The utility and cost of embedding geriatric expertise in a tertiary referral renal clinic.

BACKGROUND

To address the changing demographic and increasing frailty and comorbidity of people referred to renal services, we initiated novel, routine, embedded, consultant-led, focused geriatric assessment of a selected group of patients in our Renal Low Clearance Clinic, seeking effects on treatment decision-making, patient outcomes and undertaking a health economic analysis.

METHODS

A total of 133 patients fulfilling study-developed referral criteria received focused geriatric assessment. Short-term results (treatment decisions) of all 133 patients, plus long-term (survival) data for the first 77 patients for whom we have 3 years' follow-up are presented. Health economic analysis compared the cost of employing the Geriatrician versus avoiding unnecessary/futile dialysis access (arteriovenous fistula) creation based on historic rates in our own unit.

RESULTS

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 [mean age 78 (range 62-92) years; 70% male]. Following focused geriatric assessment, the number of patients undecided about treatment changed from 43 to 3; those choosing dialysis reduced from 80 to 44 and those choosing conservative management (CM) increased from 10 to 74. The number of advance care plans made increased from 0 to 77, and recorded resuscitation decisions from 6 to 42. Thirty-six months after focused geriatric assessment, the survival rate in the group choosing dialysis was 50% and in the CM group was 33%; most deaths were unrelated to renal failure and there was a trend towards clinical frailty scores impacting outcome more than treatment choice. Health economic analysis demonstrated that the costs of providing this review were more than offset by reductions in unnecessary/futile fistula formation.

CONCLUSIONS

Routine, protocol-supported focused geriatric assessment in a tertiary referral renal service appears cost-effective and is associated with improved dialysis decision-making, advance care-planning and resuscitation decision-making.