Home Dialysis Program Research Articles

Integrated home dialysis model: facilitating home-to-home transition

ABSTRACT Peritoneal dialysis (PD) and home hemodialysis (HHD) are the two home dialysis modalities offered to patients. They promote patient autonomy, enhance independence, and are generally associated with better quality of life compared to facility hemodialysis. PD offers some advantages (enhanced flexibility, ability to travel, preservation of residual kidney function, and vascular access sites) but few patients remain on PD indefinitely due to peritonitis and other complications. By contrast, HHD incurs longer and more intensive training combined with increased upfront health costs compared to PD, but is easier to sustain in the long term. As a result, the integrated home dialysis model was proposed to combine the advantages of both home-based dialysis modalities. In this paradigm, patients are encouraged to initiate dialysis on PD and transfer to HHD after PD termination. Available evidence demonstrates the feasibility and safety of this approach and some observational studies have shown that patients who undergo the PD-to-HHD transition have clinical outcomes comparable to patients who initiate dialysis directly on HHD. Nevertheless, the prevalence of PD-to-HHD transfers remains low, reflecting the multiple barriers that prevent the full uptake of home-to-home transitions, notably a lack of awareness about the model, home-care “burnout,” clinical inertia after a transfer to facility HD, suboptimal integration of PD and HHD centers, and insufficient funding for home dialysis programs. In this review, we will examine the conceptual advantages and disadvantages of integrated home dialysis, present the evidence that underlies it, identify challenges that prevent its success and finally, propose solutions to increase its adoption.

Patient Training and Patient Safety in Home Hemodialysis.

The success of a home hemodialysis program depends largely on a patient safety framework and the risk tolerance of a home dialysis program. Dialysis treatments require operators to perform dozens of steps repeatedly and reliably in a complex procedure. For home hemodialysis, those operators are patients themselves or their care partners, so attention to safety and risk mitigation is front of mind. While newer, smaller, and more user-friendly dialysis machines designed explicitly for home use are slowly entering the marketplace, teaching patients to perform their own treatments in an unsupervised setting hundreds of times remains a foundational programmatic obligation regardless of machine. Just how safe is home hemodialysis? How does patient training affect this safety? There is a surprising lack of literature surrounding these questions. No consensus exists among home hemodialysis programs regarding optimized training schedules or methods, with each program adopting its own approach on the basis of local experience. Furthermore, there are little available data on the safety of home hemodialysis as compared with conventional in-center hemodialysis. This review will outline considerations for training patients on home hemodialysis, discuss the safety of home hemodialysis with an emphasis on the risk of serious and life-threatening adverse effects, and address the methods by which adverse events are monitored and prevented.

Setting Up Home Dialysis Programs: Now and in the Future.

Home dialysis utilization has been growing in the United States over the past decade but still lags behind similar socioeconomic nations. More than half of dialysis facilities in the United States either are not licensed to offer home dialysis or, despite a license, have no patients dialyzing at home, and many programs have a relatively small census. Multiple stakeholders, including patients, health care providers, and payers, have identified increased home dialysis use as an important goal. To realize these goals, nephrologists and kidney care professionals need a sound understanding of the key considerations in home dialysis center operation. In this review, we outline the core domains required to set up and operate a home dialysis program in the United States now and in the future.

Quantification of Recyclable Peritoneal Dialysis Plastics in a Home Dialysis Program–An Opportunity for Resource Stewardship

Climate change is the greatest threat to human health. An estimated 4.6% of global annual greenhouse gas (GHG) emissions arise from health care.1 Rising temperatures and heat stress can cause dehydration resulting in stone disease, acute kidney injury (AKI) and chronic kidney disease (CKD).2

Utilization of Peritoneal Dialysis in the United States: Progress in Tackling Obstacles to Expansion.

To facilitate the desired increase in home dialysis utilization in the United States, multiple factors need to be taken into consideration in order to achieve this complex task. Through policy-level facilitators such as the Advancing American Kidney Health Initiative and the expansion of telehealth utilization, adjustments to the existing payment models, providing health equity incentives, increasing number of provider education materials on home therapies, and allaying patient fears with the expansion of home dialysis education nationwide, we have taken several steps in the right direction. There is still a long way to go, and further improvements can be made while utilizing lessons learned from some of our international peers who have been successful in their implementation of large-scale home dialysis programs.

Evaluation of the experience with the use of telemedicine in a home dialysis program—a qualitative and quantitative study

IntroductionAssisted home hemodialysis is a therapeutic modality for patients diagnosed with end-stage renal disease who require dialysis replacement therapy and have concomitant health limitations that prevent them from attending a satellite dialysis unit or performing their own treatment.ObjectiveThe main objective of this study was to evaluate whether telemedicine provided through telemonitoring can improve the ongoing relationship between the doctor, the nurse and the patient.MethodThis prospective longitudinal, qualitative and quantitative study analyzes the impact of telemedicine through an evaluation of the experiences of patients and nurses. During the study, we performed remote weekly monitoring for 6 months.ResultsA total of 17 patients and 12 nurses were included. We observed that the patients and nurses had positive experiences with telemonitoring and highlighted feelings of being cared for and improved confidence, although they indicated that telemonitoring does not replace face-to-face visits.ConclusionTelemonitoring is a useful tool to increase satisfaction with and confidence in home hemodialysis.

Changes in patient activation in people starting dialysis: A prospective longitudinal, observational study.

IntroductionIncreased patient activation is associated with improved health outcomes; however, little is known about patient activation in people with end‐stage kidney disease at the start of their dialysis journey. This study aimed to measure activation status changes over the first 4 months of dialysis.MethodsProspective, longitudinal, and observational study. Incident patients initiating dialysis at 25 in‐center hemodialysis and 17 home dialysis programs across three US states managed by the same dialysis provider completed the 13‐item Patient Activation Measure (PAM‐13) survey at baseline (month 1 after commencement of dialysis) and follow‐up (month 4). The survey yields a score (0–100) that corresponds to four levels (1–4), with higher scores or levels indicating higher activation.FindingsOne hundred eighty‐two participants (139 center, 43 home) completed both baseline and follow‐up surveys. Mean age was 60 ± 15 years, 40% female. Mean PAM‐13 scores were 65.1 ± 16.8 and 64.8 ± 17.8 at baseline and follow‐up, respectively; mean intraindividual change: −0.3 ± 17.3. The proportions of patients at levels 1–4 at baseline were 11%, 23%, 35%, and 31% respectively. At follow‐up, 50%, 64%, 52%, and 37% of participants at levels 1–4, respectively, changed to a different PAM level (Spearman correlation = 0.47; p < 0.001). Home dialysis was associated with higher PAM scores when compared to in‐center hemodialysis in multivariable analyses, adjusted for sociodemographic variables, comorbidities, and predialysis nephrology care (β = 5.74, 95% confidence intervals [CI]: 0.11–11.37 and 9.02, 95% CI: 3.03–15.02, at baseline and follow–up, respectively).DiscussionAlthough aggregated group scores and levels remained stable, intra‐individual patient activation changed significantly during the first 4 months of dialysis. This novel finding is foundational to future projects aiming to design interventions to improve patient activation.

ETC Model: How One Small Dialysis Organization Is Navigating Uncharted Policy Waters.

The ETC model proposes to increase access to home dialysis and transplant for patients with ESRD. Implementation of this model is happening while many dialysis organizations are still suffering the far-reaching effects of the coronavirus disease 2019 (COVID-19) pandemic. In addition, the model has the potential to negatively affect small and independent dialysis organizations disproportionately. It incentivizes home dialysis over transplant and promotes development of new home dialysis programs, rewards achievement over improvement, and places an excessive burden on small and independent dialysis organizations. Advantages of the program include the focus on self-care as an acceptable alternative to home dialysis for some patients and the potential for some organizations to make improvements in care with increased reimbursements. The authors hope that the Centers for Medicare and Medicaid Services will address many of these concerns in updated rulemaking and guidance.

From Home Dialysis Access to Home Dialysis Quality.

The number and percentage of patients dialyzing at home has steadily increased during the past decade, and federal policy initiatives have driven interest to a new high. However, the mere utilization of home dialysis does not ensure better outcomes for patients and care partners. Although public reporting systems for dialysis quality are mature and robust, the incorporation of home dialysis quality in those systems is immature; the advent of the End-Stage Renal Disease Treatment Choices payment model brings this problem into sharp relief. The home dialysis modalities present both common and unique targets for quality measurement. For both modalities, therapy duration (or its inverse, technique failure) is a potential target. For peritoneal dialysis, peritonitis, catheter complications, and residual kidney function are additional targets; for home hemodialysis, vascular access infections, dialysis adequacy, and treatment adherence are targets. Patient-reported experience measures are also important; this domain is a long-standing disparity, as in-facility hemodialysis patients have been routinely surveyed for several years. The statistical aspect of quality measurement in home dialysis requires some adaptation, as the typical home dialysis program is small, thus presenting a threat to reliability; pooling programs may be necessary. Ultimately, promoting high-quality home dialysis will likely increase utilization of home dialysis.

Challenges, Facilitators, and Recommendations for Implementation of Home Dialysis in the Veterans Health Administration: Patient, Caregiver, and Clinician Perceptions.

Home dialysis confers similar survival and greater quality of life than in-center hemodialysis for adults with ESKD but remains underutilized. We examined challenges and facilitators to implementation of home dialysis and identified stakeholder-centered strategies for improving it. We conducted a qualitative, cross-sectional, multisite evaluation that included five geographically dispersed Veterans Health Administration (VHA) home dialysis programs. Participants included patients with ESKD receiving home dialysis, their informal caregivers, and home dialysis staff. Semistructured telephone interviews were conducted and audio-recorded from 2017 through 2018, to assess perceived barriers and facilitators to patient home dialysis use in VHA. Transcribed interviews were analyzed thematically by each participant group. Participants included 22 patients receiving home dialysis (18 on peritoneal dialysis [PD] and four hemodialysis [HD]); 20 informal caregivers, and 19 home dialysis program staff. Ten themes emerged as challenges to implementing home dialysis, of which six (60%) spanned all groups: need for sterility, burden of home dialysis tasks, lack of suitable home environment, physical side effects of home dialysis, negative psychosocial effects of home dialysis, and loss of freedom. Four themes (40%), identified only by staff, were insufficient self-efficacy, diminished peer socialization, geographic barriers, and challenging health status. Twelve themes emerged as facilitators to implementing home dialysis, of which seven (58%) spanned all groups: convenience, freedom, avoidance of in-center HD, preservation of autonomy, adequate support, favorable disposition, and perceptions of improved health. Two themes (17%) common among patients and staff were adequate training and resources, and physical and cognitive skills for home dialysis. Recommendations to promote implementation of home dialysis common to all participant groups entailed incorporating mental health care services, offering peer-to-peer coaching, increasing home visits, providing health data feedback, and reducing patient burden. Stakeholder-centered challenges were rigorously identified. Facilitators and recommendations can inform efforts to support home dialysis implementation.

Epidemiology and Outcomes of COVID-19 in Home Dialysis Patients Compared with In-Center Dialysis Patients.

Epidemiology and Outcomes of COVID-19 in Home Dialysis Patients Compared with In-Center Dialysis Patients.

COVID-19: A Home Dialysis Nurse Perspective.

As the nurse supervisor of a home dialysis program, I admit that this has been one of the most challenging times of my dialysis career. The home program training facility is one of seven satellite dialysis facilities in the state of Vermont, and one of five satellite facilities that are under the umbrella of the University of Vermont Medical Center (UVMMC). Due to its physical layout and central location in the state, our training site was the ideal location for the UVMMC coronavirus disease 2019 (COVID-19) dialysis treatment facility. The resultant change in the use of our clinic space, however, has affected both our routine workflow and usual procedure practices, prompting us to reexamine unit operations. Setting up our COVID-19 treatment corridor took careful planning, more planning, and replanning. We designated three of our six private exam rooms as COVID-19 treatment rooms and the hallway became known as the “COVID corridor.” Additional travel staff were hired and a designated COVID-19 staff roster was developed. Our home program uses NxStage machines but, based on the number of estimated cases positive for COVID-19 and the limited number of staff familiar with NxStage technology, we decided to bring in Fresenius machines and portable reverse osmosis machines to dialyze the patients positive for COVID-19 in these rooms. There is a plan in place to employ NxStage machines if the number of patients exceeds the Fresenius fitted room capacity, but we have not needed to do so. Having the right equipment available in the corridor has been essential to provide safe care and eliminate the need to send out for additional items necessary during treatment. Affording easy access to supplies and setting up makeshift storage areas was a struggle due to the limited corridor space, but with a lot of creativity and old-fashioned ingenuity, we …

Setting Up and Expanding a Home Dialysis Program: Is There a Recipe for Success?

Home dialysis modalities remain significantly underused in the United States despite similar overall survival in the modalities, and recent incentives to expand these modalities. Although the absolute number of patients using home modalities has grown, the proportion compared to in-center hemodialysis (ICHD) continues to remain quite low. Well known barriers to home dialysis utilization exist, and an organized and team-based approach is required to overcome these barriers. Herein, we describe our efforts at growing our home dialysis program at a large academic medical center, with the proportion of home dialysis patients growing from 12% to 21% over the past 9 years. We prioritized individualized education for patients and better training for physicians, with the help of existing resources, aimed at better utilization of home modalities; an example includes dedicated dialysis education classes taught twice monthly by an experienced nurse practitioner, as well as the utilization of the dialysis educator from a dialysis provider for inpatient education of patients with CKD. The nephrology fellowship curriculum was restructured with emphasis on home modalities, and participation in annual home dialysis conferences has been encouraged. For timely placement and troubleshooting of access for dialysis, we followed a complementary team approach using surgeons and interventional radiologists and nephrologists, driven by a standardized protocol developed at UAB, and comanaged by our access coordinators. A team-based approach, with emphasis on staff engagement and leadership opportunities for dialysis nurses as well as collaborative efforts from a team of clinical nephrologists and the dialysis provider helped maintain efficiency, kindle growth, and provide consistently high-quality clinical care in the home program. Lastly, efforts at reducing burden of disease such as decreased number of monthly visits as well as using innovative strategies, such as telenephrology and assisted PD and HHD, were instrumental in reducing attrition.

Overcoming Barriers for Uptake and Continued Use of Home Dialysis: An NKF-KDOQI Conference Report

Home dialysis modalities are used in a minority of patients with kidney failure in the United States. During the 2018 National Kidney Foundation-Kidney Disease Outcomes Quality Initiative (NKF-KDOQI) Home Dialysis Conference, numerous ideas were suggested to help minimize barriers for the uptake and retention of home dialysis therapies. First, educational tools are needed to increase knowledge about home dialysis modalities (eg, continuous ambulatory peritoneal dialysis, continuous cycling peritoneal dialysis, and home hemodialysis). Implementation of a hub and spoke model, pairing smaller and/or newer home dialysis programs with larger more sophisticated programs that offer education and mentoring, may help dialysis programs to grow and prosper. This pairing can be facilitated by traditional conferences and newer modalities such as telemedicine and training applications. Peer support to patients, such as that offered through the NKF Peers Program, and support and respite to care partners can have beneficial effects toward both increasing the number of patients who choose home dialysis as a modality and improving retention in home dialysis programs. Anticipating and understanding both patient and care partner burden is important for the development and implementation of patient- and care partner-centered support programs that can be deployed before a patient ceases home therapy. Finally, aligning Medicare reimbursement to support appropriate increased home dialysis uptake to prioritize both transplantation and home dialysis as the first-line treatments for kidney failure.

An Environmental Scan and Evaluation of Home Dialysis Quality Indicators Currently Used in Canada.

Background:Quality indicators are important tools to measure and ultimately improve the quality of care provided. Performance measurement may be particularly helpful to grow disciplines that are underutilized and cost-effective, such as home dialysis (peritoneal dialysis and home hemodialysis).Objective:To identify and catalog home dialysis quality indicators currently used in Canada, as well as to evaluate these indicators as a starting point for future collaboration and standardization of quality indicators across Canada.Design:An environmental scan of quality indicators from provincial organizations, quality organizations, and stakeholders.Setting:Sixteen-member pan-Canadian panel with expertise in both nephrology and quality improvement.Patients:Our environmental scan included indicators relevant to patients on home dialysis.Measurements:We classified existing indicators based on the Institute of Medicine (IOM) and Donabedian frameworks.Methods:To evaluate the indicators, a 6-person subcommittee conducted a modified version of the Delphi consensus technique based on the American College of Physicians/Agency for Healthcare Research and Quality criteria. We shared these consensus ratings with the entire 16-member panel for further examination. We rated items from 1 to 9 on 6 domains (1-3 does not meet criteria to 7-9 meets criteria) as well as a global final rating (1-3 unnecessary to 7-9 necessary) to distinguish high-quality from low-quality indicators.Results:Overall, we identified 40 quality indicators across 7 provinces, with 22 (55%) rated as “necessary” to distinguish high quality from poor quality care. Ten indicators were measured by more than 1 province, and 5 of these indicators were rated as necessary (home dialysis prevalence, home dialysis incidence, anemia target achievement, rates of peritonitis associated with peritoneal dialysis, and home dialysis attrition). None of these indicators captured the IOM domains of timely, patient-centered, or equitable care.Limitations:The environmental scan is a nonexhaustive list of quality indicators in Canada. The panel also lacked representation from patients, administrators, and allied health professionals.Conclusions:These results provide Canadian home dialysis programs with a starting point on how to measure quality of care along with the current gaps. This work is an initial and necessary step toward future collaboration and standardization of quality indicators across Canada, so that home dialysis programs can access a smaller number of highly rated balanced indicators to motivate and support patient-centered quality improvement initiatives.

A decision support system for home dialysis visit scheduling and nurse routing

Over the last years home dialysis has become the preferred treatment option for some patients with kidney failure. However, determining efficient and effective daily home-dialysis service plans imposes multiple challenges to hospital administrators, as it is a complex task with a number of interrelated decisions. These decisions are about the number of nurses required for daily visits and their travel itineraries, and involve multiple (often conflicting) objectives.Working together with physicians and administrators from The Ottawa Hospital (TOH) in Canada, we have developed a system intended to support administrators of nephrology departments in creating daily visit schedules and routes for nurses assisting with dialysis treatment in patients' homes. The decision support system, called Home Dialysis Scheduler System (HDSS), employs a mixed-integer linear programming model to create daily nurse itineraries that minimize the cost of providing home dialysis for a pre-specified group of patients. In developing this model, we also considered nurses' workload balance, overtime work, need for mealtime breaks (lunch or dinner, depending on shift times), restrictions and preferences associated with the time of the visits, and different types of services provided to patients. The model was validated using data provided by the Division of Nephrology at TOH. The interface of the HDSS was developed following the principles of user-centred design and validated with a group of end-users. In the validation stage, daily visit schedules and nurse routes generated by the HDSS were compared to nurse itineraries created manually by hospital administrators. The use of the HDSS resulted in improved workload distribution among nurses, simpler routes, and reduced total distance travelled — which translates into lower costs for the home dialysis program. In this paper, we provide details about the mixed-integer linear programming model, describe the HDSS, and discuss its implementation results and managerial implications.

Home hemodialysis with a central venous catheter

Nowadays, there is a trend towards the development of home dialysis ; more than 300 patients in France benefit from this technique, mostly on a daily rythm (between 4 to 7 sessions per week, in a short period : 2 to 3 hours per session).&#x0D; The majority of patients in home dialysis programs have an arterio-venous fistula as a vascular access. According to the RDPLF reports, only 13 patients dialyse regularly with a central venous catheter.&#x0D; In this article we report the first patient trained for home dialysis making a self-connexion with the Physidia S3 system.

The Benefit of Therapeutic Drug Monitoring of Vancomycin in a Respiratory ICU; A Patient with Acute Kidney Injury: A Case Report

Introduction: Vancomycin damage to the kidney is one of the severe adverse reactions. The primary objective of this study was to discuss how the clinical pharmacists should deal with the results of therapeutic drug monitoring (TDM) for Vancomycin. Case Presentation: A case of severe acute kidney injury in a 60-year-old woman receiving Vancomycin as empirical therapy is reported here. The patient was admitted to the respiratory intensive care unit (RICU) of the First Affiliated Hospital of Bengbu Medical College, China, on 15 Oct 2015. On Day 7, the steady-state serum trough concentration and peak concentration of Vancomycin were 102.2 and 111.9 μg/mL, respectively. Clinical pharmacists immediately contacted the clinicians and advised them to discontinue Vancomycin therapy as soon as possible, and the proposal was adopted. On Day 8, serum creatinine (SCr) increased to 719 μmol/L, and creatinine clearance rate (CrCl) decreased to 6 mL/min; then, the patient was given dialysis treatment. After she underwent dialysis treatment, SCr decreased to 330 μmol/L and CrCl increased to 14 mL/min on Day 19; then, the patient was discharged after she accepted the doctor’s advice to start a home-dialysis program outside the hospital. Conclusions: In this case, clinical pharmacists contacted the doctor to avoid further aggravated renal damage timely when they found a significant increase in Vancomycin concentrations. It indicates that the Vancomycin level can be used as an indirect marker of renal function as increased Vancomycin level results from and contributes to acute kidney injury.

Supporting the Establishment of New Home Dialysis Programs Through the Explore Home Dialysis Program

IntroductionThe globally increasing prevalence of chronic kidney disease has resulted in an ever-growing demand for renal replacement therapy. Although programs are present around the world, there is a paucity of immersive educational programs that train clinicians and administrators to develop new home dialysis programs. Explore Home Dialysis (EHD) is a program created to fill this gap.MethodsWe present the results of the evaluation of the EHD program. Our team interviewed 23 clinicians and administrators who participated in the EHD program. We also assessed country-specific needs and challenges associated with home dialysis.ResultsThe 4 main findings include (i) the evaluation of the effectiveness of the EHD program; (ii) the need for an educational program to train individuals on how to deploy home dialysis programs; (iii) evidence that such an educational program is beneficial to participants and for the establishment of new home dialysis programs; and (iv) the identification of barriers to the development of home dialysis programs in countries represented in this study. The data show an increased demand, with strong patient and provider interest in establishing new programs, interest in accessing resources to train clinical and administrative staff in how to run a home dialysis program, and positive feedback about the EHD program in general.ConclusionsThe data from this study were used in the next iteration of the EHD program, to inform clinicians about challenges in the deployment of new home dialysis programs, and to present educational resources that need to be developed in the future.

Prevalence-Based Targets Underestimate Home Dialysis Program Activity and Requirements for Growth.

Many renal programs have targets to increase home dialysis prevalence. Data from a large Canadian home dialysis program were analyzed to determine if home dialysis prevalence accurately reflects program activity and whether prevalence-based assessments adequately reflect the work required for program growth. Data from home dialysis programs in British Columbia, Canada, were analyzed from 2005 to 2015. Prevalence data were compared to dialysis activity data including intakes and exits to describe program turnover. Using current attrition rates, recruitment rates needed to increase home dialysis prevalence proportions were identified. We analyzed 7,746 patient-years of peritoneal dialysis (PD) and 1,362 patient-years of home hemodialysis (HHD). The proportion of patients on home dialysis increased by 3.34% over the ten years examined, while the number of prevalent home dialysis patients increased 2.65% per year and the number of patients receiving home dialysis at any time in the year increased 4.04% per year. For every 1 patient net home dialysis growth, 13.6 new patients were recruited. Patient turnover included higher rates of transplantation in home dialysis than facility-based HD. Overall, the proportion dialyzing at home increased from 29.3 to 32.6%. There is high patient turnover in home dialysis such that program prevalence is an incomplete marker of total program activity. This turnover includes high rates of transplantation, which is a desirable interaction that affects home dialysis prevalence. The shortcomings of this commonly used metric are important for renal programs to consider, and better understanding of the activities that support home dialysis and the complex trajectories that home dialysis patients follow is needed.