Quantifying Missed Opportunities for Recruitment to Home Dialysis Therapies.

BACKGROUND: Despite the recognized benefits of home therapies for patients and the health care system, most individuals with kidney failure in Canada continue to be initiated on in-center hemodialysis. To optimize recruitment to home therapies, there is a need for programs to better understand the extent to which potential candidates are not successfully initiated on these therapies. OBJECTIVE: We aimed to quantify missed opportunities to recruit patients to home therapies and explore where in the modality selection process this occurs. DESIGN: Retrospective observational study. SETTING: British Columbia, Canada. PATIENTS: All patients aged >18 years who started chronic dialysis in British Columbia between January 01, 2015, and December 31, 2017. The sample was further restricted to include patients who received at least 3 months of predialysis care. All patients were followed for a minimum of 12 months from the start of dialysis to capture any transition to home therapies. METHODS: Cases were defined as a "missed opportunity" if a patient had chosen a home therapy, or remained undecided about their preferred modality, and ultimately received in-center hemodialysis as their destination therapy. These cases were assessed for: (1) documentation of a contraindication to home therapies; and (2) the type of dialysis education received. Differences in characteristics among patients classified as an appropriate outcome or a missed opportunity were examined using Wilcoxon rank-sum test or χ2 test, as appropriate. RESULTS: Of the 1845 patients who started chronic dialysis during the study period, 635 (34%) were initiated on a home therapy. A total of 320 (17.3%) missed opportunities were identified, with 165 (8.9%) having initially chosen a home therapy and 155 (8.4%) being undecided about their preferred modality. Compared with patients who chose and initiated or transitioned to a home therapy, those identified as a missed opportunity tended to be older with a higher prevalence of cardiovascular disease. A contraindication to both peritoneal dialysis and home hemodialysis was documented in 8 "missed opportunity" patients. General modality orientation was provided to most (71%) patients who had initially chosen a home therapy but who ultimately received in-center hemodialysis. These patients received less home therapy-specific education compared with patients who chose and subsequently started a home therapy (20% vs 35%, P < .001). LIMITATIONS: Contraindications to home therapies were potentially under-ascertained, and the nature of contraindications was not systematically captured. CONCLUSIONS: Even within a mature home therapy program, we discovered a substantial number of missed opportunities to recruit patients to home therapies. Better characterization of modality contraindications and enhanced education that is specific to home therapies may be of benefit. Mapping the recruitment pathway in this way can define the magnitude of missed opportunities and identify areas that could be optimized. This is to be encouraged, as even small incremental improvements in the uptake of home therapies could lead to better patient outcomes and contribute to significant cost savings for the health care system. TRIAL REGISTRATION: Not applicable as this was a qualitative study.

CONTEXTE: Les avantages de la dialyse à domicile pour les patients et le système de santé sont reconnus. Pourtant, la majorité des personnes atteintes d'insuffisance rénale au Canada continue de recevoir des traitements d'hémodialyse en centre. Pour recruter davantage de patients sur les thérapies à domicile, il est nécessaire d'instaurer des programmes qui permettent d'établir dans quelle mesure les candidats potentiels n'y sont pas initiés avec succès. OBJECTIF: Nous souhaitions quantifier les occasions manquées de recruter des patients pour les modalités à domicile et déterminer où ces occasions manquées se produisent dans le processus de sélection de la modalité. CONCEPTION: Étude de cohorte rétrospective. CADRE: Colombie-Britannique (Canada). SUJETS: Tous les adultes ayant amorcé des traitements de dialyse chronique en Colombie-Britannique entre le 1er janvier 2015 et le 31 décembre 2017. L'échantillon a été davantage restreint pour inclure les patients ayant reçu au moins trois mois de soins prédialyse. Le suivi s'est étalé sur un minimum de douze mois à compter de l'amorce de la dialyse afin de capter toute transition vers une modalité à domicile. MÉTHODOLOGIE: Les cas ont été définis comme une « occasion manquée ¼ si la personne avait d'emblée choisi une modalité à domicile ou si elle était demeurée indécise quant à sa modalité préférée et avait finalement reçu des traitements d'hémodialyse en centre de façon permanente. Les occasions manquées ont été examinées pour: i) une contre-indication aux thérapies à domicile et; ii) le type de formation reçue pour la dialyse. L'évaluation des différences dans les caractéristiques des patients, selon que leur cas était classé comme un résultat favorable ou une occasion manquée, a été effectuée à l'aide du test de Wilcoxon ou du test du Chi-carré. RÉSULTATS: Des 1 845 patients ayant débuté des traitements de dialyse chronique au cours de la période étudiée, 635 (34 %) avaient amorcé la dialyse à domicile. En tout, 320 cas (17,3 %) ont été classés comme « occasions manquées ¼, soit 165 patients (8,9 %) ayant d'emblée choisi une thérapie à domicile et 155 (8,4 %) indécis quant à leur modalité préférée. Comparativement aux patients qui avaient choisi et amorcé un traitement à domicile ou qui avaient fait une transition (hémodialyse en centre vers une modalité à domicile), les patients classés « occasion manquée ¼ tendaient à être plus âgés avec une prévalence plus élevée de maladies cardiovasculaires. Une contre-indication à la fois à la dialyse péritonéale et à l'hémodialyse à domicile était documentée pour huit patients classés « occasion manquée ¼. Une orientation générale sur la modalité avait été fournie à la majorité des patients (71 %) qui avaient initialement choisi une thérapie à domicile, mais qui avaient finalement reçu une hémodialyse en centre. Ces patients avaient reçu moins d'information spécifique aux modalités pratiquées à domicile que les patients qui avaient d'emblée choisi et poursuivi leurs traitements à domicile (20 % contre 35 %, p < 0,001). LIMITES: Les contre-indications aux modalités à domicile pourraient avoir été sous-évaluées et leur nature n'était pas systématiquement prise en compte. CONCLUSION: Un nombre significatif d'occasions manquées de recruter des patients pour les modalités de dialyse à domicile a été observé, bien que le programme étudié soit solidement établi. Une meilleure caractérisation des contre-indications à ces modalités et davantage de formation spécifique à ces thérapies pourraient s'avérer bénéfiques. De plus, une cartographie du processus de recrutement pourrait contribuer à mieux définir l'ampleur des occasions manquées et à cerner les domaines susceptibles d'être optimisés. Cette démarche est à encourager, car toute amélioration progressive dans l'adoption des thérapies à domicile, aussi infime soit-elle, est susceptible d'améliorer les résultats des patients et de générer des économies importantes pour le système de santé. ENREGISTREMENT DE L'ESSAI: Sans objet, il s'agit d'une étude qualitative.

Perceptions of Multidisciplinary Renal Team Members toward Home Dialysis Therapies.

Background: Patients with ESKD are encouraged to pursue home dialysis therapy with the aims of improving quality of life, increasing patient autonomy, and reducing cost to health care systems. In a multidisciplinary team setting, patients interact with nephrologists, nurses, and allied health staff, all of whom may influence a patient's modality choice. Our objective was to evaluate the perceptions of all renal team members toward home dialysis therapies. Methods: We performed a cross-sectional survey of multidisciplinary renal team members across five renal programs in British Columbia, Canada. The survey contained questions regarding primary work area, modality preference, patient and system factors that may influence modality candidacy, perceived knowledge of home therapies, and need for further education. Results: A total of 334 respondents (22 nephrologists, 172 hemodialysis nurses, 49 home nurses, 20 predialysis nurses, and 71 allied health staff) were included (48% response rate). All respondents felt that home dialysis was beneficial for patients who work or study, improved patients' quality of life, and provided cost savings to the system. Compared with in-center hemodialysis nurses, home therapies nurses were between five and nine times more likely to favor a home therapy for patients of older age, lower socioeconomic status, lower educational level, higher burden of comorbidities, and those lacking social supports. Nephrologists and patients were felt to have the most influence on modality choice, whereas dialysis nurses were seen as having the least effect on modality choice. Most respondents felt the need for further education in home therapies. Conclusions: The majority of multidisciplinary team members, including allied health staff, acknowledged the benefits of home therapies. There were significant discrepancies among team members regarding patient-/system-level factors that may affect the candidacy of home therapies. Structured, focused, and repeated education sessions for all renal team members may help to address misperceptions around factors that influence modality candidacy.

Predictors of Care Gaps in Home Dialysis: The Home Dialysis Virtual Ward Study.

BACKGROUND: Home dialysis patients may be at an increased risk of adverse events after transitional states. The home dialysis virtual ward (HDVW) trial was conducted in Canadian dialysis centers and aimed to evaluate potential care gaps and patient satisfaction during the HDVW. METHODS: The HDVW was a multicenter single-arm trial including peritoneal dialysis and home hemodialysis patients after 4 different events (hospital discharge, medical procedure, antibiotics, completion of training). Telephone-led interviews using a standardized assessment tool were performed over a 2-week period to assess a patient's care and adjust treatment as required. Upon completion, patients were surveyed to evaluate their perceived impact on domains of care using a rating scale; 1 not satisfied to 10 completely satisfied. RESULTS: The HDVW trial included 193 patients with a median number of potential care gaps/interventions of 1 (0-2) per patient. Patients admitted to the HDVW after hospital discharge were at a higher risk of potential gaps in care (OR 2.16, 95% CI 1.29-3.62), while longer dialysis vintage was -associated with a lower number of gaps/interventions (OR 0.97 per year, 95% CI 0.95-0.98). A total of 105/193 (54%) patients completed satisfaction surveys. Patients were highly satisfied with the HDVW (median rating scale score 8, IQR 2) and felt it had a positive impact (rating scale score ≥7) on their overall health, understanding of treatment and access to a nephrologist. CONCLUSION: The HDVW was effective at identifying several potential care gaps, and patients were satisfied across several domains of care. This intervention may be valuable in supporting home dialysis patients during care transitions.

Buttonhole versus Stepladder Cannulation for Home Hemodialysis: A Multicenter, Randomized, Pilot Trial.

BACKGROUND AND OBJECTIVES: Canadian home hemodialysis guidelines highlight the potential differences in complications associated with arteriovenous fistula (AVF) cannulation technique as a research priority. Our primary objective was to determine the feasibility of randomizing patients with ESKD training for home hemodialysis to buttonhole versus stepladder cannulation of the AVF. Secondary objectives included training time, pain with needling, complications, and cost by cannulation technique. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: All patients training for home hemodialysis at seven Canadian hospitals were assessed for eligibility, and demographic information and access type was collected on everyone. Patients who consented to participate were randomized to buttonhole or stepladder cannulation technique. Time to train for home hemodialysis, pain scores on cannulation, and complications over 12 months was recorded. For eligible but not randomized patients, reasons for not participating in the trial were documented. RESULTS: Patient recruitment was November 2013 to November 2015. During this time, 158 patients began training for home hemodialysis, and 108 were ineligible for the trial. Diabetes mellitus as a cause of ESKD (31% versus 12%) and central venous catheter use (74% versus 6%) were more common in ineligible patients. Of the 50 eligible patients, 14 patients from four out of seven sites consented to participate in the study (28%). The most common reason for declining to participate was a strong preference for a particular cannulation technique (33%). Patients randomized to buttonhole versus stepladder cannulation required a shorter time to complete home hemodialysis training. We did not observe a reduction in cannulation pain or complications with the buttonhole method. Data linkages for a formal cost analysis were not conducted. CONCLUSIONS: We were unable to demonstrate the feasibility of conducting a randomized, controlled trial of buttonhole versus stepladder cannulation in Canada with a sufficient number of patients on home hemodialysis to be able to draw meaningful conclusions.

Type B lactic acidosis from fluorouracil in fluorouracil, oxaliplatin and leucovorin treatment for carcinoma of the colon in a hemodialysis patient.

Type B lactic acidosis complicating malignancies is rare. Increased lactate production from abnormal metabolism of tumor tissue and extensive liver metastases impairing clearance are usual causes. Fluorouracil, commonly used as adjuvant cancer chemotherapy, is not well recognized among drugs that can lead to lactic acidosis. We report a hemodialysis patient, tumor free after surgery for colon carcinoma, developing acute severe lactic acidosis and encephalopathy. Pharmacogenetic studies failed to show common variants predisposing to the more typical patterns of fluorouracil toxicity. Routine monitoring of hemodialysis patients after fluorouracil is the only practical way to detect this potentially lethal complication.

Prevalence-Based Targets Underestimate Home Dialysis Program Activity and Requirements for Growth.

BACKGROUND: Many renal programs have targets to increase home dialysis prevalence. Data from a large Canadian home dialysis program were analyzed to determine if home dialysis prevalence accurately reflects program activity and whether prevalence-based assessments adequately reflect the work required for program growth. METHODS: Data from home dialysis programs in British Columbia, Canada, were analyzed from 2005 to 2015. Prevalence data were compared to dialysis activity data including intakes and exits to describe program turnover. Using current attrition rates, recruitment rates needed to increase home dialysis prevalence proportions were identified. RESULTS: We analyzed 7,746 patient-years of peritoneal dialysis (PD) and 1,362 patient-years of home hemodialysis (HHD). The proportion of patients on home dialysis increased by 3.34% over the ten years examined, while the number of prevalent home dialysis patients increased 2.65% per year and the number of patients receiving home dialysis at any time in the year increased 4.04% per year. For every 1 patient net home dialysis growth, 13.6 new patients were recruited. Patient turnover included higher rates of transplantation in home dialysis than facility-based HD. Overall, the proportion dialyzing at home increased from 29.3 to 32.6%. CONCLUSIONS: There is high patient turnover in home dialysis such that program prevalence is an incomplete marker of total program activity. This turnover includes high rates of transplantation, which is a desirable interaction that affects home dialysis prevalence. The shortcomings of this commonly used metric are important for renal programs to consider, and better understanding of the activities that support home dialysis and the complex trajectories that home dialysis patients follow is needed.

Evaluation of a 12-Month Pilot of Long-Term and Temporary Assisted Peritoneal Dialysis.

♦ BACKGROUND: Peritoneal dialysis (PD) is challenging for patients with functional limitations, and assisted PD can support these patients, but previous reports of assisted PD have not examined the role of temporary assisted PD and had difficulty identifying adequate comparator cohorts. ♦ METHODS: Peritoneal Dialysis Assist (PDA), a 12-month pilot of long-term and temporary assisted PD was completed in multiple PD centers in British Columbia, Canada. Continuous cycler PD (CCPD) patients were identified for PDA by standardized criteria, and service could be long-term or temporary/respite. The PDA program provided daily assistance with cycler dismantle and setup, but patients remained responsible for cycler connections and treatment decisions. Outcomes were compared against both the general CCPD population and patients who met PDA criteria but were not enrolled (PDA-eligible). ♦ RESULTS: Fifty-three PDA patients had an 88% 1-year death- and transplant-censored technique survival that was similar to the general CCPD cohort (84%) and PDA-eligible cohort (86%). The PDA cohort had lower peritonitis rates (0.18 episodes/patient-year vs 0.22 and 0.36, respectively), but higher hospitalization (55% vs 34% and 35%, respectively). Long-term PDA cost approximately CDN$15,000/year in addition to existing dialysis costs. A total of 8/11 respite PDA patients (73%) returned to self-care PD after a median PDA use of 29 days, which costs $1,250/patient. ♦ CONCLUSIONS: Peritoneal Dialysis Assist provides effective support to functionally-limited CCPD patients and yields acceptable clinical outcomes. The program costs less than transfer to HD or long-term care, which represents cost minimization for failing self-care PD patients. Respite PDA provides effective temporary support; most patients returned to self-care PD and service was cost-effective compared with alternatives of hospitalization or transfer to HD.

Isolated renal giant cell arteritis.

Giant cell arteritis, which most commonly affects the temporal arteries, may involve intrarenal vessels and may be associated with a variety of renal lesions, including necrotizing arteritis, necrotizing glomerulonephritis, granulomatous glomerulonephritis, and membranous glomerulopathy. Isolated giant cell arteritis of the kidney is a rare cause of renal failure. We report a case of a previously healthy 54-year-old white woman who presented with nonoliguric renal failure and a 4-week history of persistent low-grade fever associated with diffuse mild myalgias. She had no history of previous renal or neurologic disease and denied any headaches or visual disturbances. Antinuclear antibody and antineutrophilic cytoplasmic antibody were negative. Renal biopsy revealed noncaseating granulomatous infiltration of arterial and arteriolar walls, a patchy mononuclear cell interstitial infiltrate, and no significant glomerular changes. Treatment with prednisone resulted in dramatic improvement of renal function.