Does greater pediatric experience influence treatment choices in chronic disease management? Dialysis modality choice for children with end-stage renal disease

Objective: To determine whether treatment choice for children with end-stage renal disease varies with greater pediatric experience at the dialysis facility. Design: National cross-sectional study. Setting: Outpatient dialysis facilities throughout the United States. Patients: All children (age, less than or equal to 19 years) undergoing dialysis in 1990, identified using the Medicare End-stage Renal Disease registry (1990 facility survey and quarterly dialysis records). Outcome Measures: The odds of receiving peritoneal dialysis vs hemodialysis according to the pediatric experience of the facility. ''Pediatric experience'' for dialysis facilities was defined as the number of patients 19 years old or younger divided by the total number of patients treated at that facility. Adjustment, using multiple logistic regression, was made for differences in age, sex, cause and duration of end-stage renal disease, income, education, and facility characteristics. Results: In 1990, there were 1256 patients 19 years old or younger who underwent a single-treatment modality at a single facility for most of the year. Sixty-three percent (790/1256) were treated at facilities with fewer than 5% of patients younger than 19 years. Thirty-six percent were treated at centers with less than 1% of pediatric patients. In a multivariate analysis, pediatric experience in a facility was independently associated with the use of peritoneal dialysis in children. Children treated at facilities with more than 10% pediatric patients were 60% more likely to be treated with peritoneal dialysis rather than hemodialysis compared with children treated at facilities with fewer than 1% of pediatric patients, even after controlling for patient age, race, income, education, cause and duration of end-stage renal disease, and facility characteristics such as hospital-based vs independent unit and for-profit vs not-for-profit status (odds ratio, 1.6; 95% confidence interval, 1.1-2.3). Conclusions: Children receiving care at dialysis facilities that have greater experience with pediatric patients are more likely to receive peritoneal dialysis than hemodialysis, a therapy with recognized clinical benefits for children that is inherently less resource intensive than is hemodialysis.