Nephrology News & Issues
The potential for home therapies
by Mark E. Neumann
The explanations as to why the use of home therapies has not shown significant progress in the last decade are varied––a lack of physician education and comfort with prescribing the therapy, inadequate funding for patient training, a lower monthly capitated rate for physicians compared to in-center care, supply shortages, lack of competition in machine offerings, and poor patient selection/burnout/technique failure that sends patients from home to in-center are some of the explanations given. The Centers for Medicare & Medicaid Services has attempted to incentivize providers by starting treatment payments early when patients get dialysis at home.
There are some encouraging signs: according to Nephrology News & Issues’ annual dialysis provider survey (latest data reported: May 2016), the number of PD patients increased from 34,067 at the end of June 2013 to 41,624 at end of June 2016, a 22% increase, while HHD increased from 5,783 to 6,932 a 20% increase over the same time period. 1 But the in-center-patient population also grew, from 330,865 in 2013 to 380,892 in 2016, an increase that matches the entire patient population on home therapy in 2016.
Is there a magic number?
With growing research that home therapies offer a better quality of life, reduced reliance on drug therapy, and other clinical benefits, is there any reason why 25% of the dialysis patient population could not be home-bound? Chief medical officers from 13 dialysis providers said they believe it can be done in a special report on home therapy in the February 2017 issue of NN&I. “Clearly the Institute for Healthcare Improvement’s paradigm of the Triple Aim––better outcome, improved patient experience, and sustainable costs––is more likely to be achieved by shifting more patients to home dialysis rather than continuing to build center HD facilities across the country,” wrote Burkart et al. “Countries like Canada, Australia, and New Zealand have lead the way with considerably higher home dialysis penetration for years. These are examples for the US ESRD community to possibly emulate.” 2
Notes Allan J. Collins, MD, and Christopher Chan, MD, in a editorial published in a special supplement on intensive dialysis in the American Journal of Kidney Diseases, “The mix of dialysis modalities needs to be expanded to address clinical and psychosocial issues that patients, their families, and their physicians are facing.” 3
In expanding that mix, peritoneal dialysis therapy, either continuous ambulatory or automated, has a good head start, representing close to 10% of patients opting for home dialysis. It’s a simplier dialysis process and thus easier to train patients on the therapy. But issues to further growth remain. “…These efforts to provide PD to more patients within dialysis organizations continue. At the same time the government’s and CMS’ continued efforts to promote home will require new approaches to remove current and future barriers that are beyond provider control,” wrote Burkart and colleagues in the NN&I article.
Notes Martin J. Schreiber Jr., head of Clinical Affairs for Home Modalities at DaVita Kidney Care in a Seminars in Dialysis article on the potential for PD growth: “The low utilization rate for incident ESRD patients, patient and family burden, and the high technique failure rate are major reasons why PD has not grown consistently and at a greater rate than it has over the last two decades. A PD growth strategy must determine how innovations will provide value for patients deciding to manage their kidney disease at home, lower the burden on patients and families, and improve time on therapy.
“…For PD to grow, there needs to be an increase focus on why PD should be the first therapy and how to extend time on therapy,” he said. 4
If dialysis providers show a concerted effort to increase the use of home therapies, that 25% may not seem so elusive.
1. Neumann M. The largest dialysis providers in 2016: Poised for change. Nephrology News & Issues (30:8) pp. 26-28, July 2016
2. Burkart J, Schreiber M, Hymes J, Schiller B. Peritoneal dialysis growth in the U.S. encounters unexpected hurdles. Nephrology News & Issues (31:2) pp.16-18, 28. February 2017
3. Collins A, Chan C. Intensive hemodialysis: Potential for improving patient outcomes. American Journal of Kidney Diseases (68:5 Suppl 1) November 2016
4. Schreiber M. Changing landscape for peritoneal dialysis: Optimizing utilization. Seminars in Dialysis (30:2) February 2017