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Lokhande A, Painter DF, Vogt B, Shah A. Policy and Payment Decisions on Peritoneal Dialysis in the United States: A Review. Med Care Res Rev 2024:10775587241233614. [PMID: 38404115 DOI: 10.1177/10775587241233614] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/27/2024]
Abstract
End-stage kidney disease (ESKD) accounts for a sizable proportion of Medicare spending. Peritoneal dialysis remains an underutilized treatment modality for ESKD despite its quality of life and cost-saving benefits. Medicare policy on reimbursements and patient eligibility for dialysis coverage has been amended numerous times since its inception in 1972. Over the last two decades, Medicare policy on ESKD reimbursements has evolved from a primarily fee-for-service model to a prospective payment system, and within the past few years, it has begun including more experimental payment structures. While prior work has explored the evolution of Medicare's ESKD policy as a whole, we specifically outline the impact of Medicare policy changes on peritoneal dialysis reimbursement rates, uptake by physicians and dialysis facilities, and accessibility to patients. This narrative review offers historical insights, an overview of modern ESKD policy, actionable strategies, and policy opportunities to increase the accessibility of this treatment modality.
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Affiliation(s)
- Anagha Lokhande
- The Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - David F Painter
- The Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Braden Vogt
- The Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Ankur Shah
- The Warren Alpert Medical School of Brown University, Providence, RI, USA
- Rhode Island Hospital, Providence, USA
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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: 21] [Impact Index Per Article: 21.0] [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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Rajora N, Shastri S, Pirwani G, Saxena R. How To Build a Successful Urgent-Start Peritoneal Dialysis Program. ACTA ACUST UNITED AC 2020; 1:1165-1177. [DOI: 10.34067/kid.0002392020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Accepted: 08/07/2020] [Indexed: 12/15/2022]
Abstract
In-center hemodialysis (HD) remains the predominant dialysis therapy in patients with ESKD. Many patients with ESKD present in late stage, requiring urgent dialysis initiation, and the majority start HD with central venous catheters (CVCs), which are associated with poor outcomes and high cost of care. Peritoneal dialysis (PD) catheters can be safely placed in such patients with late-presenting ESKD, obviating the need for CVCs. PD can begin almost immediately in the recumbent position, using low fill volumes. Such PD initiations, commencing within 2 weeks of the catheter placement, are termed urgent-start PD (USPD). Most patients with an intact peritoneal cavity and stable home situation are eligible for USPD. Although there is a small risk of PD catheter–related mechanical complications, most can be managed conservatively. Moreover, overall outcomes of USPD are comparable to those with planned PD initiations, in contrast to the high rate of catheter-related infections and bacteremia associated with urgent-start HD. The ongoing coronavirus disease 2019 pandemic has further exposed the vulnerability of patients with ESKD getting in-center HD. PD can mitigate the risk of infection by reducing environmental exposure to the virus. Thus, USPD is a safe and cost-effective option for unplanned dialysis initiation in patients with late-presenting ESKD. To develop a successful USPD program, a strong infrastructure with clear pathways is essential. Coordination of care between nephrologists, surgeons or interventionalists, and hospital and PD center staff is imperative so that patient education, home visits, PD catheter placements, and urgent PD initiations are accomplished expeditiously. Implementation of urgent-start PD will help to increase PD use, reduce cost, and improve patient outcomes, and will be a step forward in fostering the goal set by the Advancing American Kidney Health initiative.
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