Home as the First Site of Care for Managing End Stage Renal Disease
Over the past decade, several countries around the world have embraced home dialysis as a preferred initial therapy for managing kidney failure in clinically appropriate patients (those for whom home dialysis is an appropriate choice). This approach has been fueled by advocacy by nephrologists and health economists and the general industry seeking access to dialysis. Within the United States, nephrology practices are experiencing an upward shift in acceptance of home as an initial site of care for managing end stage kidney disease. The factors responsible for this shift may include the move from a fee-for-service health care payment system to value-based health care (achieving better outcomes and reducing dollars spent), emerging telehealth innovations, avoidance of tunneled central venous catheters (CVCs), focus on Medicare beneficiary engagement in dialysis modality option decisions and a continued realization that preserving residual renal function benefits mortality rates.
The essence of home dialysis as an initial therapy (for clinically appropriate patients), in today’s health care environment, acknowledges the following three core tenets:
- Home as the site of care has a positive impact on how a patient responds to chronic disease management
- Available telehealth technology (such as remote monitoring, video chat and messaging) can increase the sense of connection and personalization for patients caring for themselves at home
- Recognizing that residual renal function preservation matters and avoiding tunneled CVCs is critical to a patient’s survival
Encouraging home as the initial site of care for clinically appropriate patients requires a shift from a one-option-cures-all mentality toward dialysis (i.e., in-center hemodialysis) to a more-personalized ESRD approach built on dialysis education and informed modality choice. Just as physicians change treatment regimens to achieve the best disease management outcomes for patients with diabetes, hypertension, congestive heart failure or asthma, they should pursue this same strategy for ESRD patients. The main steps to consider in developing a more patient-centric approach for a medical practice include:
- Constructing the list of treatment options to be considered by the patient
- Deciding on the one current treatment that aligns best with the patient’s current clinical status
- Deciding ahead of time with the patient which clinical quality markers would result in a transition to an alternate option
Education sessions play a key role in helping patients attain the comfort and confidence to choose home dialysis if it best fits their needs. In addition, it’s never been more important for nephrologists to work with their patients to jointly select the best dialysis modality (following CMS’ proposed shared decision making (SDM) model). Nephrologists continue to play a key role in dialysis selection.
The importance of treatment sequence
Consequences and complications from a treatment modality can limit the success of future treatment options—whether for alternative dialysis modalities or transplantation. The initial treatment modality plays a key role in quality outcomes and survival for the patient. The most appropriate initial and subsequent treatment selection should match the patient’s unfolding clinical course. If the current therapy is not lowering risk (related to concerns for CVC rates, residual renal function, left ventricular hypertrophy, blood pressure, phosphorous, ultrafiltration rates and vascular access preservation) patients will potentially experience an increase in their morbidity or mortality rate. During clinic visits or integrated dialysis team rounds, the care team should identify patients who have reached a transition point that warrants an alternate modality. The sequencing of these treatment options is critical to potentially lowering risk and preserving future treatment options, but it all begins with the initial modality selection.
Home as an initial therapy (when clinically appropriate) captures the essence of what Stephen R. Covey so aptly wrote in the 7 Habits of Highly Effective People: For every day, task or project, “begin with the end in mind.” In other words, with ESRD, begin with the optimal outcome in mind. Selecting the correct initial option is not important for only today but also for tomorrow. Practices should ensure the infrastructure is in place to educate patients, help patients make informed choices, develop capacity to build an urgent-start program to avoid tunneled CVCs and champion a dialysis therapy approach with the goal of achieving the longest-lasting quality outcomes.