Perceptions of Home Dialysis Training and Experience Among US Nephrology Fellows

Home Hemodialysis Practice and Curriculum Recommendations Among Graduates of a Military Nephrology Training Program Without Home Hemodialysis Clinic Experience

INTRODUCTION

The Advancing American Kidney Health Initiative set a goal that ≥80% of new end-stage kidney disease patients receive home dialysis or kidney transplant by 2025. Home hemodialysis (HHD) prevalence remains low, and one barrier may be a lack of familiarity with HHD among nephrologists and insufficient training during fellowship.

MATERIALS AND METHODS

We performed an anonymous survey of 92/94 graduates from the Walter Reed military nephrology program (1984-2023) regarding their HHD practice and training. The home dialysis program includes only peritoneal dialysis, and HHD training is limited to didactics and training with machines used for low-flow dialysate HHD. The survey was conducted from April 12, 2023 to April 2, 2024.

RESULTS

Fifty-two out of ninety-two (57%) responded; 96% completed the survey. Seventy-five percent (38/51) had been in practice for ≤20 years. Forty-three percent (22/51) practice(d) HHD. Of these, 54% (12/22) had been HHD directors/co-directors, and 73% (16/22) had started practice in the last 10 years. The majority were in the southern (50%) or western (23%) United States, and 32% had rural practices. 54% (12/22) followed 6 to 10 patients. Sixty-eight percent reported learning HHD skills "on the job." Barriers most commonly cited were lack of patient interest (41%), lack of patient partners (27%), and lack of nursing staff (27%). Overall, graduates indicated that the minimum effective curriculum for HHD competence should include block/longitudinal HHD clinic (84%), familiarization with HHD machines (82%), didactic lectures (80%), and training in effective counseling (80%).

CONCLUSIONS

Among graduates of a military nephrology training program without HHD clinic experience, 43% reported subsequently practicing HHD, the majority learning "on the job." Overall, graduates indicated that block/longitudinal HHD clinic was the most effective way for fellows to learn HHD skills. Nephrology programs should expect that graduates are likely to care for HHD patients, and prepare them accordingly. In addition, for military nephrologists, HHD skills can be applied to dialysis delivery in austere settings.

Program Director and Nephrology Fellow's Perceptions of Home Hemodialysis Education in the United States

Key Points

Our survey reports the existence of home hemodialysis (HHD) curricula, including didactic, outside HHD courses, shared decision-making training, and continuity clinics. Fellows attending outpatient clinics were more likely to be confident in their ability and prepared to manage HHD patients. The critical barrier to HHD education identified by program directors and fellows was insufficient patients.

Background

Public policy focuses on increasing the prevalence of home dialysis. Home hemodialysis (HHD) education and comfort with the procedure are significant barriers to increasing prevalence. This study examines nephrology fellowship didactic curriculum, training program infrastructure, and barriers identified by both program directors and trainees.

Methods

An anonymous, online survey was developed to assess HHD curriculum in US nephrology fellowship programs. During academic year 2023–2024, all US nephrology program directors (n =150) were surveyed and asked to forward survey link to their fellows and to indicate the number to whom they forwarded the link.

Results

Fifty-five (55/150; 37%) US nephrology program directors responded to the survey; 80% completed it. Thirty-seven (37/55, 67%) forwarded the link to their fellows. Fellow response rate was 53/237 (22%); 50/53 completed it (94%). Seventy-five percent of the program directors reported either having an HHD curriculum or were developing one. Program directors reported that didactic lectures (87%) were the most frequently available curriculum component, whereas fellows report education on counseling (72%) was most frequent. Sixty percent of fellows and 86% of program directors reported fellow attendance at HHD longitudinal/continuity clinic (routinely or as part of a block rotation). Both peritoneal dialyses and fellows identified insufficient patients as a key barrier to implementing HHD curriculum. Fellows who attended outpatient HHD clinic felt more confident and prepared in HHD-related competencies.

Conclusions

The HHD curriculum exists as didactic lectures, attendance at outside HHD courses, and ESKD-shared decision-making at training programs. Most programs also have continuity clinics. Our findings highlight the presence of curriculum although inconsistent. Fellows who worked in clinic were more likely to be confident and more prepared to manage HHD patients. In addition, fellows with longitudinal clinic felt better prepared than those attending block rotations. Training programs should consider incorporating HHD longitudinal clinical rotations, although this may require creativity to achieve.

Policy and Payment Decisions on Peritoneal Dialysis in the United States: A Review

End-stage kidney disease (ESKD) accounts for a sizable proportion of Medicare spending. Peritoneal dialysis remains an underutilized treatment modality for ESKD despite its quality of life and cost-saving benefits. Medicare policy on reimbursements and patient eligibility for dialysis coverage has been amended numerous times since its inception in 1972. Over the last two decades, Medicare policy on ESKD reimbursements has evolved from a primarily fee-for-service model to a prospective payment system, and within the past few years, it has begun including more experimental payment structures. While prior work has explored the evolution of Medicare's ESKD policy as a whole, we specifically outline the impact of Medicare policy changes on peritoneal dialysis reimbursement rates, uptake by physicians and dialysis facilities, and accessibility to patients. This narrative review offers historical insights, an overview of modern ESKD policy, actionable strategies, and policy opportunities to increase the accessibility of this treatment modality.

American Board of Internal Medicine Nephrology Procedure Requirements for Initial Certification: Time for a Change and Pursuing Consensus in the Nephrology Community

In 1988, the American Board of Internal Medicine (ABIM) defined essential procedural skills in nephrology, and candidates for ABIM certification were required to present evidence of possessing the skills necessary for placement of temporary dialysis vascular access, hemodialysis, peritoneal dialysis, and percutaneous renal biopsy. In 1996, continuous renal replacement therapy was added to the list of nephrology requirements. These procedure requirements have not been modified since 1996 while the practice of nephrology has changed dramatically. In March 2021, the ABIM Nephrology Board embarked on a policy journey to revise the procedure requirements for nephrology certification. With the guidance of nephrology diplomates, training program directors, professional and patient organizations, and other stakeholders, the ABIM Nephrology Board revised the procedure requirements to reflect current practice and national priorities. The approved changes include the Opportunity to Train standard for placement of temporary dialysis catheters, percutaneous kidney biopsies, and home hemodialysis, which better reflects the current state of training in most training programs, and the new requirements for home dialysis therapies training will align with the national priority to address the underuse of home dialysis therapies. This perspective details the ABIM process for considering changes to the certification procedure requirements and how ABIM collaborated with the larger nephrology community in considering revisions and additions to these requirements.

Why are we Not Getting More Patients onto Peritoneal Dialysis? Observations From the United States with Global Implications

Peritoneal dialysis (PD) offers lifestyle advantages over in-center hemodialysis (HD) and is less costly. However, in the United States, less than 12% of end-stage kidney disease (ESKD) patients are maintained on this modality. In this brief review, we discuss some of the factors underlying the low prevalence of PD. These include inadequate patient education, a shortage of sufficiently well-trained medical and nursing personnel, absence of infrastructure to support urgent start PD, and lack of support for assisted PD, among other factors. Understanding and addressing these various issues may help increase the prevalence of PD in the United States and globally.

A Survey Study of Trends in Adult Nephrology Advanced Training in Australia and New Zealand

BACKGROUND

There has been considerable growth in nephrology advanced trainee numbers in Australia and New Zealand, with uncertain effects on clinical experience, competence and employment outcomes.

AIM

To review the perceived adequacy and temporal trends of advanced training in nephrology in Australia and New Zealand by evaluating training experiences, personal views on important aspects of training and nephrology, career paths and early employment outcomes.

METHODS

An online survey was distributed to members of the Australian and New Zealand Society of Nephrology via email in December 2020. Responses were sought from current trainees and from nephrologists qualifying since 2014. Likert scale proportions were calculated and group comparisons made using the Chi-square test.

RESULTS

A total of 88 participants returned the survey yielding a response rate of 32%, with a representative sample of trainees and consultants from across Australia and New Zealand. Training was reported as adequate in most aspects of clinical nephrology, although 88% of respondents felt poorly prepared for entering private practice and 61% reported inadequate training in kidney histopathology. Exposure to clinical procedures was variable, with adequate training in percutaneous kidney biopsy but mostly inadequate training in dialysis access insertion. Sixty-nine percent of nephrologists completed their advanced training entirely in large urban centres and 85% worked in an urban area after training. Only 23% of consultants were engaged in full-time clinical employment in their first year post-training and 78% were undertaking at least one of dual specialty training or a higher degree by research. Demand for subspecialty fellowships was high.

CONCLUSION

Trainees and nephrologists in Australia and New Zealand are currently satisfied with their training in most aspects of nephrology, however some clinical experiences are perceived as inadequate and early career paths after advanced training are increasingly diverse. This article is protected by copyright. All rights reserved.

Economic Impact of Home Hemodialysis

Home hemodialysis (HD) is growing in the United States, but the economics of the modality are largely unknown, especially considering the unique aspects of home HD in the United States . In this review, I focus on details of Medicare coverage, which directly applies to most patients on dialysis and influences the policies of private insurers. Key details in Medicare comprise the relationship between home dialysis training and initial Medicare eligibility, reimbursement for home HD training, coverage of additional HD treatments (ie., in excess of 3 treatments per week), and monthly capitated payments to nephrologists. The overarching narrative is that frequent home HD directly increases Medicare costs for outpatient dialysis, but these added costs can be mitigated by lower inpatient expenditures if increased HD treatment frequency lowers the risk of cardiovascular hospitalization and infection control is emphasized. I also review recent international literature; conventional home HD exhibits a superior cost profile, whereas frequent home HD is generally cost-effective over multiple treatment years (ie, if early technique failure is avoided). Out-of-pocket expenses for patients should be considered. The future economics of home HD in the United States will be determined by new equipment, new adaptations of the modality, and new payment models.

Innovations to Increase Home Hemodialysis Utilization: The Transitional Care Unit

A large proportion of patients undergoing incident dialysis start in-center hemodialysis with suboptimal preparation and predialysis education. Transitional care units deliver a structured program by dedicated staff, with less patient-to-staff ratios than in regular in-center dialysis care, with the goals of supporting the emotional and physical well-being of patients while providing them with education and equipping them with the right tools to start their journey on dialysis. Key components of these programs include an emphasis on patient activation and self-management, educating and supporting patients to make informed modality choices, timely coordination of care, and an integrated approach to formation and use of the dialysis access. While data are still limited on best practices and on outcomes of these programs at a large scale, endorsing the model of transitional care units is a step in the right direction to fill the gap in our current care system.

Strategic Planning for Starting or Expanding a Home Hemodialysis Program

The American Advancing Kidney Health Initiative has renewed interest in home hemodialysis (HHD). Many perceived barriers exist for adoption of HHD despite well-reported clinical benefits. A well-designed program ensures patient success further engaging more patients. The initial planning regarding the surrounding patient population, stakeholders, economics, and physical location is essential. The services offered including modality education and different kinds of HHD modalities depend on local expertise and economics. The program should fulfill conditions for coverage requirements for personnel, physical infrastructure, and quality metrics to begin operations. The patient recruitment is facilitated by a patient-centric modality education program developed by the multidisciplinary team. If the patient is interested, a training schedule should be discussed with the patient and caregiver. A system to ensure remote patient monitoring, respite care, and 24 hours on-call availability should be established. These practical considerations ensure initial success and future growth of the program.

The use of virtual physician mentoring to enhance home dialysis knowledge and uptake

Home dialysis therapies are flexible kidney replacement strategies with documented clinical benefits. While the incidence of end-stage kidney disease continues to increase globally, the use of home dialysis remains low in most developed countries. Multiple barriers to providing home dialysis have been noted in the published literature. Among known challenges, gaps in clinician knowledge are potentially addressable with a focused education strategy. Recent national surveys in the United States and Australia have highlighted the need for enhanced home dialysis knowledge especially among nephrologists who have recently completed training. Traditional in-person continuing professional educational programmes have had modest success in promoting home dialysis and are limited by scale and the present global COVID-19 pandemic. We hypothesize that the use of a 'Hub and Spoke' model of virtual home dialysis mentorship for nephrologists based on project ECHO would support home dialysis growth. We review the home dialysis literature, known educational gaps and plausible educational interventions to address current limitations in physician education.