A patient centered approach to the treatment of renal vascular disease to prevent end stage renal failure.

Abstract

Atherosclerotic renal vascular disease (RVD) is a cause of renal failure especially in the elderly. There has never been a clinical trial to determine how effective invasive therapy is over medical therapy to prevent end stage renal disease. The objective of this study was to determine how effective invasive therapy for RVD to prevent renal failure should be from the perspective of the patient to warrant implementation. Subjects included 28 elderly dialysis patients and 26 renal health care workers (HCW). Subjects were asked directly how effective invasive therapy should be if they were to undertake the procedure. Invasive therapy would have to eliminate the need for dialysis permanently by 41 +/- 6% for the dialysis patients and 21 +/- 4% for the HCW to be acceptable. This difference in efficacy between the two groups was statistically significant (P = 0.014). Efficacy was also determined using a medical decision analysis model that incorporated patient health related quality of life status for dialysis and non-dialysis. To be cost-effective (< $50,000 incremental cost/quality adjusted life year) invasive therapy had to reduce the development of end stage renal failure by 35 +/- 1% (M +/- SE) for dialysis patients and 15 +/- 1% for HCW. These results show that patients demand better efficacy rates than their providers and that this difference appears to be appropriate based on their perceptions of health and projected outcomes. Both patient and health care workers are more conservative than predicted by the medical decision analysis model. Since the range of patient responses was large, methods of documenting patient perspectives for risky procedures may help clinicians determine how aggressively to investigate and treat patients with RVD.