1
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Desbiens LC, Bargman JM, Chan CT, Nadeau-Fredette AC. Integrated home dialysis model: facilitating home-to-home transition. Clin Kidney J 2024; 17:i21-i33. [PMID: 38846416 PMCID: PMC11151120 DOI: 10.1093/ckj/sfae079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2023] [Indexed: 06/09/2024] Open
Abstract
Peritoneal dialysis (PD) and home hemodialysis (HHD) are the two home dialysis modalities offered to patients. They promote patient autonomy, enhance independence, and are generally associated with better quality of life compared to facility hemodialysis. PD offers some advantages (enhanced flexibility, ability to travel, preservation of residual kidney function, and vascular access sites) but few patients remain on PD indefinitely due to peritonitis and other complications. By contrast, HHD incurs longer and more intensive training combined with increased upfront health costs compared to PD, but is easier to sustain in the long term. As a result, the integrated home dialysis model was proposed to combine the advantages of both home-based dialysis modalities. In this paradigm, patients are encouraged to initiate dialysis on PD and transfer to HHD after PD termination. Available evidence demonstrates the feasibility and safety of this approach and some observational studies have shown that patients who undergo the PD-to-HHD transition have clinical outcomes comparable to patients who initiate dialysis directly on HHD. Nevertheless, the prevalence of PD-to-HHD transfers remains low, reflecting the multiple barriers that prevent the full uptake of home-to-home transitions, notably a lack of awareness about the model, home-care "burnout," clinical inertia after a transfer to facility HD, suboptimal integration of PD and HHD centers, and insufficient funding for home dialysis programs. In this review, we will examine the conceptual advantages and disadvantages of integrated home dialysis, present the evidence that underlies it, identify challenges that prevent its success and finally, propose solutions to increase its adoption.
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Affiliation(s)
- Louis-Charles Desbiens
- Department of Medicine, Université de Montréal, Montreal, Canada
- Department of Medicine, Hôpital Maisonneuve-Rosemont, Montreal, Canada
| | - Joanne M Bargman
- Toronto General Hospital, University Health Network, Toronto, ON, Canada
| | - Christopher T Chan
- Toronto General Hospital, University Health Network, Toronto, ON, Canada
| | - Annie-Claire Nadeau-Fredette
- Department of Medicine, Université de Montréal, Montreal, Canada
- Department of Medicine, Hôpital Maisonneuve-Rosemont, Montreal, Canada
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2
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Iadarola GM, Giorda E, Borca M, Morero D, Sciascia S, Roccatello D. Is the cost of the new home dialysis techniques still advantageous compared to in-center hemodialysis? An Italian single center analysis and comparison with experiences from western countries. Front Med (Lausanne) 2024; 11:1345506. [PMID: 38529121 PMCID: PMC10961330 DOI: 10.3389/fmed.2024.1345506] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Accepted: 02/21/2024] [Indexed: 03/27/2024] Open
Abstract
Introduction Potential advantages of home dialysis remained a questionable issue. Three main factors have to be considered: the progressive reduction in the cost of consumables for in-Center hemodialysis (IC-HD), the widespread use of incremental Peritoneal Dialysis (PD), and the renewed interest in home hemodialysis (H-HD) in the pandemic era. Registries data on prevalence of dialysis modalities generally report widespread underemployment of home dialysis despite PD and H-HD could potentially provide clinical benefits, improve quality of life, and contrast the diffusion of new infection among immunocompromised patients. Methods We examined the economic impact of home dialysis by comparing the direct and indirect costs of PD (53 patients), H-HD (21 patients) and IC-HD (180 patients) in a single hospital of North-west Italy. In order to achieve comparable weekly costs, the average weekly frequency of dialysis sessions based on the dialysis modality was calculated, the cost of individual sessions per patient per week normalized, and the monthly and yearly costs were derived. Results As expected, PD resulted the least expensive procedure (€ 23,314.79 per patient per year), but, notably, H-HD has a lower average cost than IC-HD (€ 35,535.00 vs. € 40,798.98). A cost analysis of the different dialysis procedures confirms the lower cost of PD, especially continuous ambulatory PD, compared to any extracorporeal technique. Discussion Among the hemodialysis techniques, home bicarbonate HD showed the lowest costs, while the weekly cost of Frequent Home Hemodialysis was found to be comparable to In-Center Bicarbonate Hemodialysis.
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Affiliation(s)
| | | | | | | | | | - Dario Roccatello
- University Center of Excellence on Nephrological, Rheumatological and Rare Diseases (ERK-net, ERN-Reconnect and RITA-ERN Member) Including Nephrology and Dialysis Unit and Center of Immuno-Rheumatology and Rare Diseases (CMID), Coordinating Center of the Interregional Network for Rare Diseases of Piedmont and Aosta Valley (North-West Italy), San Giovanni Bosco Hub Hospital, ASL Città di Torino and Department of Clinical and Biological Sciences of the University of Turin, Turin, Italy
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3
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Abra GE, Weinhandl ED, Hussein WF. Setting Up Home Dialysis Programs: Now and in the Future. Clin J Am Soc Nephrol 2023; 18:1490-1496. [PMID: 37603364 PMCID: PMC10637466 DOI: 10.2215/cjn.0000000000000284] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Accepted: 08/09/2023] [Indexed: 08/22/2023]
Abstract
Home dialysis utilization has been growing in the United States over the past decade but still lags behind similar socioeconomic nations. More than half of dialysis facilities in the United States either are not licensed to offer home dialysis or, despite a license, have no patients dialyzing at home, and many programs have a relatively small census. Multiple stakeholders, including patients, health care providers, and payers, have identified increased home dialysis use as an important goal. To realize these goals, nephrologists and kidney care professionals need a sound understanding of the key considerations in home dialysis center operation. In this review, we outline the core domains required to set up and operate a home dialysis program in the United States now and in the future.
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Affiliation(s)
- Graham E. Abra
- Satellite Healthcare, San Jose, California
- Division of Nephrology, Stanford University, Palo Alto, California
| | - Eric D. Weinhandl
- Satellite Healthcare, San Jose, California
- Department of Pharmaceutical Care and Health Systems, University of Minnesota, Minneapolis, Minnesota
| | - Wael F. Hussein
- Satellite Healthcare, San Jose, California
- Division of Nephrology, Stanford University, Palo Alto, California
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4
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Perl J, Brown EA, Chan CT, Couchoud C, Davies SJ, Kazancioğlu R, Klarenbach S, Liew A, Weiner DE, Cheung M, Jadoul M, Winkelmayer WC, Wilkie ME. Home dialysis: conclusions from a Kidney Disease: Improving Global Outcomes (KDIGO) Controversies Conference. Kidney Int 2023; 103:842-858. [PMID: 36731611 DOI: 10.1016/j.kint.2023.01.006] [Citation(s) in RCA: 29] [Impact Index Per Article: 29.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2022] [Revised: 12/09/2022] [Accepted: 01/09/2023] [Indexed: 02/02/2023]
Abstract
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.
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Affiliation(s)
- Jeffrey Perl
- Division of Nephrology, St. Michael's Hospital and the Keenan Research Center in the Li Ka Shing Knowledge Institute, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada.
| | - Edwina A Brown
- Imperial College Renal and Transplant Centre, Hammersmith Hospital, London, United Kingdom
| | - Christopher T Chan
- University Health Network, University of Toronto, Toronto, Ontario, Canada
| | | | - Simon J Davies
- School of Medicine, Keele University, Staffordshire, United Kingdom
| | - Rümeyza Kazancioğlu
- Department of Nephrology, Bezmialem Vakif University, Faculty of Medicine, Istanbul, Turkey
| | - Scott Klarenbach
- Division of Nephrology, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Adrian Liew
- The Kidney & Transplant Practice, Mount Elizabeth Novena Hospital, Singapore, Singapore
| | - Daniel E Weiner
- William B. Schwartz Division of Nephrology, Tufts Medical Center, Boston, Massachusetts, USA
| | | | - Michel Jadoul
- Cliniques Universitaires Saint Luc, Université Catholique de Louvain, Brussels, Belgium
| | - Wolfgang C Winkelmayer
- Selzman Institute for Kidney Health, Section of Nephrology, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Martin E Wilkie
- Sheffield Kidney Institute, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, United Kingdom.
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5
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Redeker S, Massey EK, van Merweland RG, Weimar W, Ismail S, Busschbach J. Induced Demand in Kidney Replacement Therapy. Health Policy 2022; 126:1062-1068. [DOI: 10.1016/j.healthpol.2022.07.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Revised: 07/23/2022] [Accepted: 07/28/2022] [Indexed: 11/25/2022]
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6
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Baerman EA, Kaplan J, Shen JI, Winkelmayer WC, Erickson KF. Cost Barriers to More Widespread Use of Peritoneal Dialysis in the United States. J Am Soc Nephrol 2022; 33:1063-1072. [PMID: 35314456 PMCID: PMC9161798 DOI: 10.1681/asn.2021060854] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
The United States Department of Health and Human Services launched the Advancing American Kidney Health Initiative in 2019, which included a goal of transforming dialysis care from an in-center to a largely home-based dialysis program. A substantial motivator for this transition is the potential to reduce costs of ESKD care with peritoneal dialysis. Studies demonstrating that peritoneal dialysis is less costly than in-center hemodialysis have often focused on the perspective of the payer, whereas less consideration has been given to the costs of those who are more directly involved in treatment decision making, including patients, caregivers, physicians, and dialysis facilities. We review comparisons of peritoneal dialysis and in-center hemodialysis costs, focusing on costs incurred by the people and organizations making decisions about dialysis modality, to highlight the financial barriers toward increased adoption of peritoneal dialysis. We specifically address misaligned economic incentives, underappreciated costs for key stakeholders involved in peritoneal dialysis delivery, differences in provider costs, and transition costs. We conclude by offering policy suggestions that include improving data collection to better understand costs in peritoneal dialysis, and sharing potential savings among all stakeholders, to incentivize a transition to peritoneal dialysis.
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Affiliation(s)
- Elliot A Baerman
- Section of Nephrology, Baylor College of Medicine, Houston, Texas
| | - Jennifer Kaplan
- Section of Nephrology, Baylor College of Medicine, Houston, Texas
| | - Jenny I Shen
- Division of Nephrology, The Lundquist Institute at Harbor UCLA Medical Center, West Carson, California
| | | | - Kevin F Erickson
- Section of Nephrology, Baylor College of Medicine, Houston, Texas .,Rice University, Baker Institute, Houston, Texas
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7
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Reddy YNV, Mendu ML, Weinhandl ED. Funding Innovative Dialysis Technology in the United States: Home Dialysis and the ESRD Transitional Add-on Payment for New and Innovative Equipment and Supplies (TPNIES). Am J Kidney Dis 2021; 78:892-896. [PMID: 34051309 PMCID: PMC8608674 DOI: 10.1053/j.ajkd.2021.03.025] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2020] [Accepted: 03/15/2021] [Indexed: 11/11/2022]
Abstract
Innovative, patient-centered, and pragmatic dialysis technologies are urgently needed to accommodate the growing national interest in home dialysis use. To help achieve this goal, the US Centers for Medicare & Medicaid Services (CMS) are expanding reimbursement for eligible home dialysis machines through an existing payment mechanism, the transitional add-on payment for new and innovative equipment and supplies (TPNIES). This mechanism incentivizes the early adoption of innovative equipment into practice by reimbursing dialysis providers up to 26% of the total cost of approved home dialysis machines. Machines are evaluated for TPNIES eligibility using prespecified substantial clinical improvement (SCI) criteria that are derived from the Inpatient Prospective Payment System (for non-nephrology technologies). Although the SCI criteria may be suitable for some non-nephrology technologies, they have not been adapted to consider the unique and complex care inherent in home dialysis. Thus, many of the SCI criteria appear unsuitable for home dialysis machines. To better incentivize innovation, CMS should develop nephrology-specific transparent and pragmatic criteria for TPNIES. In this perspective, we provide an overview of the TPNIES payment mechanism, highlight areas of concern within the policy, and offer solutions for improving TPNIES that could better promote the adoption of new home dialysis machines.
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Affiliation(s)
- Yuvaram N V Reddy
- Nephrology Division, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts; Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, Massachusetts.
| | - Mallika L Mendu
- Nephrology Division, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts
| | - Eric D Weinhandl
- Chronic Disease Research Group, Hennepin Healthcare Research Institute, Minneapolis, Minnesota; Department of Pharmaceutical Care and Health Systems, University of Minnesota, Minneapolis, Minnesota
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8
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Poinen K, Van Der Hoek M, Copland MA, Tennankore K, Canney M. Perceptions of Multidisciplinary Renal Team Members toward Home Dialysis Therapies. KIDNEY360 2021; 2:1592-1599. [PMID: 35372972 PMCID: PMC8785775 DOI: 10.34067/kid.0006222020] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Accepted: 08/09/2021] [Indexed: 02/04/2023]
Abstract
Background Patients with ESKD are encouraged to pursue home dialysis therapy with the aims of improving quality of life, increasing patient autonomy, and reducing cost to health care systems. In a multidisciplinary team setting, patients interact with nephrologists, nurses, and allied health staff, all of whom may influence a patient's modality choice. Our objective was to evaluate the perceptions of all renal team members toward home dialysis therapies. Methods We performed a cross-sectional survey of multidisciplinary renal team members across five renal programs in British Columbia, Canada. The survey contained questions regarding primary work area, modality preference, patient and system factors that may influence modality candidacy, perceived knowledge of home therapies, and need for further education. Results A total of 334 respondents (22 nephrologists, 172 hemodialysis nurses, 49 home nurses, 20 predialysis nurses, and 71 allied health staff) were included (48% response rate). All respondents felt that home dialysis was beneficial for patients who work or study, improved patients' quality of life, and provided cost savings to the system. Compared with in-center hemodialysis nurses, home therapies nurses were between five and nine times more likely to favor a home therapy for patients of older age, lower socioeconomic status, lower educational level, higher burden of comorbidities, and those lacking social supports. Nephrologists and patients were felt to have the most influence on modality choice, whereas dialysis nurses were seen as having the least effect on modality choice. Most respondents felt the need for further education in home therapies. Conclusions The majority of multidisciplinary team members, including allied health staff, acknowledged the benefits of home therapies. There were significant discrepancies among team members regarding patient-/system-level factors that may affect the candidacy of home therapies. Structured, focused, and repeated education sessions for all renal team members may help to address misperceptions around factors that influence modality candidacy.
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Affiliation(s)
- Krishna Poinen
- University of British Columbia, Vancouver, British Columbia, Canada,BC Renal, Vancouver, British Columbia, Canada
| | | | - Michael A. Copland
- University of British Columbia, Vancouver, British Columbia, Canada,BC Renal, Vancouver, British Columbia, Canada
| | - Karthik Tennankore
- Division of Nephrology, Nova Scotia Health Authority, Halifax, Nova Scotia, Canada
| | - Mark Canney
- BC Renal, Vancouver, British Columbia, Canada,Department of Medicine, University of Ottawa and the Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
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9
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Abra G, Weinhandl ED. Pulling the goalie: What the United States and the world can learn from Canada about growing home dialysis. Perit Dial Int 2021; 41:437-440. [PMID: 34323152 DOI: 10.1177/08968608211034696] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
- Graham Abra
- Satellite Healthcare, San Jose, CA, USA.,Department of Medicine, Division of Nephrology, 6429Stanford University, Palo Alto, CA, USA
| | - Eric D Weinhandl
- Chronic Disease Research Group, Hennepin Healthcare Research Institute, Minneapolis, MN, USA.,Department of Pharmaceutical Care and Health Systems, 5635University of Minnesota, Minneapolis, MN, USA
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10
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Beaumier M, Calvar E, Launay L, Béchade C, Lanot A, Schauder N, Touré F, Lassalle M, Couchoud C, Châtelet V, Lobbedez T. Effect of social deprivation on peritoneal dialysis uptake: A mediation analysis with the data of the REIN registry. Perit Dial Int 2021; 42:361-369. [PMID: 34196237 DOI: 10.1177/08968608211023268] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Social deprivation could act as a barrier to peritoneal dialysis (PD). The objective of this study was to assess the association between social deprivation estimated by the European deprivation index (EDI) and PD uptake and to explore the potential mediators of this association. METHODS From the Renal Epidemiology and Information Network registry, patients who started dialysis in 2017 were included. The EDI was calculated based on the patient's address. The event of interest was the proportion of PD 3 months after dialysis initiation. A mediation analysis with a counterfactual approach was carried out to evaluate the direct and indirect effect of the EDI on the proportion of PD. RESULTS Among the 9588 patients included, 1116 patients were on PD; 2894 (30.2%) patients belonged to the most deprived quintile (Q5). PD was associated with age >70 years (odds ratio (OR) 0.79 [95% confidence interval (CI): 0.69-0.91]), male gender (0.85 [95% CI: 0.74-0.97]), cardiovascular disease (OR 0.86 [95% CI: 0.86-1.00]), chronic heart failure (OR 1.34 [95% CI: 1.13-1.58]), active cancer (OR 0.67 [95% CI: 0.53-0.85]) and obesity (OR 0.75 [95% CI: 0.63-0.89]). In the mediation analysis, Q5 had a direct effect on PD proportion OR 0.84 [95% CI: 0.73-0.96]. The effect of Q5 on the proportion of PD was mediated by haemoglobin level at dialysis initiation (OR 0.96 [95% CI: 0.94-0.98]) and emergency start (OR 0.98 [95% CI: 0.96-0.99]). CONCLUSION Social deprivation, estimated by the EDI, was associated with a lower PD uptake. The effect of social deprivation was mediated by haemoglobin level, a proxy of predialysis care and emergency start.
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Affiliation(s)
- Mathilde Beaumier
- Service de Néphrologie, Centre Hospitalier Public du Cotentin, rue du Val de Saire, Cherbourg, France
| | - Eve Calvar
- Centre Universitaire des Maladies Rénales, CHU de Caen Avenue Côte de Nacre, Caen, France
| | - Ludivine Launay
- U1086 Inserm, ANTICIPE, Centre de Lutte Contre le Cancer François Baclesse, Caen, France
| | - Clémence Béchade
- Centre Universitaire des Maladies Rénales, CHU de Caen Avenue Côte de Nacre, Caen, France.,U1086 Inserm, ANTICIPE, Centre de Lutte Contre le Cancer François Baclesse, Caen, France
| | - Antoine Lanot
- Centre Universitaire des Maladies Rénales, CHU de Caen Avenue Côte de Nacre, Caen, France
| | - Nicole Schauder
- REIN Registry, Biomedecine Agency, France.,Observatoire Régional de la Santé Grand Est, Strasbourg, France
| | - Fatouma Touré
- REIN Registry, Biomedecine Agency, France.,Service de Néphrologie, dialyse, transplantations, CHU de Limoges, Caen, France
| | | | | | - Valérie Châtelet
- Centre Universitaire des Maladies Rénales, CHU de Caen Avenue Côte de Nacre, Caen, France.,U1086 Inserm, ANTICIPE, Centre de Lutte Contre le Cancer François Baclesse, Caen, France
| | - Thierry Lobbedez
- Centre Universitaire des Maladies Rénales, CHU de Caen Avenue Côte de Nacre, Caen, France.,U1086 Inserm, ANTICIPE, Centre de Lutte Contre le Cancer François Baclesse, Caen, France.,RDPLF, Pontoise, Caen, France
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11
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Blake PG, McCormick BB, Taji L, Jung JK, Ip J, Gingras J, Boll P, McFarlane P, Pierratos A, Aziz A, Yeung A, Patel M, Cooper R. Growing home dialysis: The Ontario Renal Network Home Dialysis Initiative 2012-2019. Perit Dial Int 2021; 41:441-452. [PMID: 33969759 DOI: 10.1177/08968608211012805] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
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.
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Affiliation(s)
- Peter G Blake
- Ontario Renal Network, 573450Ontario Health, Toronto, Ontario, Canada.,Division of Nephrology, Department of Medicine, Western University, London, Ontario, Canada.,10033London Health Sciences Centre, Ontario, Canada
| | - Brendan B McCormick
- Ontario Renal Network, 573450Ontario Health, Toronto, Ontario, Canada.,Division of Nephrology, Department of Medicine, 27337The Ottawa Hospital, Ontario, Canada
| | - Leena Taji
- Ontario Renal Network, 573450Ontario Health, Toronto, Ontario, Canada
| | - James Kh Jung
- Ontario Renal Network, 573450Ontario Health, Toronto, Ontario, Canada
| | - Jane Ip
- Ontario Renal Network, 573450Ontario Health, Toronto, Ontario, Canada
| | - Joanie Gingras
- Ontario Renal Network, 573450Ontario Health, Toronto, Ontario, Canada
| | - Phil Boll
- Ontario Renal Network, 573450Ontario Health, Toronto, Ontario, Canada.,Trillium Health Partners, Mississauga, Ontario, Canada
| | - Phil McFarlane
- Ontario Renal Network, 573450Ontario Health, Toronto, Ontario, Canada.,Division of Nephrology, Department of Medicine, University of Toronto, Ontario, Canada.,St Michaels Hospital, Toronto, Ontario, Canada
| | | | - Anas Aziz
- Ontario Renal Network, 573450Ontario Health, Toronto, Ontario, Canada
| | - Angie Yeung
- Ontario Renal Network, 573450Ontario Health, Toronto, Ontario, Canada
| | - Monisha Patel
- Ontario Renal Network, 573450Ontario Health, Toronto, Ontario, Canada
| | - Rebecca Cooper
- Ontario Renal Network, 573450Ontario Health, Toronto, Ontario, Canada
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12
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Rastogi A, Lerma EV. Anemia management for home dialysis including the new US public policy initiative. Kidney Int Suppl (2011) 2021; 11:59-69. [PMID: 33777496 PMCID: PMC7983021 DOI: 10.1016/j.kisu.2020.12.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2020] [Revised: 12/17/2020] [Accepted: 12/29/2020] [Indexed: 12/28/2022] Open
Abstract
Patients with end-stage kidney disease (ESKD) requiring kidney replacement therapy are often treated in conventional dialysis centers at substantial cost and patient inconvenience. The recent United States Executive Order on Advancing American Kidney Health, in addition to focusing on ESKD prevention and reforming the kidney transplantation system, focuses on providing financial incentives to promote a shift toward home dialysis. In accordance with this order, a goal was set to have 80% of incident dialysis patients receiving home dialysis or a kidney transplant by 2025. Compared with conventional in-center therapy, home dialysis modalities, including both home hemodialysis and peritoneal dialysis, appear to offer equivalent or improved mortality, clinical outcomes, hospitalization rates, and quality of life in patients with ESKD in addition to greater convenience, flexibility, and cost-effectiveness. Treatment of anemia, a common complication of chronic kidney disease, may be easier to manage at home with a new class of agents, hypoxia-inducible factor-prolyl hydroxylase inhibitors, which are orally administered in contrast to the current standard of care of i.v. iron and/or erythropoiesis-stimulating agents. This review evaluates the clinical, quality-of-life, economic, and social aspects of dialysis modalities in patients with ESKD, including during the coronavirus disease 2019 pandemic; explores new therapeutics for the management of anemia in chronic kidney disease; and highlights how the proposed changes in Advancing American Kidney Health provide an opportunity to improve kidney health in the United States.
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Affiliation(s)
- Anjay Rastogi
- Division of Nephrology, Department of Medicine, David Geffen School of Medicine, UCLA, Los Angeles, California, USA
| | - Edgar V. Lerma
- Department of Medicine, Division of Nephrology, University of Illinois at Chicago/Advocate Christ Medical Center, Section of Nephrology, Oak Lawn, Illinois, USA
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13
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Lavoie-Cardinal M, Nadeau-Fredette AC. Physical Infrastructure and Integrated Governance Structure for Home Hemodialysis. Adv Chronic Kidney Dis 2021; 28:149-156. [PMID: 34717861 DOI: 10.1053/j.ackd.2021.02.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2020] [Revised: 02/11/2021] [Accepted: 02/25/2021] [Indexed: 01/17/2023]
Abstract
In view of the growing enthusiasm for home dialysis use, new dialysis centers may build or expend their home hemodialysis program in the next few years. This review will discuss the main challenges faced by small and large home hemodialysis programs in terms of physical spaces, human resource, training considerations, and overall governance. We will elaborate on the inclusion of home hemodialysis in the kidney replacement therapy care continuum, with a specific interest for collaboration and transition between peritoneal dialysis and home hemodialysis programs.
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14
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Boyer A, Lanot A, Lambie M, Guillouet S, Lobbedez T, Béchade C. Trends in assisted peritoneal dialysis over the last decade: a cohort study from the French Peritoneal Dialysis Registry. Clin Kidney J 2021; 13:1003-1011. [PMID: 33391743 PMCID: PMC7769513 DOI: 10.1093/ckj/sfaa051] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Accepted: 03/26/2020] [Indexed: 12/19/2022] Open
Abstract
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.
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Affiliation(s)
- Annabel Boyer
- Centre Universitaire des Maladies Rénales, CHU de Caen, 14 033 Caen Cedex 9, France.,U1086, INSERM-ANTICIPE-Centre, Régional de Lutte contre, le Cancer, François Baclesse, Caen, France
| | - Antoine Lanot
- Centre Universitaire des Maladies Rénales, CHU de Caen, 14 033 Caen Cedex 9, France.,U1086, INSERM-ANTICIPE-Centre, Régional de Lutte contre, le Cancer, François Baclesse, Caen, France.,Normandie Université, Unicaen, UFR, de médecine, 2 rue des Rochambelles, 14032 Caen Cedex, France
| | - Mark Lambie
- Renal Unit, Royal Stoke University Hospital, University Hospitals of North Midlands NHS Trust, Stoke-on-Trent, UK.,Faculty of Medicine and Health Sciences, Keele University, Keele, UK
| | - Sonia Guillouet
- Centre Universitaire des Maladies Rénales, CHU de Caen, 14 033 Caen Cedex 9, France.,U1086, INSERM-ANTICIPE-Centre, Régional de Lutte contre, le Cancer, François Baclesse, Caen, France.,Normandie Université, Unicaen, UFR, de médecine, 2 rue des Rochambelles, 14032 Caen Cedex, France
| | - Thierry Lobbedez
- Centre Universitaire des Maladies Rénales, CHU de Caen, 14 033 Caen Cedex 9, France.,U1086, INSERM-ANTICIPE-Centre, Régional de Lutte contre, le Cancer, François Baclesse, Caen, France.,Normandie Université, Unicaen, UFR, de médecine, 2 rue des Rochambelles, 14032 Caen Cedex, France
| | - Clémence Béchade
- Centre Universitaire des Maladies Rénales, CHU de Caen, 14 033 Caen Cedex 9, France.,U1086, INSERM-ANTICIPE-Centre, Régional de Lutte contre, le Cancer, François Baclesse, Caen, France.,Normandie Université, Unicaen, UFR, de médecine, 2 rue des Rochambelles, 14032 Caen Cedex, France
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15
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Tonelli M, Vanholder R, Himmelfarb J. Health Policy for Dialysis Care in Canada and the United States. Clin J Am Soc Nephrol 2020; 15:1669-1677. [PMID: 32586926 PMCID: PMC7646249 DOI: 10.2215/cjn.14961219] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Contemporary dialysis treatment for chronic kidney failure is complex, is associated with poor clinical outcomes, and leads to high health costs, all of which pose substantial policy challenges. Despite similar policy goals and universal access for their kidney failure programs, the United States and Canada have taken very different approaches to dealing with these challenges. While US dialysis care is primarily government funded and delivered predominantly by private for-profit providers, Canadian dialysis care is also government funded but delivered almost exclusively in public facilities. Differences also exist for regulatory mechanisms and the policy incentives that may influence the behavior of providers and facilities. These differences in health policy are associated with significant variation in clinical outcomes: mortality among patients on dialysis is consistently lower in Canada than in the United States, although the gap has narrowed in recent years. The observed heterogeneity in policy and outcomes offers important potential opportunities for each health system to learn from the other. This article compares and contrasts transnational dialysis-related health policies, focusing on key levers including payment, finance, regulation, and organization. We also describe how policy levers can incentivize favorable practice patterns to support high-quality/high-value, person-centered care and to catalyze the emergence of transformative technologies for alternative kidney replacement strategies.
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Affiliation(s)
- Marcello Tonelli
- Division of Nephrology, Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Raymond Vanholder
- Nephrology Section, Department of Internal Medicine, Ghent University Hospital, Ghent, Belgium, European Kidney Health Alliance
| | - Jonathan Himmelfarb
- Kidney Research Institute, School of Medicine, Seattle, Washington .,Division of Nephrology, Department of Medicine, University of Washington, Seattle, Washington
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16
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Argilés A, Kerr PG. Home based therapies: can wishes be realized? Nephrol Dial Transplant 2020; 35:1836-1839. [PMID: 33151335 DOI: 10.1093/ndt/gfaa082] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2020] [Accepted: 03/23/2020] [Indexed: 12/15/2022] Open
Affiliation(s)
- Angel Argilés
- RD-Néphrologie, Montpellier, France.,Bio-Communication Cardio-Métabolique (BC2M), Universite Montpellier, Montpellier, France.,Néphrologie Dialyse St Guilhem, Sète, France.,Department of Nephrology, University Hospital Lapeyronie, Montpellier, France
| | - Peter G Kerr
- Department of Nephrology, Monash Medical Centre, Monash University, Clayton, Victoria, Australia
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17
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Van Biesen W, Lameire N. Increasing peritoneal dialysis initiation worldwide: ‘there are none so blind as those who will not see’. Nephrol Dial Transplant 2020; 35:1458-1461. [DOI: 10.1093/ndt/gfaa024] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2019] [Accepted: 12/28/2019] [Indexed: 01/01/2023] Open
Affiliation(s)
- Wim Van Biesen
- Renal Division, University Hospital Ghent, Ghent, Belgium
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18
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Diebel L, Jafari M, Shah S, Day C, McNaught C, Prasad B. Barriers to Home Hemodialysis Across Saskatchewan, Canada: A Cross-Sectional Survey of In-Center Dialysis Patients. Can J Kidney Health Dis 2020; 7:2054358120948293. [PMID: 32843987 PMCID: PMC7418229 DOI: 10.1177/2054358120948293] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Accepted: 06/24/2020] [Indexed: 01/28/2023] Open
Abstract
Background Despite clinical and lifestyle advantages of home hemodialysis (HHD) compared with in-center hemodialysis (ICHD), it remains underutilized in our province. The aim of the study was to explore the patients' perception and to identify the barriers to use of HHD in Saskatchewan, Canada. Objectives The primary objective of the study was to evaluate and explore patient perceptions of HHD and to identify the obstacles for adoption of HHD in Saskatchewan. The secondary objective was to examine variations in the patients' perceptions and barriers to HHD by center (main dialysis units vs satellite dialysis units). Design This is 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 ICHD patients across Saskatchewan, 398 agreed to participate in the study. Measurements Self-reported barriers to HHD were assessed using a questionnaire. Methods A questionnaire was designed to determine the patients' perceived barriers to HHD. Descriptive statistics was used to present the data. Chi-square and Mann-Whitney U test were used to compare the patients' responses between main and satellite units. Results Satisfaction with current dialysis care (91%), increase in utility bills (65%), fear of catastrophic events at home (59%), medicalization of one's home (54%), and knowledge deficits toward treatment modalities (54%) were the main barriers to HHD uptake. Compared with patients dialyzing in our main units, satellite patients chose not to pursue HHD more frequently because they had greater satisfaction with their current dialysis unit care (97% vs 87%, P < .001), felt more comfortable dialyzing under the supervision of medical staff (95% vs 86%, P < .007), could not afford additional utility costs (92% vs 45%, P < .001), were unaware of the risks and benefits of HHD (83% vs 33%, P < .001), had concerns over time commitments for training to HHD (69% vs 32%, P < .001), and had concern for family burnout (60.8% vs 40.6%, P < .001). Limitations We used questionnaires to quantify known barriers, and this prevents inclusion of additional barriers that individual patients may consider important. Cross-sectional data can only be used as a snapshot. Only 398 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. Conclusions Satisfaction with in-center care, lack of awareness and education, specifically in the satellite population, concerns with family burnout, expenses associated with utilities, and training time will need to be addressed to increase the uptake of HHD. Trial Registration The study was not registered on a publicly accessible registry as it did not involve any health care intervention on human participants.
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Affiliation(s)
- Lucas Diebel
- College of Medicine, University of Saskatchewan, Regina, Canada
| | - Maryam Jafari
- Dr. T. Bhanu Prasad Medical Professional Corporation, Regina, SK, Canada
| | - Sachin Shah
- Section of Nephrology, Department of Medicine, St. Paul's Hospital, Saskatoon, SK, Canada
| | - Christine Day
- Peritoneal Dialysis, Regina General Hospital, Saskatchewan Health Authority, Regina, Canada
| | - Connie McNaught
- Hemodialysis, Regina General Hospital, Saskatchewan Health Authority, Regina, Canada
| | - Bhanu Prasad
- Section of Nephrology, Department of Medicine, Regina General Hospital, Saskatchewan Health Authority, Regina, Canada
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19
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Beaumier M, Béchade C, Dejardin O, Lassalle M, Vigneau C, Longlune N, Launay L, Couchoud C, Ficheux M, Lobbedez T, Châtelet V. Is self-care dialysis associated with social deprivation in a universal health care system? A cohort study with data from the Renal Epidemiology and Information Network Registry. Nephrol Dial Transplant 2020; 35:861-869. [PMID: 31821495 DOI: 10.1093/ndt/gfz245] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Accepted: 10/25/2019] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Socioeconomic status is associated with dialysis modality in developed countries. The main objective of this study was to investigate whether social deprivation, estimated by the European Deprivation Index (EDI), was associated with self-care dialysis in France. METHODS The EDI was calculated for patients who started dialysis in 2017. The event of interest was self-care dialysis 3 months after dialysis initiation [self-care peritoneal dialysis (PD) or satellite haemodialysis (HD)]. A logistic model was used for the statistical analysis, and a counterfactual approach was used for the causal mediation analysis. RESULTS Among the 9588 patients included, 2894 (30%) were in the most deprived quintile of the EDI. A total of 1402 patients were treated with self-care dialysis. In the multivariable analysis with the EDI in quintiles, there was no association between social deprivation and self-care dialysis. Compared with the other EDI quintiles, patients from Quintile 5 (most deprived quintile) were less likely to be on self-care dialysis (odds ratio 0.81, 95% confidence interval 0.71-0.93). Age, sex, emergency start, cardiovascular disease, chronic respiratory disease, cancer, severe disability, serum albumin and registration on the waiting list were associated with self-care dialysis. The EDI was not associated with self-care dialysis in either the HD or in the PD subgroups. CONCLUSIONS In France, social deprivation estimated by the EDI is associated with self-care dialysis in end-stage renal disease patients undergoing replacement therapy.
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Affiliation(s)
- Mathilde Beaumier
- Centre Universitaire des maladies rénales, CHU de Caen, Caen, France
| | - Clémence Béchade
- Centre Universitaire des maladies rénales, CHU de Caen, Caen, France
| | - Olivier Dejardin
- U1086 Inserm, «ANTICIPE », Centre de Lutte Contre le Cancer François Baclesse, Caen, France
| | | | - Cécile Vigneau
- Centre Hospitalier Universitaire Pontchaillou, Service de Néphrologie, Rennes, France
| | - Nathalie Longlune
- Department of Nephrology, Dialysis and Organ Transplantation, CHU Rangueil, Toulouse, France
| | - Ludivine Launay
- U1086 Inserm, «ANTICIPE », Centre de Lutte Contre le Cancer François Baclesse, Caen, France
| | - Cécile Couchoud
- REIN Registry, Biomedecine Agency, Saint-Denis-La-Plaine, France
| | - Maxence Ficheux
- Centre Universitaire des maladies rénales, CHU de Caen, Caen, France
| | - Thierry Lobbedez
- Centre Universitaire des maladies rénales, CHU de Caen, Caen, France
| | - Valérie Châtelet
- Centre Universitaire des maladies rénales, CHU de Caen, Caen, France
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20
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van der Tol A, Stel VS, Jager KJ, Lameire N, Morton RL, Van Biesen W, Vanholder R. A call for harmonization of European kidney care: dialysis reimbursement and distribution of kidney replacement therapies. Nephrol Dial Transplant 2020; 35:979-986. [DOI: 10.1093/ndt/gfaa035] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2019] [Accepted: 12/12/2019] [Indexed: 12/12/2022] Open
Abstract
Abstract
Background
We compare reimbursement for haemodialysis (HD) and peritoneal dialysis (PD) in European countries to assess the impact on government healthcare budgets. We discuss strategies to reduce costs by promoting sustainable dialysis and kidney transplantation.
Methods
This was a cross-sectional survey among nephrologists conducted online July–December 2016. European countries were categorized by tertiles of gross domestic product per capita (GDP). Reimbursement data were matched to kidney replacement therapy (KRT) data.
Results
The prevalence per million population of patients being treated with long-term dialysis was not significantly different across tertiles of GDP (P = 0.22). The percentage of PD increased with GDP across tertiles (4.9, 8.2, 13.4%; P < 0.001). The HD-to-PD reimbursement ratio was higher in countries with the highest tertile of GDP (0.7, 1.0 versus 1.7; P = 0.007). Home HD was mainly reimbursed in countries with the highest tertile of GDP (15, 15 versus 69%; P = 0.005). The percentage of public health expenditure for reimbursement of dialysis decreased across tertiles of GDP (3.3, 1.5, 0.7%; P < 0.001). Transplantation as a proportion of all KRT increased across tertiles of GDP (18.5, 39.5, 56.0%; P < 0.001).
Conclusions
In Europe, dialysis has a disproportionately high impact on public health expenditure, especially in countries with a lower GDP. In these countries, the cost difference between PD and HD is smaller, and home dialysis and transplantation are less frequently provided than in countries with a higher GDP. In-depth evaluation and analysis of influential economic and political measures are needed to steer optimized reimbursement strategies for KRT.
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Affiliation(s)
- Arjan van der Tol
- Nephrology Section, Department of Internal Medicine, Ghent University Hospital, Ghent, Belgium
| | - Vianda S Stel
- ERA-EDTA Registry, Department of Medical Informatics, Amsterdam Public Health Research Institute, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Kitty J Jager
- ERA-EDTA Registry, Department of Medical Informatics, Amsterdam Public Health Research Institute, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Norbert Lameire
- Nephrology Section, Department of Internal Medicine, Ghent University Hospital, Ghent, Belgium
| | - Rachael L Morton
- National Health and Medical Research Council Clinical Trials Centre, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
| | - Wim Van Biesen
- Nephrology Section, Department of Internal Medicine, Ghent University Hospital, Ghent, Belgium
| | - Raymond Vanholder
- Nephrology Section, Department of Internal Medicine, Ghent University Hospital, Ghent, Belgium
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21
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22
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Abra G, Schiller B. Public policy and programs – Missing links in growing home dialysis in the United States. Semin Dial 2020; 33:75-82. [DOI: 10.1111/sdi.12850] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Affiliation(s)
- Graham Abra
- Satellite Healthcare San Jose CA USA
- Division of Nephrology Department of Medicine Stanford University Palo Alto CA USA
| | - Brigitte Schiller
- Satellite Healthcare San Jose CA USA
- Division of Nephrology Department of Medicine Stanford University Palo Alto CA USA
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23
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Glickman A, Lin E, Berns JS. Conflicts of interest in dialysis: A barrier to policy reforms. Semin Dial 2020; 33:83-89. [PMID: 31899827 DOI: 10.1111/sdi.12848] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
Conflicts of interest involving physicians are commonplace in the US, occurring across many different specialties and subspecialties in a variety of clinical settings. In nephrology, two important scenarios in which conflicts of interest arise are dialysis facility joint venture (JV) arrangements and financial participation in End-stage Kidney Disease Seamless Care Organizations (ESCOs). Whether conflicts of interest occurring in either of these settings influence decision-making or patient care outcomes is not known due to a lack of transparent, publicly available information, and opportunities to conduct independent study. We discuss possible benefits and risks of nephrologist's financial participation in JVs and ESCOs and possible mechanisms for disclosure and reporting of such arrangements as well as risk mitigation.
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Affiliation(s)
- Aaron Glickman
- Department of Medical Ethics & Health Policy, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Eugene Lin
- Department of Medicine, Division of Nephrology, Keck School of Medicine at the University of Southern California, Los Angeles, CA, USA.,Leonard D Schaeffer Center for Health Policy & Economics, University of Southern California, Los Angeles, CA, USA.,Sol Price School of Public Policy, University of Southern California, Los Angeles, CA, USA
| | - Jeffrey S Berns
- Renal, Electrolyte, and Hypertension Division, Hospital of the University of Pennsylvania, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
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24
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Hager D, Ferguson TW, Komenda P. Cost Controversies of a "Home Dialysis First" Policy. Can J Kidney Health Dis 2019; 6:2054358119871541. [PMID: 31516718 PMCID: PMC6719463 DOI: 10.1177/2054358119871541] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2019] [Accepted: 06/16/2019] [Indexed: 11/15/2022] Open
Abstract
Purpose of review Kidney Failure is highly prevalent and uses a disproportionate amount of health care funding. In Canada (excluding Quebec), 37 647 people were living with kidney failure in 2016. The single-payer Canadian health care system spends approximately 1.2% of their annual budget on kidney failure. In 2016, 58.4% of patients with kidney failure in Canada (excluding Quebec) were on dialysis as opposed to living with a functioning kidney transplant. Home dialysis modalities including peritoneal dialysis (PD) and home hemodialysis (HD) were used by 18.9% and 4.7% of these patients, respectively. In-center HD and home dialysis (PD and home HD) are often considered equally efficacious and have similar impacts on quality of life. Despite cost minimization analyses suggesting that home dialysis offers cost savings over in-center HD, there has been a slow uptake of home dialysis in developed nations over time, suggesting that controversies and barriers to implementation currently exist. The primary objective of this health policy briefing article is to introduce and address some of the major controversies surrounding the cost effectiveness in supporting advocacy for a "Home Dialysis First" policy with a primary focus on single-payer systems in a developed nation such as Canada. Sources of information Canadian Agency for Drugs and Technologies in Health (CADTH), Canadian and US epidemiologic databases, national/international conference presentations, primary literature review, and discussion with experts within the field of home dialysis. Methods We have conducted a focused primary literature review alongside individuals with expertise in the field of home dialysis to discuss the cost controversies surrounding the implementation of a "Home Dialysis First" policy. Key findings First, the primary literature is limited to mostly observational studies which are highly variable in study design and content. Local economic assessments, however, have provided convincing data for home dialysis cost savings in Canada. Second, the cost of delivering dialysis differs significantly throughout the world, explained by differing costs of labor and supplies in developing nations. Third, the indirect patient costs of water, energy, and home modifications are often barriers to implementation and may be overcome by introducing cost reimbursement programs. Fourth, home dialysis requires upfront training costs. We explore the impact of premature switches from home dialysis to in-center HD or a functioning kidney transplant on overall cost savings. Fifth, we discuss the effect of physician financial incentives and program funding on the uptake of home dialysis. Finally, we introduce the controversial topic of comparing the societal value of freedom of modality choice against the societal cost savings of a "Home Dialysis First" policy. Limitations Narrative reviews, due to their inherently reduced methodological quality in comparison with systematic reviews, may expose our collected literature to selection bias. We have attempted to compose a diverse collection of available literature alongside consensus expertise to provide a fair and concise review of home dialysis cost controversies. Implications Implementation of a "Home Dialysis First" policy would be a disruptive change to kidney failure care in Canada. To make informed policy decisions, we should recognize the cost savings associated with home dialysis in developed nations, the significance of patient-borne costs as a barrier to implementation, the impact of training costs and early modality switching in home dialysis, the lack of evidence regarding physician financial incentives, and the importance of program funding. Ultimately, we must consider the societal value of freedom of patient modality choice in comparison with the potential cost savings of a "Home Dialysis First" policy.
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Affiliation(s)
- Drew Hager
- Internal Medicine Residency Program, Max Rady College of Medicine, University of Manitoba, Winnipeg, Canada
| | | | - Paul Komenda
- Chronic Disease Innovation Centre, Seven Oaks General Hospital, Winnipeg, MB, Canada.,Section of Nephrology, Department of Internal Medicine, University of Manitoba, Winnipeg, Canada
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25
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Marshall MR, Hsiao CY, Li PK, Nakayama M, Rabindranath S, Walker RC, Yu X, Palmer SC. Association of incident dialysis modality with mortality: a protocol for systematic review and meta-analysis of randomized controlled trials and cohort studies. Syst Rev 2019; 8:55. [PMID: 30782218 PMCID: PMC6379951 DOI: 10.1186/s13643-019-0972-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2018] [Accepted: 02/04/2019] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND At least 2.6 million adults and children receive dialysis treatment for end-stage kidney disease (ESKD) worldwide. The large majority of these receive hemodialysis (HD), while the remaining receive peritoneal dialysis (PD). Peritoneal dialysis may be associated with similar mortality outcomes as HD, and patient-reported outcomes are potentially increased with PD. Existing evidence for the mortality associated with PD was summarized over 20 years ago, and there has been greater marginal improvement in survival with PD relative to HD since that time. It is therefore timely to reexamine the question of differential mortality by modality and summarize evidence from more contemporary practice settings. METHODS/DESIGN Electronic databases will be systematically searched for publications that report the association between dialysis modality (HD or PD) with death from any cause and cause-specific death in incident patients with end-stage kidney disease. The database searches will be supplemented by searching through citations and references and consultation with experts. Studies published before 1995 will be excluded. Screening of both titles and abstracts will be done by two independent reviewers. All disagreements will be resolved by an independent third reviewer. A quantitative meta-analysis of effect sizes and standard errors will be applied. DISCUSSION Our systematic review will update previous evidence summaries and provide a quantitative and standardized assessment of the contemporary literature comparing HD and PD including published and unpublished non-English studies from greater China, Taiwan, and Japan. This review will inform shared decision-making around initial dialysis modality choice and jurisdiction-level considerations of dialysis practice. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42018111829.
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Affiliation(s)
- Mark R Marshall
- School of Medicine, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand. .,Department of Renal Medicine, Middlemore Hospital, Counties Manukau Health, Auckland, New Zealand. .,Baxter Healthcare (Asia) Pte Ltd, Singapore, Singapore.
| | - Chun-Yuan Hsiao
- Department of Renal Medicine, Middlemore Hospital, Counties Manukau Health, Auckland, New Zealand
| | - Philip K Li
- Department of Medicine & Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong, China
| | - Masaaki Nakayama
- Research Division of Chronic Kidney Disease and Dialysis Treatment, Tohoku University Hospital, Sendai, Japan.,Nephrology Department, St Lukes International Hospital, Tokyo, Japan
| | - S Rabindranath
- Department of Nephrology, Waikato District Hospital, Hamilton, New Zealand
| | - Rachael C Walker
- Nursing and Health Science, Eastern Institute of Technology, Hawke's Bay, New Zealand
| | - Xueqing Yu
- Institute of Nephrology, Guangdong Medical University, Dongguan, Guangdong, China.,Department of Nephrology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Suetonia C Palmer
- Department of Medicine, University of Otago Christchurch, Christchurch, New Zealand
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26
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Chan CT, Wallace E, Golper TA, Rosner MH, Seshasai RK, Glickman JD, Schreiber M, Gee P, Rocco MV. Exploring Barriers and Potential Solutions in Home Dialysis: An NKF-KDOQI Conference Outcomes Report. Am J Kidney Dis 2018; 73:363-371. [PMID: 30545707 DOI: 10.1053/j.ajkd.2018.09.015] [Citation(s) in RCA: 54] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2018] [Accepted: 09/27/2018] [Indexed: 11/11/2022]
Abstract
Home dialysis therapy, including home hemodialysis and peritoneal dialysis, is underused as a modality for the treatment of chronic kidney failure. The National Kidney Foundation-Kidney Disease Outcomes Quality Initiative sponsored a home dialysis conference in late 2017 that was designed to identify the barriers to starting and maintaining patients on home dialysis therapy. Clinical, operational, policy, and societal barriers were identified that need to be overcome to ensure that dialysis patients have the freedom to choose their treatment modality. Education of patients and patient partners, as well as health care providers, about home dialysis therapy, if offered at all, is often provided in a cursory manner. Lack of exposure to home dialysis therapies perpetuates a lack of familiarity and thus a hesitancy to refer patients to home dialysis therapies. Patient and care partner support, both psychosocial and financial, is also critical to minimize the risk for burnout leading to dropout from a home dialysis modality. Thus, the facilitation of home dialysis therapy will require a systematic change in chronic kidney disease education and the approach to dialysis therapy initiation, the creation of additional incentives for performing home dialysis, and breakthroughs to simplify the performance of home dialysis modalities. The home dialysis work group plans to develop strategies to overcome these barriers to home dialysis therapy, which will be presented at a follow-up home dialysis conference.
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Affiliation(s)
| | - Eric Wallace
- University of Alabama at Birmingham, Birmingham, AL
| | | | | | | | - Joel D Glickman
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | | | - Patrick Gee
- Quality Insights Renal Network 5, Mid-Atlantic Renal Coalition, North Chesterfield, VA
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