The United States Secretary of Health & Human Services, Alex Azar, recently highlighted in a speech at the National Kidney Foundation’s Kidney Patient Summit the fact that due to misaligned financial incentives, we are paying for kidney sickness rather than kidney health. He outlined a plan to realign economic forces in kidney care to favor interventions that are both more cost-effective and better for the patient.

One key strategy is increasing emphasis on peritoneal dialysis (PD), an intervention that is both more cost-effective than in-center hemodialysis and affords a more flexible lifestyle for dialysis patients. Secretary Azar’s own father had end-stage kidney disease (ESKD) and received in-center hemodialysis prior to being transitioned to PD and ultimately receiving a kidney transplant. This statement was echoed by Deputy Administrator for CMS, Adam Boehler, at the May 2019 Kidney Health Initiative, who stated, “Our goal is by 2025, 80% of new starts will be either transplant or home therapies.”

A recent Narrative Review published in AJKD by Briggs et al is fortuitously timed. The authors review PD utilization worldwide, emphasizing existing hurdles and outlining successful strategies for overcoming them. PD utilization varies markedly across the globe, with Hong Kong at the highest around 70% while Bangladesh is at less than 5% (the United States hovers around 12%).

Distribution of the percentage of prevalent dialysis patients using in-center hemodialysis (HD), home HD, or peritoneal dialysis (PD; continuous ambulatory PD/automated PD/intermittent PD), 2015. Denominator was calculated as the sum of patients receiving HD, PD, and home HD; does not include patients with other/unknown modality. ˆUnited Kingdom: England, Wales, and Northern Ireland (data for Scotland reported separately). Data for France exclude Martinique. Data for Italy include 5 regions. Data for Canada exclude Quebec. Data for Latvia represent 80% of country’s population. Data collection methods vary across countries, suggesting caution in making direct comparisons. Adapted from Saran et al. Figure 1 from Briggs et al, AJKD .

Briggs et al are quick to point out that macroeconomic forces and the specifics of dialysis reimbursement are much more important in influencing PD uptake than the specific demographic and comorbidities of the patient population. While there are patient factors limiting suitability for PD, the vast majority of patients are medically and psychologically appropriate candidates. What are the strategies observed in other countries that can help Americans promote the uptake of PD and streamline kidney care to improve the patient experience?

First, patient education prior to the initiation of dialysis is crucial. Many patients start dialysis without ever seeing a nephrologist and those patients who start dialysis in an unplanned fashion are twice as likely to choose hemodialysis (HD) over PD.  On the other hand, those receiving patient-targeted education are 3-times more likely to choose PD over HD. Work is needed to build relationships that could help overcome patients’ preconceptions that in-center hemodialysis is the default, and therefore, better option.

Nephrologists need help demonstrating that PD is more consistent with patient values and allows for greater independence, more time spent at home, and flexible travel options. To this end, small-group and family involvement in educational programs may be useful tools to promote PD that were associated with higher uptake of home self-care modalities.  Additionally, peer educators may add value to information by providing cultural context, particularly among minorities.

Second, financial incentives favoring in-center hemodialysis must be realigned. Caring for patients on in-center hemodialysis is more profitable and easier for both nephrologists and large dialysis organizations. This potentially discourages placement of patients on PD, despite the fact that it is clear from multiple analyses that shifting to PD results in cost savings and may be associated with an increase in quality-adjusted life years. Already, a shift toward a more PD-favorable prospective payment system in the United States was temporally associated with a doubling of the number of patients on PD.

Trends in the number of incident end-stage kidney disease cases using home dialysis, by type of therapy, in the US population, 1996-2015. Adapted from Saran et al. Figure 2 from Briggs et al, AJKD .

More can still be done, as Hong Kong has successfully implemented a PD-first initiative and has consistently high rates of PD uptake with good outcomes. A similar program in Thailand has led to a promising large expansion in access to kidney replacement therapy. To prevent restricting choice, patients in the US may benefit from a discussion strategy focused on mitigating costs (both out-of-pocket and employment earnings) by promoting PD.

Finally, continuous quality improvement to mitigate the most harmful complications and limit technique failure is of critical importance to the success of any initiative to increase the uptake of PD. Careful attention to treatment of peritonitis is key as this is the most dreaded complication and can lead to technique failure. Emergence of anti-microbial resistance is particularly worrisome and results in even higher rates of catheter loss. With PD growth, even more importance is placed on adherence to International Society of Peritoneal Dialysis Guidelines for prevention and treatment of peritonitis. Documentation of infection rates and causes helps immeasurably allowing for intervention in trouble areas. An international database can identify emerging trends and highlight variation in practices in treatment of peritonitis facilitating remediation towards best-practices.

Through expanding access to pre-dialysis CKD patient education, realigning financial incentives that favor in-center hemodialysis, and continuous quality improvement to mitigate complications and technique failure, we can expand access to PD and fulfill our commitment to improve care for patients with ESKD without breaking the bank.

– Post prepared by Nathaniel Reisinger @nephrothaniel, AJKDBlog Contributor.

To view Briggs et al (subscription required), please visit AJKD.org.

Title: International Variations in Peritoneal Dialysis Utilization and Implications for Practice
Authors: Victoria Briggs, Simon Davies, and Martin Wilkie
DOI: 10.1053/j.ajkd.2018.12.033