By its very nature, chronic kidney disease can rob individuals of their independence. It gradually causes a person to lose the ability to filter wastes from the body, and should kidneys fail entirely, a patient must rely on renal replacement therapy (dialysis) to live. An estimated 26 million Americans have chronic kidney disease of varying degrees; more than 600,000 have end-stage kidney failure. In my home state of West Virginia, some 3,500 patients were on dialysis in 2013, and for most of the past two decades, our state has led the nation in per capita numbers of patients starting dialysis.
Dialysis can be provided thrice weekly in a center specifically for this purpose or at home. Most patients in the US dialyze in-center despite the benefits of home dialysis and the potential for restored independence. I have seen the benefits over the course of my career. During my nephrology training at Henry Ford Hospital in Detroit, because there were more new patients than there were dialysis chairs, everyone was steered toward home-based peritoneal dialysis.
Coming to West Virginia in 1993, distance from dialysis centers led many patients to choose home dialysis. Currently, about 20 percent of our patients dialyze at home, and some are able to continue or return to work. Lengthy trips to a facility multiple times a week have the potential to interfere with a patient’s work and personal life, and research shows that over half of in-center patients are unable to maintain thesame level of employment after six months.

Home Dialysis Benefits And Barriers

Last month, a new report highlighted the economic benefits of home dialysis — and cited a “confluence of factors” that inhibit patients from choosing a home dialysis modality, three of which are highlighted below.
First, the study links low socioeconomic status with the low utilization of home dialysis. In West Virginia, I see many patients who present with kidney disease who have had little to no access to kidney disease care and education. For patients who come to care deep into their disease progression, the economic, physical, and emotional burdens of kidney disease are formidable.
They may require the totality of a patient’s energy and resources, thus the choice of in-center dialysis over home dialysis may seem easier. Similarly, research shows patients who start dialysis in a hospital or facility are more likely to continue to receive treatment there instead of transitioning to home dialysis. Our responsibility as nephrologists is to empower those for whom home dialysis is appropriate to try it.
Second, in a comparable vein, the study correctly acknowledges gaps in nephrologist training pertaining to home dialysis. I strongly believe that patients need to be informed about all available treatment options, and providers need to be equipped to discuss all of the treatment options with their patients. We require our doctors in training to spend a lot of time learning about home dialysis, and I would encourage other programs to expand their time spent in this area.
Third, the report indicates that patients may be deterred from home dialysis because they lack a care giver — but this doesn’t necessarily need to be a barrier. While some patients are not comfortable with or physically able to perform the operation of dialysis on their own, others are eager and capable. Prohibiting such patients from doing home dialysis because that they lack a partner may be appropriate for some, but not all, patients.
The use of telehealth technology for real-time monitoring and ad hoc physician-patient interaction could increase eligibility for home dialysis by providing enhanced support for face-to-face clinician visits. Unfortunately, Medicare does not reimburse telehealth services that originate in a patient’s home. Changing this policy, at least for home dialysis patients, could enable many more patients to move to home dialysis.
Other barriers include concerns on the part of physicians that coverage for patients needing more frequent dialysis will be difficult to assure for patients receiving their dialysis at home. Additionally, the lack of infrastructure and resources needed to develop and grow a home dialysis program, particularly in rural areas, can constrain the progression of these programs.

Recommendations

While the option to dialyze at home is not necessarily best for all patients, it may be beneficial for more than those who currently use it. Home dialysis gives patients more autonomy over their care and their lives, and offers certain patients tremendous clinical and quality-of-life benefits. Patients deserve to have choices in their medical care and the option to dialyze at home, when safe and appropriate, is especially key in rural states like mine where many patients live distant to a dialysis center.
I urge policymakers nationwide to make home dialysis a more feasible option for more patients by supporting policies to eliminate current barriers in access. Designating the home as an originating site for telehealth and providing targeted funding and policy initiatives addressing shortcomings in infrastructure and nephrologist training concerns would go a long way towards diminishing these barriers.
tags: chronic disease, dialysis, kidney disease, nephrology, rural health, telehealth