Taking hospital treatments home: a mixed methods case study looking at the barriers and success factors for home dialysis treatment and the influence of a target on uptake rates

Abstract

BackgroundDespite healthcare policies and evidence which promote home dialysis, uptake rates have been falling for over 10 years in England. A target introduced by commissioners in the West Midlands provided a unique opportunity to study how hospitals can increase home-based treatment for a group of patients with complex life-threatening conditions.MethodsQuantitative changes in home treatment uptake rates in seven hospitals in the West Midlands were compared with the rest of England for 3 years pre and post the introduction of the target in 2010, using a logistic regression model. Qualitative interviews in four hospitals with 96 clinical and managerial staff and 93 dialysis patients explored the barriers and facilitators to increasing the uptake of home treatment and the impact of the target.ResultsHome treatment uptake rates increased significantly in the seven study hospitals compared with the 3 years prior to the introduction of the target and compared with the rest of England where rates remained static. The four main factors facilitating increased uptake were as follows: the commissioner’s target, linked to financial penalties; additional funding for specialist staff and equipment; committed, visible clinical champions and good systems for patient training and ongoing healthcare support at home. The three main barriers were as follows: lack of training for non-specialist staff, poorly developed patient education and considerable unrecognised and unmet emotional and psychological patient needs.ConclusionsThis study shows the impact of using targets with financial penalties to achieve change and how hospitals can increase significantly the uptake of home-based self-care for a group of patients with complex medical needs. It provides useful pointers to the main barriers and facilitators, which are likely to be relevant to other groups of patients who could be treated at home. It also highlights two neglected areas which need to improve if patients with life-threatening long-term conditions are to be encouraged to take up home treatment: individualised patient education which allows exploration of the impacts of treatment options and the provision of ongoing emotional support.

UK Renal Registry 19th Annual Report: Chapter 13 Home Therapies in 2015: National and Centre-specific Analyses

“…Between 2010 and 2012, the West Midlands introduced a commissioning target to increase HT uptake, with evidence that this led to an increase in HT rates [3]. This can also be seen in the UKRR data.…”

Exploring patients’ attitudes to different intervention approaches for supporting psychosocial needs

“…A recent study reported that more than a third of people who are new to dialysis had experienced emotional and psychological difficulties, yet there was an absence of support for patients whose psychosocial problems fell below the threshold of clinical depression (Combes et al . ). Although patients who have ESKD want improved support, particularly in the areas of coping and adjustment, their needs tend to be ignored and frequently remain untreated (Schell et al .…”

“…depression (Combes et al 2015). Although patients who have ESKD want improved support, particularly in the areas of coping and adjustment, their needs tend to be ignored and frequently remain untreated (Schell et al 2012;Gill & Lowes 2014).…”

Improving clinical skills to support the emotional and psychological well-being of patients with end-stage renal disease: a qualitative evaluation of two interventions

“…Dialysis and renal transplantation are life-saving treatments, but they are also demanding and impact appreciably on the everyday lives of end-stage renal disease (ESRD) patients, often negatively affecting emotional and psychological well-being. Many patients find the transition to dialysis frightening and traumatic [ 1 – 3 ]. They can continue to experience periods of distress throughout their time on dialysis due to the stress of treatment, loss of sexual function, altered body image and decreased physical and cognitive functioning, as well as consequent effects on employment, relationships and lifestyle [ 4 – 7 ].…”

“…No robust data exist on the prevalence of lower-level emotional and psychological problems, defined as difficulties in coping effectively with the diagnosis, physical symptoms and treatment, which result in distress, poor emotional adjustment and reduced quality of life [ 12 , 13 ]. Nonetheless, a recent study found that more than a third of dialysis patients experienced emotional difficulties, particularly during the transition to dialysis and early months on dialysis [ 3 ]. Furthermore, untreated psychosocial problems are associated with withdrawal from dialysis [ 14 , 15 ], poor medication and diet compliance [ 16 – 18 ] and reduced ability to engage in pre-renal replacement therapy education and treatment choice [ 3 , 19 , 20 ].…”