Elsevier

The Lancet

Volume 356, Issue 9241, 4 November 2000, Pages 1543-1550
The Lancet

Articles
Clinical outcomes, quality of life, and costs in the North Thames Dialysis Study of elderly people on dialysis: a prospective cohort study

https://doi.org/10.1016/S0140-6736(00)03123-8Get rights and content

Summary

Background

Evidence-based health policy is urgently needed to meet the increasing demand for health services among elderly people, particularly for expensive technologies such as renal-replacement therapy. Age has been used to ration dialysis, although not always explicitly, despite the lack of rigorous empirical evidence about how elderly people fare on dialysis. We undertook a comprehensive assessment of outcomes in patients 70 years or over.

Methods

We did a 12-month prospective cohort study of outcomes in 221 patients with end-stage renal failure aged 70 years or over recruited from four hospital-based renal units. We assessed 1-year survival in 125 incident patients (70–86 years) and disease burden (hospital admissions, quality of life, costs) in 174 prevalent patients (70–93 years).

Findings

1-year survival rates were: 71% overall; 80%, 69%, and 54% in patients 70–74 years, 75–79 years, and 80 years and older, respectively (p=0·008); and 88%, 71%, and 64% in patients with no, one, or two or more comorbid conditions, respectively (p=0·056). Cox regression analyses showed that mortality was significantly associated with age 80 years and older (relative risk 2·79 [95% Cl 1·28–6·93]) and peripheral vascular disease (2·83 [1·29–6·17]), but not with diabetes, ischaemic heart disease, cerebrovascular disease, chronic obstructive airways disease, sex, or treatment method. In terms of disease burden, hospital admissions represent a low proportion of costs and was not required by a third of patients, mental quality of life in elderly dialysis patients was similar to that of elderly people in the general population, and the average annual cost per patient of ɛ20 802 (US$31 200) (68% dialysis treatment, 1% transport, 19% inpatient hospital admissions, 12% medications) was within the range of other life-extending interventions.

Interpretation

Our results suggest that age alone should not be used as a barrier to referral and treatment and emphasise the need to consider the benefits of dialysis in elderly people. Indicators of the ability to benefit from treatment, rather than chronological age, should be used to develop policies that ensure equal access to care for all.

Introduction

Health-care rationing has become one of the most intensely debated issues in the UK National Health Service and health services worldwide. Dialysis features prominently on the rationing agenda; in the UK it has been argued that there has been a longstanding and effective policy of covert rationing of dialysis that is now giving way to pressure for explicit rationing.1 Age has been used to ration treatment,2, 3 including renal services,4, 5 although not always openly. Suitability for treatment is sometimes decided on factors such as comorbidity and reduced life expectancy, problems that are clearly associated with age.

The issue of age rationing in dialysis is becoming an urgent health-policy concern in view of the increasing demand for renal-replacement therapy for elderly people in the UK and worldwide. This increase is inevitable because of population ageing, the liberalisation of acceptance criteria for dialysis, and the age-related increase in the incidence of chronic renal failure.6 Among all new patients starting renal-replacement therapy in England and Wales, the percentage of patients who were over 65 years increased from 11% in 1982–84 to 39% in 1995.6 A doubling of the prevalence of patients on renal-replacement therapy in the UK has been predicted over the next 15 years, with the highest growth in elderly people and those on dialysis.7 Despite such growth, treatment in the UK falls short of that provided in many other western countries, particularly with respect to elderly people.

The arguments for rationing dialysis by age–ie, that elderly people have poor survival and quality of life, that dialysis is costly, and that older people have a societal obligation to demand less—have been much debated.2, 3 However, there is little empirical evidence to inform the debate about how elderly people fare on dialysis and to guide decision-making in this area. Although survival is poorer in older than in younger patients, little is known about quality of life and costs to the health service that are associated with reduced life expectancy. There is the need for a comprehensive assessment of outcomes in elderly people on dialysis—based on rigorous evidence not only about clinical outcomes but also about quality of life and costs—so that priorities for future policy and service developments can be worked out.

Previous research on outcomes in elderly dialysis patients provides a limited picture of how elderly people fare on dialysis. Most studies have focused mainly on survival and have not considered other important outcomes that need to be taken into account in deciding whether dialysis should be offered to elderly people, such as quality of life and costs. Moreover, even this knowledge about clinical outcomes is limited. For example, comorbidity has been shown to have a more important influence on survival than age,8, 9 but it is unknown which specific comorbid conditions predict outcome in elderly patients. Although diabetes mellitus is commonly used to implicitly ration dialysis, the appropriateness of this criterion has been challenged.10 In addition, several studies purporting to provide information about how elderly people do on dialysis in fact define elderly as 55 years of age or older. And, although the costs of dialysis have been examined,11, 12 previous studies have not focused specifically on elderly patients nor have they included the full range of health and social services in cost estimates. It is important to identify costs specific to services for elderly patients in order to budget for additional expenditure.

We report the results of the North Thames Dialysis Study (NTDS), a 12-month prospective cohort study designed to assess outcomes, including clinical outcomes, quality of life, and costs, in a large sample of elderly people (70 years or over) on dialysis.

Section snippets

Study sites

Approval was obtained from the ethics committee of the hospitals taking part in the study. Patients were recruited from all renal units in the former north-west part of the current North Thames Region: Charing Cross Hospital, Hammersmith Hospital, St Mary's Hospital, and Lister Hospital. All four units have an on-site haemodialysis unit and satellite units. The first three units are based in teaching hospitals and the fourth in a district general hospital. The units vary in size from 148 to 400

Recruitment and follow-up

We recruited a total of 221 patients with end-stage renal failure aged 70 years or over at the start of dialysis. All 125 new patients 70 years and over (representing 29% of new patients of all ages) who started dialysis during the recruitment period were the incident-patient cohort. The prevalent-patient cohort included a mix of new patients in the incident cohort who survived to 90 days and stock patients who were already on dialysis. A total of 110 (88%) new patients who met the 90-day rule

Discussion

In debates about priority setting in health care, elderly people in general and costly health technologies such as dialysis are frequently targeted. The demographic changes and population ageing that are taking place, and the substantial increase in the number of people surviving into old age have led to growing demand for health services for elderly people. The development of evidence-based health policy is urgently required to manage this increasing demand.

Although there is no explicit policy

Findings

about comorbidities other than peripheral vascular disease and outcome, however, need to be interpreted with caution. The unexpected finding that diabetes, cerebrovascular disease, and ischaemic heart disease, in particular, did not predict survival may be an artifact of selection bias in referral to and acceptance onto dialysis. It may be that patients over 70 years with these conditions who are on dialysis are a highly selected group of hardy survivors who are in particularly good health or

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