We Need National GOALS for Home Dialysis!

So, I was scanning PubMed for this month's Home Dialysis Central email update*, and ran across a UK paper that reminded me of a vital point. Here's the quote, (my emphasis is in bold): "Ten years on from the National Institute of Health and Clinical Excellence' technology appraisal guideline on haemodialysis in 2002; the clinical community is yet to rise to the challenge of providing home haemodialysis (HHD) to 10-15% of the dialysis cohort."¹ Wait, "the challenge of providing HHD to 10-15% of the dialysis cohort"? They have a GOAL for home HD in the UK—and, for all I know as an American, for PD as well. And, since they haven't met their goal, they are doing a study to find out why. Imagine that!

You know what we don't have in the US? Goals for the numbers of folks on dialysis who do home treatments. As NN&I pointed out,² when Congress created the composite rate in 1983—30 years ago now—they set the same rate for in-center HD, PD, and home HD, to encourage home dialysis. In the new Conditions for Coverage in 2008 (5 years sure flew by!), CMS supported home therapies by clarifying that clinics don't need home certification to teach patients to self-cannulate (a bridge to home HD), adding a mandate to teach patients about all of their options—a change MEI advocated for, and requiring that clinics document why patients are not candidates for home. Provisions of the bundle in 2011 also support PD, at least. Why? Because training costs are less than for home HD, since PD training requires so little time, and PD patients use fewer drugs. PD is much cheaper than standard in-center HD and clinics make more money on it.

Back to US home dialysis goals. We don't have any!

When Fistula First set goals for increasing use of AV fistulas (and reducing HD catheters), developed key principles for change, and involved a multidisciplinary working group—the effort nearly doubled prevalent fistula use from 32.2% in 2003 to 60.4% in 2012.³

According to the 2012 Dialysis Facility Report⁴, 11.4% of US patients are now using some type of home dialysis. This means use of home options has finally recovered to levels last seen in the late 1990s . To illustrate, here are few quick facts I pulled out of the USRDS 2012 Table D.1 (Modalities):

• PD peaked as a percent of all dialysis in 1993, at 14.76%--then slid downhill until 2010, when the rates started to rise.
• Home HD peaked as a percent of all dialysis in 1985, at 6.72%, hit bottom in 2002, at 0.56%, and are now back up to 1.7%.⁴
• All home dialysis topped 15% for 11 years, and was >10% for 17 years.
• Home HD was > 2% of all dialysis for 12 years.

At the Annual Dialysis Conference last winter, I buttonholed a few provider reps and asked them if they'd support a home dialysis target. The answer was an enthusiastic, YES, and some already had internal company goals. When I asked what number they would feel comfortable with, expecting 10% at most, they surprised me by saying 15%.

And, why not 15%, at least to start? In fact, why not 20%? Come on CMS: it's long past time for a Home Dialysis Breakthrough Initiative.

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References

1. Jayanti A, Wearden AJ, Morris J, Brenchley P, Abma I, Bayer S, Barlow J, Mitra S. Barriers to successful implementation of care in home haemodialysis (BASIC-HHD):1. Study design, methods, and rationale. BMC Nephrol. 2013 14:197
2. http://www.nephrologynews.com/articles/congress-and-cms-remove-major-disincentives-to-home-dialysis
3. Prevalent AVF Use By Network, July 2003 – April 2012. www.Fistulafirst.org, accessed 10/20/2013
4. http://www.dialysisreports.org/pdf/esrd/public/SampleReport.pdf