Shared decision-making and non-hemodialysis kidney replacement therapy selection in end-stage kidney disease: a quasi-experimental, difference-in-differences study

Shared decision-making (SDM) is essential in selecting kidney replacement therapy, yet its impact within Korea's hemodialysis (HD)-dominant environment remains unclear. This study evaluated whether a structured SDM program was associated with the selection of peritoneal dialysis (PD) or kidney transplantation (KT) over HD after accounting for secular trends.

We conducted a retrospective cohort study of patients with advanced chronic kidney disease at a tertiary center (2017- 2022). Using a quasi-experimental, difference-in-differences design, patients were grouped by SDM period and physician participation. The primary outcome was selecting PD or KT over HD; the secondary outcome was unplanned dialysis. Multivariable logistic regression models included an interaction term between SDM period and physician participation.

Among 556 patients, pre-SDM modality distributions were similar between physician groups. During the SDM period, patients managed by SDM-participating physicians more often selected PD or KT (48.5% vs. 21.9%). The fully adjusted interaction was significant for the primary composite outcome of PD or KT selection (odds ratio [OR], 3.49; 95% confidence interval [CI], 1.16- 10.54; p = 0.027). In separate analyses, the interaction was significant for KT selection (OR, 4.43; 95% CI, 1.38-14.26) but not for PD selection (OR, 0.82; 95% CI, 0.16-4.19), indicating that KT primarily drove the composite association. The interaction term was not significantly associated with unplanned dialysis.

A structured SDM program was associated with increased PD or KT selection beyond secular trends, contingent upon participating physicians. This association was driven primarily by KT rather than PD. Unplanned dialysis was not reduced, and further multicenter validation is warranted.