Erklärungsansätze für die Inanspruchnahme der Peritonealdialyse auf Patient*innenebene

Die Hämodialyse (HD) und Peritonealdialyse (PD) gelten als medizinisch gleichwertige Behandlungsverfahren für Patient*innen mit terminaler Niereninsuffizienz. Die PD-Rate liegt in Deutschland zwischen 7 und 9,3 %. Bei gleichwertiger Aufklärung und freier Behandlungswahl wird diese auf 20-40 % geschätzt. Die Inanspruchnahme der PD in Deutschland gilt daher als unterrepräsentiert. In drei Forschungsarbeiten werden folgende Erklärungsansätze für die Inanspruchnahme der PD auf Patient*innenebene aufgezeigt: (1) Eine hohe interne Kontrollüberzeugung als patient*innenseitige Einstellung kann förderlich für die Inanspruchnahme einer PD sein. (2) Ein Anteil von 56 % der befragten HD-Patient*innen wurde über verschiedene Dialyseverfahren informiert. Höher gebildete und jüngere HD-Patient*innen wiesen eine höhere Chance auf, diese Informationen zu erhalten. Informierte HD-Patient*innen bewerteten die partizipative Entscheidungsfindung höher als nicht-informierte HD-Patient*innen. (3) Abrechnungsdaten zweier Krankenkassen zeigen einen Zusammenhang zwischen der Inanspruchnahme der PD und einer frühzeitigen Überweisung in die Nephrologie mehr als sechs Monate vor der ersten Dialyse. Die Arbeit identifiziert so mit Analysen einer Patient*innenbefragung und Abrechnungsdaten zweier Krankenkassen drei Erklärungsansätze für die Inanspruchnahme der PD auf Patient*innenebene. Sie liefert ebenfalls einen Beitrag zur Erklärung der niedrigen PD-Rate in Deutschland. Die Einordnung der Ergebnisse in das Verhaltensmodell zur Inanspruchnahme von Gesundheitsleistungen nach Andersen zeigt auf, dass die identifizierten Erklärungsansätze nicht nur patient*innenseitige Faktoren enthalten. Vielmehr beleuchtet die Einordnung der Informationsvermittlung und gemeinsamen Entscheidungsfindung sowie der frühzeitigen Überweisung auch die Relevanz von Interaktionsprozessen zwischen Ärzt*innen und Patient*innen für die Inanspruchnahme der PD. Zusätzlich bietet die Arbeit Möglichkeiten zur Operationalisierung von unabhängigen Variablen für Andersens Verhaltensmodell sowohl aus Primär- als auch aus Sekundärdaten

Hemodialysis and Peritoneal Dialysis in Germany from a Health Economic View-A Propensity Score Matched Analysis.

BACKGROUND Hemodialysis (HD) and peritoneal dialysis (PD) are deemed medically equivalent for therapy of end-stage renal disease (ESRD) and reimbursed by the German statutory health insurance (SHI). However, although the home dialysis modality PD is associated with higher patient autonomy than HD, for unknown reasons, PD uptake is low in Germany. Hence, we compared HD with PD regarding health economic outcomes, particularly costs, as potentially relevant factors for the predominance of HD. METHODS Claims data from two German health insurance funds were analysed in a retrospective cohort study regarding the prevalence of HD and PD in 2013-2016. Propensity score matching created comparable HD and PD groups (n = 436 each). Direct annual health care costs were compared. A sensitivity analysis included a comparison of different matching techniques and consideration of transportation costs. Additionally, hospitalisation and survival were investigated using Poisson regression and Kaplan-Meier curves. RESULTS Total direct annual average costs were higher for HD (€47,501) than for PD (€46,235), but not significantly (p = 0.557). The additional consideration of transportation costs revealed an annual cost advantage of €7000 for PD. HD and PD differed non-significantly in terms of hospitalisation and survival rates (p = 0.610/p = 0.207). CONCLUSIONS PD has a slight non-significant cost advantage over HD, especially when considering transportation costs

Having a Break or Being Imprisoned: Influence of Subjective Interpretations of Quarantine and Isolation on Boredom

Boredom has been identified as one of the greatest psychological challenges when staying at home during quarantine and isolation. However, this does not mean that the situation necessarily causes boredom. On the basis of 13 explorative interviews with bored and non-bored persons who have been under quarantine or in isolation, we explain why boredom is related to a subjective interpretation process rather than being a direct consequence of the objective situation. Specifically, we show that participants vary significantly in their interpretations of staying at home and, thus, also in their experience of boredom. While the non-bored participants interpret the situation as a relief or as irrelevant, the bored participants interpret it as a major restriction that only some are able to cope with

The role of personal attitudes of control and responsibility for the uptake of peritoneal dialysis-a national survey among dialysis patients

Background: Although most patients are suitable for both hemodialysis (HD) and peritoneal dialysis (PD), there seem to be differences in the outlook of patients who choose one modality over the other. There is currently limited literature about the impact of patients' personal attitudes on the decision for PD or HD. In this study, we tried to find out whether there were differences between patients who were on HD and PD in their desire for control and responsibility for their treatment. Methods: The data were drawn from a nationwide postal survey of 630 HD and PD patients. Patients' desire for control was measured by scores on the internal locus of control (ILOC) scale. Patients were also asked how important taking responsibility for their dialysis had been for their treatment decision (ITR). Two multivariate logistic regression models, both adjusted for age, were applied to investigate whether there were differences between HD and PD patients in ILOC and ITR. Having one generic measure (ILOC) and one tailored to the dialysis context (ITR) gave the opportunity to investigate if it is a generic personality trait or rather a specific attitude that affects choice of dialysis modality. Results: PD patients were younger and showed higher ILOC and ITR values. Multivariate logistic regression models adjusted for age confirmed the significant influence of ILOC and ITR on the uptake of PD. The odds ratios for being in the PD group were 1.53 for ILOC (p = 0.030; 95% CI 1.04-2.25), 1.49 for ITR (p = 0.019; 95% CI 1.07-2.07), and 0.95 (p = 0.000; 95% CI 0.94-0.97) for age in both models. Conclusions: Our analysis shows the impact of personal attitudes on the uptake of PD. Participants who generally want to keep control of their lives and take responsibility for their dialysis treatment tended to choose PD. As PD is a home dialysis treatment that requires patients to participate and contribute, it is beneficial if patients' personalities support the treatment procedure. Having two completely different treatment options that suit to different personalities gives us the opportunity to consider the relationship between personal attitudes and choice of dialysis modality

Information about different treatment options and shared decision making in dialysis care - a retrospective survey among hemodialysis patients

Background: Hemodialysis (HD) and peritoneal dialysis (PD) are equivalent treatment alternatives for patients with end stage renal disease. In Germany, there is a legal obligation to inform every patient about all treatment alternatives and their possible harms and benefits. However, there is a low utilization of PD. Therefore, the question arises, whether HD patients perceive that they were informed about different dialysis options. We further investigate, if personal characteristics of informed and non-informed patients vary, and if both groups experienced the decision for their dialysis treatment as shared decision making (SDM). Methods: The database was a nationwide postal survey of 590 HD patients from two statutory health insurers in Germany. Participants were asked whether they have been informed about both dialysis options. A logistic regression model examines impact factors on this information. We investigate differences in the German version of the 9-item SDM Questionnaire (SDM-Q-9) between informed and non-informed patients with a multivariate linear regression model. Results: 56 % of the respondents reported they had been informed about different dialysis treatment options. Patients older than 65 had a 61 % lower chance than patients <= 65 for this information (p < 0.001). High educated patients had a 47 % higher chance for this information than patients with low education level (p = 0.030). Informed patients rated a higher SDM-Q-9 scores than non-informed patients (76.9 vs. 44.2; p < 0.001). Non-informed patients showed high values in those SDM-Q-9 items which had no regard to different treatment options. Conclusions: A great proportion of HD patients - mostly elderly patients and patients with a low education level - did not perceive that they were informed about different dialysis options before dialysis was initiated. The current obligation to provide information about all treatment alternatives in Germany is a first step to assure the unselected access to different treatment options. But it has not reached routine application in health care yet. Information about different treatment options can pave the way for SDM. While SDM is considered to be a valuable tool in clinical medicine, there is still room for improvement for its successful implementation when it comes to decision making on different dialysis treatment options

Early Referral to Nephrological Care and the Uptake of Peritoneal Dialysis. An Analysis of German Claims Data

Background: Hemodialysis (HD) and peritoneal dialysis (PD) are medically equivalent alternatives for symptomatic therapy of end-stage renal disease (ESRD). An early referral (ER) of patients with chronic kidney disease (CKD) to a nephrological specialist is associated with a higher proportion of patients choosing PD. Germany historically shows a low PD uptake. This article is the first investigation into the impact of ER on the uptake of PD, using a large German claims database. Methods: Claims data of 4727 incident dialysis patients in 2015 and 2016 were analyzed. Accounting codes for nephrological care and dialysis modalities were identified. Their first documentation was defined as their first encounter with a nephrologist and their first dialysis treatment (HD or PD). ER was determined as receiving nephrological care at least six months before the first dialysis. A multivariate logistic regression model with adjusted odds ratios (AOR) investigates the impact of ER, outpatient dialysis start, age, comorbidities, and sex on the chance for PD. Results: Forty-three percent were referred to the nephrologist six months before their first dialysis (ER). Single tests, as well as the adjusted multivariate logistic regression, highlighted that ER significantly increases the chance for PD. In the multivariate model, the uptake of PD was associated with ER (AOR = 3.05; p < 0.001; 95% CI = 2.16-4.32), outpatient dialysis start (AOR = 0.71; p = 0.044; 95% CI = 0.51-0.99), younger age (AOR = 0.96; p < 0.001; 95% CI = 0.95-0.97), and fewer comorbidities (AOR = 0.85; p < 0.001; 95% CI = 0.44-1.58). Conclusions: ER of patients with CKD to a nephrologist increases PD uptake. It gives both nephrologists and patients enough time for patient education about different treatment options and can contribute to informed decisions about the dialysis treatment

Multidimensional analysis of factors responsible for the low prevalence of ambulatory peritoneal dialysis in Germany (MAU-PD): a cross-sectional Mixed-Methods Study Protocol

Introduction Patients with end-stage kidney failure can be treated either by transplant or by dialysis, which can be administered as haemodialysis (HD) or peritoneal dialysis (PD). Although they are equivalent therapeutic options in terms of mortality, the percentage of patients in Germany treated with PD is currently very low (similar to 6%) compared with other countries. The aim of our study is to analyse the factors behind this percentage and their relevance to the choice of dialysis treatment in Germany. This includes analyses of regional disparities in the provision of care for dialysis patients as well as the evaluations of costs and the influence of reimbursement structures. This approach should provide further insights to explain the variation in the usage of PD and HD and will help to define starting points for future interventions. Methods and analysis A mixed-methods approach will be applied to several data sources, including administrative data (ambulatory physicians' claim data, statutory health insurance claim data), quality assurance data from one of the largest German dialysis providers Kuratorium fur Dialyse (KfH) and qualitative and quantitative survey data (patients, nephrologists and dialysis nurses). Qualitative data will be analysed content-analytically. Based on the quantitative data, multivariable analyses will be performed and, where possible, hierarchical models will be tested. This multidimensional approach will enable us to account for the different factors influencing the penetration of PD in Germany. Ethics and dissemination Ethics approval (17-299) has been obtained from the Ethics Committee of the Medical Faculty of the University of Cologne on 25 April 2018. National and international dissemination will be accomplished by informing healthcare practitioners, patients and professional organisations and other stakeholders via conferences, scientific and non-scientific publications and seminars

The somatic care of patients with comorbid mental disorders: protocol of a mixed-methods study aiming to identify barriers to and enablers of utilization of somatic healthcare (SoKo)

Abstract Background Healthcare for people with somatic and comorbid mental diseases can pose a challenge to the healthcare system. The aim of the SoKo study (the Somatic care of patients with mental Comorbidity) is to assess the current state of care and the facilitators and barriers of somatic care of people with somatic disorders and comorbidity of a mental disorder. Methods The study is conducted as a mixed-methods approach and will include (a) descriptive and inferential analysis of secondary claims data of persons insured by a German statutory health insurance company in North Rhine-Westphalia (Techniker Krankenkasse, TK-NRW), (b) qualitative individual interviews and group discussions, and (c) based on (a) and (b), quantitative surveys of both patients and physicians. We intend to analyse a sample of claims data of about 2.6 million persons insured by TK-NRW (group comparisons between TK-NRW insured persons with a diagnosis of a prevalent somatic disease [ICD-10-GM E01–E07, E11, E66, I10–I15, I20–I25, I60–I64] with and without comorbidity of a mental disorder [F00–F99]), in order to assess the uptake of somatic care by people with mental and somatic comorbidity. In addition, primary data from patients with the aforementioned somatic illnesses and a mental comorbidity as well as primary data from physicians (general practitioners and medical specialists) will be collected. The focus here will be on support factors and barriers in the somatic care of people with mental comorbidity. Discussion Up to now, there have been no published results of a systematic collection of both secondary and primary data on the utilisation of different care services of somatically ill patients with mental comorbidity for Germany. The present mixed-methods study aims to address this gap. Trial registration The trial is registered with the German Clinical Trials Register DRKS: DRKS00030513. The trial was registered on 3rd February 2023