Why Peritoneal Dialysis is Underutilized in the United States: A Review of Inequities

Abstract

Given a choice, most patients with end-stage renal disease prefer home dialysis over in-center hemodialysis (HD). Peritoneal dialysis (PD) is a home dialysis method and offers benefits such as absence of central venous access and therefore preservation of veins, low cost, and decreased time per dialysis session, as well as convenience. Survival rate for patients on PD has increased to levels comparable to in-center HD. Despite endorsement by leaders in the medical field, professional societies, and those in government, PD has reached only 11% adoption among incident patients according to the 2019 United States Renal Data System Annual Data Report. This figure is dwarfed in comparison to rates as high as 79% in other countries. In addition, research has shown that inequities exist in PD access, which are most pronounced in rural, minority, and low-income regions as demonstrated by trends in regional PD supplies. To complicate things further, technique failure has been implicated as a major determinant of poor PD retention rates. The low initiation and retention rates of PD in the United States points to barriers within the healthcare system, many of which are in the early phases of being addressed.

The two methods by which end-stage renal disease (ESRD) patients generally dialyze are in-center hemodialysis (HD) and home-based peritoneal dialysis (PD). Although HD is performed by healthcare professionals in dialysis facilities three times weekly, PD is performed by the patient multiple times throughout the day with a monthly visit to a facility for maintenance. Social and geographic barriers such as unreliable transportation, inconsistent child care, lack of adequate paid-time-off, and distance to the nearest in-center dialysis centers are important considerations when choosing the appropriate treatment for ESRD patients. In particular, rural patients may need to travel significant distances to the nearest in-center HD centers to receive treatment, which places additional strain on them. The concerns of these patients should not be discounted, as, according to census data, approximately 20% of the U.S. population lives in rural areas, which makes up 97% of the land mass. Healthcare resources to these areas are far less developed than urban areas which theoretically offer an advantage to home-based dialysis methods, as less infrastructure is required for their success. PD is an attractive and viable option for individuals whose lives are not compatible with the time constraints and transportation demands that HD places on patients. ^{1 2 3 4 5 6}

Factors Contributing to the Limited Use of Peritoneal Dialysis as a Home Dialysis Modality

Governmental Policies and Financial Incentives

A financial incentive exists for private dialysis facilities to care for HD patients over PD patients. Growth of private dialysis facilities has outpaced the general population. Indeed, Medicare reimbursement rates were $15,000 more per patient on HD than with PD in 2016. ⁷ Private dialysis facilities provide the vast majority of in-center dialysis services, yet PD is underutilized in this setting. ⁸ Policies have recently been set forth to encourage the adoption of PD in the United States. The Centers for Medicare and Medicaid Services (CMS) has expedited health insurance coverage for home dialysis such that the 90-day waiting period is waived in patients eligible for home dialysis. With the introduction of the bundled payment system by CMS in 2011, which altered dialysis treatment by packing dialysis, medications, and ancillary services into a single payment that is adjusted for patient- and facility-level characteristics, there has been a small, but demonstrable, increase in PD utilization. In 2006, the number of facilities offering PD assistance was only at 36%; this number increased by 6% in 2013 after the adoption of the bundled payment system, with 42% of dialysis centers reporting PD services. Similarly, PD use increased by single-digit percentage from 2011 to 2013 (9.4% before payment reform to 12.6% after in-patients using PD within the first 90 days of initiating dialysis). ⁹ The number of dialysis centers providing PD support has made modest growth since the implementation of CMS reform, but this rate does not meet the increasing demands of a quickly expanding patient population that seeks personal flexibility in treatment options for ESRD.

Further policies and reforms to make PD a priority in the United States should be implemented to reach a broader patient population. Palliative dialysis, for instance, is not currently eligible for reimbursement by CMS for those on hospice care if the reason for hospice is due to kidney failure. PD offers those patients who are conscious of their end-stage illness to maintain their personal independence and remain at home rather than be taken to a facility for HD. ¹⁰ Assisted PD (APD) is currently not eligible for reimbursement either. ¹¹ APD involves nurses or family members who have been specially trained to help perform PD, often for elderly patients. Limitations in coverage of services and strict parameters for reimbursement qualifications place an undue burden on patients in choosing treatment for ESRD; it hinders patients from considering therapeutic options that best suit their needs based on lifestyle preferences. Ultimately, ESRD patients may abnegate PD for treatments that their insurance covers but are more cumbersome to manage in their day-to-day lives.

Socioeconomic Barriers

In addition to socioeconomic and regional barriers, age can affect a clinician's decision to place the ESRD patient on one dialysis modality over another. It has been demonstrated that younger patients with fewer comorbidities are more likely to have PD recommended to them than their older counterparts. ¹² Prerequisites such as intact cognitive ability, manual dexterity, and vision impairment may bias healthcare providers from referring older patients from receiving PD. However, strategies have been effectively employed to ensure these individuals properly administer PD; measures such as APD and telemedicine increase the subset of patients who can receive PD for their ESRD, including those of increased age, mild cognitive decline, and modest visual or physical handicaps that may need minor assistance or monitoring to perform PD at home. ¹³ Many options exist for the individualization of PD by nephrologists when selecting patients to receive this treatment. Increasing healthcare providers' knowledge about the options for tailoring PD regimens specifically to the needs of the patient, as well as recognizing implicit biases about age, disabilities, and cognitive ability, will prevent premature dismissal of PD as an appropriate therapy for ESRD.

Knowledge and Experience with Peritoneal Dialysis among Nephrologists

The majority of ESRD patients meet criteria to opt for PD, with some research indicating up to 85% of ESRD patients qualifying for treatment. Absolute contraindications for PD are few but include lack of functional peritoneal membrane, active inflammatory bowel disease, and recent placement of ostomy. For PD to be conferred onto the patient, a process of selection and informed consent must be performed. This involves screening tests as well as empowering and guiding the patient though a process of shared decision making by the provider. Predictably, the majority of ESRD patients have no prior knowledge of PD. ¹⁴ It has been shown that educating the patient in the initial stages of ESRD results in higher uptake of home dialysis. ¹⁵ Selection of PD over HD is associated with having established relationship with a nephrologist upon diagnosis of ESRD and having a higher levels of education. ¹² Albeit most nephrologists are uncomfortable with considering PD as an option for their patients due to lack of experience with this modality. ¹⁶

Attitude toward PD among nephrologists has changed drastically over the decades. In the 1980s, leading nephrologists looked down on PD, referring to it as second-class therapy. Early PD experience had problems with considerable risk of peritonitis, inadequate clearance of small solutes, and deterioration of the peritoneal membrane. This led to a decline of PD use in the 1990s. However, the science of studying PD in small groups from that period showed a significant reduction in risk of death as PD technology improved. Since then, nephrology professional organizations have represented PD in a positive light including the incorporation of the International Society for Peritoneal Dialysis (ISPD) in 2008. Publication of the 2020 ISPD practice recommendations about PD emphasized high-quality, goal-directed PD in working with the patient which differed from previous guidelines that focused simply on adequacy of dialysis. This prompted the convening of a National Kidney Foundation's Kidney Disease Outcomes Quality Initiative (KDOQI) working group to provide guidance for clinicians in the United States. The commentary was backed by the National Kidney Foundation and applauded the guidelines as “very timely and welcome.” ¹⁷ PD as a modality, however, is not without its faults.

Technique Failure

A significant issue with PD is technique failure, which can be defined as abandonment of PD for another method of dialysis either temporarily or permanently. Return to PD in patients who experience technique failure lasting greater than 30 days is a modest 24%. That figure drops to 3% if the duration of HD is greater than 180 days. ¹⁸ In addition, up to a quarter of overall technique failure happens in the first year. ¹⁹ Death, infection, inadequate dialysis, mechanical, and patient-related factors are the most common reasons for technique failure listed in order of decreasing prevalence according to the Australian and New Zealand Dialysis and Transplant Registry study. ²⁰ Patient-related factors for technique failure include young age, high body mass index, non-white race, lower socioeconomic status, and comorbidities such as diabetes. ²¹ Despite this, the economic impact of switching to HD modalities after PD technique failure is comparable to HD-only patients at 3 years. ²² Reducing technique failure is paramount for continued improvement in perception of PD among providers and patients.

Patient populations who are particularly susceptible to technique failure are blacks and Hispanics, specifically related to the issue of patient preference. ²³ Patient preference is a multifactorial issue composed of mental illness, inability to tolerate the number of treatment sessions required by PD, and loss of support network. Indeed, the number of treatment sessions required by PD can lead to burnout, a feeling of suffering felt by patients and caregivers. These are mostly controllable factors which exist despite efforts to oversee and educate minority populations undergoing PD. This education should include building resilience against burnout by drawing support from family and/or religion. ²⁴

Disparities in PD among Minorities

The percentage of African American and Hispanic patients who receive renal replacement therapy with PD is lower than that of white patients. ^{25 26} In fact, African Americans make up a third of the ESRD patients but represent only 21% of the patients on PD. ³ Demographic and clinical features of these minority groups are not sufficient to explain this finding considering they are generally younger at the time of diagnosis and have a lower prevalence of coexisting cardiovascular disease. ²⁶ This points to other factors influencing choice of renal replacement therapy. It is possible that patient preference plays a large role. Socioeconomic differences such as having enough space in the home or ability to afford the extra cost of electricity to run the equipment may contribute to the decision-making process. Interestingly, minority groups stand a lower risk of death once on PD. Conversely, it may point to a lack of awareness about PD. Currently, teaching for unplanned PD does not uniformly include information on home PD versus in-center HD and home HD. ²⁷ The risk of transfer to in-center HD is markedly higher for blacks treated with PD compared with whites.

Conclusion

The benefits of PD are clearly established including improved patient survival, preservation of residual kidney function, minimal risk of infection, and increased patient satisfaction, as well as decreased healthcare costs. While PD is not universally desirable for the ESRD patient, many patients would choose PD if certain inequities within the healthcare system are overcome. Awareness of PD as a viable dialysis method should increase among nephrologists and healthcare providers alike as they are the gatekeepers. Strategies to increase education about PD include one-on-one teaching by providers. A concerted effort by healthcare systems and policy makers to increase resources in minority populations will help address racial disparities. Potential pitfalls to continuing PD must be anticipated by providers, especially those factors which are controllable such as burnout. With these improvements, PD may reach a broader patient population and improve outcomes in ESRD.