A patient perspective on the barriers to home dialysis

Citizens' perspectives on relocating care: a scoping review

BACKGROUND

Healthcare systems around the world are facing large challenges. There are increasing demands and costs while at the same time a diminishing health workforce. Without reform, healthcare systems are unsustainable. Relocating care, for example, from hospitals to sites closer to patients' homes, is expected to make a key contribution to keeping healthcare sustainable. Given the significant impact of this initiative on citizens, we conducted a scoping review to provide insight into the factors that influence citizens' attitudes towards relocating care.

METHOD

A scoping review was conducted. The search was performed in the following databases: Pubmed, Embase, Cinahl, and Scopus. Articles had to include relocating healthcare and citizens' perspectives on this topic and the articles had to be about a European country with a strong primary care system. After applying the inclusion and exclusion criteria, 70 articles remained.

RESULTS

Factors positively influencing citizens' attitudes towards relocating care included: convenience, familiarity, accessibility, patients having more control over their disease, and privacy. Factors influencing negative attitudes included: concerns about the quality of care, familiarity, the lack of physical examination, contact with others, convenience, and privacy. Furthermore, in general, most citizens preferred to relocate care in the studies we found, especially from the hospital to care provided at home.

CONCLUSION

Several factors influencing the attitude of citizens towards relocating care were found. These factors are very important when determining citizens' preferences for the location of their healthcare. The majority of studies in this review reported that citizens are in favour of relocating care. In general citizens' perspectives on relocating care are very often missing in articles. It was significant that very few studies on relocation from the hospital to the general practitioner were identified.

Home hemodialysis technique survival: insights and challenges

Home hemodialysis (HHD) offers several clinical, quality of life and cost-saving benefits for patients with end-stage kidney disease. While uptake of this modality has increased in recent years, its prevalence remains low and high rates of discontinuation remain a challenge. This comprehensive narrative review aims to better understand what is currently known about technique survival in HHD patients, elucidate the clinical factors that contribute to attrition and expand on possible strategies to prevent discontinuation. With increasing efforts to encourage home modalities, it is imperative to better understand technique survival and find strategies to help maintain patients on the home therapy of their choosing. It is crucial to better target high-risk patients, examine ideal training practices and identify practices that are potentially modifiable to improve technique survival.

Main Barriers to the Introduction of a Home Haemodialysis Programme in Poland: A Review of the Challenges for Implementation and Criteria for a Successful Programme

Introduction: Home dialysis in Poland is restricted to the peritoneal dialysis (PD) modality, with the majority of dialysis patients treated using in-centre haemodialysis (ICHD). Home haemodialysis (HHD) is an additional home therapy to PD and provides an attractive alternative to ICHD that combines dialysis with social distancing; eliminates transportation needs; and offers clinical, economic, and quality of life benefits. However, HHD is not currently provided in Poland. This review was performed to provide an overview of the main barriers to the introduction of a HHD programme in Poland. Main findings: The main high-level barrier to introducing HHD in Poland is the absence of specific health legislation required for clinician prescribing of HHD. Other barriers to overcome include clear definition of reimbursement, patient training and education (including infrastructure and experienced personnel), organisation of logistics, and management of complications. Partnering with a large care network for HHD represents an alternative option to payers for the provision of a new HHD service. This may reduce some of the barriers which need to be overcome when compared with the creation of a new HHD service and its supporting network due to the pre-existing infrastructure, processes, and staff of a large care network. Conclusions: Provision of HHD is not solely about the provision of home treatment, but also the organisation and definition of a range of support services that are required to deliver the service. HHD should be viewed as an additional, complementary option to existing dialysis modalities which enables choice of modality best suited to a patient’s needs.

Exploring stakeholders and their requirements in the process of home hemodialysis: A literature review

Providing home hemodialysis (HHD) therapy is a complex process that not only requires the use of a complex technology but also involves a diverse group of stakeholders, and each stakeholder has their requirements and may not share a common interest. Bringing them together will require the alignment of their interests. A process management perspective can help to accomplish the alignment of their interests. To align their interests, it is crucial to identify interest groups and understand their interests. The main objective of this paper is to identify the stakeholders and represents their interests as a list of requirements in the HHD process. An extensive literature review has been carried out and PubMed was used for literature extraction. In total, 1848 articles were retrieved of which 80 have fulfilled the inclusion criteria. A large array of actors is identified and their interests/requirements at different stages of the HHD process are represented in the form of a list. They have both common and conflicting requirements in the HHD process. If these requirements are aligned and balanced, a stakeholder's driven treatment process will be developed and a real improvement will be achieved in the treatment process.

Barriers to home dialysis: Unraveling the tapestry of policy

Home dialysis use as a treatment for end-stage kidney disease varies locally, nationally, and internationally. There is a call to action in the United States to significantly increase access and uptake of home dialysis as the preferred dialysis treatment option. Although most do not object to patient choice in modality selection, the reality is that there are multilevel barriers both obvious and subtle that interfere with expanding home dialysis access. Financial barriers and how payment is structured continue to be key drivers, although new models of care are emerging that include for the first time incentives rather than penalties regarding home dialysis. Resources to support implementation include expert personnel requiring educational training. Policies requiring training curriculum content that is not only specified within nephrology but also for these multidisciplinary providers requisite for successful home dialysis to ensure professional expertise is ready and available, and also to cultivate champions of home modality within the broader nephrology community. Perhaps most importantly, innovation through expanded investment in research is necessary to advance practices, elevate quality, and improve outcomes. Policy in a variety of sectors at local, regional, national, and international levels has the potential to drastically drive expansion and increasing success of home dialysis.

The Potential Burden of Home Dialysis on Patients and Caregivers: A Narrative Review

Purpose of review:

Home dialysis modalities offer several benefits for patients with end-stage kidney disease when compared with facility-based thrice-weekly hemodialysis. To increase uptake of home dialysis, many centers are encouraging a “home-first” approach. However, it is important to appreciate that “one size may not fit all” and that dialysis modality selection is a complex decision that needs to be individualized. The purpose of this review was to explore aspects associated with home dialysis that may be associated with burden for patients and their caregivers and to discuss strategies to alleviate these concerns.

Sources of information:

Original research articles were identified from PubMed using search terms “peritoneal dialysis,” “home hemodialysis,” “home dialysis,” “barriers,” “quality of life” and “burden.”

Methods:

We performed a focused narrative review examining potential sources of burden with home dialysis therapies after conducting a critical appraisal of the literature and identifying the major recurring themes.

Key findings:

Home dialysis is associated with burden for certain patients. Indeed, some patients may experience ongoing concerns regarding the risks of adverse events and of inadequately performing dialysis on their own. Psychosocial issues affecting quality of life may also arise and include fear of social isolation, sleep disturbances, perceived financial burden, anxiety, and fatigue. Patients who depend on a caregiver may worry about creating a stressful home environment for their close ones. Furthermore, the demands associated with being a caregiver may lead to psychosocial distress in the caregivers themselves. All these factors may lead to burnout and consequently, therapy discontinuation necessitating an unplanned transition to in-center hemodialysis leading to adverse outcomes. However, certain strategies may help alleviate burden especially if concerns are identified early on.

Limitations:

As we did not apply any formal tool to assess the quality of the studies included, selection bias may have occurred. Nonetheless, we have attempted to provide a comprehensive review on the topic using numerous diverse studies and extensive review of the literature.

Implications:

Future studies should focus on better identifying patient priorities and strategies to facilitate dialysis modality selection and improve quality of life.

Cost of dialysis therapies in rural and remote Australia - a micro-costing analysis

BACKGROUND

Maintenance dialysis is a costly and resource intense activity. In Australia, inadequate health infrastructure and poor access to technically skilled staff can limit service provision in remote areas where many Aboriginal dialysis patients live. With most studies based on urban service provision, there is little evidence to guide service development. However permanent relocation to an urban area for treatment can have significant social and financial impacts that are poorly quantified. This study is part of a broader project to quantify the costs and benefits of dialysis service models in urban and remote locations in Australia's Northern Territory (NT).

METHODS

We undertook a micro-costing analysis of dialysis service delivery costs in urban, rural and remote areas in the NT from the payer perspective. Recurrent maintenance costs (salaries, consumables, facility management and transportation) as well as capital costs were included. Missing and centralised costs were standardised; results were inflated to 2017 values and reported in Australian dollars.

RESULTS

There was little difference between the average annual cost for urban and rural services with respective median costs of $85,919 versus $84,629. However remote service costs were higher ($120,172 - $124,492), driven by higher staff costs. The inclusion of capital costs did not add substantially to annual costs. Annual home haemodialysis costs ($42,927) were similar to other jurisdictions despite the significant differences in program delivery and payment of expenses not traditionally borne by governments. Annual peritoneal dialysis costs ($58,489) were both higher than home and in-centre haemodialysis by recent national dialysis cost studies.

CONCLUSION

The cost drivers for staffed services were staffing models and patient attendance rates. Staff salaries and transport costs were significantly higher in remote models of care. Opportunities to reduce expenditure exist by encouraging community supported services and employing local staff. Despite the delivery challenges of home haemodialysis including high patient attrition, the program still provides a cost benefit compared to urban staffed services. The next component of this study will examine patient health service utilisation and costs by model of care to provide a more comprehensive analysis of the overall cost of providing services in each location.

Obstáculos y estrategias de afrontamiento en la atención renal: estudio cualitativo en jóvenes con enfermedad renal crónica en diálisis peritoneal

Resumen Este trabajo se propone identificar los obstáculos que enfrentan individuos jóvenes en tratamiento de diálisis peritoneal, así como examinar las estrategias de afrontamiento que utilizan en la atención renal. Para ello, se llevó a cabo un estudio cualitativo desde una perspectiva crítico-interpretativa. Participaron 12 jóvenes con insuficiencia renal y en tratamiento de diálisis peritoneal, viviendo en Guadalajara, México. Mediante un muestreo por bola de nieve, se seleccionaron siete hombres y cinco mujeres. La información se obtuvo mediante entrevistas narrativas y observación participante, además de conversaciones en WhatsApp y Facebook. Se hizo análisis de contenido. Además del consentimiento informado, se aseguró el anonimato y la confidencialidad de la información. Los resultados desvelan cuatro ejes temáticos que emergen del análisis de la información: Enfrentando dificultades económicas, Viviendo las deficiencias de los servicios de salud, Interferencias en la comunicación con los profesionales sanitarios y En búsqueda permanente de estrategias. Múltiples estrategias se emplean para enfrentar los problemas económicos, la falta de información y el control emocional. Se observó que la falta de recursos económicos es el principal obstáculo que enfrentan los jóvenes en diálisis. Estos jóvenes impulsan estrategias, junto con familiares y sus pares, para afrontar las dificultades.

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

INTRODUCTION

The globally increasing prevalence of chronic kidney disease has resulted in an ever-growing demand for renal replacement therapy. Although programs are present around the world, there is a paucity of immersive educational programs that train clinicians and administrators to develop new home dialysis programs. Explore Home Dialysis (EHD) is a program created to fill this gap.

METHODS

We present the results of the evaluation of the EHD program. Our team interviewed 23 clinicians and administrators who participated in the EHD program. We also assessed country-specific needs and challenges associated with home dialysis.

RESULTS

The 4 main findings include (i) the evaluation of the effectiveness of the EHD program; (ii) the need for an educational program to train individuals on how to deploy home dialysis programs; (iii) evidence that such an educational program is beneficial to participants and for the establishment of new home dialysis programs; and (iv) the identification of barriers to the development of home dialysis programs in countries represented in this study. The data show an increased demand, with strong patient and provider interest in establishing new programs, interest in accessing resources to train clinical and administrative staff in how to run a home dialysis program, and positive feedback about the EHD program in general.

CONCLUSIONS

The data from this study were used in the next iteration of the EHD program, to inform clinicians about challenges in the deployment of new home dialysis programs, and to present educational resources that need to be developed in the future.

Factors Associated with the Choice of Peritoneal Dialysis in Iran: Qualitative Study

BACKGROUND

Decision making about the type of dialysis in renal failure is a matter of great importance involving the patients, his/her family, and the health care team. Identifying the factors influencing decision making for undergoing peritoneal dialysis (PD) helps the development of this therapeutic method in patients.

AIM

The present study aims at explaining the factors influencing decision making about undergoing PD in End Stage Renal Failure patients.

METHOD

The present study is a qualitative research, which used content analysis method. A semi-structured and in-depth interview was conducted with the 19 participants that selected by purposefully sampling. All interviews were recorded subsequent to receiving consent of the participants and were analyzed using content analysis method.

RESULTS

The first codification process resulted in 345 codes, which finally decreased to 278 codes by continuous reading and removal of duplicates. Overall, two main categories and eight categories namely facilitating factors (viz. family atmosphere, hemodialysis problems, PD advantages, and social environment) and inhibitory factors (viz. inefficient family, PD requirements, attitudes towards hemodialysis, and the country treatment system) were selected from the total 19 sub-categories and 278 codes.

CONCLUSIONS

Results indicated that various personal, family-related, psychological, social, and economic factors could affect the decision on the type of dialysis in patients. Therefore, basic infrastructures such as social support, education, and even the specialist and positive perspective of the Ministry of Health are required to choose this therapeutic method.

Self-cannulation of the vascular access in home hemodialysis: Overcoming patient-level barriers

Patients with end-stage kidney disease who are considering home hemodialysis (HHD) face the challenge of learning to self-cannulate their arteriovenous access. Current practice discourages the use of tunneled central venous catheters, with recent indications that self-cannulating patients have superior outcomes. Patient-level barriers do not appear to preclude a successful HHD program and should not be viewed as insurmountable by healthcare staff or patients. The healthcare team must address patient fears while instructing the patient to perform self-cannulation safely. Identification and understanding of the barriers perceived by the patient will allow the patient and healthcare team work collaboratively, toward the goal of independence with self-cannulation both during initial training and follow-up care. The aim of this review was to provide a practical resource to aid in the identification and resolution of these patient-level barriers, with the overall goal of improving the patient experience and medical outcomes in home hemodialysis programs.

Progressive exhaustion: A qualitative study on the experiences of Iranian family caregivers regarding patients undergoing hemodialysis

Objective

The aim of this study was to explore the burden of care for patients undergoing hemodialysis from the experiences of family caregivers.

Methods

In this qualitative study, a content analysis approach was used for data collection and analysis. Participants were 16 family caregivers selected through purposive sampling from four medical education centers affiliated with Ahvaz Jundishapur University of Medical Sciences, Iran. Semi-structured interviews were held to collect data.

Results

Four categories were developed as follows: ‘care challenges’, ‘psychological vulnerabilities’, ‘the chronic nature of care ’and “care in the shade”. The categories led to the development of the main theme of ‘progressive exhaustion’ experienced by the family caregivers during the provision of care to patients undergoing hemodialysis.

Conclusion

Family caregivers have a significant role in the process of patient care, and this role leads them to progressive exhaustion; therefore, the overall health of the caregivers should be taken into account and more attention should be paid to their quality of life, social welfare, and satisfaction level.

Is replacement modality choice knowledge important in the non-renal multidisciplinary team? Experience from a single UK centre

Dialysis remains the mainstay treatment for patients with end stage renal disease. In the UK, there has been a significant decline in home dialysis despite its benefits and cost effectiveness. Patients with chronic kidney disease (CKD) are often known to other specialties who they may continue to consult when approaching dialysis. We wished to assess the knowledge of the non-renal multidisciplinary team (MDT) regarding home dialysis and establish whether further education was warranted. This was assessed using an online survey sent to specialties likely to deal with CKD patients. In total, 364 questionnaires were sent out with a 26.4% response rate. According to the survey responses, 81.5% of non-renal MDTs lack confidence in discussing home dialysis options with patients and 74.55% feel that they need further education about home dialysis. Targeted education may increase home dialysis uptake by multimorbid CKD patients who have a consistent message delivered by all relevant healthcare teams about the benefits of home dialysis.

A Matter of Choice: Opportunities and Obstacles Facing People with ESRD

Kidney failure is an overwhelming, life-shattering event, but patients with ESRD do not see themselves as being at the end stage of their lives. On the contrary, patients opting for kidney dialysis are choosing to live. Ideally, then, public policy would support patients' choices about how to live-specifically, the choice to continue working. Many patients with ESRD faced with the limitations of their health status and the demands of their treatment understandably choose to leave their jobs, a choice that is facilitated by the availability of public disability and health insurance. However, other patients who have the desire and opportunity to continue working may not get the guidance and support that can actually make their employment possible. Specifically, current disability and health insurance may fail to provide timely treatment and employment counseling to help patients with ESRD remain in their jobs. We, therefore, propose that the Center for Medicare and Medicaid Services support ESRD Networks to initiate more timely employment and treatment counseling in both the ESRD and the late-stage pre-ESRD setting. Although it is too late to require such counseling in the new network scope of work for 2016-2020, active experimentation in the next few years can lay the groundwork for a subsequent contract.

The Choice of Renal Replacement Therapy (CORETH) project: study design and methods

BACKGROUND

To date, research has neglected the patient's psychosocial and cognitive conditions as contributing factors to dialysis modality decision-making. Hence, the Choice of Renal Replacement Therapy (CORETH) study aims to examine these conditions with regard to their impact on the choice. Here we describe the design of the multicentre study, which is supported by a grant from the German Ministry for Education and Research.

METHODS

Two groups of patients will be compared after having chosen peritoneal or haemodialysis as permanent treatment. About 1200 participants from 50 dialysis centres all over Germany will be questioned. The questionnaire addresses social, psychological and shared decision-making aspects. Furthermore, cognitive functioning will be tested. For an economic evaluation direct and indirect costs of treatment will be calculated. Changes will be examined through a one-year follow-up.

CONCLUSIONS

The results will enlighten the treatment choice under the German healthcare system. They will provide further insight regarding the discussion on patient autonomy. From the patients' perspective, the results will help to strengthen their participation in the individual process of health-related decision-making.

Development and Testing of Self-Management Scale for PD Patients

OBJECTIVES

To develop and evaluate the self-management scale for peritoneal dialysis (PD) patients.

METHODS

The item pool was formulated based on literature reviews and in-depth interviews. An initial scale containing five factors and 44 items was constructed through two rounds of Delphi expert consultation and a preliminary test. A total of 313 PD patients from the Jiangsu-Zhejiang-Shanghai area were surveyed to test the reliability and validity of the scale.

RESULTS

Five factors, namely solution bag replacement, troubleshooting during operation, diet management, complication monitoring, emotion management and return to social life, were extracted by exploratory factor analysis: the 28 items could explain 64.567% of the total variance; the content validity index was 0.963; the Cronbach's α coefficient and split-half coefficient were 0.926 and 0.960 respectively; and test-retest reliability was 0.937.

CONCLUSION

The scale has been proved to be a reliable and valid tool which allows PD nurses to evaluate the self-management ability of PD patients. The evaluation outcomes can serve as a basis for individualized nursing plans and interventions so as to provide highly effective nursing care.