Home Therapies Research Articles

THE AUSTRALIAN AND NEW ZEALAND DIALYSIS WORKFORCE STUDY IN THE INTERNATIONAL CONTEXT

Given increasing demand for renal replacement therapy, this study sought to identify of key workforce issues facing dialysis units, based on a "snapshot" of the current workforce. A web-based survey of all dialysis unit managers in Australia and New Zealand, in October 2008, about their workforce. A significant minority of dialysis staff in most regions were not registered nurses. Many renal registered nurses worked part-time. Staff/patient ratios in dialysis units varied significantly by region, reflecting the relative prevalence of home therapies. Most dialysis units were generally adequately staffed. The proportion of registered nurses with specific renal qualifications varied significantly by region. The changing character of the workforce in the dialysis unit in the future will require clarification of the relationships between different categories of dialysis staff. Specialty education for nurses needs to be oriented to equipping staff to be effective in their changing work environment.

Should We Rely only on Physician-Diagnosed Arthritis?

The purpose of this study was to compare Latinos who have chronic joint pain symptoms that have been diagnosed as arthritis by a physician with those who have chronic joint pain symptoms but have not received a physician's diagnosis of arthritis. This study is based on a recently completed survey of 588 Latinos interviewed, using a convenience sampling approach. Of the 576 Latinos with chronic joint pain, 45% were physician-diagnosed with arthritis. For all age groups, using the chi-square test, we found no differences between the two groups in terms of over-the-counter drug use, application of home therapies, use of vitamins, and self-assessed health status. Physician-diagnosed participants were more likely to have health insurance, to have seen a health professional, to use prescription drugs, and to have co-morbid conditions. Eliminating the question about chronic joint pain symptoms from BRFSS poses potential harm to the uninsured and to minority populations by underestimating the burden of arthritis on this population.

The Economics of Home Dialysis: Acting for the Individual While Planning Responsibly for the Population

Traditional medical education paradigms tend not to focus on health economics and economic evaluation. This has led to a culture in which bedside clinicians simply allocate health care resources made available to them, with often minimal input as to what these resources are at the population or health care system level. Life sustaining chronic dialysis therapies for end-stage renal disease are heterogeneous in terms of health care costs and the quality of life provided to patients receiving them. From the traditional clinician's perspective, they may be considered equivalent because there are no well-designed randomized control trials establishing the superiority of one particular dialysis modality in terms of all-cause mortality or cardiovascular events. The intent of this review is to provide clinicians practicing in the area of chronic kidney disease some insights into the concepts of economic evaluation and how it may be integrated into clinical decision making at a programmatic level while not compromising individual patient care at the bedside. An epidemiologic perspective will be used to help frame how the implementation of home dialysis modalities vary depending on local health policies in place. Lessons learned by regional nephrology care systems may be readily transferable to other jurisdictions in augmenting the uptake of home dialysis modalities where they are dwindling or struggling to grow. A high-level understanding of economic data in this area may help influence health policy in the direction of the most efficient provision of dialysis to patients while not adversely affecting their quality of life or health outcomes.

Implementing a home haemodialysis programme without adversely affecting a peritoneal dialysis programme

As the population with stage 5 CKD grows, the associated costs of providing dialysis care increase. Due to the high costs of these therapies, home haemodialysis is enjoying a renaissance in many jurisdictions. However, concerns persist as to whether home haemodialysis programmes grow at the expense of other home therapies such as peritoneal dialysis. This study attempts to look at the impact of a new home haemodialysis programme on an existing peritoneal dialysis programme in the province of British Columbia. Using the provincial renal database in British Columbia (PROMIS), all patients receiving dialysis were tracked over the years preceding the implementation of a home haemodialysis programme and following its implementation. Rate of growth by specific dialysis modality (hospital haemodialysis, community haemodialysis, home haemodialysis, and peritoneal dialysis) were tracked. When comparing the provincial growth rates in the peritoneal dialysis programme, using the 4 years before and following the introduction of the home haemodialysis programme, they were unchanged both annually (7.84% versus 7.34%) and overall (25.27% versus 23.62%). The growth within the home haemodialysis programme appears to have come from the community haemodialysis programme (annual growth rate 12.28% versus 5.87%) and in-hospital haemodialysis (annual growth rate 4.61% versus 1.3%). Incident rates of dialysis were similar both prior to and following the introduction of the home haemodialysis programme.Finally, only 6.4% of the total patients entering the home haemodialysis programme had discontinued peritoneal dialysis within the 6 months preceding home haemodialysis training, indicating a low frequency of movement from peritoneal dialysis to home haemodialysis. Successful implementation of a home haemodialysis programme can be done at a provincial level without having an adverse impact on the growth rate of existing peritoneal dialysis programmes.

Pneumatic compression devices for in-home management of lymphedema: two case reports.

The two patients in this case series had experienced long-term difficulty controlling lymphedema at home. Both patients had used numerous home therapies, including older-generation intermittent pneumatic compression devices, without success. The Flexitouch system, an advanced pneumatic device, was prescribed to assist them with in-home efforts by providing therapy to their affected limbs in addition to the lower trunk area for the patient with lymphedema of the lower extremity; and the trunk, chest wall, and shoulder areas for the patient with lymphedema of the upper extremity. Both patients achieved successful home maintenance of lymphedema, as judged by limb volume, clinical observations, and subjective patient impressions, after incorporating the Flexitouch system. Neither patient experienced the deleterious effects (worsening genital edema; fibrotic cuff development) that they had experienced with the older-generation intermittent pneumatic compression devices they had previously used. Incorporating the Flexitouch system as part of maintenance may improve success for lymphedema patients who have previously struggled with in-home management.

Pneumatic compression devices for in-home management of lymphedema: two case reports

The two patients in this case series had experienced long-term difficulty controlling lymphedema at home. Both patients had used numerous home therapies, including older-generation intermittent pneumatic compression devices, without success. The Flexitouch® system, an advanced pneumatic device, was prescribed to assist them with in-home efforts by providing therapy to their affected limbs in addition to the lower trunk area for the patient with lymphedema of the lower extremity; and the trunk, chest wall, and shoulder areas for the patient with lymphedema of the upper extremity. Both patients achieved successful home maintenance of lymphedema, as judged by limb volume, clinical observations, and subjective patient impressions, after incorporating the Flexitouch® system. Neither patient experienced the deleterious effects (worsening genital edema; fibrotic cuff development) that they had experienced with the older-generation intermittent pneumatic compression devices they had previously used. Incorporating the Flexitouch® system as part of maintenance may improve success for lymphedema patients who have previously struggled with in-home management.

Fractional Polynomials in a New Metastatic Renal Carcinoma Continuous Prognostic Index Involving Histology, Laboratory, and Clinical Predictors

We analyzed the effect of histology and various clinical and laboratory predictors in a new continuous prognostic index for metastatic renal-cell carcinoma based on fractional polynomials. We evaluated 322 metastatic renal-cell carcinoma patients treated with subcutaneous recombinant cytokine-based home therapies in consecutive trials. We evaluated papillary histology, along with age, disease localizations, C-reactive protein, and neutrophil count in a new prognostic index, which was based on the multivariable fractional polynomial (MFP) algorithm. The MFP model allowed us to divide patients into three risk groups, using seven selected significant prognostic factors: histology, neutrophils, C-reactive protein, bone metastases, liver metastases, lymph node metastases, and age. Using the multivariable fractional polynomial model, median overall survival for high-, intermediate-, and low-risk patients was 10 months (n=80), 23 months (n=162), and 41 months (n=80) (scheme A; p <or= 0.01), or 7.9 months (n=16), 20 months (n=226), and 41 months (n=80) (scheme B; p <or= 0.001), respectively. Histology, clinical, and laboratory predictors contribute to a MFP algorithm-based prognostic index, allowing for a highly effective long-term risk discrimination in metastatic renal-cell carcinoma patients receiving recombinant immunotherapy. The flexibility in creating patient groups by using a continuous prognostic index allows to meet clinical needs in terms of improved prediction and optimized treatment selection.

The Resurgence of Home Dialysis Therapies

A recent resurgence of interest in home dialysis treatment is being driven by several factors, including (1) improved clinical outcomes associated with more frequent hemodialysis possible with home therapy; (2) patient preference for and greater convenience of home treatments; (3) lower treatment cost; (4) reduced staffing requirements; and (5) the availability of equipment specifically designed for self-care/home therapy. An important factor has been the recognition that the outcomes of peritoneal dialysis are similar to those of conventional in-center hemodialysis, and the advantages to the patient of utilizing different modalities during their dialysis "lifetime." Additionally, regional home-dialysis programs that offer the full continuum of home therapies and provide comprehensive patient education and clinical support have been developed as a model for reinvigorating home therapies. A shift away from the current model with all too frequent late referral of patients for in-center treatment to a new model characterized by early intervention and home-based dialysis therapies will improve outcomes, while more effectively handling the growing population of patients requiring maintenance renal replacement therapy.

Ultrapure Dialysate for Home Hemodialysis?

Use of ultrapure dialysate (bacteria < 0.1 CFU/mL and endotoxin < 0.03 EU/mL) is associated with a reduction in inflammation and morbidity in patients treated with conventional thrice-weekly dialysis. The improved outcomes obtained with more frequent dialysis schedules have reawakened interest in home hemodialysis. More frequent dialysis also appears to reduce inflammation, and whether combining more frequent dialysis with use of ultrapure dialysate will have an additive effect on inflammation and its consequences remains unclear. Routinely producing ultrapure dialysate in a home environment with a conventional hemodialysis machine poses technical challenges related to the design of the equipment and the intermittent nature of hemodialysis. Solutions to these problems include use of a system in which the water-treatment equipment is fully integrated with the dialysis machine, use of dry-powder cartridges or sterile prepackaged liquids for bicarbonate concentrate, and use of a bacteria-retentive and endotoxin-retentive filter for final purification of the dialysate immediately before it enters the dialyzer. Alternatively, ultrapure dialysate may be achieved with newer machines designed specifically for home hemodialysis that use a new batch of dialysate for each treatment. The volume of dialysate available with these machines, however, currently limits their use to short-daily dialysis.

CMS May Establish Rule for NH Dialysis Units

CMS May Establish Rule for NH Dialysis Units

An approach to estimating prognosis using fractional polynomials in metastatic renal carcinoma

We present a prognostic model for metastatic renal cell carcinoma based on fractional polynomials. We retrospectively analysed 425 metastatic renal cell carcinoma patients treated with subcutaneous recombinant cytokine-based home therapies in consecutive trials. In our approach, we categorised a continuous prognostic index produced by the multivariable fractional polynomial (MFP) algorithm, using a strategy in which continuous predictors are kept continuous. The MFP algorithm selected five prognostic factors as significant at the 5% level in a multivariable model: lymph node metastases, liver metastases, bone metastases, age, C-reactive protein and neutrophils. The MFP model allowed us to divide patients into four risk groups achieving median overall survivals of 38 months (low risk), 23 months (low intermediate risk), 15 months (high intermediate risk) and 5.6 months (high risk). Our approach, based on categorising a continuous prognostic index produced by the MFP algorithm, allowed more flexibility in the determination of risk groups than traditional approaches.

Poster 49: Acute rehabilitation of the geriatric patient: sociocultural, clinical, and functional characteristics with implications

Objectives: To define the sociodemographics, clinical, and functional characteristics of the Singapore population and to discuss the implications. Design: A database review of patients defined as geriatric (age >64y) compared with the nongeriatric patients. Setting: Rehabilitation unit. Participants: 172 (46%) of 374 consecutively admitted patients. Interventions: Not applicable. Main Outcome Measure: FIM™ instrument. Results: 87 (51%) of the geriatric group were men and stroke (64.5%) was the most common primary diagnosis. 39 patients (22.6%) had depression, and urinary tract infection (UTI) was the most common (n=36, 20.1%) medical complication. Comparing the geriatric and nongeriatric groups, no significant differences were found in the rehabilitation length of stay ( P=.41). In the geriatric group, the mean admission FIM score was 65 while the final FIM score was 84.1 and these were lower than the corresponding scores for the nongeriatric group (admission FIM=70.2, P=.03; discharge FIM=90.4, P=.008). However, there were no differences in the quantum of improvement of the FIM scores ( P=.45) between the 2 groups. 24 geriatric patients (14%) had no ready caregiver. Most geriatric patients (90.1%) were discharged home and outpatient therapies were arranged for most (80%). Conclusions: About half of our patients were geriatric, and good functional gains were achieved compared with the nongeriatric patients. Depression and UTI are common and vigilance should be maintained in detecting and treating these. A home disposition is an achievable goal and discharge planning should consider options if no caregiver is available. Outpatient therapies should remain affordable and accessible.

Metastatic renal carcinoma comprehensive prognostic system.

The purpose of the study was to identify a comprehensive prognostic system of pretreatment clinical parameters in 425 patients (pts) with metastatic renal-cell carcinoma treated with different subcutaneous (s.c.) recombinant cytokine-based home therapies in consecutive trials. Treatment consisted of (A) s.c. interferon-α2a (INF-α), s.c. interleukin-2 (IL-2) (n=102 pts), (B) s.c. IFN-α2a, s.c. IL-2, and i.v. 5-fluorouracil (5-FU) (n=235 pts) or (C) s.c. IFN-α2a, s.c. IL-2, and i.v. 5-FU combined with p.o. 13-cis-retinoic acid (13cRA) (n=88 pts). Kaplan–Meier survival analysis, log-rank statistics, and Cox regression analysis were employed to identify risk factors and to create a multiple risk factor model. The following pretreatment risk factors were identified by univariate analysis: (1) three and more metastatic sites, (2) presence of liver, lymph node or bone metastases, (3) neutrophil count ⩾6500 cells μl−1, (4) serum lactate dehydrogenase level (LDH) ⩾220 U l−1, and (5) serum C-reactive protein level (CRP) ⩾11 mg l−1. Cox regression analysis with forward stepwise variable selection identified neutrophil count as the major prognostic factor (hazard ratio=1.9, P<0.001), while serum levels of LDH and CRP, time between diagnosis of tumour and onset of metastatic disease, number of metastatic sites, and bone metastases were significant but somewhat less important prognostic variables within the multiple risk factor model (hazard ratio ⩽1.5). Patients were assigned to one of the three risk groups according to cumulative risk defined as the sum of simplified risk s.c.ores for six pretreatment variables. Low-, intermediate-, and high-risk patients achieved a median overall survival of 32+ months (95% CI 24, 43; 5-year survival of 27%), 18+ months (95% CI 15, 20; 5-year survival of 11%), and 8+ months (95% CI 6, 10; 5-year survival of 5%), respectively. These prognostic categories are helpful both in individual patient care and in the assessment of patients entering prospective clinical trials.

Knowledge of Home Dialysis Among Inner-City Satellite Hemodialysis Patients.

There is limited use of home renal replacement therapies in the U.S.A. One percent of dialysis patients are on home hemodialysis (HHD) and only 9% undergo peritoneal dialysis (PD). In an effort to better understand this, 161 satellite hemodialysis patients in 6 units in Brooklyn were surveyed. Forty-eight percent of patients were women, 86% were black, 5% white, 8% Hispanic, and 1% other. Mean age was 49.4 years (range 22 - 69 years). Etiology of renal disease was hypertension (41%), diabetes mellitus (31%), polycystic kidney disease (3%), systemic lupus erythematosus (4%), and other or unknown (21%). Patients were queried about knowledge of and attitudes toward home therapies. Seventy-nine percent of patients knew of home dialysis. The source of this information was the nephrologist (59%), the social worker (14%), a nurse (8%), other patients (4%), and other sources (15%). Only 10% of patients had ever considered HHD. Fifty-four percent were afraid to do self-care at home and 35% were not interested. Surprisingly, only 3% felt they had no reliable helper and 8% felt that their housing was not suitable. Similarly, 78% of patients had been spoken to about PD, but only 11% had considered it. Forty-one percent were afraid of doing self-care on PD, and 45% were not interested. We conclude that, although the majority of patients in six inner-city dialysis units had heard of home dialysis, only a small number ever considered it. As many patients were afraid of doing home therapy, better education about the risks and benefits needs to be disseminated.

Difficult wart cases - use of imiquimod cream 5%

Treatment of genital warts is a significant part of genitourinary medicine work load. Home therapies are the sensible way forward. Even problem cases can be managed successfully. Four difficult cases with successful outcomes are discussed.

21st century home haemodialysis: a new approach to an old treatment.

Home therapies are increasingly being demonstrated to be the best treatments for the early stages of the dialysis life-cycle. Although home haemodialysis has declined dramatically over the last 20 years from 41% in 1983 (1) to 3.2% in 1998 in the UK alone (2), many studies have suggested that it offers the optimum dialysis in terms of outcomes (3,4,5). Evidence from a 1998 survey of UK dialysis staff indicates that the major perceived drawbacks of home haemodialysis were lack of suitable patients, family stress, cost of machines and training time (6). The study also strongly indicated that a lack of familiarity with the treatment was a major cause of its decline in many units. We set out to redesign our approach to home haemodialysis to make it suitable for many more patients.

What Do American Nephrologists Think About Dialysis Modality Selection?

In the United States, 87.3% of the patients with end-stage renal disease (ESRD) requiring dialysis are treated with hemodialysis (HD) and 12.7% with peritoneal dialysis (PD). This represents a greater use of HD than in many other nations. We mailed a survey questionnaire to members of the National Kidney Foundation Council on Dialysis to better understand the attitudes of American nephrologists toward dialysis modality decisions. We received responses from 240 of 507 nephrologists (47.3%). The respondents were heavily involved in clinical dialysis work. Results showed that decisions regarding modality selection were strongly based on patient preference (4.54 on a scale of 1 to 5), quality of life (4.18), morbidity (4.02), and mortality (3.90), whereas the least important factors reported were facility reimbursement (2.09) and physician reimbursement (1.98). When asked about the current use of modalities, hospital-based HD and full-care HD were believed to be overused (2.63 for each on a scale of 1 [vastly overused] to 5 [vastly underused]), whereas home HD (4.29), continuous ambulatory PD (3.71), and cycler PD (3.59) were underused. A hypothetical question about optimal modality distribution to maximize survival or costeffectiveness showed that HD should constitute 71% or 66% of dialysis (with 11% or 14% in the form of home HD, respectively). PD use would increase between two- and threefold over current practices. Our results suggest that American nephrologists believe home therapies are underused. Because modality distribution is an important determinant of costs and possibly outcomes in patients with ESRD, there is an urgent need for further research in this area. In the United States, 87.3% of the patients with end-stage renal disease (ESRD) requiring dialysis are treated with hemodialysis (HD) and 12.7% with peritoneal dialysis (PD). This represents a greater use of HD than in many other nations. We mailed a survey questionnaire to members of the National Kidney Foundation Council on Dialysis to better understand the attitudes of American nephrologists toward dialysis modality decisions. We received responses from 240 of 507 nephrologists (47.3%). The respondents were heavily involved in clinical dialysis work. Results showed that decisions regarding modality selection were strongly based on patient preference (4.54 on a scale of 1 to 5), quality of life (4.18), morbidity (4.02), and mortality (3.90), whereas the least important factors reported were facility reimbursement (2.09) and physician reimbursement (1.98). When asked about the current use of modalities, hospital-based HD and full-care HD were believed to be overused (2.63 for each on a scale of 1 [vastly overused] to 5 [vastly underused]), whereas home HD (4.29), continuous ambulatory PD (3.71), and cycler PD (3.59) were underused. A hypothetical question about optimal modality distribution to maximize survival or costeffectiveness showed that HD should constitute 71% or 66% of dialysis (with 11% or 14% in the form of home HD, respectively). PD use would increase between two- and threefold over current practices. Our results suggest that American nephrologists believe home therapies are underused. Because modality distribution is an important determinant of costs and possibly outcomes in patients with ESRD, there is an urgent need for further research in this area.

What do American nephrologists think about dialysis modality selection?

In the United States, 87.3% of the patients with end-stage renal disease (ESRD) requiring dialysis are treated with hemodialysis (HD) and 12.7% with peritoneal dialysis (PD). This represents a greater use of HD than in many other nations. We mailed a survey questionnaire to members of the National Kidney Foundation Council on Dialysis to better understand the attitudes of American nephrologists toward dialysis modality decisions. We received responses from 240 of 507 nephrologists (47.3%). The respondents were heavily involved in clinical dialysis work. Results showed that decisions regarding modality selection were strongly based on patient preference (4.54 on a scale of 1 to 5), quality of life (4.18), morbidity (4.02), and mortality (3.90), whereas the least important factors reported were facility reimbursement (2.09) and physician reimbursement (1.98). When asked about the current use of modalities, hospital-based HD and full-care HD were believed to be overused (2.63 for each on a scale of 1 [vastly overused] to 5 [vastly underused]), whereas home HD (4.29), continuous ambulatory PD (3.71), and cycler PD (3.59) were underused. A hypothetical question about optimal modality distribution to maximize survival or cost-effectiveness showed that HD should constitute 71% or 66% of dialysis (with 11% or 14% in the form of home HD, respectively). PD use would increase between two- and threefold over current practices. Our results suggest that American nephrologists believe home therapies are underused. Because modality distribution is an important determinant of costs and possibly outcomes in patients with ESRD, there is an urgent need for further research in this area.

Superior mesenteric artery syndrome in traumatic paraplegia: A case report and literature review

Wilkinson R, Huang C-T. Superior mesenteric artery syndrome in traumatic paraplegia: a case report and literature review. Arch Phys Med Rehabil 2000;81:991-4. Superior mesenteric artery syndrome (SMAS) is a relatively rare condition thought to be caused by the functional obstruction of the third part of the duodenum as it passes between the superior mesenteric artery and the aorta. The following case report describes a patient who developed SMAS in the setting of traumatic paraplegia. The patient began to exhibit symptoms consistent with SMAS (epigastric pain, postprandial epigastric fullness, nausea, emesis) shortly after his injury and during home therapies. On admission to an inpatient rehabilitation hospital, the patient's symptoms persisted and prevented participation in any therapies. When radiographic studies demonstrated the existence of SMAS, conservative and surgical management were discussed with the patient and the family. The patient was managed conservatively with positional changes during feeding and the administration of metoclopramide (10mg orally, three times a day) before meals and before sleep. The patient was able to meet or exceed all short-term physical and occupational therapy goals with one episode of postprandial nausea noted. The patient returned home 21 days after admission to the rehabilitation hospital with home therapies. The patient was able to perform transfer skills and most self-care tasks. © 2000 by the American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehabilitation

Healthcare systems and end-stage renal disease (ESRD) therapies--an international review: access to ESRD treatments.

Assessment of healthcare technology and economics can be used to assess the access to healthcare, its quality and efficacy as well as its cost and cost efficiency. This report addresses these issues for the provision of care for end-stage renal disease (ESRD) patients. An international comparison of access to ESRD treatment modalities was made with reference to the healthcare provider structure in a range of industrial countries. The countries were grouped into 'public' (Beveridge model), 'mixed' (Bismarck model) and 'private' (Private Insurance model). In 'public' provider countries, 20-52% of dialysis patients are treated with home therapies (haemodialysis and peritoneal dialysis), and the number of patients with renal transplants is 45-81% of all ESRD patients. In 'mixed' provider countries, only 9 17% of all dialysis patients are treated with home therapies, and 20-48% of ESRD patients have renal transplants. In 'private' provider countries, 17% of US and 6% Japanese dialysis patients are treated with home therapies. Japan has 0.3% and the US has 26% of ESRD patients who receive renal transplants. It thus seems that provider structure influences access to and choice of ESRD treatment. With a growing elderly population and longer life expectancy, there will be an increased requirement for ESRD treatments in all industrial countries. Equal access to, and quality of ESRD care in the future will require adequate funding and reimbursement strategies in a cost-constrained healthcare environment. growing elderly population, new and innovative healthcare technologies, increasing expectations of the population and the dilemma of economic constraints. Therefore, new disciplines such as health technology assessment and healthcare economics are developing to support the needs of health policy decision makers. Their main objective is to create a balance between the three key factors of a healthcare system: access to healthcare (equity for all), quality of healthcare (efficacy) and finally the cost or cost efficiency of healthcare provision [1; see also Lameire et al., this issue]. This report will assess access to healthcare in a very specific and very costly area that of end-stage renal disease (ESRD). An international comparison of access to ESRD treatment for patients from a series of industrial countries will be used as a means for evaluation of this access.