#3078 The utility and cost-effectiveness of embedding geriatric expertise in a tertiary referral renal clinic

Abstract

Abstract Background and Aims The demographic of people receiving dialysis is changing with an increasing prevalence of frailty, co-morbidity and geriatric syndromes. To address this, we initiated routine, embedded, consultant geriatric review of a selected group of patients (frail/living with frailty syndromes, age>80 preparing for dialysis, undecided between treatment options, patient/family judged by MDT to have unrealistic perception of treatment benefit) in our renal low clearance (pre-dialysis) clinic alongside our already-established palliative care service to support decision-making about treatment options for end stage kidney disease Method Starting in 2018, 77 patients were reviewed before suspension enforced by the Covid-19 pandemic in March 2020 and a further 56 since resumption between July 2021 and January 2023. We present the short-term results of all 133 patients immediately following geriatric review, plus long-term outcome data for the first 77 patients for whom we have 3 years’ follow up, including health economic analysis and ANOVA of frailty and treatment choice. Results Initially the cohort included 10 patients who had already chosen conservative management (CM) of their renal failure, but after one PDSA cycle only patients choosing dialysis or undecided about treatment choices underwent review in the service (mean age 78 [range 62-92]; 70% male). Following geriatric review, the number of patients uncertain about their future renal treatment plan changed from 43 to 3; the number choosing to have dialysis reduced from 80 to 44 and the number choosing CM increased from 10 to 74. The number of advance care plans made among the group reviewed by the geriatrician increased from 0 to 77, and the number of DNACPR records increased from 6 to 43; there were increased referrals to falls, memory and continence clinics. Overall, 57% of patients left clinic with a different management plan. 36 months after geriatric review, the survival rate in the group choosing dialysis was 46% and in the CM group was 33%; the majority of deaths were unrelated to renal failure. ANOVA indicated that clinical frailty scores impacted outcome more than treatment choice; health economic analysis showed the costs of providing this review (average 193 GBP per patient) were highly likely to be more than off-set by reductions in unnecessary fistula formation alone (average 288 GBP per patient) Conclusion Routine, protocol-supported geriatric review in a tertiary referral renal service is cost effective and associated with increased dialysis decision-making, reduced dialysis uptake, increased advance care-planning, increased CPR decision-making plus recognition and appropriate referral of geriatric syndromes. Outcomes in the group suggest little difference in survival among those choosing dialysis vs CM, and that frailty is more indicative of prognosis than treatment choice.