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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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Pérez Alba A, Soldevila Orient A, Muñoz de Bustillo E, Reque Santiváñez J, García Peris B, Sánchez Pérez P. Characteristics and technical survival of home hemodialysis in the Valencian Community (1976-2020). Nefrologia 2022; 42:585-593. [PMID: 36697297 DOI: 10.1016/j.nefroe.2021.08.010] [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: 04/25/2021] [Revised: 08/02/2021] [Accepted: 08/10/2021] [Indexed: 06/17/2023] Open
Abstract
INTRODUCTION Home hemodialysis (HDD) is implemented in the Valencian Community with a higher prevalence than to the rest of the national territory, with a prevalence of 13.4 patients pmp in December 2018. We carried out an assessment of the patients characteristics and the overall and technical survival in HDD depending on the historical moment of onset and its origin. MATERIAL AND METHODS We conducted a retrospective and descriptive study including patients of the Valencian Registry of Renal Patients from the beginning of data reported until December 2020. We calculated overall survival (combined event death-technical failure, censoring transplantation) and technical survival (event technical failure, censoring exitus and transplantation). Comparing technical survival according to the starting era: ancient (1976-2000) vs modern (2001-2020) and according to the modality of origin. We performed univariate and multivariate Cox regression in the total series for both overall and technical survival. RESULTS 236 patients on HDD (611.4 patient-years of follow-up), mean age 49.7±16.3 years; median time of prior renal replacement therapy 0.2 years. The ratio of transplantation, death, and technical failure were 13.2, 4.4, and 7 events per 100 patient-years, respectively. In the comparison by ancient (n=57) vs modern (n=179) eras, age (37.5 vs 53.5 years), DM (3.5 vs 13.4%) and chronic tubuleinterstitial nephropathy (24.6 vs 8.9%) as a cause of chronic kidney disease were statistically significant. The probability of coming from outpatient consultation (33.3 vs 48.6%) and peritoneal dialysis (1.8 vs 12.8%) were higher in modern era with statistical significance. In the ancient era a single hospital centralized 57.9% of the patients, and in the modern era between two hospitals centralized 55.8% of the patients. Overall survival in the ancient era was 83.7% at 1year, 77.4% at 2 years, and 61% at 5 years; and in the modern era 87.3% per year, 83% 2 years and 47.8% 5 years (Log Rank 0.521). Technical survival in the ancient era was 85.4% at 1year, 79% 2 years, and 64.1% 5 years; and in the modern era 91.4% per year, 88.5% 2 years and 74.5% 5 years (Log Rank 0.195). There were no statistical differences in the comparison based on technical of provenance. In the Cox regression it was statistically significant for overall survival: the age and being diagnosed with heart disease, vascular disease or active neoplasia and for technical survival liver disease or social problem, both in univariate and multivariate. CONCLUSIONS In the modern era there is a considerable increase in HDD patients in the Valencian Community. There was a center effect in the development of HDD programs, most of the patients depended on few healthcare centers. The patients were older and had greater comorbidity in the modern era, despite this without affecting the technical and overall survival of the HDD.
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Affiliation(s)
- Alejandro Pérez Alba
- Servicio de Nefrología, Hospital General Universitario de Castellón, Castelló de la Plana, Spain.
| | | | | | - Javier Reque Santiváñez
- Servicio de Nefrología, Hospital General Universitario de Castellón, Castelló de la Plana, Spain
| | - Beatriz García Peris
- Servicio de Nefrología, Hospital General Universitario de Castellón, Castelló de la Plana, Spain
| | - Pilar Sánchez Pérez
- Servicio de Nefrología, Hospital Universitario La Fe de Valencia, Valencia, Spain
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Guerraoui A, Galland R, Belkahla-Delabruyere F, Didier O, Berger V, Sauvajon P, Serve C, Zuriaga JC, Riquier F, Caillette-Beaudoin A. Design of therapeutic education workshops for home haemodialysis in a patient-centered chronic kidney diseases research: a qualitative study. BMC Nephrol 2022; 23:53. [PMID: 35109808 PMCID: PMC8812054 DOI: 10.1186/s12882-022-02683-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2021] [Accepted: 01/24/2022] [Indexed: 12/02/2022] Open
Abstract
Rationale & Objective A quarter of patients do not receive any information on the modalities of renal remplacement therapy (RRT) before its initiation. In our facility, we provide therapeutic education workshops for all RRT except for home hemodialysis (HHD). The objectives of this study were to identify and describe the needs of CKD patients and caregivers for RRT with HHD and design therapeutic education workshops. Setting & participants Two sequential methods of qualitative data collection were conducted. Interviews with patients treated with HHD and doctors specialized in HHD were performed to define the interview guide followed by semi-structured interviews with the help of HHD patients from our center. Analytic approach Thematic analysis was conducted and were rooted in the principles of qualitative analysis for social scientists. Data were analyzed by two investigators. Transcribed interviews were entered into RQDA 3.6.1 software for data organization and coding purposes (Version 3.6.1). Results In total, five interviews were performed. We identified six themes related to the barriers, facilitators, and potential solutions to home dialysis therapy: (1) HHD allows autonomy and freedom with constraints, (2) safety of the care environment, (3) the caregiver and family environment, (4) patient’s experience and experiential knowledge, (5) self-care experience and impact on life, and (6) factors that impact the choice of treatment with HHD. We designed therapeutic education workshops in a group of patients and caregivers. Conclusions Our study confirmed previous results obtained in literature on the major barriers, facilitators, and potential solutions to HHD including the impact of HHD on the caregiver, the experiences of patients already treated with HHD, and the role of nurses and nephrologists in informing and educating patients. A program to develop patient-to-patient peer mentorship allowing patients to discuss their dialysis experience may be relevant. Supplementary Information The online version contains supplementary material available at 10.1186/s12882-022-02683-0.
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Affiliation(s)
| | - Roula Galland
- Department of Nephrology-Dialysis, Calydial, Lyon, France
| | | | - Odile Didier
- Department of Nephrology-Dialysis, Calydial, Lyon, France
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Pérez Alba A, Soldevila Orient A, Muñoz de Bustillo E, Reque Santiváñez J, García Peris B, Sánchez Pérez P. Characteristics and technical survival of home hemodialysis in the Valencian Community (1976-2020). Nefrologia 2021; 42:S0211-6995(21)00175-2. [PMID: 34556353 DOI: 10.1016/j.nefro.2021.08.003] [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: 04/25/2021] [Revised: 08/02/2021] [Accepted: 08/10/2021] [Indexed: 10/20/2022] Open
Abstract
INTRODUCTION Home hemodialysis (HDD) is implemented in the Valencian Community with a higher prevalence than to the rest of the national territory, with a prevalence of 13.4 patients' pmp in December 2018. We carried out an assessment of the patients' characteristics and the overall and technical survival in HDD depending on the historical moment of onset and its origin. MATERIAL AND METHODS We conducted a retrospective and descriptive study including patients of the Valencian Registry of Renal Patients from the beginning of data reported until December 2020. We calculated overall survival (combined event death-technical failure, censoring transplantation) and technical survival (event technical failure, censoring exitus and transplantation). Comparing technical survival according to the starting era: ancient (1976-2000) vs modern (2001-2020) and according to the modality of origin. We performed univariate and multivariate Cox regression in the total series for both overall and technical survivals. RESULTS 236 patients on HDD (611.4 patient-years of follow-up), mean age 49.7±16.3 years; median time of prior renal replacement therapy 0.2 years. The ratio of transplantation, death, and technical failure were 13.2, 4.4, and 7 events per 100 patient-years, respectively. In the comparison by ancient (n=57) vs modern (n=179) eras, age (37.5 vs 53.5 years), DM (3.5 vs 13.4%) and chronic tubuleinterstitial nephropathy (24.6 vs 8.9%) as a cause of chronic kidney disease were statistically significant. The probability of coming from outpatient consultation (33.3 vs 48.6%) and peritoneal dialysis (1.8 vs 12.8%) were higher in modern era with statistical significance. In the ancient era a single hospital centralized 57.9% of the patients, and in the modern era between two hospitals centralized 55.8% of the patients. Overall survival in the ancient era was 83.7% at 1 year, 77.4% at 2 years, and 61% at 5 years; and in the modern era 87.3% per year, 83% 2 years and 47.8% 5 years (Log Rank 0.521). Technical survival in the ancient era was 85.4% at 1 year, 79% 2 years, and 64.1% 5 years; and in the modern era 91.4% per year, 88.5% 2 years and 74.5% 5 years (Log Rank 0.195). There were no statistical differences in the comparison based on technical of provenance. In the Cox regression it was statistically significant for overall survival: the age and being diagnosed with heart disease, vascular disease or active neoplasia and for technical survival liver disease or social problem, both in univariate and multivariate. CONCLUSION In the modern era there is a considerable increase in HDD patients in the Valencian Community. There was a center effect in the development of HDD programs, most of the patients depended on few healthcare centers. The patients were older and had greater comorbidity in the modern era, despite this without affecting the technical and overall survival of the HDD.
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Affiliation(s)
- Alejandro Pérez Alba
- Servicio de Nefrología, Hospital General Universitario de Castellón, Castelló de la Plana, España.
| | | | | | - Javier Reque Santiváñez
- Servicio de Nefrología, Hospital General Universitario de Castellón, Castelló de la Plana, España
| | - Beatriz García Peris
- Servicio de Nefrología, Hospital General Universitario de Castellón, Castelló de la Plana, España
| | - Pilar Sánchez Pérez
- Servicio de Nefrología, Hospital Universitario La Fe de Valencia, Valencia, España
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Malavade TS, Dey A, Chan CT. Nocturnal Hemodialysis: Why Aren't More People Doing It? Adv Chronic Kidney Dis 2021; 28:184-189. [PMID: 34717866 DOI: 10.1053/j.ackd.2021.04.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Accepted: 04/13/2021] [Indexed: 11/11/2022]
Abstract
Nocturnal hemodialysis is a form of intensive hemodialysis, which may be done in center or at home. Despite the documented clinical and economic benefits of ncturnal hemodialysis, uptake of this modality has been relatively low. In this review, we aim to address the potential barriers and possible mitigation strategies. Among the patient-related barriers, lack of knowledge and awareness remains the most common barrier, while administrative inertia to change from conventional in-center hemodialysis continues to be a challenge. Current global effort to grow home dialysis will re-focus the need for better patient education, innovate home dialysis technology, and evolve new models of care. New patient-focused policy will allow changes in reimbursement and develop appropriate momentum toward an integrated "home first model" to kidney replacement therapy.
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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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Zhao S, Dou P, Song J, Nghiem LD, Li XM, He T. Direct preparation of dialysate from tap water via osmotic dilution. J Memb Sci 2020. [DOI: 10.1016/j.memsci.2019.117659] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Friberg IO, Mårtensson L, Haraldsson B, Krantz G, Määttä S, Järbrink K. Patients’ Perceptions and Factors Affecting Dialysis Modality Decisions. Perit Dial Int 2020; 38:334-342. [DOI: 10.3747/pdi.2017.00243] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2017] [Accepted: 05/05/2018] [Indexed: 02/07/2023] Open
Abstract
Background Home-based dialysis, including peritoneal dialysis (PD) and home hemodialysis (HHD), has been shown to be associated with lower costs and higher health-related quality of life than in-center HD. However, factors influencing the choice of dialysis modality, including gender, are still not well understood. Methods A questionnaire was sent out to all dialysis patients in the western region of Sweden in order to investigate factors affecting choice of dialysis modality. Logistic regression was used to analyze the data. Results Patients were more likely to have home dialysis if they received predialysis information from 3 or more sources and, to a greater extent, perceived the information as comprehensive and of high quality. In addition, patients had a lower likelihood of receiving home dialysis with increasing age and if they lived closer to a dialysis center. Men had in comparison with women a greater likelihood of receiving home dialysis if they lived with a spouse. In-center dialysis patients more often believed that the social interaction and support provided through in-center HD treatment influenced the choice of dialysis modality. Conclusion This study highlights the need for increased awareness of various factors that influence the choice of dialysis modality and the importance of giving repeated, comprehensive, high-quality information to dialysis and predialysis patients and their relatives. Information and support must be adapted to the needs of individual patients and their relatives if the intention is to improve patients’ well-being and the proportion of patients using home dialysis.
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Affiliation(s)
- Ingrid O. Friberg
- Institute of Medicine, Department of Public Health and Community Medicine, Section for Epidemiology and Social Medicine, Sahlgrenska Academy, Gothenburg University, Sweden
- Centre for Equity in Healthcare, Region Västra Götaland, Sweden
| | - Lena Mårtensson
- Institute of Neuroscience and Physiology, Department of Clinical Neuroscience and Rehabilitation, Sahlgrenska Academy, University of Gothenburg, Sweden
| | - Börje Haraldsson
- Institute of Neuroscience and Physiology, Department of Physiology, Sahlgrenska Academy, University of Gothenburg, Sweden
| | - Gunilla Krantz
- Institute of Medicine, Department of Public Health and Community Medicine, Section for Epidemiology and Social Medicine, Sahlgrenska Academy, Gothenburg University, Sweden
| | - Sylvia Määttä
- Department of Systems Development and Strategy, Region Västra Götaland, Sweden
| | - Krister Järbrink
- Centre for Population Health Sciences (CePHaS), Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore
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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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Walker RC, Howard K, Morton RL. Home hemodialysis: a comprehensive review of patient-centered and economic considerations. CLINICOECONOMICS AND OUTCOMES RESEARCH 2017; 9:149-161. [PMID: 28243134 PMCID: PMC5317253 DOI: 10.2147/ceor.s69340] [Citation(s) in RCA: 55] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Internationally, the number of patients requiring treatment for end-stage kidney disease (ESKD) continues to increase, placing substantial burden on health systems and patients. Home hemodialysis (HD) has fluctuated in its popularity, and the rates of home HD vary considerably between and within countries although there is evidence suggesting a number of clinical, survival, economic, and quality of life (QoL) advantages associated with this treatment. International guidelines encourage shared decision making between patients and clinicians for the type of dialysis, with an emphasis on a treatment that aligned to the patients’ lifestyle. This is a comprehensive literature review of patient-centered and economic impacts of home HD with the studies published between January 2000 and July 2016. Data from the primary studies representing both efficiency and equity of home HD were presented as a narrative synthesis under the following topics: advantages to patients, barriers to patients, economic factors influencing patients, cost-effectiveness of home HD, and inequities in home HD delivery. There were a number of advantages for patients on home HD including improved survival and QoL and flexibility and potential for employment, compared to hospital HD. Similarly, there were several barriers to patients preferring or maintaining home HD, and the strategies to overcome these barriers were frequently reported. Good evidence reported that indigenous, low-income, and other socially disadvantaged individuals had reduced access to home HD compared to other forms of dialysis and that this situation compounds already-poor health outcomes on renal replacement therapy. Government policies that minimize barriers to home HD include reimbursement for dialysis-related out-of-pocket costs and employment-retention interventions for home HD patients and their family members. This review argues that home HD is a cost-effective treatment, and increasing the proportion of patients on this form of dialysis compared to hospital HD will result in a more equitable distribution of good health outcomes for individuals with ESKD.
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Affiliation(s)
- Rachael C Walker
- School of Public Health, Sydney Medical School, University of Sydney, Sydney, Australia; Hawke's Bay District Health Board, Hastings, New Zealand
| | - Kirsten Howard
- School of Public Health, Sydney Medical School, University of Sydney, Sydney, Australia
| | - Rachael L Morton
- NHMRC Clinical Trials Centre, Sydney Medical School, University of Sydney, Sydney, Australia
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