Home Hemodialysis: Bending the Utilization Curve With Novel Strategies

Abstract

with HHD prevalence remaining <2% of the dialysis population. Significant barriers to HHD can generally be divided into several categories: social, financial, regulatory, and educational (Box 1). Social barriers primarily relate to the patient; these include concerns of isolation, fear of a catastrophic event, “medicalization” of the home environment, and family or caregiver burden. Other barriers related to patients reflect the living situation, particularly if the patient lives in a space that is too small to accommodate the necessary equipment and supplies. Financial barriers for patients include the costs of plumbing and electrical modifications to the home, ongoing utility costs (electricity and water use), and costs of transportation to the clinic for training. From the perspective of the dialysis provider, financial barriers are entwined to some degree with regulatory factors regarding reimbursement for training (of both patients and nurses) and continuous machine and supply costs. Regulations regarding training qualifications and oversight of home dialysis vary from state to state in the United States, further complicating the initiation and maintenance of HHD programs. Perhaps the most significant impediment is the lack of education of nurses and especially physicians in the practice of HHD. Although exposure to HHD in fellowship programs has improved slightly during the past decade, there are still many nephrologists in this country uncomfortable prescribing HHD, particularly long nocturnal treatments. Because the attitude of professional caregivers has a profound influence on patients’ acceptance of home dialysis, it is imperative that we increase the level of awareness of and comfort with prescription of HHD in the United States. Recently enacted changes by Medicare Administrative Contractors have further complicated efforts to combine effective patient therapy and cost efficiencies. Given the profound physiologic advantages with more intensive hemodialysis (HD), what can be done to improve uptake of nontraditional approaches to delivery of dialysis? The study by Walker et al in this issue of Kidney Medicine adds to the growing body of literature regarding alternative modes of delivery of more intensive HD. The authors have previously explored patient and caregiver