Providers, staff must make ‘radical changes’ to reach HHS goals for home dialysis
Wednesday, September 9, 2020
Posted by: Diane Berg
It could take close to 5 decades for dialysis providers to reach the Advancing American Kidney Health goal of starting 50% of new patients on home dialysis, a speaker said at the American Nephrology Nurses Association National Symposium.
“At the current rate of growth, we can be expected to achieve a 50% home dialysis rate in about 50 years unless there are radical changes in education of patients regarding modality options,” Lisa Koester-Wiedemann, ANP, CNN-NP, told attendees.
The Advancing American Kidney Health (AAKH) goal is to have 80% of patients with end-stage kidney disease starting on home dialysis or have a functioning transplant by 2025.
Improvements that are needed to draw closer to that goal include committed home dialysis nurses, staff-assisted home dialysis, greater use of telehealth for home patients and user-friendly interfaces to improve use of treatment data, Koester-Wiedemann, who is with the division of nephrology at the Washington University School of Medicine in St Louis, said.
Likewise, the lack of experience for nephrologists and fellows needs to be addressed. Koester-Wiedemann suggested an update made by the Accreditation Council for Graduate Medical Education nephrology fellowship program requirements to allow more home dialysis training; develop home dialysis fellowships similar to transplant nephrology fellowships; update the American Board of Internal Medicine nephrology board examination to reflect a larger amount of home dialysis content, and offer continued support and efforts by national professional organizations and industry in providing home modality education.
While dialysis providers have made inroads in sending more patients home for dialysis, it will be difficult to change practice patterns that have sent most patients to dialysis clinics for thrice-weekly treatments, she said.
“In 1973, fully 40% of patients were doing hemodialysis at home,” Koester-Wiedemann said, citing data from the 2017 Annual Data Report of the U.S. Renal Data System. “Today, that number is 1.8%, with [peritoneal dialysis] PD at 9%. In-center hemodialysis covers 89.2% of patients.”
While several polls among nephrologists indicate they would select home dialysis as their treatment of choice if they had ESKD, only 26% of dialysis providers offer home hemodialysis and 49% are certified to offer PD, according to data from the Dialysis Facility Compare website, Koester-Wiedemann said.
Training nurses to manage patients on home dialysis is important. “Home dialysis nursing requires a completely different skill set and commitment from in-center hemodialysis nursing,” Koester-Wiedemann said. “It requires teaching skills and nurses need to be on-call since home dialysis problems don’t just occur during business hours.”
“Most nurses prefer shift work in an in-center hemodialysis unit because when they go home, they’re done for the day,” she said.
Likewise, a plan for sending patients home must be in place, Koester-Wiedemann said.
“We need to create an infrastructure to support patients before sending them home,” she told attendees. “Some need more support than others, but the goal is to get them home and keep them home. From cannulation to inventory to family dynamics, it is our responsibility, as advocates, clinicians and educators to help them transition to the ‘new normal,’” she said.
Koester-Wiedemann acknowledged that health care coverage and patient denial of kidney disease can make directing patients to home dialysis more difficult.
“Forty percent of patients have had no nephrology care prior to ESRD, vulnerable populations tend to have poor insurance and there is a lack of consistent criteria for nephrology referral,” she said. “Of patients who have had nephrology care, most are ill-educated and ill-prepared for dialysis. They don’t go to pre-dialysis education classes.” Likewise, patients may have fears of doing dialysis by themselves and their home environment may not be sterile enough, large enough or appropriate for maintenance and supplies.
The safety of the dialysis process, mishaps or complications with the process, unstable health or cognitive issues, homelessness or an unstable home situation, and a feeling of isolation at home may be factors patients consider regarding home dialysis, Koester-Wiedemann told attendees.
“We need to increase the home dialysis expertise and enthusiasm among nephrologists, and we need to increase the workforce of experienced home dialysis nurses” in an effort to reach the AAKH goal, Koester-Wiedemann said. “Eliminating economic disincentives and providing economic incentives for all stakeholders would make a difference. We also need to simplify home dialysis regulatory requirements, address patient costs and barriers, and report meaningful comparative home dialysis metrics,” she said.