Stars are aligning on home dialysis

Today, the combined percentage of patients dialyzing at home––thrice weekly, short daily, or nocturnal hemodialysis, and the various forms of peritoneal dialysis––might be pushing past 10%. But what’s important is not the numbers today, but what they could be tomorrow. Some recent observations:

Incentive payments under the ESRD payment bundle for home dialysis have helped to push use of PD up two percentage points over the last three years.
A movement started by Los Angeles nephrologist Arshia Ghaffari to offer patients “urgent” PD therapy instead of the traditional route from the emergency room of a hemodialysis catheter and in-center dialysis has caught fire. Over 175 cases to date have some asking about technique survival in these patients.
By this time next year, we may see two to three new home hemodialysis machines getting ready for the market. Products from Baxter, Home Dialysis Plus, and Fresenius are getting closer to reality; some are in limited human trials now.
The North American chapter of the International Society for Peritoneal Dialysis, led by its president Peter Blake, is developing a new research arm that will tackle some of the sore spots for the therapy, including infections, technique survival, and a closer look at the value of new PD solutions.
On October 7, NxStage Medical announced the opening of its first dialysis center catering to both home and in-center patients. Others are expected to follow the St. Louis Mo.-based Kidney Care facility. The plan is to offer flexible hours for various home therapies and for those wanting in-center care (see the Business News section on page 12 for more details).
A recent article in the journal Seminars in Dialysis entitled “PD First: Peritoneal dialysis as the default transition to dialysis therapy,” and authored by Ghaffari and chief medical officers and program managers of both DaVita and Fresenius Medical Care, suggest for the first time that PD should replace in-center hemodialysis as the initial therapy. Wrote the authors:
“The predominance (of in-center hemodialysis) has little to do with clinical outcomes, patient choice, cost, or quality of life. It has been driven by ease of HD initiation, physician experience and training, inadequate pre-ESRD patient education, ample in-center HD capacity, and lack of adequate infrastructure for PD-related care.”

The lure of incentives

We still have a long way to go. The sudden uptick in interest in PD appears to be driven by financial incentives; medical schools didn’t just change their curriculum and start graduating armies of nephrologists who champion PD. If Medicare changes the financial incentives in the bundle tomorrow, would we still see this level of support for sending patients home? We have seen the renal community respond before to making choices based on improving the bottom line.

The believers

Earlier this month, I was asked to give presentations at two conferences focused on home therapies. In both cases, it was remarkable to see the passion that both patients and clinicians have for the outcomes that home dialysis can offer. It’s a “we are family” type atmosphere.

Find more articles about Home Dialysis

In our CMO Initiative series this month (see page 42), the chief medical officers from dialysis companies around the country discuss their views on home dialysis. Commenting on the group’s statement, CMO Group co-organizer and Dialysis Clinic Inc. Board vice-chair Doug Johnson, MD, made it clear what his intentions would be:

“If I were a patient on dialysis, I would choose to dialyze at home. I would dialyze with peritoneal dialysis to maintain my residual renal function, and would transition to home hemodialysis if I could no longer receive adequate treatment with PD.”

If CMOs believe in it and are putting their money where there mouth is, home dialysis has a fighting chance. Your turn to make a choice. -by Mark Neumann

Find more articles from the November 2013 issue of NN&I