This past March, chief medical officers of 14 major dialysis providers convened a meeting in Chicago. Physicians Tom Parker (Renal Ventures Management), Doug Johnson (Dialysis Clinic Inc.) and Allen Nissenson (DaVita) initiated the meeting. In attendance were the officers themselves, operations personnel and the president of the American Nephrology Nurses Association. We invited NN&I to cover the two-day gathering.
The spirit of the meeting was to share programs and processes that various providers are using to enhance patient outcomes. A condition of attending was a willingness to share information, even protocols, across all providers. There was, indeed, a widespread sharing of those programs that really make differences in patients’ lives. Everyone agreed to move forward with this open-minded approach; likely, there will be a similar meeting next year to assess progress and advance other programs.
Over the next several months, NN&I will publish a series of reports from the CMOs attending the conference. During the meeting, specific topics were assigned and groups were organized to such subjects as nutrition, sodium and volume, initiation of dialysis, vascular access, and CKD education. These reports summarize the views of each group on how to improve patient outcomes.
Our fourth report in this series is about home therapies and exploring the value of nontraditional models of in-center dialysis, and is prepared collectively by the CMO Group. We welcome NN&I readers to offer their own views so we can continue to dialogue on making dialysis care a better treatment. Send comments to firstname.lastname@example.org.
–– Tom Parker III, MD • Doug Johnson, MD • Allen Nissenson, MD
What is a reasonable goal for the percent of peritoneal dialysis patients within the ESRD population?
The CMO Group agreed that a 20% penetration for PD in the United States is a realistic and desirable goal. Achieving this goal has several requirements:
- The nephrologist must be responsible for modality education, possibly with the support of the dialysis provider. This needs to take place prior to the need for renal replacement therapy (stages 3 and 4 CKD). Patients should be making decisions about the best modality for RRT based on their goals in life without the stress associated with managing their disease. The CMO Group believes this early intervention of modality education is crucial, and nephrologists have not taken this responsibility seriously, defaulting too frequently to in-center hemodialysis.
- Current physician reimbursement, including differing monthly capitated payments for home- vs. in-center dialysis, as well as inadequate payment for training costs, are thought to limit endorsement by nephrologist; however, this should not be an impediment to immediate change. Upcoming shared savings models should consider this as an incentive to solve this issue.
Are stand-alone home programs essential to reaching the 20% goal?
- There should be specific home therapy-centric centers of excellence with dedicated staff, experienced and skilled, in home modalities, not intermingled with the in-center staff. Home therapy staff should not be distracted by having to staff in-center dialysis.
What other opportunities exist to increase the use of PD?
- Novel delivery systems, including “urgent-start” PD for “crash starts on dialysis” and assisted PD delivery in nursing homes, are considered valuable by the CMO Group. The former therapy is a valuable tool for the introduction of PD and this capability should be available in every community. Assisted PD at home for elderly patients would also likely increase use of the therapy and address potential dropout due to the burden of therapy for patients and/or their partner.
Should there be a clinical priority to increase the percent of patients on home hemodialysis? What is the long-term goal?
- Home HD is underutilized in the United States and its penetration should increase. A reasonable target should be around 5% of the dialysis population. Given the superior clinical results, including quality of life, HHD should be promoted.
How do we address financial barriers of growing home hemodialysis?
- Currently, the economics for HHD are a barrier to further penetration. Innovation in developing new equipment is encouraged to lower the burden of care and improve quality of life on dialysis. Training for HHD is on average 3-5 weeks long and costly, both for the provider and the patients. For intensive (more frequent) home hemodialysis it is important that payers (and particularly Medicare) recognize the need and the science supporting reimbursement for more than 3-4 treatments and longer treatments/week. Having to provide medical justification, rather than having frequent therapy at home as a default, is a key issue and will perpetuate resistance to this therapy until it is resolved. Agreement on this payment approach must be uniform among all Medicare administrative contractors. Providers can help by being proactive and increase awareness of the value of this therapy to payers. (Parenthetically, this should also apply to reimbursing for extra treatments for in-center dialysis; streamlining the exception process.). Integrated shared savings models will likely encourage this therapy
How can we do a better job of helping patients start and stay on home therapies?
- A coordinated effort by nephrologists and provider could increase the likelihood of keeping patients dialyzing at home. Patients who are at the end of their PD lifespan should be aggressively pursued for transition to HHD. Such efforts have been successful when driven by nephrologists. A similar concept to urgent PD could make urgent HHD a viable alternative when patients start dialysis unplanned. This should be considered especially in patients transitioning to transplantation. A catheter should not be a hindrance to undergoing HHD; it is better to have a catheter at home, where the infection risk is lower, than a catheter in an in-center HD environment.
Non-conventional in-center dialysis
What are other options to obtaining the benefits of home therapy but in a more structured environment?
- Some providers are offering in-center dialysis shifts with longer treatment times (up to six hours), sometimes in the early evenings. With increasing recognition of the potential risk of standard in-center dialysis due to adverse events associated with large fluid removal in a short period of time, the importance of time spent on HD is increasingly evident. Therefore the metric of keeping the ultrafiltration at a preferable rate of less than 13 mL/kg/h should be part of the prescription of adequate clearance. This should be in addition to a minimum solute removal goal of Kt/V > 1.2. For patients dialyzing more than three times a week, the standard Kt/V should be ≥ 2.0.
- Dialysis shifts that allow greater than 4-5 hours of therapy should be made available in each community. And CMS and state licensing agencies should become aware of the decreased staffing needs in these therapies, thereby changing ratios.
Home dialysis can be a journey to a better quality of life
Doug Johnson, MD
July 4, 2013. Independence Day. The picture above is one of dialysor Bill Peckham on the Colorado River, where he’s both the giver and receiver of the first dialysis treatment in the Grand Canyon in 30 years. I was privileged to be with Bill on this trip. The red can in the picture is champagne (no bottles allowed on the river). This was definitely a champagne-worthy event.
"If I were a patient on dialysis, I would choose to dialyze at home. I would dialyze with peritoneal dialysis to maintain my residual renal function, and would transition to home hemodialysis if I could no longer receive adequate treatment with PD. Most importantly, I would work to get a kidney transplant so that my life would not be limited by dialysis."
When Bill was a teenager, he passed on an opportunity to raft through the Grand Canyon, believing that this dream could wait a little longer. He did not imagine that his kidneys would fail, and his dream would appear to be permanently out of reach. However, Bill would not allow a temporary setback (or a chronic condition) to deter him, and so here he was on an eight-day rafting trip through the Grand Canyon that included three dialysis treatments. Twenty-three years after starting dialysis, he was finally living his dream.
Not everyone wants to raft down the Colorado River. But everyone does have dreams, and goals for how they hope to live. To me, our job in caring for patients is to make it as likely as possible that they can live the life they want to live, and experience their dreams, without having dialysis treatment get in the way. In my opinion, if more people were able to dialyze at home, they would be more likely to live the life they want to live.
If I were a patient on dialysis, I would choose to dialyze at home. I would dialyze with peritoneal dialysis to maintain my residual renal function, and would transition to home hemodialysis if I could no longer receive adequate treatment with PD. Most importantly, I would work to get a kidney transplant so that my life would not be limited by dialysis.
I struggle with the knowledge that, in the United States, less than 10% of our patients dialyze at home. Among DCI patients, the number is 11% and increasing. I know as a company we can do better. Below is a summary of our strategies to empower more patients to choose to dialyze at home.
Talk about choices early. First, we need to talk with patients early about their choices in care, including home dialysis. Once a patient makes this selection for care, we should help the patient navigate the system to implement this choice. We call this process CKD care coordination, and provide this service in 17 communities to over 1100 patients. Our model program is in Spartanburg, S.C. In 2012, 42% of our new dialysis patients there received CKD care coordination; 24% started dialysis at home.
Incident patients going home. We will also work intensively with patients during their first 120 days to enable them the opportunity to choose home dialysis. We have also started urgent start programs in a few locations with encouraging initial outcomes; many other locations are hoping to join. We anticipate that 24% of patients receiving intensive choices education will select home therapy within 120 days of starting dialysis. Initial results from our programs are encouraging. For all DCI patients who started in 2013, more than 14.5% were dialyzing at home within 120 days.
ACOs and home dialysis. The accountable care organization model provides a unique opportunity to implement innovative practices to encourage home therapy. DCI submitted three applications for the upcoming Comprehensive ESRD Care model. If approved, we look forward to implementing unique strategies to empower our patients to choose home therapies. If our interventions are successful, we hope to implement them in other communities served by DCI.
Bill Peckham’s destination isn’t for all dialysis patients. But each should have the opportunity to direct and map out his or her own journey. Home dialysis can help.
Dr. Johnson is vice chairman of the board of directors of Dialysis Clinic Inc., based in Nashville, Tenn.