With a focus on health equity, barriers to home dialysis can be overcome
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In my role as a practicing nephrologist and clinical executive, much of my focus involves helping patients overcome their initial reticence about dialysis at home and helping them understand and harness its potential benefits.
To truly achieve widespread adoption, it is critical that we identify, analyze and develop solutions to overcome the factors driving disparities in home dialysis.
Increase in use
Home dialysis utilization in the United States has seen a steady increase in the last decade, with the most recent data from the U.S. Renal Data System (USRDS) Annual Report showing an increase in the prevalent population from 9.7% in 2011 to 14.1% in 2021 for patients with end-stage kidney disease. During the same time frame, we have also seen a significant increase in home dialysis utilization in incident (new start) patients from 7.5% to 13.4%. Despite those positive trends in home dialysis utilization, disparities between patient populations help illustrate where the nephrology community can continue to address barriers to home treatments, despite a decade of progress.
According to USRDS data, among new starts at home for patients on dialysis in 2011, 8.3% were white patients; 10.7% were Asian patients; 6% were Black patients and 6.7% were Hispanic patients.
In 2021, 14.8% of new patients starting dialysis at home were white patients; 20.3% were Asian patients; 10.9% were Black patients and 11.9% were Hispanic patients. A similar trend is seen among prevalent patients on home dialysis.
Barriers
Through research at DaVita and as a larger kidney community, we have identified contributing factors that can serve as barriers to home adoption for Black and Hispanic patients. These factors include lack of kidney health education, conscious and unconscious biases of health care providers on “ideal” home patients, cultural concerns related to dialysis treatment options, family and community support, and other social drivers of health, including access to health care, education, housing and transportation.
At ASN Kidney Week in 2023, health equity and clinical research teams from DaVita presented findings on challenges for increasing home dialysis along with opportunities for African American patients and Spanish-speaking Mexican American patients.
For both patient groups and their care partners, trust in their physician was cited as the most important factor in the initial modality decision. For Spanish-speaking Mexican American patients, physicians are considered a mostly unquestioned source of truth. For African American patients, trust in a physician’s recommendation is largely high but comes with some reservations. If the provider is less than forthcoming or insensitive when sharing information, trust is quickly eroded. While most patients and care partners acknowledge the benefits of home dialysis, significant barriers include fear of being solely responsible for a complex procedure, risk of infection, loss of social interaction and/or support from other dialysis patients and center staff.
Management of health conditions
Patients also reported that physicians did not make a clear connection between poor management of underlying health conditions and the potential for kidney failure, regardless of a patient’s access to primary care. This, in turn, led to difficulty accepting the need for dialysis.
The research concluded that opportunities exist for early education about the direct linkage of comorbidities (such as hypertension and diabetes) with kidney disease and consideration of patient concerns in home dialysis modality education. The research also found that opportunities exist to build on the strong patient preference for physician-led health information and to focus on decreasing literacy and language barriers in the Spanish-speaking Mexican American population.
Our approach to reducing racial and socioeconomic disparities began by building a strong, data-driven foundation that informs an operational strategy to address inequities. Today, we are working to overcome pervasive inequities by increasing awareness, mitigating biases on our care teams and across the physician community through robust trainings and acting on patient insights. Additionally, we have built internal health equity dashboards to measure and track outcomes by demographics. We also seek insights directly from patients, families and communities to help shape person-centered interventions rooted in lived experience.
In the article, “A person-centered approach to kidney care,” the authors use ESKD as a model to present a vision for more effective, holistic person-centered care delivery. In the article, the authors recommend that “clinicians engage in conscientious, thorough discussions with patients at the outset of treatment — taking into account their social, cultural and personal circumstances — to ultimately improve outcomes and drive down costs in the long term.”
While overall growth in home treatments demonstrates improvements, we have relentless ambitions to go further. As a kidney care community, we must continue to do our part to ensure underserved and at-risk communities have access to education, resources and support to embrace home dialysis and benefit from the outcomes and quality of life it delivers.
- References:
- Liou-Johnson V, et al. NEJM Catal Innov Care Deliv. 2024;doi:10.1056/CAT.23.037.
- U.S. Renal Data System, 2023 Annual Data Report, End Stage Renal Disease. Figure 2.1a. https://usrds-adr.niddk.nih.gov/2023/end-stage-renal-disease/2-home-dialysis. Accessed April 2, 2024.
- For more information:
- Mihran Naljayan, MD, MHA, FASN, FNKF, is clinical associate professor of medicine for nephrology and hypertension at LSU School of Medicine and chief medical officer for DaVita home modalities and pediatrics. He can be reached at mihran.naljayan@davita.com.
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