Departments of Research and, ¶Internal Medicine, Veterans Administration Greater Los Angeles Healthcare System, Los Angeles, California;, †University of California at Los Angeles, Veterans Administration Center for Outcomes Research and Education, Los Angeles, California;, ‡Global Health Economics, Amgen, Inc., Thousand Oaks, California;, §Department of Internal Medicine, David Geffen School of Medicine at University of California at Los Angeles, Los Angeles, California, ‖Department of Health Services, University of California at Los Angeles School of Public Health, Los Angeles, California.
Clin J Am Soc Nephrol. 2013 Nov;8(11):1942-51. doi: 10.2215/CJN.00160113. Epub 2013 Aug 8.
Red blood cell transfusion was previously the principle therapy for anemia in CKD but became less prevalent after the introduction of erythropoiesis-stimulating agents. This study used adaptive choice-based conjoint analysis to identify preferences and predictors of transfusion decision-making in CKD.
DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: A computerized adaptive choice-based conjoint survey was administered between June and August of 2012 to nephrologists, internists, and hospitalists listed in the American Medical Association Masterfile. The survey quantified the relative importance of 10 patient attributes, including hemoglobin levels, age, occult blood in stool, severity of illness, eligibility for transplant, iron indices, erythropoiesis-stimulating agents, cardiovascular disease, and functional status. Triggers of transfusions in common dialysis scenarios were studied, and based on adaptive choice-based conjoint-derived preferences, relative importance by performing multivariable regression to identify predictors of transfusion preferences was assessed.
A total of 350 providers completed the survey (n=305 nephrologists; mean age=46 years; 21% women). Of 10 attributes assessed, absolute hemoglobin level was the most important driver of transfusions, accounting for 29% of decision-making, followed by functional status (16%) and cardiovascular comorbidities (12%); 92% of providers transfused when hemoglobin was 7.5 g/dl, independent of other factors. In multivariable regression, Veterans Administration providers were more likely to transfuse at 8.0 g/dl (odds ratio, 5.9; 95% confidence interval, 1.9 to 18.4). Although transplant eligibility explained only 5% of decision-making, nephrologists were five times more likely to value it as important compared with non-nephrologists (odds ratio, 5.2; 95% confidence interval, 2.4 to 11.1).
Adaptive choice-based conjoint analysis was useful in predicting influences on transfusion decisions. Hemoglobin level, functional status, and cardiovascular comorbidities most strongly influenced transfusion decision-making, but preference variations were observed among subgroups.
红细胞输注曾是 CKD 患者贫血的主要治疗方法，但促红细胞生成素刺激剂问世后，其应用变得不那么普遍。本研究采用适应性选择基于联合分析的方法，以确定 CKD 患者输血决策的偏好和预测因素。
设计、设置、参与者和测量：2012 年 6 月至 8 月，通过美国医学协会大师名录，向肾病学家、内科医生和医院医生发放计算机化自适应选择基于联合调查。该调查量化了 10 个患者属性的相对重要性，包括血红蛋白水平、年龄、粪便潜血、疾病严重程度、是否适合移植、铁指标、促红细胞生成素、心血管疾病和功能状态。研究了常见透析情况下的输血触发因素，并根据基于适应性选择基于联合分析得出的偏好，通过多变量回归评估输血偏好的预测因素，确定其相对重要性。
共有 350 名提供者完成了调查（305 名肾病学家；平均年龄 46 岁；21%为女性）。在所评估的 10 个属性中，绝对血红蛋白水平是输血的最重要驱动因素，占决策的 29%，其次是功能状态（16%）和心血管合并症（12%）；92%的提供者在血红蛋白为 7.5g/dl 时进行输血，而与其他因素无关。在多变量回归中，退伍军人事务部的提供者更有可能在血红蛋白为 8.0g/dl 时进行输血（优势比，5.9；95%置信区间，1.9 至 18.4）。尽管移植资格仅解释了 5%的决策，但与非肾病学家相比，肾病学家将其视为重要因素的可能性高出五倍（优势比，5.2；95%置信区间，2.4 至 11.1）。
适应性选择基于联合分析可用于预测输血决策的影响。血红蛋白水平、功能状态和心血管合并症对输血决策的影响最大，但在亚组之间观察到偏好差异。
