Home dialysis options are significantly underutilized in the U.S.—plagued by low start rates and high attrition rates, especially during the first six months of use. As the U.S. faces rising rates of kidney disease and rising costs nationwide, the U.S. government seeks to improve and increase home dialysis as a treatment option. 

In an effort to encourage and facilitate this transition, researchers at the University of Alabama at Birmingham (UAB) developed and implemented a program designed to address the major barriers to home dialysis utilization.*

What barriers are there for home dialysis?

Some of the barriers of effective and widespread home dialysis use include:

• inadequate dialysis education for both patients and nephrologists;
• lack of a cohesive, organized team of trained and available staff to troubleshoot issues and provide appropriate care; and
• inadequate infrastructure to support home dialysis patients. 

Education 

Research reveals that both patients and nephrologists feel undereducated about home dialysis options regarding their benefits and drawbacks, and the actual practical workings.

Patient education

Insufficient pre-dialysis education has prevented many patients from choosing home-based dialysis methods. Most patient pre-dialysis education provides a brief description of in-center and home modalities and a few basic advantages and disadvantages of each. It doesn’t account for individual circumstances or preferences. As a result, many patients feel ill-equipped to have an informed say in their own healthcare decisions.

The UAB team found a more effective approach involving an organized program comprised of the following:

1. Attend an initial group session in the nephrology clinic, in which all dialysis options (and kidney transplants) are explained. A mannequin, catheter, and dialysis machine prototype are available at the clinic for a demonstration of peritoneal dialysis (PD).
2. Attend bimonthly education classes that are 45- to 90-minutes long and taught by a nurse practitioner.
3. Hold Q&A sessions with patients already on dialysis, whether in-center or at home.
4. Have one-on-one sessions with an educator regarding personal preferences and individual factors, such as age, familial support, occupation, and transportation, among others
5. Go on guided visits to both in-center and home-based hemodialysis (HD) units.
6. Provide reading materials, videos, and other audio-visual resources.

Nephrologist education

Nephrologist training has also fallen short. A 2010 study found that only 55.6% of recent nephrology graduates felt well-trained and competent in home-based peritoneal dialysis—dropping to 15.8% for home HD.

The study further revealed that nephrology trainees in the U.S.:

• are not trained using a structured home dialysis curriculum;
• have limited home dialysis exposure and hands-on training; and
• are not trained in continuity of care for home dialysis patients. 

The UAB program established a comprehensive, structured curriculum for nephrology trainees that includes:

• supervised, dedicated rotations for home dialysis; 
• extensive exposure to patients; and
• special attention to dosing, troubleshooting, and volume management. 

UAB also holds an annual 2.5-day course, called Home Dialysis Academy, which is usually attended by 40 to 50 trainees.  

Team-based approach 

A team-based approach is crucial for providing seamless and effective home dialysis care. Led by a nephrologist, the team must include nurses, access coordinators, nutritionists, social workers, and surgeons. 

Knowledgeable and available professionals are necessary for:

• patient training;
• proper placement of catheters (for PD) and access units (for HD); 
• troubleshooting technical malfunctions and patient issues; and
• assistance with changes in home situations and continuity of care. 

Unfortunately, this ideal has been hindered by:

• expectations of a high patient-to-nurse ratio;
• 24-hour patient call coverage; and
• lack of availability of surgeons to ensure proper catheter and accent unit placement, both at outset and after equipment malfunction.

UAB addressed these issues through:

• cross-training; 
• flexible scheduling for nurses, enabling them to spend more time with each patient to individualize care; and 
• cohesive teamwork that allowed for rotations and substitutions of well-informed, competent staff.

Infrastructure

Improved and innovative technology has made it possible for healthcare teams to provide better care for home dialysis patients, such as:

• digital remote patient monitoring;
• 24/7 patient telehealth access to their home dialysis team; 
• more frequent home visits; and
• training in, and utilization of, “urgent start” dialysis protocols for when dialysis is unplanned but necessary.

The experimental program proved successful in increasing and sustaining home dialysis use in microcosm, and it provided a model that encourages more people nationwide to choose home dialysis.

*Ahmad, M., Wallace, E.L., Jain, G. (2020, May 1). “Setting up and expanding a home dialysis Program: Is there a recipe for success?.” Kidney360.