Home hemodialysis: a comprehensive review of patient-centered and economic considerations

Dialysis Modality Education Timing and Home Dialysis Uptake: A Quality Improvement Study

Rationale & Objective

Investigating the effect of a quality improvement intervention aimed at enhancing the choice of home dialysis among patients through improved educational sessions on dialysis modalities.

Study Design

A new referral protocol initiated on September 15, 2022, sought to direct patients with advanced kidney disease to modality education sessions. This protocol involved an updated referral form and process, requiring nephrologists to refer patients with an estimated glomerular filtration rate below 15 mL/min/1.73 m2 or specified Kidney Failure Risk Equation scores to modality educators for education. The impact was measured by the uptake of the education and the choice of home dialysis by patients.

Setting & Participants

The study took place at Sunnybrook Health Sciences Centre in Toronto, Canada, involving 532 patients across 1,723 clinical encounters from October 2019 to June 2023.

Predictor

The intervention was predicted to lead to an increase in both the number of patients receiving modality education and those choosing home dialysis.

Outcomes

The primary outcome measured was the selection of home dialysis following modality education, with a secondary focus on the proportion of patients educated post intervention.

Analytical Approach

Statistical process charts were used for monitoring changes in education uptake and home dialysis selection rates following the intervention.

Results

After implementing the standardized referral system, the proportion of patients receiving modality education increased from 27.1%-56.7%. However, the rate of selecting home dialysis remained constant at 50.9%. Overall home dialysis prevalence at our center averaged 19.6%, remaining lower than the provincial average of 24.4% by the end of the study period.

Limitations

The study was limited to 1 center, without evaluating patient satisfaction or dissecting the complexity of educational content and delivery.

Conclusions

We succeeded in boosting education rates but failed to achieve higher home dialysis choice rates, possibly owing to the complexity involved in modality choices. We plan to further investigate the factors influencing patient choices during modality education to better promote home dialysis selection.

Challenges of Glycemic Control in People With Diabetes and Advanced Kidney Disease and the Potential of Automated Insulin Delivery

Diabetes is the leading cause of chronic kidney disease (CKD) and end-stage kidney disease in the world. It is known that maintaining optimal glycemic control can slow the progression of CKD. However, the failing kidney impacts glucose and insulin metabolism and contributes to increased glucose variability. Conventional methods of insulin delivery are not well equipped to adapt to this increased glycemic lability. Automated insulin delivery (AID) has been established as an effective treatment in patients with type 1 diabetes mellitus, and there is emerging evidence for their use in type 2 diabetes mellitus. However, few studies have examined their role in diabetes with concurrent advanced CKD. We discuss the potential benefits and challenges of AID use in patients with diabetes and advanced CKD, including those on dialysis.

Impact of chronic kidney disease on everyday life: A descriptive qualitative study

BACKGROUND

Living with chronic kidney disease is stressful as the disease and its treatments impact on everyday physical, psychological, and social activities. As this disease has a long trajectory, it is important to understand everyday life experiences of those at different points along this trajectory.

OBJECTIVES

To explore the impact of chronic kidney disease and its treatment on everyday life.

DESIGN

Descriptive qualitative design PARTICIPANTS: Twenty-five adults with chronic kidney disease across various grades were purposively recruited.

APPROACH

Data were collected using semistructured interviews. Deductive content analysis informed by the revised Wilson and Cleary model was used to analyse data.

FINDINGS

There were four themes. Theme 1, experiencing deterioration of kidney function, reflected the physical and psychological problems experienced by participants. Theme 2, changes that happened to me and my family, explained the subsequent limitations in their physical, social and role functioning. Theme 3, responding to a new normal, identified adjustments needed in everyday life to cope with the disease and its treatments. The final theme, thinking ahead and making a decision, captured the future plans and decisions needed while living with chronic kidney disease.

CONCLUSIONS

People with chronic kidney disease experience complex challenges such as greater symptom burden and functional limitations across the disease grades which impact on their everyday life. Nurses' recognition of these challenges is crucial for identifying and addressing unmet needs. Early individualised interventions, such as routine symptom assessment and management strategies that improve the wellbeing of people are needed.

Developing a haemodialysis acuity tool (the HAT study): A qualitative study

BACKGROUND

Haemodialysis units are now managing an increasing number of patients with varying needs and levels of acuity. To maintain safety, haemodialysis patients must be placed in the most appropriate dialysis unit that has the required human and physical resources to care for them. The first step towards achieving these goals is to develop a tool specific to haemodialysis units to effectively measure patient acuity.

OBJECTIVE

To develop a haemodialysis acuity tool, utilising a focus group approach, in assessing patient's suitability for a specific dialysis location thus ensuring patient safety.

DESIGN

This is a cross-sectional qualitative study via a focus group approach.

PARTICIPANTS

Participants were nurse unit managers and team leaders of a District Renal Service.

APPROACH

Participants were interviewed to explore their views on the elements and measures identified in the research aims. Themes for interviews were informed by current literature on acuity tools for haemodialysis patients' admission to the dialysis units. Interviews were recorded and transcribed verbatim and progressively analysed using a thematic analysis approach.

RESULTS

Ten nurse unit managers/team leaders (100%) were interviewed and thematic analysis of the transcripts was conducted utilising the deductive approach. Five themes were identified which will form the main categories in the development of the tool, namely: Age/frailty; co-morbidity; physical; dialysis; and psychosocial.

CONCLUSION

This study is instrumental in the development of the haemodialysis acuity tool which can be used in allocating dialysis location specific to patient's needs and available resources. The tool can also be used in analysing patient care processes and resource requirements based on the patients' and unit's profile.

Self-efficacy and home dialysis: An integrative review

BACKGROUND

Enhancing patient confidence in their ability (self-efficacy) is vital to ensure people are equipped to maintain home dialysis protocols. Bandura's social cognitive theory provided a framework for understanding the role of self-efficacy in patients managing home dialysis.

OBJECTIVES

To identify self-reported levels of self-efficacy, the measurements used to assess self-efficacy and the effectiveness of interventions to enhance self-efficacy in patients undergoing home dialysis.

DESIGN

An integrative review approach was employed using Whittemore and Knafl's methodology.

METHODS

A comprehensive search was conducted to identify literature on self-efficacy in patients managing home dialysis. Searches were conducted in CINAHL, MEDLINE, Embase and Scopus databases without a date limit. The included literature was critically appraised for methodological quality. Data extraction was conducted to report the study characteristics, measurement tools used and interventions conducted along with the synthesis of findings in a narrative format.

RESULTS

Fifteen studies were included in the review were predominantly quantitative examining training programmes promoting self-efficacy in adults conducting home dialysis. The finding that self-efficacy builds over time was structured into two themes; gaining skills to develop self-efficacy and building and maintaining knowledge of self-efficacy.

CONCLUSION

The findings highlighted the importance of employing multifaceted strategies with support from health professionals including nurses, families and peer support to develop self-efficacy in patients undergoing home dialysis.

Environmentally sustainable design guide for haemodialysis facilities: An Australian and New Zealand society of Nephrology initiative

Haemodialysis facilities have a large environmental impact due to high energy, water and consumable usage by haemodialysis equipment. As climate change and natural resource scarcity escalate, all the while the number of people requiring dialysis increases, there is an urgent need for dialysis facilities that meet care needs while minimising environmental impact. To address this, the Australian and New Zealand Society of Nephrology engaged an environmental sustainability consulting practise to develop a best practise guide for the environmentally sustainable design and operation of haemodialysis facilities. Four opportunity areas were considered, namely energy, water, waste and resource recovery, and additional sustainability. A total of 28 environmental improvement initiatives were identified. The majority (n = 23) were general measures that could be applied across all healthcare settings, while five were specific to haemodialysis facilities. Recommendations were made regarding specific measures that should be undertaken and/or standards that must be met to achieve the intent of each initiative. These were stratified to enable their application to both existing dialysis facilities and new builds. The lifecycle stage of a haemodialysis facility to which each initiative applied was highlighted, as was its potential impact. This guide provides a tailored and comprehensive resource for the kidney care community to enable the integration of best practise sustainability considerations into both existing and new facilities. If broadly implemented, it has the potential to markedly improve the environmental impact of haemodialysis provision.

Exploring the factors affecting home dialysis patients' participation in telehealth-assisted home visits: A mixed-methods study

BACKGROUND

Technology, such as telehealth, is increasingly used to support home dialysis patients. The challenges patients and carers face when home dialysis nursing visits are provided via telehealth have yet to be explored.

OBJECTIVES

To explore patients' and carers' perspectives as they transition to telehealth-assisted home visits and identify the factors influencing their engagement in this modality.

DESIGN

A mixed-methods approach, guideed by the behaviour change wheel using the capability, opportunity, motivation-behaviour model to explore individual's perceptions of telehealth.

PARTCIPANTS

Home dialysis patients and their carers.

MEASURUEMENTS

Suveys and qualitative interviews.

METHODS

A mixed-methods approach was undertaken, combining surveys and qualitative interviews. It was guided by the Behaviour Change Wheel using the Capability, Opportunity, Motivation- Behaviour model to explore individuals' perceptions of telehealth.

RESULTS

Thirty-four surveys and 21 interviews were completed. Of 34 survey participants, 24 (70%) preferred face-to-face home visits and 23 (68%) had previously engaged in telehealth. The main perceived barrier identified in the surveys was knowledge of telehealth, but participants believed there were opportunities for them to use telehealth. Interview results revealed that the convenience and flexibility of telehealth were perceived as the main advantages of telehealth. However, challenges such as the ability to conduct virtual assessments and to communicate effectively between clinicians and patients were identified. Patients from non-English speaking backgrounds and those with disabilities were particularly vulnerable because of the many barriers they faced. These challenges may further entrench the negative view regarding technology, as discussed by interview participants.

CONCLUSION

This study suggested that a blended model combining telehealth and face-to-face services would allow patient choice and is important to facilitate equity of care, particularly for those patients who were unwilling or had difficulty adopting technology.

The integrated care model: facilitating initiation of or transition to home dialysis

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.

Home Dialysis in North America: The Current State

There is widespread interest in expanding the uptake of home dialysis in North America. Although kidney transplantation should be the preferred option in eligible patients, home hemodialysis (HD) and peritoneal dialysis (PD) offer cost-effective options for KRT. In this review, the motivation for promoting home dialysis is presented, and the literature supporting it is critically reviewed. Randomized comparisons of home HD and PD with in-center HD have been challenging to conduct and provide only limited information. Nonrandomized studies are heterogeneous in their design and have often yielded conflicting results. They are prone to bias, and this must be carefully considered when evaluating this literature. Home modalities seem to have equivalent clinical outcomes and quality of life when compared with in-center HD. However, the cost of providing home therapies, particularly PD, is lower than conventional, in-center HD. Measures of home dialysis utilization, the philosophy behind their measurement, and important factors to consider when interpreting them are discussed. The importance of understanding measures of home dialysis utilization in the context of rates of kidney failure, the proportion of individuals who opt for conservative care, and rates of kidney transplantation is highlighted, and a framework for proposing targets is presented, using PD as an example.

Home hemodialysis technique survival: insights and challenges

Home hemodialysis (HHD) offers several clinical, quality of life and cost-saving benefits for patients with end-stage kidney disease. While uptake of this modality has increased in recent years, its prevalence remains low and high rates of discontinuation remain a challenge. This comprehensive narrative review aims to better understand what is currently known about technique survival in HHD patients, elucidate the clinical factors that contribute to attrition and expand on possible strategies to prevent discontinuation. With increasing efforts to encourage home modalities, it is imperative to better understand technique survival and find strategies to help maintain patients on the home therapy of their choosing. It is crucial to better target high-risk patients, examine ideal training practices and identify practices that are potentially modifiable to improve technique survival.

Portable, wearable and implantable artificial kidney systems: needs, opportunities and challenges

Haemodialysis is life sustaining but expensive, provides limited removal of uraemic solutes, is associated with poor patient quality of life and has a large carbon footprint. Innovative dialysis technologies such as portable, wearable and implantable artificial kidney systems are being developed with the aim of addressing these issues and improving patient care. An important challenge for these technologies is the need for continuous regeneration of a small volume of dialysate. Dialysate recycling systems based on sorbents have great potential for such regeneration. Novel dialysis membranes composed of polymeric or inorganic materials are being developed to improve the removal of a broad range of uraemic toxins, with low levels of membrane fouling compared with currently available synthetic membranes. To achieve more complete therapy and provide important biological functions, these novel membranes could be combined with bioartificial kidneys, which consist of artificial membranes combined with kidney cells. Implementation of these systems will require robust cell sourcing; cell culture facilities annexed to dialysis centres; large-scale, low-cost production; and quality control measures. These challenges are not trivial, and global initiatives involving all relevant stakeholders, including academics, industrialists, medical professionals and patients with kidney disease, are required to achieve important technological breakthroughs.

Choice of the Dialysis Modality: Practical Considerations

Chronic kidney disease and the need for kidney replacement therapy have increased dramatically in recent decades. Forecasts for the coming years predict an even greater increase, especially in low- and middle-income countries, due to the rise in metabolic and cardiovascular diseases and the aging population. Access to kidney replacement treatments may not be available to all patients, making it especially strategic to set up therapy programs that can ensure the best possible treatment for the greatest number of patients. The choice of the "ideal" kidney replacement therapy often conflicts with medical availability and the patient's tolerance. This paper discusses the pros and cons of various kidney replacement therapy options and their real-world applicability limits.

Effect of remote patient monitoring for patients with chronic kidney disease who perform dialysis at home: a systematic review

OBJECTIVE

The purpose of the systematic review was to assess the effectiveness of remote patient monitoring (RPM) follow-up compared with standard care, for patients with chronic kidney disease (CKD) who perform dialysis at home.

METHODS

We conducted a systematic review in accordance with international guidelines. We performed systematic searches for publications from 2015 to 2021 in five databases (eg, Medline, Cinahl, Embase) and a search for grey literature in reference lists. Included effect measures were quality of life, hospitalisation, technical failure as the cause for transfer to a different dialysis modality, infections and time patients use for travel. Screening of literature, data extraction, risk-of-bias assessment and certainty of evidence assessment (using the Grading of Recommendations Assessment, Development and Evaluation approach) were done by two researchers. We conducted meta-analyses when possible.

RESULTS

Seven studies met the inclusion criteria, of which two were randomised controlled trials and five were retrospective cohort studies with control groups. The studies included 9975 participants from 5 countries, who were a good representation of dialysis patients in high-income and upper-middle-income countries. The patients were on peritoneal dialysis (six studies) or home haemodialysis (one study). There was very low certainty of evidence for the outcomes, except for hospitalisations: there was low certainty evidence from three cohort studies for fewer hospitalisation days in the RPM group. No studies included data for time patients used for travel.

CONCLUSION

We found low to very low certainty evidence that indicate there may be positive effects of RPM follow-up, in comparison to standard care only, for adult patients with CKD who perform dialysis at home. Offering RPM follow-up for home dialysis patients as an alternative or supplement to standard care appears to be safe and provide health benefits such as fewer hospitalisation days. Future implementation should be coupled with robust, high-quality evaluations.

PROSPERO REGISTRATION NUMBER

CRD42021281779.

Estimating the cost of home dialysis in Tunisia: Application of the Activity-based costing methodology

INTRODUCTION

In Tunisia, in-centre haemodialysis (ICHD) is the most common type of dialysis. Despite the increasing demand, the number of haemodialysis machines per 100,000 inhabitants is still low. Home Haemodialysis (HHD) is a candidate solution to this problem. Despite its confirmed benefits over ICHD, HHD has not taken place in Tunisia.

AIM

To describe the processes of home dialysis modalities, especially HHD, evaluate their costs, analyse them, in the context of medical practice in public health structures in Tunisia.

METHOD

The Activity-Based Costing technique was applied: the processes of home dialysis modalities were modelled, the main activity and resource cost drivers identified, and cost equations developed. Based on data from the nephrology department of Sahloul hospital, the cost per session and annual costs for each home dialysis modality were calculated and analyzed.

RESULTS

Home Peritoneal Dialysis, already implemented in Tunisia; presented the lowest annual cost per patient 25344 TND versus 29232 TND for Conventional HHD and 54144 TND for Short-Daily HHD. The cost per session of the Short-Daily HHD (188,8 TND) was comparable to ICHD (180 TND). Consumables presented the most expensive resource for these modalities. Finally, the cost structure of HHD was comparable in Tunisia and France as well as in previous costing studies.

CONCLUSION

The cost of one session of HHD is estimated to 188,8 TND. The Tunisian ministry of health could adopt a flexible policy to start HHD program by implementing Conventional HHD first.

Patients’ perspectives of home and self-assist haemodialysis and factors influencing dialysis choices in Singapore

Background

The rise in end stage kidney disease (ESKD) prevalence globally calls for a need to deliver quality and cost-effective dialysis. While most are familiar with centre-based haemodialysis (HD), there is a move to increase uptake of home-based modalities (peritoneal dialysis (PD) or home haemodialysis (HHD)) and self-assist haemodialysis (SAHD) due to the economic, clinical and lifestyle advantages they confer. However, HHD and SAHD are not yet widely adopted in Singapore with majority of patients receiving in-centre HD. Although much research has examined patient decision-making around dialysis modality selection, there is limited literature evaluating patient’s perspectives of HHD and SAHD in Asia where the prevalence of these alternative modalities remained low. With this background, we aimed to evaluate patient’s perspectives of HHD and SAHD and the factors influencing their choice of dialysis modality in Singapore to determine the challenges and facilitators to establishing these modalities locally.

Methods

Semi-structured interviews were conducted with 17 patients on dialysis from a tertiary hospital in Singapore in this exploratory qualitative study. Data collected from one-to-one interviews were analysed via thematic content analysis and reported via an interpretative approach.

Results

The findings were segregated into: (1) factors influencing choices of dialysis modality; (2) perspectives of HHD; and (3) perspectives of SAHD. Modality choices were affected by environmental, personal, social, financial, information and family-related factors. Most perceived HHD as providing greater autonomy, convenience and flexibility while SAHD was perceived as a safer option than HHD. For both modalities, patients were concerned about self-care and burdening their family.

Conclusions

The findings provided a framework for healthcare providers to understand the determinants affecting patients’ dialysis modality decisions and uncovered the facilitators and challenges to be addressed to establish HHD and SAHD modalities in Singapore.

Optical Chemical Sensor Based on Fast-Protein Liquid Chromatography for Regular Peritoneal Protein Loss Assessment in End-Stage Renal Disease Patients on Continuous Ambulatory Peritoneal Dialysis

Point-of-care testing (POCT) devices are becoming increasingly popular in the medical community as an alternative to conventional laboratory testing, especially for home treatments or other forms of outpatient care. Multiple-use chemical sensors with minimal requirements for disposables are among the most practical and cost-effective POC diagnostic instruments, especially in managing chronic conditions. An affordable, simple, and easy-to-use optical sensor based on fast protein liquid chromatography with direct UV absorption detection was developed for the rapid determination of the total protein concentration in effluent peritoneal dialysate and for the assessment of protein losses in end-stage renal disease (ESRD) patients on constant ambulatory peritoneal dialysis (CAPD). The sensor employs non-disposable PD-10 desalting columns for the separation of molecules with different molecular weights and a deep UV LED (maximum at 285 nm) as a light source for optical detection. The analytic procedure is relatively simple, takes 10–15 min, and potentially can be performed by patients themselves or nursing staff without laboratory training. Preliminary clinical trials on a group of 23 patients on CAPD revealed a good concordance between the protein concentrations in dialysate samples measured with the sensor and an automated biochemical analyzer; the mean relative error was about 10%, which is comparable with routine clinical laboratory methods.

Intervening to eliminate the centre-effect variation in home dialysis use: protocol for Inter-CEPt-a sequential mixed-methods study designing an intervention bundle

INTRODUCTION

Use of home dialysis by centres in the UK varies considerably and is decreasing despite attempts to encourage greater use. Knowing what drives this unwarranted variation requires in-depth understanding of centre cultural and organisational factors and how these relate to quantifiable centre performance, accounting for competing treatment options. This knowledge will be used to identify components of a practical and feasible intervention bundle ensuring this is realistic and cost-effective.

METHODS AND ANALYSIS

Underpinned by the non-adoption, abandonment, scale-up, spread and sustainability framework, our research will use an exploratory sequential mixed-methods approach. Insights from multisited focused team ethnographic and qualitative research at four case study sites will inform development of a national survey of 52 centres. Survey results, linked to patient-level data from the UK Renal Registry, will populate a causal graph describing patient and centre-level factors, leading to uptake of home dialysis and multistate models incorporating patient-level treatment modality history and mortality. This will inform a contemporary economic evaluation of modality cost-effectiveness that will quantify how modification of factors facilitating home dialysis, identified from the ethnography and survey, might yield the greatest improvements in costs, quality of life and numbers on home therapies. Selected from these factors, using the capability, opportunity and motivation for behaviour change framework (COM-B) for intervention design, the optimal intervention bundle will be developed through workshops with patients and healthcare professionals to ensure acceptability and feasibility. Patient and public engagement and involvement is embedded throughout the project.

ETHICS AND DISSEMINATION

Ethics approval has been granted by the Health Research Authority reference 20-WA-0249. The intervention bundle will comprise components for all stake holder groups: commissioners, provider units, recipients of dialysis, their caregivers and families. To reache all these groups, a variety of knowledge exchange methods will be used: short guides, infographics, case studies, National Institute for Health and Care Excellence guidelines, patient conferences, 'Getting it Right First Time' initiative, Clinical Reference Group (dialysis).

Shared Decision-Making for a Dialysis Modality

The prevalence of kidney failure continues to rise globally. Dialysis is a treatment option for individuals with kidney failure; after the decision to initiate dialysis has been made, it is critical to involve individuals in the decision on which dialysis modality to choose. This review, based on evidence arising from the literature, examines the role of shared decision-making (SDM) in helping those with kidney failure to select a dialysis modality. SDM was found to lead to more people with kidney failure feeling satisfied with their choice of dialysis modality. Individuals with kidney failure must be cognizant that SDM is an active and iterative process, and their participation is essential for success in empowering them to make decisions on dialysis modality. The educational components of SDM must be easy to understand, high quality, unbiased, up to date, and targeted to the linguistic, educational, and cultural needs of the individual. All individuals with kidney failure should be encouraged to participate in SDM and should be involved in the design and implementation of SDM approaches.

Understanding the low take-up of home-based dialysis through a shared decision-making lens: a qualitative study

OBJECTIVES

To explore how people with chronic kidney disease who are pre-dialysis, family members and healthcare professionals together navigate common shared decision-making processes and to assess how this impacts future treatment choice.

DESIGN

Coproductive qualitative study, underpinned by the Making Good Decisions in Collaboration shared decision-model. Semistructured interviews with a purposive sample from February 2019 - January 2020. Interview data were analysed using framework analysis. Coproduction of logic models/roadmaps and recommendations.

SETTING

Five Welsh kidney services.

PARTICIPANTS

95 participants (37 patients, 19 family members and 39 professionals); 44 people supported coproduction (18 patients, 8 family members and 18 professionals).

FINDINGS

Shared decision-making was too generic and clinically focused and had little impact on people getting onto home dialysis. Preferences of where, when and how to implement shared decision-making varied widely. Apathy experienced by patients, caused by lack of symptoms, denial, social circumstances and health systems issues made future treatment discussions difficult. Families had unmet and unrecognised needs, which significantly influenced patient decisions. Protocols containing treatment hierarchies and standards were understood by professionals but not translated for patients and families. Variation in dialysis treatment was discussed to match individual lifestyles. Patients and professionals were, however, defaulting to the perceived simplest option. It was easy for patients to opt for hospital-based treatments by listing important but easily modifiable factors.

CONCLUSIONS

Shared decision-making processes need to be individually tailored with more attention on patients who could choose a home therapy but select a different option. There are critical points in the decision-making process where changes could benefit patients. Patients need to be better educated and their preconceived ideas and misconceptions gently challenged. Healthcare professionals need to update their knowledge in order to provide the best advice and guidance. There needs to be more awareness of the costs and benefits of the various treatment options when making decisions.

Perceptions of Multidisciplinary Renal Team Members toward Home Dialysis Therapies

Background

Patients with ESKD are encouraged to pursue home dialysis therapy with the aims of improving quality of life, increasing patient autonomy, and reducing cost to health care systems. In a multidisciplinary team setting, patients interact with nephrologists, nurses, and allied health staff, all of whom may influence a patient's modality choice. Our objective was to evaluate the perceptions of all renal team members toward home dialysis therapies.

Methods

We performed a cross-sectional survey of multidisciplinary renal team members across five renal programs in British Columbia, Canada. The survey contained questions regarding primary work area, modality preference, patient and system factors that may influence modality candidacy, perceived knowledge of home therapies, and need for further education.

Results

A total of 334 respondents (22 nephrologists, 172 hemodialysis nurses, 49 home nurses, 20 predialysis nurses, and 71 allied health staff) were included (48% response rate). All respondents felt that home dialysis was beneficial for patients who work or study, improved patients' quality of life, and provided cost savings to the system. Compared with in-center hemodialysis nurses, home therapies nurses were between five and nine times more likely to favor a home therapy for patients of older age, lower socioeconomic status, lower educational level, higher burden of comorbidities, and those lacking social supports. Nephrologists and patients were felt to have the most influence on modality choice, whereas dialysis nurses were seen as having the least effect on modality choice. Most respondents felt the need for further education in home therapies.

Conclusions

The majority of multidisciplinary team members, including allied health staff, acknowledged the benefits of home therapies. There were significant discrepancies among team members regarding patient-/system-level factors that may affect the candidacy of home therapies. Structured, focused, and repeated education sessions for all renal team members may help to address misperceptions around factors that influence modality candidacy.

Is home hemodialysis a practical option for older people?

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.

Intelligent "Internet Plus" services in the first case of home hemodialysis in mainland China

BACKGROUND

Many studies have shown that compared with those who use other dialysis modalities, patients using home hemodialysis (HHD) have an increased rate of survival and better quality of life. It was noted in 2006 that there was opportunity for significant expansion of the use of HHD in many countries. China covers a vast area and has a large amount of end-stage renal failure patients. But in mainland China, all dialysis treatments are in-center, and the number of HHD patients is zero. In 2018, our hospital received the permission of the Shanghai government to carry out HHD.

CASE PRESENTATION

We initiated four incident hemodialysis patients on an HHD regimen, one patient has been dialyzed in the home safely for 8 months. The biochemical parameters of the first patient remained stable on the regimen and he achieved standard Kt/V urea targets. Treatment-related adverse events were not reported during the follow-up. We combined HHD with intelligent "Internet Plus" real-time remote monitoring and introduced the Internet, especially visualization software, to replace traditional telephone and home visit methods. It is more intuitive and quicker to assist patients in performing home hemodialysis and improve the safety of treatment.

CONCLUSIONS

HHD can be performed by selected trained patients in mainland China. Combined with the internet, visualization software, and traditional telephone and home visits, it is intuitive and quick to assist patients in carrying out HHD and improve the safety of treatment. HHD broadens the choices for uremia patients in China.

What can a home hemodialysis program offer to patients in a nursing home setting? A case series and feasibility analysis

INTRODUCTION

Over the last decades, the number of elderly patients on dialysis has rapidly grown on account of increased life expectancy, improved care and reduced mortality rate. Therefore, cooperation between geriatricians and nephrologists has become mandatory for co-managing kidney disease in these patients. Based on renewed interest in home hemodialysis (HHD), elderly patients may benefit from not being transported from their home for therapy.

METHODS

Here, we report our experience with HHD involving three elderly patients who were followed-up over a 15-months period in a nursing home.

FINDINGS

Our experience demonstrates that hospitalization abruptly dropped from 40 days to zero days, the need for erythropoietin stimulating agents (ESAs) diminished, transportation-related costs for home treatments decreased, and quality of life (QoL) improved. This was confirmed by a questionnaire administered to our patients at the start and again after 6 months of HHD which evaluated the Physical Health Component Score (PCS) and the Mental Health Component Score (MCS).

DISCUSSION

Home hemodialysis may represent an important way to improve social, mental, and physical recovery, while also eliminating the cost of transportation and the discomfort of abandoning their "homes" and daily habits. Home hemodialysis is an effective alternative to in-center HD or peritoneal dialysis (PD) that should be offered to elderly patients when a home caregiver is not available, nonetheless, nursing assistance is required. Moreover, HHD allows patients to stay at home, thereby avoiding several weekly trips to the dialysis center, and may be useful in reducing infections, especially in times of the COVID-19 pandemic, as demonstrated by our experience.

Anemia management for home dialysis including the new US public policy initiative

Patients with end-stage kidney disease (ESKD) requiring kidney replacement therapy are often treated in conventional dialysis centers at substantial cost and patient inconvenience. The recent United States Executive Order on Advancing American Kidney Health, in addition to focusing on ESKD prevention and reforming the kidney transplantation system, focuses on providing financial incentives to promote a shift toward home dialysis. In accordance with this order, a goal was set to have 80% of incident dialysis patients receiving home dialysis or a kidney transplant by 2025. Compared with conventional in-center therapy, home dialysis modalities, including both home hemodialysis and peritoneal dialysis, appear to offer equivalent or improved mortality, clinical outcomes, hospitalization rates, and quality of life in patients with ESKD in addition to greater convenience, flexibility, and cost-effectiveness. Treatment of anemia, a common complication of chronic kidney disease, may be easier to manage at home with a new class of agents, hypoxia-inducible factor-prolyl hydroxylase inhibitors, which are orally administered in contrast to the current standard of care of i.v. iron and/or erythropoiesis-stimulating agents. This review evaluates the clinical, quality-of-life, economic, and social aspects of dialysis modalities in patients with ESKD, including during the coronavirus disease 2019 pandemic; explores new therapeutics for the management of anemia in chronic kidney disease; and highlights how the proposed changes in Advancing American Kidney Health provide an opportunity to improve kidney health in the United States.

COVID-19 pandemic era: is it time to promote home dialysis and peritoneal dialysis?

The novel coronavirus, called severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), was declared a pandemic in March 2020 by the World Health Organization. Older individuals and patients with comorbid conditions such as hypertension, heart disease, diabetes, lung disease, chronic kidney disease (CKD) and immunologic diseases are at higher risk of contracting this severe infection. In particular, patients with advanced CKD constitute a vulnerable population and a challenge in the prevention and control of the disease. Home-based renal replacement therapies offer an opportunity to manage patients remotely, thus reducing the likelihood of infection due to direct human interaction. Patients are seen less frequently, limiting the close interaction between patients and healthcare workers who may contract and spread the disease. However, while home dialysis is a reasonable choice at this time due to the advantage of isolation of patients, measures must be assured to implement the program. Despite its logistical benefits, outpatient haemodialysis also presents certain challenges during times of crises such as the coronavirus disease 2019 (COVID-19) pandemic and potentially future ones.

Physical Infrastructure and Integrated Governance Structure for Home Hemodialysis

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.

Cost-Utility of Dialysis in Canada: Hemodialysis, Peritoneal Dialysis, and Nondialysis Treatment of Kidney Failure

Rationale & Objective

The kidney failure population is growing, necessitating the expansion of dialysis programs. These programs are costly and require a substantial amount of health care resources. Tools that accurately forecast resource use can aid efficient allocation. The objective of this study is to describe the development of an economic simulation model that incorporates treatment history and detailed modality transitions for patients with kidney disease using real-world data to estimate associated costs, utility, and survival by initiating modality.

Study Design

Cost-utility model with microsimulation.

Setting & Population

Adult incident maintenance dialysis patients in Canada who initiated facility-based hemodialysis (HD) or home peritoneal dialysis (PD) between 2004 and 2013.

Intervention

HD and PD.

Outcomes

Costs (related to dialysis, transplantation, infections, and hospitalizations), survival, utility, and dialysis modality mix over time.

Model, Perspective, & Timeframe

The model took the perspective of the health care payer. Patients were followed up for 10 years from initiation of dialysis. Our cost-utility analysis compared the intervention with receiving no treatment.

Results

During a 10-year time horizon, the cost-utility ratio for all patients initiating dialysis was $103,779 per quality-adjusted life-year (QALY) in comparison to no treatment. Patients who initiated with facility-based HD were treated at a cost-utility ratio of $104,880/QALY and patients who initiated with home PD were treated at a cost-utility ratio of $83,762/QALY. During this time horizon, the total mean cost and QALYs per patient were estimated at $350,774 ± $204,704 and 3.38 ± 2.05) QALYs respectively.

Limitations

The results do not include costs from the societal perspective. Rare patient trajectories were unable to be assessed.

Conclusions

This model demonstrates that patients who initiated dialysis with PD were treated more cost-effectively than those who initiated with HD during a 10-year time horizon.

Health Policy for Dialysis Care in Canada and the United States

Contemporary dialysis treatment for chronic kidney failure is complex, is associated with poor clinical outcomes, and leads to high health costs, all of which pose substantial policy challenges. Despite similar policy goals and universal access for their kidney failure programs, the United States and Canada have taken very different approaches to dealing with these challenges. While US dialysis care is primarily government funded and delivered predominantly by private for-profit providers, Canadian dialysis care is also government funded but delivered almost exclusively in public facilities. Differences also exist for regulatory mechanisms and the policy incentives that may influence the behavior of providers and facilities. These differences in health policy are associated with significant variation in clinical outcomes: mortality among patients on dialysis is consistently lower in Canada than in the United States, although the gap has narrowed in recent years. The observed heterogeneity in policy and outcomes offers important potential opportunities for each health system to learn from the other. This article compares and contrasts transnational dialysis-related health policies, focusing on key levers including payment, finance, regulation, and organization. We also describe how policy levers can incentivize favorable practice patterns to support high-quality/high-value, person-centered care and to catalyze the emergence of transformative technologies for alternative kidney replacement strategies.

A Systematic Approach To Promoting Home Hemodialysis during End Stage Kidney Disease

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.

Patients' and caregivers' perspectives on access to kidney replacement therapy in rural communities: systematic review of qualitative studies

OBJECTIVE

Patients with chronic kidney disease (CKD) requiring kidney replacement therapy (KRT) in rural communities encounter many barriers in accessing equitable care and have worse outcomes compared with patients in urban areas. This study aims to describe the perspectives of patients and caregivers on access to KRT in rural communities to inform strategies to maximise access to quality care, and thereby reduce disadvantage, inequity and improve health outcomes.

SETTING

18 studies (n=593 participants) conducted across eight countries (Australia, Canada, the UK, New Zealand, Ghana, the USA, Tanzania and India).

RESULTS

We identified five themes: uncertainty in navigating healthcare services (with subthemes of struggling to absorb information, without familiarity and exposure to options, grieving former roles and yearning for cultural safety); fearing separation from family and home (anguish of homesickness, unable to fulfil family roles and preserving sense of belonging in community); intense burden of travel and cost (poverty of time, exposure to risks and hazards, and taking a financial toll); making life-changing sacrifices; guilt and worry in receiving care (shame in taking resources from others, harbouring concerns for living donor, and coping and managing in isolation).

CONCLUSION

Patients with CKD in rural areas face profound and inequitable challenges of displacement, financial burden and separation from family in accessing KRT, which can have severe consequences on their well-being and outcomes. Strategies are needed to improve access and reduce the burden of obtaining appropriate KRT in rural communities.

Barriers to Home Hemodialysis Across Saskatchewan, Canada: A Cross-Sectional Survey of In-Center Dialysis Patients

Background

Despite clinical and lifestyle advantages of home hemodialysis (HHD) compared with in-center hemodialysis (ICHD), it remains underutilized in our province. The aim of the study was to explore the patients' perception and to identify the barriers to use of HHD in Saskatchewan, Canada.

Objectives

The primary objective of the study was to evaluate and explore patient perceptions of HHD and to identify the obstacles for adoption of HHD in Saskatchewan. The secondary objective was to examine variations in the patients' perceptions and barriers to HHD by center (main dialysis units vs satellite dialysis units).

Design

This is a cross-sectional observational survey study.

Setting

Two major centers (Regina and Saskatoon) and 5 associated satellite units attached to each center across the province of Saskatchewan.

Patients

We approached all prevalent ICHD patients across Saskatchewan, 398 agreed to participate in the study.

Measurements

Self-reported barriers to HHD were assessed using a questionnaire.

Methods

A questionnaire was designed to determine the patients' perceived barriers to HHD. Descriptive statistics was used to present the data. Chi-square and Mann-Whitney U test were used to compare the patients' responses between main and satellite units.

Results

Satisfaction with current dialysis care (91%), increase in utility bills (65%), fear of catastrophic events at home (59%), medicalization of one's home (54%), and knowledge deficits toward treatment modalities (54%) were the main barriers to HHD uptake. Compared with patients dialyzing in our main units, satellite patients chose not to pursue HHD more frequently because they had greater satisfaction with their current dialysis unit care (97% vs 87%, P < .001), felt more comfortable dialyzing under the supervision of medical staff (95% vs 86%, P < .007), could not afford additional utility costs (92% vs 45%, P < .001), were unaware of the risks and benefits of HHD (83% vs 33%, P < .001), had concerns over time commitments for training to HHD (69% vs 32%, P < .001), and had concern for family burnout (60.8% vs 40.6%, P < .001).

Limitations

We used questionnaires to quantify known barriers, and this prevents inclusion of additional barriers that individual patients may consider important. Cross-sectional data can only be used as a snapshot. Only 398 patients agreed to participate, and the results cannot be generalized to 740 prevalent HD patients. We did not capture data on demographics (age, income, and literacy level), comorbidities, and dialysis vintage, which would have been helpful in interpretation of the results.

Conclusions

Satisfaction with in-center care, lack of awareness and education, specifically in the satellite population, concerns with family burnout, expenses associated with utilities, and training time will need to be addressed to increase the uptake of HHD.

Trial Registration

The study was not registered on a publicly accessible registry as it did not involve any health care intervention on human participants.

Outcomes Following Revision Joint Arthroplasty Among Hemodialysis-Dependent Patients

BACKGROUND

Hemodialysis (HD) dependence is known to impact the integrity of bone and has long been associated with metabolic bone disease and other adverse events postoperatively. The aim of this study is to analyze postoperative outcomes following revision hip and knee arthroplasty in hemodialysis-dependent (HDD) patients and to characterize the common indications for revision procedures among this patient population.

METHODS

A total of 1779 HDD patients who underwent a revision joint arthroplasty (930 revision total knee arthroplasty [TKA] and 849 revision total hip arthroplasty [THA]) between 2005 and 2014 were identified from a retrospective database review. Our resulting study groups of revision TKA and THA HDD patients were compared to their respective matched control groups for hospital length of stay (LOS), 90-day mean total cost, hospital readmission, and other major medical and surgical complications.

RESULTS

HD was significantly associated with increased LOS (7.7 ± 8.3 vs 4.8 ± 4.5; P < .001), mean 90-day total cost ($47,478 ± $33,413 vs $24,286 ± $21,472; P < .001), hospital readmission (odds ratio [OR], 2.25; 95% confidence interval [CI], 1.96-2.58; P < .001), septicemia (OR, 3.18; 95% CI, 2.70-3.74; P < .001), postoperative infection (OR, 1.72; 95% CI, 1.50-1.98; P < .001), and mortality (OR, 3.99; 95% CI, 3.12-5.06; P < .001) following revision TKA. Among revision THA patients, HD was associated with increased LOS (9.4 ± 9.5 vs 5.7 ± 5.7; P < .001), mean 90-day total cost ($40,182 ± $27,082 vs $26,519 ± $22,856; P < .001), hospital readmission (OR, 2.33; 95% CI, 2.02-2.68; P < .001), septicemia (OR, 3.61; 95% CI, 3.05-4.27; P < .001), and mortality (OR, 3.55; 95% CI, 2.86-4.37; P < .001).

CONCLUSION

HD remains a significant risk factor for increased LOS, mean total cost, hospital readmission, septicemia, and mortality following revision joint arthroplasty.

A call for harmonization of European kidney care: dialysis reimbursement and distribution of kidney replacement therapies

Background

We compare reimbursement for haemodialysis (HD) and peritoneal dialysis (PD) in European countries to assess the impact on government healthcare budgets. We discuss strategies to reduce costs by promoting sustainable dialysis and kidney transplantation.

Methods

This was a cross-sectional survey among nephrologists conducted online July–December 2016. European countries were categorized by tertiles of gross domestic product per capita (GDP). Reimbursement data were matched to kidney replacement therapy (KRT) data.

Results

The prevalence per million population of patients being treated with long-term dialysis was not significantly different across tertiles of GDP (P = 0.22). The percentage of PD increased with GDP across tertiles (4.9, 8.2, 13.4%; P &lt; 0.001). The HD-to-PD reimbursement ratio was higher in countries with the highest tertile of GDP (0.7, 1.0 versus 1.7; P = 0.007). Home HD was mainly reimbursed in countries with the highest tertile of GDP (15, 15 versus 69%; P = 0.005). The percentage of public health expenditure for reimbursement of dialysis decreased across tertiles of GDP (3.3, 1.5, 0.7%; P &lt; 0.001). Transplantation as a proportion of all KRT increased across tertiles of GDP (18.5, 39.5, 56.0%; P &lt; 0.001).

Conclusions

In Europe, dialysis has a disproportionately high impact on public health expenditure, especially in countries with a lower GDP. In these countries, the cost difference between PD and HD is smaller, and home dialysis and transplantation are less frequently provided than in countries with a higher GDP. In-depth evaluation and analysis of influential economic and political measures are needed to steer optimized reimbursement strategies for KRT.

Nocturnal home hemodialysis in children: Advantages, implementation, and barriers

Chronic kidney disease and end-stage renal disease (ESRD) in children are major health concerns worldwide with increasing incidence and prevalence. Renal replacement therapies and kidney transplants have remarkably improved the management of patients with ESRD in both adult and pediatric populations. Kidney transplant has the best patient outcomes, but many a time it has a considerable waiting period. In the meantime, the majority of patients with pediatric ESRD are dependent on dialysis. The conventionally utilized hemodialysis regimen is the three times weekly, in-center hemodialysis. Many studies have demonstrated the unfavorable long-term morbidity associated with the conventional regimen. Intensified dialysis programs, which include extended nocturnal hemodialysis or short daily hemodialysis, are being increasingly advocated over the past two decades. In addition to having much better clinical outcomes as compared with the conventional regimen, the flexibility to provide dialysis at home serves as a great incentive. PubMed/Medline, Embase and Cochrane databases for literature on nocturnal home hemodialysis in children with ESRD were extensively searched. Contrary to the noticeable literature available on adult home hemodialysis, a small number of studies exist in the pediatric population. In this review, the benefits, implementation and associated barriers of nocturnal home hemodialysis in children were addressed.

Enhancement of solute clearance using pulsatile push-pull dialysate flow for the Quanta SC+: A novel clinic-to-home haemodialysis system

BACKGROUND AND OBJECTIVE

The SC+ haemodialysis system developed by Quanta Dialysis Technologies is a small, easy-to-use dialysis system designed to improve patient access to self-care and home haemodialysis. A prototype variant of the standard SC+ device with a modified fluidic management system generating a pulsatile push-pull dialysate flow through the dialyser during use has been developed for evaluation. It was hypothesized that, as a consequence of the pulsatile push-pull flow through the dialyser, the boundary layers at the membrane surface would be disrupted, thereby enhancing solute transport across the membrane, modifying protein fouling and maintaining the surface area available for mass and fluid transport throughout the whole treatment, leading to solute transport (clearance) enhancement compared to normal haemodialysis (HD) operation.

METHODS

The pumping action of the SC+ system was modified by altering the sequence and timings of the valves and pumps associated with the flow balancing chambers that push and pull dialysis fluid to and from the dialyser. Using this unique prototype device, solute clearance performance was assessed across a range of molecular weights in two related series of laboratory bench studies. The first measured dialysis fluid moving across the dialyser membrane using ultrasonic flowmeters to establish the validity of the approach; solute clearance was subsequently measured using fluorescently tagged dextran molecules as surrogates for uraemic toxins. The second study used human blood doped with uraemic toxins collected from the spent dialysate of dialysis patients to quantify solute transport. In both, the performance of the SC+ prototype was assessed alongside reference devices operating in HD and pre-dilution haemodiafiltration (HDF) modes.

RESULTS

Initial testing with fluorescein-tagged dextran molecules (0.3 kDa, 4 kDa, 10 kDa and 20 kDa) established the validity of the experimental pulsatile push-pull operation in the SC+ system to enhance clearance and demonstrated a 10 to 15% improvement above the current HD mode used in clinic today. The magnitude of the observed enhancement compared favourably with that achieved using pre-dilution HDF with a substitution fluid flow rate of 60 mL/min (equivalent to a substitution volume of 14.4 L in a 4-hour session) with the same dialyser and marker molecules. Additional testing using human blood indicated a comparable performance to pre-dilution HDF; however, in contrast with HDF, which demonstrated a gradual decrease in solute removal, the clearance values using the pulsatile push-pull method on the SC+ system were maintained over the entire duration of treatment. Overall albumin losses were not different.

CONCLUSIONS

Results obtained using an experimental pulsatile push-pull dialysis flow configuration with an aqueous blood analogue and human blood ex vivo demonstrate an enhancement of solute transport across the dialyser membrane. The level of enhancement makes this approach comparable with that achieved using pre-dilution HDF with a substitution fluid flow rate of 60 mL/min (equivalent to a substitution volume of 14.4 L in a 4-hour session). The observed enhancement of solute transport is attributed to the disruption of the boundary layers at the fluid-membrane interface which, when used with blood, minimizes protein fouling and maintains the surface area.

Health-Related Quality of Life in Home Dialysis Patients Compared to In-Center Hemodialysis Patients: A Systematic Review and Meta-analysis

RATIONALE & OBJECTIVE

Dialysis patients judge health-related quality of life (HRQoL) as an essential outcome. Remarkably, little is known about HRQoL differences between home dialysis and in-center hemodialysis (HD) patients worldwide.

STUDY DESIGN

Systematic review and meta-analysis.

SETTING & STUDY POPULATIONS

Search strategies were performed on the Cochrane Library, Pubmed, and EMBASE databases between 2007 and 2019. Home dialysis was defined as both peritoneal dialysis and home HD.

SELECTION CRITERIA FOR STUDIES

Randomized controlled trials and observational studies that compared HRQoL in home dialysis patients versus in-center HD patients.

DATA EXTRACTION

The data extracted by 2 authors included HRQoL scores of different questionnaires, dialysis modality, and subcontinent.

ANALYTICAL APPROACH

Data were pooled using a random-effects model and results were expressed as standardized mean difference (SMD) with 95% CIs. Heterogeneity was explored using subgroup analyses.

RESULTS

Forty-six articles reporting on 41 study populations were identified. Most studies were cross-sectional in design (90%), conducted on peritoneal dialysis patients (95%), and used the 12-item or 36-item Short-Form Health Survey questionnaires (83%). More than half the studies showed moderate or high risk of bias. Pooled analysis of 4,158 home dialysis patients and 7,854 in-center HD patients showed marginally better physical HRQoL scores in home dialysis patients compared with in-center HD patients (SMD, 0.14; 95% CI, 0.04 to 0.24), although heterogeneity was high (I 2>80%). In a subgroup analysis, Western European home dialysis patients had higher physical HRQoL scores (SMD, 0.39; 95% CI, 0.17 to 0.61), while home dialysis patients from Latin America had lower physical scores (SMD, -0.20; 95% CI, -0.28 to -0.12). Mental HRQoL showed no difference in all analyses.

LIMITATIONS

No randomized controlled trials were found and high heterogeneity among studies existed.

CONCLUSIONS

Although pooled data showed marginally better physical HRQoL for home dialysis patients, the quality of design of the included studies was poor. Large prospective studies with adequate adjustments for confounders are necessary to establish whether home dialysis results in better HRQoL.

TRIAL REGISTRATION

PROSPERO 95985.

Impact of payment model on the behaviour of specialist physicians: A systematic review

Physician payment models are perceived to be an important strategy for improving health, access, quality, and the value of health care. Evidence is predominantly from primary care, and little is known regarding whether specialists respond similarly. We conducted a systematic review to synthesize evidence on the impact of specialist physician payment models across the domains of health care quality; clinical outcomes; utilization, access, and costs; and patient and physician satisfaction. We searched Medline, Embase, and six other databases from their inception through October 2018. Eligible articles addressed specialist physicians, payment models, outcomes of interest, and used an experimental or quasi-experimental design. Of 11,648 studies reviewed for eligibility, 11 articles reporting on seven payment reforms were included. Fee-for-service (FFS) was associated with increased desired utilization and fewer adverse outcomes (in the case of hemodialysis patients) and better access to care (in the case of emergency department services). Replacing FFS with capitation and salary models led to fewer elective surgical procedures (cataracts and tubal ligations) and, with an episode-based model, appeared to increase the use of less costly resources. Four of the seven reforms met their goals but many had unintended consequences. Payment model appears to affect utilization of specialty care, although the association with other outcomes is unclear due to mixed results or lack of evidence. Studies of salary and salary-based reforms point to specialists responding to some incentives differently than theory would predict. Additional research is warranted to improve the evidence driving specialist payment policy.

The Potential Burden of Home Dialysis on Patients and Caregivers: A Narrative Review

Purpose of review:

Home dialysis modalities offer several benefits for patients with end-stage kidney disease when compared with facility-based thrice-weekly hemodialysis. To increase uptake of home dialysis, many centers are encouraging a “home-first” approach. However, it is important to appreciate that “one size may not fit all” and that dialysis modality selection is a complex decision that needs to be individualized. The purpose of this review was to explore aspects associated with home dialysis that may be associated with burden for patients and their caregivers and to discuss strategies to alleviate these concerns.

Sources of information:

Original research articles were identified from PubMed using search terms “peritoneal dialysis,” “home hemodialysis,” “home dialysis,” “barriers,” “quality of life” and “burden.”

Methods:

We performed a focused narrative review examining potential sources of burden with home dialysis therapies after conducting a critical appraisal of the literature and identifying the major recurring themes.

Key findings:

Home dialysis is associated with burden for certain patients. Indeed, some patients may experience ongoing concerns regarding the risks of adverse events and of inadequately performing dialysis on their own. Psychosocial issues affecting quality of life may also arise and include fear of social isolation, sleep disturbances, perceived financial burden, anxiety, and fatigue. Patients who depend on a caregiver may worry about creating a stressful home environment for their close ones. Furthermore, the demands associated with being a caregiver may lead to psychosocial distress in the caregivers themselves. All these factors may lead to burnout and consequently, therapy discontinuation necessitating an unplanned transition to in-center hemodialysis leading to adverse outcomes. However, certain strategies may help alleviate burden especially if concerns are identified early on.

Limitations:

As we did not apply any formal tool to assess the quality of the studies included, selection bias may have occurred. Nonetheless, we have attempted to provide a comprehensive review on the topic using numerous diverse studies and extensive review of the literature.

Implications:

Future studies should focus on better identifying patient priorities and strategies to facilitate dialysis modality selection and improve quality of life.

Paying for Frequent Dialysis

In late 2017, the 7 regional contractors responsible for paying dialysis claims in Medicare proposed new payment rules that would restrict payment for hemodialysis treatments in excess of 3 weekly to exceptional acute-care circumstances. Frequent hemodialysis is performed more frequently than the traditional thrice-weekly pattern, and many stakeholders-patients, providers, dialysis machine manufacturers, and others-have expressed concern that these payment rules will inhibit the growth of this treatment modality's use among US dialysis patients. In this Perspective, we explain the role of these contractors in the context of Medicare's in-center hemodialysis-centric dialysis payment system and assess how well this system accommodates the higher treatment frequencies of both peritoneal dialysis and frequent hemodialysis. Then, given the available evidence concerning the relative effectiveness of these modalities versus thrice-weekly in-center hemodialysis and trends in their use, we discuss options for modifying Medicare's payment system to support frequent dialysis.

Human factors testing of the Quanta SC+ hemodialysis system: An innovative system for home and clinic use

INTRODUCTION

Uptake rates of home hemodialysis are the lowest among all modality types, despite providing patients with clinical and quality of life benefits at a lower cost to providers. Currently, there is a need to develop dialysis systems that are appealing to patients while also being suitable for use across the continuum of care. The SC+ hemodialysis system was developed by Quanta Dialysis Technologies Ltd. to provide patients with a dialysis system that is small, simple to use, and powerful enough to deliver acceptable dialysis adequacy.

METHODS

As part of the SC+ design validation, human factors testing was performed with 17 Healthcare Professionals (nephrology nurses and healthcare assistants) and 15 Home Users (patients and caregivers). To assess usability and safety, the human factors testing involved between 4.5 and 6 hours of training and, after a period of training decay, a subsequent test session in which participants independently performed tasks on SC+.

FINDINGS

Between the two user groups, there were only 29 errors observed out of 1216 opportunities for errors, despite minimal training. Errors that did occur were minor and attributed to an initial lack of familiarity with the device; none were safety related.

DISCUSSION

Among prevalent dialysis patients and healthcare professionals, the SC+ hemodialysis system was easy to use, even with minimal training and a learning decay period, and had a high level of use safety. By taking into account human factors to optimize the user experience, SC+ has the potential to address systemic and patient barriers, allowing for wider self-care and home hemodialysis adoption.

Cost of dialysis therapies in rural and remote Australia - a micro-costing analysis

BACKGROUND

Maintenance dialysis is a costly and resource intense activity. In Australia, inadequate health infrastructure and poor access to technically skilled staff can limit service provision in remote areas where many Aboriginal dialysis patients live. With most studies based on urban service provision, there is little evidence to guide service development. However permanent relocation to an urban area for treatment can have significant social and financial impacts that are poorly quantified. This study is part of a broader project to quantify the costs and benefits of dialysis service models in urban and remote locations in Australia's Northern Territory (NT).

METHODS

We undertook a micro-costing analysis of dialysis service delivery costs in urban, rural and remote areas in the NT from the payer perspective. Recurrent maintenance costs (salaries, consumables, facility management and transportation) as well as capital costs were included. Missing and centralised costs were standardised; results were inflated to 2017 values and reported in Australian dollars.

RESULTS

There was little difference between the average annual cost for urban and rural services with respective median costs of $85,919 versus $84,629. However remote service costs were higher ($120,172 - $124,492), driven by higher staff costs. The inclusion of capital costs did not add substantially to annual costs. Annual home haemodialysis costs ($42,927) were similar to other jurisdictions despite the significant differences in program delivery and payment of expenses not traditionally borne by governments. Annual peritoneal dialysis costs ($58,489) were both higher than home and in-centre haemodialysis by recent national dialysis cost studies.

CONCLUSION

The cost drivers for staffed services were staffing models and patient attendance rates. Staff salaries and transport costs were significantly higher in remote models of care. Opportunities to reduce expenditure exist by encouraging community supported services and employing local staff. Despite the delivery challenges of home haemodialysis including high patient attrition, the program still provides a cost benefit compared to urban staffed services. The next component of this study will examine patient health service utilisation and costs by model of care to provide a more comprehensive analysis of the overall cost of providing services in each location.

Changing ethnic and clinical trends and factors associated with successful home haemodialysis at Auckland District Health Board

BACKGROUND

The health and diversity of the population in New Zealand (NZ) is changing under the influence of many socio-economic factors. This may have shifted the landscape of home haemodialysis (HHD).

AIMS

To examine the demographic and clinical changes, determinants of HHD training and technique outcome and mortality between 2008 and 2015 at Auckland District Health Board, NZ.

METHODS

We compared three incident cohorts of HHD patients between 2008 and 2015. Relevant factors, including demographic and clinical characteristics, training failure, technique failure and mortality were recorded. Factors associated with training and technique failure were examined by multivariate logistic regression.

RESULTS

Of 152 patients, 133 completed training, 13 (10%) experienced technique failure and 15 (11%) died. Significant changes in ethnicity (increased: Māori 1.7-fold, Asian 1.7-fold and Pasifika 1.4-fold; decreased: NZ European 2.7-fold, P = 0.001), and major comorbidities, ≥2 major comorbidities (1.8-fold increase, P = 0.03), diabetes (2.1-fold increase, P = 0.013) and heart failure (P = 0.04) were seen. HHD as first renal replacement therapy modality increased 15-fold (P = 0.0001) and training time increased by 4.5 weeks (P = 0.004). Death and technique failure were unchanged over time. Shorter training time, employment and lower C-reactive protein were associated with 'Successful HHD'. 'Unsuccessful HHD' patient characteristics differed by ethnicity.

CONCLUSIONS

The HHD population has become more representative of the NZ population, but significantly more comorbid over time. Patient training time has increased, but mortality and technique failure remain stable. 'Successful HHD' is predicted by social and clinical factors, and 'unsuccessful HHD' may have different mechanisms in different patient groups.