Overcoming Barriers for Uptake and Continued Use of Home Dialysis: An NKF-KDOQI Conference Report

Chan, Christopher T.; Collins, Kelli K.; Ditschman, Erich P.; Koester-Wiedemann, Lisa; Saffer, Tonya L.; Wallace, Eric; Rocco, Michael V.

doi:10.1053/j.ajkd.2019.11.007

Cited by 51 publications

(60 citation statements)

References 27 publications

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“…Policy initiatives that require and incentivize education and training of nurses, surgeons, and non‐physician support personnel for home dialysis are crucial to expand home dialysis access. Initiatives leveraging existing quality programs, such as the ESRD Networks in the United States, could be required to create and maintain dedicated mentor networks of home dialysis professional experts in a hub and spoke model with pairing of smaller and/or newer home dialysis programs with larger more established programs to offer education and mentoring 6 …”

Section: Expertise and Staffingmentioning

confidence: 99%

“…Initiatives leveraging existing quality programs, such as the ESRD Networks in the United States, could be required to create and maintain dedicated mentor networks of home dialysis professional experts in a hub and spoke model with pairing of smaller and/or newer home dialysis programs with larger more established programs to offer education and mentoring. 6 Proficiency in delivery of modality options education is necessary but itself insufficient to increase home dialysis access. Success requires investment at all levels of the health system, but most importantly championed by the leadership.…”

Section: E Xpertis E and S Taffingmentioning

confidence: 99%

“…Urgent start PD, in which a peritoneal dialysis catheter is placed and used within 24 hours, also has the potential to increase PD prevalence, but it requires expertise. Education for urgent start is limited and not reimbursed, and education within training programs are varied and scattered 6. Policy to require education in urgent start peritoneal dialysis for nephrology fellows, nurses, surgeons, and practicing nephrologists within either initial training curriculum or continuous education could make this option more familiar and, thus, available to ESKD patients at more home dialysis units.6 | G APS IN RE S E ARCHResearch is often at the forefront of innovation and a driver of healthcare practice change.…”

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confidence: 99%

“…5 It is not clear that these important changes in delivery of dialysis will continue into the future, and it is only a small component of the necessary strategies to increase access to home dialysis.Several professional societies have met recently, to provide guidance for overcoming operational and policy barriers to home dialysis. 6,7 Sustained, successful home dialysis requires effective and persistent coordination between multiple supportive entities. These include surgeons, home therapy nurses, nephrologists, hospitals, and their staff, and in many cases a caregiver in the home.…”

mentioning

confidence: 99%

“…Several professional societies have met recently, to provide guidance for overcoming operational and policy barriers to home dialysis. 6,7 Sustained, successful home dialysis requires effective and persistent coordination between multiple supportive entities. These include surgeons, home therapy nurses, nephrologists, hospitals, and their staff, and in many cases a caregiver in the home.…”

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confidence: 99%

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Barriers to home dialysis: Unraveling the tapestry of policy

Fissell

Cavanaugh

2020

Seminars in Dialysis

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Home dialysis therapies for end-stage kidney disease (ESKD), both hemodialysis (HD) and peritoneal dialysis (PD), are underutilized in the United States. The Advancing American Kidney Health (AAKH) Initiative makes clear that initiating and maintaining dialysis patients on home therapies is a national priority. 1 There are several key reasons driving this U.S. policy proceeding. Compared to in-center HD, home dialysis can usually be provided at a lower cost. 2 Home dialysis also allows for more flexible patient-centered schedules, and therefore may contribute to a higher quality of life. 3 Although often debated, evidence suggests that more gradual removal of fluid and solutes is clinically beneficial compared to intermittent removal with the relatively shorter HD treatments provided in outpatient HD units. 4 Recent events due to the COVID-19 pandemic have prompted not only the urgency of home dialysis but its expanded use through widespread authority to provide care through telehealth visits as a mechanism for dialysis patients to safely remain at home. 5 It is not clear that these important changes in delivery of dialysis will continue into the future, and it is only a small component of the necessary strategies to increase access to home dialysis. Several professional societies have met recently, to provide guidance for overcoming operational and policy barriers to home dialysis. 6,7 Sustained, successful home dialysis requires effective and persistent coordination between multiple supportive entities. These include surgeons, home therapy nurses, nephrologists, hospitals, and their staff, and in many cases a caregiver in the home. Advocacy from the local community, and the nephrology community more broadly, is a fundamental requisite to demonstrate to regulatory stakeholders that polices directed at increasing home dialysis access are desired by those who receive and deliver this type of healthcare. Policy is a powerful lever to drive initial action, direct talent, and various resources, and ensure the highest quality of care. The purpose of this review is to provide an overview of where policy, in addition to nephrologist and dialysis center reimbursement, may be needed to support expanded use of home dialysis therapies (Table 1).

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Section: Expertise and Staffingmentioning

confidence: 99%

Section: E Xpertis E and S Taffingmentioning

confidence: 99%

mentioning

confidence: 99%

mentioning

confidence: 99%

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confidence: 99%

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Barriers to home dialysis: Unraveling the tapestry of policy

Fissell

Cavanaugh

2020

Seminars in Dialysis

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Early Findings From Medicare’s End-Stage Renal Disease Treatment Choices Model

2022

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Patients with end-stage kidney disease (ESKD) incur substantial costs for the Medicare program while experiencing high rates of adverse outcomes. 1 Substantial racial, ethnic, and socioeconomic disparities also persist among patients with ESKD. 2 Consequently, improving ESKD care has been a key focus for the US Centers for Medicare & Medicaid Services. A recent major initiative focuses on increasing home dialysis (peritoneal dialysis and home hemodialysis), kidney transplant waitlisting, and living donor transplant rates through Medicare's End-Stage Renal Disease (ESRD) Treatment Choices (ETC) Model. 3 In this issue of JAMA Health Forum, Ji and colleagues 4 report what is to our knowledge the first peer-reviewed evaluation of a key outcome in the ETC model. Their study found that financial incentives in the ETC model's first year (2021) had no significant effect on the percentage of patients initiating treatment with home dialysis. Results were consistent across patient characteristics, dialysis facility size, and facility profit status.The ETC model and this evaluative study are important for several reasons. First, the ETC model is one of the largest health care policy experiments in US history and randomizes 30% of hospital referral regions to receive financial incentives. Its randomized design with mandatory participation overcomes issues with selection bias that are typically seen with voluntary models. Second, the policy design tests a meaningful shift in financial incentives through pay-for-performance elements.The ETC model focuses on a parsimonious set of performance measures and uses sizeable payment incentives to motivate changes in practice patterns (up to 8% bonus or −10% penalty in the final year). Third, the ETC model has taken a novel step forward by adding an equity incentive in 2022 to reduce socioeconomic disparities in home dialysis and transplant.Ji and colleagues 4 have provided timely, actionable findings to inform policy implementation of the ETC model. Their evaluation is exemplary in its use of a prespecified analysis plan, power calculations to inform detectable effect sizes, and rigorous sensitivity analyses. Their finding that home dialysis use increased in ETC and non-ETC regions (from 16.5% in 2018 to 20.6% in 2021) is promising because home dialysis is associated with clinical benefits compared with in-center hemodialysis, including improved quality of life and better preservation of residual kidney function. 5 Home dialysis use has been increasing since 2008, so interrupted time series could examine if the increases reported by Ji and colleagues 4 represent a departure from prior trends. 1 This study raises several opportunities for further inquiry. First, rates of home dialysis use in the study sample (patients with incident ESKD 66 years or older) are higher than estimates from the US Renal Data System (16.5% vs 9.1% in 2018) and analyses of prevalent patients. 1,6 Differences in inclusion criteria and/or outcome definitions may explain these discrepancies and will be important...

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Barriers and Facilitators to Home Dialysis Among Latinx Patients with Kidney Disease

et al. 2023

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ImportanceLatinx people have a high burden of kidney disease but are less likely to receive home dialysis compared to non-Latinx White people. The disparity in home dialysis therapy has not been completely explained by demographic, medical, or social factors.ObjectiveTo understand the barriers and facilitators to home dialysis therapy experienced by Latinx individuals with kidney failure receiving home dialysis.Design, Setting, and ParticipantsThis qualitative study used semistructured interviews with Latinx adults with kidney failure receiving home dialysis therapy in Denver, Colorado, and Houston, Texas, between November 2021 and March 2023. Patients were recruited from home dialysis clinics affiliated with academic medical centers. Of 39 individuals approached, 27 were included in the study. Interviews were audio-recorded, transcribed verbatim, and analyzed using thematic analysis.Main Outcomes and MeasuresThemes and subthemes regarding barriers and facilitators to home dialysis therapy.ResultsA total of 27 Latinx adults (17 [63%] female and 10 [37%] male) with kidney failure who were receiving home dialysis participated. Themes and subthemes were identified, 3 related to challenges with home dialysis and 2 related to facilitators. Challenges to home dialysis included misinformation and immigration-related barriers to care (including cultural stigma of dialysis, misinformation regarding chronic disease care, and lack of health insurance due to immigration status), limited dialysis education (including lack of predialysis care, no-nephrologist education, and shared decision-making), and maintenance of home dialysis (including equipment issues, lifestyle restrictions, and anxiety about complications). Facilitators to home dialysis included improved lifestyle (including convenience, autonomy, physical symptoms, and dietary flexibility) and support (including family involvement, relationships with staff, self-efficacy, and language concordance).Conclusions and RelevanceLatinx participants in this study who were receiving home dialysis received misinformation and limited education regarding home dialysis, yet were engaged in self-advocacy and reported strong family and clinic support. These findings may inform new strategies aimed at improving access to home dialysis education and uptake for Latinx individuals with kidney disease.

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Overcoming Barriers for Uptake and Continued Use of Home Dialysis: An NKF-KDOQI Conference Report

Cited by 51 publications

References 27 publications

Barriers to home dialysis: Unraveling the tapestry of policy

Barriers to home dialysis: Unraveling the tapestry of policy

Early Findings From Medicare’s End-Stage Renal Disease Treatment Choices Model

Barriers and Facilitators to Home Dialysis Among Latinx Patients with Kidney Disease

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