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Cheetham MS, Ethier I, Krishnasamy R, Cho Y, Palmer SC, Johnson DW, Craig JC, Stroumza P, Frantzen L, Hegbrant J, Strippoli GF. Home versus in-centre haemodialysis for people with kidney failure. Cochrane Database Syst Rev 2024; 4:CD009535. [PMID: 38588450 PMCID: PMC11001293 DOI: 10.1002/14651858.cd009535.pub3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/10/2024]
Abstract
BACKGROUND Home haemodialysis (HHD) may be associated with important clinical, social or economic benefits. However, few randomised controlled trials (RCTs) have evaluated HHD versus in-centre HD (ICHD). The relative benefits and harms of these two HD modalities are uncertain. This is an update of a review first published in 2014. This update includes non-randomised studies of interventions (NRSIs). OBJECTIVES To evaluate the benefits and harms of HHD versus ICHD in adults with kidney failure. SEARCH METHODS We contacted the Information Specialist and searched the Cochrane Kidney and Transplant Register of Studies up to 9 October 2022 using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Registry Platform (ICTRP) Search Portal, and ClinicalTrials.gov. We searched MEDLINE (OVID) and EMBASE (OVID) for NRSIs. SELECTION CRITERIA RCTs and NRSIs evaluating HHD (including community houses and self-care) compared to ICHD in adults with kidney failure were eligible. The outcomes of interest were cardiovascular death, all-cause death, non-fatal myocardial infarction, non-fatal stroke, all-cause hospitalisation, vascular access interventions, central venous catheter insertion/exchange, vascular access infection, parathyroidectomy, wait-listing for a kidney transplant, receipt of a kidney transplant, quality of life (QoL), symptoms related to dialysis therapy, fatigue, recovery time, cost-effectiveness, blood pressure, and left ventricular mass. DATA COLLECTION AND ANALYSIS Two authors independently assessed if the studies were eligible and then extracted data. The risk of bias was assessed, and relevant outcomes were extracted. Summary estimates of effect were obtained using a random-effects model, and results were expressed as risk ratios (RR) and their 95% confidence intervals (CI) for dichotomous outcomes and mean difference (MD) or standardised mean difference (SMD) and 95% CI for continuous outcomes. Confidence in the evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. Meta-analysis was performed on outcomes where there was sufficient data. MAIN RESULTS From the 1305 records identified, a single cross-over RCT and 39 NRSIs proved eligible for inclusion. These studies were of varying design (prospective cohort, retrospective cohort, cross-sectional) and involved a widely variable number of participants (small single-centre studies to international registry analyses). Studies also varied in the treatment prescription and delivery (e.g. treatment duration, frequency, dialysis machine parameters) and participant characteristics (e.g. time on dialysis). Studies often did not describe these parameters in detail. Although the risk of bias, as assessed by the Newcastle-Ottawa Scale, was generally low for most studies, within the constraints of observational study design, studies were at risk of selection bias and residual confounding. Many study outcomes were reported in ways that did not allow direct comparison or meta-analysis. It is uncertain whether HHD, compared to ICHD, may be associated with a decrease in cardiovascular death (RR 0.92, 95% CI 0.80 to 1.07; 2 NRSIs, 30,900 participants; very low certainty evidence) or all-cause death (RR 0.80, 95% CI 0.67 to 0.95; 9 NRSIs, 58,984 patients; very low certainty evidence). It is also uncertain whether HHD may be associated with a decrease in hospitalisation rate (MD -0.50 admissions per patient-year, 95% CI -0.98 to -0.02; 2 NRSIs, 834 participants; very low certainty evidence), compared with ICHD. Compared with ICHD, it is uncertain whether HHD may be associated with receipt of kidney transplantation (RR 1.28, 95% CI 1.01 to 1.63; 6 NRSIs, 10,910 participants; very low certainty evidence) and a shorter recovery time post-dialysis (MD -2.0 hours, 95% CI -2.73 to -1.28; 2 NRSIs, 348 participants; very low certainty evidence). It remains uncertain if HHD may be associated with decreased systolic blood pressure (SBP) (MD -11.71 mm Hg, 95% CI -21.11 to -2.46; 4 NRSIs, 491 participants; very low certainty evidence) and decreased left ventricular mass index (LVMI) (MD -17.74 g/m2, 95% CI -29.60 to -5.89; 2 NRSIs, 130 participants; low certainty evidence). There was insufficient data to evaluate the relative association of HHD and ICHD with fatigue or vascular access outcomes. Patient-reported outcome measures were reported using 18 different measures across 11 studies (QoL: 6 measures; mental health: 3 measures; symptoms: 1 measure; impact and view of health: 6 measures; functional ability: 2 measures). Few studies reported the same measures, which limited the ability to perform meta-analysis or compare outcomes. It is uncertain whether HHD is more cost-effective than ICHD, both in the first (SMD -1.25, 95% CI -2.13 to -0.37; 4 NRSIs, 13,809 participants; very low certainty evidence) and second year of dialysis (SMD -1.47, 95% CI -2.72 to -0.21; 4 NRSIs, 13,809 participants; very low certainty evidence). AUTHORS' CONCLUSIONS Based on low to very low certainty evidence, HHD, compared with ICHD, has uncertain associations or may be associated with decreased cardiovascular and all-cause death, hospitalisation rate, slower post-dialysis recovery time, and decreased SBP and LVMI. HHD has uncertain cost-effectiveness compared with ICHD in the first and second years of treatment. The majority of studies included in this review were observational and subject to potential selection bias and confounding, especially as patients treated with HHD tended to be younger with fewer comorbidities. Variation from study to study in the choice of outcomes and the way in which they were reported limited the ability to perform meta-analyses. Future research should align outcome measures and metrics with other research in the field in order to allow comparison between studies, establish outcome effects with greater certainty, and avoid research waste.
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Affiliation(s)
- Melissa S Cheetham
- Renal Unit, Sunshine Coast University Hospital, Birtinya, Australia
- Faculty of Medicine, The University of Queensland, Herston, Australia
| | - Isabelle Ethier
- Department of Nephrology, Centre Hospitalier de l'Université de Montréal, Montréal, Canada
- Health Innovation and Evaluation Hub, Centre de Recherche du Centre Hospitalier de l'Université de Montréal, Montréal, Canada
| | - Rathika Krishnasamy
- Renal Unit, Sunshine Coast University Hospital, Birtinya, Australia
- Faculty of Medicine, The University of Queensland, Herston, Australia
- Australasian Kidney Trials Network, Translational Research Institute, Woolloongabba, Australia
| | - Yeoungjee Cho
- Faculty of Medicine, The University of Queensland, Herston, Australia
- Department of Nephrology, Princess Alexandra Hospital, Woolloongabba, Australia
- Australasian Kidney Trials Network, The University of Queensland, Brisbane, Australia
| | - Suetonia C Palmer
- Department of Medicine, University of Otago Christchurch, Christchurch, New Zealand
| | - David W Johnson
- Department of Nephrology, Princess Alexandra Hospital, Woolloongabba, Australia
| | - Jonathan C Craig
- Cochrane Kidney and Transplant, Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, Australia
- College of Medicine and Public Health, Flinders University, Adelaide, Australia
| | - Paul Stroumza
- Medical Office, Diaverum Marseille, Marseille, France
| | - Luc Frantzen
- Medical Office, Diaverum Marseille, Marseille, France
| | - Jorgen Hegbrant
- Division of Nephrology, Department of Clinical Sciences, Lund University, Lund, Sweden
| | - Giovanni Fm Strippoli
- Cochrane Kidney and Transplant, Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, Australia
- Department of Emergency and Organ Transplantation, University of Bari, Bari, Italy
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2
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Rizzolo K, Shen JI. Barriers to home dialysis and kidney transplantation for socially disadvantaged individuals. Curr Opin Nephrol Hypertens 2024; 33:26-33. [PMID: 38014998 DOI: 10.1097/mnh.0000000000000939] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2023]
Abstract
PURPOSE OF REVIEW People with kidney disease facing social disadvantage have multiple barriers to quality kidney care. The aim of this review is to summarize the patient, clinician, and system wide factors that impact access to quality kidney care and discuss potential solutions to improve outcomes for socially disadvantaged people with kidney disease. RECENT FINDINGS Patient level factors such as poverty, insurance, and employment affect access to care, and low health literacy and kidney disease awareness can affect engagement with care. Clinician level factors include lack of early nephrology referral, limited education of clinicians in home dialysis and transplantation, and poor patient-physician communication. System-level factors such as lack of predialysis care and adequate health insurance can affect timely access to care. Neighborhood level socioeconomic factors, and lack of inclusion of these factors into public policy payment models, can affect ability to access care. Moreover, the effects of structural racism and discrimination nay negatively affect the kidney care experience for racially and ethnically minoritized individuals. SUMMARY Patient, clinician, and system level factors affect access to and engagement in quality kidney care. Multilevel solutions are critical to achieving equitable care for all affected by kidney disease.
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Affiliation(s)
- Katherine Rizzolo
- Boston University Chobanian & Avedisian School of Medicine and Boston Medical Center, Section of Nephrology
| | - Jenny I Shen
- The Lundquist Institute at Harbor-UCLA Medical Center, Torrance, California, USA
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3
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Watnick S, Blake PG, Mehrotra R, Mendu M, Roberts G, Tummalapalli SL, Weiner DE, Butler CR. System-Level Strategies to Improve Home Dialysis: Policy Levers and Quality Initiatives. Clin J Am Soc Nephrol 2023; 18:1616-1625. [PMID: 37678234 PMCID: PMC10723911 DOI: 10.2215/cjn.0000000000000299] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Accepted: 08/18/2023] [Indexed: 09/09/2023]
Abstract
Advocacy and policy change are powerful levers to improve quality of care and better support patients on home dialysis. While the kidney community increasingly recognizes the value of home dialysis as an option for patients who prioritize independence and flexibility, only a minority of patients dialyze at home in the United States. Complex system-level factors have restricted further growth in home dialysis modalities, including limited infrastructure, insufficient staff for patient education and training, patient-specific barriers, and suboptimal physician expertise. In this article, we outline trends in home dialysis use, review our evolving understanding of what constitutes high-quality care for the home dialysis population (as well as how this can be measured), and discuss policy and advocacy efforts that continue to shape the care of US patients and compare them with experiences in other countries. We conclude by discussing future directions for quality and advocacy efforts.
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Affiliation(s)
- Suzanne Watnick
- Northwest Kidney Centers, Seattle, Washington
- Department of Medicine, University of Washington, Seattle, Washington
- VA Puget Sound Health Care System, U.S. Department of Veterans Affairs, Seattle, Washington
| | - Peter G. Blake
- Division of Nephrology, Western University, London, Ontario, Canada
- Ontario Renal Network, Toronto, Ontario, Canada
| | - Rajnish Mehrotra
- Department of Medicine, University of Washington, Seattle, Washington
| | - Mallika Mendu
- Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Glenda Roberts
- Department of Medicine, University of Washington, Seattle, Washington
| | - Sri Lekha Tummalapalli
- Department of Population Health Sciences, Weill Cornell Medicine, New York, New York
- The Rogosin Institute, New York, New York
| | - Daniel E. Weiner
- Department of Medicine, Tufts Medical Center, Boston, Massachusetts
| | - Catherine R. Butler
- Department of Medicine, University of Washington, Seattle, Washington
- VA Puget Sound Health Care System, U.S. Department of Veterans Affairs, Seattle, Washington
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4
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Knapp CD, Li S, Kou C, Gilbertson DT, Weinhandl ED, Wetmore JB, Hart A, Johansen KL. Increased Access, Persistent Disparities: Trends in Disparities in Peritoneal Dialysis (PD) Use, 2009-2019. Clin J Am Soc Nephrol 2023; 18:1483-1489. [PMID: 37499680 PMCID: PMC10637445 DOI: 10.2215/cjn.0000000000000222] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Accepted: 07/21/2023] [Indexed: 07/29/2023]
Abstract
Peritoneal dialysis (PD) use has increased in the United States since 2009, but how this has affected disparities in PD use is unclear. We used data from the United States Renal Data System to identify a cohort of incident dialysis patients from 2009 to 2019. We used logistic regression models to examine how odds of PD use changed by demographic characteristics. The incident PD population increased by 203% from 2009 to 2019, and the odds of PD use increased in every subgroup. PD use increased more among older people because the odds for those aged 75 years or older increased 15% more per 5-year period compared with individuals aged 18-44 years (odds ratio [OR] 1.68, 95% confidence interval [CI], 1.64 to 1.73 versus OR 1.46, 95% CI, 1.42 to 1.50). The odds of PD use increased 5% more per 5-year period among Hispanic people compared with White people (OR 1.58, 95% CI, 1.53 to 1.63 versus OR 1.51, 95% CI, 1.48 to 1.53). There was no difference in odds of PD initiation among people who were Black, Asian, or of another race. The odds of PD use increased 5% more for people living in urban areas compared with people living in nonurban areas (5-year OR 1.54, 95% CI, 1.52 to 1.56 versus 5-year OR 1.46, 95% CI, 1.42 to 1.50). The odds of PD use increased 7% more for people living in socioeconomically advantaged areas compared with people living in more deprived areas (5-year OR 1.60, 95% CI, 1.56 to 1.63 for neighborhoods with lowest Social Deprivation Index versus 5-year OR 1.50, 95% CI, 1.48 to 1.53 in the most deprived areas). Expansion of PD use led to a reduction in disparities for older people and for Hispanic people. Although PD use increased across all strata of socioeconomic deprivation, the gap in PD use between people living in the least deprived areas and those living in the most deprived areas widened.
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Affiliation(s)
- Christopher D. Knapp
- Chronic Disease Research Group, Hennepin Healthcare Research Institute, Minneapolis, Minnesota
| | - Shuling Li
- Chronic Disease Research Group, Hennepin Healthcare Research Institute, Minneapolis, Minnesota
| | - Chuanyu Kou
- Chronic Disease Research Group, Hennepin Healthcare Research Institute, Minneapolis, Minnesota
| | - David T. Gilbertson
- Chronic Disease Research Group, Hennepin Healthcare Research Institute, Minneapolis, Minnesota
- Department of Medicine, University of Minnesota, Minneapolis, Minnesota
| | - Eric D. Weinhandl
- Chronic Disease Research Group, Hennepin Healthcare Research Institute, Minneapolis, Minnesota
- University of Minnesota School of Pharmacy, Minneapolis, Minnesota
- Satellite Healthcare, San Jose, California
| | - James B. Wetmore
- Chronic Disease Research Group, Hennepin Healthcare Research Institute, Minneapolis, Minnesota
- Department of Medicine, University of Minnesota, Minneapolis, Minnesota
| | - Allyson Hart
- Chronic Disease Research Group, Hennepin Healthcare Research Institute, Minneapolis, Minnesota
- Department of Medicine, University of Minnesota, Minneapolis, Minnesota
| | - Kirsten L. Johansen
- Chronic Disease Research Group, Hennepin Healthcare Research Institute, Minneapolis, Minnesota
- Department of Medicine, University of Minnesota, Minneapolis, Minnesota
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Crews DC, Patzer RE, Cervantes L, Knight R, Purnell TS, Powe NR, Edwards DP, Norris KC. Designing Interventions Addressing Structural Racism to Reduce Kidney Health Disparities: A Report from a National Institute of Diabetes and Digestive and Kidney Diseases Workshop. J Am Soc Nephrol 2022; 33:2141-2152. [PMID: 36261301 PMCID: PMC9731627 DOI: 10.1681/asn.2022080890] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
Structural racism embodies the many ways in which society fosters racial discrimination through "mutually reinforcing inequitable systems" that limit access to resources and opportunities that can promote health and well being among marginalized communities. To achieve health equity, and kidney health equity more specifically, structural racism must be eliminated. In February 2022, the National Institute of Diabetes and Digestive and Kidney Diseases convened the "Designing Interventions that Address Structural Racism to Reduce Kidney Health Disparities" workshop, which was aimed at describing the mechanisms through which structural racism contributes to health and health care disparities for people along the continuum of kidney disease and identifying actionable opportunities for interventional research focused on dismantling or addressing the effects of structural racism. Participants identified six domains as key targets for interventions and future research: (1) apply an antiracism lens, (2) promote structural interventions, (3) target multiple levels, (4) promote effective community and stakeholder engagement, (5) improve data collection, and (6) advance health equity through new health care models. There is an urgent need for research to develop, implement, and evaluate interventions that address the unjust systems, policies, and laws that generate and perpetuate inequities in kidney health.
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Affiliation(s)
- Deidra C. Crews
- Division of Nephrology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Rachel E. Patzer
- Department of Epidemiology, Rollins School of Public Health and School of Medicine, Emory University, Atlanta, Georgia
- Department of Surgery, School of Medicine, Emory University, Atlanta, Georgia
| | - Lilia Cervantes
- Division of Hospital Medicine and General Internal Medicine, University of Colorado School of Medicine, Denver, Colorado
| | - Richard Knight
- American Association of Kidney Patients, Tampa, Florida
- College of Business, Bowie State University, Bowie, Maryland
| | - Tanjala S. Purnell
- Departments of Epidemiology and Surgery, Johns Hopkins University, Baltimore, Maryland
| | - Neil R. Powe
- Department of Medicine, University of California San Francisco School of Medicine, San Francisco, California
| | | | - Keith C. Norris
- Department of Medicine, University of California Los Angeles, Los Angeles, California
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6
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Baerman EA, Kaplan J, Shen JI, Winkelmayer WC, Erickson KF. Cost Barriers to More Widespread Use of Peritoneal Dialysis in the United States. J Am Soc Nephrol 2022; 33:1063-1072. [PMID: 35314456 PMCID: PMC9161798 DOI: 10.1681/asn.2021060854] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
The United States Department of Health and Human Services launched the Advancing American Kidney Health Initiative in 2019, which included a goal of transforming dialysis care from an in-center to a largely home-based dialysis program. A substantial motivator for this transition is the potential to reduce costs of ESKD care with peritoneal dialysis. Studies demonstrating that peritoneal dialysis is less costly than in-center hemodialysis have often focused on the perspective of the payer, whereas less consideration has been given to the costs of those who are more directly involved in treatment decision making, including patients, caregivers, physicians, and dialysis facilities. We review comparisons of peritoneal dialysis and in-center hemodialysis costs, focusing on costs incurred by the people and organizations making decisions about dialysis modality, to highlight the financial barriers toward increased adoption of peritoneal dialysis. We specifically address misaligned economic incentives, underappreciated costs for key stakeholders involved in peritoneal dialysis delivery, differences in provider costs, and transition costs. We conclude by offering policy suggestions that include improving data collection to better understand costs in peritoneal dialysis, and sharing potential savings among all stakeholders, to incentivize a transition to peritoneal dialysis.
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Affiliation(s)
- Elliot A Baerman
- Section of Nephrology, Baylor College of Medicine, Houston, Texas
| | - Jennifer Kaplan
- Section of Nephrology, Baylor College of Medicine, Houston, Texas
| | - Jenny I Shen
- Division of Nephrology, The Lundquist Institute at Harbor UCLA Medical Center, West Carson, California
| | | | - Kevin F Erickson
- Section of Nephrology, Baylor College of Medicine, Houston, Texas .,Rice University, Baker Institute, Houston, Texas
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7
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Kshirsagar AV, Weiner DE, Mendu ML, Liu F, Lew SQ, O’Neil TJ, Bieber SD, White DL, Zimmerman J, Mohan S. Keys to Driving Implementation of the New Kidney Care Models. Clin J Am Soc Nephrol 2022; 17:1082-1091. [PMID: 35289764 PMCID: PMC9269631 DOI: 10.2215/cjn.10880821] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Contemporary nephrology practice is heavily weighted toward in-center hemodialysis, reflective of decisions on infrastructure and personnel in response to decades of policy. The Advancing American Kidney Health initiative seeks to transform care for patients and providers. Under the initiative’s framework, the Center for Medicare and Medicaid Innovation has launched two new care models that align patient choice with provider incentives. The mandatory ESRD Treatment Choices model requires participation by all nephrology practices in designated Hospital Referral Regions, randomly selecting 30% of all Hospital Referral Regions across the United States for participation, with the remaining Hospital Referral Regions serving as controls. The voluntary Kidney Care Choices model offers alternative payment programs open to nephrology practices throughout the country. To help organize implementation of the models, we developed Driver Diagrams that serve as blueprints to identify structures, processes, and norms, and generate intervention concepts. We focused on two goals that are directly applicable to nephrology practices and central to the incentive structure of the ESRD Treatment Choices and Kidney Care Choices: (1) increasing utilization of home dialysis, and (2) increasing the number of kidney transplants. Several recurring themes became apparent with implementation. Multiple stakeholders from assorted backgrounds are needed. Communication with primary care providers will facilitate timely referrals, education, and comanagement. Nephrology providers (nephrologists, nursing, dialysis organizations, others) must lead implementation. Patient engagement at nearly every step will help achieve the aims of the models. Advocacy with federal and state regulatory agencies will be crucial to expanding home dialysis and transplantation access. Although the models hold promise to improve choices and outcomes for many patients, we must be vigilant that they not do reinforce existing disparities in health care or widen known racial, socioeconomic, or geographic gaps. The Advancing American Kidney Health initiative has the potential to usher in a new era of value-based care for nephrology.
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Affiliation(s)
- Abhijit V. Kshirsagar
- University of North Carolina Kidney Center and Division of Nephrology & Hypertension, University of North Carolina School of Medicine, Chapel Hill, North Carolina
- Quality Committee, American Society of Nephrology, Washington, DC
| | - Daniel E. Weiner
- Quality Committee, American Society of Nephrology, Washington, DC
- Division of Nephrology, Tufts Medical Center, Boston, Massachusetts
| | - Mallika L. Mendu
- Quality Committee, American Society of Nephrology, Washington, DC
- Renal Division, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Frank Liu
- Quality Committee, American Society of Nephrology, Washington, DC
- Division of Nephrology and Hypertension, Weill Cornell Medicine, Rogosin Institute, New York, New York
| | - Susie Q. Lew
- Quality Committee, American Society of Nephrology, Washington, DC
- Division of Renal Diseases and Hypertension, George Washington University, Washington, DC
| | - Terrence J. O’Neil
- Quality Committee, American Society of Nephrology, Washington, DC
- James Quillen Veterans Administration Medical Center, Johnson City, Tennessee
| | - Scott D. Bieber
- Quality Committee, American Society of Nephrology, Washington, DC
- Kootenai Health, Coeur d’Alene, Idaho
| | - David L. White
- Quality Committee, American Society of Nephrology, Washington, DC
- Policy and Government Affairs, American Society of Nephrology, Washington, DC
| | - Jonathan Zimmerman
- Center for Health Innovation, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Sumit Mohan
- Quality Committee, American Society of Nephrology, Washington, DC
- Division of Nephrology, Department of Medicine and Department of Epidemiology, Columbia University, New York, New York
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Wilk AS, Cummings JR, Plantinga LC, Franch HA, Lea JP, Patzer RE. Racial and Ethnic Disparities in Kidney Replacement Therapies Among Adults With Kidney Failure: An Observational Study of Variation by Patient Age. AMERICAN JOURNAL OF KIDNEY DISEASES 2022; 80:9-19. [DOI: 10.1053/j.ajkd.2021.12.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Accepted: 12/07/2021] [Indexed: 12/13/2022]
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9
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Lavoie-Cardinal M, Nadeau-Fredette AC. Physical Infrastructure and Integrated Governance Structure for Home Hemodialysis. Adv Chronic Kidney Dis 2021; 28:149-156. [PMID: 34717861 DOI: 10.1053/j.ackd.2021.02.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2020] [Revised: 02/11/2021] [Accepted: 02/25/2021] [Indexed: 01/17/2023]
Abstract
In view of the growing enthusiasm for home dialysis use, new dialysis centers may build or expend their home hemodialysis program in the next few years. This review will discuss the main challenges faced by small and large home hemodialysis programs in terms of physical spaces, human resource, training considerations, and overall governance. We will elaborate on the inclusion of home hemodialysis in the kidney replacement therapy care continuum, with a specific interest for collaboration and transition between peritoneal dialysis and home hemodialysis programs.
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10
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Abstract
End-stage kidney disease (ESKD) is a common and morbid disease that affects patients' quality and length of life, representing a large portion of health care expenditure in the United States. These patients commonly have associated diabetes and cardiovascular disease, with high rates of cardiovascular-related death. Management of ESKD requires renal replacement therapy via dialysis or transplantation. While transplantation provides the greatest improvement in survival and quality of life, the vast majority of patients are treated initially with hemodialysis. However, outcomes differ significantly among patient populations. Barriers in access to care have particularly affected at-risk populations, such as Black and Hispanic patients. These patients receive less pre-ESKD nephrology care, are less likely to initiate dialysis with a fistula, and wait longer for transplants-even in pediatric populations. Priorities for ESKD care moving into the future include increasing access to nephrology care in underprivileged populations, providing patient-centered care based on each patient's "life plan," and focusing on team-based approaches to ESKD care. This review explores ESKD from the perspective of epidemiology, costs, vascular access, patient-reported outcomes, racial disparities, and the impact of the COVID-19 crisis.
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Affiliation(s)
- Ryan Gupta
- Division of Vascular Surgery and Endovascular Therapy, University of Colorado, Anschutz School of Medicine, Aurora, CO
| | - Karen Woo
- Division of Vascular Surgery, University of California Los Angeles, David Geffen School of Medicine, 200 UCLA Medical Plaza, Suite 526, Los Angeles, CA 90095.
| | - Jeniann A Yi
- Division of Vascular Surgery and Endovascular Therapy, University of Colorado, Anschutz School of Medicine, Aurora, CO
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11
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Ethier I, Cho Y, Hawley C, Pascoe EM, Roberts MA, Semple D, Nadeau-Fredette AC, Sypek MP, Viecelli A, Campbell S, van Eps C, Isbel NM, Johnson DW. Effect of patient- and center-level characteristics on uptake of home dialysis in Australia and New Zealand: a multicenter registry analysis. Nephrol Dial Transplant 2020; 35:1938-1949. [PMID: 32031636 DOI: 10.1093/ndt/gfaa002] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2019] [Accepted: 12/09/2019] [Indexed: 01/14/2023] Open
Abstract
BACKGROUND Home-based dialysis therapies, home hemodialysis (HHD) and peritoneal dialysis (PD) are underutilized in many countries and significant variation in the uptake of home dialysis exists across dialysis centers. This study aimed to evaluate the patient- and center-level characteristics associated with uptake of home dialysis. METHODS The Australia and New Zealand Dialysis and Transplant (ANZDATA) Registry was used to include incident dialysis patients in Australia and New Zealand from 1997 to 2017. Uptake of home dialysis was defined as any HHD or PD treatment reported to ANZDATA within 6 months of dialysis initiation. Characteristics associated with home dialysis uptake were evaluated using mixed effects logistic regression models with patient- and center-level covariates, era as a fixed effect and dialysis center as a random effect. RESULTS Overall, 54 773 patients were included. Uptake of home-based dialysis was reported in 24 399 (45%) patients but varied between 0 and 87% across the 76 centers. Patient-level factors associated with lower uptake included male sex, ethnicity (particularly indigenous peoples), older age, presence of comorbidities, late referral to a nephrology service, remote residence and obesity. Center-level predictors of lower uptake included small center size, smaller proportion of patients with permanent access at dialysis initiation and lower weekly facility hemodialysis hours. The variation in odds of home dialysis uptake across centers increased by 3% after adjusting for the era and patient-level characteristics but decreased by 24% after adjusting for center-level characteristics. CONCLUSION Center-specific factors are associated with the variation in uptake of home dialysis across centers in Australia and New Zealand.
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Affiliation(s)
- Isabelle Ethier
- Division of Nephrology, Centre Hospitalier de l'Université de Montréal, Montréal, Canada.,Department of Nephrology, Princess Alexandra Hospital, Brisbane, QLD, Australia
| | - Yeoungjee Cho
- Department of Nephrology, Princess Alexandra Hospital, Brisbane, QLD, Australia.,Australia and New Zealand Dialysis and Transplant Registry, Adelaide, SA, Australia.,Australasian Kidney Trials Network, University of Queensland, Brisbane, QLD, Australia
| | - Carmel Hawley
- Department of Nephrology, Princess Alexandra Hospital, Brisbane, QLD, Australia.,Australia and New Zealand Dialysis and Transplant Registry, Adelaide, SA, Australia.,Australasian Kidney Trials Network, University of Queensland, Brisbane, QLD, Australia.,Translational Research Institute, Brisbane, QLD, Australia
| | - Elaine M Pascoe
- Australasian Kidney Trials Network, University of Queensland, Brisbane, QLD, Australia.,School of Medicine, University of Queensland, Brisbane, QLD, Australia
| | - Matthew A Roberts
- Eastern Health Clinical School, Monash University, Melbourne, VIC, Australia
| | - David Semple
- Department of Renal Medicine, Auckland District Health Board, Auckland, New Zealand.,School of Medicine, University of Auckland, Auckland, New Zealand
| | - Annie-Claire Nadeau-Fredette
- Division of Nephrology, Hôpital Maisonneuve-Rosemont and Research Center, Université de Montréal, Montreal, Canada
| | - Matthew P Sypek
- Australia and New Zealand Dialysis and Transplant Registry, Adelaide, SA, Australia
| | - Andrea Viecelli
- Department of Nephrology, Princess Alexandra Hospital, Brisbane, QLD, Australia.,Australasian Kidney Trials Network, University of Queensland, Brisbane, QLD, Australia
| | - Scott Campbell
- Department of Nephrology, Princess Alexandra Hospital, Brisbane, QLD, Australia
| | - Carolyn van Eps
- Department of Nephrology, Princess Alexandra Hospital, Brisbane, QLD, Australia
| | - Nicole M Isbel
- Department of Nephrology, Princess Alexandra Hospital, Brisbane, QLD, Australia.,Australasian Kidney Trials Network, University of Queensland, Brisbane, QLD, Australia
| | - David W Johnson
- Department of Nephrology, Princess Alexandra Hospital, Brisbane, QLD, Australia.,Australia and New Zealand Dialysis and Transplant Registry, Adelaide, SA, Australia.,Australasian Kidney Trials Network, University of Queensland, Brisbane, QLD, Australia.,Translational Research Institute, Brisbane, QLD, Australia
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Abstract
The development of dialysis by early pioneers such as Willem Kolff and Belding Scribner set in motion several dramatic changes in the epidemiology, economics and ethical frameworks for the treatment of kidney failure. However, despite a rapid expansion in the provision of dialysis — particularly haemodialysis and most notably in high-income countries (HICs) — the rate of true patient-centred innovation has slowed. Current trends are particularly concerning from a global perspective: current costs are not sustainable, even for HICs, and globally, most people who develop kidney failure forego treatment, resulting in millions of deaths every year. Thus, there is an urgent need to develop new approaches and dialysis modalities that are cost-effective, accessible and offer improved patient outcomes. Nephrology researchers are increasingly engaging with patients to determine their priorities for meaningful outcomes that should be used to measure progress. The overarching message from this engagement is that while patients value longevity, reducing symptom burden and achieving maximal functional and social rehabilitation are prioritized more highly. In response, patients, payors, regulators and health-care systems are increasingly demanding improved value, which can only come about through true patient-centred innovation that supports high-quality, high-value care. Substantial efforts are now underway to support requisite transformative changes. These efforts need to be catalysed, promoted and fostered through international collaboration and harmonization. Dialysis is a life-saving therapy; however, costs of dialysis are high, access is inequitable and outcomes are inadequate. This Review describes the current landscape of dialysis therapy from an epidemiological, economic, ethical and patient-centred framework, and describes initiatives that are aimed at stimulating innovations in the field to one that supports high-quality, high-value care. The global dialysis population is growing rapidly, especially in low-income and middle-income countries; however, worldwide, a substantial number of people lack access to kidney replacement therapy, and millions of people die of kidney failure each year, often without supportive care. The costs of dialysis care are high and will likely continue to rise as a result of increased life expectancy and improved therapies for causes of kidney failure such as diabetes mellitus and cardiovascular disease. Patients on dialysis continue to bear a high burden of disease, shortened life expectancy and report a high symptom burden and a low health-related quality of life. Patient-focused research has identified fatigue, insomnia, cramps, depression, anxiety and frustration as key symptoms contributing to unsatisfactory outcomes for patients on dialysis. Initiatives to transform dialysis outcomes for patients require both top-down efforts (that is, efforts that promote incentives based on systems level policy, regulations, macroeconomic and organizational changes) and bottom-up efforts (that is, patient-led and patient-centred advocacy efforts as well as efforts led by individual teams of innovators). Patients, payors, regulators and health-care systems increasingly demand improved value in dialysis care, which can only come about through true patient-centred innovation that supports high-quality, high-value care.
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13
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Weiner DE, Meyer KB. Home Dialysis in the United States: To Increase Utilization, Address Disparities. Kidney Med 2020; 2:95-97. [PMID: 32734953 PMCID: PMC7380419 DOI: 10.1016/j.xkme.2020.02.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
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14
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Crews DC, Novick TK. Achieving equity in dialysis care and outcomes: The role of policies. Semin Dial 2020; 33:43-51. [PMID: 31899828 DOI: 10.1111/sdi.12847] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Socially disadvantaged persons, including racial and ethnic minorities, individuals with low incomes, homeless persons, and non-US citizens bear a disproportionate burden of end-stage kidney disease (ESKD). Inequities in nephrology referral, vascular access, use of home dialysis modalities, kidney transplantation, and mortality are prominent. Public policies, including the Patient Protection and Affordable Care Act, end-stage renal disease Quality Incentive Program, and the Prospective Payment System, were enacted to improve healthcare access and dialysis care. Here, we highlight inequities in dialysis care and outcomes, how current ESKD and other public policies may influence or exacerbate these inequities, and gaps in the literature needed to inform future policies toward achieving equity in ESKD. We give special attention to the 2019 Advancing American Kidney Health Executive Order, which has high potential to radically transform dialysis care.
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Affiliation(s)
- Deidra C Crews
- Division of Nephrology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA.,Johns Hopkins Center for Health Equity, Johns Hopkins Medical Institutions, Baltimore, MD, USA.,Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Tessa K Novick
- Division of Nephrology, Department of Internal Medicine, Dell Medical School, University of Texas at Austin, Austin, TX, USA
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15
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Sloan CE, Coffman CJ, Sanders LL, Maciejewski ML, Lee SYD, Hirth RA, Wang V. Trends in Peritoneal Dialysis Use in the United States after Medicare Payment Reform. Clin J Am Soc Nephrol 2019; 14:1763-1772. [PMID: 31753816 PMCID: PMC6895485 DOI: 10.2215/cjn.05910519] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2019] [Accepted: 09/10/2019] [Indexed: 01/04/2023]
Abstract
BACKGROUND AND OBJECTIVES Peritoneal dialysis (PD) for ESKD is associated with similar mortality, higher quality of life, and lower costs compared with hemodialysis (HD), but has historically been underused. We assessed the effect of the 2011 Medicare prospective payment system (PPS) for dialysis on PD initiation, modality switches, and stable PD use. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS Using US Renal Data System and Medicare data, we identified all United States patients with ESKD initiating dialysis before (2006-2010) and after (2011-2013) PPS implementation, and observed their modality for up to 2 years after dialysis initiation. Using logistic regression models, we examined the associations between PPS and early PD experience (any PD 1-90 days after initiation), late PD use (any PD 91-730 days after initiation), and modality switches (PD-to-HD or HD-to-PD 91-730 days after initiation). We adjusted for patient, dialysis facility, and regional characteristics. RESULTS Overall, 619,126 patients with incident ESKD received dialysis at Medicare-certified facilities, 2006-2013. Observed early PD experience increased from 9.4% before PPS to 12.6% after PPS. Observed late PD use increased from 12.1% to 16.1%. In adjusted analyses, PPS was associated with increased early PD experience (odds ratio [OR], 1.51; 95% confidence interval [95% CI], 1.47 to 1.55; P<0.001) and late PD use (OR, 1.47; 95% CI, 1.45 to 1.50; P<0.001). In subgroup analyses, late PD use increased in part due to an increase in HD-to-PD switches among those without early PD experience (OR, 1.59; 95% CI, 1.52 to 1.66; P<0.001) and a decrease in PD-to-HD switches among those with early PD experience (OR, 0.92; 95% CI, 0.87 to 0.98; P=0.004). CONCLUSIONS More patients started, stayed on, and switched to PD after dialysis payment reform. This occurred without a substantial increase in transfers to HD.
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Affiliation(s)
- Caroline E Sloan
- Departments of Medicine.,Health Services Research and Development Center of Innovation, Durham Veterans Affairs Health Care System, Durham, North Carolina; and
| | - Cynthia J Coffman
- Health Services Research and Development Center of Innovation, Durham Veterans Affairs Health Care System, Durham, North Carolina; and.,Biostatistics and Bioinformatics, and
| | | | - Matthew L Maciejewski
- Departments of Medicine.,Health Services Research and Development Center of Innovation, Durham Veterans Affairs Health Care System, Durham, North Carolina; and.,Population Health Sciences, Duke University School of Medicine, Durham, North Carolina
| | - Shoou-Yih D Lee
- Department of Health Management and Policy, University of Michigan School of Public Health, Ann Arbor, Michigan
| | - Richard A Hirth
- Department of Health Management and Policy, University of Michigan School of Public Health, Ann Arbor, Michigan
| | - Virginia Wang
- Departments of Medicine, .,Health Services Research and Development Center of Innovation, Durham Veterans Affairs Health Care System, Durham, North Carolina; and.,Population Health Sciences, Duke University School of Medicine, Durham, North Carolina
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16
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Affiliation(s)
- Kerri L Cavanaugh
- Division of Nephrology and Hypertension, Department of Medicine and .,Center for Effective Health Communication, Vanderbilt University Medical Center, Nashville, Tennessee
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