NKF-Kidney Disease Outcomes Quality Initiative conference seeks to increase home dialysis utilization
Click Here to Manage Email Alerts
Although the 2017 conference focused on identifying barriers to home dialysis initiation and how to retain patients on such therapies, the purpose of the 2018 National Kidney Foundation-Kidney Disease Outcomes Quality Initiative Home Dialysis Conference was to develop actionable steps to achieve these goals. A report from the conference, details of which were presented at the Annual Dialysis Conference, held in Kansas City, Missouri, this week, was recently published in the American Journal of Kidney Diseases.
Four months after the 2018 conference, HHS Secretary Alex Azar II stressed the importance of ensuring more patients with kidney failure are either transplanted or initiate home dialysis, Christopher T. Chan, MD, of the University Health Network in Canada, and colleagues, wrote in the report. According to the authors, Azar demonstrated that “developed and developing countries alike are embracing home modalities,” by referencing home dialysis rates of 80% and 51% in Hong Kong and Guatemala, respectively. The United States lags behind, with peritoneal dialysis and home hemodialysis used at lower rates. While the stated CMS goal is to have 80% of new patients with kidney failure begin care with either preemptive kidney transplantation or a home dialysis therapy by 2025, the question of how to increase the uptake of home dialysis remains.
Based on discussions with an array of attendees — including patients, care partners, physicians, nurses, social workers, technicians and representatives from dialysis organizations and CMS — the authors touched on awareness and education for patients and providers, peer support for care partners and changes to Medicare reimbursement payment methods.
The authors noted that approximately 35% of patients begin dialysis “with little to no nephrology care,” as most begin treatment in the hospital. Less “urgent starts” would allow for more opportunities to provide patients with education on alternative treatment modalities. They argued that, while there are many educational materials about dialysis, “they are segregated and scattered” and “educational programs for patients with urgent-start dialysis are limited and are not reimbursed.” To address this barrier, the authors suggested the creation of a “task force” to locate current educational materials and to uncover how patients and providers currently access them, followed by the development of a tool to evaluate the effectiveness of the materials. “With this information,” they wrote, “NKF will then be able to establish a state-of-the-art CKD education program that can be piloted in selected programs nationally.”
Regarding health care providers who, the authors argued, are often reluctant to advocate for home dialysis due to lack of comfort level (findings suggest 55% of fellows graduating are not comfortable prescribing home dialysis), they suggested the creation of surveys aimed at identifying knowledge gaps, which would be administered to providers through videoconferences. To assist with this, they cited Project Extension for Community Healthcare Outcome, a “distance health education model that uses videoconferencing technology to connect care providers across multiple geographical settings and areas of expertise.” After knowledge gaps are addressed, a home dialysis curriculum tailored to each specific provider can be developed.
Next, the authors looked at care partner support and wrote, “care partners are vital to the success of a home dialysis patient. Deciding to conduct home dialysis with a care partner, compared with solo treatment, must involve the whole family because it affects their entire living situation.” To address the challenges care partners face (eg, stress, burnout and isolation), the authors suggested expanding NKF’s Peer Mentoring Program to include care partners. Expansion of the program would consist of recruiting and training more peer mentors, using video chats and developing a tool to assess care partner burden.
Finally, the authors examined the proposed End-Stage Renal Disease Treatment Choices model that proposes to move reimbursement incentives away from in-center dialysis and toward transplantation or home dialysis. They argued these reimbursement changes “may not be enough alone to encourage successful and long-term growth in home dialysis uptake and could continue to disempower patients by limiting their choices.” Further, “Payment incentives to increase home dialysis or measuring dialysis facilities on the percentage of home patients they treat could have other unintended consequences of penalizing facilities or nephrologists for patients for whom home dialysis would not be appropriate,” they cautioned. “However, incentives could be appropriate if unintended consequences were minimized and monitored.”
To expand on the proposed reimbursement changes, they suggested further modifying the monthly capitated payment to equalize payments to nephrologists who treat home patients and incentivizing the creation of urgent-start home dialysis programs to help patients transition to home dialysis. In addition, the Medicare Kidney Disease Education benefit could be modified to increase the reimbursement to providers delivering patient education (and allow other types of providers, other than the currently allowed physician or advanced practitioner, to engage in this role), as well as to remove the 20% coinsurance obligation for patients.
“There remains a great deal of work to develop, test and refine these proposals to prioritize the use of home dialysis modalities,” the authors wrote. “The work group is presently developing a roadmap of initiatives that address the concepts discussed in this report, as well as a timeline for implementation of these projects. The work group is hopeful that this multipronged approach will facilitate an increase in both the uptake and retention of home dialysis modalities by patients with kidney failure.” – by Melissa J. Webb
Disclosures: Chan reports holding the R. Fraser Elliott Chair in Home Dialysis. He has also consulted for NxStage, Baxter and Medtronic, and holds an investigator-initiated grant from Medtronic Extramural Research program. Please see the study for all other authors’ relevant financial disclosures.
Read more about
Click Here to Manage Email Alerts