Table 5.
Barriers and priorities needed to expand assisted PD
| Country | Barriers to growth | What is needed to grow | Top three priorities |
|---|---|---|---|
| Austria | Low use of PD. In general, no reimbursement for assistance. No nationwide standardized predialysis education programmes |
Good collaboration between PD centres; yet a few centres have expertise and resources for training, quality assurance and on-site supervision, which are crucial to establish a successful asPD programme |
1. In the predialysis period, structured predialysis education programmes for patients and their relatives 2. We need to recruit PD enthusiastic healthcare professionals 3. Collaboration between PD centres is essential to overcome problems while setting up an asPD programme |
| Denmark | Same barriers as to growth of PD in general. Mainly lack of experience, confidence and education among nephrologists. Unused capacity for in-centre HD | Better education of nephrologists. A change in attitude from ‘high dose dialysis—high Kt/V dialysis’ towards relief of symptoms—especially for the frail elderly patients | 1. Better education of nephrologists/decision makers 2. Implementation of ISPD practice recommendations: prescribing high-quality goal-directed PD 3. Provide more data on clinical outcome including quality of life |
| Finland | Costs. Need a new system with separate team doing home visits | A totally new system, who will assist the patient? Costs taken by the community sector of the social security system | 1. Increase the number of PD patients 2. Enable support for old fragile patient at home 3. Home first policy |
| France | 50% of French PD patients are treated by nurse-assisted PD. Barriers are mainly in rural areas where the number of private nurses is too low | We do not believe that nurse-assisted PD could grow significantly in terms of % of patients. The potential growth of nurse-assisted PD mainly depends on the growth of the utilization of PD in France | 1. Shared decision making 2. Healthcare professional education 3. Financial incentive at the centre level (payment for performance) |
| Germany | Patients are not informed about the asPD option. Lack of standard reimbursement for asPD. Staff resources low for care providers. Too little awareness with existing need for asPD. Lack of support from professional societies and providers so far. Very good infrastructure of dialysis centres (∼1050 centres in Germany) |
asPD as standard reimbursement for care providers. Information and education for patients and society. Training—curriculum and certification of nurses from caregivers. Overall, creating greater awareness of home dialysis procedures (training doctors, nursing). Information for politicians and health insurance companies |
1. Financing and inclusion of asPD in the catalogue of services 2. Training and certification of care providers 3. Clarification of all parties involved |
| Greece | PD delivered only by public sector in a small number of general hospitals in big cities. Large number of HD patients unaware of alternatives | Increase prevalence of PD. According to the latest data of the Coordination and Control Service, PD prevalence: 6.3% in 2017 down from 8.2% in 2009. Benefits of PD should be communicated in effective ways to candidate patients. Creation of a network of trained nurses in PD who will visit mainly elderly and non-self-sufficient patients | 1. Convince healthcare decision makers about need to increase use of PD 2. Develop public home-based healthcare system with trained nurses and doctors 3. Early information/education for patients and nephrologists, in predialysis period about benefits of PD |
| Ireland | Primarily lack of funding. Currently, in-centre HD is supported directly on a ‘money follow the patient model’, whereas home dialysis therapy is funded as an annual block funding with no incentives to increase uptake. More predialysis education—limited by lack of predialysis nurses Incentives for patients to commence home dialysis. Patients do not receive any funding for the costs of providing home dialysis, e.g. electricity and waste disposal |
Formal support structure and funding stream for PD. Engagement with policymakers to incentivise patient uptake. Increase predialysis education and support structures |
1. Formal support structure and funding stream for PD 2. Engagement with policymakers to incentivise patient uptake 3. Increase predialysis education and support structures |
| Italy | Most families cannot afford to support caregiver. Absence of a more convenient tariff for asPD, considering the need for more money to cover the cost of caregivers. Nursing homes show a low propensity to take care of PD patients | Pilot projects increased incidence but not prevalence of asPD: increasing reimbursement may not be enough. Education of nephrologists and nurses about advantages of asPD and PD in general is key. Nursing homes also need to be included in asPD development projects |
1. asPD recognition and adequate reimbursement from public healthcare system 2. Social support for patient and family, e.g. housing availability 3. Nurses and nephrologists home visits should be part of PD programme |
| Norway | Barriers to asPD same as to PD in general: getting the information and education out to the patients and to nephrology teams | Increasing the prevalence of PD patients. More frequent deliveries as patients complain of number of boxes. Well-functioning PD clinics with nurses with solid experience are a key factor for success as is good collaboration with the surgical team operating PD catheters |
1. Increasing prevalence of PD in general 2. More education, experience and confidence in the treatment 3. Well-functioning PD clinics and cooperation between clinics enabling exchange of experience and enhancing confidence |
| Portugal | Lack of funding for asPD. AsPD may seem economically less attractive (due to bundle payment without the cost of transport for in-centre HD patients). Most nephrologists prefer HD |
Governmental strategy to increment home dialysis:• awareness of the unmet need: absence of asPD;• allocation of the cost of transportations and vascular accesses for HD to Dialysis Unit providing home dialysis;• determination of a minimum percentage of home dialysis patients (and regular audit);• creation of a reimbursed ‘PD assistant’ position/adjust the present reimbursement policy of informal assistant;• regulation of nursing homes/rehabilitation units’ responsibilities towards home dialysis patients’ needs. Nephrologists’ awareness of end-of-life care, quality of life and asPD benefits | 1. Government regulation of home dialysis patients’ allocation 2. Financial incentive at the centre level (payment for performance) with abolition of conflict of interest between HD and PD 3. Payment to the carers |
| Spain | Low use of PD by many nephrologists. No payment for caregivers, including family members. No legal coverage for carers—important if they are not relatives (travel insurance, legal defence against home care problems, etc.). Kidney patients associations not aware of specific needs of dependent dialysis patients |
1. Increasing use of PD 2. Spread awareness of PD including among nephrologists 3. Public health system should pay for caregivers, including family members 4. Legal coverage must be offered to carers, mainly if they are not relatives 5. Kidney patients associations should be aware of specific needs of dependent dialysis patients |
1. Broadening the definition of asPD (not only for older people) 2. Paying carers 3. Involving patients associations in the promotion of asPD |
| Sweden | Organisational differences between municipalities and regions | Inform and share positive patient experiences with asPD to patients, health care professionals and society overall. Collaboration with patient organisations, to endorse importance of equal care and overcome regional differences. Strengthen the importance of the predialysis team to give recurrent and updated predialysis information about modalities |
1. Predialysis information about self-dialysis, PD and asPD as modalities 2. Establishing strategic goals within each nephrology clinic to align all healthcare professionals 3. Well-functioning PD clinics with solid experienced nurses to educate and support asPD |
| UK | Variable use of PD in different countries in the UK and centres. Default use of in-centre HD for frail older patients in many centres. Use of 1 visit/day model only suitable for patients able to do own connection/disconnection on APD unless family support and excludes use of CAPD unless renal unit funds extra visits. National health and social care funding problems resulting in shortage of available assistants |
Increase awareness of advantages of PD and disadvantages of in-centre HD for frail older people—to patients, families and renal teams. Increase reimbursement for asPD so that 2 visits/day become the norm for APD and more visits possible for CAPD. Realistic comparison of costs between asPD and in-centre HD by including transport costs in HD costs |
1. ‘Levelling-up’ of PD use in renal centres to minimize variability and therefore increase access to PD overall 2. Increase reimbursement from public healthcare system for asPD to minimum of 2 visits/day 3. Critical shortage of assistants in many areas needs addressing: pay structure, career growth, integration with other caregivers |