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Strategies to optimize patient retention in home hemodialysis
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The growing consensus in the kidney community is greater home dialysis use is essential to achieving clinical, patient quality-of-life and public policy objectives. Providers acknowledge the need to reframe how we think about delivering dialysis care to patients. As Adam Boehler, director of the Center for Medicare & Medicaid Innovation (CMMI), notes, treatment for patients with kidney failure should be “transplant wherever possible; if not, [treatment at] home wherever possible; and it should be a last resort that people go to a dialysis center.”
PD is an important part of the home dialysis equation, but it may not be appropriate or adequate for every patient. Home hemodialysis (HHD) is another solution to get more patients home, yet is often overlooked: only 2% of patients on dialysis in the United States use this modality today. Still, pockets of excellence exist. Programs treating nearly 10% of their patients with HHD have shown excellent results.
HHD programs that expand successfully follow a simple formula: increasing the number of patients who start HHD therapy (patient access) while minimizing the number of patients who discontinue therapy (patient retention and success).
Much emphasis, particularly when starting a program, is appropriately placed on the patient access element of the equation. Simply put, a patient has no chance of being successful with a home therapy if not given the opportunity to start. However, as programs mature, patient retention is essential to enabling HHD program growth and success.
Source: Michelle Carver
Find what works
In 2018, we pursued a multi-pronged effort to determine the influencers of HHD patient success. This effort consisted of analyzing Medicare claims data, the NxStage Inc. patient registry and de-identified data from the NxStage Nx2me Connected Health Platform, formal clinic site interviews, and interviews of patients that had discontinued therapy. In these efforts, we identified four key practices that correlate with HHD success in top performing programs.
1. Train consistently, and train well;
2. Get the prescription right for the individual patient;
3. Ensure participation of the interdisciplinary team, particularly the social worker and the patient care technician (PCT); and
4. Monitor and get actively involved when the predictors of patient discontinuation – hospitalization and missed treatments – present themselves.
Programs that follow these practices had noticeably higher patient success, indicated by a high percentage of patients completing training and low technique failure rates.
Study tools and results
Prior analyses of factors that contribute to HHD patient success have focused primarily on patient-related factors (demographics, socioeconomic status, comorbidity). In contrast, we sought to gain insight into specific clinic behaviors that others could adopt to improve patient success on HHD.
Fundamental to this effort were formal clinic interview visits. We identified the 50 HHD programs in the United States with the highest NxStage training rates from 2013 to 2017, and stratified programs by HHD training graduation and 12-month patient retention rates. We sampled and visited 10 of these clinics to gather data from a diverse group of dialysis providers, geographies and performance. Two trained individuals used a formal interview guide administered on-site to assess the clinics’ operational structure, program oversight, training curriculum, pre-training preparation and post-training support.
The second primary initiative involved retrospective data analysis, using Medicare claims data, HHD prescription data and de-identified treatment data from the Nx2Me Connected Health database to identify predictors of technique failure.
Finally, we performed 10 in-depth interviews of patients who had recently discontinued therapy to provide additional information for our study.
What we found was HHD programs with the most successful patient graduation and retention rates were differentiated by their approach in the following areas.
Train consistently, and train well. As mentioned earlier, a patient not given the chance to try HHD has a zero chance of success with HHD. Today, most patients who complete HHD training will not experience technique failure for well over 3 years. However, we can improve.
Whether from the anecdotes in Malcolm Gladwell’s book, Outliers: The Story of Success or from the generally accepted relationship in health care between quality of outcomes and number of procedures performed, we are constantly reminded of the experience curve effect – the more we do something, the better we get. It is no surprise, that the same effect holds true in HHD training.
Using our prescription registry database, we looked at patients who began NxStage HHD therapy between 2014 and 2017 and discontinued therapy for reasons related to patient or care partner burden. Patients were grouped according to how many HHD patients their center had graduated in the prior three months: zero, one, two or greater than two. Each patient was followed during the first year at home.
As shown in Figure 1, the lowest rates of HHD technique failure due to patient or partner burden were observed in programs with the highest number of training graduates. The risk for technique failure was more than 15% lower in programs training more than two patients per quarter vs. in those who seldom or sporadically train. As the care team develops more experience, the team may become more adept at proactively and reactively managing patient and partner burden. However, by no means does this imply that an indiscriminate increase in training will lead to improved patient success. We found that expectation setting and training adaptability are critical.
In our clinic visits and patient interviews, it was evident that setting clear expectations prior to training aided in patient acceptance of roles and responsibilities and reduced frustration once training began. In successful programs, care team personnel proactively met with the patients and/or partners to clearly outline the home dialysis process and environment considerations. In some instances, new patients were given the opportunity to speak to current HHD patients and ask questions about their experience with training and HHD transition.
Similarly, best practice programs demonstrated training flexibility, using a variety of tools and techniques to accommodate the learning preferences and pace of the patient and/or care partner. Training times were also tailored to meet patients’ needs, even if that meant offering evening and/or weekend time slots.
Get the prescription right for the individual patient. Treatment frequency, session duration and dialysate volume were prescribed based on a holistic assessment of the patient’s clinical needs and lifestyle. HHD prescriptions were adjusted using the NxStage Dosing Calculator as a patient’s clinical and lifestyle needs changed.
The high-success programs also had a strong commitment to offering solo treatment without a care partner during waking hours and nocturnal hemodialysis for well-suited patients. These therapy options were potential tools to reduce patient and care partner burden.
During our interviews, we expected to find a strong physician champion at the core of each thriving program. Surprisingly, we found this was not always the case. However, a successful program absolutely requires a physician who is knowledgeable, supportive, involved and an effective communicator.
Regarding training, the nephrologist is frequently the point person in patient selection as a consistent source of patients for training. He or she is a guide to patients and families through communication of the benefits of HHD, particularly delivered more frequently. The physician must be transparent in setting expectations for the patient and be responsive and attentive during training.
The nephrologist is primarily responsible for individualizing the prescription to meet the needs of the patient – when, how long and how often. Strong understanding of the therapy itself is essential, as well as that of the realities of patient and caregiver benefits and/or burdens tied to different approaches. Patients who leave therapy due to burden do so often because the prescription is not adjusted to needs or benefits, or when they do not understand its rationale. We heard this explicitly in our interviews of patients who discontinued HHD.
Ensure participation of the interdisciplinary team. Too often, the home program is the sole responsibility of the home program nurse. Everyone shares in the responsibility of a successful home program. We found top-performing programs integrated social workers and PCTs into the interdisciplinary care team along with nurses, in many cases hiring social workers and PCTs who were completely dedicated to home dialysis.
Social workers focused on supporting patients throughout the HHD experience, including conversations with patients and care partners prior to HHD training. In many best-practice locations, the social worker actively participated in home visits to help plan for supplies and identify the optimal spaces for conducting treatments prior to the patient transitioning home. Once patients and care partners transitioned, the social worker consistently followed up and monitored for signs of burden or issues with adapting to dialysis at home.
PCTs were used to support home-training registered nurses in administering respite treatments, monitoring treatments during the final weeks of training (during which patients/care partners are independent), performing clerical tasks and assisting with supply management and equipment swaps when needed.
Regarding the interdisciplinary team, a successful physician leads the team and listens to all members equally. The nephrologist should encourage the best of group dynamics. Monitoring patients and the interactions of the home unit drives job satisfaction of the team and patient retention.
Monitor and get actively involved. During the interviews, one nurse advised, “Be there for your patients. After they go home, your training hasn’t stopped. Monthly education and follow-up are just as important as the training they get when they first start.”
Closely monitoring patients provides an opportunity to identify those at risk for therapy discontinuation, and to intervene. Our analyses indicate there are distinct predictors of elevated risk for technique failure, and best practices to help these patients succeed on HHD.
Medicare claims data analyses indicate that hospital admissions rates during the 3 months before conversion from HHD to in-center hemodialysis are significantly higher than typical. In fact, the rate of hospital admissions during the last month before HHD discontinuation is roughly three-times higher than typical. Admissions for infection and fluid overload were common and may be preventable with better volume management and infection control.
Another predictor of patient discontinuation was poor treatment adherence. Lower adherence, especially under 80%, was strongly associated with higher risk for technique failure.
The Nx2me Connected Health platform facilitated the treatment adherence analysis. A study of 606 HHD patients found that compared with matched controls, patients using Nx2me had a lower risk for HHD technique failure. This was especially evident when use of Nx2me was initiated during the first 3 months of therapy, where 34% lower risk for technique failure was observed.
When at-risk triggers were identified, successful programs implemented timely interventions. Best-practice programs actively promoted respite care. Respite treatments were performed in the home dialysis area of the clinic, and patients were kept on the same prescribed frequency as at home. Patients were not pressured to use respite care, but respite was frequently offered as an option to give patients or care partners a break from home therapy when needed.
An attentive nephrologist is in the natural position to respond to the indicators of potential patient therapy discontinuation. With the data readily available through the electronic medical records and connected health platforms, reviewed routinely with the patients, the physician should proactively identify potential issues and advise the interdisciplinary team on the need for interventions.
Finally, clinic interviews indicated that home visits are used in best-practice programs as a tool to support patients through the HHD journey. Patient homes were assessed before training commenced. If that was not possible, then the care team assessed the home while the patient was in training to identify any barriers that needed to be addressed prior to the first treatment at home. High-retention programs also offered training or retraining in the home.
Conclusion
The success of patients on home dialysis is dependent on a dedicated professional team, including the nephrologist, nurse, social worker and PCT, and enabled by supportive processes. At a time when physician satisfaction has been declining in medicine, the nephrologist will be able to enjoy the improvements in quality of care, better physician-patient communication and increased physician satisfaction. Not surprisingly, most home dialysis champions feel the home clinics and patients are the best part of their jobs.
A nurse interviewed at one of the highest performing centers summarized her approach as follows: “Take every patient that wants to do home. Take them any day, any time. Make it work for the patient, find out what they are struggling with, and fix it.”
Clearly, building a successful HHD program is neither driven solely by patient access nor by patient retention, but by patient-centric consideration of both, while leveraging the resources and technologies available to the care team. Real-world examples demonstrate approaches that make success possible. We invite care providers to assess their current situation using the diagnostic tool in Figure 2, and to identify current areas of strength and potential areas for improvement.
- References:
- Medpage Today. Feb. 15, 2019. https://www.medpagetoday.com/meetingcoverage/himss/78077.
- NxStage Data on File, CRM Database, February 2019.
- US Renal Data System USRDS Annual Data Report, www.usrds.org/2018/download/v2_c01_IncPrev_18_usrds.pdf.
- For more information:
- Michelle Carver, BSN, RN, CNN, is the senior director of clinical education for national accounts at NxStage Medical. She helps create clinical education programs and platforms to support patients on home hemodialysis.
- Michael Kraus, MD, is associate chief medical officer at NxStage Medical, and former service line chief for IU Health Physicians Kidney Diseases and clinical chief of nephrology at Indiana University School of Medicine in Indianapolis, Indiana.
- Marienne Moro Sanders, MS, is vice president of home dialysis marketing at NxStage Medical and is responsible for expanding education and awareness of home dialysis by health care providers and patients.
- Eric Weinhandl, PhD, MS, is an epidemiologist and biostatistician with NxStage Medical, with more than 15 years of research experience in chronic kidney disease, dialysis and pharmaceuticals.
Disclosures: The authors are employees of NxStage Medical, which manufacturers the System One and Versi home hemodialysis systems and the Nx2me connected health technology.
Editor’s note: On August 6, 2019, Figure 2 was updated as two bullet points under ”Ensure participation of the interdisciplinary team” were incorrect as initially published. The Editors regret this error.