Background
Home hemodialysis (HHD) is associated with improved clinical and quality of life outcomes compared with in-center hemodialysis but remains an underused modality in the United States. Discontinuation from HHD may be an important contributor to the low utilization of this modality. This study aimed to describe the rate and timing of HHD discontinuation, or technique failure, and identify contributing factors.
Study Design
Retrospective cohort study
Setting & Participants
Using data from a large dialysis provider, we identified a nationally representative cohort of patients who initiated HHD from 2007 – 2009 (N=2840).
Factors
Demographics, ESRD duration, kidney transplant listing status, co-morbid conditions, level of urbanization or rurality based on residence zip code, socioeconomic status based on residence zip code, and dialysis facility factors.
Outcomes
Discontinuation from HHD, defined as ≥60 days with no HHD treatments.
Measurements
Competing risk models were used to produce cumulative incidence plots and to identify socio-demographic and clinical variables associated with HHD discontinuation. Transplantation and death were treated as competing risks for HHD discontinuation.
Results
The 1-year incidence of discontinuation was 24.9% and the 1-year mortality estimate was 7.6%. Median ESRD duration prior to initiating HHD was 2.1 years. Diabetes and smoking/alcohol/drug use were associated with increased risk of HHD discontinuation (HRs of 1.34 [95% CI, 1.07–1.68] and 1.34 [95% CI, 1.01–1.78], respectively). Listing for kidney transplant and rural residence (rural-urban commuting area ≥ 7) were associated with decreased risk of HHD discontinuation (HRs of 0.73 [95% CI, 0.61–0.87] and 0.78 [95% CI, 0.59–1.02], respectively).
Limitations
Limited to variables available within the DaVita dialysis and US Renal Data System datasets.
Conclusions
A substantial proportion of patients discontinue HHD within the first 12 months of use of the modality. Patients with diabetes, substance use, non-listing for kidney transplant, and urban residence are at greater risk for discontinuation. Targeting high-risk patients for increased support from clinical teams is a potential strategy for reducing HHD discontinuation and increasing technique survival.
On 1 January 2011, a new payment system for Medicare patients will be implemented in the United States. This new system bundles services previously charged separately and under a "fee for service" environment. The authors discuss the implications of this approach. Over the next several pages is a response by American physicians and dialysis innovators to a federal initiative to change the way dialysis is paid for in the United States. Peter Blake, the Editor-in-Chief of Peritoneal Dialysis International, invited Thomas Golper to articulate physicians' concerns with this new payment scheme. After the government of the USA closed its comment period over the new payment methodology, called "bundling," Golper sought out colleagues from diverse backgrounds and compiled this collective view of the situation.
Introduction: Home hemodialysis (HHD) is an under‐utilized renal replacement modality in the United States in part because of high rates of discontinuation and transfer to in‐center hemodialysis. Understanding, from the perspective of patients, facilitators, and barriers to sustained use of HHD is important for increasing successful use of this modality.
Methods: We conducted 25 semistructured interviews with 15 current and 10 former adult patients treated with home hemodialysis (23 short daily HHD and 2 nocturnal HHD). Interview transcripts were audiotaped, transcribed verbatim, and thematically analyzed.
Findings: Five themes related to continuation or discontinuation of HHD emerged: (1) degree of independence (increased flexibility, burden of therapy), (2) availability of support (emotional and physical support and caregiver burden), (3) technical aspects (familiarity with machine), (4) home environment (ability to organize supplies, space in home), and (5) attitude and expectations (positive or negative outlook about performing HHD). For each theme, positive aspects facilitated continuation of HHD and negative aspects contributed to discontinuation of HHD.
Discussion: HHD can be burdensome to patients and family members, and some discontinuations may be preventable. Helping patients with scheduling and organization, improving communication about expectations and trouble‐shooting, supporting patients as well as family members, adapting the dialysis prescription to the patient's lifestyle when possible, and providing respite when needed may make HHD more sustainable for patients.
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