Lack of health equity challenges patients’ access to home dialysis
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CMS is making efforts to address health disparities in the Medicare End-Stage Renal Disease Program, and DaVita Inc. chief medical officer Jeffrey Giullian, MD, MBA, FASN, said dialysis providers need to make important changes to correct the imbalance.
“There is an equity gap industry-wide for Black and Hispanic patients in choosing a home dialysis modality and in getting kidney transplants,” Giullian told Healio/Nephrology News & Issues. “We continue to pursue both qualitative and quantitative research to identify the root causes of health inequity and understand how we can implement meaningful change.”
In a recent interview with the New England Journal of Medicine’s Catalyst, Giullian said health inequity goes beyond kidney care; it was evident when patients were first seeking COVID-19 vaccinations. “ ... [W]hen COVID-19 vaccines first became available, we began to notice worrisome trends of inequity among our Black and Hispanic patients. They were initially around 40% less likely to receive the COVID-19 vaccine ... What we were seeing was inequality develop in real time right in front of our eyes,” Giullian said. “Here were communities that were devastated by the COVID-19 virus, and these people weren’t getting vaccinated at the same rates as white patients and Asian patients.”
Financial incentives
According to the latest annual data report for the U.S. Renal Data System (USRDS), use of home dialysis has improved in the last decade. From 2010 to 2020, the percentage of new patients on dialysis who choose the home modality option increased from 6.8% to 13.3%. But 54% of the 7,800 dialysis facilities in the United States have home programs, according to the report. More telling is the ethnicity of patients in those programs.
“Higher percentages of incident and prevalent (peritoneal dialysis) PD patients were white and Asian, and smaller percentages were Black and Hispanic compared with patients receiving in-center HD,” according to the USRDS.
To help direct efforts toward moving more patients with health disparities to home dialysis therapies, CMS added a new round of financial incentives this year to its End-Stage Renal Disease Treatment Choices (ETC) demonstration.
That program, started in January 2021 and mandated for about 30% of dialysis clinics in the United States, already offers additional payments for centers that increase the number of patients placed on home dialysis or waitlisted for a kidney transplant. Under a final rule that took effect in January, however, dialysis clinics in the ETC demonstration will also receive higher payments if the centers direct more socially and economically disadvantaged patients to home dialysis.
The incentives “would aim to encourage dialysis providers to decrease disparities in rates of home dialysis and kidney transplants among (end-stage renal disease) ESRD patients with lower socioeconomic status,” according to a CMS press release. The incentives offered to facilities in the ETC model are the first in CMS ACO demonstrations to directly address health equity, the agency said.
Those incentives may have limited success, however, because of the 2,405 dialysis facilities participating in the ETC model, only 27% offer both PD and home hemodialysis (HHD), according to results shared by CMS for the first year of the demonstration. Another 23% of the facilities offer PD, but not HHD.
Researchers are questioning whether financial incentives are working in the ETC model.
In an article published in JAMA Health Forum, Yunan Ji, PhD, and colleagues wrote that there has been little change in home dialysis rates in the ETC demonstration.
“We found no statistically significant difference between treatment and control groups in the percentage of patients with any home dialysis during the first 90 days when we looked at various patient subsamples,” Ji and colleagues wrote. “These included analyses by patient characteristics, such as Medicaid status, race and ethnicity, urbanity, and distance to the nearest facility, as well as facility characteristics, such as ownership type or chain status.”
The authors wrote that the review “raises questions about the efficacy of the financial incentives in the model and suggests that higher incentives may be necessary to affect behavioral change by dialysis clinicians and facilities.”
Get patients ‘activated’
Financial incentives were not on the table when Alice Wei, MD, embarked on an effort to introduce home dialysis to patients at a Harlem, New York dialysis clinic marked by poor outcomes, including high mortality.
“Socioeconomically, these were disadvantaged groups,” Wei told Healio/Nephrology News & Issues. She spent 16 years in private practice before becoming senior medical director at the kidney care management company Strive Health.
Source: Strive Health
Wei was successful at turning around the poor outcomes at the dialysis clinic, “as measured by all the metrics we use to determine quality of care,” but she was not “creating the impact I thought I would in my patients’ lives,” she said.
“I could tell my patients were still unhappy. Many seemed downright miserable” about coming into the clinic three times a week, Wei said. “That’s when I started looking into home dialysis.”
Wei convinced Fresenius Medical Care to open a home training center and began selecting patients for home dialysis. But it was not an easy sell and she said she did not have a lot of support from colleagues. Patients were initially skeptical, too, she said.
“There was a fear of self-care among patients who were used to receiving care provided by doctors and nurses,” Wei said. “And there is some fear by staff that the patients won’t thrive because of challenges in the home environment.”
But Wei pressed on, training patients on PD and colleagues on the merits of home dialysis. “We succeeded beyond our expectations in that first year,“ Wei said.
The key to her success was patient activation. That helped to overcome the social disparities her patients faced.
“For patients to be successful they must want to succeed at home dialysis. Our patients were activated in believing that their quality of life would improve,” Wei said.
Wei is not a big proponent of financial incentives to solve problems the economically disadvantaged population faced.
“It’s a nice start, but you will soon find when you dig deeper into this issue [of financial incentives] that it is not going to be truly impactful in a way that will transform this problem” of health inequity, Wei said. “We are not going to be able to incentivize this away. It is a complex and deep-rooted problem.”
Use of transitional care units
One way to help ease patients who face social disparities into home dialysis is through a transitional care unit (TCU).
“There are certain issues with access to CKD care that are difficult for patients to overcome,” Brendan Bowman, MD, vice president of medical affairs at DaVita Kidney Care, told Healio/Nephrology News & Issues. He served as regional medical director of the University of Virginia’s independent outpatient dialysis program for 6 years, with a special focus on expanding access to patient education and home therapies by creating TCUs.
“If you look at the USRDS data on pre-dialysis education, it is lower for Black and Hispanic populations,” Bowman said. “The TCU can help address these disparities in pre-dialysis education. “It was remarkable when we implemented it, because you could see there really was no discrepancy in patients’ level of interest in home dialysis. Yes, some still had structural barriers, but in terms of interest in home dialysis, it was there.
“Our take was everyone deserves a chance at home dialysis unless they have some absolute contraindication,” Bowman said.
In his interview with the Catalyst, Giullian said managing kidney disease is a natural area for medicine to find health inequity. “Chronic kidney disease and end-stage kidney disease disproportionately affect persons of color,” Giullian said. “They generally receive less education about kidney health, and subsequently, we see that they end up having fewer choices in their treatment options. Then, of course, if they do unfortunately go on to develop full kidney failure, they’re 30% to 40% less likely to have the opportunity to dialyze at home and they are significantly less likely to get a kidney transplant,” he said.
DaVita has done recent work to address racial disparities in the waitlist and transplant process. “This continues to be an important focus for us, and we’ll continue to share our learnings with the industry to help enact systemic change,” Giullian said.
The company is also working to implement change “through cultural humility training for teammates on the front lines, targeted upstream education and peer-to-peer work, including physician engagement,” Giullian said.
Federal action
CMS has started a new web page to help promote health equity.
“Everyone has a fair and just opportunity to access their optimal health regardless of race, ethnicity, disability, sexual orientation, gender identity, socioeconomic status, geography, preferred language or other factors that affect access to care and health outcomes,” the agency said in a press release.
Wei said goals set for increasing the use of dialysis by the Advancing American Kidney Health initiative, now entering its fourth year, are helpful in pushing through barriers created by health disparities. All patients should have the option of choosing the modality that fits their lifestyle and their needs, Wei said.
“We learned in our work in Harlem that not all patients want the responsibility of doing self-care,” Wei said. “It has to be the right fit.”
- References:
- Annual Data Report. U.S. Renal Data System. 2022; https://usrds-adr.niddk.nih.gov/2022/end-stage-renal-disease/2-home-dialysis. Accessed Jan. 20, 2023.
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- Brendan Bowman, MD, can be reached at brendan.bowman@gmail.com.
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