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Relation between pediatric experience and treatment recommendations for children and adolescents with kidney failure
1Division of Pediatric Nephrology, Department of Pediatrics, Welch Center for Prevention, Epidemiology and Clinical Research, The Johns Hopkins Medical Institutions, Baltimore, MD, USA. sfurth@jhmi.edu
Insights
Pediatric nephrologists are 60% more likely to recommend peritoneal dialysis for children with kidney failure than adult nephrologists. This highlights how clinician specialization impacts treatment decisions for pediatric end-stage renal disease.
Area of Science:
- Nephrology
- Pediatric Nephrology
- Dialysis Treatment
Background:
- Children with renal failure often receive care from adult subspecialists.
- Peritoneal dialysis is the preferred dialysis method for children, unlike in adults.
- Existing data show variations in peritoneal dialysis use among pediatric patients, but the influence of clinician experience is unclear.
Purpose of the Study:
- To determine if a nephrologist's pediatric experience influences their treatment recommendations for pediatric kidney failure patients.
- To assess the impact of subspecialty training on dialysis modality selection for children.
Main Methods:
- A cross-sectional survey was conducted using 10 case vignettes per participant.
- Vignettes presented randomized patient characteristics to evaluate treatment recommendations.
- A national random sample of 316 adult and pediatric nephrologists responded to the survey.
Main Results:
- Pediatric nephrologists were 60% more likely to recommend peritoneal dialysis over hemodialysis for identical pediatric patients.
- This increased likelihood persisted regardless of patient characteristics, clinician's training, practice setting, or years in practice.
- The odds ratio for recommending peritoneal dialysis was 1.61 (95% CI, 1.35-1.92) for pediatric specialists.
Conclusions:
- Clinician specialization significantly influences treatment recommendations for pediatric end-stage renal disease.
- Referrals to adult subspecialists may result in different treatment choices and care processes for children.
- Ensuring care by pediatric-specialized nephrologists is crucial for optimal dialysis modality selection in children.
Context:
Children and adolescent patients with renal failure are frequently cared for by adult subspecialists. While peritoneal dialysis is used in less than 17% of adults with kidney failure, it is the preferred dialysis treatment for children. National data show that 45% of children receiving dialysis are treated with peritoneal dialysis and pediatric nephrologists report its use in 65% of patients receiving dialysis. Whether differences in peritoneal dialysis use among children are due to the pediatric experience of the clinician has not been examined.
Objective:
To assess whether the pediatric experience of nephrologists directly affects treatment recommendations for children with kidney failure.
Design:
Cross-sectional survey using 10 case vignettes per survey based on random combinations of 8 patient characteristics (age, sex, race, distance from facility, cause of renal failure, family structure, education, and compliance).
Setting And Participants:
National random sample of office-, hospital-, and academic medical center-based adult and pediatric nephrologists, stratified by geographic region and conducted June to November 1999. Of 519 eligible physicians, 316 (61%) responded, including 191 adult and 125 pediatric nephrologists.
Main Outcome Measure:
Treatment recommendations for peritoneal dialysis vs hemodialysis, compared based on nephrologists' pediatric experience.
Results:
After controlling for patient characteristics, pediatric nephrologists were 60% more likely than adult nephrologists to recommend peritoneal dialysis for identical patients (odds ratio, 1.61; 95% confidence interval, 1.35-1.92). This was true regardless of dialysis training, years in practice, practice setting, geography, or patient characteristics.
Conclusions:
Our data indicate that pediatric specialization of clinicians influences treatment recommendations for children and adolescents with end-stage renal disease. Referring children to adult subspecialists may lead to differences in treatment choices and processes of care.
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