Seventy-five percent of patients beginning in-center hemodialysis are unaware of the option to dialyze at home, according to a new report in the December issue of the American Journal of Kidney Diseases. Once informed, 40% of patients are interested in this treatment option, and less than 10% actually initiate home dialysis.

"Home dialysis, which allows a patient to maintain a more normal lifestyle, is a very attractive option to many individuals facing the burden of incipient dialysis.  However, many barriers prevent the patient from being offered this key choice," explained Beth Piraino, MD, of the University of Pittsburgh, one of the study’s senior co-authors and President-elect of the National Kidney Foundation, "We intended to focus on these barriers, which can be overcome through the collective coordinated action of dialysis organizations, the nephrology team and the government, all striving to ensure that the patient is educated and afforded proper options and is at the center of this process."

The researchers categorized the barriers to home dialysis into three groups: inadequate education, faulty regulation and provider philosophy and practice. 
 
Inadequate education
Patients are often unaware of their options and nephrologists are inadequately educated regarding home dialysis, according to the report. In addition, dialysis staff are often insufficiently informed and are unable to provide accurate information regarding the option of home dialysis and appropriate care and sufficient support for patients undergoing home dialysis. 

Flawed regulations
A number of government policies stymie the possibility of widespread home dialysis.  "These regulations are generally systematic rather than fundamental to providing optimal medical care," Piraino said, "They should be reappraised in order to reverse their adverse effects on the option of home dialysis." 
According to the report, regulations that serve as barriers include:

• Patients on home dialysis are inconveniently required to visit the center more often than practically necessary; 

• Patients unable to perform self-care are forced to choose in-center HD, despite the fact that the Canadian and European experiences indicate that home dialysis with home-assistance is more economically efficient for the medical system than providing the same patient with in-center HD; 

• Certification of home-dialysis units is lengthy, often delayed, and involves multiple sets of regulations; 

• The FDA's regulatory process is significantly more protracted than its European counterparts, and therefore many advances in home-dialysis technology which have been available in Europe for years are still not available to American potential home-dialysis patients.   

Provider Philosophy and practice
The policies and practices of dialysis providers make home dialysis less efficient and less attractive to patients. The researchers recommend that a focus on these policies and practices, which are often the result of inattention rather than specific design, can help remedy these issues and make home dialysis more of an option to patients. 

Practices that serve as barriers to home dialysis, according to the report, include:

• Exclusivity contracts and financial considerations that compel some providers to enact restrictive policies on medication and machinery for home dialysis; 

• Delayed, infrequent delivery of supplies to home dialysis programs;

• Subpar services in terms of responsiveness and data processing to  home dialysis patients on the part of dialysis-provider affiliated laboratory services who  favor in-center HD;

• Lack of access to prompt treatment of peritonitis for peritoneal dialysis patients since currently home dialysis programs are not allowed to stock these medications.