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Poinen K, Mitra S, Quinn RR. The integrated care model: facilitating initiation of or transition to home dialysis. Clin Kidney J 2024; 17:i13-i20. [PMID: 38846413 PMCID: PMC11151114 DOI: 10.1093/ckj/sfae076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2023] [Indexed: 06/09/2024] Open
Abstract
A proportion of end-stage kidney disease (ESKD) patients require kidney replacement therapy to maintain clinical stability. Home dialysis therapies offer convenience, autonomy and potential quality of life improvements, all of which were heightened during the COVID-19 pandemic. While the superiority of specific modalities remains uncertain, patient choice and informed decision-making remain crucial. Missed opportunities for home therapies arise from systemic, programmatic and patient-level barriers. This paper introduces the integrated care model which prioritizes the safe and effective uptake of home therapies while also emphasizing patient-centered care, informed decision-making, and comprehensive support. The integrated care framework addresses challenges in patient identification, assessment, eligibility determination, education and modality transitions. Special considerations for urgent dialysis starts are discussed, acknowledging the unique barriers faced by this population. Continuous quality improvement is emphasized, with the understanding that local challenges may require tailored solutions. Overall, the integrated care model aims to create a seamless and beneficial transition to home dialysis therapies, promoting flexibility and improved quality of life for ESKD patients globally.
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Affiliation(s)
- Krishna Poinen
- Division of Nephrology, Department of Medicine, University of British Columbia, Vancouver, Canada
| | - Sandip Mitra
- Department of Renal Medicine, Manchester Academy of Health Sciences Centre Manchester University Hospitals, University of Manchester, Manchester, UK
| | - Robert R Quinn
- Departments of Medicine and Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
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Abra GE, Weinhandl ED, Hussein WF. Setting Up Home Dialysis Programs: Now and in the Future. Clin J Am Soc Nephrol 2023; 18:1490-1496. [PMID: 37603364 PMCID: PMC10637466 DOI: 10.2215/cjn.0000000000000284] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Accepted: 08/09/2023] [Indexed: 08/22/2023]
Abstract
Home dialysis utilization has been growing in the United States over the past decade but still lags behind similar socioeconomic nations. More than half of dialysis facilities in the United States either are not licensed to offer home dialysis or, despite a license, have no patients dialyzing at home, and many programs have a relatively small census. Multiple stakeholders, including patients, health care providers, and payers, have identified increased home dialysis use as an important goal. To realize these goals, nephrologists and kidney care professionals need a sound understanding of the key considerations in home dialysis center operation. In this review, we outline the core domains required to set up and operate a home dialysis program in the United States now and in the future.
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Affiliation(s)
- Graham E. Abra
- Satellite Healthcare, San Jose, California
- Division of Nephrology, Stanford University, Palo Alto, California
| | - Eric D. Weinhandl
- Satellite Healthcare, San Jose, California
- Department of Pharmaceutical Care and Health Systems, University of Minnesota, Minneapolis, Minnesota
| | - Wael F. Hussein
- Satellite Healthcare, San Jose, California
- Division of Nephrology, Stanford University, Palo Alto, California
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Teitelbaum I, Finkelstein FO. Why are we Not Getting More Patients onto Peritoneal Dialysis? Observations From the United States with Global Implications. Kidney Int Rep 2023; 8:1917-1923. [PMID: 37849989 PMCID: PMC10577320 DOI: 10.1016/j.ekir.2023.07.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Revised: 06/11/2023] [Accepted: 07/17/2023] [Indexed: 10/19/2023] Open
Abstract
Peritoneal dialysis (PD) offers lifestyle advantages over in-center hemodialysis (HD) and is less costly. However, in the United States, less than 12% of end-stage kidney disease (ESKD) patients are maintained on this modality. In this brief review, we discuss some of the factors underlying the low prevalence of PD. These include inadequate patient education, a shortage of sufficiently well-trained medical and nursing personnel, absence of infrastructure to support urgent start PD, and lack of support for assisted PD, among other factors. Understanding and addressing these various issues may help increase the prevalence of PD in the United States and globally.
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Affiliation(s)
- Isaac Teitelbaum
- Division of Kidney Diseases and Hypertension, Department of Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA
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Cheng XBJ, Chan CT. Systems Innovations to Increase Home Dialysis Utilization. Clin J Am Soc Nephrol 2023; 19:01277230-990000000-00231. [PMID: 37651291 PMCID: PMC10843223 DOI: 10.2215/cjn.0000000000000298] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Accepted: 08/18/2023] [Indexed: 09/02/2023]
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.
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Affiliation(s)
- Xin Bo Justin Cheng
- Division of Nephrology, Department of Medicine, University Health Network, Toronto, Ontario, Canada
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Goldman S, Chan CT, Einbinder Y, Rozen-Zvi B, Morduchowicz G, Perl J. Nephrologists' Perspectives on Home Dialysis Utilization: A National Survey From Israel. Kidney Med 2023; 5:100680. [PMID: 37576430 PMCID: PMC10421980 DOI: 10.1016/j.xkme.2023.100680] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/15/2023] Open
Affiliation(s)
- Shira Goldman
- Division of Nephrology, St. Michael’s Hospital, Toronto, Ontario, Canada
- Division of Nephrology, University Health Network, University of Toronto, Toronto, Ontario, Canada
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Department of Nephrology and Hypertension, Rabin Medical Center, Petach-Tikva, Israel
| | - Christopher T. Chan
- Division of Nephrology, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Yael Einbinder
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Department of Nephrology and Hypertension, Meir Medical Center, Kfar Saba, Israel
| | - Benaya Rozen-Zvi
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Department of Nephrology and Hypertension, Rabin Medical Center, Petach-Tikva, Israel
| | - Gabriel Morduchowicz
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Department of Nephrology and Hypertension, Rabin Medical Center, Petach-Tikva, Israel
| | - Jeffrey Perl
- Division of Nephrology and Keenan Research Center, Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Toronto, Ontario, Canada
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Hamidi S, Zarnke S, Turcotte K, Silver SA. The Feasibility of a Transitional Care Unit for Patients Newly
Started on In-Center Hemodialysis: A Research Letter. Can J Kidney Health Dis 2023; 10:20543581231162235. [PMID: 36970567 PMCID: PMC10031589 DOI: 10.1177/20543581231162235] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Accepted: 01/30/2023] [Indexed: 03/23/2023] Open
Abstract
Background: Patients with end-stage kidney disease face high mortality and morbidity
after dialysis initiation. Transitional care units (TCUs) are typically 4-
to 8-week structured multidisciplinary programs targeted toward patients
starting hemodialysis during this high-risk time in their care. The goals of
such programs are to provide psychosocial support, provide dialysis modality
education, and reduce risks of complications. Despite apparent benefits, the
TCU model may be challenging to implement, and the effect on patient
outcomes is unclear. Objective: To assess a newly created multidisciplinary TCUs’ feasibility for patients
newly started on hemodialysis. Design: Before-and-after study. Setting: Kingston Health Sciences Centre hemodialysis unit in Ontario, Canada. Patients: We considered all adult patients (age 18+) who initiated in-center
maintenance hemodialysis eligible for the TCU program, although patients on
infection control precautions and evening shifts were not able to receive
TCU care due to staffing limitations. Measurements: We defined feasibility as eligible patients completing the TCU program in a
timely fashion without additional need for space, no signal of harm, and
without explicit concerns from TCU staff or patients at weekly meetings. Key
outcomes at 6 months included mortality, proportion hospitalized, dialysis
modality, vascular access, initiation of transplant workup, and code
status. Methods: The TCU care consisted of 1:1 nursing and education until predefined clinical
stability and dialysis decisions were satisfied. We compared outcomes among
the pre-TCU cohort who initiated hemodialysis between June 2017 and May
2018, and TCU patients who initiated dialysis between June 2018 and March
2019. We summarized outcomes descriptively, along with unadjusted odds
ratios (ORs) and 95% confidence intervals (CIs). Results: We included 115 pre-TCU patients and 109 post-TCU patients, of whom 49/109
(45%) entered and completed the TCU. The most common reasons for not
participating in the TCU included evening hemodialysis shifts (18/60, 30%)
or contact precautions (18/60, 30%). The TCU patients completed the program
in a median of 35 (25-47) days. We observed no differences in mortality (9%
vs 8%; OR = 0.93, 95% CI = 0.28-3.13) or proportion hospitalized (38% vs
39%; OR = 1.02, 95% CI = 0.51-2.03) between the pre-TCU cohort and TCU
patients. There was also no difference in use of home dialysis (16% vs 10%;
OR = 1.67, 95% CI = 0.64-4.39), non-catheter access (32% vs 25%; OR = 1.44,
95% CI = 0.69-2.98), initiation of transplant workup (14% vs 12%; OR 1.67;
95% CI = 0.64-4.39), and choosing “do not resuscitate” (DNR) orders (22% vs
19%; OR = 1.22, 95% CI = 0.54-2.77). There was no negative patient or staff
feedback on the program. Limitations: Small sample size and potential for selection bias given inability to provide
TCU care for patients on infection control precautions or evening
shifts. Conclusions: The TCU accommodated a large number of patients, who completed the program in
a timely fashion. The TCU model was determined to be feasible at our center.
There was no difference in outcomes due to the small sample size. Future
work at our center is required to expand the number of TCU dialysis chairs
to evening shifts and evaluate the TCU model in prospective, controlled
studies.
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Affiliation(s)
- Shabnam Hamidi
- Division of Nephrology, Department of
Medicine, Queen’s University, Kingston, ON, Canada
- Kingston Health Sciences Centre, ON,
Canada
| | - Sasha Zarnke
- Division of Nephrology, Department of
Medicine, Queen’s University, Kingston, ON, Canada
| | | | - Samuel A. Silver
- Division of Nephrology, Department of
Medicine, Queen’s University, Kingston, ON, Canada
- Kingston Health Sciences Centre, ON,
Canada
- Samuel A. Silver, Division of Nephrology,
Department of Medicine, Queen’s University, 76 Stuart Street, 3-Burr 21-3-039,
Kingston, ON K7L 2V7, Canada.
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Blankenship DM, Usvyat L, Kraus MA, Chatoth DK, Lasky R, Turk JE, Maddux FW. Assessing the impact of transitional care units on dialysis patient outcomes: A multicenter, propensity score-matched analysis. Hemodial Int 2023; 27:165-173. [PMID: 36757059 DOI: 10.1111/hdi.13068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2022] [Revised: 10/28/2022] [Accepted: 01/19/2023] [Indexed: 02/10/2023]
Abstract
INTRODUCTION Inadequate predialysis care and education impacts the selection of a dialysis modality and is associated with adverse clinical outcomes. Transitional care units (TCUs) aim to meet the unmet educational needs of incident dialysis patients, but their impact beyond increasing home dialysis utilization has been incompletely characterized. METHODS This retrospective study included adults initiating in-center hemodialysis at a TCU, matched to controls (1:4) with no TCU history initiating in-center hemodialysis. Patients were followed for up to 14 months. TCUs are dedicated spaces where staff provide personalized education and as-needed adjustments to dialysis prescriptions. For many patients, therapy was initiated with four to five weekly dialysis sessions, with at least some sessions delivered by home dialysis machines. Outcomes included survival, first hospitalization, transplant waiting-list status, post-TCU dialysis modality, and vascular access type. FINDINGS The study included 724 patients initiating dialysis across 48 TCUs, with 2892 well-matched controls. At the end of 14 months, patients initiating dialysis in a TCU were significantly more likely to be referred and/or wait-listed for a kidney transplant than controls (57% vs. 42%; p < 0.0001). Initiation of dialysis at a TCU was also associated with significantly lower rates of receiving in-center hemodialysis at 14 months (74% vs. 90%; p < 0.0001) and higher rates of arteriovenous access (70% vs. 63%; p = 0.003). Although not statistically significant, TCU patients were more likely to survive and less likely to be hospitalized during follow-up than controls. DISCUSSION Although TCUs are sometimes viewed as only a means for enhancing utilization of home dialysis, patients attending TCUs exhibited more favorable outcomes across all endpoints. In addition to being 2.5-fold more likely to receive home dialysis, TCU patients were 42% more likely to be referred for transplantation. Our results support expanding utilization of TCUs for patients with inadequate predialysis support.
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Affiliation(s)
| | - Len Usvyat
- Fresenius Medical Care, Global Medical Office, Waltham, Massachusetts, USA
| | - Michael A Kraus
- Fresenius Medical Care, Global Medical Office, Waltham, Massachusetts, USA
| | - Dinesh K Chatoth
- Fresenius Medical Care, Global Medical Office, Waltham, Massachusetts, USA
| | - Rachel Lasky
- Fresenius Medical Care, Global Medical Office, Waltham, Massachusetts, USA
| | - Joseph E Turk
- Fresenius Medical Care, Global Medical Office, Waltham, Massachusetts, USA
| | - Franklin W Maddux
- Fresenius Medical Care AG & Co. KGaA, Global Medical Office, Bad Homburg, Germany
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Fraga Dias B, Rodrigues A. Managing Transition between dialysis modalities: a call for Integrated care In Dialysis Units. BULLETIN DE LA DIALYSE À DOMICILE 2022. [DOI: 10.25796/bdd.v4i4.69113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Summary
Patients with chronic kidney disease have three main possible groups of dialysis techniques: in-center hemodialysis, peritoneal dialysis, and home hemodialysis. Home dialysis techniques have been associated with clinical outcomes that are equivalent and sometimes superior to those of in-center hemodialysisTransitions between treatment modalities are crucial moments. Transition periods are known as periods of disruption in the patient’s life associated with major complications, greater vulnerability, greater mortality, and direct implications for quality of life. Currently, it is imperative to offer a personalized treatment adapted to the patient and adjusted over time.An integrated treatment unit with all dialysis treatments and a multidisciplinary team can improve results by establishing a life plan, promoting health education, medical and psychosocial stabilization, and the reinforcement of health self-care. These units will result in gains for the patient’s journey and will encourage home treatments and better transitions.Peritoneal dialysis as the initial treatment modality seems appropriate for many reasons and the limitations of the technique are largely overcome by the advantages (namely autonomy, preservation of veins, and preservation of residual renal function).The transition after peritoneal dialysis can (and should) be carried out with the primacy of home treatments. Assisted dialysis must be considered and countries must organize themselves to provide an assisted dialysis program with paid caregivers.The anticipation of the transition is essential to improve outcomes, although there are no predictive models that have high accuracy; this is particularly important in the transition to hemodialysis (at home or in-center) in order to plan autologous access that allows a smooth transition.
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Transitions between dialysis modalities. J Nephrol 2022; 35:2411-2415. [PMID: 35849263 DOI: 10.1007/s40620-022-01397-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2022] [Accepted: 07/01/2022] [Indexed: 10/17/2022]
Abstract
Thanks to the progress of dialysis, survival of patients with end-stage renal disease is increasing. For those patients who cannot benefit from a kidney transplantation, several dialysis alternatives exist, but the transition between dialysis techniques may be difficult. Home dialysis offers many advantages but requires personal commitment from the patients and the caregivers. How can we ensure smooth transitioning to the best dialysis technique at the right time for the right person? One of the main caveats of peritoneal dialysis is its limited technique survival, however, it combines the advantages of preserving residual kidney function, avoiding the need for a vascular access, or preserving it, when present, while providing good cost-effectiveness. On the other hand, home hemodialysis has excellent long-term technique survival. The home integrated model of peritoneal dialysis followed by home hemodialysis has been described as the ideal pathway of care. Eventually, in-center hemodialysis can be provided according to several schedules to adapt to the needs of the patients. The issue of technique survival and the possible need to switch to another technique should be part of the initial discussion, when the patient needs to choose the first dialysis modality. Unplanned transfers are associated with poor outcomes and unwanted shifts to in-center hemodialysis. Therefore, transfers from home-based techniques should be anticipated as much as possible in order to establish a shared decision modality process and to choose the desired new modality. Dialysis units dedicated to "transition care" should answer the needs of patients and smooth the transition process between dialysis modalities.
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Cui M, Hua J, Shi X, Yang W, Geng Z, Qian X, Geng G. Factors associated with instrumental support in transitional care among older people with chronic disease: a cross-sectional study. BMC Nurs 2022; 21:230. [PMID: 35996136 PMCID: PMC9394025 DOI: 10.1186/s12912-022-01014-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2021] [Accepted: 08/05/2022] [Indexed: 11/10/2022] Open
Abstract
Background Instrumental support, which is defined as practical, tangible, and informational assistance extended to patients, is crucial for older people in transition. However, little is known about instrumental support in transitional care. Thus, the aim of this study was to evaluate the instrumental support of older people in transitional care. Methods This cross-sectional study was conducted using the Questionnaire of Instrumental Support in Transitional Care (QISCT) to collect data from 747 older people in China from September to November 2020. Survey items consisted of a sociodemographic characteristics questionnaire and the QISCT. Multiple regression analyses were conducted to examine the association between independent variables and the QISCT scores. Results The total score of the QISCT was 39.43 (± 9.11), and there was a significant gap between the anticipated support and received support. The satisfaction of instrumental support was low. Multiple regression analyses showed that educational level, the number of intimate relationships, monthly family income, monthly costs of transitional care, diabetes, and chronic obstructive pulmonary disease were associated with instrumental support in transitional care. Conclusions To cope with the burden caused by chronic disease, the government and transitional care teams should establish a demand-oriented transitional care service model and pay more attention to helping older people obtain adequate and satisfactory instrumental support.
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Affiliation(s)
- Min Cui
- School of Medical, Nantong University, No19, Qixiu Road, Chong Chuan District, Nantong, Jiangsu Province, 226001, China
| | - Jianing Hua
- Affiliated Hospital of Jiangnan University, 1800 Lihu Avenue, Wuxi, Jiangsu Province, China
| | - Xiaoliu Shi
- Affiliated Hospital of Nantong University, 20 Xisi Road, Chongchuan District, Nantong, Jiangsu Province, China
| | - Wenwen Yang
- School of Medical, Nantong University, No19, Qixiu Road, Chong Chuan District, Nantong, Jiangsu Province, 226001, China
| | - Zihan Geng
- School of Medical, Nantong University, No19, Qixiu Road, Chong Chuan District, Nantong, Jiangsu Province, 226001, China
| | - Xiangyun Qian
- Affiliated Nantong Hospital 3 of Nantong University, No. 60 Qingnian Zhong road, Chongchuan District, Nantong, 226001, Jiangsu, China.
| | - Guiling Geng
- School of Medical, Nantong University, No19, Qixiu Road, Chong Chuan District, Nantong, Jiangsu Province, 226001, China.
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