It was the theme for a special event at the Annual Dialysis Conference in San Antonio this past weekend, but home dialysis really is about giving people the power to direct their own care.
The event, sponsored by NxStage Medical, added to the home dialysis focused program that the ADC offers each year at its annual meeting.
The conference, which started more than 30 years ago with a primary focus on peritoneal dialysis, has expanded to include a separate program on pediatric care and, for the last 18 years, on hemodialysis.
But it’s the focus on home care that makes the conference unique among the five or six nephrology-directed meetings in the United States each year. Renal providers tout their latest home dialysis programs, and manufacturers offer their best equipment.
Attention to home therapies is needed. Those who dialyze at home make up less than 10% of the ESRD patient population (about 1.6% for home hemodialysis and around 7% for peritoneal dialysis). Despite surveys that show nephrology professionals themselves would chose home therapy if they had renal failure, few of them actually send their own patients home.
PD remains a fledging modality choice, despite the fact that it has been available for more than 30 years. It has become the ‘hot’ modality choice in countries like Thailand, where they have placed over 10,000 patients on PD in the last five years as part of their “PD First” approach to dialysis care. China boasts 80% on PD; Hong Kong is at 74%. Mexico is also a big user.
But countries that expand their PD programs are doing so primarily because of cost (although outcomes have been good). In a country like the United States, where dialysis is offered to everyone and patients are given the option to choose their modality (more on that later), PD use remains scant. It also suffers from a lack of champions – yes, there are dedicated physicians to this modality, but patient endorsement seems limited. It is a modality choice that needs to find that power to reach the next level.
The Medicare program has offered some help. Facilities that put patients on PD from the start get incentivized: payment begins immediately (rather than the 90 day wait for in-center dialysis) and a 51% bonus payment for incident patients is added. It also helps a clinic reduce its reliance on catheters: PD patients don’t get temporary access for in-center hemodialysis. PD also does a better job of preserving residual renal function. So there are lots of ways to jump-start PD.
But home hemodialysis, particularly in short daily or nocturnal form, has become the new kid on the block (although its history goes back to the early days of dialysis). New studies and news about health plans offering their stamp of approval have given the modality a sense of ‘what’s old is new again.” No less than four companies are working on home hemodialysis machines , and the current market leader – NxStatge – is making refinements to its System One. Patients who go home and perform slower, longer hemodialysis say they feel better. They also use fewer medications, and tend to see a hospital bed less often than those who pick conventional in-center treatments.
Many are younger – and have commercial health plans. So providers get paid more. But the incentives offered by Medicare to providers for sending patients home should help level out the economic playing field.
Based on the presentations made at the meeting, there are several key components to making home the place to be for more dialysis patients.
- Modality education. Many patients are not being informed about choices beyond in-center hemodialysis therapy. New requirements set by Congress and CMS make modality options education mandatory.
- Building programs that will succeed. Whether it is PD or HHD, larger programs with a dedicated staff will have the best outcomes.
- Better medical education. Fellows are not being taught about modality options beyond conventional in-center hemodialysis and transplant. The renal community is doing a disservice to thousands of individuals diagnosed with kidney failure when they don’t make it clear what options are available.
- Respite care is needed to help with burnout. Patients who go home save providers and the Medicare system thousands of dollars by requiring less staffing, staying healthier, and staying employed. When they need a break, give them a place to go.
Power to the Patients means they need to be at the table when it comes to selecting the best therapy for them – for now. That means that their first choice might not be their last. A life plan of treatment choices means a patient may experience multiple therapies over time. That avoids burnout and keeps the patient focused on self-care.
Let’s give them that power.