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First exposure to home therapy options--where, when, and how.

Goal

To provide an overview of a kidney disease education management program that has been successful at improving the rates of patients on home therapies.

Objectives

1. Discuss recent data from the U.S. Renal Data System related to patients on a home hemodialysis modality.

2. Describe the components of a home dialysis therapies education program.

3. Develop a nursing intervention plan to improve the delivery of home modality education.

Multiple reports have demonstrated that home dialysis therapies are an effective alternative to conventional in-center hemodialysis (HD) with equivalent or improved outcomes (Mehrotra, Chiu, Kolantar-Zadeh, Barglnan, & Vonesh, 2011; Pauly et al., 2009). Home therapies allow for a more flexible lifestyle for patients and have been shown to improve blood pressure, phosphate control, quality of life (QOL), and recovery after dialysis, and lessen depression (FHN Trial Group, 2010;Jaber et al., 2010; McLaughlin et al., 2008; Pauly et al., 2009). However, despite equivalent or improved outcomes, there has been a decline in the penetration of home modalities nationwide. Peritoneal dialysis (PD) peaked as the home modality of choice in 1993, reaching a 15% penetration, but PD currently reaches only about 7% penetration in the U.S. (U.S. Renal Data System [USRDS], 2012). PD and home HD (HHD) utilization in the U.S. is one of the lowest of any developed nation and widely recognized as underused (Merighi, Schatell, Bragg-Gresham, Witten, & Mehrotra, 2012; Rubin et al., 2004). However, it is evident that nephrologists consider the

majority of their patients with chronic kidney disease (CKD) eligible for PD (Mendelssohn et al., 2009). Survey results of Canadian and U.S. nephrologists show that 45% to 55% of patients being treated with some form of home-based modalities is considered an optimal modality distribution (Mendelssohn et al., 2009).

While the nephrology community has advocated for the use of home modalities among patients, there is still a disparity between its voice and the number of patients currently utilizing home modalities. In the continuing search to expand and improve the quality of care for patients on dialysis, pre-dialysis education is a promising and proven tool to increase the adoption of home therapies. At Satellite Healthcare, Inc., roughly 50% of patients on dialysis who attend Option classes choose to initiate therapy with a home modality, confirming prior data from Canada (Prichard, 1996). At WellBound Centers, part of Satellite Healthcare, a non-profit dialysis provider with centers across the U.S., 800/0 of patients undergoing dialysis choose PD, and 20% choose HHD.

WellBound Centers were established as part of Satellite Healthcare in 2004 as exclusively dedicated home dialysis centers across the U.S. Option classes are provided in the WellBound Centers either as group sessions or one-on-one with patients. Patients receive education in all treatment options, including home and in-center HD, PD, transplantation, and conservative therapy. Education is provided by nurses, and patients are offered a support network of trusted advocates who answer questions and solve problems. In 2011, 24% of incident patients at Satellite Healthcare started renal replacement therapy with PD and 4% with HHD. Despite the nephrology community's stated support and recommendations for the use of home modalities for many patients with CKD, the numbers do not match these statements. While most nephrologists agree that patients with CKD should be referred early to a nephrologist to receive comprehensive modality education, and that informed patient choice should then guide modality decision, this goal is not always met (Mendelssohn et al., 2009). In addition, 44% of nephrology physician graduates report not feeling sufficiently trained in PD, and more than 84% reported a lack of training in HHD, a situation likely further contributing to suboptimal education in home alternative dialysis therapies (Merighi et al., 2012).

For the past few years, 77% of all Satellite Healthcare, Inc. patients were treated with in-center HD, and 23%> were treated with home dialysis modalities. This represents the highest home penetration among U.S. dialysis providers--three times the national average. Continued efforts in pre-dialysis education for several years and the improved infrastructure of home dialysis access through dedicated WellBound home dialysis training centers is considered the reason for this success (Schiller, Munroe, & Neitzer, 2011).

The purpose of this study was to explore where, when, and how patients received pre-dialysis education in a provider setting where potential barriers to home modalities had been purposefully reduced. This study also sought to discover what factors influenced patients' decisions and to evaluate interventions that may further facilitate and advance access to home therapies.

Methods

A prospective study of incident patients starting home dialysis at WellBound Centers was conducted between September 1, 2010, and August 31, 2011. A questionnaire was distributed to all new English-speaking patients. Each patient was approached within the first week of initiating therapy and asked to complete and return the survey to the WellBound dialysis staff. A total of 411 patients were eligible for the survey. All returned questionnaires were collected, and results were tabulated. The questionnaire consisted of a total of five yes/no or multiple-response questions. The following questions were utilized in the survey.

* When did you first hear about home dialysis?

* Did you attend a dialysis options class (at a WellBound Center)?

* Did your doctor talk to you about home dialysis at the doctor's office or in the hospital before you started dialysis?

* If you have been dialyzing in an in-center dialysis unit, did you hear about the home therapy in your dialysis clinic?

* What were the factors that lead to your decision to do home dialysis, either peritoneal or hemodialysis?

Results

Patient Characteristics

A total of 486 patients started home therapy at WellBound between September 1, 2010, and August 31, 2011. Of those, 411 English-speaking patients were presented with the questionnaire, and 287 patients returned the survey, resulting in a response rate of 70%. Of the returned surveys, 217 were answered completely, and 70 were answered partially. Demographics were identified with patient medical record numbers from the electronic medical record. Demographic data included age, gender, vintage on dialysis, diabetes mellitus, race, employment, and marital status. Demographics of the respondents are summarized in Table 1. There were no significant differences in race distribution between all admissions and patients who returned questionnaires; however, 57% of the respondents were male, while only 44% of all admissions were male. All other characteristics - employment status, diabetic status, marital status, age, dialysis vintage, and treatment modality--were similar in both groups. This was a representative group of patients when compared to USRDS data, which showed an average age of 61.2 years and 570/0 males among patients with ESRD in 2010 (USRDS, 2012). The answers to the questionnaire are summarized in Table 2.

Are discussions about home therapies being held with patients?

The vast majority (n = 244, 850/0) of patients reported their doctor had spoken with them about home therapies prior to initiation of dialysis therapy either during an office visit or during a hospitalization. Many patients (n = 132) indicated they had first heard about home dialysis in their doctor's office, 49 patients reported they had heard in the hospital, and 32 reported they had heard in the dialysis clinic after starting dialysis. The remaining group of patients first heard about home therapies from online sources or a family member/ friend. At some stage, 212 of the 287 patients had been treated with in-center HD. Only 79 of these patients reported having heard about home therapies in their dialysis clinic.

Did you attend an Options class?

The majority of patients (n = 211) attended an Options class, with the vast majority (97%) at a WellBound Center. However, only 20 patients reported the Options class was the first time they heard about home modalities.

Factors that Influenced Decision to Choose Home Therapy

The ability to perform dialysis at home (n = 180) and having control over their schedule and therapy (n = 154) were the two most common answers among the factors leading to the decision to undergo a home modality. Other reasons included the potential for better outcomes (n = 112), having less dietary restrictions (n = 75), transportation issues (n = 68), and the ability to keep working (n = 62). Other reasons were listed by written comment from 84 patients. These can be grouped into three main categories of increased independence, improved health outcomes similar to the above outlined factors, and physician recommendations.

Implications for Nephrology Nurses

Nephrology nurses play a strategic role in educating patients regarding home therapies. If the goal of renal replacement therapies, more specifically dialysis, is to allow patients freedom to experience a somewhat normal lifestyle while receiving a life-sustaining medical therapy, the effective implementation of education becomes part of the responsibilities of all nephrology nurses. Whenever possible prior to dialysis initiation, nurses must initiate a conversation regarding home dialysis modalities with the patient. Physicians are more likely to initiate the conversation regarding home therapies in an environment where access to Options classes and training are available. During these discussions, barriers to home therapies need to be discussed, and pros and cons of each therapy should be presented to patients. Once patients understand their options, they are better prepared to make informed decisions regarding their modality selection.

Discussion

In recent years, the percentage of patients on home therapies has declined nationally; however, thrice the national average of patients undergo home therapies at Satellite Healthcare. Much of this success is attributed to the deliberate creation of centers of excellence for home therapies with a focus on educating the patient early, as well as through a dedicated training program for home therapies. Pre-dialysis education occurs primarily through Options classes. In this setting, with easy access to education and an infrastructure for convenient training in home therapies, it is not surprising that the majority of patients were informed about home therapies prior to starting dialysis, thus confirming the premise of this approach. Options classes in close proximity to patients and nephrologists decrease the burden for both and facilitate early education. Pre-dialysis education prior to reaching uremia is a vital component to guide patients requiring renal replacement therapy toward home treatments (Lee, Gudex, Povlsen, Bonnevie, & Nielson, 2008). As evident when comparing to USRDS data, patients starting home therapies at Satellite-WellBound are comparable to the general U.S. ESRD population data (USRDS, 2012).

It has been shown that 78% of patients are considered eligible for PD with respect to psychological-medical conditions, a number considered to be generalizable across urban centers in North America, both Canada and the U.S. (Mendelssohn et al., 2009). However, in the past, many patients reported not having been told about alternative dialysis therapies at home (Lee et al., 2008, Mehrotra, Marsh, Vonesh, Peters, & Nissenson, 2005). The current survey shows that nephrologists of patients who choose a home modality had talked with their patients about home dialysis. Out of the 287 patients, 244 had spoken with their doctor about home dialysis, a promising number because recent data show a large number of patients reported never having been informed about home alternatives by their nephrologists (Mehrotra et al., 2005).

Patients first hear about home modalities at the hospital, at the doctor's office, or from family/friends. Very few get the first information online, an untapped opportunity possibly worthwhile to evaluate further. The number of patients who first heard about home therapies prior to starting dialysis is surprisingly low, with only 73 patients, and 132 patients hearing about it after starting dialysis. This is consistent with the range of the vintage of these patients (9 to 252 months), indicating that many patients experienced in-center HD prior to choosing home modalities. Seventy-five percent (n = 211) of all patients attended an Options class prior to starting home dialysis, suggesting this venue is the most frequent education tool. Only 76 patients started the home-based modality without it. The majority of patients attend the Options classes at WellBound, but alternative classes in the community are available, indicating that pre-dialysis education is embraced as an effective means to provide comprehensive education.

The majority (n= 212) of patients indicated they had been exposed to in-center HD at some time. Of these, only 79 noted they had heard about home modalities in the dialysis center. This may reflect an opportunity in the future for in-center dialysis employees to initiate such discussion with patients, examining their interest and attitude. To further guarantee individualized patient care, home modalities must remain an option for patients with ESRD, and education must reach new patients early in the course of their disease.

Results of the questionnaire clearly show that the main reason for patients to select home therapies is the improved quality of life (for example, having control over their own schedule and environment). The biggest motivation is being able to do the therapy at home, and avoid transportation issues and time restraints mandated by the dialysis center. Patients seem to understand that despite daily therapies that occur often with both PD and HHD, the home setting eliminates hours of transportation from and to the dialysis center, as well as time to recover from thrice weekly HD, thus resulting in gaining "functioning time" spent at home instead.

Professionals in nephrology and dialysis may expect improved outcomes to be the primary reason for such choices, but surprisingly, it is only mentioned by 250/o of respondents as one of their reasons. One might speculate that discussions about superior outcomes may be limited as a response to the lack of randomized controlled trials. Observational data and a randomized trial, however, encourage a more individualized messaging to patients (FHN Trial Group, 2010; Mehrotra et al., 2011; Pauly et al., 2009). Further, the choice of nephrology professionals heavily focuses on home therapies when asked about the hypothetical scenario if they required dialysis therapy. Such a dominant endorsement of home therapies by both nurses and nephrologists as their preferred "hypothetical" choice begs the question of potential implications on our recommendation to patients (Schiller, Neitzer, & Doss, 2010).

A fair assessment would be that attempting to further decrease barriers to home therapies is a much-needed approach for more individualized care for patients with ESRD. One of the most frequently reported barriers to home therapies is the lack of support at home. A home-based modality affects not only the patient, but also his or her family/partner. While a strong social support system has long been known to benefit patient outcomes in many chronic diseases, it is vital for home dialysis (Lee et al., 2008, Mendelssohn et al., 2008). The current study found that the majority of patients, 650/0 of respondents, listed their relationship status as married or partnered. One can infer that having a partner is a valued comfort in many patients choosing home therapies, but not a mandatory requirement; the remaining patients were single, divorced, or widowed. Statistics on employment status are somewhat surprising; only 22% of all patients treated with home dialysis were working either full time (14%) or part time (8%). This low number for employment was even lower (18%) when analyzing only patients responding to the questionnaire. A large number of home patients (36% to 42%) were retired, with about 13% to 15% of patients being on disability. While one may assume employment is the major motivation for home dialysis, these numbers indicate that the improvement of quality of life is a persistent motivator beyond the working life period and consistent with factors favoring home therapy in the questionnaire.

Conclusion

With currently almost 200,000 of U.S. patients 20 to 65 years of age undergoing renal replacement therapy, and with 40- to 65-year-old patients ("Baby Boomers") representing the largest absolute number of incident patients per USRDS (2012), fostering comprehensive education prior to the start of dialysis will benefit these patients. The Satellite-WellBound experience confirms that Options classes and a compelling infrastructure to home therapies is a vital element to bring alternative modalities to more patients. Opportunities to educate patients undergoing in-center hemodialysis should not be missed.

Acknowledgments: The authors would like to thank the nurses of WellBound, Inc., for their assistance in distributing the questionnaires within their dinics and the patients who answered the questionnaire and trust us with their care.

Statement of Disclosure: The authors reported no actual or potential conflict of interest in relation to this continuing nursing education activity.

Note: Additional statements of disclosure and instructions for CNE evaluation can be found on page 35.

References

FHN Trial Group. (2010). In-center hemodialysis six times per week versus three times per week. New England Journal of Medicine, 363, 2287-2300.

Jaber, B.L., Lee, Y., Collins, A.J., Hull, A.R., Krans, M.A., McCarthy, J., ... Finkelstein, F.O. (2010). Effect of daily hemodialysis on depressive symptoms and postdialysis recovery time: Interim report from the FREEDOM (Following Rehabilitation, Economics and Everyday-Dialysis Outcome Measurements) Study. American Journal of Kidney Diseases, 56, 531-539.

Lee, A., Gudex, C., Povlsen, J.V., Bonnevie, B., & Nielsen, C.E (2008). Patients' views regarding choice of dialysis modality. Nephrology Dialysis Transplantation, 12, 3953-3959.

McLaughlin, K., Jones, H., VanderStraeten, C., Mills, C., Visser, M., Taub, K., & Manns, B. (2008). Why do patients choose self-care dialysis? Nephrology Dialysis Transplantation. 23, 3972-3976.

Mehrotra, R., Chiu, Y.W., Kalantar-Zadeh, K., Bargman, J., & Vonesh, E. (2011). Similar outcomes with hemodialysis and peritoneal dialysis in patients with end-stage renal disease. Archives of Internal Medicine, 171(2), 110-118.

Mehrotra, R., Marsh, D., Vonesh, E., Peters, V., & Nissenson, A. (2005). Patient education and access of ESRD patients to renal replacement therapies beyond in-center hemodialysis. Kidney International, 68, 378-390.

Mendelssohn, D.C., Mujais, S.K., Soroka, S.D., Brouillette,J., Takano, T., Barre, P.E., ... Finkelstein, F.O. (2009). A prospective evaluation of renal replacement therapy modality eligibility. Nephrology Dialysis Transplantation, 24, 555-561.

Merighi, J.R., Schatell, D.R., Bragg-Gresham, J.L., Witten, B., & Mehrotra, R. (2012). Insights into nephrologist training, clinical practice, and dialysis choice. Hemodialysis International, 16, 242-251.

Panly, R.P., Gill, J.S., Rose, C.L. Asad, R.A., Chery, A., Pierratos, A., & Chan, C.T. (2009). Survival among nocturnal home haemodialysis patients compared to kidney transplant recipients. Nephrology Dialysis Transplantation, 24, 2915-2919.

Pilchard, S.S. (1996). Treatment modality selection in 150 consecutive patients starting ESRD therapy. Peritoneal Dialysis International, 16, 69-72.

Rubin, H.R., Fink, N.E., Plantinga, L.C., Sadler, J.H., Kliger, A.S., & Powe, N.R. (2004). Patient ratings of dialysis care with peritoneal dialysis vs hemodialysis. Journal of the American Medical Association, 291, 697-703.

Schiller, B., Munroe, H., & Neitzer, A. (2011). Thinking outside the box-identifying patients for home dialysis. Nephrology Dialysis Transplantation, 4(Suppl. 3), iii11-iii13.

Schiller, B., Neitzer, A., & Doss, S. (2010). Perceptions about renal replacement therapy among nephrology professionals. Nephrology News & Issues, 24(10), 36-44.

U S Renal Data System (USRDS). (2012). USRDS 2012 annual data report: Atlas of chronic kidney disease and end-stage renal disease in the United States. Bethesda, MD: National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases. Retrieved from http://www.usrds.org/reference.aspx

Thomas Czajkowski, BS, is a Medical Student, Chicago Medical School, Rosalind Franklin University of Medicine and Science, Chicago, IL.

Shaun Pienkos, BS, is a Research Associate, Satellite Healthcare, Inc., San Jose, CA.

Brigitte Schiller, MD, FACP, is Chief Medical Officer, Satellite Healthcare, Inc., San Jose, CA.

Sheila Doss-McQuitly, BSN, RN, CNN, CCRA, is Nursing Director of Research, Satellite Healthcare, Inc., San Jose, CA, the ANNA Western Region Vice-President, and a member of ANNA's Northern California Chapter. She may be contacted directly via e-mail at dosss@satellitehealth.com

This offering for 1.3 contact hours is provided by the American Nephroogy Nurses Association (ANNA).

American Nephrology Nurses Association is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center Commission on Accreditation,

ANNA is a provider approved by the California Board of Registered Nursing, provider number CEP 00910.

Accreditation status does not imply endorsement by ANNA or ANCC of any commercial product,

This CNE article meets the Nephrology Nursing Certification Commission's (NNCC's) continuing nursing education requirements for certification and recertification.


Table 1
Demographics

                                              Patients Returning
                             All Admissions     Questionnaires
Measure                        (N= 411)          (N = 287)

Race
  American Indian                4 (1%)             3 (1%)
  Asian                         70 (17%)           69 (24%)
  Black                         74 (18%)           35 (15%)
  Hispanic origin               74 (18%)           44 (15%)
  White                        185 (45%)          132 (47%)
  Unknown                        4 (1%)             4 (1%)

Gender

  Male                         181 (44%)          162 (57%)
  Female                       230 (56%)          125 (43%)

Employment Status

  Disabled not working          53 (13%)           44 (15%)
  Full-time                     58 (56%)           35 (12%)
  Medical leave of absence      17 (13%)           14 (5%)
  Part-time                     30 (8%)            18 (6%)
  Retired                      149 (36%)          117 (42%)
  Student                        5 (1%)             3 (1%)
  Unemployed                    58 (14%)           29 (10%)
  Unknown                       41 (10%)           27 (9%)

Diabetes Status

  Has diabetes                 205 (50%)          144 (50%)
  Does not have diabetes       206 (50%)          143 (50%)

Marital Status

  Divorced                      33 (8%)            20 (7%)
  Married                      243 (59%)          177 (63%)
  Partnered                     12 (3%)             7 (2%)
  Separated                      8 (2%)             4 (1%)
  Single                        66 (16%)           48 (16%)
  Widowed                       37 (9%)            29 (10)%
  Unknown                       12 (3%)               2%

Age

  Mean (years)                     60                 61
  Range (years)                 20 to 98           20 to 92

Vintage

  Mean (months)                    30                 27
  Range (months)                9 to 318           9 to 252

Modality

  PD (number of patients)      329 (80%)          243 (85%)
  HHD (number of patients)      82 (20%)           44 (15%)

Notes: PD = peritoneal dialysis; HD = hemodialysis.

Table 2
Survey Questions and Patient Responses
                                      Number
Measure

Did you attend a Dialysis
Options class?
Before starting dialysis.               73
In the hospital.                        49
In the dialysis clinic                  32
after I started dialysis.
In the doctor's office.                132
Online.                                 3
From a family member or friend.         15
At an Options class.                    20

Did you attend Dialyals Options class?

Yes                                    211
No                                      76

At a WellBound Center?

Yes                                    205
No                                      82

Did your doctor talk to you about home dialysis at
the doctor's office or in the hospital before you
started dialysis?

Yes                                    244
No                                      43

If you have been dialyzing in an in-center
dialysis unit did you hear about the home therapy
in your dialysis clinic?

Yes                                     79
No                                     133

What were the factors that lead to your decision
to home dialysis either peritoneal or
hemodialysis?

Ability to perform dialysis at home    180
Less dietary restrictions               75
Control over schedule and therapy      154
Transportation issues                   68
Potential for better outcomes          112
To allow me to keep working             62
Other (Please specify)                  84

Note: Total number of respondents = 287.
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Article Details
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Author:Czajkowski, Thomas; Pienkos, Shaun; Schiller, Brigitte; Doss-McQuitty, Sheila
Publication:Nephrology Nursing Journal
Article Type:Report
Geographic Code:1USA
Date:Jan 1, 2013
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