February 03, 2020
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Dialysis providers embrace technology to improve home dialysis care

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In 1972, Congress passed legislation to fund the ESRD Program. The result was a shift in how and where dialysis was performed. With a guaranteed payment backed by the federal government, nephrologists joined with investors in opening freestanding clinics across the United States and created the three-times-a-week in-center dialysis model. According to Medicare.gov, there were 6,871 dialysis facilities in the United States at the end of 2016, the most current data available.

Interest in home dialysis, both peritoneal dialysis (PD) and home hemodialysis (HHD), has made a comeback, however, partly fueled by the same government agencies that unintentionally almost killed it with the creation of the ESRD Program.

“We don’t know what the limits are [on how many patients can do home dialysis therapy],” Jeffrey Hymes, MD, chief medical officer for Fresenius Kidney Care and senior vice president of clinical and scientific affairs for Fresenius Medical Care North America, told Nephrology News & Issues. “I think we need to put all our efforts into making home dialysis and transplant more available to patients. We want to take advantage of this moment in time where everyone seems to be pointed in the same direction.”

Vesh Srivatana, MD, director of the PD program at The Rogosin Institute, said connected health can help patients stay on home modalities longer.

Source: The Rogosin Institute

Advancing American Kidney Health

The “moment” Hymes referred to is Advancing American Kidney Health (AAKH), an initiative developed by HHS after President Donald J. Trump signed an executive order in July 2019 directed at improving kidney care. It calls for 50% of new patients starting on home dialysis by 2025. HHS also has set goals for increasing kidney transplants and reducing the incidence of ESRD within the next 10 years.

Hymes cautions there will still be patients who prefer to be treated in the dialysis unit, including those with failed transplants. However, the goals of AAKH may not only lead to more patients dialyzing at home, but also may provide new energy in a specialty in which residencies have gone unfilled across the United States.

“I think the most rewarding patients I see are home dialysis patients who manage their dialysis care well and then receive kidney transplants at a high frequency,” Brent W. Miller, MD, the Michael A. Kraus Professor of Medicine, and clinical chief of nephrology at Indiana University School of Medicine, told Nephrology News & Issues.

With the United States producing only about 250 clinical nephrology graduates a year in the setting of an aging population, nephrology could benefit from the push that AAKH presents for home dialysis, he said.

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Tech tools for home dialysis

Dialysis providers had been making progress in increasing the number of patients on home dialysis in the United States before AAKH was announced (see sidebar below). However, emerging technologies, like telemedicine (teleconferencing between patients and dialysis staff) and connected health, are helping clinicians identify patients at risk during home dialysis. Doing so can help the kidney care team anticipate complications sooner.

Martin Schreiber

“Because [telemedicine] is an investment, you want to apply it to patients who benefit the most — the high-risk and the rising-risk patients,” Martin Schreiber, MD, director of home modalities for DaVita Kidney Care, told Nephrology News & Issues. Schreiber said DaVita, through its Home Dialysis Connect system, has had more than 15,000 patients using home remote monitoring, with 4,700 currently in the program.

Applying new technologies to dialysis patient care has the support of HHS and Medicare as well. Congress approved new provisions in the Bipartisan Budget Act of 2018 that expanded telemedicine options for patients on home dialysis. Medicare began paying nephrologists for telehealth visits in 2019 and recognized a patient’s home as an acceptable location. Previously, a patient had to go to an authorized medical facility to take part in a teleconference.

Improved adherence

Clinicians have looked at ways technology can be used to improve retention, but nephrologists like Schreiber and Vesh Srivatana, MD, director of the PD program at New York-based home dialysis provider The Rogosin Institute, believe connected health can keep patients on dialysis longer. Srivatana uses the Sharesource connectivity program developed by Baxter to remotely connect with patients. He can check clinical indicators after patients dialyze and intervene by changing the prescription remotely from his clinic when needed.

“We can identify patients who are at high risk of complications and develop a plan to address it before it occurs,” Srivatana told Nephrology News and Issues. The Rogosin Institute has almost 150 patients on PD in four of its centers.

Srivatana said patients have shared positive feedback about having their health more closely monitored and it allows nephrologists to be more transparent by sharing information between physician and patient. He detailed a case study of a young patient who was on PD with a cycler and had a busy schedule of work and classes.

“We were getting notices through the Sharesource portal that the treatments were not being completed,” Srivatana said.

After discussions with the patient, the staff were able to modify the prescription remotely, so the patient was able to do long or short treatments as his schedule allowed. Srivatana said the patient returned to daily treatments.

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“It is a good example of how telehealth gives us a lot more flexibility in tailoring treatments for patients than we had in the past,” Srivatana said.

Schreiber presented results of a study at ASN Kidney Week in 2019 on the use of home remote monitoring (HRM) for a group of high-risk PD patients to determine if it reduced the occurrence of peritonitis and lowered hospitalizations. Patients deemed at high or rising risk for hospitalization or dropout included patients new to dialysis and to PD; patients with early peritonitis; patients with depression or high social demographic burden characteristics, and patients with new or worsening comorbidities. The DaVita researchers designed algorithms for the biometric values they wanted to track, including blood pressure, weight and temperature. The study began in April 2017 and more than 12,000 high-risk patients on PD received HRM.

“More than 1 million data points have been collected to date,” Schreiber wrote. “Metrics tracked during implementation included patient enrollment rate, consistency of patient data transmission and speed of alert resolution by the care team. Adoption metrics were assessed by program, along with hospitalization rates and mean time on therapy,” according to the abstract.

Researchers plan to continue the remote monitoring of the high-risk patients in the study and improve adherence and adoption of HRM into clinic workflow, Schreiber said.

Fine-tune prescriptions

Jeffrey Hymes

Fresenius Medical Care North America launched its connected health platform called TheHub in October 2019 to help kidney specialists connect with patients at home. The platform has three applications that enable patients, care teams and providers to better collaborate and monitor patient treatments.

“This best-in-class solution offers a technology hub that improves the experience for patients and the entire care team,” Jeff Burbank, Fresenius’ chief strategy and transformation officer, said in a release at the launch. “The simple and streamlined experience supports our effort to advance and accelerate the adoption of home therapies while ensuring our patients stay well connected to their care teams.”

TheHub has three applications. The PatientHub allows patients to stay connected with their care team and submit daily treatment data, access lab results and medications, message the dialysis staff, order home dialysis supplies and access a community that offers peer-to-peer support. The CareTeamHub enables home therapy nurses to monitor patients and offer clinical decision support, allowing the care team to catch potential issues earlier and intervene. The ProviderHub offers physicians and advanced practitioners convenient, real-time access to medical records from their device of choice, whether a phone, tablet or laptop/desktop. The application makes it easier to create notes, track visits and sign orders, Burbank said.

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Hymes said the Hub-derived data is “invaluable for monitoring a patient’s status and making adjustments to patient prescriptions.”

Fresenius said more than 15,000 patients have visited the PatientHub, submitting more than 2 million flowsheets and 17,000 supply orders. More than 3,000 nurses have used the CareTeamHub to triage more than 1 million daily treatment data records, and more than 2,000 providers have used the ProviderHub, with more than 1 million rounding notes submitted.

“There are a lot of things that will continue to advance home therapies, both for PD and HHD,” Joe Turk, president of Home and Critical Care Therapies at Fresenius Medical Care, said. “Connected health and telehealth are essential to make home [dialysis] easier and to improve the connection between the patient and the caregiver.”

Artificial intelligence

Brent W. Miller

Care models can use artificial intelligence to predict medical complications and prescribe corrective treatment before costly care is needed. In November 2019, Cricket Health Care released a white paper on how artificial intelligence could be used to develop predictive treatment models for chronic kidney disease care.

“These models use claims data only to predict eGFR with a high degree of accuracy — no EHR or lab data is required to make a prediction,” the company noted in the paper’s executive summary.

In a study presented at ASN Kidney Week in 2019, artificial intelligence helped create a predictive model to track the risk of peritonitis on a monthly basis for the PD population treated by Fresenius Kidney Care. Home visits for patients were scheduled within the first 30 days, and patients on dialysis received a phone call between 30 and 90 days. Researchers used a predictive model to segment 10% of patients into high-, medium- and low-risk groups. High-risk patients had a home visit, and medium-risk patients received a phone call. Researchers created an assessment in February 2018 to track specific interventions. Overall, researchers made 14,000 phone calls and more than 7,000 home visits based on risk assessment. The researchers noted the result was reviews of infection control, home environment or equipment.

“Integrating artificial intelligence into clinical decision support allows us to intervene with the right patient at the right time for the right reason,” they concluded. “Future work must be conducted to improve the model to include additional reasons for intervention such as psychosocial or educational needs.”

Buy-in from nephrologists

Joe Turk

Hymes said artificial intelligence, together with connected health tools, will help the kidney care community reach the goals of AAKH. He acknowledged a key influence is the nephrologist.

“We have heard for many years that nephrologists aren’t comfortable with home dialysis,” Hymes said.

In addition to improved education efforts, Fresenius Kidney Care has launched its Home Champion program, enlisting physicians who are home dialysis advocates to become mentors.

“We vetted them carefully ... it is a job that has substance to it,” Hymes said.

Making nephrologists feel more at ease with prescribing home dialysis may come with “smart” machines that make treatments easier for patients. Advances in connected health can not only deliver more real-time clinical information during the treatment but can offer nephrologists more face-to-face time with patients — even if it is a “virtual” visit.

“I have often told my patients and their families that my goal is to transform ESRD into an annoyance from a disaster,” IU Health’s Miller wrote in an article for Nephrology News & Issues in February 2019. “Home dialysis is one strategy for this. Adding telehealth lessens that annoyance.” – by Mark E. Neumann

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Disclosures: Burbank, Hymes, Turk, Miller, Schreiber and Srivatana report no relevant financial disclosures.