Dialysis Team Research Articles

Variations in provider practices in remote patient monitoring on peritoneal dialysis in the USA and Canada.

Automation has allowed clinicians to program PD treatment parameters, all while obtaining extensive individual treatment data. This data populates in a centralized online platform shortly after PD treatment completion. Individual treatment data available to providers includes patients' vital signs, alarms, bypasses, prescribed PD treatment, actual treatment length, individual cycle fill volumes, ultrafiltration volumes, as well as fill, dwell, and drain times. However, there is no guidance about how often or if this data should be assessed by the clinical team members. We set out to determine current practice patterns by surveying members of the home dialysis team managing PD patients across the United States and Canada. A total of 127 providers completed the survey. While 91% of respondents reported having access to a remote monitoring platform, only 31% reported having a standardized protocol for data monitoring. Rating their perceived importance of having a standard protocol for remote data monitoring, on a scale of 0 (not important at all) to 10 (extremely important), the average response was 8 (physicians 7; nurses 9). Most nurses reported reviewing the data multiple times per week, whereas most physicians reported viewing the data only during regular/monthly visits. Although most of the providers who responded have access to remote monitoring data and feel that regular review is important, the degree of its utilization is variable, and the way in which the information is used is not commonly protocolized. Working to standardize data interpretation, testing algorithms, and educating providers to help process and present the data are important next steps.

#782 Latent profiles of patients undergoing maintenance hemodialysis based on hemodynamic indicators

Abstract Background and Aims Both intradialytic hypotension and intradialytic hypertension are conditions occurring frequently during hemodialysis and are associated with unfavorable clinical outcomes. However, they remain incompletely understood and poorly defined in the literature. Since intradialytic parameters are now captured automatically in electronic medical records in many institutions, machine learning could emerge as an innovative tool for hemodialysis clinical research. Latent Profile Analysis is a model-based clustering method. It allows to identify hidden subpopulations derived from a set of observed indicator variables, maximizing between-group differences and within-group similarities. Method The objectives of this study were to identify latent profiles using a set of hand-crafted indicators and to interpret these subgroups of patients in a clinically meaningful manner. We conducted a retrospective single-center cohort study of adult patients receiving hemodialysis between January 2017 and December 2022 in Montreal. Given the highly heterogeneous nature of this population, we only enrolled incidental patients. The data were extracted from the NephroCare database, which is the clinical information system used by dialysis teams in our center. Sixteen indicators were derived from time series of blood pressure and heart rate measurements, capturing various patient-centric aspects of intradialytic hemodynamics, including trends, zeniths, nadirs, and time-related features. Latent Profile Analysis involved fitting a series of models, and the best model was selected based on fit indices, evaluation metrics, and clinical interpretation of the distribution of indicator within identified profiles. The primary analysis used complete-case data, and a sensitivity analysis assessed the impact of missing data through multiple imputation. Internal model validation was conducted using k-fold cross-validation. Results The selected model consisted of four profiles with varying variance and null covariance across indicators. Fig. 1 presents radar plots summarizing the identified profiles. Profile 1 included patients with prolonged early nadirs and a nadir-to-zenith transition pattern at the session level. Profile 2 was characterized by frequent nadirs and zeniths without a specific timing preference. Profile 3 comprised patients with infrequent blood pressure variations altogether. Profile 4 included patients with frequent early nadirs but no zeniths. The model demonstrated good generalization to unseen cases and exhibited relative robustness to missing data. Conclusion In this preliminary study, we demonstrated that Latent Profile Analysis can identify clinically meaningful subpopulations of hemodialysis patients based on hemodynamic indicators. The association between the identified profiles and hard clinical endpoints remains to be established.

Nursing management of catheter-related non-infectious complications of PD: Your questions answered.

A review from the last seven years (August 2016-July 2023) of questions posted to the International Society for Peritoneal Dialysis (ISPD) website "Questions about PD" by nurses and physicians from around the world revealed that 19 of the questions were associated with optimal approaches for preventing, assessing, and managing issues related to PD catheter non-infectious complications. Our review focused on responses to these questions whereby existing best practice recommendations were considered, if available, relevant literature was cited and differences in international practices discussed. We combined similar questions, revised both the original questions and responses for clarity, as well as updated the references to these questions. PD catheter non-infectious complications can often be prevented or, with early detection, the potential severity of the complication can be minimized. We suggest that the PD nurse is key to educating the patient on PD about PD catheter non-infectious complications, promptly recognize a specific complication and bring that complication to the attention of the Home Dialysis Team. The questions posted to the ISPD website highlight the need for more education and resources for PD nurses worldwide on the important topic of non-infectious complications related to PD catheters, thereby enabling us to prevent such complications as PD catheter malfunction, peri-catheter leakage and infusion or drain pain, as well as recognize and resolve these issues promptly when they do arise, thus allowing patients to extend their time on PD therapy and enhance their quality of life whilst on PD.

Palliative Care and Advance Care Planning Integration into the Dialysis Team: A Quality Improvement Intervention at a Hospital-Based Outpatient Hemodialysis Clinic

Palliative Care and Advance Care Planning Integration into the Dialysis Team: A Quality Improvement Intervention at a Hospital-Based Outpatient Hemodialysis Clinic

#4894 EFFICIENCY AND SAFETY OF AN ASSISTED HOME HEMODIALYSIS PROGRAM IN THE STATE OF QATAR: A RETROSPECTIVE STUDY

Abstract Background and Aims Home hemodialysis (HHD) usually done as self-care by patient themselves through a portable haemodialysis (HD) machine under training and monitoring by dialysis team. HHD offers greater patient autonomy, cost benefits, treatment-related flexibility, and improved quality of life compared to traditional in-centre HD. Uptake of HHD is limited by patient motivation, cognitive and/or physical barriers, as well as lack of support of family and community. Assisted HHD (AHHD) is a new concept where dialysis team provides HD at home. Usually, it is done by a visiting dialysis nurse using mobile HD machine. Its use is limited due to financial and logistical restriction. We like to present our unique experience in providing AHHD in the State of Qatar. Planning for our AHHD program started in July 2020. Because of COVID-19 pandemic, it faced many challenges and delays. We started first patient in July of 2021. In our program, we use traditional HD machine (not portable) with connection set up in the house in a dedicated room. Special training was provided to AHHD staff regarding the special care needed for home setting (including social, complication of home dialysis settings, decision making, follow up of protocols and policies, etc.) Method We performed a retrospective study between July 1st, 2021 - December 31st, 2022. Our primary objectives were efficiency and safety of AHHD, and secondary objective was cost effectiveness. We included adult chronic HD patients (on HD >3 months) using ambulance (or eligible for it) with functional dialysis access. We excluded patients who are not suitable for home environment (psychiatric illness, aggressive behaviour, etc.). Data were collected from our national electronic health record system. Results 946 patients screened for the program. 237 were eligible (exclusion mostly due to lack of national insurance coverage or not meeting mobility/transport criteria). 121 patients refused to participate (mostly for feeling safer in the clinic setting or improper home environment), 40 patients were undecided, and 76 patients accepted and started AHHD. Age was 73+/-11 years. We had 32 males and 44 females. Mean follow up period were 7 months. 12 patients died and 2 patients returned to dialysis centre during follow up period. Only 15 out of the total 126 hospitalizations were related to dialysis (mostly due to volume overload and non-compliance with dialysis schedule and time). We had 55 patients with permcath and 21 with AV fistulas. We had 8 incidents of dialysis catheter malfunction (6 required tissue plasminogen activator installation in the house setting and only two needed catheter exchange (one had catheter related infection)). No reported significant access bleeding or hypotension episodes. We had 20 technical incidents during the study related to electricity or water supply failures. All incidents were resolved without much interruption of treatment. The program overall was cost effective and reduced cost by over 25% (mostly related to saving of ambulance cost). Patients and their families were very satisfied with the program overall. Conclusion We present a unique successful program related to providing AHHD. Targeting certain dialysis population showed great care, safety, cost saving, better QOL and satisfaction.

Hemodialysis vascular access coordinator: Three-level model for access management.

Management of vascular access is a challenge for the dialysis team, particularly to keep the arteriovenous access working. The vascular access coordinator can positively contribute to increase the number of arteriovenous fistulas and reduce central venous catheters. In this article, we introduce a new approach to vascular access management centered on (the results of setting up) the role of vascular access coordinator. We described the three-level model (3Level_M) for vascular access management organized in three levels: vascular access nurse manager, vascular access coordinator, and vascular access consultant. We defined the instrumental skills and training required to be developed by each element and clarify the articulation between the model and all members of the dialysis team related to vascular access.

Implementing Advance Care Planning for dialysis patients: HIGHway project

BackgroundPatients undergoing hemodialysis have a high mortality rate and yet underutilize palliative care and hospice resources. The Shared Decision Making-Renal Supportive Care (SDM-RSC) intervention focused on goals of care conversations between patients and family members with the nephrologist and social worker. The intervention targeted deficiencies in communication, estimating prognosis, and transition planning for seriously ill dialysis patients. The intervention showed capacity to increase substantially completion of advance care directives. The HIGHway Project, adapted from the previous SDM-RSC, scale up training social workers or nurses in dialysis center in advance care planning (ACP), and then support them for a subsequent 9-month action period, to engage in ACP conversations with patients at their dialysis center regarding their preferences for end-of-life care.MethodsWe will train between 50–60 dialysis teams, led by social workers or nurses, to engage in ACP conversations with patients at their dialysis center regarding their preferences for end-of-life care. This implementation project uses the Knowledge to Action (KTA) Framework within the Consolidated Framework for Implementation Research (CFIR) to increase adoption and sustainability in the participating dialysis centers. This includes a curriculum about how to hold ACP conversation and coaching with monthly teleconferences through case discussion and mentoring. An application software will guide on the process and provide resources for holding ACP conversations. Our project will focus on implementation outcomes. Success will be determined by adoption and effective use of the ACP approach. Patient and provider outcomes will be measured by the number of ACP conversations held and documented; the quality and fidelity of ACP conversations to the HIGHway process as taught during education sessions; impact on knowledge and skills; content, relevance, and significance of ACP intervention for patients, and Supportive Kidney Care (SKC) App usage. Currently HIGHway is in the recruitment stage.DiscussionEffective changes to advance care planning processes in dialysis centers can lead to institutional policy and protocol changes, providing a model for patients receiving dialysis treatment in the US. The result will be a widespread improvement in advance care planning, thereby remedying one of the current barriers to patient-centered, goal-concordant care for dialysis patients.Trial registrationThe George Washington University Protocol Record NCR213481, Honoring Individual Goals and Hopes: Implementing Advance Care Planning for Persons with Kidney Disease on Dialysis, is registered in ClinicalTrials.gov Identifier: NCT05324878 on April 11th, 2022.

My Journey Through a Kidney Transplant Procedure.

My Journey Through a Kidney Transplant Procedure James Moran Polycystic Kidney Disease is hereditary. My grandmother died at home before dialysis was readily available. My mother, uncle, and great aunt all had dialysis treatments for extended periods of time and eventually died. My uncle was most fortunate in that he had a heart attack while on dialysis. My mother and great aunt suffered through the disease before it consumed them. The magic age for adult onset PKD requiring dialysis is in the early fifties. First diagnosed at age 25, I watched my creatinine levels increase over the years and knew what awaited me. I was 52 when my nephrologist said it was time for me to have the surgical procedure to attach a vein to an artery in my left arm. This arteriovenous fistula is the access point for dialysis. He said that I would probably need dialysis within about three months. It was about one year more before I really needed it. Even though it was an eventuality we had expected for over 25 years, my wife said: “I thought we had more time.” I considered myself fortunate to have dialysis available and so close. The center was about ten minutes from my house. The 5:30 AM appointment time was not my first choice, but it did enable me to continue working and still have evenings at home with my family. The initial few months are called the “honeymoon” period. Things were going well, I was tolerating the treatments, and I felt better. Why would I need a transplant? I attended a pre-transplant session at a hospital at my wife’s insistence. I really had reservations about the process. Except for the out-patient AV fistula surgery, I had not been “under the knife” and never had a hospital stay. A pre-transplant session at a different hospital was even more graphic and made me less enthusiastic. Eventually, dialysis became more difficult and I felt more fatigued. It was more disruptive and vacations always created scheduling issues. Both hospitals as well as the dialysis team, encouraged me to look for a live donor. They suggested that I contact family members and friends to tell them I was in need of a kidney donor. My oldest son who was 21 at the time offered immediately without being asked. Personally, I felt reluctant to put someone else at risk for me even though they assured me that the donor would remain safe and my outcome would be better. I reluctantly placed myself on the transplant list and received dialysis for about four years before a cadaver kidney became available. The story of the call from the transplant clinic was interesting. My transplant surgeon had told me that I would need a bilateral nephrectomy because my polycystic kidneys were large and infected. He said that they needed to be removed before the transplant, but the removal should be delayed until I was closer to the top of the transplant list as it would add extra stress on my body. After about three years on dialysis, I received my first call. I declined the kidney and scheduled the nephrectomy. This surgery was difficult and I was in a lot of pain. The following year was brutal while I waited for the next call. Without my native kidneys, I was no longer producing urine and I had severe limitations on fluid intake. This was most unbearable during hot summer days. The long wait between the first and second calls was exacerbated by a nearby transplant center being closed as people transferred their wait time to the center on which I was listed. In the ideal scenario, I would have received a call soon after the nephrectomy had healed. The second call came while I was on a Boy Scout camping trip. I had been involved in Boy Scouts for 25 years in varying capacities but many as Scout-master and frequently camping. I probably spent several hundred nights in a tent. On this trip, I had no cell signal inside the camp. My wife received the call at home and, after failing to reach me, drove to our camp and walked...

Challenges Faced by Dialysis Unit Staff During COVID-19 Times: A Qualitative Study

Background: The Coronavirus has caused an epidemic affecting the whole world for the last two years and has been spreading steadily. The hemodialysis patients are at high risk because of their lowered immunity status. The dialysis staff is also at higher risk of contracting COVID-19 as these patients come for twice/thrice weekly treatment sessions. Objectives: This study was done to study the hardships and problems afflicting the dialysis staff during the infections caused by COVID-19 in a rural hemodialysis unit. Methods: This study setting was the hemodialysis unit located in a rural hospital in Pondicherry, India. Free listing and pile sorting were done to study the structure and salient problems as felt in the cognitive domain by the dialysis team. Smith's S value was calculated for a free listing. Multidimensional scaling and cluster analysis were conducted to do pile sorting of data. Data were analyzed using Anthropac 4.983/X. Group interviews were carried out to get in-depth information and validate the findings obtained from the free list and pile sorting exercise. Results: Twelve salient items were obtained from the free list. Three broad domains emerged: the absence of personal safety, shortage of personal safety equipment, and presence of logistical and operational problems. Surprisingly, RT-PCR testing was not perceived to be of importance for them. Conclusions: Accepting the true feelings, fears, and needs of the dialysis staff, helping to tackle the impediments to personal safety, and the lack of personal safety equipment in a dialysis unit during COVID-19 outbreak are vital in ensuring personal safety and improving working dynamics.

MO851: Impact of COVID-19 on Dialysis Patients: Reported Experience in Qatar

Abstract BACKGROUND AND AIMS Patient-centred care is a concept focussing on meeting the specific health needs of patients as expressed by them. There is increasing evidence to show that patient centred care can help to achieve higher rates of patient satisfaction, clinical outcomes and overall better experience, particularly for patients with chronic disease. Patients Reported Experience Measures (PREM) is another concept associated with patient-cantered care. PREM surveys capture information about the healthcare experience as perceived by patients. Its importance lies in the incorporation of patient feedback into the clinical decisions and service evolution. Dialysis patients play an important role in their treatment and their voice matters to provide proper care. PREM was first conducted in 2019 in our dialysis unit including 200 patients. In 2020, COVID-19 impacted the dialysis services and resulted in many challenges including staff shortage and deployment. METHOD We used a validated questionnaire from the National Health Service in United Kingedm. It consisted of 7 questions covering demographics, dialysis options, patient portal, patient's relationship with the staff, teamwork and travelling abroad. The survey involved 317 randomly selected patients who have been at least 1 year on dialysis. We performed a comparison of the 2019 and 2020 results using Chi-squared test. RESULTS 257 patients on hemodialysis and 60 on peritoneal dialysis participated in the survey. Majority of the surveyed patients (65%) were on dialysis from 1–5 years and 32% with more than 5 years’ survival on dialysis. Sixty five % of patients responded that they were on follow up in nephrology or low clearance clinic before starting dialysis. Access to dialysis team, nurses and doctors from home declined in 2020 due to the shortage of staff in the dialysis services and deployment of many staff to COVID-19 facilities, 62% of surveyed patients were able to contact their care givers from home compared with 87% in 2019 (P < 0.0001). Regarding education, 78% of the patients responded that they received education before starting dialysis and it was in an understandable manner while patients' response to the same question was 85% in 2019 (P = 0.047). 44% received education on side effects, which is remarkably less compared with 74% in 2019 (P = 0.0001). CONCLUSION Patient reported experience helps in the evaluation of health services. Exploring patient experience in dialysis patients in Qatar, we found negative impact of COVID-19 from patients’ perspectives. Our PREM survey showed significant decline in many parameters likely attributed to COVID-19 consequences including the shortage of staff.

Evaluation of Complications of Peritoneal Dialysis Catheter in Children: A Retrospective Single Center Study

Introduction:Peritoneal dialysis is a long-term method of dialysis for children. Peritoneal dialysis, when performed effectively, saves valuable time for children with advanced kidney transplant, till they reach the appropriate age for the kidney transplant. In children, due to their rapid physical growth and the large catheter size, as well as the thin and weak abdominal wall, especially before the age of 4, the complications of catheterization such as catheter leak and incisional hernia are higher than that of adult population. In this study we aim to evaluatethedysfunction and complications of the cathetersof peritoneal dialysis in children. Materials and Methods:We assessedmedical records of all patients, who underwent peritoneal dialysis since 2006 till 2015 at Mofid hospital, Tehran, Iran. Total number of 41 records were evaluated, of which 11 cases were excluded dueto incomplete data and 30 patients were analyzed eventually.Complications of catheter were recorded. Results:We studied 30 patients, 14 males and 16 females; the mean age of the children was 72.6 months(5 to 12 years old). The leading cause of end stage renal disease(ESRD) were primary glomerulopathies. There were total of 3 catheterreplacements,mostly due to peritonitis and catheter obstruction. The incidence of infectious complications was 40.3%. The incidence of all complications was 1 out of 6.4 patients/month. Conclusion: Regarding the high prevalence of catheter-related complications in children undergoing chronic peritoneal dialysis, especially infectious complications, adopting standard surgical technique of catheter insertion accompanied bywell trained peritoneal dialysis team isessential to prevent the complications and to increase the functional life span of the catheter and to enhance the quality of life of the patient.

Qualidade de vida, aspectos clínicos e sociodemográficos de indivíduos com doença renal crônica em hemodiálise

Este é um estudo transversal, quantitativo e descritivo, realizado em Uberaba-MG de agosto de 2016 a fevereiro de 2017, com objetivo de avaliar e correlacionar aspectos sociodemográficos e clínicos com a qualidade de vida de indivíduos com doença renal crônica em hemodiálise. Utilizaram-se os seguintes instrumentos, aplicados em 51 participantes: questionários com informações sociodemográficas/clínicas e o KidneyDiseaseandQualityof Life Short Form 1.3, pontuado pelo “ScoringProgram (v2.0)”. Foram realizadostestes de normalidade e análise inferencial de correlação. Os domínios com melhores resultados foram “Função Sexual”, “Função Cognitiva” e “Apoio da equipe da diálise”, e os piores “Situação de trabalho”, “Papel da limitação física” e “Saúde Física”. Os domínios “funcionalidade física” e “Saúde Física” correlacionaram-se negativamente com idade (r=-0,521 e r=-0,380, respectivamente) e “Saúde Geral” e “Efeitos da doença renal” com peso seco (r=-0,319 e r=-0,502, respectivamente).Esses resultados indicam o comprometimento da qualidade de vida, necessitando de atenção geral a esses indivíduos junto a ações que promovam melhores condições gerais de saúde.

POS-796 "MY PARENT HAS END-STAGE RENAL DISEASE": EXPLORING THE UNMET NEEDS OF ADULT CHILDREN CARING FOR THEIR PARENTS ON HEMODIALYSIS

In-center hemodialysis (HD) is the most common treatment for patients with end-stage renal disease (ESRD). This treatment is highly demanding and associated with complications (e.g. hypotension crises, cardiac disease) that increase patients’ dependence on family members. For older patients, adult children generally assume the role of the primary caregiver. However, caring for a parent with ESRD is a stressful experience due to the several requirements that this disease entails such as fluid and diet restrictions, vascular access care, and poly-pharmacy protocols. Also, adult children have their responsibilities to manage, namely their marital relationships, young children, and jobs. However, to date and to the best of our knowledge, the unmet needs of adult children caring for parents undergoing in-center HD have never been explored. This study aims to explore the unmet needs of adult children caring for their parents with ESRD undergoing in-center HD. A qualitative exploratory study was conducted with a purposive sample. Semi-structured face-to-face interviews were conducted with 19 adults (44.9 ± 11.7 years old) caring for their parents undergoing in-center HD for an average of 39.8 (± 36.4) months. The interviews were digitally audio-recorded, transcribed verbatim, and submitted to content analysis by two independent researchers. Six unmet needs were identified: i) lack of support and recognition of the caregiver role from other family members (n=9); ii) lack of sufficient information about nutritional restrictions (the need for written information delivered directly to the caregiver and how to develop creative meals; n=6); iii) need of first aid assistance skills (to deal with hypotension crises and hemorrhages at home; n=5); iv) need of psychological support (to help face caregiving burden and to help the patient cope with ESRD; n=5); v) improve communication skills (learn how to communicate with a difficult patient/parent and improve communication with health professionals; n=3); and vi) social and financial support (to face disease’ expenses with meal preparation and transport to dialysis; n=3). Adult children caring for a parent with ESRD have identified a multitude of unmet emotional, relational, and educational needs. The dialysis team can play an important role in mitigating those needs, by developing multidisciplinary interventions combining an educational and a supportive component. These interventions should focus on maximizing disease management skills while providing emotional support and facilitating communication with the healthcare renal team.

Caring for patients with end-stage renal disease during COVID-19 lockdown: What (additional) challenges to family caregivers?

IntroductionCaring for a patient with end‐stage renal disease undergoing in‐centre haemodialysis can be a stressful experience, likely to involve significant burden. Within the context of the new coronavirus pandemic, these patients are highly vulnerable to infection by COVID‐19, which might increase the care demands and burden of family caregivers.AimThis study aimed to explore the subjective experiences of family caregivers of non‐COVID‐19 patients with end‐stage renal disease undergoing in‐centre haemodialysis during the COVID‐19 lockdown.Study designA qualitative study was performed with a purposive sample.MethodsSemi‐structured telephone interviews were conducted with 19 family caregivers (50.7 ± 14 years old) of patients undergoing in‐centre haemodialysis in April 2020.FindingsFour major themes were identified: (1) emotional distress; (2) changes in caregiving responsibilities; (3) educational and supportive needs; and (4) coping strategies to deal with the outbreak and with the lockdown.DiscussionThe findings suggest that family caregivers of patients undergoing in‐centre haemodialysis have to manage several additional care responsibilities due to COVID‐19 lockdown. The dialysis team should consider the development of educational and supportive interventions to meet family caregivers’ needs, mitigate emotional distress, fears and concerns, and prevent caregiver burden during the COVID‐19 pandemic.

Evaluation of quality of life and functionality of patients chronic renal in hemodialysis treatment

Introduction: Chronic Renal Disease (CKD) is an insidious, asymptomatic, progressive and irreversible renal damage. Added to hemodialysis treatment triggers negative effects on the cardiorespiratory, musculoskeletal system and quality of life (QOL). Therefore, we sought to evaluate functionality, quality of life and respiratory muscle strength and peak expiratory flow in patients with chronic renal failure on hemodialysis. Materials and methods: A cross-sectional and descriptive study, with a convenience sample of 30 individuals. An individual identification form, the Kidney Disease and Quality-of-Life Short-Form (KDQOL- SF) quality of life assessment instrument and the Functional Independence Measure (FIM) instrument were used. Also, specific tests for evaluation of respiratory muscle strength (RMS) and peak expiratory flow (PEF). Results: A homogeneous sample characterized as old adults with low schooling, and mostly hypertensive and diabetic. Individuals with complete functional independence (FIM: 118.13±17.1). There was a great decline in respiratory muscle strength and peak expiratory flow, about 40-50% of predicted values. With significant impact on the situation of work and sexual function, 25±42.9 and 45.5±44.3, respectively. Positive values were obtained on social interaction and stimulation by the dialysis team. Conclusion: It was concluded that there are no impacts on its functionality. However, there is a significant decline in respiratory functional parameters, such as respiratory muscle strength and peak expiratory flow, as well as in the health-related quality of life of chronic renal patients undergoing hemodialysis treatment.

Association of Chronic Condition Special Needs Plan With Hospitalization and Mortality Among Patients With End-Stage Kidney Disease

While several studies have demonstrated the benefit of enrollment in chronic condition special needs plans (C-SNPs) for other chronic diseases (eg, diabetes), there is no evaluation of the association of C-SNPs with outcomes among patients with end-stage kidney disease (ESKD). To examine whether and to what degree C-SNP enrollment was associated with improved clinical outcomes and quality of life in patients with ESKD. This multicenter cohort study included 2718 patients who were newly enrolled in an ESKD C-SNP between January 1, 2013, and September 30, 2017, and receiving dialysis from DaVita Kidney Care. Patients were followed up until death, loss to follow-up, or end of study (ie, December 31, 2018). Enrollees in C-SNP were matched via multiple clinical and demographic characteristics with 2 different control populations, as follows: (1) those in the same facilities (n = 2545) or (2) those in similar counties (n = 1986). Patients enrolled in CareMore C-SNPs (n = 206) were excluded from the study. Data analysis was conducted June to December 2019. Standard ESKD care with dialysis plus access to an integrated care team who worked with the patient and the dialysis team, comprehensive health assessments done by the integrated care team, and access to select benefits (such as vision and dental care) as a C-SNP enrollee. Hospitalizations, mortality, laboratory values indicative of metabolic control, and Kidney Disease Quality of Life 36-item (KDQOL-36) survey scores. The 2545 C-SNP enrollees in the facility-matched analysis had a mean (SD) age of 57.2 (12.9) years, and included 968 (38.0%) women, 1328 (52.2%) Hispanic individuals, and 553 (21.7%) African American individuals. The 1986 C-SNP enrollees in the county-matched analysis had a mean (SD) age of 57.8 (12.2) years, with 705 (35.5%) women, 1085 (54.6%) Hispanic individuals, and 472 (23.8%) African American individuals. Compared with patients not enrolled in C-SNP, enrollees had lower hospitalization rates, with incidence rate ratios of 0.90 (95% CI, 0.84-0.97; P = .006) in the facility-matched analysis and 0.76 (95% CI, 0.70-0.83; P < .001) in the county-matched analysis. Compared with patients not enrolled in C-SNP, enrollees had decreased mortality risk in the same facilities (hazard ratio, 0.77; 95% CI, 0.68-0.88; P < .001) and in the same counties (hazard ratio, 0.77; 95% CI, 0.66-0.88; P < .001). No significant differences were observed between C-SNP enrollees and matched patients in metabolic laboratory values or KDQOL-36 survey scores. This cohort study found a positive association of C-SNP enrollment with lower rates of hospitalization and mortality. The findings suggest that the additional services and benefits C-SNPs provide may improve outcomes compared with standard of care for patients with ESKD.

Patients' and caregivers' expectations and experiences of remote monitoring for peritoneal dialysis: A qualitative interview study.

Peritoneal dialysis (PD) can offer more flexibility and independence compared with hemodialysis, yet uptake of PD remains low. Barriers to PD include the fear of dialyzing without medical assistance and uncertainty about recognizing and managing complications. There is increasing use of remote monitoring in automated peritoneal dialysis (APD), but little is known about its acceptability by patients and caregivers. We aimed to describe patients' and caregivers' expectations and experiences of remote monitoring for APD. Qualitative study design, using semi-structured face-to-face interviews of patients who either receiving PD or were considered eligible for PD, and their caregivers. Transcripts were analyzed using thematic analysis. Of the 34 participants, 27 were patients and the remainder caregivers. Four themes (with subthemes) were identified reducing patient burden (seeking reassurance and shared responsibility, convenience and accuracy); strengthening partnerships in care (empowering knowledge and understanding, increased accountability to dialysis team); improving access to treatment (saving time and money, providing timely care and avoiding hospital); and preserving quality patient-provider interactions (enhancing face-to-face contact, clarifying expectations of access and use of data). Remote monitoring may increase patient knowledge about their kidney disease and its treatment, encourage accountability to the clinical team, enhance partnerships with clinicians, and improve access to treatment and timely care. It is also important to ensure that remote monitoring does not replace face-to-face clinical contact with clinicians.

Telehealth for Home Dialysis in COVID-19 and Beyond: A Perspective From the American Society of Nephrology COVID-19 Home Dialysis Subcommittee

The coronavirus disease 2019 (COVID-19) pandemic, technological advancements, regulatory waivers, and user acceptance have converged to boost telehealth activities. Due to the state of emergency, regulatory waivers in the United States have made it possible for providers to deliver and bill for services across state lines for new and established patients through Health Insurance Portability and Accountability Act (HIPAA)- and non–HIPAA-compliant platforms with home as the originating site and without geographic restrictions. Platforms have been developed or purchased to perform videoconferencing, and interdisciplinary dialysis teams have adapted to perform virtual visits. Telehealth experiences and challenges encountered by dialysis providers, clinicians, nurses, and patients have exposed health care disparities in areas such as access to care, bandwidth connectivity, availability of devices to perform telehealth, and socioeconomic and language barriers. Future directions in telehealth use, quality measures, and research in telehealth use need to be explored. Telehealth during the public health emergency has changed the practice of health care, with the post–COVID-19 world unlikely to resemble the prior era. The future impact of telehealth in patient care in the United States remains to be seen, especially in the context of the Advancing American Kidney Health Initiative.

Home Dialysis in the Coronavirus Disease 2019 Era.

The coronavirus disease 2019 pandemic has had a significant impact on patients with end-stage kidney disease and their care, especially given the potential for severe coronavirus disease 2019 in those with a depressed immune status. Patients receiving in-center hemodialysis have been particularly affected by this pandemic because of their need to travel multiple times a week to receive treatment. Although patients on home dialysis are able to avoid such exposure, they face their own unique challenges. In this review, we will discuss the challenges posed by the coronavirus disease 2019 pandemic for patients on home dialysis, the impact of coronavirus disease 2019 on various aspects of their care, and the resultant rapid adaptations in policy/health-care delivery mechanisms with implications for the future care of patients on home dialysis.

Early Use of Telehealth in Home Dialysis during the COVID-19 Pandemic in New York City.

The current coronavirus disease 2019 (COVID-19) pandemic is forcing unprecedented changes in daily life in the United States. During this time, many patients are under “lockdown” or “shelter-in-place” orders, and the nephrology community has been forced to adapt quickly to this new reality. New York City is the epicenter of the American outbreak, and patients on dialysis are at especially high risk of COVID-19 exposure due to widespread use of public transportation and densely packed clinical spaces. Here, we report the early use and success of using telehealth visits in place of usual in-person monthly comprehensive visits in an effort to provide excellent patient care while limiting the risk of patient and staff exposure to COVID-19. Telehealth has distinct advantages during this crisis for the vulnerable home dialysis population; however, many practical challenges remain. Under the 2018 Bipartisan Budget Act, the Centers for Medicare & Medicaid Services (CMS) allowed patients on home dialysis to choose to have their monthly ESKD clinical assessments through telehealth. However, restrictions have remained, and the use of telehealth was only available after completing in-person visits for the first 3 months of home dialysis; additionally, only two of three monthly visits each quarter were eligible for telehealth thereafter (1). On March 20, 2020, the CMS released a telemedicine and telehealth toolkit for ESKD providers to help providers establish and operate a telehealth program to increase access to health care for patients at home and especially patients on dialysis who are at significant risk of morbidity and mortality if infected by COVID-19 (2). As of March 27, 2020, New York City has over 25,000 cases of COVID-19, with the number rising each day (3). The Rogosin Institute is an independent dialysis provider affiliated with New York-Presbyterian Hospital with a home dialysis population of 210 patients: …