Opportunities exist to fix health inequities in access to home dialysis

Kidney care professionals and policymakers continue to seek ways to eliminate longstanding racial and ethnic inequities in kidney health outcomes, including well-described disparities in use of home dialysis and transplantation.

CMS has developed the End-Stage Renal Disease Treatment Choices (ETC) model to enhance provider accountability for improving home dialysis and transplant waitlist rates through financial incentives. But several members of the kidney community have commented on the efficacy and key factors needed to ensure such strategies mitigate disparities without penalizing facilities that disproportionately serve patients facing sociopolitical disadvantages (eg, racism-mediated structural barriers to care including health care insurance and poverty).

Others have raised concern that preliminary analyses of ETC models suggest that the efficacy of such initiatives is uncertain and requires further evaluation. Many solutions to access disparities may lie outside of the traditional scope of nephrology practice, rather manifesting deficiencies in upstream investments in preventing and managing early chronic kidney disease. This includes policies and interventions designed to ensure patients have equity in access to disease-modifying therapies, nephrology referral, kidney disease and kidney replacement therapy education, and ensuring the social conditions necessary for patients to make truly informed choices about their kidney care.

Racial inequities

As we collectively tackle racial inequities in home dialysis and transplant utilization, several additional questions deserve attention. What will it take to fully uncover and address the root causes of these disparities? Do we have the collective will within and outside of nephrology to invest in the multi-sector solutions needed to resolve these issues?

Disparities in the use of home dialysis modalities have mirrored multi-decade racial and ethnic disparities in the burden of kidney failure in the United States and in the receipt of kidney transplants. In a landmark study, researchers examined data from incident patients receiving treatment at a large dialysis organization between 2007 and 2011. The odds of treatment with peritoneal dialysis were lower for all historically underrepresented groups vs. white patients, and markedly lowest among Black patients. Subsequent analyses have confirmed these findings, demonstrating that Black and Hispanic patients are less likely to have PD as a modality at dialysis initiation.

In another study by Jenny Shen, MD, and colleagues, Black and Hispanic patients had less nephrology referral before dialysis initiation and were more often uninsured vs. white patients. Furthermore, the strongest correlate of PD-based dialysis initiation in this study was pre-dialysis nephrology care. Without addressing these well-known early barriers to kidney health equity, including access to high-quality care and early disease education regarding kidney disease, we will have limited capacity to disrupt long-term trends in home dialysis disparities.

Policymakers and funders should consider these findings regarding key correlates of low PD utilization in the context of studies demonstrating that patients from historically underrepresented groups are less likely to receive pre-dialysis care vs. white counterparts. The persistent association between higher neighborhood social deprivation, Black race, Hispanic ethnicity, diabetes/hypertension-related kidney failure and female sex and lower home dialysis utilization requires further attention and thoughtful interventions.

Shared and informed decision-making

Shared and informed decisionmaking, a process whereby patients are facilitated to achieve their values-based treatment goals through collaborative engagement with their health care providers, requires bi-directional discussions about the risks, benefits and alternatives of medical decisions, and collaborative consideration of patients’ values and preferences. Ideally, patient values are then integrated with provider recommendations to achieve patients’ values-aligned care.

However, achieving these important goals requires not only transparency in the process of careful consideration of medical decisions, but also multiple supports, including health systems and caregivers, to ensure that decisions are feasible and achievable. For instance, if access to social support or supportive housing conditions are identified by patients as a key barrier to home dialysis, policies should aim to mitigate these barriers, which may be challenging for dialysis providers to resolve on their own.

Shared and informed decision-making has been suboptimal for historically underrepresented patients with advanced kidney disease. For instance, in a study among a cohort of patients with advanced kidney disease, participants who identified as female, Black, and low vs. high income reported more thorough discussions of dialysis than transplant. Studies are needed to explore whether racial, ethnic, gender and other socioeconomic status-related differences exist in the content, quality and nature of discussions and offerings regarding home dialysis modalities.

Expand access

Several investigators have described barriers and policy solutions to enhancing equity in home dialysis use, including cost considerations and economic incentives essential for success. This includes supporting policies and economic incentives that align with and help overcome cost barriers that preclude patients, caregivers, physicians and dialysis facilities from considering PD. In a retrospective longitudinal analysis of U.S. dialysis facilities between 2006 and 2013, Caroline E. Sloan, MD, and colleagues identified an increase in the proportion of facilities offering PD per hospital referral region; however, supply was in areas with higher regional prevalence of white patients, higher income, PD prevalence and urbanicity.

This strategy is essential to ensuring success given extensive data suggesting that patients and caregivers describe persistent cost-related barriers to PD including out-of-pocket costs for supplies, and those related to ensuring PD-suitable living conditions. Further attention is also needed to reimburse for high-quality education regarding all dialysis and transplant modalities, which includes discussing associated risks and benefits and evidence-based requirements for candidacy.

Finally, we must collectively address the nephrology workforce and our preparation to provide high-quality home dialysis. Studies suggest nephrology trainees have low to moderate perceptions of “preparedness” to manage home hemodialysis and PD. Opportunities to expand knowledge of PD and mechanisms to enhance patient-provider communication regarding this option are essential for nephrologists, nurses and other kidney care providers, especially in fellowship training and in regions that have had lower home-dialysis uptake.

As we strive to enhance equity in access to high-quality patient-centered value-concordant kidney care, we should carefully evaluate strategies that have proved effective in other settings that could be adapted to specific regional contexts. For instance, assisted PD delivered at home through a trained caregiver is reimbursed in European and Canadian health systems, which may allow mitigation of barriers including transportation and social support challenges. Peer navigators and community health workers could be deployed to provide direct support and enhance meaningful patient-and community-level education about home dialysis modalities.

In seeking solutions to multi-sector, multi-decade inequities in home-dialysis access, solutions will require collaborations, policies and investments, including consideration of the most critical ingredient: patients’ values, goals and preferences.

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• For more information:
• Dinushika Mohottige, MD, MPH, is an assistant professor in the Institute of Health Equity Research at the Icahn School of Medicine and a member of the Barbara T. Murphy Division of Nephrology at Mount Sinai Hospital. Mohottige is also a member of the Editorial Advisory Board for Healio/Nephrology News & Issues. She can be reached at dinushika.mohottige@mountsinai.org.