Improved training for in-home therapy might increase use, spark interest in nephrology

Improved residency training programs that include exposure to home dialysis, particularly home hemodialysis, might help to increase its usage and make the specialty more appealing for students considering a career in nephrology, wrote nephrologists Joel D. Glickman, MD, and Rebecca Kurnik Seshasal, MD, in a recently published article.

The two authors, from the Perelman School of Medicine at the University of Pennsylvania, said while recognition of improved outcomes has resulted in a notable rise in the use of home hemodialysis (HHD) during the last 10 years — from about 2,000 to 2,500 patients to more than 8,000 patients — a high dropout rate and, the authors believe, limited education in HHD fellowship training may explain why only 2% of patients on dialysis in the United States are on the therapy.

“There are many factors that may contribute to low utilization among which include physician unfamiliarity and lack of training in HHD,” Glickman and Kurnik Seshasal wrote. “A survey of recent graduates of nephrology fellowship programs noted that only 15.8% of respondents reported self-assessed competence in HHD and 61.7% reported little or no training. While there are no data measuring impact of education on utilization of HHD, it is reasonable to assume that without education, physician interest and success with HHD will be suboptimal. For the benefit of patient care, the nephrology community has an obligation to assure that all nephrologists have adequate training in HHD.”

Defining a good training program, the authors acknowledge, has not been determined, but said “an essential component for fellow education is at least one faculty member with expertise in HHD who is passionate about promoting the use of this modality.” A curriculum for training should include both lectures about HHD and outpatient clinical experience to the modality during a period of at least 6 to 12 months.

“Fellows benefit from the opportunity to transition at least three patients to a home modality to gain experience with modality education, access placement, initial prescriptions, and home dialysis training. They should spend time with HHD training nurses to learn more about modality education, observe nurse intake interviews with patients in order to learn the criteria for entrance into the home dialysis program as well as recognize how to identify potential barriers to successful home dialysis therapy,” Glickman and Kurnik Seshasal wrote.

Fellows should also be exposed to all aspects of HHD beyond clinic visits and be “encouraged to take first call during the day for HHD patients,” they wrote. “There are many opportunities to do research and quality improvement projects which might also propel some fellows into an academic career as a home dialysis nephrologist.” – by Mark E. Neumann

Reference:

Glickman JD, et al. Semin Dial. 2018;doi:10.1111/sdi.12673.

Disclosures: The authors had no relevant financial disclosures.