Assisted peritoneal dialysis may improve technique survival
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Dialysis programs that offer a medically trained assistant to patients who elect to go on peritoneal dialysis could help increase use of the modality and extend technique survival, according to a recently published editorial.
Advancing American Kidney Health, which seeks a dramatic increase in the use of home dialysis means, “the time is right to start assisted PD in the United States,” Canadian nephrologist Matthew J. Oliver, MD, and Page Salenger, MD, who leads the home therapies division of Nashville-based Dialysis Clinic Inc, wrote.
In Canada, 21% of patients who start dialysis and are older than the age of 65 years chose PD compared to about 7% in the United States. In that age group, assistance with the technique would be the most effective. “Barriers may occur at any age but are more likely in older patients,” the authors wrote, noting dexterity to make the machine connections lessens, along with strength to lift PD bags. Hearing and vision loss also may make it difficult to understand commands and alarms from the PD machine. “Cognitive barriers include dementia, learning disabilities and active psychiatric conditions (eg, depression, schizophrenia)” also occur, making an assistant a good option, the authors wrote.
Oliver and colleagues examined data for 121 patients who underwent PD training in his program in the department of medicine at the University of Toronto. The mean age of the group was 69 years; 66% had functional dependency and 65% were categorized as frail. Another 59% had impaired cognition. Caregiver assistance ranged from 29% to 40% in that patient group, depending on level of impairment.
Assisted programs have existed for decades in countries like Canada, Denmark and France, and results from those countries indicated that providing patients with help during treatments can improve technique survival, Oliver told Healio Nephrology. “In France, they have a large experience with assisted PD and found better technique survival with assistance,” Oliver said. “Possible mechanisms include improved surveillance and compliance. If the patients and families know someone is coming to check on them, they may be more likely to be compliant with therapies, keep their house orderly, be sure their technique is good, etc.,” Oliver said. “Also, visiting assistants can assess patients and troubleshoot early.”
He added, “For these reasons, the skill set of the visiting person could make a difference. Nurses are more capable of assessments compared to personal support workers who just do physical tasks.”
Oliver said assisted PD would also be beneficial to pediatric patients who choose the modality. “A major value of assisted PD is providing support to family members who are providing most of the assistance at home ... In this case, parents could be supplemented by assisted PD in cases when they are ill or have other responsibilities, eg, caring for an elderly parent,” he said.
Oliver and Salenger said an assisted PD program in the United States would need to have a funding mechanism, because the monthly payment bundle for ESKD does not cover the costs. A pilot program in British Columbia of assisted PD provided one visit per day by training caregivers without prior health care training. The mean cost of the visits was CA $43 per day. In Ontario, the assisted PD program provides up to two visits per day, often by home care nurses.
“The short-term bundle in Ontario was funded at CA $2,792 (US $1,904) with a median use of 50 days,” the authors noted. “The cost of the long-term program is CA$20,566 (US $15,714) with a median use of 202 days.”
A pilot program would be the best way to test the feasibility and the outcomes of providing patients with assistance. “In a pilot program in the United States, a target usage of 30% to 40% seems reasonable to balance cost while providing sufficient support to meet home dialysis targets,” the authors wrote. – by Mark E. Neumann
Disclosures: Oliver reports receiving a grant and consulting fees from Baxter Healthcare, a grant from Medtronic and personal fees from Pursuit Vascular, outside of the submitted work. Salenger is home therapies medical director of Dialysis Clinic Inc.