Education, champions key to help patients stay committed to home dialysis
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In the 1960s, if you were lucky enough to be approved for dialysis by your regional patient selection committee, home care was the one – and only – choice.
That changed in the 1970s after Congress passed legislation approving Medicare coverage for dialysis and transplantation for U.S. citizens who were diagnosed with end-stage kidney disease. Outpatient centers sprouted up across United States, and home dialysis virtually disappeared.
Room for optimism
While about 13% of the prevalent ESKD population is using home therapies today, the kidney care community, along with CMS, is pushing for change. The ESRD Treatment Choices demonstration, launched last year, offers financial incentives to dialysis providers who place more patients on home dialysis. The Kidney Care Choices demonstration, a voluntary payment model started in January, focuses on helping patients in stages 4 to 5 CKD to learn more about dialysis options, like peritoneal and home hemodialysis, before kidney failure occurs.
“In 2009, 6.8% of new dialysis patients were treated at home. In 2019, that number was 12.6%,” Eric Weinhandl, PhD, MS, senior director of data analytics and home therapies for Satellite Health Care, told Nephrology News & Issues. “Correspondingly, the percentage of all dialysis patients who were treated at home increased from 8.9% in 2009 to 13.1% in 2019, with over one percentage point of that growth between just 2017 and 2019,” Weinhandl said, citing the 2021 annual data report of the U.S. Renal Data System (USRDS).
“There are some positive signs that home dialysis is growing,” Paul Komenda, MD, wrote in his First Word column this month in Nephrology News & Issues. “Due to advances in home hemodialysis and peritoneal dialysis, qualified patients who are properly prepared and supported throughout home-based care can achieve greater quality of life at lower cost compared with conventional in-center hemodialysis.”
Retention a challenge
While introducing patients to home therapy is productive – particularly in early stages of chronic kidney disease – keeping patients on home dialysis long term after being diagnosed with kidney failure is a challenge. According to the USRDS, 25% of patients who initiated home hemodialysis in 2017 to 2018 converted to in-center hemodialysis (ICHD) after 2 years. The corresponding conversion with peritoneal dialysis was 24%, according to the 2021 data report.
“[Retention] is something we will continue to follow closely, as we believe one of the biggest keys to expanding home dialysis is to significantly reduce the previously high attrition rates that have plagued PD and HHD,” Michael Aragon, MD, chief medical officer for Outset Medical, told Nephrology News & Issues.
Outset’s Tablo hemodialysis machine received FDA approval in March 2020 for home use.
Aragon said his team has identified several factors that make retention more achievable. Keeping the burden of dialysis to a minimum is important.
“Flexibility and simplicity is key in helping to reduce the overall burden of home hemodialysis while allowing more opportunity to fit dialysis into the patient and care partners lives, as opposed to the other way around,” Aragon said. “We have also been told that fear – fear of the unknown, fear of self-injury, fear of being unsuccessful – can often stand in the way of patients going home on home hemodialysis.”
Aragon said company data show home retention on Tablo has been high compared with historical retention rates reported by the USRDS.
Reduction in mortality
There is a benefit in keeping patients on home dialysis vs. transferring care to ICHD. A 2021 study found patients who experienced failure with HHD showed a “significant” increase in mortality following a switch to facility-based HD.
“We found that the risk of death is high after the transition, and it remains high after 3 months,” David J. Semple, PhD, from the department of renal medicine of the Auckland District Health Board and a faculty member of medical and health sciences at the University of Auckland in New Zealand, and colleagues wrote in a recent issue of the American Journal of Kidney Diseases. “We could not discern the cause of this association, but we suspect it is due to the events that caused patients to stop home hemodialysis.”
“While the mechanisms of failure in the study from Semple are unknown, it is likely that medical instability and caregiver burnout play a role,” Christopher T. Chan, MD, from the division of nephrology at the University Health Network of the University of Toronto in Canada, wrote in an editorial that accompanied the article. “Given the similarities in the nature of dialysis transitions, it is tempting to hypothesize that modifications in process of care to minimize fragmentation may be a reasonable approach to address the elevated risk during the vulnerable period of dialysis switch.”
Added Komenda in his First Word column: “Instead of switching to ICHD – which has inherent risks and challenges that have been exacerbated since the onset of the COVID-19 pandemic – providers should consider ways to better assist patients at home. The value in doing so is apparent: HHD is not only preferred by many patients but can alleviate costs, discomfort and patient indignity.”
Patient selection
It seems logical that being careful about who you select for home dialysis would improve retention. Aragon disagrees. “I think the biggest key to patient selection is to eliminate our own biases as to what constitutes a ‘good’ home patient,” Aragon said. “Every patient should be educated regarding all of their options, including in-center, transplant and home modalities. Once patients have been empowered with this information and have made a modality choice together with their family and care team, it should be our role as clinicians, payers, manufacturers and providers to support that patient to be successful on whatever modality they choose.”
Treatment plan for life
A life plan for modality choices can help patients stay engaged and focused on self-care whether it is with PD or HHD, Martin J. Schreiber, Jr., MD, with DaVita’s Home Modalities program, told Nephrology News & Issues. “Oliver Graham Bell said, ‘Before anything else, preparedness is the key to success.’ Every patient needs a life plan, and life planning should be part of shared decision-making,” Schreiber said.
“Treatment decisions are similar to medication selection,” he added. “A physician should select the best medication/drug for a patient. Think of dialysis as a drug, then providers and patients need to find the ideal ‘can-do-it approach’ for the patient to be successful on a given therapy.”
Educate early, often
Planning for transitions between modalities begins with early education, according to Nephrology News & Issues sources. “The whole process starts with early and frequent education,” Schreiber said.
At Fresenius Kidney Care, staff have developed an interactive educational tool that becomes part of a patient’s formal home dialysis training and then is available on-demand.
“The work to train, retain and ultimately expand the number of patients on home therapies requires new tools that support patients throughout their journey,” Michelle Carver, BSN, RN, CNN, vice president of clinical services initiatives at Fresenius Kidney Care, told Nephrology News & Issues. Carver has more than 20 years of experience in dialysis nursing care specifically in PD and HHD training and support.
The digital platform is customizable, she said, offering a personalized experience depending on modality, some co-morbid conditions, machine selection, and more, and allows educators to move away from static, one-size-fits-all paper training resources, Carver said.
Since launching a pilot of the education modules in 2021, Carver said nearly 10,000 users are registered with an average of 600 new enrollments each month.
But training is not just important for patients, Aragon said. In efforts to keep patients at home, nurses and nephrologists can benefit from training, too. “Few practicing nephrologists received enough education and experience in home hemodialysis during their training to be confident in prescribing home dialysis,” he said.
Schreiber said the life plan for modality options leans heavily on patient education – so patients can make the decisions about their care. “In the past, we may not have designed the decision process to achieve optimal outcome results. But this is changing.
“The patient is now at the center of the selection process. Considering home first does not obligate all patients to start home dialysis, but rather positions ‘home-based care’ as the starting point or default option for a significantly greater number of incident ESKD patients.
“I believe we can make this transformation a reality,” Schreiber said.
- References:
- https://adr.usrds.org/2021/end-stage-renal-disease/2-home-dialysis.
- www.healio.com/news/nephrology/20220113/home-hemodialysis-failure-correlates-with-a-significant-increase-in-mortality For more information:
- Michael Aragon, MD, can be reached at maragon@outsetmedical.com.
- Michelle Carver, BSN, RN, CNN, can be reached at michelle.carver1@fmc-na.com.
- Paul Komenda, MD, FRCPC, MHA, FACP, can be reached at paulkomenda@yahoo.com.
- Martin J. Schreiber, Jr., MD, can be reached at martin.schreiber@davita.com.
- Eric Weinhandl, PhD, MS, can be reached at weinhandle@satellitehealth.com.
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