Potential Advantages with a Large Peritoneal Dialysis Program

Clinical results can greatly vary among peritoneal dialysis (PD) programs for patients with end stage renal disease (ESRD). Often smaller PD programs (ranging from 6 to 25 patients, according to varying literature) achieve lower PD penetration and inferior results.^{[i],[ii],[iii],[iv],[v]}  Small centers could also stunt PD growth, potentially because of limited resources for proactively educating patients, training and building experience with the care team on PD and consistently applying best-demonstrated protocols. Many PD programs (whether affiliated with large or medium dialysis organizations, hospitals or independent practices) stay small rather than combine into larger programs. This is often because they want to care for their patients locally; however, they can still experience challenges due to their size. Fortunately, there are approaches that small PD programs can take to optimize care for their patients.

Advantages of a large PD program

One of the biggest advantages experienced by large PD programs is a greater ability to build out a comprehensive, multidisciplinary, highly coordinated care team to address the complexities experienced by ESRD patients. A larger care team can allow for a broader scope of experiences and clinical competence in physicians, nurses, dietitians, social workers, pharmacists, behavioral specialists and long-term care experts. The team can also include a care coordinator, who oversees and coordinates all care for one patient. While a diverse, high-performing care team may be a vital component for achieving quality patient-centered care, unfortunately reimbursements decreasing below a certain payment model make this difficult to implement in many small programs.

Large PD programs may also have a greater ability to implement informatics (such as digital tools to better engage with patients) and the right incentive structures (to reward individuals on the care team for better health outcomes). In addition, large PD programs may have increased bandwidth to collaborate with government agencies, faith-based groups and the family and friends of patients.

Improving Outcomes in Small PD Programs

While large PD programs may experience certain advantages, small PD programs may not always have the ability to consolidate. There may be other ways to improve outcomes in small PD programs, including the following.

1. Outsource services that may be better provided at larger centers with strong multidisciplinary care teams (i.e., placing catheters or training the care team).
2. Cultivate a virtual care team to better coordinate care and monitor for quality.
3. Collaborate with other programs to continuously improve the PD care model.
4. Apply best-demonstrated practices, both clinically and operationally, to care pathways.
5. Consistently analyze the cause behind every instance of peritonitis, hospitalization and patient loss.
6. Provide on-call nurse support regionally.

Despite the variability in outcomes across PD programs of all sizes, PD therapy shows significant potential for improving hospitalizations, mortality and quality of life for ESRD patients. There is a need to continuously improve on delivering PD, ensuring that all eligible patients are given the chance to experience the full benefits of this therapy through the lens of individualized, coordinated care.

[i] Htay H, Cho Y, Pascoe EM, et al. Multicenter registry analysis of center characteristics associated with technique failure in patients on incident peritoneal dialysis. Clin J Am Soc Nephrol. 2017;doi:10.2215/CJN.12321216.

[ii] Afolalu B, Troidle L, Osayimwen O, et al. Technique failure and center size in a large cohort of peritoneal dialysis patients in a defined geographic area. Perit Dial Int. 2009 May-Jun;29(3):292-6.

[iii] Schaubel DE, Blake PG, Fenton SS. Effect of renal center characteristics on mortality and technique failure on peritoneal dialysis. Kidney Int. 2001; 60:1517–24.

[iv] Huisman RM, Nieuwenhuizen MG, Th de Charro F. Patient-related and centre-related factors influencing technique survival of peritoneal dialysis in The Netherlands. Nephrol Dial Transplant. 2002; 17:1655–60.

[v] Béchade C, Guillouët S, Verger C, et al. Centre characteristics associated with the risk of peritonitis in peritoneal dialysis: a hierarchical modelling approach based on the data of the French Language Peritoneal Dialysis Registry. Nephrol Dial Transplant. 2017;doi:10.1093/ndt/gfx051.