Making the case for in-center, self-care hemodialysis

Introduction

Conventional in-center hemodialysis is the modality used by approximately 90% of patients receiving dialysis in the U.S.¹ For patients and providers, there are clear disadvantages to conventional in-center HD therapy. The current alternative is to use a home-based self-care modality, either home hemodialysis or peritoneal dialysis. These home-based self-care modalities have been shown to have a number of advantages, but are not widely adopted for a variety of reasons.² Another option would be to offer in-center self-care HD, which could provide many of the advantages of home-based dialysis, and remove many of the barriers that prevent patients from choosing to do dialysis at home.

The drawbacks of traditional in-center dialysis

For patients, conventional in-center HD binds them to a rigid schedule and makes them dependent on others for their care, which puts them on a path to “learned helplessness.”³ For dialysis care providers, conventional in-center HD is human resource intensive and, as reimbursement has not kept up with costs, providers have found it increasingly challenging to deliver affordable, high quality care.

Home hemodialysis has been associated with a number of clinical advantages, including enhanced survival, fewer hospitalizations, and improved health-related quality of life. Patients report appreciating the independence and engagement offered by HHD. However, there are also burdens that patients and their families accept in doing HHD, such as the desire (or need) to have a partner present during therapy, provision of physical space in the home for machines, and ongoing costs of power and water.⁴ Patients on HHD report ongoing anxiety about vascular access cannulation, confusion regarding optimal management of intradialytic clinical events, including hypotension, and legitimate fears of bleeding following completion of the session and removal of needles and other catastrophic events. These burdens and fears contribute to the high dropout rate for HHD. They also represent barriers to selecting HHD, either as an initial modality, or after established therapy on conventional in-center HD.

In addition, current devices used for HHD are seen as complex and difficult to learn and master, an additional barrier to patients feeling confident that they can successfully manage their own dialysis.²

Peritoneal dialysis also offers patients advantages relative to conventional in-center HD, including independence and engagement with their therapy, no need for vascular access, better preservation of residual renal function and possibly, enhanced survival for some patient groups. Patients receiving PD report greater satisfaction with the care they receive from their health care providers compared to patients on conventional in-center HD.⁵ Barriers to patients doing PD include medical suitability (e.g., extensive prior abdominal surgery, obesity, and poorly controlled type 2 diabetes are relative contraindications), fear of peritonitis, space requirements in the home for supplies, and often, difficulty in mastering the therapy and/or the need for a dialysis partner at home.

Peritoneal dialysis has consistently been reported to cost approximately 30% less than conventional in-center HD; HHD also costs less than conventional in-center HD after the training period. Medicare has created incentives to increase the utilization of home therapies. However, the percent of patients going home on dialysis remains low and dropout from home therapy is high. Dropout from HHD or PD, especially early dropout, is very costly to providers and to Medicare given the high up-front costs of training. Currently, dropout rates for both home modalities are in excess of 25% in the first year.

Offering dialysis patients the opportunity for self-care

In-center self-care HD is an alternative, “hybrid” modality that can offer a larger number of patients many of the advantages of home dialysis but with fewer barriers and burdens of home-based therapy. With in-center self-care HD, patients are trained to perform their own HD, as if they were selecting HHD, but they receive HD in a clinic setting with minimal staff support. Staff may assist with access cannulation, a key barrier to HHD, but typically, the patient takes full responsibility for machine set up and take down, and for the majority of the monitoring and management during the course of the session. “Insourcing” hemodialysis care to the patient him- or herself allows the facility to reduce the number of on-site staff and reduces associated costs. Advantages of in-center self-care HD include many of the advantages of HHD, plus a supportive environment that does not require a partner or home modifications.

Is there interest?

There is evidence that patients may be more capable of, and willing to perform, self-care HD than we might think.⁶ A survey of 250 patients receiving dialysis and 51 board-certified nephrologists assessed key barriers to, and attitudes surrounding, in-center self-care HD and HHD. Overall, 69% of patients reported that they were very likely or likely to consider a self-care HD modality if they received adequate training with a HD system designed for self-care use. Nephrologists indicated that they believed that patients were capable of performing many of the tasks required to do self-care HD, including weighing themselves (98%), clearing alarms (53%), taking vital signs (46%), and access cannulation (43%). Patients most frequently identified being in control of their own care as the most appealing feature of self-care dialysis.^{2, 6} Other appealing factors for patients are flexibility in the treatment schedule, health benefits (including less depression), being able to immediately solve their own problems, and not having to wait to start or come off dialysis.

The most frequent reported barriers for home dialysis were fear of access cannulation, the time required for training, lack of space for supplies and equipment at home, the need for a partner, and not wanting to bring medical care into the home.² In-center self-care HD with an intuitive, easy-to-learn system can overcome these barriers. Nephrologists thought that patients would be hesitant to do self-care HD because commercially available machines are too complicated, the process is too intimidating, too much work, and takes too long to learn.⁶ They also had the perception that patients have physical limitations, worry about safety, and would not want to self-cannulate. These concerns do not fully align with patients’ concerns. Many patients indicated that they had not pursued HHD because it was never offered. Perhaps nephrologists believed that their patients were not capable of self-care (despite what many report), or that they were concerned that caring for a patient on HHD would be too time intensive. Either way, employing an in-center self-care HD option could broaden opportunities for patient engagement and empowerment.

Current studies

In 2011, Jones et al. reported in this publication on their preliminary experience with in-center self-care.⁸ In the current issue, the authors report favorable clinical outcomes with longer-term experience.⁹ In the latter study, clinical outcomes of 40 patients on in-center self-care HD were compared to propensity score-matched patients (1:2) on conventional in-center HD. Patients were well matched at baseline based on age, race, comorbidities, Kt/V_urea and laboratory data. The minimum follow-up period was 12 months, with a median follow-up of 14 months. Data collected included mortality rates, hospitalizations, unexcused missed treatments, technique survival, and an array of laboratory tests. At follow up, patients receiving in-center self-care HD had a significantly lower rates of mortality (0.02 vs. 0.07 per patient year) and hospitalization (0.82 vs. 1.7 per patient year). Unexcused missed sessions were also less frequent in patients receiving in-center, self-care HD compared with matched patients on conventional in-center HD (1.1% vs. 3.8%).

Another interesting observation described by Jones et al. was that after one year, patients receiving in-center self-care HD had longer session lengths (nearly all dialyzing for four or more hours), whereas more than one in five (23%) matched patients on conventional in-center HD shortened their sessions. The authors attribute the differences in missed and shortened sessions to “motivated compliance” of patients on in-center self-care HD, cultivated by staff expectations and patient empowerment that is part of self-care training.

We must be cautious when making causal inference from observational data, even when data are analyzed using sophisticated techniques akin to those employed by Jones et al. Nevertheless, it is tempting to attribute the benefits observed by Jones et al. to the motivation of patients who choose in-center self-care HD. In other chronic diseases, patient engagement and empowerment have been linked to enhanced survival and fewer untoward complications.

If in-center self-care HD provides clinical benefits, that alone would be a compelling reason to offer the therapy. In addition, it is likely that there would be economic advantages of in-center self-care HD for the dialysis provider and the health care system at large.

Cost savings with self-care

For the health care system, reduced hospitalization rates will be the major driver of cost savings. If in-center, self-care HD patients transition to HHD, additional savings could be anticipated. From the provider perspective, a key source of saving over time is the reduced need for technician staff, as patients take responsibility for performing and monitoring dialysis themselves, with less intensive oversight. Although comprehensive training is required, patients going to in-center, self-care HD are immediately entitled to their Medicare benefit on day one of dialysis and training fees are also provided for self-care, as for patients receiving home dialysis. A hemodialysis system designed for self-care will be expected to require significantly less time for training compared to a conventional hemodialysis machine. Once the training is complete, the ongoing requirement for staff support will be less. One would also anticipate that dropout rates for in-center self-care HD will be substantially lower than for HHD because the burdens and fears of HHD are largely eliminated by in-center self-care HD. Fewer skipped sessions owing to lower hospitalization rates could also enhance provider reimbursement.

There may also be financial considerations for patients that make in-center self-care HD attractive. A recent study from New Zealand reported that an additional barrier to home dialysis is the expense incurred by patients for power and water, which is not reimbursed.⁴ In addition, poorer patients who live in homes too small to accommodate home dialysis supplies were unable to consider home dialysis. These concerns are not a barrier for in-center self-care HD and may allow patients from a broader socioeconomic background to choose the therapy and to benefit from the improved outcomes that it can offer.

Conclusion

In-center self-care HD delivered with a well-designed system would be expected to minimize training times, make in-center self-care HD more appealing to a broader number of patients, reduce dropout, optimize reimbursement, and require fewer staff to support patients during therapy. These factors drive an economic advantage for the health care system, providers, and patients. -by Sarah S. Prichard, MD, FRCP(C); Glenn M. Chertow, MD, MPH

References

United States Renal Data System, 2014 Annual Data Report. National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD, 2014.

Young BA, Chan CT, Blagg C, Lockridge R, Golper T, Finkelstein FO, Schaffer R, Mehrotra R. ASN Dialysis Advisory Group. How to overcome barriers and establish a successful home HD program. Clin J Am Soc Nephrol 2012; 7:2023–32.

Seligman ME. Depression and learned helplessness. In: The Psychology of Depression; Contemporary Theory and Research, edited by Friedman R J, Katz MN, Washington, DC, Halsted Press, 1974, pp 83–111

Walker RC, Howard K, Tong A, Palmer SC, Marshall MR, Morton RL. The economic considerations of patients and caregivers in choice of dialysis modality. Hemodial Int 2016 [epub ahead of print].

Rubin HR, Fink NE, Plantinga LC, Sadler JH, Kliger AS, Powe NR. Patient ratings of dialysis care with peritoneal dialysis vs hemodialysis. JAMA 2004; 291:697-703.

Yau M, Carver M, Alvarez L, Block GA, Chertow GM. Understanding barriers to home-based and self-care in-center hemodialysis. Hemodial Int 2016; 20:235-41.

Wilcox SB, Carver M, Yau M, Sneeringer P, Prichard S, Alvarez L, Chertow GM. Results of human factors testing of a novel hemodialysis system designed for ease of patient use. Hemodial Int 2016 [epub ahead of print].

Jones ER, James L. In-center self-care hemodialysis: An unappreciated modality in renal care. Nephrol News Issues 2011; 9:31-3.

Jones ER, James L, Rosen S, Mooney A, Lacson Jr. E. Outcomes among patients receiving in-center, self-care hemodialysis. Nephrol News Issues 2016 [in press, October issue].