Home dialysis is growing but more tools are needed
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Remarkably, more than 3 years have passed since the release of the executive order on the HHS initiative Advancing American Kidney Health.
That order, signed on July 10, 2019, focused energy on several domains, including home dialysis, and was punctuated by release of a preliminary version of the End-Stage Renal Disease Treatment Choices (ETC) payment model.
However, as uniquely exciting as that executive order was, it is also reasonable to characterize that day as another bronze plaque on the long journey to wider utilization of home dialysis.
Ten years earlier, the proposal to place Medicare payments for hemodialysis (HD) and peritoneal dialysis on equal footing was aimed at jumpstarting PD. Despite the glittering success of the policy, growth in placing patients on home dialysis slowed by 2014 due to a shortage of PD fluid. Meanwhile, regional skirmishes about coverage of more frequent, or daily hemodialysis, at home curtailed growth of that modality.
Growth spurt
However, these dams crumbled by the second half of 2017. Dialysis Facility Report data showed utilization of home dialysis increased from 11.9% at the end of 2017 to 12.5% at the end of 2018 and to 13.4% at the end of 2019 — interestingly, without a codified change in coverage or payment policy.
There are two ways to look at that 13.4% figure. One way is positive: The United States rotated 1.5% of its dialysis population from facility to home in 24 months. That is no small feat. However, another way is more painful: 13.4% was still decisively lower than contemporary readings of home dialysis of 17% in the United Kingdom, 25% in Australia and 26% in Canada.
Indeed, these comparisons beg a serious question: Setting aside bluster from political actors and commercial entities, what is a reasonable target for home dialysis utilization in the United States, whether in 2025 or 2030? For that matter, can we catch Canada by the end of this decade?
COVID-19
These questions had answers, at least in the minds of some experts, before COVID-19 flipped the script.
The pandemic has had an interesting array of effects on home therapies (see Table). Some are intuitive; deaths in patients on home dialysis from COVID-19 decreased the census and recent problems with staffing have limited training capacity. However, other effects are more difficult to understand. Fewer kidney transplants, as occurred in 2020, leave more patients on dialysis — especially PD, which historically is associated with a relatively high likelihood of transplantation. Fewer people initiating dialysis, as also occurred in 2020, leads to a smaller “foundation” on which PD — and to a lesser degree, home HD — is built.
For all these reasons, identifying whether home dialysis “grew” during the first year of the pandemic is difficult. Of course, utilization looks like it increased: 13.4% at the end of 2019 and 14.5% just 10 months later. The deception of this statistical comparison, however, is rooted in the carnage that visited in-center HD. There were so many COVID-19 deaths among patients on in-center HD that the entire dialysis population shrunk. This is an epidemiologic force that none of us have ever seen. In other words, the percent of patients on dialysis utilizing home therapies increased in 2020 not only because of organic growth in home therapies, but also because of premature deaths among patients who would have dialyzed in facilities, sans the pandemic.
Home dialysis expands
This tempers the view of home dialysis growth during the first year of the pandemic. Based on public disclosures, we know that home dialysis utilization in DaVita Inc. and Fresenius Medical Care networks is now about 15%. Take a moment to memorize this: With all our enthusiasm for home therapies, as well as all the bleakness of COVID-19, the United States has marched from 12% home dialysis utilization on the eve of 2018 to 15% around 4.5 years later. Simple math indicates that our home dialysis growth trajectory, on an absolute scale, is 0.6% to 0.7% per year, with a high end around 0.9% per year.
Where does that put home dialysis utilization by the middle of 2025? Around 17% or maybe 18%. And by 2030? On the low end, around 20%; on the high end, around 22%.
That range could put the United States ahead of the United Kingdom, but not Canada. It is important to recognize that 20% home dialysis utilization would be an accomplishment; back in 2008, when utilization had reached its nadir, setting a goal of 20% might have been labeled as “crazy.” However, 22 years between “crazy” and “mission accomplished” is probably not what many of us would characterize as a stunning pace of transformation.
Increase home dialysis
What would it take to go faster? Unfortunately, there is no “easy button.” But there are buttons — many buttons, in fact. A non-exhaustive list includes the following:
- multi-payer coverage of staff-assisted home dialysis;
- community houses (ie, communal settings) in which patients can self-dialyze;
- on-demand fluid generation for PD;
- devices that detect peritonitis at home;
- serious debate about whether Kt/V has a useful role in PD quality measurement;
- home HD machines with dialysate flow rates of at least 500 mL/min so that conventional HD may be widely accessible to patients who select it;
- accelerated pathways for nocturnal and solo indications for machines already cleared for home HD;
- pay-for-performance agreements that reward frequent HD for what it does best: improve volume status, lower blood pressure and reduce cardiovascular risk; and
- coverage of PD for the treatment of dialysis-dependent acute kidney injury.
Many, if not all, of these ideas require support from CMS and the FDA, if not Congress itself. Five-year timelines to complete political processes — such as those ending with small modifications to the bundled payment — or to recruit patients to home dialysis device studies that are unlikely to generate surprising information have a real cost — one that is borne by patients who could live healthier, more goal-concordant lives if they could more easily dialyze at home (or a setting like home).
Ultimately, the story is simple: The United States can go to 20% home dialysis utilization this decade, but if we want to go to 30% or 35%, we must think bigger and move faster. The ETC payment model, which now features prescheduled inflation of home dialysis benchmarks, necessitates bigger and faster in 30% of markets, lest onerous penalties be levied in coming years. As an aside, it will become increasingly important for the insurers that sponsor Medicare Advantage plans to engage in this transformation; year by year, the traditional coverage and payment tools in Medicare Part B are losing their strength.
The stark excess mortality that has characterized the pandemic experience of patients on dialysis is finally waning, thus presenting us with a second attempt at the 2020s — albeit one with the twin challenges of inflation and staffing shortages. We can see that home dialysis utilization is growing, but at less than 1 percentage point per year.
We have to decide if we are satisfied with that pace, or do we want more.
- For more information
- Eric D. Weinhandl, PhD, MS, is an epidemiologist and the senior director of data analytics and home therapies at Satellite Healthcare. He is also an adjunct assistant professor in the Department of Pharmaceutical Care & Health Systems at the University of Minnesota College of Pharmacy and a member of the Editorial Advisory Board for Nephrology News & Issues. He can be reached at weinhandle@satellitehealth.com.
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