Home care assistance and the utilization of peritoneal dialysis

A retrospective clinical and economic analysis of an assisted automated peritoneal dialysis programme in Western Australia

BACKGROUND

Assisted peritoneal dialysis (aPD) represents an alternative kidney replacement therapy for dialysis-dependent patients whose only other options are prolonged hospitalisations or transfer to in-centre haemodialysis (HD). Most programmes have not examined the role of temporary aPD, and there is limited data surrounding the economic implications of temporary aPD programmes. The main aim of this study was to describe the cost-effectiveness of an assisted automated peritoneal dialysis (aAPD) programme, for patients whose only reason to stay in hospital was the temporary inability to independently perform PD at home.

METHODS

Retrospective, single-centre analysis of 45 referrals for aAPD from November 2015 to May 2021. Two groups of patients were enrolled in the study: respite patients already established on PD (to facilitate discharge or prevent admission) and new patients who were not yet trained (to facilitate discharge). To calculate the cost differential, patients were allocated to either staying in hospital or transferring to centre-based HD with comparison to costs on aAPD. Costs were calculated using a healthcare system perspective over the duration of aAPD assistance. Clinical outcomes including peritonitis rate, hospitalisation and mortality were also assessed.

RESULTS

Overall, 1349 episodes of aAPD care were delivered. One thousand forty-two episodes (77%) were for respite patients and 307 episodes (23%) were for new patients awaiting training. The mean duration of assistance was 18 days for pretraining patients and 37 days for respite patients. Overall, the mean length of stay on the programme was 30 days with a range of 1-263 days (SD 43) and 73% of patients graduated to self-care PD. The cost of the aAPD programme was $242 per visit, with an average cost $7260 per patient-episode. The aAPD programme was significantly cheaper than the alternatives, with average hospitalization costs $46,170 per episode, and in-centre HD costs of $9667. $1.497 million was saved over the course of the study. Eleven hospitalisations occurred and the peritonitis rate was 0.8 episodes per patient-year. Two patients died while on aAPD.

CONCLUSION

This study provides the first detailed description of an aAPD respite programme in Australia. We conclude that the implementation of a temporary aAPD programme could lead to a significant reduction in healthcare costs, however peritonitis rates were high.

Evaluation and outcomes of a 5-year assisted peritoneal dialysis program

BACKGROUND

In 2016, Peritoneal Dialysis Assist (PDA) was implemented in British Columbia, Canada, as a pilot program to allow patients with physical, cognitive and social impairments to access an independent dialysis modality. This is a presentation of the usage and 5-year clinical outcomes of our provincial assisted peritoneal dialysis (PD) program.

METHODS

Patients who utilised long-term or respite PDA services in British Columbia, Canada, from 2016 to 2021 were included in this program evaluation. Incident and prevalent patient numbers were characterised annually as well as indications for PDA and patient demographics both annually and over time. Outcomes of interest included death, transfer to haemodialysis, transplantation and cessation of the PDA program but retention on PD.

RESULTS

Three hundred twenty-two total patients received services through the PDA program. The percentage of PD patients supported by long-term PDA service has grown to 11.2% in the most recent year. Patients spend a median of 13.6 (95% CI: 11.0, 16.1) months on long-term PDA, prolonging overall patient duration on PD by a little over a year. Of the patients who exited the long-term PDA program, 73 (37.4%) were able to utilise the service until they died.

CONCLUSION

PDA is an accessible, patient-centric service with clear and standardised referral criteria. Through the implementation of a local PDA program, patients have accessed PD and may have extended their PD life span, through avoidance of in-centre haemodialysis, by over 13 months during this 5-year study period. A significant proportion of patients on long-term PDA were able to use their preferred kidney replacement modality at home until they reached end of life.

Ongoing Peritoneal Dialysis Training at Home Allows for the Improvement of Patients' Empowerment: A Single Center Experience

INTRODUCTION

Peritoneal dialysis (PD), as a home treatment, ensures better patient autonomy and lower intrusiveness compared to hemodialysis. However, choosing PD comes with an increased burden of responsibility that the patient may not always be able to bear, due to advanced age and deteriorating health condition. Various approaches have been explored to address this issue and mitigate its primary complications. In this study, we aim to present the ongoing PD training at-home program implemented by the Vicenza PD Center, and evaluate its impact on patients' prognoses.

MATERIAL AND METHODS

We enrolled 210 patients who underwent PD at Vicenza Hospital between 1 January 2019 and 1 January 2022 for a minimum of 90 days. Each patient was observed retrospectively for one year. We categorized the patients into three groups based on their level of autonomy regarding their PD management: completely independent patients; patients able to perform some parts of the PD method on their own, while the remaining aspects were carried out by a caregiver; and patients who required complete assistance from a caregiver, like in the assisted PD program (asPD).

RESULTS

A total of 70% of the PD population were autonomous regarding their PD therapy, 14% had an intermediate degree of autonomy, and 16% were entirely dependent on caregivers. The PD nurses performed a median of four home visits per patient per year, with a tendency to make more visits to patients with a lower degree of autonomy. All the groups achieved similar clinical outcomes. At the end of the year of observation, only 6% of the patients witnessed a decline in their autonomy level, whereas 7% demonstrated an enhancement in their level of autonomy, and 87% remained stable.

CONCLUSIONS

A home care assistance program ensures clinical support to a household with the purpose of improving the empowerment of the PD population and reducing the prevalence of assisted PD. Ongoing PD training at home helps patients to maintain a stable degree of autonomy and stay in their home setting, even though they present with relative attitudinal or social barriers.

Exploration of patients' preference for modalities of care among peritoneal dialysis patients in Singapore: a single-center experience

INTRODUCTION

Peritoneal dialysis (PD) is home-based dialysis therapy and therefore a suitable modality for kidney failure patients, particularly, during the COVID-19 pandemic. The present study examined patients' preferences for different PD-related services.

METHODS

This was a cross-sectional survey study. Anonymized data from PD patients followed up at a single center in Singapore were collected using an online platform. The study focused on telehealth services, home visits, and monitoring of quality-of-life (QoL).

RESULTS

A total of 78 PD patients responded to the survey. The majority of participants were Chinese (76%), married (73%), and between 45 and 65 years old (45%). The in-person visit was preferred over teleconsultation for consultation with nephrologists (68% versus 32%), counseling for kidney disease and dialysis by renal coordinators (59%), whereas the telehealth service was favored over in-person visit for dietary counseling (60%) and medication counseling (64%). Most participants (81%) preferred medication delivery over self-collection, and the acceptable turnaround time was 1 week. Sixty percent would like to have a regular home visit, but 23% refused such visits. The preferred frequency of home visits was one-to-three visits within the first 6 months (74%) and then 6 monthly for subsequent visits (40%). The majority of participants (87%) agreed with QoL monitoring, and the preferred frequency of monitoring varied between 6 monthly (45%) and yearly (40%). Participants also indicated three key areas in research to improve QoL, such as the development of artificial kidneys, portable PD devices, and simplification of PD procedure. Participants also would like to see improvement in two main areas of PD services, such as delivery service for PD solutions and social (instrumental, informational, and emotional) support.

CONCLUSIONS

Most PD patients preferred in-person visits with nephrologists or renal coordinators; however, they favored telehealth services with dieticians and pharmacists. PD patients also welcomed home visit service and QoL monitoring. Future studies should confirm these findings.

Differences in Outcomes by Place of Origin among Hispanic Patients with Kidney Failure

SIGNIFICANCE STATEMENT

Hispanic patients are known to have a higher risk of kidney failure and lower rates of home dialysis use and kidney transplantation than non-Hispanic White patients. However, it is unknown whether these outcomes differ within the Hispanic community, which is heterogeneous in its members' places of origins. Using United States Renal Data System data, the authors found similar adjusted rates of home dialysis use for patients originating from places outside the United States and US-born Hispanic patients, whereas the adjusted risk of mortality and likelihood of transplantation differed depending on place (country or territory) of origin. Understanding the heterogeneity in kidney disease outcomes and treatment within the Hispanic community is crucial in designing interventions and implementation strategies to ensure that Hispanic individuals with kidney failure have equitable access to care.

BACKGROUND

Compared with non-Hispanic White groups, Hispanic individuals have a higher risk of kidney failure yet lower rates of living donor transplantation and home dialysis. However, how home dialysis, mortality, and transplantation vary within the Hispanic community depending on patients' place of origin is unclear.

METHODS

We identified adult Hispanic patients from the United States Renal Data System who initiated dialysis in 2009-2017. Primary exposure was country or territory of origin (the United States, Mexico, US-Puerto Rico, and other countries). We used logistic regression to estimate differences in odds of initiating home dialysis and competing risk models to estimate subdistribution hazard ratios (SHR) of mortality and kidney transplantation.

RESULTS

Of 137,039 patients, 44.4% were US-born, 30.9% were from Mexico, 12.9% were from US-Puerto Rico, and 11.8% were from other countries. Home dialysis rates were higher among US-born patients, but not significantly different after adjusting for demographic, medical, socioeconomic, and facility-level factors. Adjusted mortality risk was higher for individuals from US-Puerto Rico (SHR, 1.04; 95% confidence interval [CI], 1.01 to 1.08) and lower for Mexico (SHR, 0.80; 95% CI, 0.78 to 0.81) and other countries (SHR, 0.83; 95% CI, 0.81 to 0.86) compared with US-born patients. The adjusted rate of transplantation for Mexican or US-Puerto Rican patients was similar to that of US-born patients but higher for those from other countries (SHR, 1.22; 95% CI, 1.15 to 1.30).

CONCLUSIONS

Hispanic people from different places of origin have similar adjusted rates of home dialysis but different adjusted rates of mortality and kidney transplantation. Further research is needed to understand the mechanisms underlying these observed differences in outcomes.

Renal Replacement Therapy For Elderly Patients with ESKD Through Shared Decision-Making

The incidence and prevalence of end-stage kidney disease (ESKD) in Korea are increasing, and ESKD constitutes a very important medical and social issue. Elderly dialysis patients have the highest risk of early mortality within 3 months after initiating dialysis, and geriatric syndromes such as aging, frailty, functional impairment, and cognitive impairment are crucial for the prognosis of elderly patients. Shared decision-making (SDM) is an approach through which clinicians and patients can achieve informed preferences, thereby yielding better clinical outcomes and quality of life. Through SDM-based, close consultation among patients, families, and healthcare providers, an ESKD Life-Plan for elderly patients should be established. A multidisciplinary approach led by nephrologists can help them to provide proper vascular access for dialysis at the right time, with the right evidence, and to the right patient. Strategies that can improve peritoneal dialysis in elderly patients include assisted peritoneal dialysis, homecare support programs, and automated peritoneal dialysis. In order to enhance the role of kidney transplantation in elderly patients with ESKD, it is necessary to accurately identify patients' clinical conditions before transplantation and to perform active rehabilitation activities and postoperative management to promote recovery after transplantation. With the aging population and the increase in ESKD in the elderly, clinicians must identify factors affecting the mortality and quality of life of elderly dialysis patients.

Home dialysis: conclusions from a Kidney Disease: Improving Global Outcomes (KDIGO) Controversies Conference

Home dialysis modalities (home hemodialysis [HD] and peritoneal dialysis [PD]) are associated with greater patient autonomy and treatment satisfaction compared with in-center modalities, yet the level of home-dialysis use worldwide is low. Reasons for limited utilization are context-dependent, informed by local resources, dialysis costs, access to healthcare, health system policies, provider bias or preferences, cultural beliefs, individual lifestyle concerns, potential care-partner time, and financial burdens. In May 2021, KDIGO (Kidney Disease: Improving Global Outcomes) convened a controversies conference on home dialysis, focusing on how modality choice and distribution are determined and strategies to expand home-dialysis use. Participants recognized that expanding use of home dialysis within a given health system requires alignment of policy, fiscal resources, organizational structure, provider incentives, and accountability. Clinical outcomes across all dialysis modalities are largely similar, but for specific clinical measures, one modality may have advantages over another. Therefore, choice among available modalities is preference-sensitive, with consideration of quality of life, life goals, clinical characteristics, family or care-partner support, and living environment. Ideally, individuals, their care-partners, and their healthcare teams will employ shared decision-making in assessing initial and subsequent kidney failure treatment options. To meet this goal, iterative, high-quality education and support for healthcare professionals, patients, and care-partners are priorities. Everyone who faces dialysis should have access to home therapy. Facilitating universal access to home dialysis and expanding utilization requires alignment of policy considerations and resources at the dialysis-center level, with clear leadership from informed and motivated clinical teams.

Left ventricular hypertrophy, carotid atherosclerosis, and cognitive impairment in peritoneal dialysis patients

BACKGROUND

Left ventricular hypertrophy (LVH) and carotid atherosclerosis (CAS) have been identified as factors associated with cognitive impairment (CI) but have not been studied in patients undergoing peritoneal dialysis (PD). This study investigated the relationship between LVH and CAS and cognitive function in patients undergoing PD.

METHODS

In this single-center cross-sectional study, the clinically stable patients who were over 18 years of age and had undergone PD for at least 3 months were enrolled. Cognitive function was assessed using the Montreal Cognitive Assessment (MoCA), which included seven areas: visuospatial/executive function, naming, attention, language, abstraction, delayed recall, and orientation. LVH was defined as LVMI > 46.7 g/m^2.7 in women and LVMI > 49.2 g/m^2.7 in men. CAS was defined as carotid intima-media thickness ≥ 1.0 mm and/or the presence of plaque.

RESULTS

A total of 207 patients undergoing PD were recruited, with an average age of 52.14 ± 14.93 years and a median PD duration of 8 months (5-19 months). The CI rate was 56%, and the prevalence of CAS was 53.6%. LVH occurred in 110 patients (53.1%). Patients in the LVH group tended to be older, and had a higher body mass index, a higher pulse pressure, a higher male proportion, a lower ejection fraction, a higher prevalence of cardiovascular disease and CI, and a lower MoCA scores.Multivariate logistic regression analysis was conducted to analyze the association between LVH and CI (OR, 10.087; 95% confidence interval, 2.966-34.307). And the association between LVH and CI was still supported after propensity matching scores. CAS was not significantly associated with CI.

CONCLUSION

LVH is independently associated with CI in patients undergoing PD, while CAS is not significantly associated with CI.

Assisted peritoneal dialysis (asPD): age is not the key

BACKGROUND

Peritoneal dialysis (PD) has multiple advantages over other dialysis modalities. As a home-based therapy, it allows patients to keep their autonomy, avoid frequent hospital visits and carry on with their usual lifestyle. However, as a self-care therapy, dependency has been traditionally considered a contraindication. However, assistance to perform PD (asPD) can be provided regardless of the patient's age and the duration of such help. This paper is aimed at reporting on assisted PD use in a Spanish Center, and is the first report on asPD from this country.

METHODS

We retrospectively reviewed the electronic medical records of all patients consecutively treated with PD between May 1997 and December 2020 in our PD Unit. Assisted PD was defined as PD treatment requiring the help of another person. On the basis of the duration of dependency, we divided our cohort into: Group 1: Patients totally dependent at the start of PD treatment; Group 2: self-care patients that developed total dependency during follow up; Group 3: patients who needed short-term PD assistance. Group 4, consisting of 175 self-care PD, served as the control group.

RESULTS

Seventy-three percent of patients who required asPD did so during their follow up, showing that an important proportion of patients may require some help even if they were autonomous at the beginning of PD. Even for short time periods, asPD should be an option, as up to 44% of autonomous PD patients became dependent for different reasons over time. Spouses were the most frequent caregivers and absence or loss of caregiver was a main reason for switching to hemodialysis. Fourteen percent of the patients received asPD as palliative care, with clinical symptoms and perceived well-being as the main treatment goals, with adequate results. The need for support and the quality of life were periodically discussed by patients, family members and hospital staff.

CONCLUSION

Assisted PD is a safe option for dependent patients, young or elderly, and may result less expensive for our healthcare system, even when caregivers receive a financial incentive.

Assisted peritoneal dialysis performed by caregivers and its association with patient outcomes

BACKGROUND

Although caregivers allow peritoneal dialysis (PD) patients with disabilities the opportunity to perform PD, it is crucial to clarify the safety and effectiveness of assisted PD performed by caregivers compared to self-PD.

METHODS

PD patients from 22 PD centres in Thailand were prospectively followed in the Peritoneal Dialysis Outcomes and Practice Patterns Study during 2016-2017. Patients receiving assisted PD performed by caregivers were matched 1:1 with self-PD patients using propensity scores calculated by logistic regression. The associations between assisted PD and risk of mortality, peritonitis and permanent transfer to haemodialysis (HD) were assessed by multivariable competing risk regression.

RESULTS

Of 778 eligible patients, 447 (57%) required assisted PD performed by caregivers. Most of the caregivers were family members (98%), while the rest were non-family paid caregivers (2%). Patient factors associated with assisted PD were older age, female gender, lower educational level, cardiovascular comorbidities, diabetes, automated PD modality, poorer functional status and lower blood chemistries (albumin, creatinine, sodium, potassium and phosphate). After 1:1 matching, the baseline characteristics were adequately matched, and 269 patients in each group were analysed. Compared with self-PD, assisted PD was significantly associated with an increased risk of all-cause mortality (adjusted sub-hazard ratio: 2.15, 95% confidence interval: 1.24-3.74). There were no differences in the occurrences of peritonitis and permanent HD transfer between the groups.

CONCLUSIONS

Assisted PD was required by more than half of Thai PD patients and was independently associated with a higher mortality risk. This may reflect causal effect or confounding by indication.

Financial Incentives to Facilities and Clinicians Treating Patients With End-stage Kidney Disease and Use of Home Dialysis: A Randomized Clinical Trial

Importance

Home dialysis rates for end-stage kidney disease (ESKD) treatment are substantially lower in the US than in other high-income countries, yet there is limited knowledge on how to increase these rates.

Objective

To report results from the first year of a nationwide randomized clinical trial that provides financial incentives to ESKD facilities and managing clinicians to increase home dialysis rates.

Design, Setting, and Participants

Results were analyzed from the first year of the End-Stage Renal Disease Treatment Choice (ETC) model, a multiyear, mandatory-participation randomized clinical trial designed and implemented by the US Center for Medicare & Medicaid Innovation. Data were reported on Medicare patients with ESKD 66 years or older who initiated treatment with dialysis in 2021, with data collection through December 31, 2021; the study included all eligible ESKD facilities and managing clinicians. Eligible hospital referral regions (HRRs) were randomly assigned to the ETC (91 HRRs) or a control group (211 HRRs).

Interventions

The ESKD facilities and managing clinicians received financial incentives for home dialysis use.

Main Outcomes and Measures

The primary outcome was the percentage of patients with ESKD who received any home dialysis during the first 90 days of treatment. Secondary outcomes included other measures of home dialysis and patient volume and characteristics.

Results

Among the 302 HRRs eligible for randomization, 18 621 eligible patients initiated dialysis treatment during the study period (mean [SD] age, 74.8 [1.05] years; 7856 women [42.1%]; 10 765 men [57.9%]; 859 Asian [5.2%], 3280 [17.7%] Black, 730 [4.3%] Hispanic, 239 North American Native, and 12 394 managing clinicians. The mean (SD) share of patients with any home dialysis during the first 90 days was 20.6% (7.8%) in the control group and was 0.12 percentage points higher (95% CI, -1.42 to 1.65 percentage points; P = .88) in the ETC group, a statistically nonsignificant difference. None of the secondary outcomes differed significantly between groups.

Conclusions and Relevance

The trial results found that in the first year of the US Center for Medicare & Medicaid Innovation-designed ETC model, HRRs assigned to the model did not have statistically significantly different rates in home dialysis compared with control HRRs. This raises questions about the efficacy of the financial incentives provided, although further evaluation is needed, as the size of these incentives will increase in subsequent years.

Trial Registration

ClinicalTrials.gov Identifier: NCT05005572.

Factors Affecting Selection of a Dialysis Modality in Elderly Patients With Chronic Kidney Disease: A Prospective Cohort Study in Korea

Background

We investigated factors associated with the selection of a dialysis modality for elderly patients compared to younger patients.

Methods

This study included 2,514 incident dialysis patients from a Korean multicenter prospective cohort. Multivariate logistic regression analyses were performed with demographic, socioeconomic, and clinical data to analyze factors associated with the chosen dialysis modality. Differences in these factors were compared between the elderly (≥65 years) and younger (<65 years) patients.

Results

Of the enrolled patients, 1,746 (69.5%) and 768 (30.6%) selected hemodialysis (HD) and peritoneal dialysis (PD), respectively. The percentage of PD was higher in younger patients than in elderly patients (37.1 vs. 16.9%, p < 0.001). Multivariate analysis showed that planned dialysis (p < 0.001), employment status (p < 0.001), and independent economic status (p = 0.048) were independent factors for selecting PD, whereas peripheral vascular disease (p = 0.038) and tumor (p = 0.010) were factors for selecting HD in the younger group. In the elderly group, planned dialysis (p < 0.001) and congestive heart failure (CHF; p = 0.002) were associated with choosing PD; however, tumor (p = 0.006) was associated with choosing HD. A two-way ANOVA showed that planned dialysis and CHF showed a significant interaction effect with age on modality selection.

Conclusions

As the age of patients with chronic kidney disease increased, HD was more frequently selected compared to PD. Dialysis planning and CHF interacted with age in selecting dialysis modalities in elderly patients. Elderly patients were less affected by socioeconomic status than younger patients.

Peritoneal dialysis in the modern era

The practice and clinical outcomes of peritoneal dialysis (PD) have demonstrated significant improvement over the past 20 years. The aim of this review is to increase awareness and update healthcare professionals on current PD practice, especially with respect to patient and technique survival, patient modality selection, pathways onto PD, understanding patient experience of care and use prior to kidney transplantation. These improvements have been impacted, at least in part, by greater emphasis on shared decision-making in dialysis modality selection, the use of advanced laparoscopic techniques for PD catheter implantation, developments in PD connecting systems, glucose-sparing strategies, and modernising technology in managing automated PD patients remotely. Evidence-based clinical guidelines such as those prepared by national and international societies such as the International Society of PD have contributed to improved PD practice underpinned by a recognition of the place of continuous quality improvement processes.

Assisted Peritoneal Dialysis Implementation: A Pilot Program From a Large Dialysis Unit in Quebec

Background:

Kidney failure prevalence is increasing in older patients for whom dialysis initiation can be challenging. Assisted peritoneal dialysis (PD), where PD is performed with the help of a healthcare worker, can facilitate PD for frailer patients who may not be candidate otherwise.

Objectives:

This study aimed to assess the feasibility of implementing the first pilot assisted PD program in Quebec (Canada) and to evaluate the characteristics and outcomes of the PD cohort before and after assisted PD availability.

Design:

Observational retrospective cohort study.

Setting and Population:

All adult patients initiating PD between 2015 and 2020 in a single-center dialysis unit were included.

Measurements:

Incidence, characteristics, and outcomes of patients with PD were compared between (1) the “pre” (2015-2017) and the “post” assisted PD era (2018-2020) and (2) patients with assisted PD and independent PD in the more recent period.

Methods:

The primary outcome was peritonitis rate over the first year. Secondary outcomes included hospitalization, transfers to in-center hemodialysis (HD) and mortality.

Results:

Overall, 124 patients initiated PD with an annual incidence of 17 ± 3 patients during the “pre” and 24 ± 8 patients during the “post” assisted PD era (P = .18). First-year peritonitis rate was similar over the 2 eras. Years of PD initiation and use of assisted PD were not associated with risk peritonitis (over total follow-up) after adjustment. Adjusted hazard of transfer to HD or death was higher during the “post” era (hazard ratio [HR]: 2.77; 95% confidence interval [CI]: 1.42-5.58). Seventeen patients received assisted PD including 13 (18%) of the 72 patients initiated between 2018 and 2020. Patients with assisted PD were older than those with independent PD (72 [64-84] vs. 59 [47-67], P = .006) and received assistance for 0.8 (0.4-1.5) years. When comparing assisted and independent cohorts, there were no differences in crude rates of peritonitis or hospitalization.

Limitations:

Single-center study with small sample size.

Conclusion:

This study shows the feasibility of implementing an assisted PD program, with favorable overall outcomes including similar rates of peritonitis during the first year after PD initiation.

Dialysis modality utilization patterns and mortality in older persons initiating dialysis in Australia and New Zealand

AIM

The benefits of dialysis in the older population remain highly debated, particularly for certain dialysis modalities. This study aimed to explore the dialysis modality utilization patterns between in-centre haemodialysis (ICHD), peritoneal dialysis (PD) and home haemodialysis (HHD) and their association with outcomes in older persons.

METHODS

Older persons (≥75 years) initiating dialysis in Australia and New Zealand from 1999 to 2018 reported to the Australia and New Zealand Dialysis and Transplant (ANZDATA) registry were included. The main aim of the study was to characterize dialysis modality utilization patterns and describe individual characteristics of each pattern. Relationships between identified patterns and survival, causes of death and withdrawal were examined as secondary analyses, where the pattern was considered as the exposure.

RESULTS

A total of 10 306 older persons initiated dialysis over the study period. Of these, 6776 (66%) and 1535 (15%) were exclusively treated by ICHD and PD, respectively, while 136 (1%) ever received HHD during their dialysis treatment course. The remainder received both ICHD and PD: 906 (9%) started dialysis on ICHD and 953 (9%) on PD. Different individual characteristics were seen across dialysis modality utilization patterns. Median survival time was 3.0 (95%CI 2.9-3.1) years. Differences in survival were seen across groups and varied depending on the time period following dialysis initiation. Dialysis withdrawal was an important cause of death and varied according to individual characteristics and utilization patterns.

CONCLUSION

This study showed that dialysis modality utilization patterns in older persons are associated with mortality, independent of individual characteristics.

Availability of assisted peritoneal dialysis in Europe: call for increased and equal access

INTRODUCTION

Availability of assisted PD (asPD) increases access to dialysis at home, particularly for the increasing numbers of older and frail people with advanced kidney disease. Although asPD has been widely used in some European countries for many years, it remains unavailable or poorly utilised in others. A group of leading European nephrologists have therefore formed a group to drive increased availability of asPD in Europe and in their own countries.

METHODS

Members of the group filled in a proforma with the following headings: personal experience, country experience, who are the assistants, funding of asPD, barriers to growth, what is needed to grow, and their top 3 priorities.

RESULTS

Only 5 of the 13 countries surveyed provided publicly funded reimbursement for asPD. The use of asPD depends on overall attitudes to PD with all respondents mentioning need for nephrology team education and/or patient education and involvement in dialysis modality decision making.

CONCLUSION AND CALL TO ACTION

Many people with advanced kidney disease would prefer to have their dialysis at home, yet if the frail patient chooses PD most healthcare systems cannot provide their choice. AsPD should be available in all countries in Europe and for all renal centres. The top priorities to make this happen are education of renal healthcare teams about the advantages of PD, education of and discussion with patients and their families as they approach the need for dialysis, and engagement with policy makers and healthcare providers to develop and support assistance for PD.

Exploring agreement and feasibility between virtual home visits and in-person home visits for peritoneal dialysis patients-a paired study

INTRODUCTION

Virtual home visits may improve chronic disease management. However, whether they are suitable for peritoneal dialysis (PD) patients has not yet been fully investigated. This study aimed to compare the agreement and acceptance of virtual home visits and in-person home visits in PD patients.

METHODS

This was a paired, single center, noninferiority trial. Participants received a virtual home visit and an in-person home visit simultaneously. A home visit checklist was built for standardization visits. The content was divided into three parts: domestic habits (57 items), bag exchange procedures (56 items), and exit site care (53 items). Satisfaction questionnaires for both patients and nurses were designed to assess attitudes toward home visits and socioeconomic effects.

RESULTS

A total of 30 PD patients were enrolled in a single center. The information collected from virtual home visits and in-person home visits was found to be highly consistent. The perfect agreement was found in 52/57, 49/56, and 44/53 items (Cohen's kappa 0.81-1.00), substantial agreement in 4/57, 7/56, and 8/53 items (Cohen's kappa 0.61-0.80). Patients reported almost identical satisfaction for virtual home visits and in-person home visits (Z = 0.39, p = 0.70). PD nurses reported similar feasibility and patient cooperation for the two visit types (Z = 0.99, p = 0.33; Z = 1.65, p = 0.10, respectively). In addition, virtual home visits were found to be more cost-effective than in-person home visits.

CONCLUSIONS

Virtual home visits information collection was similar to in-person home visits in PD. There were no differences in participant satisfaction and feasibility between the two visit types.

Assisted peritoneal dialysis: strategies and outcomes

Assisted peritoneal dialysis (asPD) is a modality intended for not self-sufficient patients, mainly elderly, who are not able to perform peritoneal dialysis (PD) alone and require some help to manage the treatment. In the last decades, many countries developed strategies of asPD to face with aging of dialysis population and give an answer to the increasing demand of health service for elderly. Model of asPD varies according to the type of assistants employed and intensity of assistance provided. Both health care and non-health care assistants have been used with good clinical results. A mixed model of help, using different professional figures for short time or for longer according to patients’ need, has been proved successful and cost-effective. Outcomes of asPD are reported in different ways, and the comparative effect of asPD is unclear. Quality of life has rarely been evaluated; however, patients seem to be satisfied with the assistance provided, since it allows them to both retain independence and to be relieved from the burden of self-care. Assisted PD should not be intended as a PD-favoring strategy, but as a model that allows home dialysis also in patients who would not be eligible for PD because of social, cognitive or physical barriers.

Trends in home dialysis use differ among age categories in past two decades: A Dutch registry study

BACKGROUND

Although the number of patients with end-stage kidney disease is growing, the number of patients who perform dialysis at home has decreased during the past two decades. The aim of this study was to explore time trends in the use of home dialysis in the Netherlands.

METHODS

Dialysis episodes of patients who started dialysis treatment were studied using Dutch registry data (RENINE). The uptake of home dialysis between 1997 through 2016 was evaluated in time periods of 5 years. Home dialysis was defined as start with peritoneal dialysis or home haemodialysis, or transfer to either within 2 years of dialysis initiation. All analyses were stratified for age categories. Mixed model logistic regression analysis was used to adjust for clustering at patient level.

RESULTS

A total of 33 340 dialysis episodes in 31 569 patients were evaluated. Mean age at dialysis initiation increased from 62.5 ± 14.0 to 65.5 ± 14.5 years in in-centre haemodialysis patients, whereas it increased from 51.9 ± 15.1 to 62.5 ± 14.6 years in home dialysis patients. In patients <65 years, the uptake of home dialysis was significantly lower during each 5-year period compared with the previous period, whereas kidney transplantation occurred more often. In patients ≥65 years, the incidence of home dialysis remained constant, whereas mortality decreased.

CONCLUSIONS

In patients <65 years, the overall use of home dialysis declined consistently over the past 20 years. The age of home dialysis patients increased more rapidly than that of in-centre dialysis patients. These developments have a significant impact on the organization of home dialysis.

Costs of Assisted Home Dialysis: A Single-Payer Canadian Model From Manitoba

Rationale & Objective

The prevalence of kidney failure is increasing globally. Most of these patients will require life-sustaining dialysis at a substantial cost to the health care system. Assisted peritoneal dialysis (PD) and assisted home hemodialysis (HD) are potential alternatives to in-center HD and have demonstrated equivalent outcomes with respect to mortality and morbidity. We aim to describe the costs associated with assisted continuous cycling PD (CCPD) and assisted home HD.

Study Design

Cost minimization model.

Setting & Population

Adult incident maintenance dialysis patients in Manitoba, Canada.

Intervention

Full- and partial-assist home HD and CCPD. Full-assist modalities were defined as nurse-assisted dialysis setup and takedown performed by a health care aide, whereas partial-assist modalities only included nurse-assisted setup. Additionally, full-assist home HD was evaluated under a complete care scenario with the inclusion of a health care aide remaining with the patient throughout the duration of treatment.

Outcomes

Annual per-patient maintenance and training costs related to assisted and self-care home HD and CCPD, presented in 2019 Canadian dollars.

Model, Perspective, & Time Frame

This model took the perspective of the Canadian public health payer using a 1-year time frame.

Results

Annual total per-patient maintenance (and training) costs by modality were the following: full-assist CCPD, $75.717 (initial training costs, $301); partial-assist CCPD, $67,765 ($4,385); full-assist home HD, $47,862 ($301); partial-assist home HD, $44,650 ($14,813); and full-assist home HD (complete care), $64,659 ($301).

Limitations

This model did not account for costs taken from the societal perspective or costs related to PD failure and modality switching. Additionally, this analysis reflects only costs experienced by a single center.

Conclusions

Assisted home-based dialysis modalities are viable treatment options for patients from a cost perspective. Future studies to consider graduation rates to full self-care from assisted dialysis and the cost implications of respite care are needed.

Assisted peritoneal dialysis across Europe: Practice variation and factors associated with availability

BACKGROUND

In Europe, the number of elderly end-stage kidney disease patients is increasing. Few of those patients receive peritoneal dialysis (PD), as many cannot perform PD autonomously. Assisted PD programmes are available in most European countries, but the percentage of patients receiving assisted PD varies considerably. Hence, we assessed which factors are associated with the availability of an assisted PD programme at a centre level and whether the availability of this programme is associated with proportion of home dialysis patients.

METHODS

An online survey was sent to healthcare professionals of European nephrology units. After selecting one respondent per centre, the associations were explored by χ ² tests and (ordinal) logistic regression.

RESULTS

In total, 609 respondents completed the survey. Subsequently, 288 respondents from individual centres were identified; 58% worked in a centre with an assisted PD programme. Factors associated with availability of an assisted PD programme were Western European and Scandinavian countries (OR: 5.73; 95% CI: 3.07-10.68), non-academic centres (OR: 2.01; 95% CI: 1.09-3.72) and centres with a dedicated team for education (OR: 2.87; 95% CI: 1.35-6.11). Most Eastern & Central European respondents reported that the proportion of incident and prevalent home dialysis patients was <10% (72% and 63%), while 27% of Scandinavian respondents reported a proportion of >30% for both incident and prevalent home dialysis patients. Availability of an assisted PD programme was associated with a higher incidence (cumulative OR: 1.91; 95% CI: 1.21-3.01) and prevalence (cumulative OR: 2.81; 95% CI: 1.76-4.47) of patients on home dialysis.

CONCLUSIONS

Assisted PD was more commonly offered among non-academic centres with a dedicated team for education across Europe, especially among Western European and Scandinavian countries where higher incidence and prevalence of home dialysis patients was reported.

Choice of dialysis modality among patients initiating dialysis: results of the Peridialysis study

Background

In patients with end-stage kidney disease (ESKD), home dialysis offers socio-economic and health benefits compared with in-centre dialysis but is generally underutilized. We hypothesized that the pre-dialysis course and institutional factors affect the choice of dialysis modality after dialysis initiation (DI).

Methods

The Peridialysis study is a multinational, multicentre prospective observational study assessing the causes and timing of DI and consequences of suboptimal DI. Clinical and biochemical data, details of the pre-dialytic course, reasons for DI and causes of the choice of dialysis modality were registered.

Results

Among 1587 included patients, 516 (32.5%) were judged unsuitable for home dialysis due to contraindications [384 ( 24.2%)] or no assessment [106 (6.7%); mainly due to late referral and/or suboptimal DI] or death [26 (1.6%)]. Older age, comorbidity, late referral, suboptimal DI, acute illness and rapid loss of renal function associated with unsuitability. Of the remaining 1071 patients, 700 (65.4%) chose peritoneal dialysis (61.7%) or home haemodialysis (HD; 3.6%), while 371 (34.6%) chose in-centre HD. Somatic differences between patients choosing home dialysis and in-centre dialysis were minor; factors linked to the choice of in-centre dialysis were late referral, suboptimal DI, acute illness and absence of a ‘home dialysis first’ institutional policy.

Conclusions

Given a personal choice with shared decision making, 65.4% of ESKD patients choose home dialysis. Our data indicate that the incidence of home dialysis potentially could be further increased to reduce the incidence of late referral and unplanned DI and, in acutely ill patients, by implementing an educational programme after improvement of their clinical condition.

Assisted peritoneal dialysis: a feasible KRT modality for frail older patients with end-stage kidney disease (ESKD)

Assisted PD is used as an alternative option for the growing group of frail, older ESKD patients unable to perform their own PD. This study was undertaken to investigate the outcomes of assisted PD in older patients by comparing assisted PD patients with self-care PD patients. This study included all patients aged 70 and above who started on PD in our hospital from 2009 to 2018. Patients were followed up until death, PD cessation or to the end of the study (December 31, 2019). Risk factors associated with mortality, peritonitis and technique failure were evaluated using both cause-specific hazards and subdistribution hazards models. 180 patients were enrolled, including 106 (58.9%) males with a median age of 77.5 (77.2-81.2) years. Among the 180 patients, 62 patients (34.4%) were assisted. Patients on assisted PD group were older, more likely to be female, more prevalent in DM and CVD, with a higher Charlson score than patients undergoing self-care PD (P all < 0.05). In the multivariable analysis, assisted patients had a comparable patient survival and peritonitis-free survival compared to self-care PD patients either in the Cox or in the FG models. According to a Cox model, the use of assisted PD was associated with a lower risk of technique failure (cs-HR 0.20, 95% CI 0.04-0.76), but the association lost its statistical significance in the Fine and Gray model. Our results suggest that assisted PD could be a safe and effective KRT modality for older ESKD patients who need assistance.

Key elements in selection of pre-dialysis patients for home dialysis

BACKGROUND

Most pre-dialysis patients are medically eligible for home dialysis, and home dialysis has several advantages over incentre dialysis. However, accurately selecting patients for home dialysis appears to be difficult, since uptake of home dialysis remains low. The aim of this study was to investigate which medical or psychosocial elements contribute most to the selection of patients eligible for home dialysis.

METHODS

All patients from a Dutch teaching hospital, who received treatment modality education and subsequently started dialysis treatment, were included. The pre-dialysis programme consisted of questionnaires for the patient, nephrologist and social worker, followed by an assessment of eligibility for home dialysis by a multidisciplinary team. Clinimetric assessment and logistic regression were used to identify domains and questions associated with home dialysis treatment.

RESULTS

A total of 135 patients were included, of whom 40 were treated with home dialysis and 95 with incentre haemodialysis. The key elements associated with long-term home dialysis treatment were part of the domains 'suitability of the housing', 'self-care', 'social support' and 'patient capacity', with adjusted odds ratios ranging from 0.13 for negative to 18.3 for positive associations.

CONCLUSION

The assessment of contraindications by a nephrologist followed by the assessment of possibilities by a social worker or dialysis nurse who investigates four key elements, ideally during a home visit, and subsequent detailed education offered by specialized nurses is an optimal way to select patients for home dialysis.

Patients undergoing assisted peritoneal dialysis to show a better technique survival: A competing risk analysis

AIMS

To compare patient mortality and technique survival between patients undergoing assisted peritoneal dialysis (aPD) and self-care peritoneal dialysis (sPD).

METHODS

Patients who underwent peritoneal dialysis (PD) at the dialysis center of Second Affiliated Hospital of Soochow University from January 1, 2012 to December 31, 2016, were included and followed to December 31, 2019. Subjects were divided into aPD and sPD groups according to whether the patient could independently complete the PD procedure. Differences in mortality and technique failure rates were compared using competing risk analysis.

RESULTS

A total of 384 patients were included in this study, with 274 patients in the sPD group and 110 patients in the aPD group. The multivariate competing risk regression analysis revealed that age (HR 1.03,95%CI 1.01-1.05, P < .001), aPD (HR 1.84,95%CI 1.10-3.08, P = .02), diabetes (HR 1.51, 95%CI 1.00-2.30, P = .05), residual renal function (HR 0.89, 95%CI 0.82-0.97, P = .005) and serum albumin level (HR 0.92, 95% CI 0.89-0.96, P < .001) were the independent risk factors for mortality. Besides, technique failure in aPD patients was lower than in the sPD group (HR 0.85, 95% CI 0.68-0.97, P = .03).

CONCLUSION

These results found that aPD patients had higher mortality rates but lower technique failure rates than sPD patients. Higher mortality in aPD is probably related to the negative selection of the more comorbid patients. ​ ​.

Growing home dialysis: The Ontario Renal Network Home Dialysis Initiative 2012-2019

The Ontario Renal Network (ORN), a provincial government agency in Ontario, Canada, launched an initiative in 2012 to increase home dialysis use province-wide. The initiative included a new modality-based funding formula, a standard mandatory informatics system, targets for prevalent home dialysis rates, the development of a 'network' of renal programmes with commitment to home dialysis and a culture of accountability with frequent meetings between ORN and each renal programme leadership to review their results. It also included funding of home dialysis coordinators, encouragement and funding of assisted peritoneal dialysis (PD), and support for catheter insertion and urgent start PD. Between 2012 and 2017, home dialysis use rose from 21.9% to 26.5% and then between 2017 and 2019 stabilised at 26% to 26.5%. Over 7 years, the absolute number of people on home dialysis increased 40% from 2222 to 3105, while the number on facility haemodialysis grew 11% from 7935 to 8767. PD prevalence rose from 16.6% to 20.9%, a relative increase of 25%. The initiative showed that a sustained multifaceted approach can increase home dialysis utilisation.

Starting Dialysis on Time, At Home on the Right Therapy (START): Description of an Intervention to Increase the Safe and Effective Use of Peritoneal Dialysis

Background:

Most of the patients with end-stage kidney failure are treated with dialysis. Jurisdictions around the world are actively promoting peritoneal dialysis (PD) because it is equivalent to hemodialysis in terms of clinical outcomes, but is less costly. Unfortunately, PD penetration remains low.

Objectives:

The Starting dialysis on Time, At Home, on the Right Therapy (START) Project had 2 overarching goals: (1) to provide information that would help programs increase the safe and effective use of PD, and (2) to reduce inappropriate, early initiation of dialysis in patients with kidney failure. In this article, we focus on the first objective and describe the rationale for START and the methods employed.

Design:

The START Project was a comprehensive, province-wide quality improvement intervention.

Setting:

The START project was implemented in both Alberta Kidney Care (AKC)-South and AKC-North, including all 7 renal programs in the province.

Patients:

The project included all patients who commenced maintenance dialysis between October 1, 2015, and March 31, 2018, in Alberta, Canada who met our inclusion criteria.

Measurements:

We reported baseline characteristics of incident dialysis patients overall, and by site. Our key performance indicator was the proportion of patients who received PD for any period of time within 180 days of the first dialysis treatment. Reports also included detailed metrics pertaining to the 6 steps in the process of modality selection and we had the capacity to provide more granular data on an as-needed basis. To understand loss of PD patients, we reported the numbers of incident patients who recovered kidney function, experienced technique failure, received a transplant, were lost to follow-up, transferred to another program, or died.

Methods:

START provided dialysis programs with a conceptual framework for understanding the drivers of PD utilization. High-quality, detailed data were collected using a tool that was custom-built for this purpose, and were mapped to steps in the process of care that drove the outcomes of interest. This allowed sites to identify gaps in care, develop action plans, and implement local interventions to address them. The process was supported by an Innovation Learning Collaborative consisting of 3 learning sessions that brought frontline staff together from across the province to share strategies and learnings. Ongoing data collection allowed teams to determine whether their interventions were effective at each subsequent learning session, and to revisit their interventions if required (the “Plan-Do-Study-Act Cycle”).

Results:

Future work will report on the impact of the START project on incident PD utilization at a provincial and regional level.

Limitations:

The time required to design and implement interventions in practice, as well as the need for multiple PDSA (Plan-Do-Study-Act) cycles to see results, meant that the true potential may not be realized during a relatively short intervention period. Change required buy-in and support from local and provincial leadership and frontline staff. In the absence of accountability for local performance, we relied on the goodwill of participating programs to use the information and resources provided to effect change. Finally, the burden of documentation and data collection for frontline staff was high at baseline. We anticipated that adding supplemental data collection would be difficult.

Conclusions:

The START project was a comprehensive, province-wide initiative to maximize the safe and effective use of PD in Alberta, Canada. It standardized the management of incident dialysis patients, leveraged high-quality data to facilitate the reporting of metrics mapped to steps in the process of care that drove incident PD utilization, and helped programs to identify gaps in care and target them for improvement. Future work will report on the impact of the program on incident utilization at the provincial and regional level.

Quantifying Missed Opportunities for Recruitment to Home Dialysis Therapies

Background:

Despite the recognized benefits of home therapies for patients and the health care system, most individuals with kidney failure in Canada continue to be initiated on in-center hemodialysis. To optimize recruitment to home therapies, there is a need for programs to better understand the extent to which potential candidates are not successfully initiated on these therapies.

Objective:

We aimed to quantify missed opportunities to recruit patients to home therapies and explore where in the modality selection process this occurs.

Design:

Retrospective observational study.

Setting:

British Columbia, Canada.

Patients:

All patients aged >18 years who started chronic dialysis in British Columbia between January 01, 2015, and December 31, 2017. The sample was further restricted to include patients who received at least 3 months of predialysis care. All patients were followed for a minimum of 12 months from the start of dialysis to capture any transition to home therapies.

Methods:

Cases were defined as a “missed opportunity” if a patient had chosen a home therapy, or remained undecided about their preferred modality, and ultimately received in-center hemodialysis as their destination therapy. These cases were assessed for: (1) documentation of a contraindication to home therapies; and (2) the type of dialysis education received. Differences in characteristics among patients classified as an appropriate outcome or a missed opportunity were examined using Wilcoxon rank-sum test or χ² test, as appropriate.

Results:

Of the 1845 patients who started chronic dialysis during the study period, 635 (34%) were initiated on a home therapy. A total of 320 (17.3%) missed opportunities were identified, with 165 (8.9%) having initially chosen a home therapy and 155 (8.4%) being undecided about their preferred modality. Compared with patients who chose and initiated or transitioned to a home therapy, those identified as a missed opportunity tended to be older with a higher prevalence of cardiovascular disease. A contraindication to both peritoneal dialysis and home hemodialysis was documented in 8 “missed opportunity” patients. General modality orientation was provided to most (71%) patients who had initially chosen a home therapy but who ultimately received in-center hemodialysis. These patients received less home therapy–specific education compared with patients who chose and subsequently started a home therapy (20% vs 35%, P < .001).

Limitations:

Contraindications to home therapies were potentially under-ascertained, and the nature of contraindications was not systematically captured.

Conclusions:

Even within a mature home therapy program, we discovered a substantial number of missed opportunities to recruit patients to home therapies. Better characterization of modality contraindications and enhanced education that is specific to home therapies may be of benefit. Mapping the recruitment pathway in this way can define the magnitude of missed opportunities and identify areas that could be optimized. This is to be encouraged, as even small incremental improvements in the uptake of home therapies could lead to better patient outcomes and contribute to significant cost savings for the health care system.

Trial Registration:

Not applicable as this was a qualitative study.

Health Outcomes and Cost Considerations of Assisted Peritoneal Dialysis: A Narrative Review

BACKGROUND

Peritoneal dialysis (PD) is underutilized in many parts of the world despite pro-PD health policies. The physical and cognitive demands of PD means that over half of eligible patients require some form of assistance. As such, many countries now offer assisted PD (aPD) programs to help patients start or stay on PD as opposed to in-center hemodialysis (HD). In order to evaluate the potential scope of aPD, it is important to review the outcomes and cost considerations of aPD.

SUMMARY

We reviewed available data from different countries and regions for health outcomes between aPD and in-center HD, with a focus on quality of life (QoL), mortality, hospitalization, and technique survival. We also evaluated studies discussing the overall costs of delivering aPD, including training, operating costs, and indirect costs and compared these to in-center HD costs for the same regions. Key Messages: aPD patients are older and more frail than either self-care PD patients and many in-center HD patients. We found no evidence for any difference in QoL, mortality, or hospitalization between aPD and in-center HD after adjustment for these differences. There is some evidence for an association between nurse assistance and improved technique survival as compared to family assistance or self-care PD. Despite increased cost of providing assistance in PD, it is still significantly less expensive than in-center HD in Western Europe and Canada.

Impact of the implementation of an assisted peritoneal dialysis service on peritoneal dialysis initiation

BACKGROUND

There is limited information available on the impact that provision of an assisted peritoneal dialysis (PD) service has on the initiation of PD. The aim of this study was to assess this impact in a centre following initiation of assisted PD in 2011.

METHODS

This retrospective, single-centre study analysed 1576 patients incident to renal replacement therapies (RRTs) between January 2002 and 2017. Adjusted Cox regression with a time-varying explanatory variable and a Fine and Gray model were used to examine the effect of assisted PD use on the rates and cumulative incidence of PD initiation, accounting for the non-linear impact of RRT starting time and the competing risks (transplant and death).

RESULTS

Patients starting PD with assistance were older than those starting unassisted: median (interquartile range): 70.0 (61.5-78.3) versus 58.7 (43.8-69.2) years old, respectively. In the adjusted analysis assisted PD service availability was associated with an increased rate of PD initiation [cause-specific hazard ratio (cs-HR) 1.78, 95% confidence interval 1.21-2.61]. During the study period, the rate of starting PD fell before flattening out. Transplantation and death rates increased over time but this did not affect the fall in PD initiation [for each year in the study cs-HR of starting PD 0.95 (0.93-0.98), sub-distribution HR 0.95 (0.94-0.97)].

CONCLUSIONS

In a single-centre study, introducing an assisted PD service significantly increased the rate of PD initiation, benefitting older patients most. This offsets a fall in PD usage over time, which was not explained by changes in transplantation or death.

Trends in assisted peritoneal dialysis over the last decade: a cohort study from the French Peritoneal Dialysis Registry

BACKGROUND

There is limited information available on the use of assisted peritoneal dialysis (PD) over time and the impact of economic incentives on its utilization. The aim of this study was to describe the trends in assisted PD utilization and the type of assistance provided. We wanted to estimate if an economic incentive implemented in 2011 in France was associated with an increase in the utilization of nurse-assisted PD.

METHODS

This retrospective, multicentre study, based on data from the French Language Peritoneal Dialysis Registry, analysed 11 987 patients who initiated PD in France between 1 January 2006 and 31 December 2015. Adjusted Cox regression with robust variance was used to examine the initiation of assisted PD, both nurse-assisted and family-assisted, accounting for the nonlinear impact of the PD starting time.

RESULTS

There were 6149 (51%) incident patients on assisted PD, 5052 (82%) on nurse-assisted PD and 1097 (18%) on family-assisted PD over the study period. In the adjusted analysis, calendar time was associated with the assisted PD rate: it declined from 2008 until 2013 before flattening out and then it increased after 2014. Nurse-assisted PD utilization increased significantly after 2012, whereas family-assisted PD utilization decreased linearly over time (prevalence ratio = 0.94, 95% confidence interval 0.92-0.97).

CONCLUSIONS

The assisted PD rate decreased until 2013, mainly because of a decline in family-assisted PD. The uptake in nurse-assisted PD observed from 2013 reflects the effect of an economic incentive adopted in late 2011 to increase PD utilization.

Barriers to Peritoneal Dialysis in Saskatchewan Canada: Results From a Province-Wide Survey

Background:

Peritoneal dialysis (PD) is an underutilized, therapeutic option to in-center hemodialysis (HD), given its similar survival and clinical efficacy but provides lifestyle benefits and cost savings. Despite these advantages, PD prevalence rates remains below 20% in many Canadian jurisdictions.

Objectives:

The primary objective of this study was to identify and assess patient-perceived barriers to PD implementation in Saskatchewan. The secondary objectives were to examine variations in patient-perceived barriers to PD by dialysis units (main dialysis units vs satellite dialysis units) and specific challenges faced by First Nation patients residing on reserves.

Design:

A cross-sectional observational survey study.

Setting:

Two major centers (Regina and Saskatoon) and 5 associated satellite units attached to each center across the province of Saskatchewan.

Patients:

We approached all prevalent in-center HD patients across Saskatchewan, 366 (49%) agreed to participate in the study.

Measurements:

Self-reported barriers to PD were assessed using a 26-question survey which was created after engagement of our multidisciplinary team.

Methods:

We conducted a cross-sectional survey of 740 prevalent in-center HD patients within the province of Saskatchewan, Canada, from June 2018 to January 2019. Around 366 (49%) patients agreed to participate in the study. The questionnaire was designed to capture patients’ perceived barriers to PD. Descriptive statistics were used to present the data. Chi-square and Mann-Whitney U-test were used to compare the patients’ responses (main dialysis units vs satellite dialysis units, and First Nation reserves vs nonreserves).

Results:

Of the 366 patients who completed the survey, 284 met the eligibility criteria and were included in the analysis. Patient-reported satisfaction with current in-center HD care was the most common barrier to PD uptake (92%), followed by proximity to their HD unit (61%). A lack of understanding of the benefits/risks of PD, fear of family burden (54% each), and unwillingness to dialyze daily and to learn a new technique (51% each) were additional factors. Patients residing on reserves compared to nonreserve residents felt PD had a higher risk of infection compared to HD (54% vs 34%, P = .005), and felt PD led to suboptimal care (47% vs 31%, P = .021).

Limitations:

We used a nonstandardized locally derived questionnaire to quantify barriers, and this prevents inclusion of additional barriers than individual patients may consider important. Cross-sectional data can only be used as a snapshot. Only 366 patients agreed to participate, and the results cannot be generalized to 740 prevalent HD patients. We did not capture data on demographics (age, income, and literacy level), comorbidities, and dialysis vintage, which would have been helpful in interpretation of the results. We did not involve patients, carers, or patients of First Nations heritage, in the design of the survey and the study.

Conclusions:

The results of our survey indicate that the major patient-reported barrier to PD uptake in our province is clinical inertia in patients defaulted to in-center HD at the onset of dialysis. Lack of patient awareness and knowledge of PD as a viable treatment modality also figured prominently, as did fears/concerns surrounding the safety, efficacy, and perceived family burden with PD compared with in-center HD.

Trial Registration:

The study was not registered on a publicly accessible registry because it did not involve any health care intervention on human participants.

Facilitators and Barriers to Care in Rural Emergency Departments in Alberta for Patients on Peritoneal Dialysis (PD): An Interpretive Descriptive Study

Background:

Home dialysis offers many advantages to patients, but they require support to manage a home-based therapy such as peritoneal dialysis (PD). A rural emergency department provides an important safety net for patients requiring medical care, including managing complications of PD, such as peritonitis. Patients living in northern Alberta are spread out geographically and can be far from a PD training center, yet anecdotally, many rural sites do not provide care for these patients.

Objective:

Our aim was to identify the facilitators and barriers to nursing care in rural emergency departments in northern Alberta for patients receiving PD.

Design:

A qualitative interpretive descriptive approach was used.

Setting:

Rural emergency departments across northern Alberta.

Participants:

Purposeful sampling was used to seek participants from 1 of 4 rural acute care hospital emergency departments in northern Alberta. Six registered nurses and 1 licensed practical nurse agreed to participate in the study. They ranged in experience from 2 to 18 years. Two of the participants were unit managers, 2 were clinical nurse educators (CNEs), and the other 3 were staff nurses with 1 of them in a leadership position.

Methods:

Individual semistructured interview were conducted over the telephone. The interview guide was developed based on a review of the literature. Interviews continued until no new information was obtained, that is, data were saturated. Interviews were audio recorded and transcribed verbatim. Field notes were recorded. A constant comparative approach was used for analysis. The coding process was both deductive (drawing from the literature) and inductive.

Results:

Seven participants were interviewed, and there were 4 main themes and 1 subtheme that emerged from the analysis: education (along with the subtheme of resources) was seen as both facilitators and barriers; patient/family ability to perform PD; infrequent exposure; and physician supports. Continuing education about PD was a facilitator, and the lack of education was a barrier to provision of PD care. Similarly, availability of resource materials about PD and access to a CNE were facilitators, while lack of these resources was a barrier to offering PD care. As PD was not always seen regularly, infrequent exposure was a barrier to offering PD care. Lack of physician supports, both from the locum physicians who were sometimes reluctant to care for these patients and the delays in reaching nephrologists were barriers.

Limitations:

The findings represent the perceptions of the emergency department nurses who participated. These perceptions may differ from those of nurses who work in other regions of the country. Furthermore, most participants were in a leadership role, and it may be that their perspectives differ from those of front-line nurses.

Conclusions:

The findings from our study highlight the need for availability of education and resource materials/persons to care for these patients. There is also a need for greater physician support from both local physicians as well as nephrologists to offer high-quality PD care.

Trial registration:

Not applicable. This study is not a clinical trial. It did not involve prospective assignment of participants to a treatment group.

Assessment of patients referred to urgent start peritoneal dialysis: when does the nurse contraindicate?

INTRODUCTION

Urgent-start peritoneal dialysis (US-PD) has been used worldwide with very positive results. The prior assessment of candidates for this therapy by a nurse can favor the success of the therapy.

OBJECTIVES

To identify the profile of patients who are candidates for US-PD, the causes of contraindication of the method by the nurse and their permanence in the method after 30 days, as well as the growth of the service after implementing the program.

METHODS

We retrospectively analyzed the forms used to assess candidates for US-PD applied by nurses between May 2017 and August 2019 in a clinic in Santa Catarina. We analyzed information on demographic profile, reasons for contraindication and permanence in the method after 30 days, as well as service growth after the program was implemented.

RESULTS

Of the 215 patients indicated for US-PD, 51% were male, 55% were under 60 years old, 51% had diabetes mellitus and 89% were hypertensive. Of these, 173 (80%) patients had the nurse's approval for PD. The only cause contraindicated was the inability to self-care associated with the lack of family support. In the first 30 days after the assessment, 89% of the patients who started PD remained on it. During the study period, the PD service grew by 91%.

CONCLUSION

During the study period, a fifth of patients referred to US-PD received contraindication by nursing due to self-care inability associated with the lack of family support. After 30 days, 89% of the patients remained on it.

Social Support in the Peritoneal Dialysis Experience: A Qualitative Descriptive Study

Background:

People with end-stage kidney disease can either pursue conservative (palliative) management or kidney replacement therapy. Although transplant is preferred, there is a limited number of organs available rendering the majority of patients treated with some form of dialysis. Hemodialysis and peritoneal dialysis are equivalent regarding clinical outcomes, but peritoneal dialysis is much less costly to provide. Peritoneal dialysis is most often done in the home by the patient or a support person and carries a self-care burden on patients and families. Social support is important for patients receiving peritoneal dialysis and in sustaining peritoneal dialysis therapy. Few studies have comprehensively explored social support in the context of peritoneal dialysis.

Objective:

To explore how patients, family members, and nurses view social support.

Design:

Qualitative, descriptive study.

Setting:

An outpatient peritoneal dialysis clinic in Western Canada.

Participants:

Patients, family members, and nurses.

Methods:

Patients (n = 15), family members (n = 6), and nurses (n = 11) were interviewed between January and May 2018. Content analysis was undertaken using 4 attributes of social support (ie, emotional support, instrumental support, informational support, and appraisal support) as an analytic framework.

Results:

Themes related to the 4 attributes of social support were identified: addressing emotional needs and managing emotion (emotional support); peritoneal dialysis tasks and life tasks (instrumental support); accessing information, receiving information, and learning (informational support); and affirmation/external reassurance and self-confidence (appraisal support). The social support needs of both patients and family members varied and were dependent on their existing support networks and individual perspectives of support.

Limitations:

It is possible that some of the study findings were gender-bound as well as context-specific. The study findings could be different if the patient and caregiver sample were more balanced based on sex. There are also unique attributes of each peritoneal dialysis program that may impact the transferability of these findings to other practice settings.

Conclusion:

Home-based peritoneal dialysis has potential benefit to patients and health care systems. However, receiving peritoneal dialysis requires support. If health care providers wish to promote this treatment, they must also understand how to best support patients and their family members.

Trial Registration:

Not applicable.

A Systematic Review and Jurisdictional Scan of the Evidence Characterizing and Evaluating Assisted Peritoneal Dialysis Models

BACKGROUND AND OBJECTIVES

Compared with hemodialysis, home peritoneal dialysis alleviates the burden of travel, facilitates independence, and is less costly. Physical, cognitive, or psychosocial factors may preclude peritoneal dialysis in otherwise eligible patients. Assisted peritoneal dialysis, where trained personnel assist with home peritoneal dialysis, may be an option, but the optimal model is unknown. The objective of this work is to characterize existing assisted peritoneal dialysis models and synthesize clinical outcomes.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

A systematic review of MEDLINE, Cochrane Central Register of Controlled Trails, Cochrane Database of Systematic Reviews, Embase, PsycINFO, and CINAHL was conducted (search dates: January 1995-September 2018). A focused gray literature search was also completed, limited to developed nations. Included studies focused on home-based assisted peritoneal dialysis; studies with the assist provided exclusively by unpaid family caregivers were excluded. All outcomes were narratively synthesized; quantitative outcomes were graphically depicted.

RESULTS

We included 34 studies, totaling 46,597 patients, with assisted peritoneal dialysis programs identified in 20 jurisdictions. Two categories emerged for models of assisted peritoneal dialysis on the basis of type of assistance: health care and non-health care professional assistance. Reported outcomes were heterogeneous, ranging from patient-level outcomes of survival, to resource use and transfer to hemodialysis; however, the comparative effect of assisted peritoneal dialysis was unclear. In two qualitative studies examining the patient experience, the maintenance of independence was identified as an important theme.

CONCLUSIONS

Reported outcomes and quality were heterogeneous, and relative efficacy of assisted peritoneal dialysis could not be determined from included studies. Although the patient voice was under-represented, suggestions to improve assisted peritoneal dialysis included using a person-centered model of care, ensuring continuity of nurses providing the peritoneal dialysis assist, and measures to support patient independence. Although attractive elements of assisted peritoneal dialysis are identified, further evidence is needed to connect assisted peritoneal dialysis outcomes with programmatic features and their associated funding models.

Should Older Patients be Offered Peritoneal Dialysis?

On haemodialysis, my life was not my own — handing control to nursing staff for 4 hours, 3 days a week, surrounded by noisy machines and unhappy patients, returning home after 11 hours, too exhausted to eat and falling into bed. However, peritoneal dialysis has given me back my life. I am in control of me and am treated like a human being, not just a patient. There are minor drawbacks, such as storage for the fluids and being unable to have a bath, but it is a small price to pay.

In-Center Intermittent Peritoneal Dialysis: Retrospective Ten-Year Single-Center Experience with Thirty Consecutive Patients

Background

In-center intermittent peritoneal dialysis (IPD) is sometimes performed in elderly and multimorbid patients that have failed hemodialysis and that are unable to perform peritoneal dialysis (PD) at home. Complications, frequency of hospital admission, and survival are often claimed to be dismal although current data are lacking.

Methods

We performed a retrospective cohort study of patients that underwent IPD at Hannover Medical School, Germany, between 1997 and 2007. Underlying renal disorders, comorbidity, and circumstances that precluded hemodialysis and home PD were recorded. Survival, cause of death, episodes of hospitalization, and episodes of peritonitis were calculated. Laboratory values at baseline and after 3 months of IPD were also retrieved.

Results

We identified 30 patients with severe comorbidity (median Charlson Comorbidity Index of 6; n = 30) who underwent IPD for 439 months in total. The majority of patients had vascular/hypertensive nephropathy ( n = 12; 40%); congestive heart failure was the leading cause for choosing PD ( n = 13; 43.3%); 73.3% of our patients had either no partner or at least one disease that precluded home therapy. Hospitalization rate was 1.39 admissions per patient-year and there was 1 episode of peritonitis per 48.8 IPD-months. Mean survival was 26.6 months (median 17 months; n = 30); sepsis was the leading cause of death ( n = 13; 59.1%).

Conclusions

IPD is associated with fewer episodes of peritonitis, fewer admissions, and longer survival than is often believed. Suitable patients in whom palliative care alone seems inappropriate should not be denied a trial of IPD if they so choose.