In the Journals

Article identifies solutions to increase PD use in the United States

In an editorial, researchers proposed potential solutions to increase peritoneal dialysis use in the United States that focused on social/educational, clinical and financial factors.

Erin P. Flanagin, MD, of Tufts Medical Center in Boston, and colleagues wrote that due to Advancing American Kidney Health, expanding treatment options for patients with kidney failure has become a priority in the United States. They argued that if, as the initiative calls for, 80% of new patients with ESRD are to be treated with home dialysis or transplantation by 2025, PD use will need to increase significantly (as transplantation currently accounts for approximately 30% of patients, home hemodialysis for 2% and PD for 10%).

“Many reasons exist to promote wider uptake of PD, emulating many nations with developed economies in which home dialysis use is two- to three-fold higher than in the United States,” they wrote. “Patient experience and satisfaction with care appears equivalent or better with PD vs. in-center HD.” They added that PD mitigates adverse outcomes related to catheter use in hemodialysis, and that comorbid conditions may be better managed.

Due to these benefits of PD, they examined barriers and came up with some solutions to increase use They touched on social and educational factors, arguing that both patients and their health care teams should be knowledgeable about treatment options, as patients who are educated before dialysis initiation are more likely to choose home dialysis (currently, they wrote, only one-third of incident dialysis patients are told about all treatment options available). In addition to providing patient-centric education pre-dialysis, the researchers suggested that because socioeconomically disadvantaged populations have a “outsized burden” of kidney disease, they should be supported with home visits for assisted PD soon after initiation, as well as remote monitoring applications.

Doctor talking to patient 
Researchers proposed potential solutions to increase peritoneal dialysis use in the United States.
Source: Adobe Stock

The researchers also wrote the primary clinical barrier to PD is “the lack of a functioning peritoneal membrane.” As it is often difficult to predict which patients will transfer to hemodialysis, it is important to determine the causes of transfer to help reduce the need for transition or to provide earlier interventions to aid in a safer transition. Furthermore, they suggested many care providers (in hospitals or other facilities) lack expertise in PD and, therefore, do not provide it as an option. According to the researchers, education and training on PD, as well as on discussing it with patients and their families, should be a priority.

Finally, they contended that the financial incentives currently in place encourage use of hemodialysis instead of PD. Therefore, the existing payment structure should be modified to incentivize PD “by equalizing physician payments for in-center and home care supervision,” while also increasing reimbursement for home dialysis, incentivizing surgeons for successful PD catheter placement and ensuring home dialysis supplies are “fairly priced.”

“Increasing the use of PD requires broad changes in knowledge, infrastructure, and incentives,” they concluded. “Patients, family members, nephrologists, and non-nephrology providers must be aware of PD, recognize advantages associated with PD, view potential barriers as surmountable, and support the uptake and, critically, maintenance of PD. Financial incentives must be appropriately aligned to promote PD uptake and maintenance, with support for assisted PD and PD in settings outside the home.” – by Melissa J. Webb

Disclosures: Flanagin reports no relevant financial disclosures. Please see the article for all other authors’ relevant financial disclosures.

In an editorial, researchers proposed potential solutions to increase peritoneal dialysis use in the United States that focused on social/educational, clinical and financial factors.

Erin P. Flanagin, MD, of Tufts Medical Center in Boston, and colleagues wrote that due to Advancing American Kidney Health, expanding treatment options for patients with kidney failure has become a priority in the United States. They argued that if, as the initiative calls for, 80% of new patients with ESRD are to be treated with home dialysis or transplantation by 2025, PD use will need to increase significantly (as transplantation currently accounts for approximately 30% of patients, home hemodialysis for 2% and PD for 10%).

“Many reasons exist to promote wider uptake of PD, emulating many nations with developed economies in which home dialysis use is two- to three-fold higher than in the United States,” they wrote. “Patient experience and satisfaction with care appears equivalent or better with PD vs. in-center HD.” They added that PD mitigates adverse outcomes related to catheter use in hemodialysis, and that comorbid conditions may be better managed.

Due to these benefits of PD, they examined barriers and came up with some solutions to increase use They touched on social and educational factors, arguing that both patients and their health care teams should be knowledgeable about treatment options, as patients who are educated before dialysis initiation are more likely to choose home dialysis (currently, they wrote, only one-third of incident dialysis patients are told about all treatment options available). In addition to providing patient-centric education pre-dialysis, the researchers suggested that because socioeconomically disadvantaged populations have a “outsized burden” of kidney disease, they should be supported with home visits for assisted PD soon after initiation, as well as remote monitoring applications.

Doctor talking to patient 
Researchers proposed potential solutions to increase peritoneal dialysis use in the United States.
Source: Adobe Stock

The researchers also wrote the primary clinical barrier to PD is “the lack of a functioning peritoneal membrane.” As it is often difficult to predict which patients will transfer to hemodialysis, it is important to determine the causes of transfer to help reduce the need for transition or to provide earlier interventions to aid in a safer transition. Furthermore, they suggested many care providers (in hospitals or other facilities) lack expertise in PD and, therefore, do not provide it as an option. According to the researchers, education and training on PD, as well as on discussing it with patients and their families, should be a priority.

Finally, they contended that the financial incentives currently in place encourage use of hemodialysis instead of PD. Therefore, the existing payment structure should be modified to incentivize PD “by equalizing physician payments for in-center and home care supervision,” while also increasing reimbursement for home dialysis, incentivizing surgeons for successful PD catheter placement and ensuring home dialysis supplies are “fairly priced.”

“Increasing the use of PD requires broad changes in knowledge, infrastructure, and incentives,” they concluded. “Patients, family members, nephrologists, and non-nephrology providers must be aware of PD, recognize advantages associated with PD, view potential barriers as surmountable, and support the uptake and, critically, maintenance of PD. Financial incentives must be appropriately aligned to promote PD uptake and maintenance, with support for assisted PD and PD in settings outside the home.” – by Melissa J. Webb

Disclosures: Flanagin reports no relevant financial disclosures. Please see the article for all other authors’ relevant financial disclosures.