Validity and Practice Patterns of Mortality Risk Prediction Tools in Dialysis Patients
- Voices, Choices, and Outcomes of Older Adults with CKD
November 03, 2022 | Location: Exhibit Hall, Orange County Convention Center‚ West Building
Abstract Time: 10:00 AM - 12:00 PM
Category: Geriatric Nephrology
- 1200 Geriatric Nephrology
- Bergeron, Jennifer, University of Vermont, Burlington, Vermont, United States
- Damon, Christina, Tufts University School of Medicine, Boston, Massachusetts, United States
- Meagher, Sean, University of Vermont, Burlington, Vermont, United States
- Cheung, Katharine L., University of Vermont, Burlington, Vermont, United States
Mortality rates are high among dialysis patients, but much heterogeneity exists, making it difficult to predict patients’ outcomes, particularly in older adults. Accurately predicting mortality is essential for prognostication and advance care planning. Although several risk assessment tools have been developed, few have been externally validated. Furthermore, there are no studies assessing nephrologists’ ideas and use of these tools.
All 279 of Vermont’s dialysis patients’ data were input into 3 mortality risk prediction tools: Cohen, Charlson Comorbidity Index, and Couchoud. 6 months later, chart review determined which patients had died, and the c statistic for each tool was calculated via logistic regression and subsequent ROC curve. 80% of nephrology dialysis providers in Vermont underwent a semi-structured interview regarding their experience, use, and ideas of the utility of mortality risk prediction tools. The interviews were transcribed, and common themes were identified independently by 2 reviewers.
Couchoud had the best discrimination in Vermont’s dialysis patients with a c statistic of 0.77 compared to Cohen and Charlson (both 0.68). Providers were only aware of 2 tools to predict mortality, 100% knew Cohen's surprise question and 25% knew Charlson. No nephrologists used these tools in their practice. The main barrier to use identified was concern that the tool would not be accurate in their individual patients and providers trusted their own clinical judgement over that of a tool. Most providers were open to using these tools in their prognostication if further evidence for the validity and education about the use of these tools was provided. Providers noted that if a tool with strong discrimination predicted a high mortality, it would change management of the patient- make them more likely to encourage supportive care over dialysis.
Our study shows that nephrologists do not routinely use mortality risk prediction tools in practice due to concerns about their external validity and lack of knowledge about how to use them. We also showed that Couchoud had strong discrimination, particularly in Vermont’s older population, and could be used for advanced care planning. We are currently conducting further interviews to see if this data specific to their patients changes their ideas and use of prediction tools.