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Is the Decline of Peritoneal Dialysis in the Elderly a Breakdown in the Process of Care?

Correspondence to: M. Oliver, Sunnybrook Health Sciences Centre, Room A239, 2075 Bayview Avenue, Toronto, Ontario M4N 3M5 Canada. matthew.oliver@sunnybrook.ca Received 12 May 2008; accepted 7 July 2008. Peritoneal dialysis (PD) is cost saving compared to hemodialysis (HD) and is associated with similar clinical outcomes (1,2). Prospective studies demonstrate that between 64% and 75% of incident end-stage renal disease (ESRD) patients are eligible for PD, and that between 45% and 50% will choose it as their chronic modality when PD is offered (3–6). The incident use of PD in these studies was between 34% and 39%, demonstrating that PD use can be high if a rigorous approach to how patients are assessed and offered PD is taken. However, the utilization of PD in practice is variable and, overall, is on the decline. In Europe, the percentage of patients 75 years or older treated with PD as their initial modality ranges from 2% to 33% (7), while only 6.6% of patients are treated with PD in the United States (8). In Ontario, Canada, the prevalent use of PD has fallen from 50% to 18% over the past 20 years (9). The explanation for the decline in PD utilization is not entirely clear. An aging patient population, the increasing burden of comorbid illness, as well as inadequate training of providers are potential contributors. Studies have demonstrated that age and comorbidity are certainly associated with low PD use, but these factors do not vary enough among ESRD populations to explain the wide variation in PD utilization (10–12). Mehrotra et al. analyzed the decline in PD in the United States and found that, despite adjustment for patient demographics, case mix, and laboratory data, “other factors” were at play (13). We propose an alternative explanation: low rates of PD utilization reflect a breakdown in the process of care, both in the predialysis period and shortly after the start of renal replacement therapy. We will argue that improving the process of care around modality decisions is an important and often-neglected first step toward maximizing PD utilization and preserving a patient’s right to make an informed choice. We will highlight six steps in this process of care that we feel could be improved.