Measuring, managing, and improving quality in the end-stage renal disease treatment setting: peritoneal dialysis

Peritoneal dialysis is now performed as an end-stage renal disease modality in nearly 70,000 patients worldwide. The use of this modality varies widely from less than 5% of all end-stage renal disease patients in Japan to over 95% of patients in Mexico. In addition to medical and psychosocial factors, modality selection involves many other factors, including financial reimbursement, educational deficiencies, resource availability, social mores, and cultural habits. Survival on chronic peritoneal dialysis is similar to that on hemodialysis, although older diabetic patients on peritoneal dialysis may have a higher mortality rate. Hospitalizations and transfer off modality are more common in patients on chronic peritoneal dialysis compared with patients on hemodialysis. The important factors contributing to outcome in patients on chronic peritoneal dialysis are unknown. Results of the Baxter Best-Demonstrated Practice Program suggest that process of care has a strong impact on outcome, at least in retention of patients on chronic peritoneal dialysis. Quality of life is another outcome that has been poorly assessed in chronic peritoneal dialysis patients. Available studies suffer from a lack of standardization of instruments used, no control groups, no random patient allocation to modalities, and short-term, small population groups. When chronic peritoneal dialysis and hemodialysis are compared, subjective quality of life is generally higher with chronic peritoneal dialysis. For objective quality of life, the balance of studies favor hemodialysis. It is clear that there is a dearth of information available on many aspects of delivery of chronic peritoneal dialysis. Future research should target patient factors that are important in morbidity and mortality with chronic peritoneal dialysis, facility factors ("process of care") that are important in morbidity and mortality with chronic peritoneal dialysis, quality of life in chronic peritoneal dialysis patients, and how to measure quality of life accurately and serially. If these issues can be addressed, algorithms could be developed to help the physician to match the end-stage renal disease patient to the treatment modality that will provide the highest quality of life, the least morbidity, and the longest survival.