication between patients and physicians and to better align these processes with patients’ values, goals, and preferences.