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Goldman S, Bargman JM, Lok CE, Gozdzik A, Perl J, Chan CT. The effect of implementing a dialysis start unit on modality decision among patients with unplanned start kidney replacement therapy. Hemodial Int 2024; 28:255-261. [PMID: 38937138 DOI: 10.1111/hdi.13165] [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: 09/09/2023] [Revised: 03/25/2024] [Accepted: 06/09/2024] [Indexed: 06/29/2024]
Abstract
INTRODUCTION Many individuals start dialysis in an acute setting with suboptimal pre-dialysis education. These individuals are often treated with central venous catheter insertion and initiation of in-center hemodialysis and only a minority will transfer to a home-based therapy. The dialysis start unit is a program performing in-center hemodialysis in a separate space while providing support and education on chronic kidney disease and treatment options in the initial weeks of kidney replacement therapy. We aimed to assess the uptake of home dialysis therapies between 2013 and 2021 among patients who started acute inpatient hemodialysis at University Health Network, Toronto and underwent dialysis at the dialysis start unit. METHODS This is a retrospective observational cohort study based on prospectively collected data. Patients' demographics were obtained from electronic charts. In the dialysis start unit, all patients received dialysis modality education by a nurse educator, dedicated home dialysis nurses, and the allied health care team. FINDINGS During 2013-2021, 122 patients were dialyzed in the dialysis start unit and included in the study. Among those patients, 68 patients ultimately chose home dialysis (57 peritoneal dialysis and 11 home hemodialysis). Fifty-four patients continued in-center hemodialysis. Patients adopting home dialysis were less likely to have diabetes and hypertension as the etiology of kidney failure and more likely to have glomerulonephritis or vasculitis. DISCUSSION Dialysis modality education is implementable in advanced chronic kidney disease. Individualized education and care after unplanned start dialysis can potentially enhance home dialysis choice and utilization.
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Affiliation(s)
- Shira Goldman
- Division of Nephrology, University Health Network, University of Toronto, Toronto, ON, Canada
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Department of Nephrology and Hypertension, Rabin Medical Center, Petach Tikva, Israel
| | - Joanne M Bargman
- Division of Nephrology, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Charmaine E Lok
- Division of Nephrology, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Anna Gozdzik
- Division of Nephrology, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Jeffrey Perl
- Division of Nephrology and Keenan Research Center, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada
| | - Christopher T Chan
- Division of Nephrology, University Health Network, University of Toronto, Toronto, ON, Canada
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Desbiens LC, Bargman JM, Chan CT, Nadeau-Fredette AC. Integrated home dialysis model: facilitating home-to-home transition. Clin Kidney J 2024; 17:i21-i33. [PMID: 38846416 PMCID: PMC11151120 DOI: 10.1093/ckj/sfae079] [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: 09/03/2023] [Indexed: 06/09/2024] Open
Abstract
Peritoneal dialysis (PD) and home hemodialysis (HHD) are the two home dialysis modalities offered to patients. They promote patient autonomy, enhance independence, and are generally associated with better quality of life compared to facility hemodialysis. PD offers some advantages (enhanced flexibility, ability to travel, preservation of residual kidney function, and vascular access sites) but few patients remain on PD indefinitely due to peritonitis and other complications. By contrast, HHD incurs longer and more intensive training combined with increased upfront health costs compared to PD, but is easier to sustain in the long term. As a result, the integrated home dialysis model was proposed to combine the advantages of both home-based dialysis modalities. In this paradigm, patients are encouraged to initiate dialysis on PD and transfer to HHD after PD termination. Available evidence demonstrates the feasibility and safety of this approach and some observational studies have shown that patients who undergo the PD-to-HHD transition have clinical outcomes comparable to patients who initiate dialysis directly on HHD. Nevertheless, the prevalence of PD-to-HHD transfers remains low, reflecting the multiple barriers that prevent the full uptake of home-to-home transitions, notably a lack of awareness about the model, home-care "burnout," clinical inertia after a transfer to facility HD, suboptimal integration of PD and HHD centers, and insufficient funding for home dialysis programs. In this review, we will examine the conceptual advantages and disadvantages of integrated home dialysis, present the evidence that underlies it, identify challenges that prevent its success and finally, propose solutions to increase its adoption.
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Affiliation(s)
- Louis-Charles Desbiens
- Department of Medicine, Université de Montréal, Montreal, Canada
- Department of Medicine, Hôpital Maisonneuve-Rosemont, Montreal, Canada
| | - Joanne M Bargman
- Toronto General Hospital, University Health Network, Toronto, ON, Canada
| | - Christopher T Chan
- Toronto General Hospital, University Health Network, Toronto, ON, Canada
| | - Annie-Claire Nadeau-Fredette
- Department of Medicine, Université de Montréal, Montreal, Canada
- Department of Medicine, Hôpital Maisonneuve-Rosemont, Montreal, Canada
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Liu J, Zhou Y, Tang Y, Chen J, Li J. Patient engagement during the transition from nondialysis-dependent chronic kidney disease to dialysis: A meta-ethnography. Health Expect 2023; 26:2191-2204. [PMID: 37641530 PMCID: PMC10632643 DOI: 10.1111/hex.13850] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2022] [Revised: 07/31/2023] [Accepted: 08/02/2023] [Indexed: 08/31/2023] Open
Abstract
INTRODUCTION Patient engagement, encompassing both patient experience and opportunities for involvement in care, has been associated with increased patient satisfaction and the overall quality of care. Despite its importance, there is limited knowledge regarding patient engagement in the transition from nondialysis-dependent chronic kidney disease (CKD) to dialysis-dependent treatment. This systematic review employs meta-ethnography to synthesize findings from qualitative studies examining patients' experiences of engagement during this transition, with the aim of developing a comprehensive theoretical understanding of patient engagement in the transition from nondialysis-dependent CKD to dialysis. METHODS A systematic search of six databases, namely the Cochrane Library, PsycINFO, Scopus, Embase, PubMed and Web of Science was conducted to identify eligible articles published between 1990 and 2022. Meta-ethnography was utilized to translate and synthesize the findings and develop a novel theoretical interpretation of 'patient engagement' during the transition to dialysis. RESULTS A total of 24 articles were deemed eligible for review, representing 21 studies. Patient engagement during a transition to dialysis was found to encompass three major domains: psychosocial adjustment, decision-making and engagement in self-care. These three domains could be experienced as an iterative and mutually reinforcing process, guiding patients toward achieving control and proficiency in their lives as they adapt to dialysis. Additionally, patient engagement could be facilitated by factors including patients' basic capability to engage, the provision of appropriate education, the establishment of supportive relationships and the alignment with values and resources. CONCLUSIONS The findings of this review underscore the necessity of involving patients in transitional dialysis care, emphasizing the need to foster their engagement across multiple domains. Recommendations for future interventions include the provision of comprehensive support to enhance patient engagement during this critical transition phase. Additional research is warranted to explore the effects of various facilitators at different levels. PATIENT OR PUBLIC CONTRIBUTION The studies included in our review involved 633 participants (547 patients, 14 family members, 63 healthcare providers and 9 managers). Based on their experiences, views and beliefs, we developed a deeper understanding of patient engagement and how to foster it in the future.
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Affiliation(s)
- Jinjie Liu
- School of NursingSun Yat‐sen UniversityGuangzhouChina
| | - Yujun Zhou
- The First Affiliated HospitalSun Yat‐sen UniversityGuangzhouChina
| | - Yanyao Tang
- School of NursingSun Yat‐sen UniversityGuangzhouChina
| | - Jieling Chen
- School of NursingSun Yat‐sen UniversityGuangzhouChina
| | - Jianying Li
- The First Affiliated HospitalSun Yat‐sen UniversityGuangzhouChina
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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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Dumaine CS, Fox DE, Ravani P, Santana MJ, MacRae JM. Health related quality of life during dialysis modality transitions: a qualitative study. BMC Nephrol 2023; 24:282. [PMID: 37740177 PMCID: PMC10517513 DOI: 10.1186/s12882-023-03330-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Accepted: 09/11/2023] [Indexed: 09/24/2023] Open
Abstract
BACKGROUND Modality transitions represent a period of significant change that can impact health related quality of life (HRQoL). We explored the HRQoL of adults transitioning to new or different dialysis modalities. METHODS We recruited eligible adults (≥ 18) transitioning to dialysis from pre-dialysis or undertaking a dialysis modality change between July and September 2017. Nineteen participants (9 incident and 10 prevalent dialysis patients) completed the KDQOL-36 survey at time of transition and three months later. Fifteen participants undertook a semi-structured interview at three months. Qualitative data were thematically analyzed. RESULTS Four themes and five sub-themes were identified: adapting to new circumstances (tackling change, accepting change), adjusting together, trading off, and challenges of chronicity (the impact of dialysis, living with a complex disease, planning with uncertainty). From the first day of dialysis treatment to the third month on a new dialysis therapy, all five HRQoL domains from the KDQOL-36 (symptoms, effects, burden, overall PCS, and overall MCS) improved in our sample (i.e., those who remained on the modality). CONCLUSIONS Dialysis transitions negatively impact the HRQoL of people with kidney disease in various ways. Future work should focus on how to best support people during this time.
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Affiliation(s)
- Chance S Dumaine
- Division of Nephrology, University of Saskatchewan, Saskatoon, SK, Canada
| | - Danielle E Fox
- Department of Community Health Sciences, University of Calgary, Calgary, Canada
| | - Pietro Ravani
- Department of Community Health Sciences, University of Calgary, Calgary, Canada
- Division of Nephrology, Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - Maria J Santana
- Department of Community Health Sciences, University of Calgary, Calgary, Canada
- Cumming School of Medicine, University of Calgary, Calgary, Canada
- Department of Pediatrics, University of Calgary, Calgary, Canada
| | - Jennifer M MacRae
- Division of Nephrology, Cumming School of Medicine, University of Calgary, Calgary, Canada.
- Department of Cardiac Sciences, University of Calgary, Calgary, Canada.
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Huang M, Vincent Johnson A, Pourafshar N, Malhotra R, Yang J, Shah M, Balogun R, Chopra T. Pathways to improve nephrologist comfort in managing patients on in-center or home self-care dialysis. Hemodial Int 2023. [PMID: 37157127 DOI: 10.1111/hdi.13093] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Revised: 03/29/2023] [Accepted: 04/17/2023] [Indexed: 05/10/2023]
Abstract
In end-stage kidney disease (ESKD), patient engagement and empowerment are associated with improved survival and complications. However, patients lack education and confidence to participate in self-care. The development of in center self-care hemodialysis can enable motivated patients to allocate autonomy, increase satisfaction and engagement, reduce human resource intensiveness, and cultivate a curiosity about home dialysis. In this review, we emphasize the role of education to overcome barriers to home dialysis, strategies of improving home dialysis utilization in the COVID 19 era, the significance of in-center self-care dialysis (e.g., cost containment and empowering patients), and implementation of an in-center self-care dialysis as a bridge to home hemodialysis (HHD).
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Affiliation(s)
- Minghui Huang
- School of Medicine, University of Virginia, Charlottesville, Virginia, USA
| | - Anita Vincent Johnson
- Division of Nephrology, Department of Medicine, University of Virginia, Charlottesville, Virginia, USA
| | - Negiin Pourafshar
- Division of Nephrology, Department of Medicine, MedStar Georgetown University, Washington, DC, USA
| | - Rakesh Malhotra
- Division of Nephrology and Hypertension, Department of Medicine, University of California San Diego, San Diego, California, USA
| | - Jason Yang
- Division of Nephrology and Hypertension, Department of Medicine, University of California San Diego, San Diego, California, USA
| | - Monarch Shah
- Division of Nephrology, Department of Medicine, University of Virginia, Charlottesville, Virginia, USA
| | - Rasheed Balogun
- Division of Nephrology, Department of Medicine, University of Virginia, Charlottesville, Virginia, USA
| | - Tushar Chopra
- Division of Nephrology, Department of Medicine, University of Virginia, Charlottesville, Virginia, USA
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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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9
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Wilk AS, Drewry KM, Zhang R, Pastan SO, Thorsness R, Trivedi AN, Patzer RE. Treatment Patterns and Characteristics of Dialysis Facilities Randomly Assigned to the Medicare End-Stage Renal Disease Treatment Choices Model. JAMA Netw Open 2022; 5:e2225516. [PMID: 35930284 PMCID: PMC9356315 DOI: 10.1001/jamanetworkopen.2022.25516] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
IMPORTANCE In 2021, Medicare launched the End-Stage Renal Disease Treatment Choices (ETC) model, which randomly assigned approximately 30% of dialysis facilities to new financial incentives to increase use of transplantation and home dialysis; these financial bonuses and penalties are calculated by comparing living-donor transplantation, transplant wait-listing, and home dialysis use in ETC-assigned facilities vs benchmarks from non-ETC-assigned (ie, control) facilities. Because model participation is randomly assigned, evaluators may attribute any downstream differences in outcomes to facility performance rather than any imbalance in baseline characteristics. OBJECTIVE To identify preintervention imbalances in dialysis facility characteristics that should be recognized in any ETC model evaluations. DESIGN, SETTING, AND PARTICIPANTS This cross-sectional study compared ETC-assigned and control dialysis facility characteristics in the United States from 2017 to 2018. A total of 6062 facilities were included. Data were analyzed from February 2021 to May 2022. EXPOSURES Assignment to the ETC model. MAIN OUTCOMES AND MEASURES Dialysis facilities' preintervention transplantations and home dialysis use, facility characteristics (notably, profit and chain status), patient demographic characteristics, and community socioeconomic characteristics. RESULTS Among 316 927 patients, with 6 178 855 attributed patient-months, the mean (SD) age in January 2017 was 59 (11) years, and 132 462 (42%) were female. Patients in ETC-assigned facilities had 9% (0.2 [95% CI, 0.1-0.2] percentage points) lower prevalence of living donor transplantation, 12% (3.2 [95% CI, 3.0-3.3] percentage points) lower prevalence of transplantation wait-listing, and 4% (0.4 [95% CI, 0.3-0.4] percentage points) lower prevalence of peritoneal dialysis use compared with control facilities. ETC-assigned facilities were 14% (5.1 [95% CI, 0.9-9.4] percentage points) more likely than control facilities to be owned by the second largest dialysis organization. Relative to control facilities, ETC-assigned facilities also treated 34% (6.6 [95% CI, 6.5-6.7] percentage point) fewer patients with Hispanic ethnicity and were located in communities with median household incomes that were 4% ($2500; 95% CI, $500-$4500) lower on average. CONCLUSIONS AND RELEVANCE In this study, dialysis facilities in ETC-assigned regions had lower preintervention prevalence of transplantation wait-listing, living donor transplantation, and peritoneal dialysis use, relative to control facilities. ETC-assigned and control facilities also differed with respect to other facility, patient, and community characteristics. Evaluators should account for these preintervention imbalances to minimize bias in their inferences about the model's association with postintervention outcomes.
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Affiliation(s)
- Adam S. Wilk
- Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Kelsey M. Drewry
- Rollins School of Public Health, Emory University, Atlanta, Georgia
- Emory University School of Medicine, Atlanta, Georgia
| | - Rebecca Zhang
- Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Stephen O. Pastan
- Emory University School of Medicine, Atlanta, Georgia
- Emory Transplant Center, Atlanta, Georgia
| | - Rebecca Thorsness
- Brown University School of Public Health, Providence, Rhode Island
- Providence VA Medical Center, Providence, Rhode Island
| | - Amal N. Trivedi
- Brown University School of Public Health, Providence, Rhode Island
- Providence VA Medical Center, Providence, Rhode Island
| | - Rachel E. Patzer
- Rollins School of Public Health, Emory University, Atlanta, Georgia
- Emory University School of Medicine, Atlanta, Georgia
- Emory Transplant Center, Atlanta, Georgia
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10
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Gil-Casares B, Portolés J, López-Sánchez P, Tornero F, Marques M, Rojo-Álvarez JL. Transitions in an integrated model of renal replacement therapy in a regional health system. Nefrologia 2022; 42:438-447. [PMID: 36266230 DOI: 10.1016/j.nefroe.2022.10.002] [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: 02/19/2021] [Accepted: 07/11/2021] [Indexed: 06/16/2023] Open
Abstract
INTRODUCTION AND OBJECTIVES The choice of renal replacement therapy (RRT) is an important decision that determines the quality of life and survival. Most patients change from one RRT modality to another to adapt RRT to clinical and psychosocial needs. This has been called «integrated model of RRT» that implies new questions about the best sequence of techniques. MATERIAL AND METHODS The study describes the impact of transitions between RRT modalities on survival using the Madrid Registry of Renal Patients (2008-2018). This study used the proportional hazards models and competitive risk models to perform an intention-to-treat (ITT), according to their 1st RRT modality and as-treated (AT) analysis, that consider also their 1st transition. RESULTS A total of 8971 patients started RRT during this period in Madrid (6.6 Million population): 7207 (80.3%) on hemodialysis (HD), 1401 (15.6%) on peritoneal dialysis (PD) and 363 (4.2%) received a pre-emptive kidney transplantation (KT). Incident HD-patients were older (HD group 65.3 years (SD 15.3) vs PD group 58.1 years (SD 14.8) vs KTX group 52 years (SD 17.2); p < 0.001) and had more comorbidities. They presented higher mortality (HD group 40.9% vs PD group 22.8% vs KTX group 8.3%, p < 0.001) and less access to a transplant (HD group 30.4% vs PD group 51.6%; p < 0.001). Transitions between dialysis techniques define different groups of patients with different clinical outcomes. Those who change from HD to PD do it earlier (HD → PD: 0.7 years (SD 1.1) vs PD → HD: 1.5 years (SD 1.4) p < 0.001), are younger (HD → PD: 53.5 years (SD 16.7) vs PD → HD: 61.6 years (SD 14.6); p < 0.001), presented less mortality (HD → PD: 24.5% vs PD → HD: 32.0%; p < 0.001) and higher access to a transplant (HD → PD: 49.4% vs PD → HD: 31.7%; p < 0.001). Survival analysis by competitive risks is essential for integrated RRT models, especially in groups such as PD patients, where 51.6% of the patients were considered as lost follow-up (received a KTX after during the first 2.5 years on PD). In this analysis, survival of patients who change from one technique to another, is more similar to the destination modality than the origin one. CONCLUSION Our data suggest that transitions between RRT-techniques describes different patients, who associate different risks, and could be analyzed in an integrated manner to define improvement actions. This approach should be incorporated into the analysis and reports of renal registries.
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Affiliation(s)
- Beatriz Gil-Casares
- Servicio de Nefrología, Hospital del Sureste, Arganda del Rey, Madrid, Spain; Departamento de Teoría de la Señal y Comunicaciones y Sistemas Telemáticos y de Computación, Universidad Rey Juan Carlos, Fuenlabrada, Madrid, Spain
| | - Jose Portolés
- Servicio de Nefrología, Hospital Universitario Puerta de Hierro, Majadahonda, Madrid, Spain; REDInREN RETIC ISCIII 16/009/009.
| | - Paula López-Sánchez
- Servicio de Nefrología, Hospital Universitario Puerta de Hierro, Majadahonda, Madrid, Spain
| | - Fernando Tornero
- Servicio de Nefrología, Hospital del Sureste, Arganda del Rey, Madrid, Spain
| | - María Marques
- Servicio de Nefrología, Hospital Universitario Puerta de Hierro, Majadahonda, Madrid, Spain; REDInREN RETIC ISCIII 16/009/009
| | - José Luis Rojo-Álvarez
- Departamento de Teoría de la Señal y Comunicaciones y Sistemas Telemáticos y de Computación, Universidad Rey Juan Carlos, Fuenlabrada, Madrid, Spain
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11
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Drewry KM, Trivedi AN, Wilk AS. Organizational Characteristics Associated with High Performance in Medicare's Comprehensive End-Stage Renal Disease Care Initiative. Clin J Am Soc Nephrol 2021; 16:1522-1530. [PMID: 34620648 PMCID: PMC8499003 DOI: 10.2215/cjn.04020321] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Accepted: 08/20/2021] [Indexed: 02/04/2023]
Abstract
BACKGROUND AND OBJECTIVES Medicare plans to extend financial structures tested through the Comprehensive End-Stage Renal Disease Care (CEC) Initiative-an alternative payment model for maintenance dialysis providers-to promote high-value care for beneficiaries with kidney failure. The End-Stage Renal Disease Seamless Care Organizations (ESCOs) that formed under the CEC Initiative varied greatly in their ability to generate cost savings and improve patient health outcomes. This study examined whether organizational or community characteristics were associated with ESCOs' performance. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS We used a retrospective pooled cross-sectional analysis of all 37 ESCOs participating in the CEC Initiative during 2015-2018 (n=87 ESCO-years). Key exposures included ESCO characteristics: number of dialysis facilities, number and types of physicians, and years of CEC Initiative experience. Outcomes of interest included were above versus below median gross financial savings (2.4%) and standardized mortality ratio (0.93). We analyzed unadjusted differences between high- and low-performing ESCOs and then used multivariable logistic regression to construct average marginal effect estimates for parameters of interest. RESULTS Above-median gross savings were obtained by 23 (52%) ESCOs with no program experience, 14 (32%) organizations with 1 year of experience, and seven (16%) organizations with 2 years of experience. The adjusted likelihoods of achieving above-median gross savings were 23 (95% confidence interval, 8 to 37) and 48 (95% confidence interval, 24 to 68) percentage points higher for ESCOs with 1 or 2 years of program experience, respectively (versus none). The adjusted likelihood of achieving above-median gross savings was 1.7 (95% confidence interval, -3 to -1) percentage points lower with each additional affiliated dialysis facility. Adjusted mortality rates were lower for ESCOs located in areas with higher socioeconomic status. CONCLUSIONS Smaller ESCOs, organizations with more experience in the CEC Initiative, and those located in more affluent areas performed better under the CEC Initiative.
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MESH Headings
- Accountable Care Organizations/economics
- Accountable Care Organizations/organization & administration
- Cost Savings
- Cost-Benefit Analysis
- Cross-Sectional Studies
- Delivery of Health Care, Integrated/economics
- Delivery of Health Care, Integrated/organization & administration
- Health Care Costs
- Humans
- Kidney Failure, Chronic/diagnosis
- Kidney Failure, Chronic/economics
- Kidney Failure, Chronic/mortality
- Kidney Failure, Chronic/therapy
- Medicare/economics
- Medicare/organization & administration
- Neighborhood Characteristics
- Outcome and Process Assessment, Health Care/economics
- Outcome and Process Assessment, Health Care/organization & administration
- Quality Assurance, Health Care/organization & administration
- Quality Indicators, Health Care/organization & administration
- Renal Dialysis/adverse effects
- Renal Dialysis/economics
- Renal Dialysis/mortality
- Retrospective Studies
- Social Class
- Time Factors
- Treatment Outcome
- United States
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Affiliation(s)
- Kelsey M. Drewry
- Department of Health Policy and Management, Emory University Rollins School of Public Health, Atlanta, Georgia
| | - Amal N. Trivedi
- Department of Health Services, Policy and Practice, Department of Medicine, Brown University, Providence, Rhode Island
- Department of Medicine, Brown University, Providence, Rhode Island
| | - Adam S. Wilk
- Department of Health Policy and Management, Emory University Rollins School of Public Health, Atlanta, Georgia
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12
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Gil-Casares B, Portolés J, López-Sánchez P, Tornero F, Marques M, Rojo-Álvarez JL. Transitions in an integrated model of renal replacement therapy in a regional health system. Nefrologia 2021; 42:S0211-6995(21)00149-1. [PMID: 34481678 DOI: 10.1016/j.nefro.2021.07.004] [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: 02/19/2021] [Revised: 06/01/2021] [Accepted: 07/11/2021] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION AND OBJECTIVES The choice of renal replacement therapy (RRT) is an important decision that determines the quality of life and survival. Most patients change from one RRT modality to another to adapt RRT to clinical and psychosocial needs. This has been called «integrated model of RRT» that implies new questions about the best sequence of techniques. MATERIAL AND METHODS The study describes the impact of transitions between RRT modalities on survival using the Madrid Registry of Renal Patients (2008-2018). This study used the proportional hazards models and competitive risk models to perform an intention-to-treat (ITT), according to their 1st RRT modality and as-treated (AT) analysis, that consider also their 1st transition. RESULTS A total of 8971 patients started RRT during this period in Madrid (6.6 Million population): 7207 (80.3%) on hemodialysis (HD), 1401 (15.6%) on peritoneal dialysis (PD) and 363 (4.2%) received a pre-emptive kidney transplantation (KTX). Incident HD-patients were older (HD group 65.3 years (SD 15.3) vs PD group 58.1 years (SD 14.8) vs KTX group 52 years (SD 17.2); p<0.001) and had more comorbidities. They presented higher mortality (HD group 40.9% vs PD group 22.8% vs 8.3% KTX group, p<0.001) and less access to a transplant (HD group 30.4% vs DP group 51.6%; p<0.001). Transitions between dialysis techniques define different groups of patients with different clinical outcomes. Those who change from HD to PD do it earlier (HD→PD: 0.7 years (SD 1.1) vs PD→HD: 1.5 years (SD 1.4) p<0.001), are younger (HD→PD: 53.5 years (SD 16.7) vs PD→HD: 61.6 years (SD 14.6); p<0.001), presented less mortality (HD→PD: 24.5% vs PD→HD: 32.0%; p<0.001) and higher access to a transplant (HD→PD: 49.4% vs PD→HD: 31.7%; p<0.001). Survival analysis by competitive risks is essential for integrated RRT models, especially in groups such as PD patients, where 51.6% of the patients were considered as lost follow-up (received a KTX after during the first 2.5 years on PD). In this analysis, survival of patients who change from one technique to another, is more similar to the destination modality than the origin one. CONCLUSION Our data suggest that transitions between RRT-techniques describes different patients, who associate different risks, and could be analyzed in an integrated manner to define improvement actions. This approach should be incorporated into the analysis and reports of renal registries.
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Affiliation(s)
- Beatriz Gil-Casares
- Servicio de Nefrología, Hospital del Sureste, Arganda del Rey, Madrid, España; Departamento de Teoría de la Señal y Comunicaciones y Sistemas Telemáticos y de Computación, Universidad Rey Juan Carlos, Fuenlabrada, Madrid, España
| | - Jose Portolés
- Servicio de Nefrología, Hospital Universitario Puerta de Hierro, Majadahonda, Madrid, España; REDInREN RETIC ISCIII 16/009/009.
| | - Paula López-Sánchez
- Servicio de Nefrología, Hospital Universitario Puerta de Hierro, Majadahonda, Madrid, España
| | - Fernando Tornero
- Servicio de Nefrología, Hospital del Sureste, Arganda del Rey, Madrid, España
| | - María Marques
- Servicio de Nefrología, Hospital Universitario Puerta de Hierro, Majadahonda, Madrid, España; REDInREN RETIC ISCIII 16/009/009
| | - José Luis Rojo-Álvarez
- Departamento de Teoría de la Señal y Comunicaciones y Sistemas Telemáticos y de Computación, Universidad Rey Juan Carlos, Fuenlabrada, Madrid, España
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13
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Wu HHL, Nixon AC, Dhaygude AP, Jayanti A, Mitra S. Is home hemodialysis a practical option for older people? Hemodial Int 2021; 25:416-423. [PMID: 34133069 DOI: 10.1111/hdi.12949] [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: 01/28/2021] [Revised: 03/23/2021] [Accepted: 05/23/2021] [Indexed: 11/30/2022]
Abstract
An increasing demand for in-center dialysis services has been largely driven by a rapid growth of the older population progressing to end-stage kidney disease. Since the onset of the COVID-19 pandemic, efforts to encourage home-based dialysis options have increased due to risks of infective transmission for patients receiving hemodialysis in center-based units. There are various practical and clinical advantages for patients receiving hemodialysis at home. However, the lack of caregiver support, cognitive and physical impairment, challenges of vascular access, and preparation and training for home hemodialysis (HHD) initiation may present as barriers to successful implementation of HHD in the older dialysis population. Assessment of an older patient's frailty status may help clinicians guide patients when making decisions about HHD. The development of an assisted HHD care delivery model and advancement of telehealth and technology in provision of HHD care may increase accessibility of HHD services for older patients. This review examines these factors and explores current unmet needs and barriers to increasing access, inclusion, and opportunities of HHD for the older dialysis population.
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Affiliation(s)
- Henry H L Wu
- Department of Renal Medicine, Lancashire Teaching Hospitals NHS Foundation Trust, Royal Preston Hospital, Preston, UK.,Faculty of Medical and Human Sciences, Manchester Academy of Health Sciences Centre, University of Manchester, Manchester, UK
| | - Andrew C Nixon
- Department of Renal Medicine, Lancashire Teaching Hospitals NHS Foundation Trust, Royal Preston Hospital, Preston, UK.,Faculty of Medical and Human Sciences, Manchester Academy of Health Sciences Centre, University of Manchester, Manchester, UK.,Department of Renal Medicine, Manchester University NHS Foundation Trust, Manchester, UK
| | - Ajay P Dhaygude
- Department of Renal Medicine, Lancashire Teaching Hospitals NHS Foundation Trust, Royal Preston Hospital, Preston, UK.,Faculty of Medical and Human Sciences, Manchester Academy of Health Sciences Centre, University of Manchester, Manchester, UK
| | - Anu Jayanti
- Department of Renal Medicine, Manchester University NHS Foundation Trust, Manchester, UK
| | - Sandip Mitra
- Faculty of Medical and Human Sciences, Manchester Academy of Health Sciences Centre, University of Manchester, Manchester, UK.,Department of Renal Medicine, Manchester University NHS Foundation Trust, Manchester, UK
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14
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Weinhandl ED. Economic Impact of Home Hemodialysis. Adv Chronic Kidney Dis 2021; 28:136-142. [PMID: 34717859 DOI: 10.1053/j.ackd.2021.06.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Revised: 06/12/2021] [Accepted: 06/21/2021] [Indexed: 11/11/2022]
Abstract
Home hemodialysis (HD) is growing in the United States, but the economics of the modality are largely unknown, especially considering the unique aspects of home HD in the United States . In this review, I focus on details of Medicare coverage, which directly applies to most patients on dialysis and influences the policies of private insurers. Key details in Medicare comprise the relationship between home dialysis training and initial Medicare eligibility, reimbursement for home HD training, coverage of additional HD treatments (ie., in excess of 3 treatments per week), and monthly capitated payments to nephrologists. The overarching narrative is that frequent home HD directly increases Medicare costs for outpatient dialysis, but these added costs can be mitigated by lower inpatient expenditures if increased HD treatment frequency lowers the risk of cardiovascular hospitalization and infection control is emphasized. I also review recent international literature; conventional home HD exhibits a superior cost profile, whereas frequent home HD is generally cost-effective over multiple treatment years (ie, if early technique failure is avoided). Out-of-pocket expenses for patients should be considered. The future economics of home HD in the United States will be determined by new equipment, new adaptations of the modality, and new payment models.
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15
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Hussein WF, Bennett PN, Schiller B. Innovations to Increase Home Hemodialysis Utilization: The Transitional Care Unit. Adv Chronic Kidney Dis 2021; 28:178-183. [PMID: 34717865 DOI: 10.1053/j.ackd.2021.02.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Revised: 02/18/2021] [Accepted: 02/25/2021] [Indexed: 01/20/2023]
Abstract
A large proportion of patients undergoing incident dialysis start in-center hemodialysis with suboptimal preparation and predialysis education. Transitional care units deliver a structured program by dedicated staff, with less patient-to-staff ratios than in regular in-center dialysis care, with the goals of supporting the emotional and physical well-being of patients while providing them with education and equipping them with the right tools to start their journey on dialysis. Key components of these programs include an emphasis on patient activation and self-management, educating and supporting patients to make informed modality choices, timely coordination of care, and an integrated approach to formation and use of the dialysis access. While data are still limited on best practices and on outcomes of these programs at a large scale, endorsing the model of transitional care units is a step in the right direction to fill the gap in our current care system.
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16
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Schreiber MJ, Chatoth DK, Salenger P. Challenges and Opportunities in Expanding Home Hemodialysis for 2025. Adv Chronic Kidney Dis 2021; 28:129-135. [PMID: 34717858 DOI: 10.1053/j.ackd.2021.06.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
The Advancing American Kidney Health Initiative has set an aggressive target for home dialysis growth in the United States, and expanding both peritoneal dialysis and home hemodialysis (HHD) will be required. While there has been a growth in HHD across the United States in the last decade, its value in controlling specific risk factors has been underappreciated and as such its appropriate utilization has lagged. Repositioning how nephrologists incorporate HHD as a critical renal replacement therapy will require overcoming a number of barriers. Advancing education of both nephrology trainees and nephrologists in practice, along with increasing patient and family education on the benefits and requirements for HHD, is essential. Implementation of a transitional care unit design coupled with an intensive patient curriculum will increase patient awareness and comfort for HHD; patients on peritoneal dialysis reaching a modality transition point will benefit from Experience the Difference programs acclimating them to HHD. In addition, the potential link between HHD program size and patient outcomes will necessitate an increase in the size of the average HHD program to more consistently deliver quality dialysis results. Addressing the implications of the nursing shortage and need for designing in scope staffing models are necessary to safeguard HHD growth. Seemingly, certain government payment policy changes and physician documentation requirements deserve further examination. Future HHD innovations must result in decreasing the burden of care for HHD patients, optimize the level of device and biometric data flow, facilitate a more functional centralized patient management care approach, and leverage computerized clinical decision support for modality assignment.
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17
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Lavoie-Cardinal M, Nadeau-Fredette AC. Physical Infrastructure and Integrated Governance Structure for Home Hemodialysis. Adv Chronic Kidney Dis 2021; 28:149-156. [PMID: 34717861 DOI: 10.1053/j.ackd.2021.02.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2020] [Revised: 02/11/2021] [Accepted: 02/25/2021] [Indexed: 01/17/2023]
Abstract
In view of the growing enthusiasm for home dialysis use, new dialysis centers may build or expend their home hemodialysis program in the next few years. This review will discuss the main challenges faced by small and large home hemodialysis programs in terms of physical spaces, human resource, training considerations, and overall governance. We will elaborate on the inclusion of home hemodialysis in the kidney replacement therapy care continuum, with a specific interest for collaboration and transition between peritoneal dialysis and home hemodialysis programs.
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18
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Braden GL, Chapman A, Ellison DH, Gadegbeku CA, Gurley SB, Igarashi P, Kelepouris E, Moxey-Mims MM, Okusa MD, Plumb TJ, Quaggin SE, Salant DJ, Segal MS, Shankland SJ, Somlo S. Advancing Nephrology: Division Leaders Advise ASN. Clin J Am Soc Nephrol 2021; 16:319-327. [PMID: 32792352 PMCID: PMC7863658 DOI: 10.2215/cjn.01550220] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
New treatments, new understanding, and new approaches to translational research are transforming the outlook for patients with kidney diseases. A number of new initiatives dedicated to advancing the field of nephrology-from value-based care to prize competitions-will further improve outcomes of patients with kidney disease. Because of individual nephrologists and kidney organizations in the United States, such as the American Society of Nephrology, the National Kidney Foundation, and the Renal Physicians Association, and international nephrologists and organizations, such as the International Society of Nephrology and the European Renal Association-European Dialysis and Transplant Association, we are beginning to gain traction to invigorate nephrology to meet the pandemic of global kidney diseases. Recognizing the timeliness of this opportunity, the American Society of Nephrology convened a Division Chief Retreat in Dallas, Texas, in June 2019 to address five key issues: (1) asserting the value of nephrology to the health system; (2) productivity and compensation; (3) financial support of faculty's and divisions' educational efforts; (4) faculty recruitment, retention, diversity, and inclusion; and (5) ensuring that fellowship programs prepare trainees to provide high-value nephrology care and enhance attraction of trainees to nephrology. Herein, we highlight the outcomes of these discussions and recommendations to the American Society of Nephrology.
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Affiliation(s)
- Gregory L. Braden
- Division of Nephrology, University of Massachusetts Medical School–Baystate, Springfield, Massachusetts
| | - Arlene Chapman
- Section of Nephrology, University of Chicago, Chicago, Illinois
| | - David H. Ellison
- Division of Nephrology and Hypertension, Oregon Health and Science University, Portland, Oregon
| | - Crystal A. Gadegbeku
- Section of Nephrology, Hypertension and Kidney Transplantation, Temple University, Philadelphia, Pennsylvania
| | - Susan B. Gurley
- Division of Nephrology and Hypertension, Oregon Health and Science University, Portland, Oregon
| | - Peter Igarashi
- Department of Medicine, University of Minnesota, Minneapolis, Minnesota
| | - Ellie Kelepouris
- Division of Renal Electrolyte and Hypertension, University of Pennsylvania, Philadelphia, Pennsylvania
| | | | - Mark D. Okusa
- Division of Nephrology, University of Virginia Health, Charlottesville, Virginia
| | - Troy J. Plumb
- Division of Nephrology, University of Nebraska Medical Center, Omaha, Nebraska
| | - Susan E. Quaggin
- Division of Nephrology and Hypertension, Northwestern University, Evanston, Illinois
| | - David J. Salant
- Section of Nephrology, Boston University, Boston, Massachusetts
| | - Mark S. Segal
- Division of Nephrology, Hypertension and Renal Transplantation, University of Florida, Gainesville, Florida
| | | | - Stefan Somlo
- Section of Nephrology, Yale University, New Haven, Connecticut
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19
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Attalla M, Friedman Z, McKeown S, Harel Z, Hingwala J, Molnar AO, Norman P, Silver SA. Characteristics and Effectiveness of Dedicated Care Programs for Patients Starting Dialysis: A Systematic Review. KIDNEY360 2020; 1:1244-1253. [PMID: 35372876 PMCID: PMC8815511 DOI: 10.34067/kid.0004052020] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Accepted: 09/08/2020] [Indexed: 05/09/2023]
Abstract
BACKGROUND Dedicated care programs that provide increased support to patients starting dialysis are increasingly being used to reduce the risk of complications. The objectives of this systematic review were to determine the characteristics of existing programs and their effect on patient outcomes. METHODS We searched Embase, MEDLINE, Web of Science, Cochrane CENTRAL, and CINAHL from database inception to November 20, 2019 for English-language studies that evaluated dedicated care programs for adults starting maintenance dialysis in the inpatient or outpatient setting. Any study design was eligible, but we required the presence of a control group and prespecified patient outcomes. We extracted data describing the nature of the interventions, their components, and the reported benefits. RESULTS The literature search yielded 12,681 studies. We evaluated 66 full texts and included 11 studies (n=6812 intervention patients); eight of the studies evaluated hemodialysis programs. All studies were observational, and there were no randomized controlled trials. The most common interventions included patient education (n=11) and case management (n=5), with nurses involved in nine programs. The most common outcomes were mortality (n=8) and vascular access (n=4), with only three studies reporting on the uptake of home dialysis and none on transplantation. We identified four high-quality studies that combined patient education and case management; in these programs, the relative reduction in 90-day mortality ranged from 22% (95% CI, -3% to 41%) to 49% (95% CI, 33% to 61%). Pooled analysis was not possible due to study heterogeneity. CONCLUSIONS Few studies have evaluated dedicated care programs for patients starting dialysis, especially their effect on home dialysis and transplantation. Whereas multidisciplinary care models that combine patient education with case management appear to be promising, additional prospective studies that involve patients in their design and execution are needed before widespread implementation of these resource-intensive programs.
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Affiliation(s)
- Mirna Attalla
- Department of Medicine, Kingston Health Sciences Centre, Queen’s University, Kingston, Canada
| | - Zoe Friedman
- Department of Biology, Queen’s University, Kingston, Canada
| | - Sandra McKeown
- Health Sciences Library, Queen’s University, Kingston, Canada
| | - Ziv Harel
- Department of Medicine, St. Michael’s Hospital, University of Toronto, Toronto, Canada
| | - Jay Hingwala
- Department of Internal Medicine, University of Manitoba, Winnipeg, Canada
| | - Amber O. Molnar
- Department of Medicine, McMaster University, Hamilton, Canada
| | - Patrick Norman
- Kingston General Health Research Institute, Kingston, Canada
- Department of Public Health Sciences, Queen’s University, Kingston, Canada
| | - Samuel A. Silver
- Department of Medicine, Kingston Health Sciences Centre, Queen’s University, Kingston, Canada
- Kingston General Health Research Institute, Kingston, Canada
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20
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Fissell RB, Cavanaugh KL. Barriers to home dialysis: Unraveling the tapestry of policy. Semin Dial 2020; 33:499-504. [PMID: 33210358 DOI: 10.1111/sdi.12939] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Accepted: 10/20/2020] [Indexed: 12/22/2022]
Abstract
Home dialysis use as a treatment for end-stage kidney disease varies locally, nationally, and internationally. There is a call to action in the United States to significantly increase access and uptake of home dialysis as the preferred dialysis treatment option. Although most do not object to patient choice in modality selection, the reality is that there are multilevel barriers both obvious and subtle that interfere with expanding home dialysis access. Financial barriers and how payment is structured continue to be key drivers, although new models of care are emerging that include for the first time incentives rather than penalties regarding home dialysis. Resources to support implementation include expert personnel requiring educational training. Policies requiring training curriculum content that is not only specified within nephrology but also for these multidisciplinary providers requisite for successful home dialysis to ensure professional expertise is ready and available, and also to cultivate champions of home modality within the broader nephrology community. Perhaps most importantly, innovation through expanded investment in research is necessary to advance practices, elevate quality, and improve outcomes. Policy in a variety of sectors at local, regional, national, and international levels has the potential to drastically drive expansion and increasing success of home dialysis.
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Affiliation(s)
- Rachel B Fissell
- Division of Nephrology and Hypertension, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Kerri L Cavanaugh
- Division of Nephrology and Hypertension, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA.,Center for Effective Health Communication, Vanderbilt University Medical Center, Nashville, TN, USA
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21
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Lockridge R, Weinhandl E, Kraus M, Schreiber M, Spry L, Tailor P, Carver M, Glickman J, Miller B. A Systematic Approach To Promoting Home Hemodialysis during End Stage Kidney Disease. KIDNEY360 2020; 1:993-1001. [PMID: 35369547 PMCID: PMC8815594 DOI: 10.34067/kid.0003132020] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Accepted: 07/07/2020] [Indexed: 06/14/2023]
Abstract
Home dialysis has garnered much attention since the advent of the Advancing American Kidney Health initiative. For many patients and nephrologists, home dialysis and peritoneal dialysis are synonymous. However, home hemodialysis (HHD) should not be forgotten. Since 2004, HHD has grown more rapidly than other dialytic modalities. The cardinal feature of HHD is customizability of treatment intensity, which can be titrated to address the vexing problems of volume and pressure loading during interdialytic gaps and ultrafiltration intensity during each hemodialysis session. Growing HHD utilization requires commitment to introducing patients to the modality throughout the course of ESKD. In this article, we describe a set of strategies for introducing HHD concepts and equipment. First, patients initiating dialysis may attend a transitional care unit, which offers an educational program about all dialytic modalities during 3-5 weeks of in-facility hemodialysis, possibly using HHD equipment. Second, prevalent patients on hemodialysis may participate in "trial-run" programs, which allow patients to experience increased treatment frequency and HHD equipment for several weeks, but without the overt commitment of initiating HHD training. In both models, perceived barriers to HHD-including fear of equipment, anxiety about self-cannulation, catheter dependence, and the absence of a care partner-can be addressed in a supportive setting. Third, patients on peritoneal dialysis who are nearing a transition to hemodialysis may be encouraged to consider a home-to-home transition (i.e., from peritoneal dialysis to HHD). Taken together, these strategies represent a systematic approach to growing HHD utilization in multiple phenotypes of patients on dialysis. With the feature of facilitating intensive hemodialysis, HHD can be a key not only to satiating demand for home dialysis, but also to improving the health of patients on dialysis.
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Affiliation(s)
- Robert Lockridge
- Lynchburg Nephrology Physicians, PLLC, Lynchburg, Virginia
- University of Virginia Medical Center, Charlottesville, Virginia
| | - Eric Weinhandl
- Chronic Disease Research Group, Hennepin Healthcare Research Institute, Minneapolis, Minnesota
- Department of Pharmaceutical Care and Health Systems, University of Minnesota, Minneapolis, Minnesota
| | - Michael Kraus
- Fresenius Medical Care North America, Waltham, Massachusetts
| | | | - Leslie Spry
- Lincoln Nephrology and Hypertension, PC, Lincoln, Nebraska
| | | | - Michelle Carver
- Fresenius Medical Care North America, Waltham, Massachusetts
| | - Joel Glickman
- Division of Renal Electrolyte and Hypertension, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Brent Miller
- Division of Nephrology, Department of Medicine, School of Medicine, Indiana University, Bloomington, Indiana
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22
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Singh N. Transitional care units: How successful in increasing home dialysis? Semin Dial 2020; 34:3-4. [PMID: 32776577 DOI: 10.1111/sdi.12910] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Revised: 05/30/2020] [Accepted: 07/14/2020] [Indexed: 11/29/2022]
Affiliation(s)
- Namita Singh
- Nephrology Associates of Utah, Salt Lake City, UT, USA
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23
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Kossmann RJ, Weinhandl ED. Advancing American Kidney Health: Perspective from Fresenius Medical Care. Clin J Am Soc Nephrol 2019; 14:1811-1813. [PMID: 31704671 PMCID: PMC6895482 DOI: 10.2215/cjn.10370819] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Affiliation(s)
- Robert J. Kossmann
- Chief Medical Officer, Fresenius Medical Care North America, Waltham, Massachusetts; and
| | - Eric D. Weinhandl
- Chief Medical Officer, Fresenius Medical Care North America, Waltham, Massachusetts; and
- Department of Pharmaceutical Care and Health Systems, University of Minnesota, Minneapolis, Minnesota
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24
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Slon Roblero MF, Borman N, Bajo Rubio MA. Integrated care: enhancing transition from renal replacement therapy options to home haemodialysis. Clin Kidney J 2019; 13:105-110. [PMID: 32082558 PMCID: PMC7025339 DOI: 10.1093/ckj/sfz140] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2019] [Accepted: 09/09/2019] [Indexed: 12/18/2022] Open
Abstract
Transition is an intrinsic process in the life of a patient with kidney disease and should be planned and anticipated when possible. A single therapy option might not be adequate across a patient’s entire lifespan and many patients will require a switch in their treatment modality to adapt the treatment to their clinical and psychosocial needs. There are several reasons behind changing a patient’s treatment modality, and the consequences of each decision should be evaluated, considering both short- and long-term benefits and risks. Dialysis modality transition is not only to allow for technical optimization or improved patient survival, the patient’s experience associated with the transition should also be taken into account. Transition should not be considered as treatment failure, but rather as an expected progression in the patient’s treatment options.
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Affiliation(s)
- Maria Fernanda Slon Roblero
- Department of Nephrology, Complejo Hospitalario Navarra, Navarre, Spain.,Cardiovascular Department, IdisNa, Navarre, Spain
| | - Natalie Borman
- Wessex Renal and Transplantation Unit, Queen Alexandra Hospital, Portsmouth, Portsmouth, UK
| | - Maria Auxiliadora Bajo Rubio
- Department of Nephrology, Hospital Universitario La Paz, Madrid, Spain.,Department of Nephrology, IdiPAZ, Madrid, Spain
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Shen JI, Schreiber MJ, Zhao J, Robinson BM, Pisoni RL, Mehrotra R, Oliver MJ, Tomo T, Tungsanga K, Teitelbaum I, Ghaffari A, Lambie M, Perl J. Attitudes toward Peritoneal Dialysis among Peritoneal Dialysis and Hemodialysis Medical Directors: Are We Preaching to the Right Choir? Clin J Am Soc Nephrol 2019; 14:1067-1070. [PMID: 31278114 PMCID: PMC6625627 DOI: 10.2215/cjn.01320119] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2019] [Accepted: 04/14/2019] [Indexed: 11/23/2022]
Affiliation(s)
- Jenny I Shen
- Division of Nephrology and Hypertension, LaBiomed at Harbor-UCLA Medical Center, Torrance, California;
| | | | - Junhui Zhao
- Arbor Research Collaborative for Health, Ann Arbor, Michigan
| | | | - Ronald L Pisoni
- Arbor Research Collaborative for Health, Ann Arbor, Michigan
| | - Rajnish Mehrotra
- Division of Nephrology, Department of Medicine, Kidney Research Institute, University of Washington, Seattle, Washington
| | - Matthew J Oliver
- Department of Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Tadashi Tomo
- Department of Nephrology, Oita University Hospital, Yufu, Japan
| | - Kriang Tungsanga
- Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Isaac Teitelbaum
- Department of Medicine, University of Colorado School of Medicine, Aurora, Colorado
| | - Arshia Ghaffari
- Division of Nephrology, University of Southern California, Los Angeles, California
| | - Mark Lambie
- Institute for Science and Technology in Medicine, Keele University, Crewe, United Kingdom; and
| | - 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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Shah S, Meganathan K, Christianson AL, Leonard AC, Thakar CV. Pre-dialysis acute care hospitalizations and clinical outcomes in dialysis patients. PLoS One 2019; 14:e0209578. [PMID: 30650094 PMCID: PMC6334901 DOI: 10.1371/journal.pone.0209578] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2018] [Accepted: 12/08/2018] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Patients with chronic kidney disease (CKD), a precursor of end stage renal disease (ESRD), face an increasing burden of hospitalizations. Although mortality on dialysis is highest during the first year, the impact of pre-dialysis acute hospitalizations on clinical outcomes in dialysis patients remains unknown. METHODS We evaluated 170,897 adult patients who initiated dialysis between 1/1/2010 and 12/31/2014 with linked Medicare claims from the United States Renal Data System. Using logistic regression models, we examined the association of 2-year pre-dialysis hospitalization on the primary outcome of 1-year all-cause mortality. Secondary outcomes included 90-day mortality, type of initial dialysis modality and type of vascular access at hemodialysis initiation. RESULTS Mean age was 72.7 ± 11.0 years. In the study sample, 76.0% of patients had at least one pre-dialysis hospitalization. Compared to patients with no pre-dialysis hospitalization, the adjusted 1-year mortality was higher with pre-dialysis cardiovascular related hospitalization (odds ratio [OR], 1.63; 95% confidence interval [CI], 1.57-1.68), infection related hospitalization (OR, 1.51; CI, 1.45-1.57), both cardiovascular and infection hospitalization (OR, 1.91; CI, 1.83-1.99), and neither-cardiovascular nor-infection hospitalization (OR, 1.23; CI, 1.19-1.27). Additionally, the adjusted odds of hemodialysis vs. peritoneal dialysis as the initial dialysis modality were higher, whereas adjusted odds to initiate hemodialysis with an arteriovenous access vs. central venous catheter were lower in patients with any type of hospitalization. CONCLUSION Pre-dialysis hospitalization is an independent predictor of 1-year mortality in dialysis patients. Reducing the risk of pre-dialysis hospitalization may provide opportunities to improve quality of care in ESRD.
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Affiliation(s)
- Silvi Shah
- Division of Nephrology, Kidney CARE Program, University of Cincinnati, Cincinnati, Ohio, United States of America
- * E-mail:
| | - Karthikeyan Meganathan
- Department of Biomedical Informatics, University of Cincinnati, Cincinnati, Ohio, United States of America
| | - Annette L. Christianson
- Department of Biomedical Informatics, University of Cincinnati, Cincinnati, Ohio, United States of America
| | - Anthony C. Leonard
- Department of Family and Community Medicine, University of Cincinnati, Cincinnati, Ohio, United States of America
| | - Charuhas V. Thakar
- Division of Nephrology, Kidney CARE Program, University of Cincinnati, Cincinnati, Ohio, United States of America
- Division of Nephrology, VA Medical Center, Cincinnati, Ohio, United States of America
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