Assessing the impact of transitional care units on dialysis patient outcomes: A multicenter, propensity score‐matched analysis

Abstract

Introduction Inadequate predialysis care and education impacts the selection of a dialysis modality and is associated with adverse clinical outcomes. Transitional care units (TCUs) aim to meet the unmet educational needs of incident dialysis patients, but their impact beyond increasing home dialysis utilization has been incompletely characterized. Methods This retrospective study included adults initiating in‐center hemodialysis at a TCU, matched to controls (1:4) with no TCU history initiating in‐center hemodialysis. Patients were followed for up to 14 months. TCUs are dedicated spaces where staff provide personalized education and as‐needed adjustments to dialysis prescriptions. For many patients, therapy was initiated with four to five weekly dialysis sessions, with at least some sessions delivered by home dialysis machines. Outcomes included survival, first hospitalization, transplant waiting‐list status, post‐TCU dialysis modality, and vascular access type. Findings The study included 724 patients initiating dialysis across 48 TCUs, with 2892 well‐matched controls. At the end of 14 months, patients initiating dialysis in a TCU were significantly more likely to be referred and/or wait‐listed for a kidney transplant than controls (57% vs. 42%; p < 0.0001). Initiation of dialysis at a TCU was also associated with significantly lower rates of receiving in‐center hemodialysis at 14 months (74% vs. 90%; p < 0.0001) and higher rates of arteriovenous access (70% vs. 63%; p = 0.003). Although not statistically significant, TCU patients were more likely to survive and less likely to be hospitalized during follow‐up than controls. Discussion Although TCUs are sometimes viewed as only a means for enhancing utilization of home dialysis, patients attending TCUs exhibited more favorable outcomes across all endpoints. In addition to being 2.5‐fold more likely to receive home dialysis, TCU patients were 42% more likely to be referred for transplantation. Our results support expanding utilization of TCUs for patients with inadequate predialysis support.

Home Dialysis in North America

“…A prior scoping review identified PD-first policies, modality education programs, and audit and feedback, providing assisted PD, transitional care units, and bedside catheter placement as interventions that have been associated with increased PD utilization. 49,50 It is important to note that most of these studies looking at patient-level and provider-level interventions came from single centers, lacked control groups, were implemented in centers with low PD penetration at baseline, or involved restricting patient choice. At the policy level, PD-first policies in Hong Kong and Thailand have been associated with an increase in the numbers of patients treated with PD.…”

“…54 The use of transitional care units where a 4-week educational intervention was delivered was associated with an increase in home dialysis utilization in Fresenius Medical Care units in the United States. 50 In Canada, the Ontario Renal Network introduced a modality-based funding formula, mandatory informatics system, and targets for prevalent home dialysis rates, and then conducted frequent meetings with nephrology programs to review progress. They funded home dialysis coordinators, encouraged and funded assisted PD, and provided support for catheter insertion and urgent start PD.…”

Setting Up Home Dialysis Programs

“…49,50 Among other outcomes, a recent multicenter study showed that patients going through TCU programs were 2.5 times more likely to convert to home dialysis, making them an important part of home dialysis growth in the future. 51…”

Systems Innovations to Increase Home Dialysis Utilization

“…27 Another review demonstrated higher likelihood of arteriovenous access and transplant referral at 14 months after enrollment. 33 Community House HD A community house for hemodialysis (CHH) is a facility where patients are able to receive HD in a shared space away from the in-center HD unit. Unlike community or satellite dialysis units, patients perform HD independently in a home-like environment, without the assistance or direct supervision of medical personnel.…”

“…27 Another review demonstrated higher likelihood of arteriovenous access and transplant referral at 14 months after enrollment. 33…”