Peritoneal Dialysis International | 2019
Transition—The Process of Changing from One State to Another
Abstract
Transitions in healthcare, driven by changes in circumstances, present uncertainty for patients and challenges for healthcare systems. Care transitions that are of particular importance include the hand-over from pediatric to adult care and from hospital to the community. The initiation of renal replacement therapy (RRT) has commanded considerable attention around such matters as timing, decision-making, and access to care. For patients who are established on RRT, transitions between modalities of care are commonly required following the failure of a therapy and the need to seek an alternative. The reality is that most people who require renal replacement therapy will need to change modality at some stage, and this is of particular importance for peritoneal dialysis (PD), where the therapy can be limited in its duration. Are there optimal ways to plan RRT that recognize this reality and chart better courses for patients and healthcare providers? In public health terms, integrated care attempts to make care more seamless, providing all the services that an individual requires in a single place, rather than scattered across a range of providers and establishments. In terms of RRT, integrated care recognizes that individuals are likely to require a range of therapies throughout their lifetimes and considers how best to deliver these therapies in a more continuous way. This question is both complicated and important and is explored by the INTEGRATED initiative in this issue of Peritoneal Dialysis International (Chan and colleagues). This collaboration sets out research priorities against a series of detailed objectives, including barriers/facilitators to successful transition; understanding the integrated care flow path; optimizing outcomes of transitions; impact of planned vs unplanned transitions; and experiences, perceptions, and beliefs of patients and healthcare workers on transitioning. Two papers in this issue explore transition. In the first, Kansal and colleagues use data from the United States Renal Data System (USRDS) to demonstrate an advantage in terms of survival and subsequent kidney transplantation among 521 patients who transferred from PD to home hemodialysis (HD), matched to patients who transferred to center-based HD. In the second, Dugan Maddux and colleagues examine the Fresenius Medical Care chronic kidney disease (CKD) registry to compare clinical parameter trajectories before and after therapy start for 8,088 patients initiating HD and 1,015 initiating PD. Hemodialysis starters exhibited a more rapid decline in estimated glomerular filtration rate (eGFR) in the 12 months prior to commencing dialysis. As the authors point out in the discussion, a more rapid decline in eGFR may predispose patients for HD rather than PD as there is less time for planning and preparation. This is, of course, relevant to the discussion on factors that have an impact on the decline of residual renal function in people on dialysis. In both of these studies, there are key differences between the compared populations, and the methods of adjustment that are used to enable comparison must be sophisticated to command our confidence. Best practice integrated care requires careful access planning. Barny Hole reviews this topic using the UK Renal Registry dialysis access data set. For integrated care pathways to be better understood, access must be presented holistically—for example, including pre-emptive transplantation alongside HD and PD access. Several possible quality standards can be identified, such as a target for definitive access that includes pre-emptive transplantation, PD, and primary vascular access among incident patients known to services more than 90 days; and the time-to-definitive access preparation in patients who start dialysis having been known to nephrologists for less than 90 days, which is a measure of the responsiveness of care pathways. These standards can be applied to examine variation, the quality of services, their causes and consequences. For integrated care to work effectively, patients need to have a good understanding of their options, the relative attributes of different approaches and how these fit in with their lifestyle choices. Providing information in healthcare is something we return to frequently in Peritoneal Dialysis International, and in this issue, Annamarie Horne and colleagues present an invited review on approaches to health literacy from the Scottish Government, including a case study on RRT. I should like to draw your attention to the poem by Elspeth Murray entitled “This is bad enough.”