Systems Innovations to Increase Home Dialysis Utilization

Abstract

Globally, there is an interest to increase home dialysis utilization. The most recent United States Renal Data System (USRDS) data report that 13.3% of incident dialysis patients in the United States are started on home dialysis, while most patients continue to initiate KRT with in-center hemodialysis. To effect meaningful change, a multifaceted innovative approach will be needed to substantially increase the use of home dialysis. Patient and provider education is the first step to enhance home dialysis knowledge awareness. Ideally, one should maximize the number of patients with CKD stage 5 transitioning to home therapies. If this is not possible, infrastructures including transitional dialysis units and community dialysis houses may help patients increase self-care efficacy and eventually transition care to home. From a policy perspective, adopting a home dialysis preference mandate and providing financial support to recuperate increased costs for patients and providers have led to higher uptake in home dialysis. Finally, respite care and planned home-to-home transitions can reduce the incidence of transitioning to in-center hemodialysis. We speculate that an ecosystem of complementary system innovations is needed to cause a sufficient change in patient and provider behavior, which will ultimately modify overall home dialysis utilization.

Introduction

In 2019, the Advancing American Kidney Health Initiative (AAKHI) was established by an executive order to improve the quality of care provided to Americans suffering with CKD. One central goal of the AAKHI was to increase the utilization of home dialysis or kidney transplantation to 80% by 2025 for incident patients.¹ Existing literature has documented better quality of life in multiple domains for home dialysis patients and the need for higher home therapy adoption.² Data from the United States Renal Data System (USRDS) have demonstrated that from 2010 to 2020, the utilization of home dialysis in incident dialysis patients rose from 6.8% to 13.3%.³ However, this rate of growth is inadequate to meet the target for 2025. To effect sufficient change, a cohesive set of systems innovation is therefore needed.

In this perspective, we hope to highlight existing and emerging techniques in constructing a system that promotes increased uptake of home dialysis. These include (1) improved education of patients and health care workers, (2) providing infrastructure for patients who would otherwise be destined to transfer to in-center hemodialysis (HD), and (3) policy changes that reduce economic disadvantages of home dialysis (Figure 1).

Figure 1.

Ecosystem of innovation promoting home dialysis adoption and corresponding sections within this review. PD, peritoneal dialysis.

Education and Preparedness

Patient Education

A prospective study conducted at seven North American nephrology centers showed that 78% of patients were eligible for peritoneal dialysis (PD) after detailed medical and psychosocial evaluation.⁴ The proportion of patients appropriate for all home dialysis therapies is likely greater, although there is presently a lack of robust data quantifying patients who are suitable for home HD but not PD. With this in mind, the 80% target set out by AAKHI seems feasible. The relatively low uptake rate presently may be largely related to the lack of patient education. Several studies have demonstrated that the patients' preference for a home dialysis modality is between 40% and 50% after receiving appropriate education and counseling.^5–7 From a limited analysis of USRDS claims data from 2010 to 2014, only 0.9% of patients received modality education before dialysis initiation.⁸ However, it is important to note that unbilled education or education delivered from routine care is not captured in these data.

There are several key components to a successful patient educational program. The National Kidney Foundation recommends a multidisciplinary approach to dialysis education, which is associated with improved utilization of home dialysis and lower mortality rate.⁸ Information should be delivered in the preferred learning style of the patient, at an appropriate pace, and tailored to the specific needs and concerns for the patient.⁹ It is crucial that longitudinal follow-up is implemented to assess changing needs and functional status with the progression of CKD. Kidney Disease Improving Global Outcomes recommends an iterative approach in modality education because it has been shown to lead to greater home dialysis utilization.^10,11 A large dialysis organization in the United States demonstrated an adjusted odds ratio of 5.13 (95% confidence interval, 3.58 to 7.35) for choosing PD over in-center HD and a 90-day mortality odds ratio of 0.61 (95% confidence interval, 0.50 to 0.74) with education.¹² Similarly, a matched control study demonstrated that CKD education led a three-fold increase with respect to home dialysis uptake (38.5% versus 12.6%, P < 0.001).¹³ The same study also showed lower incidence of hospitalization and overall mortality in the first year after dialysis initiation in the group that received education. There is currently a randomized control trial (NCT04064086) underway to study these outcomes further for patients with advanced CKD.¹⁴

Education of Health Care Professionals

Recommendation from the treating nephrologist has been shown to have a high degree of influence on the patient's eventual modality choice.^15,16 However, there is variable comfort and confidence among nephrologists in managing home dialysis patients.¹⁷ Based on a survey sent to graduating nephrology trainees in 2004–2008, 80% of respondents felt competent with in-center HD, while these values were 56% and 16% for PD and home HD, respectively.¹⁸ This disparity is likely multifactorial; contributing factors include lack of a comprehensive curriculum, lack of clinical exposure or longitudinal follow-up, or lack of experienced mentors in home dialysis.¹⁹ Gaps in provider knowledge and expertise may contribute to implicit persuasion to patients with regard to KRT options.²⁰

Short in-person courses have been offered by Home Dialysis University, a program associated with the International Society for Peritoneal Dialysis. A pilot cohort study completed in 2021 demonstrated that a virtual education program consisting of didactic lectures, assigned literature review, and case discussions significantly improved the comfort of practicing nephrologists with home dialysis. Overall, nephrologists who completed the program were 53% more likely to recommend and prescribe a home dialysis regimen to their patients.^18,21 Similar in-person or virtual curriculum can be implemented in all nephrology fellowship training programs to ensure greater home dialysis utilization. In addition, similar training programs can be tailored to practicing nephrologists or allied health care professionals to reduce implicit persuasion with respect to KRT options.

Infrastructure for Increased Home Dialysis Utilization

Transitional Care Unit

Up to 50% of patients starting KRT urgently do not have sufficient education and preparation and often require a hospital admission. Typically, these patients do not have predialysis education, and their clinical care may have been affected by uncertainty of the rate of kidney disease progression, unexpected acute deterioration, inadequate follow-up, and complex psychosocial factors, including fears of dialysis.^21,22 One proposed solution to improve CKD education in this vulnerable patient group is the use of a transitional care unit.²³ The initial goal of a transitional care unit is to maximize medical and psychosocial stabilization at a time when they are most needed by patients. From a medical perspective, studies have shown a higher risk of mortality, morbidity, and hospitalization within the first 90 days of initiating maintenance dialysis.^23–25 A transitional care unit is designed to have a higher staff-to-patient ratio compared with in-center HD unit. As a result, the care team, composed of multidisciplinary health professionals, is given more time and resources to address medical issues that arise after dialysis initiation. These include vascular access planning, medication review, and adjustment of the dialysis prescription.^26,27

The psychosocial effects of dialysis initiation are not extensively reported in the literature. However, they can be profound for patients and may serve as a barrier to transitioning to home dialysis.²⁸ The calming space of a transitional care unit provides patients and their family members an opportunity to discuss their goals, concerns, and fears regarding KRT in general and home dialysis.²⁶ Moreover, this model of care allows for peer-to-peer support from patients at various stages of home dialysis initiation. These interactions promote goal setting and increased self-management, which are associated with better health outcomes.²⁹

Practically, patients receive dialysis at the transitional care unit for 3–5 weeks.³⁰ Although a longer duration, such as 8 weeks, has been adopted by some centers to accommodate for home dialysis training.²⁶ Transitional care units can offer personalized HD treatment options to rapidly achieve medical stabilization. These include short daily dialysis 5 days a week or prolonged thrice-weekly dialysis with a slower pump speed and lower ultrafiltration rate.⁹ Consideration should be given with respect to the location and staffing of transitional care units. For smaller centers, a start-up transitional care unit can be created within the physical space of the main dialysis unit, with the only increased cost being increased nursing and allied health support.³¹ However, for larger programs with available space and capital, it is worthwhile to place the transitional care unit in a separate location. This will decrease the likelihood that patients perceive in-center HD as the default treatment option.²⁶ To achieve the goal of increased uptake of home dialysis, patients must be able to witness and potentially sample home dialysis modalities. As a result, equipment for both home HD and PD should be readily available in a home-like environment.³⁰ Finally, studies have demonstrated that nurses who primarily work in in-center HD are frequently exposed to patients who have failed home modalities and may offer a skewed view from anecdotal experience.³² The main goal of the transitional care unit is to find a solution that best suits the patient's life plan rather than promoting home HD or PD alone. As a result, in-center HD, transplantation, and conservative care are offered as options to suitable patients. A recent review demonstrated that 25%–50% of patients will select home HD as they transition out of the transitional care unit.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. The goal of a CHH is to facilitate independent HD for capable patients who have nonmedical barriers to home HD. The first reported use of a CHH was in 2000 in New Zealand, where the cost of the CHH is borne by the state or charities. Since then, more CHH facilities have opened in New Zealand and in rural Australia.³⁴

The most common reason patients choose CHH is due to socioeconomic barriers that preclude home HD. One of the requirements of home HD is that the patient has a stable and suitable dwelling place; however, many incident patients do not meet this requirement.³⁵ A CHH bypasses this barrier, and an argument for institutional cost savings can be made because certain equipment such as dialysis machines and water treatment facilities are shared among numerous patients. A smaller incentive for patients with disadvantageous socioeconomic backgrounds is that the costs of heating, power, and water are borne by the state.³⁶

Patients may choose to dialyze at a CHH for a variety of social reasons. Some patients fear medicalizing their home.³⁷ When small children are present at home, large bore needles and toxic chemicals may present a safety concern. Instead of explaining the treatment to distressed family members, patients at a CHH receive peer support from members of their community who share the same illness and similar burdens. The most important goal of a CHH is to provide an accessible and flexible environment for home HD. The location of a CHH therefore must be convenient to the intended cohort of patients. In addition, CHH should be open during most hours of the day to accommodate users. For example, patients should be able to receive short daily HD or extended nocturnal HD without significant disruptions to work or home life. A CHH is built and furnished as a residence, not as a health care facility. The former is more welcoming and leads to higher facility utilization and longevity.³⁴ CHH rooms may have various configurations that suit the specific needs of the community it caters to. For example, most CHH have rooms that contain two home HD machines; in this way, patients can perform dialysis in a buddy system. However, single rooms should also be available for those who prefer not to be disturbed, such as nocturnal dialysis.³⁶ Similar to transitional care units, a CHH is helpful for fostering the practice of self-motivation and independent care through peer-to-peer mentoring. In a study performed by Walker et al., it is found that two thirds of patients received more than 20 hours of dialysis each week.³⁶ From an analysis of 113 patients, 19 patients transitioned to home HD when conditions allowed, and only 12 transferred to in-center HD.³⁷

Thus far, CHH in New Zealand and Australia have been publicly funded in tightly knit communities with patients capable and willing to performing home HD but are unable do so at their own home.³⁴ Before establishing a CHH, it is recommended to conduct a thorough review of the in-center HD cohort to establish demand and financial feasibility.

PD-First Strategy

Pros and cons of a PD-first or home-first strategy have been debated. There are several advantages of using a PD-first strategy, including lower cost, higher quality of life, and comparable mortality compared with in-center HD.³⁸ The degree to which this strategy is used spans from preference within the program to a mandate where HD is only offered if PD is contraindicated, such as in Hong Kong.

Various programs have found success in choosing PD as the default option of KRT, despite its low uptake in the United States at 12.7% in 2020.^3,39,40 There is considerable cost-saving achieved by adopting a PD-first strategy, and the quality of care is deemed to be superior in many cases.^39,41 From a medical perspective, residual kidney function is better preserved on PD.⁴² There is conflicting evidence if there is a lower risk for death early on with a PD-first strategy. In observational studies, survival seems to be better after initiation of PD compared with HD among incident dialysis patients.^43–48 However, Wong et al. suggested that better survival seen in observational studies may be due to confounding patient factors because the lower risk for death with PD was lost when assessing patients who are eligible for both PD and HD.⁴⁹

In Hong Kong, where PD is the default dialysis treatment option, they have achieved a 2-year technique survival of 82% and a patient survival of 91%. However, this is achieved with PD expertise built over decades. Globally, it is impractical to mandate PD as the de facto strategy in a location where in-center HD and home HD infrastructure already exist; dialysis modality selection is ultimately a personal choice.

Extending Home Dialysis Technique Survival

Respite Care

Respite care for home dialysis is the temporary provision of dialysis to patients who cannot provide self-care. It is provided when patients are expected to recover functional status or a caregiver is able to resume care of the patient. Respite care is especially important to PD patients because transitioning to temporary HD is both medically invasive and socially disruptive.⁵⁰ In addition, temporary HD poses a significant risk to remaining residual kidney function, thus potentially reducing the longevity of PD even after the patient is ready to return to PD.⁵¹ A pilot program of assisted PD in Canada demonstrated that 73% of patients who used PD respite care were able to return to performing PD independently after a mean duration of 29 days.⁵² The cost of respite care was less than transfer to in-center HD. In another pilot study in the United States, assisted PD was offered to both new starts and prevalent PD patients who could not perform PD independently. Ninety-three percent of enrolled patients were able to perform PD independently after initial assistance, with a median program duration of merely 17 days.⁵³ For home HD patients, the option of backup dialysis also offers important support for patients and caregivers. From a resource perspective, one backup treatment per week is needed for every 100 home HD patients.⁵⁴ Furthermore, the provision of backup dialysis was not a harbinger of home HD discontinuation.⁵⁴

Integrated Care: A Pathway for Home-to-Home Transition

The concept of integrated care aims to create a seamless transition between treatment modalities.³⁵ One of the most commonly proposed models for integrated care builds on the aforementioned PD-first strategy to maximize its early benefit and transition to home HD at a predetermined window to prevent the patient from experiencing technique failure, defined in this review as unexpectedly transitioning from a home dialysis modality to in-center HD.

To date, there have been several reports of successful PD to home HD transitions or less frequently home HD to PD transitions.^55,56 Unfortunately, modality transitions often occur in concordance with progressive functional decline or a significant medical event.⁵⁷ As a result, most patients require hospitalization or in-center HD as a transitory treatment modality.⁵⁶ Because hospitalization and in-center HD can result in further functional status decline, the success rate of salvage home-to-home transition is limited. To date, two large cohorts in Australia and New Zealand and Ontario, Canada, report a home-to-home success rate of 5%–14%.^58,59 This low success rate is found among patients already accustomed to a higher quality of life compared with in-center HD and in regions where home dialysis has a higher than global average prevalence.⁶⁰

A model of integrated care proposes an anticipated gradual transition from PD to home HD at the time of PD therapy completion.⁶¹ This bypasses a period of insufficient dialysis or ultrafiltration failure associated with early features of technique failure in PD.^62,63 In addition, time is allotted for permanent access creation. Finally, this creates an opportunity for a stepwise transition, similar to incremental PD. A prospective study compared thrice-weekly HD with once-weekly HD and PD for 3032 patients who were transitioning from PD therapy. There were no detected differences with respect to all-cause mortality, cardiovascular mortality, heart failure, or infections.⁶⁴ Similarly, patients may add short daily dialysis or a few sessions of nocturnal dialysis each week to maintaining euvolemia and adequate clearance, without significant disruptions incurred in an acute modality change.

There are, however, anticipated challenges with unit-wide adoption of this model because the seamless implementation of an integrated strategy requires complete alignment in patients and providers within a system that often operates in silos.^65,66

Policy Changes to Reduce Economic Disadvantages to Home Dialysis

Removing Patient Disincentives for Home Dialysis

The effect of electricity, water, and home renovations costs associated with PD and home HD on patients has not been reported extensively in the literature. Among 71 Australian nephrologists surveyed, 48% reported that they believe a patient's financial disadvantage was a barrier to increased utilization of home HD.⁶⁶ Similarly, a survey conducted among patients and caregivers reported that unreimbursed costs related to home dialysis felt unjust and posed as a significant barrier to greater uptake of home dialysis.⁶⁷ A Taiwanese review stated the median monthly patient cost of PD to be 174 USD in 2018.⁶⁸ In the Frequent Hemodialysis Network (FHN) trial, the median cost of home renovation was 1329 USD in 2010.³⁵ The cost of water and electricity is variable depending on the frequency and duration of home HD. A cost analysis reported up to 1149 USD annually in water and electricity costs in Edmonton, Canada, in 2014.⁶⁹ These costs are in addition to loss of employment income associated with training. It has been noted that reimbursement amounts are higher in countries with more prevalent use of home dialysis.⁷⁰ For example, Denmark, Australia, New Zealand, Canada, and the United Kingdom had higher likelihood for reimbursement of water and electricity costs by the state compared with the United States. It is therefore tempting to speculate that removal of financial disincentive may be an appropriate and necessary system change to encourage patient adoption of home dialysis.

Equalization of Payment to Dialysis Providers

Before recent reforms, physicians and dialysis providers received higher compensation for HD compared with home dialysis, especially PD. Home HD in general also received similar or lower compensation compared with in-center HD across six developed nations, except in the United Kingdom.⁷¹ Nephrologists in the United States, Canada, and the United Kingdom reported that they do not consider physician compensation a major factor in determining in-center HD versus home dialysis for patients.^72–74 However, there is a lower observed rate of PD in countries where there is diminished physician compensation for PD.⁷⁵ In Ontario, Canada, equalization of physician compensation for in-center HD and home dialysis had stabilized the decline of PD utilization while the rest of Canada experienced further decline in the late 1990s.⁷⁶ Subsequently, the Centers for Medicare & Medicaid Services in the United States introduced the bundle system of dialytic care in 2011, where the service provider will receive the same payment for in-center HD or PD. For most facilities in the United States, the operational cost of PD is less than that of in-center HD.⁷⁷ The observed incident rate of PD rose from 9.4% in 2006–2010 to 12.6% in 2011–2013 from analysis of USRDS data.⁷⁸ However, it has been noted that similar payment reforms in certain European jurisdictions had not led to a similar uptake in PD use.³⁸ As a result, physician and dialysis provider compensation reforms remain only a component of factors that may affect home dialysis utilization.

In summary, we have discussed the evidence supporting various innovative system changes that aimed to increase home dialysis utilization. While improved education, equitable policy changes, infrastructure investments, and adaptive strategies are all individually important, the benefits will be maximized when they are combined to promote personalized dialysis care.

Disclosures

C.T. Chan holds the R Fraser Elliott Chair in Home Dialysis and reports consultancy for Dialco, Medtronic, and Quanta; research funding from Medtronic through their external grant program; advisory or leadership roles for DaVita, Medtronic, and Quanta; and role as an Associate Editor of CJASN. X.B.J. Cheng received GSK Home Dialysis Fellowship Funding.

Funding

None.

Author Contributions

Conceptualization: Christopher T. Chan.

Data curation: Christopher T. Chan, Xin Bo Justin Cheng.

Formal analysis: Christopher T. Chan.

Writing – original draft: Christopher T. Chan, Xin Bo Justin Cheng.

Writing – review & editing: Christopher T. Chan.