Utilization of CMS pre-ESRD Kidney Disease Education services and its associations with the home dialysis therapies

Impact of the Kidney Score Platform on Communication About and Patients' Engagement With Chronic Kidney Disease Health: Pre-Post Intervention Study

Background

Chronic kidney disease (CKD) affects 14% of the US adult population, yet patient knowledge about kidney disease and engagement in their kidney health is low despite many CKD education programs, awareness campaigns, and clinical practice guidelines.

Objective

We aimed to examine the impact of the Kidney Score Platform (a patient-facing, risk-based online tool that provides interactive health information tailored to an individual's CKD risk plus an accompanying clinician-facing Clinical Practice Toolkit) on individual engagement with CKD health and CKD communication between clinicians and patients.

Methods

We conducted a pre-post intervention study in which English-speaking veterans at risk for CKD in two primary care settings interacted with the Kidney Score platform's educational modules and their primary care clinicians were encouraged to review the Clinical Practice Toolkit. The impact of the Kidney Score on the Patient Activation Measure (the primary outcome), knowledge about CKD, and communication with their clinician about kidney health was determined with paired t tests. Multivariable linear and logistic models were used to determine whether changes in outcomes after versus before intervention were influenced by age, race or ethnicity, sex, and diabetes status, accounting for baseline values.

Results

The study population (n=76) had a mean (SD) age of 64.4 (8.2) years, 88% (67/76) was male, and 30.3% (23/76) self-identified as African-American. Approximately 93% (71/76) had hypertension, 36% (27/76) had diabetes, and 9.2% (7/76) had CKD according to the laboratory criteria but without an ICD-10 (International Classification of Diseases, 10th Edition) diagnosis. Patient interaction with the Kidney Score did not change the mean Patient Activation Measure (preintervention: 40.7%, postintervention: 40.2%, P=.23) but increased the mean CKD knowledge score (preintervention: 40.0%, postintervention 51.1%, P<.01), and changed the percentage of veterans who discussed CKD with their clinician (preintervention: 12.3%, postintervention: 31.5%, P<.01). Changes did not differ by age, sex, race, or diabetes status. Results were limited by the small sample size due to low recruitment and minimal clinician engagement with the Clinical Practice Toolkit during the COVID-19 pandemic.

Conclusions

One-time web-based tailored education for patients can increase CKD knowledge and encourage conversations about kidney health. Increasing patient activation for CKD management may require multilevel, longitudinal interventions that facilitate ongoing conversations about kidney health between patients and clinician teams.

Decision Readiness and Determinants of KRT among Veterans with Advanced CKD

Key Points

Background

Kidney disease stakeholders recommend a system-wide increase in home dialysis use. KRT decision readiness is associated with higher selection and use of home dialysis; however, KRT decision making is complex, and factors informing KRT decision readiness in patients with advanced CKD are unclear.

Methods

Using the baseline data of the Trial to Evaluate and Assess the effects of Comprehensive KRT-directed patient education on home dialysis use among VETerans, we conducted a cross-sectional analysis to evaluate prevalent KRT decision readiness, defined as ability to choose any KRT modality among US Veterans with advanced CKD. We also evaluated Veterans' ability to achieve high-quality informed KRT decisions (more than 60% decisional confidence on a scale ranging from 1% to 100%) and selection of home dialysis as secondary outcomes. Univariate and multivariable logistic regressions were used to test associations between patient-level variables and outcomes.

Results

Of the 468 enrollees with a complete baseline dataset, 282 (60%) could not pick any KRT modality; the rest were split between high (20%) versus low-quality (20%) decisions and home (21%) versus in-center (12%) dialysis. Younger age, higher CKD stage, history of receiving prior KRT-directed education, rural habitation, and objective disease knowledge were positively associated with KRT decision readiness. Only objective disease knowledge was associated with KRT decision readiness after adjustments, with participants in the highest tertile of CKD-specific knowledge having two-fold (odds ratio, 2.31; 95% confidence interval, 1.18 to 4.55) and KRT-specific knowledge having five-fold (odds ratio, 5.16; 95% confidence interval, 2.63 to 10.32) higher odds of selecting their KRT. Item-level analysis showed that difficult, specifically KRT knowledge-related, items had a high discriminatory capacity to predict KRT decision readiness.

Conclusions

Veterans with advanced CKD are ill-prepared for KRT decision making. Although social determinants of health have a potential role in identifying high-risk populations, objective kidney failure and KRT-specific knowledge have a dominant effect on KRT decision readiness.

Clinical Trial registry name and registration number:

NCT04064086.

The way home: a scoping review of public health interventions to increase the utilization of home dialysis in chronic kidney disease patients

BACKGROUND

Home dialysis (HoD) remains underutilized, despite evidence showing it provides comparable mortality rates to in-center hemodialysis (ICHD) while offering advantages such as improved quality of life and lower overall costs. This scoping review comprehensively evaluates the effects of public health interventions on the uptake and retention of HoD utilization, including both Peritoneal Dialysis (PD) and Home Hemodialysis (HHD).

METHODS

Relevant studies were searched in the Web of Science, Medline, Embase, Scopus, EBSCOhost, and EconLit databases from their inception through May 2024. Studies were eligible for review if they assessed the effectiveness of public health interventions in terms of utilization and retention rates for general HoD, PD, and HHD.

RESULTS

Forty-three studies were included, with interventions categorized into three main types: educational programs, service provision improvements, and modifications to payment structures. Our findings indicate that educational interventions-aimed at enhancing knowledge about dialysis options and promoting shared decision-making among patients, families, and healthcare providers-and service provision improvements, such as assisted PD and nephrologist-performed catheter insertions, could significantly increase the initiation, utilization, and retention rates of HoD. However, the impact of payment interventions on HoD outcomes differed across different contexts.

CONCLUSION

Education and service provision enhancements may represent the most effective public health interventions for increasing initiation, utilization, and retention rates of HoD in dialysis-requiring patients. However, these findings are predominantly based on evidence from observational studies; further experimental studies with rigorous methodology are warranted to validate the effectiveness of these interventions in promoting HoD utilization.

Home dialysis as the incident modality in patients starting dialysis in West Virginia: role of the rural outreach kidney care clinic

BACKGROUND

Despite efforts to increase its use, home dialysis remains underutilized as a modality for kidney replacement therapy (KRT). Home dialysis may offer an advantage in rural areas. We evaluated the role of a rural outreach program on the use of home dialysis as incident KRT modality in West Virginia.

METHODS

This is a retrospective cohort study of patients with end-stage kidney disease (ESKD). Data on KRT were collected using the United States Renal Data System (USRDS) database from 1965 to 2020.

RESULTS

Of the total 22,408 West Virginia patients who started KRT with a dialysis modality between 1965 and 2020, 3203 (14.3%) patients started with a home modality. Among patients from counties served by a rural outreach clinic providing kidney care, 896 (18%) patients started with home dialysis compared to 2306 (13%) patients from other counties. Patients from counties served by a rural outreach clinic were more likely to be White (96 vs 90%), have comorbid illness, and live in a rural community (90 vs 56%), but less likely to be unemployed (11 vs 14%), all p < 0.001. In a multivariable model, after adjusting for comorbid medical conditions and rurality, the odds of starting dialysis with a home modality were greater for patients from counties served by a rural clinic than for patients from counties without such clinics (OR 1.4, 95% CI 1.15-1.7).

CONCLUSION

Patients with ESKD from West Virginia counties served by rural outreach clinics were more likely to initiate KRT by a home-based modality than patients from other counties in West Virginia.

Race- and Ethnicity-Related Disparities in Predialysis Nephrology Care, Kidney Disease Education, and Home Dialysis Utilization

Key Points

Disparities in predialysis nephrology care and KRT-directed education significantly influenced home dialysis underuse among marginalized populations. The influence of predialysis care disparities on home dialysis underuse lasted for a long time even after starting the dialysis. More studies are needed to uncover the layers through which structural racism influences home dialysis underuse among marginalized populations.

Background

Predialysis nephrology care and KRT-directed education (KDE) are essential for incident home dialysis use. However, there are substantial disparities in these care parameters among patients with advanced CKD. The effect of these disparities on home dialysis underuse has not been examined.

Methods

We analyzed the 2021 United States Renal Database System to identify all adult patients with kidney failure with over 6 months of predialysis Medicare coverage initiating their first-ever dialysis between 2010 and 2019. We used a mediation analysis to dissect the attributable influence of disparities in predialysis nephrology care and KDE on incident home dialysis use. In addition, we conducted sensitivity analyses using graded levels of mediators and sustained effect on home dialysis outcomes.

Results

We identified 464,310 Medicare recipients: 428,301 using in-center hemodialysis and 35,416 using home dialysis as their first-ever dialysis modality during the study period. Compared with non-Hispanic White patients (n =294,914), adjusted odds ratio (95% confidence intervals) for receiving predialysis nephrology care, KDE service, and incident home dialysis were 0.62 (0.61 to 0.64), 0.58 (0.52 to 0.63), and 0.76 (0.73 to 0.79), respectively, among Hispanic individuals (n =49,734) and 0.74 (0.73 to 0.76), 0.84 (0.79 to 0.89), and 0.63 (0.61 to 0.65), respectively, among Black individuals (n =98,992). Mediation analyses showed that compared with non-Hispanic White individuals, lack of nephrology care explained 30% and 14% of incident home dialysis underuse among Hispanic and Black individuals, respectively (P < 0.001). Sensitivity analyses using a longer duration of nephrology care and KDE services and the sustained effect on home dialysis underuse through the first year after kidney failure showed congruent and consolidating findings.

Conclusions

Disparities in predialysis nephrology care were significantly associated with lower home dialysis use among Hispanic and Black individuals.

Dialysis Modality Education Timing and Home Dialysis Uptake: A Quality Improvement Study

Rationale & Objective

Investigating the effect of a quality improvement intervention aimed at enhancing the choice of home dialysis among patients through improved educational sessions on dialysis modalities.

Study Design

A new referral protocol initiated on September 15, 2022, sought to direct patients with advanced kidney disease to modality education sessions. This protocol involved an updated referral form and process, requiring nephrologists to refer patients with an estimated glomerular filtration rate below 15 mL/min/1.73 m2 or specified Kidney Failure Risk Equation scores to modality educators for education. The impact was measured by the uptake of the education and the choice of home dialysis by patients.

Setting & Participants

The study took place at Sunnybrook Health Sciences Centre in Toronto, Canada, involving 532 patients across 1,723 clinical encounters from October 2019 to June 2023.

Predictor

The intervention was predicted to lead to an increase in both the number of patients receiving modality education and those choosing home dialysis.

Outcomes

The primary outcome measured was the selection of home dialysis following modality education, with a secondary focus on the proportion of patients educated post intervention.

Analytical Approach

Statistical process charts were used for monitoring changes in education uptake and home dialysis selection rates following the intervention.

Results

After implementing the standardized referral system, the proportion of patients receiving modality education increased from 27.1%-56.7%. However, the rate of selecting home dialysis remained constant at 50.9%. Overall home dialysis prevalence at our center averaged 19.6%, remaining lower than the provincial average of 24.4% by the end of the study period.

Limitations

The study was limited to 1 center, without evaluating patient satisfaction or dissecting the complexity of educational content and delivery.

Conclusions

We succeeded in boosting education rates but failed to achieve higher home dialysis choice rates, possibly owing to the complexity involved in modality choices. We plan to further investigate the factors influencing patient choices during modality education to better promote home dialysis selection.

Development and Validation of KRT Knowledge Instrument

Key Points

KRT awareness is important for informed choice and use of dialysis modalities, but we lack validated instruments capable of measuring such awareness. We present a newly developed KRT Knowledge instrument, which can be used to evaluate the kidney failure and KRT awareness among patients with CKD. Our results show that KRT awareness is different and significantly lower than CKD awareness among patients with advanced CKD.

Background

Awareness of KRTs is associated with greater home dialysis use. However, validated instruments evaluating patient knowledge and awareness of various KRTs are currently lacking and are critical for informed decision making.

Methods

We developed a 24-item KRT knowledge instrument (Know-KRT) encompassing three domains of General, Technical, and Correlative information critical for informed dialysis decision making. We conducted a cross-sectional study among Veterans with advanced CKD to determine its reliability, dimensionality, and validity.

Results

The Know-KRT instrument dimensionality was acceptable with a root mean squared error of approximation of 0.095 for the conceptual three-domain model fit (χ2=824.6, P < 0.001). Corrected Item-Total Correlation indices were excellent (>0.4) for all individual items. Internal consistency was excellent for the full instrument, Cronbach's alpha, α =0.95, with α =0.86, 0.91, and 0.79 for the General, Technical, and Correlative domains, respectively. The Know-KRT score correlated strongly with the CKD knowledge score (r =0.68, P < 0.001). KRT awareness was low, with an ease index of 0.181 for the full instrument. The General, Technical, and Correlative domain scores demonstrated strong correlations with the Know-KRT total score (r =0.68, 0.61, and 0.48, respectively, P < 0.001) and CKD instrument score (r =0.95, 0.93, and 0.77, respectively, P < 0.001). KRT and CKD awareness correlated negatively with age and positively with health literacy, employment status, hypertension, and quality of nephrology care.

Conclusions

We report a newly developed Know-KRT instrument with three domains having acceptable internal consistency, reliability, and validity. We show that patients with advanced CKD have low awareness of KRTs, even for items related to basic descriptions of modalities, highlighting the need for targeted patient education efforts.

Clinical Trial registration number:

NCT04064086 .

Informed Dialysis Modality Selection Among Veterans With Advanced CKD: A Community-Level Needs Assessment

Rationale & Objective

The Advancing Americans Kidney Health Executive order has directed substantial increases in home dialysis use for incident kidney replacement therapy (KRT). Clinical guidelines recommend patients' self-selection of KRT modality through a shared decision-making process, which, at the minimum, requires predialysis nephrology care and KRT-directed comprehensive prekidney failure patient education (CoPE). The current state of these essential services among Americans with advanced (stages 4 and 5) chronic kidney disease (CKD) and their informed preferences for home dialysis are unknown.

Study Design

We conducted a community-based, cross-sectional, observational cohort study across a large regional Veteran Healthcare System from October 1, 2020, to September 30, 2021.

Setting & Participants

Of the 928 Veterans with advanced CKD, 287 (30.9%) were invited for needs assessment evaluations. Of the 218 (76% of invited cohort) responding, 178 (81.6%) were receiving nephrology care, with approximately half of those (43.6%) receiving such care from non-Veterans Affairs providers.

Outcomes

The study was targeted to assess the prevalent state of ongoing nephrology care and KRT-directed pre-kidney failure education among Veterans with advanced CKD. The secondary outcome included evaluation of dialysis decision-making state among Veterans with advanced CKD.

Analytical Approach

Veterans with advanced CKD with 2 sustained estimated glomerular filtration rates <30 mL/min/1.73 m2 were identified through an electronic database query, and a randomly selected cohort was invited for their current state of and outstanding needs for predialysis nephrology care and CoPE, essential for informed KRT selection.

Results

Basic awareness of kidney disease was high (92.2%) among Veterans with advanced CKD, although only 38.5% were aware of the severity of their CKD. KRT-directed education during clinical care was reported by 46.8% of Veterans, of which 21.1% reported having received targeted CoPE classes. Three-quarters (74.3%) of Veterans expressed interest in receiving CoPE services. Overall, awareness of CKD and its severity and receipt of KRT-directed education were significantly higher among Veterans with nephrology care than among those without. Of the 61 Veterans providing their KRT preferences, overall decision making was poor, with three-quarters (73.8%) of the cohort unable to choose any KRT modality, irrespective of ongoing nephrology care. Only 8 (13%) felt confident choosing home KRT modalities.

Limitations

The study results are primarily applicable to the Veterans with advanced CKD. Furthermore, a limited numbers of respondents provided data on their KRT decision-making state, prohibiting broad generalizations.

Conclusions

In a first-of-its-kind community-based needs assessment evaluation among Veterans with advanced CKD, we found that awareness of kidney disease is positively associated with nephrology care; however, the informed KRT selection capabilities are universally poor, irrespective of nephrology care. Our results demonstrate a critical gap between the recommended and prevalent nephrology practices such as KRT-directed education and targeted CoPE classes required for informed patient-centered home dialysis selection in advanced CKD.

Assessing knowledge of end-stage kidney disease and treatment options in hospitalized African American patients undergoing hemodialysis

OBJECTIVE

African Americans are more likely to develop end-stage kidney disease (ESKD) than whites and face multiple inequities regarding ESKD treatment, renal replacement therapy (RRT), and overall care. This study focused on determining gaps in participants' knowledge of their chronic kidney disease and barriers to RRT selection in an effort to identify how we can improve health care interventions and health outcomes among this population.

METHODS

African American participants undergoing hemodialysis were recruited from an ongoing research study of hospitalized patients at an urban Midwest academic medical center. Thirty-three patients were interviewed, and the transcribed interviews were entered into a software program. The qualitative data were coded using template analysis to analyze text and determine key themes. Medical records were used to obtain demographic and additional medical information.

RESULTS

Three major themes emerged from the analysis: patients have limited information on ESKD causes and treatments, patients did not feel they played an active role in selecting their initial dialysis unit, and interpersonal interactions with the dialysis staff play a large role in overall unit satisfaction.

DISCUSSION

Although more research is needed, this study provides information and suggestions to improve future interventions and care quality, specifically for this population.

System-Level Strategies to Improve Home Dialysis: Policy Levers and Quality Initiatives

Advocacy and policy change are powerful levers to improve quality of care and better support patients on home dialysis. While the kidney community increasingly recognizes the value of home dialysis as an option for patients who prioritize independence and flexibility, only a minority of patients dialyze at home in the United States. Complex system-level factors have restricted further growth in home dialysis modalities, including limited infrastructure, insufficient staff for patient education and training, patient-specific barriers, and suboptimal physician expertise. In this article, we outline trends in home dialysis use, review our evolving understanding of what constitutes high-quality care for the home dialysis population (as well as how this can be measured), and discuss policy and advocacy efforts that continue to shape the care of US patients and compare them with experiences in other countries. We conclude by discussing future directions for quality and advocacy efforts.

Health inequities in dialysis care: A scoping review

MAIN PROBLEM

We aim to look at potential gaps in current dialysis literature on inequities and explore future research that could contribute to more equitable care.

METHODS

Following guidelines from the Joanna Briggs Institute (JBI) and the Preferred Reporting Items for Systematic reviews and Meta Analyses extension for Scoping Reviews (PRISMA-ScR), we conducted a scoping review of health inequities in dialysis. PubMed and Ovid Embase were searched in July 2022 for articles published between 2016 and 2022 that examined at least one of the following NIH defined health inequities: race/ethnicity, sex/gender, LGBTQ+ identity, underserved rural populations, education level, income, and occupation status. Frequencies of each health inequity as well as trends over time of the four most examined inequities were analyzed.

RESULTS

In our sample of 69 included studies, gaps were identified in LGBTQ+ identity and patient education. Inequities pertaining to race/ethnicity, sex/gender, underserved rural populations, and income were sufficiently reported. No trends between inequities investigated over time were identified.

CONCLUSIONS

Our scoping review examined current literature on health inequities pertaining to dialysis and found gaps concerning LGBTQ+ and patients with lower levels of education. To help fill these gaps, and possibly alleviate additional burden to these patients, we recommend cultural competency training for providers and dialysis center staff as well as community-based educational programs to improve dialysis patients' health literacy.

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.

Needs and Considerations for Standardization of Kidney Disease Education in Patients with Advanced CKD

Kidney health advocacy organizations and leaders in the nephrology community have repeatedly emphasized the need to increase home dialysis utilization in the United States. Limited awareness and understanding of options for the management of kidney failure among patients living with advanced CKD is a significant barrier to increasing the selection and use of home dialysis. Studies have shown that providing targeted comprehensive patient education before the onset of kidney failure can improve patients' awareness of kidney disease and substantially increase the informed utilization of home dialysis. Unfortunately, in the absence of validated evidence-based education protocols, outcomes associated with home dialysis use vary widely among published studies, potentially affecting the routine implementation and reporting of these services among patients with advanced CKD. This review provides pragmatic guidance on establishing effective patient-centered education programs to empower patients to make informed decisions about their KRT and, in turn, increase home dialysis use.

Barriers and Facilitators to Home Dialysis Among Latinx Patients with Kidney Disease

Importance

Latinx people have a high burden of kidney disease but are less likely to receive home dialysis compared to non-Latinx White people. The disparity in home dialysis therapy has not been completely explained by demographic, medical, or social factors.

Objective

To understand the barriers and facilitators to home dialysis therapy experienced by Latinx individuals with kidney failure receiving home dialysis.

Design, Setting, and Participants

This qualitative study used semistructured interviews with Latinx adults with kidney failure receiving home dialysis therapy in Denver, Colorado, and Houston, Texas, between November 2021 and March 2023. Patients were recruited from home dialysis clinics affiliated with academic medical centers. Of 39 individuals approached, 27 were included in the study. Interviews were audio-recorded, transcribed verbatim, and analyzed using thematic analysis.

Main Outcomes and Measures

Themes and subthemes regarding barriers and facilitators to home dialysis therapy.

Results

A total of 27 Latinx adults (17 [63%] female and 10 [37%] male) with kidney failure who were receiving home dialysis participated. Themes and subthemes were identified, 3 related to challenges with home dialysis and 2 related to facilitators. Challenges to home dialysis included misinformation and immigration-related barriers to care (including cultural stigma of dialysis, misinformation regarding chronic disease care, and lack of health insurance due to immigration status), limited dialysis education (including lack of predialysis care, no-nephrologist education, and shared decision-making), and maintenance of home dialysis (including equipment issues, lifestyle restrictions, and anxiety about complications). Facilitators to home dialysis included improved lifestyle (including convenience, autonomy, physical symptoms, and dietary flexibility) and support (including family involvement, relationships with staff, self-efficacy, and language concordance).

Conclusions and Relevance

Latinx participants in this study who were receiving home dialysis received misinformation and limited education regarding home dialysis, yet were engaged in self-advocacy and reported strong family and clinic support. These findings may inform new strategies aimed at improving access to home dialysis education and uptake for Latinx individuals with kidney disease.

Electronic Phenotype for Advanced Chronic Kidney Disease in a Veteran Health Care System Clinical Database: Systems-Based Strategy for Model Development and Evaluation

BACKGROUND

Identifying advanced (stages 4 and 5) chronic kidney disease (CKD) cohorts in clinical databases is complicated and often unreliable. Accurately identifying these patients can allow targeting this population for their specialized clinical and research needs.

OBJECTIVE

This study was conducted as a system-based strategy to identify all prevalent Veterans with advanced CKD for subsequent enrollment in a clinical trial. We aimed to examine the prevalence and accuracy of conventionally used diagnosis codes and estimated glomerular filtration rate (eGFR)-based phenotypes for advanced CKD in an electronic health record (EHR) database. We sought to develop a pragmatic EHR phenotype capable of improving the real-time identification of advanced CKD cohorts in a regional Veterans health care system.

METHODS

Using the Veterans Affairs Informatics and Computing Infrastructure services, we extracted the source cohort of Veterans with advanced CKD based on a combination of the latest eGFR value ≤30 ml·min-1·1.73 m-2 or existing International Classification of Diseases (ICD)-10 diagnosis codes for advanced CKD (N18.4 and N18.5) in the last 12 months. We estimated the prevalence of advanced CKD using various prior published EHR phenotypes (ie, advanced CKD diagnosis codes, using the latest single eGFR <30 ml·min-1·1.73 m-2, utilizing two eGFR values) and our operational EHR phenotypes of a high-, intermediate-, and low-risk advanced CKD cohort. We evaluated the accuracy of these phenotypes by examining the likelihood of a sustained reduction of eGFR <30 ml·min-1·1.73 m-2 over a 6-month follow-up period.

RESULTS

Of the 133,756 active Veteran enrollees at North Florida/South Georgia Veterans Health System (NF/SG VHS), we identified a source cohort of 1759 Veterans with advanced nondialysis CKD. Among these, 1102 (62.9%) Veterans had diagnosis codes for advanced CKD; 1391(79.1%) had the index eGFR <30 ml·min-1·1.73 m-2; and 928 (52.7%), 480 (27.2%), and 315 (17.9%) Veterans had high-, intermediate-, and low-risk advanced CKD, respectively. The prevalence of advanced CKD among Veterans at NF/SG VHS varied between 1% and 1.5% depending on the EHR phenotype. At the 6-month follow-up, the probability of Veterans remaining in the advanced CKD stage was 65.3% in the group defined by the ICD-10 codes and 90% in the groups defined by eGFR values. Based on our phenotype, 94.2% of high-risk, 71% of intermediate-risk, and 16.1% of low-risk groups remained in the advanced CKD category.

CONCLUSIONS

While the prevalence of advanced CKD has limited variation between different EHR phenotypes, the accuracy can be improved by utilizing two eGFR values in a stratified manner. We report the development of a pragmatic EHR-based model to identify advanced CKD within a regional Veterans health care system in real time with a tiered approach that allows targeting the needs of the groups at risk of progression to end-stage kidney disease.

VA-Based Peritoneal Dialysis Program Feasibility Considerations and Process Outline

Background

Home dialysis utilization is lower among veterans than in the general US population. Several sociodemographic factors and comorbidities contribute to peritoneal dialysis (PD) underutilization. In 2019, the Veterans Health Administration (VHA) Kidney Disease Program Office convened a PD workgroup to address this concern.

Observations

The PD workgroup was explicitly concerned by the limited availability of PD within the VHA, which frequently requires veterans to transition kidney disease care from US Department of Veterans Affairs medical centers (VAMCs) to non-VHA facilities when they progress from chronic kidney disease to end-stage kidney disease, causing fragmentation of care. Since the administrative requirements and infrastructure of VAMCs vary, the workgroup focused its deliberations on synthesizing a standard process for evaluating the feasibility and establishing a new PD program within any individual VAMC. A 3-phased approach was envisioned, beginning with ascertainment of prerequisites, leading to an examination of the clinical and financial feasibility through the process of data gathering and synthesis, culminating in a business plan that translates the previous 2 steps into an administrative document necessary for obtaining VHA approvals.

Conclusions

VAMCs can use the guide presented here to improve therapeutic options for veterans with kidney failure by establishing a new or restructured PD program.

Supporting Shared Decision-Making and Home Dialysis in End-Stage Kidney Disease

It has been widely demonstrated that patient education and empowerment, especially involving shared treatment decisions, improve patient outcomes in chronic medical conditions, including chronic kidney disease requiring kidney replacement therapies. Accordingly, regulatory agencies in the US and worldwide recommend shared decision-making for finalizing one's choice of kidney replacement therapy. It is also recognized that the US needs to substantially increase home dialysis utilization to leverage its positive impacts on patient and healthcare cost-related outcomes. This perspective highlights how the routine clinical use of the recommended practice of shared decision-making can exist in synergy with the system's goal for increased home dialysis use. It introduces a pragmatic provider checklist, The Nephrologist's Shared Decision-Making Checklist, grounded in the relevant theories of shared decision-making, and, unlike some research assessments and extant tools, is easy to understand and implement in clinical practice. This qualitative Checklist can help providers ensure that they have co-constructed an SDM experience with the patient and involved caretakers, helping them benefit from the improved outcomes associated with SDM.

Peritoneal dialysis in the modern era

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

Intervening to eliminate the centre-effect variation in home dialysis use: protocol for Inter-CEPt-a sequential mixed-methods study designing an intervention bundle

INTRODUCTION

Use of home dialysis by centres in the UK varies considerably and is decreasing despite attempts to encourage greater use. Knowing what drives this unwarranted variation requires in-depth understanding of centre cultural and organisational factors and how these relate to quantifiable centre performance, accounting for competing treatment options. This knowledge will be used to identify components of a practical and feasible intervention bundle ensuring this is realistic and cost-effective.

METHODS AND ANALYSIS

Underpinned by the non-adoption, abandonment, scale-up, spread and sustainability framework, our research will use an exploratory sequential mixed-methods approach. Insights from multisited focused team ethnographic and qualitative research at four case study sites will inform development of a national survey of 52 centres. Survey results, linked to patient-level data from the UK Renal Registry, will populate a causal graph describing patient and centre-level factors, leading to uptake of home dialysis and multistate models incorporating patient-level treatment modality history and mortality. This will inform a contemporary economic evaluation of modality cost-effectiveness that will quantify how modification of factors facilitating home dialysis, identified from the ethnography and survey, might yield the greatest improvements in costs, quality of life and numbers on home therapies. Selected from these factors, using the capability, opportunity and motivation for behaviour change framework (COM-B) for intervention design, the optimal intervention bundle will be developed through workshops with patients and healthcare professionals to ensure acceptability and feasibility. Patient and public engagement and involvement is embedded throughout the project.

ETHICS AND DISSEMINATION

Ethics approval has been granted by the Health Research Authority reference 20-WA-0249. The intervention bundle will comprise components for all stake holder groups: commissioners, provider units, recipients of dialysis, their caregivers and families. To reache all these groups, a variety of knowledge exchange methods will be used: short guides, infographics, case studies, National Institute for Health and Care Excellence guidelines, patient conferences, 'Getting it Right First Time' initiative, Clinical Reference Group (dialysis).

A randomized controlled trial to evaluate and assess the effect of comprehensive pre-end stage kidney disease education on home dialysis use in veterans, rationale and design

BACKGROUND

Informed dialysis selection and greater home dialysis use are the two long-desired, underachieved targets of advanced chronic kidney disease (CKD) care in the US healthcare system. Observational institutional studies have shown that comprehensive pre-kidney failure, conventionally referred to as end stage kidney disease education (CPE) can improve both these outcomes. However, lack of validated protocols, well-controlled studies, and systemic models have limited wide-spread adoption of CPE in the US. We hypothesized that a universal CPE and patient-centered initiation of kidney replacement therapy can improve multiple clinical, patient-centered and health service outcomes in advanced CKD and kidney failure requiring dialysis therapy.

METHODS

Trial to Evaluate and Assess the effects of CPE on Home dialysis in Veterans (TEACH-VET) is a multi-method randomized controlled trial aimed to evaluate the effects of a system-based approach for providing CPE to all Veterans with advanced CKD across a regional healthcare System. The study will randomize 544 Veterans with non-dialysis stage 4 and 5 CKD in a 1:1 allocation stratified by their annual family income and the stage of CKD to an intervention (CPE) arm or control arm. Intervention arm will receive a two-phase CPE in an intent-to-teach manner. Control arm will receive usual clinical care supplemented by resources for the freely-available kidney disease information. Participants will be followed after intervention/control for the duration of the study or until 90-days post-kidney failure, whichever occurs earlier.

RESULTS

The primary outcome will assess the proportion of Veterans using home dialysis at 90-days post-kidney failure, and secondary outcomes will include post-intervention/control CKD knowledge, confidence in dialysis decision and home dialysis selection. Qualitative arm of the study will use semi-structured interviews to in-depth assess Veterans' satisfaction with the intervention, preference for delivery, and barriers and facilitators to home dialysis selection and use. Several post-kidney failure clinical, patient-centered and health services outcomes will be assessed 90-days post-kidney failure as additional secondary outcomes.

CONCLUSION

The results will provide evidence regarding the need and efficacy of a system-based, patient-centered approach towards universal CPE for all patients with advanced CKD. If successful, this may provide a blueprint for developing such programs across the similar healthcare infrastructures throughout the country.

TRIAL REGISTRATION

NCT04064086 .

Cost Barriers to More Widespread Use of Peritoneal Dialysis in the United States

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.

Keys to Driving Implementation of the New Kidney Care Models

Contemporary nephrology practice is heavily weighted toward in-center hemodialysis, reflective of decisions on infrastructure and personnel in response to decades of policy. The Advancing American Kidney Health initiative seeks to transform care for patients and providers. Under the initiative’s framework, the Center for Medicare and Medicaid Innovation has launched two new care models that align patient choice with provider incentives. The mandatory ESRD Treatment Choices model requires participation by all nephrology practices in designated Hospital Referral Regions, randomly selecting 30% of all Hospital Referral Regions across the United States for participation, with the remaining Hospital Referral Regions serving as controls. The voluntary Kidney Care Choices model offers alternative payment programs open to nephrology practices throughout the country. To help organize implementation of the models, we developed Driver Diagrams that serve as blueprints to identify structures, processes, and norms, and generate intervention concepts. We focused on two goals that are directly applicable to nephrology practices and central to the incentive structure of the ESRD Treatment Choices and Kidney Care Choices: (1) increasing utilization of home dialysis, and (2) increasing the number of kidney transplants. Several recurring themes became apparent with implementation. Multiple stakeholders from assorted backgrounds are needed. Communication with primary care providers will facilitate timely referrals, education, and comanagement. Nephrology providers (nephrologists, nursing, dialysis organizations, others) must lead implementation. Patient engagement at nearly every step will help achieve the aims of the models. Advocacy with federal and state regulatory agencies will be crucial to expanding home dialysis and transplantation access. Although the models hold promise to improve choices and outcomes for many patients, we must be vigilant that they not do reinforce existing disparities in health care or widen known racial, socioeconomic, or geographic gaps. The Advancing American Kidney Health initiative has the potential to usher in a new era of value-based care for nephrology.

Provision of Kidney Disease Education Service Is Associated with Improved Vascular Access Outcomes among US Incident Hemodialysis Patients

Background

Pre-ESKD Kidney Disease Education (KDE) has been shown to improve multiple CKD outcomes, but its effect on vascular access outcomes is not well studied. In 2010, Medicare launched KDE reimbursements policy for patients with advanced CKD.

Methods

In this retrospective USRDS analysis, we identified all adult patients on incident hemodialysis with ≥6 months of pre-ESKD Medicare coverage during the first 5 years of CMS-KDE policy and divided them into CMS-KDE services recipients (KDE cohort) and nonrecipients (non-KDE cohort). The primary outcome was incident arteriovenous fistula (AVF) and the composite of incident AVF or arteriovenous graft (AVG) utilization. Secondary outcomes were central venous catheter (CVC) with maturing AVF/AVG and pure CVC utilizations. Step-wise multivariate analyses were performed in four progressive models (model 1, KDE alone; model 2, multivariate model encompassing model 1 with sociodemographics; model 3, model 2 with comorbidity and functional status; and model 4, model 3 with pre-ESKD nephrology care).

Results

Of the 211,990 qualifying patients on incident hemodialysis during the study period, 2887 (1%) received KDE services before dialysis initiation. The rates of incident AVF and composite AVF/AVG were more than double (30% and 35%, respectively, compared with 14% and 17%), and pure catheter use about a third lower (40% compared with 65%) in the KDE cohort compared with the non-KDE cohort. The maximally adjusted odds ratios in model 4 for study outcomes were incident AVF use, 1.78, 99% confidence interval, 1.55 to 2.05; incident AVF/AVG use, 1.78, 99% confidence interval, 1.56 to 2.03; incident CVC with maturing AVF/AVG, 1.69, 99% confidence interval, 1.44 to 1.97; and pure CVC without any AVF/AVG, 0.51, 99% confidence interval, 0.45 to 0.58. The benefits of the KDE service were maintained even after accounting for the presence, duration, and facility of ESKD care.

Conclusion

The occurrence of pre-ESRD KDE service is associated with significantly improved incident vascular access outcomes. Targeted studies are needed to examine the effect of KDE on patient engagement and self-efficacy as a cause for improvement in vascular access outcomes.