Scholarly article on topic 'Identifying Factors That Influence Physicians’ Recommendations for Dialysis and Conservative Management in Indonesia'

Identifying Factors That Influence Physicians’ Recommendations for Dialysis and Conservative Management in Indonesia Academic research paper on "Clinical medicine"

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{comorbidities / "conservative management" / dialysis / "end-stage renal disease" / "survival benefits" / "treatment recommendation"}

Abstract of research paper on Clinical medicine, author of scientific article — Eric A. Finkelstein, Semra Ozdemir, Chetna Malhotra, Tazeen H. Jafar, Hui Lin Choong, et al.

Introduction For elderly end-stage renal disease (ESRD) patients with multiple comorbidities, dialysis may offer little survival benefit compared to conservative management (CM). Yet, many elderly ESRD patients undergo dialysis, partly due to physicians’ recommendations regarding treatment choice. This study aims to elucidate the factors that influence these recommendations. Methods We surveyed a convenience sample of physicians who attended the 9th Asian Forum of Chronic Kidney Disease Initiative conference. We used vignettes that vary by age and comorbidity status, and asked physicians to recommend dialysis or CM for a hypothetical patient with that profile and to predict survival with both treatment options. We also compared the physician’s recommendations to patients for what they would recommend for themselves if they were diagnosed with ESRD. Results On average, physicians believed that dialysis extends life relative to CM. Yet, a large subset believed that CM confers greater survival. Estimates range from 17.3% (for a 65-year-old with diabetes and CHF) to 50% for patients with advanced cancer. Results further reveal high discordance regarding treatment recommendations. For a 65-year-old patient with diabetes, 62% recommended dialysis and 38% did not. For advanced cancer, the split was 25% and 75%. Physicians were far more likely to recommend dialysis for themselves than for their patients. Discussion This study suggests that physicians would benefit from a greater understanding of survival benefits of dialysis and CM for elderly patients with different comorbidity profiles. This would allow patients to make more informed decisions.

Academic research paper on topic "Identifying Factors That Influence Physicians’ Recommendations for Dialysis and Conservative Management in Indonesia"

Accepted Manuscript

Identifying Factors That Influence Physicians' Recommendations for Dialysis and Conservative Management in Indonesia

Eric A. Finkelstein, PhD, Semra Özdemir, PhD, Chetna Malhotra, MBBS, Tazeen H. Jafar, MBBS, Hui Lin Choong, MBBS, Dr. Suhardjono, MBBS

PII: S2468-0249(16)30180-2

DOI: 10.1016/j.ekir.2016.12.002

Reference: EKIR 83

To appear in: Kidney International Reports

Received Date: 4 September 2016 Revised Date: 14 November 2016 Accepted Date: 5 December 2016

Please cite this article as: Finkelstein EA, Özdemir S, Malhotra C, Jafar TH, Choong HL, Suhardjono D, Identifying Factors That Influence Physicians' Recommendations for Dialysis and Conservative Management in Indonesia, Kidney International Reports (2017), doi: 10.1016/j.ekir.2016.12.002.

This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

IDENTIFYING FACTORS THAT INFLUENCE PHYSICIANS' RECOMMENDATIONS FOR DIALYSIS AND CONSERVATIVE MANAGEMENT IN INDONESIA

RUNNING HEAD: Physicians' Recommendations for Elderly ESRD Patients

Eric A. Finkelstein1*, PhD, Semra Özdemir1, PhD, Chetna Malhotra1, MBBS, Tazeen H. Jafar1,2, MBBS, Hui Lin Choong2, MBBS, Dr. Suhardjono3, MBBS

1 Duke-NUS Medical School Singapore; 2Singapore General Hospital, Singapore; 3Department of Medicine, University of Indonesia

Correspondence: eric.finkelstein@duke-nus.edu.sg

Lien Centre for Palliative Care, Duke-NUS Medical School Singapore, 8 College Road, Singapore-169857, Singapore

ABSTRACT

Introduction: For elderly end stage renal disease (ESRD) patients with multiple comorbidities, dialysis may offer little survival benefits compared to conservative management (CM). Yet, many elderly ESRD patients receive dialysis, partly due to physicians' recommendations on treatment choice. This study aims to understand the factors that influence these recommendations.

Methods: We surveyed a convenience sample of physicians who attended the 9th Asian Forum of Chronic Kidney Disease Initiative conference. We used vignettes that vary by age and comorbidity status, and asked physicians to recommend dialysis or CM for a hypothetical patient with that profile and predict survival under both the treatment options. We also compared the physician's recommendations for patients to what they would recommend for themselves if they were diagnosed with ESRD.

Results: On average, physicians believe that dialysis extends life relative to CM. Yet, a large subset believes that CM confers greater survival. Estimates range from 17.3% (for a 65 year old with diabetes and CHF) to 50% for patients with advanced cancer. Results further reveal high discordance in treatment recommendations. For a 65 year old with diabetes, 62% recommended dialysis and 38% do not. For advanced cancer, the split is 25% and 75%. Physicians were far more likely to recommend dialysis for themselves than for their patients.

Conclusions: This study suggests that physicians would benefit from a greater understanding of survival benefits of dialysis and CM for elderly patients with different comorbidity profiles. This would allow patients to make more informed decisions.

Keywords: End-stage renal disease; treatment recommendation; dialysis; conservative management; survival benefits; comorbidities

Introduction

End stage renal disease (ESRD) is a global public health challenge with 2.6 million people currently on renal replacement therapy (e.g., dialysis) worldwide. This number is projected to double by 2030, with a majority living in countries in Asia Pacific1. Although dialysis has been shown to be effective in prolonging survival 2'3, for very elderly patients with multiple comorbidities, dialysis may offer little to no survival benefits compared to conservative management (CM), which focuses on pharmacological management of symptoms, dietary control and supportive care 4'5.

There is a significant cost to patients and families resulting from dialysis. For example, patients must spend long hours being dialyzed either at home or at a dialysis centre, with the latter also requiring additional travel time and costs. Dialysis patients also have greater rates of hospitalization 6, report lower life satisfaction 7, and are less likely to die at home, which many patients prefer 6. As a result, even in cases where dialysis confers moderate survival benefits, this may not be the preferred option for many elderly patients. Yet, evidence reveals that a majority receive dialysis when it is available 8'9. Whereas many factors may be responsible for this, physician recommendations have been shown to strongly influence ESRD patients' treatment choices, especially in Asian countries 1011. Yet the factors that influence these recommendations remain largely unknown.

The issues are particularly complex in Indonesia, the 4th most populous country in the world with over 255 million people, a significant proportion of elderly (8%), a rising burden of ESRD, and a healthcare system with substantial out-of-pocket costs for dialysis, albeit aspiring for universal coverage by 2019 12.

Therefore, we conducted this study with the objective of understanding the factors that influence physicians' recommendations for dialysis and conservative management. This study relies on a survey fielded to physicians who practice in Indonesia and attended the 9th Asian Forum of Chronic

Kidney Disease Initiative (AFCKDI) conference organized in Jakarta, Indonesia on May 8-9, 2015. Indonesia is a lower middle income country with a patriarchical society and where the out-of-pocket costs are high and access to dialysis centres is limited despite recent health care reform efforts to increase access to medical care13,14,15.

We used a series of vignettes that vary by age and comorbidity status, and asked physicians to predict median survival of hypothetical patients depending on whether they undergo dialysis or CM. For each vignette, we then asked them to choose whether they would recommend dialysis over CM. Our main hypotheses are listed as follows:

1) The percentage of physicians who recommend dialysis will decrease as patient age and comorbidity status increase;

2) Physicians will be more likely to recommend to dialysis when the hypothetical patient is male and of higher economic status.

3) Most physicians will overestimate the survival benefits of dialysis relative to CM yet the variance in the estimates will be large;

4) Physicians with more optimistic assessments about the relative survival benefits of dialysis will be more likely to recommend dialysis to their hypothetical patients when compared to their peers with less optimistic assessments.

Lastly, we compare the physician's recommendations for patients to what they would recommend for themselves.If results show a large variation regarding the expected survival benefits of dialysis and CM, that physicians are making patient recommendations based on factors such as income or gender and/or are make different recommendations for patients than for themselves, then it suggests that greater physician/patient education regarding pros and cons of dialysis and CM, improved communication between physicians and patients regarding treatment options for ESRD, and greater

patient autonomy can help to ensure that the treatments patients receive are most likely to be consistent with their own preferences.

Methods

Setting and Sample: The survey was made available to a convenience sample of participants attending the 9th Asian Forum of Chronic Kidney Disease Initiative (ACKDI) conference organized in Jakarta (Indonesia) on May 8-9, 2015. Nearly 1,100 participants attended the conference, and research staff passed out surveys to participants as they registered in the morning and during conference breaks. There was also a booth where participants could come and request a survey at any time during the day. Eligibility for the survey was limited to physicians currently treating or counselling patients with ESRD in Indonesia. Although nearly 1,000 survey questionnaires were passed out, it is not clear how many recipients were eligible to participate. In total 216 attendees completed the survey, and 201 met the eligibility criteria. These surveys make up the analysis sample. Written informed consent was not required by our IRB because survey was anonymous and the IRB determined that it posed no more than minimal risks to the respondents.

Survey questionnaire: The questionnaire presented a series of vignettes describing hypothetical elderly patients with ESRD. Vignettes are commonly used for investigating clinical practice variation 16,17. Each respondent was presented with two types of vignettes- patient and self-vignettes (Appendix Table A1). Each patient vignette described hypothetical elderly patients who have been diagnosed with ESRD. These vignettes systematically varied across four attributes: 1) age (65, 75 and 85 years); 2) comorbidities (diabetes, diabetes and congestive heart failure, and advanced cancer); 3) socio-economic status (wealthy, middle class and poor); and 4) gender (male, female). For each vignette, participants were asked to predict additional years of survival under dialysis and CM and which treatment option they would recommend for each hypothetical patient. In self vignettes, participants were then asked to

assume that they were diagnosed with ESRD at a certain age and comorbidity profile and to choose either dialysis or CM for themselves given that profile.

The vignettes were created based on an experimental design generated in SAS that ensures efficient parameter estimates for each attribute level. Separate experimental designs consisting of 18 and 6 questions per design were generated for the patient and self vignettes, respectively. Because answering 24 vignette questions would be overly burdensome, the vignettes were subset into blocks such that each respondent answered 6 patient vignettes and 3 self vignettes. Each patient-vignette block was paired with one of the self-vignette blocks resulting in (3x3) 9 versions. Each respondent was randomly assigned to one of the 9 versions. The survey instrument was pilot tested before finalizing the vignette descriptions and was approved by the Institutional Review Board at the National University of Singapore.

Analysis: We first report the mean and standard deviation of the survival predictions by the physicians for dialysis and CM for each vignette, and test whether the differences in predictions are statistically significant using a Student's t-test. The standard deviation of each prediction and of the difference in predictions provides information on the variability of the estimates. As is common practice we consider any estimate whose standard deviation is greater than the mean to be highly varia ble18. We also report the percentage of respondents who believe CM to confer greater life expectancy than dialysis, with estimates nearing 50% also conferring high levels of variability. Finally, we compare physicians' survival predictions with survival estimates published in the literature based on similar patient populations.

We next report the percentage of physicians who recommend dialysis for each hypothetical patient.We report this estimate in total, and separately based on whether the physicians are more or less optimistic about the relative survival benefits compared to their peers. We categorized more

optimistic physicians as those who estimate the relative survival under dialysis for a given vignette to be above the mean prediction. We then used a two-sample test of proportions to test whether those with more optimistic assessments are more likely to recommended dialysis for each patient vignette.

To quantify the independent effect of age, comorbidity status, gender, income and physician's specialization on their choice of dialysis or CM for each vignette targeting 1) a hypothetical patient and 2) the physician, we conducted two logistic regression analyses. In each regression the dependent variable was set to 1 if the physician recommended dialysis (either for the patient or for their self) and 0 otherwise. Independent variables included dummy variables representing the characteristics for each vignette and physician's specialization (nephrologist or other) with age 65 years, diabetes, wealthy, male and non-nephrologists as the omitted reference groups. For the physician choice we coded each vignette using the physician's self-reported socio-economic status and gender. Using the predicted probabilities from the two regressions we tested whether physicians make different recommendations for themselves than for their (hypothetical) patients using a Wald test with the predictions estimated for someone who is middle class (which the vast majority of physicians report), with the male dummy variable set to 0.6, reflecting the gender mix among physicians who responded to the survey and nephrologists dummy set to 0.2, reflecting the mix of nephrologists and other physicians among the respondents. All analyses were conducted using STATA version 12.1.

Results

A total of 201 physicians who met the eligibility criteria completed the survey. The mean age of respondents was 45 years. 60% were male with specialties split between internists (35%), GPs (24%), nephrologists (22%) and unknown (not reported) (19%). Roughly half of respondents were affiliated with a public hospital. Respondents had, on average, 8 years of experience treating/counselling ESRD patients and treated and/or counselled an average of 52 ESRD patients per week (Table 1).

Table 2 shows physicians' predictions for expected years of survival under dialysis and CM for each vignette. As expected, as age and comorbidity status increases the survival estimates decrease, regardless of treatment choice. In the best case physicians predicted that a 65 year old with diabetes would live an additional 6.8 years under dialysis, whereas survival for an 85 year old with advanced cancer was predicted to be only 1.5 years under CM. Regardless of the profile, physicians, on average, believe that dialysis confers greater survival benefits than CM, with estimates ranging from 3.3 years greater for a 65 year old ESRD patient with diabetes only to roughly one year or less for 85 year old ESRD patients and/or for ESRD patients with advanced cancer. Supplemental analyses showed no difference in predictions between nephrologists and other physicians (Appendix Table A2).

Despite the finding that physicians, on average, believe that dialysis extends life relative to CM, there is a high degree of uncertainty in the predictions. This is evidenced by the large standard deviation for all vignettes considered and the fact that a significant number of physicians believed that CM confers greater survival, with proportions ranging from a low of 17.3% (65 years old with diabetes and CHF) to a high of roughly 50% for patients with advanced cancer. The latter result is what one would expect to see if physicians are making random guesses.

Table 3 shows the percentage of physicians who recommend dialysis for each patient vignette in total and separately for more and less optimistic physicians when compared to their peers. Results reveal high discordance in treatment recommendations. For a 65 year old with diabetes, where the best case can be made for dialysis, only 62% recommended it. As the age and comorbidity profiles increase the percentage who recommend dialysis decreases to as low as 34% (85 year old with diabetes and CHF). Yet, even for those with advanced cancer, at least one fourth recommend dialysis. The second and third columns of Table 3 reveal that the recommendations are largely influenced by beliefs about relative survival benefits. Not surprisingly, those who are more optimistic about the ability of dialysis to extend life are far more likely to recommend it to their (hypothetical) patients, even if the patient has

advanced cancer. These findings point to the importance of educating physicians about expected survival associated with dialysis and CM in order for them to make informed treatment recommendations.

Table 4 presents results of the logistic regressions. For the patient vignettes, age 85 years, advanced cancer, and being poor decreased the odds of the physician recommending dialysis. Being a nephrologist increased the odds of recommending dialysis to the patients. When considering choices for themselves, only advanced cancer decreased the odds and being 75 (relative to 65) and middle class (relative to wealthy) increased the odds of choosing dialysis.

Based on the regression results, Table 5 shows the predicted probabilities of the physicians recommending dialysis for their hypothetical patients and for themselves. Results reveal that for each vignette physicians are far more likely to recommend dialysis for themselves than for their patients. For example, whereas 55% of physicians recommend dialysis for a hypothetical 75 year old patient with diabetes and CHF, this figure climbs to 82% when physicians consider their own choice.

Discussion

As noted in the introduction, many ESRD patients and their surrogates rely on their physicians to educate them on the relative benefits of dialysis over CM and to recommend a treatment option. To gauge physicians understanding of these benefits we asked them to predict survival for dialysis patients with specific age/comorbity profiles and compared the predictions to published results from a study conducted in Taiwan19 1. We used the Taiwanese study as we could not find any study from Indonesia

1 Kan et al (2013) study predicted survival estimates using real data of elderly (65 years and above) ESRD patients. New Comorbidity Index (nCI) used in their study provides good predictive value for survival under dialysis but it has its own limitations. This index does not classify the severity of each comorbiditiy and considers the comorbid disease severity as clinically evident based upon prescribed treatment. This score does not incorporate body mass index, actual blood pressure, specific data on dialysis adequacy, type of vascular access used for hemodialysis patients, laboratory data and medical prescriptions, which may affect patients' survival, therefore the comparison in survival estimates should be interpreted with caution.

that reported survival for dialysis patients with comparable comorbidities. Assuming the results from Taiwan are accurate for Indonesia, many physicians over-estimated survival benefits for 75 and 85 year old patients with diabetes and for 85 year old patients with diabetes and CHF (last column of Table 2). If, within each of the subgroups considered, the patient profile and/or treatment benefits differ between Indonesia and Taiwan, then these comparisons may be invalid. No comparable estimates were available for elderly patients with advanced cancer. Even if the Taiwanese study19 results do not generalize to Indonesia, the variability in physician responses for any given patient profile suggests that many physicians have inadequate knowledge on the relative survival benefits of dialysis and may be giving advice based on opinion, dated evidence, or misinformation.

= There are several possible reasons for these results. As noted in the preceding paragraph, no Indonesian data exists that focuses on survival outcomes for ESRD patients of any age as a function of treatment choice. Physicians may also not be aware of survival scoring systems available online that provide this information (http://nephron.org/cgi-bin/rpa sdm.cgi), albeit based on data from Western countries and, even if physicians are aware, use may be limited dueto connectivity, time, and other constraints. Moreover, these survival scoring systems present one and two year survival probabilities for dialysis patients of varying age and comorbidity profiles, which is not easily translated to median survival. The scoring system also estimates survival probabilities for dialysis only, so it provides no information on survival for those who opt for CM. Many physicians may wrongly believe these estimates are relative to what would be achieved by CM and thus are overly optimistic about the relative benefits.

The published literature is also not clear on the relative survival benefits of CM for older patients with co-morbidities. There are only a few studies that investigate this issue. These studies differ on their methodological approach, inclusion criteria, and in their definition of what constitutes multiple comorbidities. For example, Murtagh et al. (2007)'s report 4 that the survival advantage of dialysis over CM was lost for patients over 75 years old with high comorbidity, yet their results were based on counts

of the number of comorbidities only, whereas Chandna et al. (2010) 5, who report a (non-statistically significant) 4 month survival advantage for dialysis, defined their profiles using both severity and number of comorbidities. The US Renal Physician Association, when describing the patient population who may not benefit from dialysis, used a modified Charlson Comorbidity Index to define 'high comorbidity' based on a combination of number and severity of co-morbidities 20. Finally, because dialysis is clearly effective for younger, healthier populations, many physicians may have a preconception bias 21that dialysis will be efficacious even for older and highly comorbid patients. This preconception bias could partly explain why more than 20% of physicians recommend dialysis even for vignettes where the patient has advanced cancer.

More research is needed to clarify the relative survival benefits of CM for patients with varying age and comorbidity profiles and this information needs to be conveyed to clinicians and patients in a manner that will allow them to make informed decisions. It is especially important to educate patients directly as the results suggest that physicians are likely to be making decisions based on non-clinical factors, including income. There may be valid reasons to consider income in the decision to undergo dialysis, as physicians possibly base their recommendations taking into account their previous experience with other patients belonging to similar income groups, noting that despite commendable efforts to improve access to renal replacement therapy, out of pocket cost of dialysis are still considerable in Indonesia 12 and present a barrier to optimal treatment. Socio-economic status may become less of a factor in the future if Universal Coverage takes on a larger fraction of the costs, but it remains to be seen how large of a fraction this will be. Regardless, this decision is best left to the patient once survival, costs, quality of life and other factors are appropriately considered.

The finding that physician specialty influences treatment recommendations is not new. It is well established that surgeons are more likely to recommend surgery than other clinicians 22,23. Consistent with this paradigm, it is not surprising that nephrologists are more likely recommend dialysis than the

other clinicians included in the survey given that dialysis is the primary treatment modality for most of their ESRD patients. Regardless, this is an important point that patients should be aware of when seeking treatment advice.

The findings suggest that physicians are more likely to choose aggressive treatments for themselves than for their patients. This dichotomy is similar to that shown in several prior studies24,25. It is possible that physicians believe that they would make for better dialysis patients. This would occur if they believe they are more likely to take mitigation strategies to avoid infection and other adverse events. However, this is one of several possible motives underlying this result. Determining the true cause should be an area of future research.

This study has several limitations. First, results are based on a convenience sample of physicians participating in a conference in Jakarta. Although results are unlikely to generalize to all physicians, those who attend international kidney conferences are likely to be most up to date on the relative benefits of dialysis. Second, we could not calculate response rate as the number of eligible respondents was not known among the conference participants. Third, as with all surveys, results are based on hypothetical vignettes. However, there is no reason to believe that the expectations of the relative survival estimates are biased or that these estimates would not influence real world choices. In the real world it is likely that physicians consider many additional factors that we could not include in a brief survey, such as patients' physical or cognitive capabilities, proximity to a dialysis centre, or level of caregiver support. Future studies can further explore the extent to which these and other factors influence treatment recommendations.

In conclusion, this study suggests that physicians, and by extension their patients, would benefit from a greater understanding of the survival benefits of dialysis and CM for elderly patients with different comorbidity profiles. However, because this information is generally not available for

Indonesian patients or for those in other countries in Asia, more research is needed before that information can be disseminated. Once available, this information can be conveyed to patients in an easily understandable format so that they can make more informed decisions about which treatment strategy is best for them2. Shared decision making should be promoted so that patients' beliefs and preferences are taken into account when these decisions are being made.. As Indonesia moves toward universal coverage of renal replacement therapy, expected to be completed by 2019, greater access to information and strategies that ensure cost effective use of health services will be increasingly important.

Conflict of Interest: The authors declare that they have no conflict of interest.

Acknowledgement: We would like to thank Dr Yusuke Tsukamoto, the President of the Asian Forum of Chronic Diseases, Dr. Vidhia Umami and Ms. Linda, and the local organizers of the conference for their help with dissemination of the survey at the conference. We also would like to thank Ms. Isha Chaudhry and Ms. Liu Joy Chang for implementing the survey.

List of Supplementary Tables:

Table A1: Example patient-vignette and self-vignette questions

Table A2: Relative survival benefits for dialysis for different patient profiles stratified by physician's specialty (nephrologists vs others).

2 http://sdm.rightcare.nhs.uk/pda/established-kidney-failure/

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Tables

Table 1. Physician characteristics (N=201)

Characteristics Statistics

Age, mean (SD) 45(12)

Male, % 60

Specialization, %

Internist 35

General Practitioner 24

Nephrologists 22

Unknown (not reported) 19

Primary affiliation with public hospital, % 51

Years of experience treating/counselling ESRD patients, mean (SD) 8 (8.2)

No. of patients treated/counselled per week, mean (SD) 52 (67.6)

Table 2. Physicians' predictions for expected years of survival under dialysis and CM for different patient profiles.

Comorbidity Age Expected years of Relative survival Percentage of Survival

survival under benefits1 of Physicians estimates for

Dialysis over CM who predict dialysis from

(in years) CM to have Kan et al

Dialysis CM Mean (SD) greater survival (2013) Mean (95%

(A) (%) CI) (B)

Diabetes 65 years 6.8 (4.2)3 3.5 (2.8) 3.3**2 (3.9) 23.6 6.4 (6.3-6.5)

75 years 6.1 (3.5) 4.2 (3.0) 1.9** (3.3) 35.7 5.0 (4.8-5.1) #

85 years 3.8 (2.9) 2.6 (2.9) 1.2** (3.0) 30.9 3.0 (2.8-3.3) #

Diabetes & 65 years 5.7 3.0 2.7** 17.3 5.1(5.0-5.3)

CHF (3.2) (2.1) (2.8)

75 years 4.4 (2.8) 2.4 (1.6) 2.0** (2.2) 22.7 4.1(3.9-4.3)

85 years 3.6 (2.0) 2.6 (1.6) 0.9** (1.8) 36.2 2.8 (2.5-3.2)#

Advanced 65 years 2.8 2.1 0.7** 53.6 -

Cancer (2.5) (2.1) (1.8)

75 years 2.4 (2.3) 1.7 (1.6) 0.7** (1.8) 48.7 -

85 years 2.1 (2.0) / 1.5 (1.5) 0.6** (1.4) 51.4 -

Notes:

1. Relative survival benefits of dialysis is the difference in expected years of survival under dialysis as published in Kan et al (2013) 19.

2. ** indicates significance at p<.01 level.

3. Figures in parentheses are standard deviations.

4. # indicates significant difference between (A) and (B) at p<0.05 level

Table 3. Percentage of physicians recommending dialysis for hypothetical patients

Comorbidity Profile Age % of Physicians who Recommend Dialysis

% Of All Physicians % of More Optimistic Physicians % of Less Optimistic Physicians

Diabetes 65 years 62.4 81.8 49.2**

75 years 56.6 69.1 43.1**

85 years 51.8 75.9 28.6**

Diabetes & CHF 65 years 61.8 84.3 42.4**

75 years 57.8 81.5 22.7**

85 years 34.3 43.4 25.0*

Advanced Cancer 65 years 29.0 45.2 18.5**

75 years 25.2 45.5 11.9**

85 years 27.5 57.9 11.3**

Notes: 1. More optimistic and less optimistic physicians are those who predict higher and ower than mean years of relative survival benefit of dialysis for the specified patient profile.

2. * indicates p < 0.05%, ** indicates p < 0.01 for differences between more optimistic and less optimistic physicians recommending dialysis for patients.

Table 4. Odds of recommending dialysis for patient and self.

Choice of dialysis for Choice of dialysis

Patient for Self

Age 65 years 2 --

75 years 0.985 (0.743, 1.305) 2.180**3 (1.475, 3.221)

85 years 0.635** (0.489, 0.825) 0.889 (0.608, 1.300)

Comorbidities Diabetes -- --

Diabetes & CHF 1.213 (0.917, 1.605) 1.340 (0.909, 1.976)

Advanced cancer 0.402** (0.297, 0.545) 0.321** (0.218, 0.472)

Socio- Wealthy --

economic Middle Class 1.006 1.481*

status (0.739, 1.369) (1.049, 2.091)

Poor 0.692* (0.518, 0.923) 1.204 (0.589, 2.463)

Gender Male -- --

Female 0.999 (0.799, 1.248) 1.224 (0.860, 1.743)

Physician's Others -- --

Specialization Nephrologists 1.511** (1.140, 2.003) 0.781 (0.521, 1.171)

Log-likelihood -772.488 -373.551

N A 201 200

Notes: 1. OR indicates odds ratio. Figures in parentheses are confic

2. -- indicates the reference category.

3. * indicates p < 0.05%, ** indicates p < 0.01%

ence intervals at 95% level.

Table 5. Predicted probabilities of recommending dialysis to patients and choosing dialysis for self.

Comorbidity Age Predicted probabilities of recommending/ choosing dialysis for.

Patient Self

Diabetes 65 years 0.52 0.62**1

75 years 0.50 0.78***

85 years 0.39 0 59***

Diabetes & CHF 65 years 0.55 0.68*

75 years 0.55 0.82***

85 years 0.44 0.66***

Advanced Cancer 65 years 0.29 0.34

75 years 0.28 0.53***

85 years 0.20 0.31*

Notes: 1. *indicates p<0.1%, ** indicates p<0.05% and *** indicates p<0.01% for difference in predicted probabilities of recommending dialysis for patients and self.

2. Probabilities are calculated assuming SES as middle class since 75% of the physicians represent middle class and weighted for gender and physician's specialization.