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The benefits of staying home

There is increasing evidence that home dialysis has not only a number of clinical and social benefits for patients, but financial benefits for the health system. Annie May reports.

Each year there are more and more Australian’s who require dialysis therapy for end-stage kidney disease. And with an ageing population and an increase in the prevalence of diabetes and hypertension the number is only set to rise.

As well as having devastating consequence to the patients and their loved ones there is also a large financial cost – for individuals, families, the wider community and governments.

The cost of treating all current and new cases of end-stage kidney disease (ESKD) from 2009 to 2020 is estimated to be around $12 billion to the federal government, according to Kidney Health Australia.

But there is a way to lessen these costs.

Recently there has been increasing evidence to suggest the use of home dialysis therapy is not only beneficial to patients, but also cost effective for the health system, when compared to tradition in-centre haemodialysis.

Kidney Health Australia reported in its report Economic Impact of End-Stage Kidney Disease in Australia that increasing the use of home-based dialysis would lead to estimated savings of about $400 million between the period 2009 to 2020.

Yet, despite the growing list of benefits, the number of people who dialyse at home is significantly less – about one-third – than it was in 1970.

“There is overwhelming support to expand the use of home therapies by health professionals. What needs to happen now is to educate patients on the advantages of home dialysis and encourage the government to support the expansion,” says Marie Ludlow, Kidney Health Australia national medical project manager.

Ludlow says aside of cost saving, advantages of home therapies include ease of increasing the duration and frequency of treatment, enhanced opportunities for rehabilitation and return to employment, improved satisfaction and quality of life, and an ability for those residing in remote locations to remain in their own homes.

“The social advantages can be enormous. As one example, patients who dialyse at home can travel more. To many, that may seem like a basic thing, but for someone who has been on dialysis for 10 years and hasn’t been able to go on holidays it has enormous implications on quality of life, for them and their families,” says Ludlow.

As well as social, there are clinical benefits with data from the Australian and New Zealand Dialysis and Transplant Registry suggesting that undertaking longer and more frequent dialysis sessions, such as those possible with home dialysis, provides a significant survival advantage for patients.

“More frequent and longer sessions, which are only possible at home, are being shown to reduce mortality,” says Ludlow.

In regards to lessening the cost, Ludlow says increasing the number of people who dialyse at home will reduce the numbers of medical and nursing personnel required to care for patients at in-centre and satellite dialysis centres. It will also minimise exposure of patients to hospital-acquired infections.

“Combine the social and clinical advantages with the financial savings and it seems to be a win-win situation to expand the use of home therapies.”

So what barriers exist in stopping this expansion?

In an attempt to answer this question, Ludlow was part of a team that surveyed senior nephrology nurses on their opinions on home dialysis in Australia, the results which are published in Renal Society of Australiasia Journal. In a separate survey, nephrologists’ views were also collected.

“We thought it was important to get the views of nurses as they are pivotal to the dialysis process and have been found to be quite influential in what mode patients choose,” she says.

Worryingly, a previous survey of patients by Kidney Health Australia found many dialysis patients had not been informed about the option of home dialysis by their renal specialist, while many said medical staff had not sufficiently educated them regarding the type of dialysis treatment they were on.

The results also showed that once patients have become established in their particular form of dialysis, they are less likely to switch modes of treatment.

“The key in expanding the use of home therapies is early education. Patients need to be educated and alerted early on in their treatment process about the option of home dialysis and other treatment options,” Ludlow says.

“Our survey of the nurses found that when they have the time and the resources, nurses are happy to talk about home dialysis, but when they don’t have support it doesn’t get done.”

When it comes to renal unit policy, approximately half the respondents (52 per cent) said their unit gave patients free choice in relation to mode of therapy, with 68 per cent also reporting their Unit encouraged patients to do home based therapies. Forty-two per cent said their unit did not have a standard unit policy about choice of modality, but rather individual physicians adopted their own personal policy.

Ludlow says nurses “overwhelmingly” supported expanding the use of home dialysis, with 91 per cent of respondents agreeing to this. However, they were also aware of the impediments that exist.

The two main barriers identified was a perception that home HD patients suffer personal financial disadvantage compared with institutionally treated patients and a lack of physical infrastructure in their Renal Units.

Other impediments for patients, as viewed by nurses, included increased age, increased number of co-morbid conditions, lack of self-motivation and patient abilities (cognition, dexterity and physical strength). But, according to Ludlow, every one of these can be overcome.

These factors should not automatically preclude a patient from being offered home dialysis. Renal staff should adopt the approach that the more patients can do for themselves, the better the outcome,” she says.

This, says Ludlow, often requires flexible solutions for individual patients and adaptation of traditional education and training methods. This could be offering training outside of the conventional Monday to Friday routine, modifying the dialysis equipment so that lifting is not an issue, adapting educational resources to suit different populations, and training nursing home staff.
Nurses also reported a perceived lack of support from medical administration, from the local level to the federal government, to appropriately fund and resource home dialysis programs.

“This reflects a counterproductive approach by administrators as there is a great potential for financial savings if home-based dialysis therapies were more widely utilised, especially with the prospective increase of 8 per cent per year of patients requiring dialysis therapies,” the authors of the survey wrote.

“Enhanced engagement of nephrology nurses with clinical and hospital networks may assist in identifying these perceived barriers and potentially garnering support for home therapy from medical administration and health policy makers.”

Nurses in the survey were also asked what incentives could be offered to increase HD.

The most popular were financial incentives, including reimbursement of out-of-pocket costs for training and setting up, payments for dialysis carers, and direct payments to Renal Units.

Ludlow says it is disappointing that a therapy that could potentially save the health care system millions of dollars each year is perceived to come at a financial cost to the patient.

“Introducing reimbursement of legitimate out-of-pocket costs could provide a solution to overcoming such problems for patients,” she says.

Ludlow says this has already occurred in some states, using the Victorian government funding model as an example. The model provides incentive payments to hospitals for each patient they put on home dialysis, in addition to annual lump sum reimbursements to patients for out-of-pocket home dialysis expenses.

Enhanced support for people dialysing at home such as improved access to respite care and holiday dialysis, and clinical and technical support were also suggested as incentives.

“The benefits to increasing the use of home dialysis are clear. Now we need to act on that evidence,” says Ludlow.

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