Fifty years ago home hemodialysis (HHD) began in the cities of Boston and Seattle and in London, England. HHD started because its lower cost would enable more patients to be treated, and the many benefits for patients soon became obvious. Six months after the start of the Medicare ESRD Program in 1973, 32.2% of the 10,306 U.S. dialysis patients were on home hemodialysis. Home hemodialysis as a percentage of all dialysis patients declined steadily after that for many reasons, reaching a low of 0.57% of the dialysis population in 2002. Since then it has gradually increased and by 2011 had grown to 1.3%. At that time 11 other countries had a higher percentage of patients on home hemodialysis, ranging from 1.5% in Hong Kong to 18.2% in New Zealand.
How to make it work
Experience in the United States and elsewhere has shown that a successful home hemodialysis program requires dedicated nurses and other staff selected for their teaching abilities, knowledge, and commitment to the therapy; space separate from the in-center dialysis area for training, and a minimum of about 10 patients starting the therapy each year. Telephone back-up support from a training nurse must be available 24 hours/seven days a week, technical service backup either from the unit or contracted out to a supplier must also be available, together with an efficient system for delivery of supplies to the home.
If at all possible, new patients must be educated about home dialysis ahead of time (see discussion of the value of early patient education from the CMO Group starting on page 19) and ongoing education should be carried out with patients dialyzing in the center. Medicare reimbursement for home hemodialysis training has been inadequate since the start of the Medicare ESRD program and even now is still insufficient to cover the actual costs of training. The break even point in a home hemodialysis training program usually is considered to be somewhere between 10 and 15 patients established at home. Finally and most importantly, a home dialysis training program should have a physician champion to direct the program.
Modality options, modality choices
From the beginning, the Medicare ESRD program has required new patients be informed about all modalities of treatment, including home dialysis and kidney transplantation and, more recently has required this information be made available to all dialysis patients annually. If a patient wants to consider home dialysis and the facility does not offer training, the patient should be told where this can be obtained. Even so, with some 6,000 dialysis units in the U.S. and close to 90% of patients been given in-center care, it is obvious that the vast majority are not able to provide an effective home dialysis training program. If, however, training was regionalized and support could be provided at a high level for large and small providers, there would be a benefit. In the 1980s, Northwest Kidney Centers had been running a very successful regional home dialysis program covering Western Washington, Montana, and Alaska for some 15 years. The success of the program showed that home hemodialysis training could be regionalized in the same way that kidney transplantation was regionalized.
Today, with increasing interest in home hemodialysis, such an approach would seem obvious. For large dialysis organizations like Fresenius, DaVita, and Dialysis Clinic Inc. it would be relatively easy to do this by designating their own regional centers in appropriate places. For smaller organizations and individual units, regional training programs could be established to serve a number of national providers and local dialysis units in a cooperative fashion. Suitable patients would be referred by their nephrologist to the regional center for assessment and training and following completion of training would go home and continue to be followed by the training unit for home dialysis-related problems whole continuing their medical care through their original referring nephrologist. Backup dialysis thereafter could be provided by their local dialysis unit or if the problem related to home hemodialysis the patient could return to the regional unit.
The possibility of developing such an approach to increase access to home hemodialysis needs to be brought to the attention of nephrologists, unit administrators, dialysis organizations, the ESRD program and other governmental agencies as well as to the many dialysis units not affiliated with a large organization. Until such an approach is developed, home hemodialysis in the U.S. will continue to be provided by only three or four percent of dialysis facilities, most of which are primarily related to universities and other larger institutions.