Understanding factors that influence the demand for dialysis among elderly in a multi-ethnic Asian society

•Awareness of conservative management as an option for elderly patients is low.•Caregivers appear to overestimate survival under dialysis.•Patients and caregivers defer to physician recommendations for treatment choice.•Subsidies on hemodialysis reduces demand for conservative management. Despite literature suggesting conservative management (CM) is a viable option for elderly comorbid ESRD patients, the vast majority in Singapore receive dialysis. We hypothesized that the high demand for dialysis is driven by 1) lack of knowledge of CM and relative benefits of dialysis to CM, 2) adherence to physician recommendations which favour dialysis, and 3) high subsidies for haemodialysis (HD). We tested these hypotheses via a survey, including a discrete choice experiment (DCE), administered to 151 elderly pre-dialysis kidney patients and their family caregivers. Results are consistent with the hypotheses: 40% (95% Confidence Interval (CI) 32–48) of patients and 46% (CI 38–55) of caregivers reported not being aware of CM, and 43% (CI 35–51) of patients and 24% (CI 17–31) of caregivers could not provide information on expected survival for dialysis or CM. Yet, once aware of CM as an option, 54% of patients and 42% of caregivers chose CM. However, if their physician recommended dialysis, 49% (CI 40–58) of patients and 68% (CI 59–77) of caregivers switched their choice. Subsidies on HD further reduced demand for CM by 6 percentage points. These results reveal that the high demand for dialysis is driven mostly by lack of awareness of CM as an option and by physician recommendations for dialysis over CM.