Brent W. Miller
KANSAS CITY, Mo. — The nephrology community will need to make major changes in how it approaches home dialysis to meet Advancing American Kidney Health goals for the modality by 2025, according to a keynote speaker at the Annual Dialysis Conference.
“The goal is to see if we can change clinical outcomes with policy,” Brent W. Miller, MD, said. “I think at this stage the answer is no. As much as I think it is the right thing to do, ... it will be difficult to achieve.”
Miller’s keynote was part of a day-long symposium on home dialysis that included debates and discussion about achieving the Advancing American Kidney Health goal, which requires nephrologists and dialysis providers to start 80% of new patients on either home dialysis or have a functioning kidney transplant by 2025.
Miller, the Michael A. Kraus Professor of Medicine and clinical chief of nephrology at Indiana University School of Medicine, cited a number of issues he said need to be resolved to reach the Advancing American Kidney Health goal, including persuading more nephrologists to champion home therapies and identifying ways to increase the number of dialysis nurses interested in caring for home patients. Although increases were seen in the number of home patients after CMS instituted the bundled payment system in 2011, which Miller said made home dialysis care more lucrative, he said he was also pessimistic that a government-directed approach that simply adds financial incentives will be successful.
“The tool we have been given is an economic tool; there is a punitive side and a reward side to it,” Miller said. “I’m not sure that will be effective.”
The goal of having 50% of patients start dialysis at home in the next 5 years will be difficult based on historic growth records for home dialysis, Miller said.
“For peritoneal dialysis, 15% is the most we have ever been able to do,” he said. Home hemodialysis, now around 3% of the patient population, could rise to around 6%, Miller suggested. “So, at our best, we can get to 21% of home dialysis.”
He added, “With best practices, we need to figure out how we can more than double that number. Think of anything that you have to do two and half more times better than you do right now. When I walk my shift [at the dialysis clinic], I don’t know if I can look at my patients and determine how 50% will have to move to home dialysis over the next 5 years. I worry about that.”
If practitioners succeed at moving patients from in-center to home dialysis, the next step would be to retain them on the modality.
“Dropout rate due to technique failure [for patients on PD] is about one in five,” Miller said. “We will have to up our game, particularly as we expand our intake” and add more patients who may not be best suited for the therapy, he said.
Finally, he said financial incentives for nephrologists need to change.
“From a nephrologist’s point of view, the most profitable thing is a patient who is in center with an advanced practitioner provider. That has to be fixed,” Miller said. - by Mark E. Neumann
Miller, BW. Is change in policy sufficient to attract 50% of patients to be on home dialysis? Presented at: The Annual Dialysis Conference; Feb. 8-11, 2020; Kansas City, Missouri.
Disclosure: Miller reports no relevant financial disclosures.