Home hemodialysis: a comprehensive review of patient-centered and economic considerations

Abstract

Internationally, the number of patients requiring treatment for end-stage kidney disease (ESKD) continues to increase, placing substantial burden on health systems and patients. Home hemodialysis (HD) has fluctuated in its popularity, and the rates of home HD vary considerably between and within countries although there is evidence suggesting a number of clinical, survival, economic, and quality of life (QoL) advantages associated with this treatment. International guidelines encourage shared decision making between patients and clinicians for the type of dialysis, with an emphasis on a treatment that aligned to the patients’ lifestyle. This is a comprehensive literature review of patient-centered and economic impacts of home HD with the studies published between January 2000 and July 2016. Data from the primary studies representing both efficiency and equity of home HD were presented as a narrative synthesis under the following topics: advantages to patients, barriers to patients, economic factors influencing patients, cost-effectiveness of home HD, and inequities in home HD delivery. There were a number of advantages for patients on home HD including improved survival and QoL and flexibility and potential for employment, compared to hospital HD. Similarly, there were several barriers to patients preferring or maintaining home HD, and the strategies to overcome these barriers were frequently reported. Good evidence reported that indigenous, low-income, and other socially disadvantaged individuals had reduced access to home HD compared to other forms of dialysis and that this situation compounds already-poor health outcomes on renal replacement therapy. Government policies that minimize barriers to home HD include reimbursement for dialysis-related out-of-pocket costs and employment-retention interventions for home HD patients and their family members. This review argues that home HD is a cost-effective treatment, and increasing the proportion of patients on this form of dialysis compared to hospital HD will result in a more equitable distribution of good health outcomes for individuals with ESKD.

Transitional dialysis care units: A new approach to increase home dialysis modality uptake and patient outcomes

“…PD outcomes over the first 3 years of dialysis therapy are superior to those of CHD . Home‐based dialysis can allow for more freedom for patients to make their own lifestyle choices, especially as it relates to employment, hobbies, and family time, improving quality of life . Several studies have reported that 90% or more of nephrologists and other dialysis health care providers would select home therapies for themselves if they required dialysis .…”

Changing ethnic and clinical trends and factors associated with successful home haemodialysis at Auckland District Health Board

“…HHD uptake by initially under‐represented portions of the community may have improved with intentional clinical advocacy, education and addressing of financial barriers to HHD. Recent studies in the NZ population have identified a lack of confidence, fear of isolation, fear of self‐needling and financial constraints as key barriers to HHD uptake . Additionally, clinician recommendation has a significant impact on decision making around the modality choice, with several recent studies confirming that recommendation from an engaged nephrologist is a prime factor in patients choosing home haemodialysis .…”

Nocturnal home hemodialysis in children: Advantages, implementation, and barriers

“…Trainee parents can talk to parents with children already on an HHD program which would reinforce their confidence in caring for their children at home. In addition, strong recommendations and support from the clinicians, home HD support staff, incorporation of remote monitoring, or after‐hours support systems can also help attenuate these fears …”

“…Overcrowding, lack of space for storage of dialysis consumables, lack of hygienic or a private room for dialysis, and inappropriate home environment are noteworthy obstacles to starting HHD. Another challenge is for people living in rental homes, where owing to lack of permission from the homeowners, the required plumbing and electrical changes cannot be made …”