KANSAS CITY, Mo. — The Advancing American Kidney Health goal of placing 50% of new patients who need renal replacement therapy on home dialysis by 2025 is achievable and may be the right thing to do, but questions about cost-effectiveness, the likelihood of improving patient outcomes and concerns about the limits that such a goal may place on patient choice need to be answered, two nephrologists debated at the Annual Dialysis Conference.
It’s [about] us ... It’s not the system. It’s not the government. This is about providing good patient care,” Brigitte Schiller, MD, chief medical officer at Satellite Healthcare, said in defense of the goal, which is one of three initiatives set forth in Advancing American Kidney Health introduced by President Donald J. Trump last July.
Reaching that 50% goal will place a burden on the ESRD Program’s current support system, Schiller acknowledged, including the training of more than 3,400 new home dialysis nurses, according to Schiller’s research. Only four other countries — Mexico, Hong Kong, Australia and New Zealand — have reached the 50% mark for home dialysis. Citing a recent paper she co-authored (Abra G, et al. 2020), Schiller said some policy changes and new programs will need to be developed in alignment with the Advancing American Kidney Health to achieve the goal in the US.
Part of the obstacle to increasing the home dialysis population in the United States is that not all patients know it is an option. “If we give the patient the right information, 50% would choose home,” Schiller said. “When you ask doctors and nurses what therapy they would choose for themselves, they all say home therapy. We, as professionals, are responsible for prescribing the therapy that we would want for ourselves,” Schiller said. Satellite Healthcare did a survey among its doctors and nurses in 2010, Schiller noted. “Less than 5% said they would choose in-center dialysis,” she said.
There are a number of strategies to help the community reach the home dialysis goal. Schiller stressed the importance of all stakeholders in the ESRD care community including physician training programs, providers and manufacturers aligning for successful implementation of increased home dialysis delivery.
“Patient-centric care should be our focus, but right now it is provider- and physician-centric,” she said. “More needs to be done ... It’s not impossible. Everyone in this room will make it possible.”
However, results are inconclusive that both peritoneal dialysis and home hemodialysis offer better outcomes than in-center care, and are more cost-effective for payers, countered Jay Wish, MD, chief medical officer for dialysis at Indiana University Health. Patients may prefer in-center care because “they decide they like the social environment of the dialysis clinic,” Wish said. While costs for PD are lower than for patients treated with in-center dialysis, “PD costs have risen significantly in recent years,” Wish noted. “Higher costs are attributed to inputs, such as supplies and equipment, and limited competition among suppliers.”
In addition, costs for hemodialysis at home are usually based on Medicare payments for three to four treatments per week — the fourth being a treatment payment that must be negotiated by the provider. “If patients are receiving five to six [home hemodialysis] HHD treatments/week, costs are considerably higher and exceed in-center care,” Wish said. Financial incentives have been in place for physicians to place patients on home dialysis since CMS bundled the dialysis payment in 2011, and home dialysis’s presence in the marketplace, while improving, still remains around 12% overall in the United States, he said.
Finally, noted Wish, directing 50% of new patients to home therapy limits their choice of modalities and may force patients who are ill-equipped to handle dialysis on their own. “For many patients, they may be in fear about doing the treatment themselves. Only about 60% of patients have seen a nephrologist before dialysis treatment options are presented,” Wish said. Patients may feel the home environment is not sterile enough, large enough or appropriate for maintenance or storage of items, he said.
Schiller acknowledged that meeting the 50% goal “will be hard,” but believes it is the right approach for patients. “We have been waiting for this for so long. This is an incredible opportunity for us to do the right thing,” she said. “We should do what is best. We are in health care.”
“Magic happens outside of our comfort zone; all this requires is that you have an open mind. Like a parachute, it works better when it is open than when it is closed,” she said. – by Mark E. Neumann
Schiller B and Wish J. Targeting 50% of ESRD patients for home dialysis: Is this a reasonable target? Presented at: The Annual Dialysis Conference; Feb. 7-11, 2020; Kansas City, Missouri.
Disclosures: Schiller and Wish report no relevant financial disclosures.