Outcomes of Renal Replacement Therapy After the Transition from ‘PD First’ to ‘Patient Choice’ Policy at Surat Thani Hospital

Abstract

Background: The “Peritoneal Dialysis (PD) First Policy” required patients with end-stage renal disease (ESRD) under the Universal Health Coverage scheme to begin renal replacement therapy with PD, unless medically contraindicated. On February 1, 2022, this policy was revised to allow “Patient Choice Dialysis,” enabling patients to freely choose their dialysis modality without incurring additional costs. In response, Surat Thani Hospital, a tertiary care center, updated its dialysis counseling process to emphasize shared decision-making starting January 1, 2023. This study aimed to assess the clinical outcomes of patients who initiated dialysis following the policy change and counseling update.
Methods: This retrospective cohort study included incident dialysis patients between January 1 and December 31, 2023. The primary outcomes were 90-day and 1-year survival, comparing planned vs. unplanned dialysis initiation and PD vs. hemodialysis (HD) modalities.
Results: A total of 212 patients were included: 66 (31%) initiated HD and 146 (69%) initiated PD. Of these, 111 (52%) started dialysis in a planned manner, while 101 (48%) had unplanned initiation. Patients in the unplanned dialysis group had significantly lower survival rates at 90 days (P=0.002) and 1 year (P=0.036) compared to the planned group. The HD group showed a trend toward a decreased 90-day survival rate compared to the PD group (P=0.056); however, this difference in survival became comparable at 1 year (P=0.26). The leading causes of hospitalization were PD-related infections in PD patients and cardiovascular complications in HD patients.
Conclusions: Planned dialysis initiation was associated with better short- and long-term survival compared to unplanned initiation. There was no significant difference in the 1-year survival rate between PD and HD modalities. Therefore, efforts to reduce unplanned dialysis may help improve clinical outcomes in ESRD patients requiring dialysis.