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Original Investigation
May 28, 2019

Association Between the Publication of the Initiating Dialysis Early and Late Trial and the Timing of Dialysis Initiation in Canada

Author Affiliations
  • 1Department of Internal Medicine, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
  • 2Seven Oaks General Hospital, Chronic Disease Innovation Centre, Winnipeg, Manitoba, Canada
  • 3Department of Epidemiology and Biostatistics, Western University, London, Ontario, Canada
  • 4Department of Medicine, Western University, London, Ontario, Canada
  • 5Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
  • 6The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
  • 7Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
  • 8Humber River Hospital, Toronto, Ontario, Canada
  • 9Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
  • 10Nova Scotia Health Authority, Halifax, Nova Scotia, Canada
  • 11Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
  • 12BC Renal Agency, Vancouver, British Columbia, Canada
  • 13Department of Medicine, McGill University Health Centre, Montreal, Quebec, Canada
  • 14O’Brien Institute for Public Health, University of Calgary, Calgary, Alberta, Canada
JAMA Intern Med. 2019;179(7):934-941. doi:10.1001/jamainternmed.2019.0489
Key Points

Question  Is the dissemination of the Initiating Dialysis Early and Late randomized clinical trial associated with changes in the proportion of patients who initiate dialysis early in Canada?

Findings  In this interrupted time series analysis involving 28 468 patients with incident dialysis, a statistically significant immediate decrease in the proportion of early dialysis initiations was observed after trial publication, and a change in the initiation trend was noted between the pretrial and posttrial periods. No statistically significant differences were observed in acute inpatient dialysis initiations, the proportion of patients receiving home dialysis as the initial modality, or the proportion of arteriovenous access creation at hemodialysis initiation.

Meaning  The Initiating Dialysis Early and Late trial appeared to be associated with an immediate and sustained change in the timing of dialysis initiation in Canada.

Abstract

Importance  Published in 2010, the Initiating Dialysis Early and Late (IDEAL) randomized clinical trial, which randomized patients with an estimated glomerular filtration rate (GFR) between 10 and 15 mL/min/1.73 m2 to planned initiation of dialysis with an estimated GFR between 10 and 14 mL/min/1.73 m2 (early start) or an estimated GFR between 5 and 7 mL/min/1.73 m2 (late start), concluded that early initiation was not associated with improved survival or clinical outcomes.

Objective  To assess the association between the IDEAL trial results and the proportion of early dialysis starts over time.

Design, Setting, and Participants  This interrupted time series analysis used data from the Canadian Organ Replacement Register to study adult (≥18 years of age) patients with incident chronic dialysis between January 1, 2006, and December 31, 2015, in Canada, which has a universal health care system. Patients from the province of Quebec were excluded because its privacy laws preclude submission of deidentified data without first-person consent. The patients included in the study (n = 28 468) had at least 90 days of nephrologist care before starting dialysis and a recorded estimated GFR at dialysis initiation. Data analyses were performed from November 2016 to January 2019.

Main Outcomes and Measures  The primary outcome was the proportion of early dialysis starts (estimated GFR >10.5 mL/min/1.73 m2), and the secondary outcomes included the proportions of acute inpatient dialysis starts, patients who started dialysis using a home modality, and patients receiving hemodialysis who started with an arteriovenous access. Measures included the trend prior to the IDEAL trial publication, the change in this trend after publication, and the immediate consequence of publication.

Results  The final cohort comprised 28 468 patients, of whom 17 342 (60.9%) were male and the mean (SD) age was 64.8 (14.6) years. Before the IDEAL trial, a statistically significant increasing trend was observed in the monthly proportion of early dialysis starts (adjusted rate ratio, 1.002; 95% CI, 1.001-1.004; P = .004). After the IDEAL trial, an immediate decrease was observed in the proportion of early dialysis starts (rate ratio, 0.874; 95% CI, 0.818-0.933; P < .001), along with a statistically significant change in trend between the pretrial and posttrial periods (rate ratio, 0.994; 95% CI, 0.992-0.996; P < .001). No statistically significant differences were found in acute inpatient dialysis initiations, the proportion of patients receiving home dialysis as the initial modality, or the proportion of arteriovenous access creation at hemodialysis initiation after the IDEAL trial publication.

Conclusions and Relevance  The publication of the IDEAL trial appeared to be associated with an immediate and meaningful change in the timing of dialysis initiation in Canada.

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