Funder-provider engagement and patient education are vital in growing home dialysis uptake across an entire region or country. Financial incentives or performance targets are among key options for achieving the former—while the assessment of all end-stage kidney disease (ESKD) patients for home dialysis eligibility, followed by adequate encouragement and continued support, is also critical. These messages were conveyed by Peter Blake (Western University, London, Canada) during his presentation of ‘the Ontario experience’ at UK Kidney Week (UKKW 2022; 7–9 June, Birmingham, UK).
Blake began by noting that, as much as many global healthcare systems would like to grow their usage of home dialysis—and, in particular, peritoneal dialysis (PD)—for cost- and patient care-related reasons, in-centre haemodialysis (ICHD) is still the default modality “almost everywhere”. He added that this is mostly driven by simplicity and corporatisation.
One of the key points that Blake pressed home throughout his UKKW talk was that growing home dialysis in a region or country, in general, is not possible without a systematic initiative. He also said it is important to assess all ESKD patients as possible home dialysis candidates from the outset. Sufficient funding is “inevitably required” too, Blake added.
In an effort to boost home dialysis rates, which had waned since the turn of the century—despite PD and home haemodialysis (HHD) being very popular in the 1980s and 1990s—the Ontario Renal Network (ORN) launched a multifaceted initiative in 2012. According to Blake, this was based around five enablers and 14 interventions, including a new, dedicated funding formula; a single, provincial data reporting system; and increased involvement of the ORN to build a ‘true network’ centred around a culture of accountability. Blake noted that this process “takes time—but was achieved”, in part via the introduction of new roles and regular meetings.
The speaker also highlighted the need to maintain “true modality choice”, adding that home modalities are not mandated and the majority of patients still receive ICHD. Patient education, support and encouragement, as well as expert advice—coupled with clinicians being advised to consider home dialysis as the first option “if at all possible”—helped provide patients with a full range of options, Blake said. Initiatives from multidisciplinary pre-dialysis clinics and regular, comparative ‘benchmarking’ between programmes, to greater PD usage in long-term care homes and even subsidising water bills for patients on HHD, were deployed too.
Blake reported that all of these measures fed into a home dialysis target of 27% across Ontario. Individual programmes and centres were, however, given realistic goals based on their own starting rates, with active performance management including discussions, site visits, reviews and, previously, small funding penalties, being used in programmes falling short of their targets.
Delivering 10-year data on the impact of this initiative, Blake said Ontario’s home dialysis rate began at around 22.5% in 2012/13 and has now risen to 26–27%. He noted that this 4% increase “may not seem huge, but is a lot” and represents a relative increase of 20% over the past decade. Blake also reported major gains in the first four or five years, which have broadly plateaued since. PD was almost solely responsible for that initial increase—jumping from 17.3% in 2012/13 to 20.8% in 2021/22, having peaked as high as 21%. Blake added that HHD has gone backwards slightly despite an early period of growth (5.4% in 2012/13; 6% in 2015/16; 5.5% in 2021/22).
“In total, the dialysis population of Ontario has risen 24% in the past decade, but ICHD has only risen 17% while home dialysis has gone up by almost 50%,” he said. “And, PD is the big driver, as it is up almost 56% while HHD is up about 30%. This gives you a sense of the change that has occurred in dialysis modality distribution across the province following the switch towards home modalities.”
While growth has slowed, almost to a halt, since the first half of the decade, Blake noted the importance of these higher rates being maintained—as many initiatives make a difference early on but ultimately fail to sustain change. In addition to reporting cost savings in the region of C$60 million, the speaker cited the development of a network of accountability, the “critical” role played by renal programme directors in controlling resources and staff, and the power given to the ORN through funding control as being key, but added that it is difficult to assess the impact of individual interventions due to the fact they were all implemented concurrently across the board.
Detailing present and future challenges, Blake said growth becomes harder over time and conceded that there may be a limit to how much more home dialysis uptake can increase. He believes the rate in Ontario, for example, is unlikely to shift above 30% without ‘compulsion’ i.e. mandating home dialysis usage. However, Blake reiterated here that he thinks these current home dialysis rates are sustainable moving forward. He also said he was “disappointed” to see HHD stagnate, adding that a “gamechanger” is likely needed here. Speaking to Renal Interventions following UKKW, Blake elaborated: “Assisted PD was crucially important in this initiative and is being used in 20–35% of patients at any given time. However, staffing shortages—especially during the COVID-19 pandemic—have been limiting availability of this support in many regions. Also, assisted PD raises costs and so care should be taken in judiciously focusing on providing it to those who truly need it.”
Blake further noted that kidney transplant rates also rose throughout the past decade—particularly prior to the COVID-19 pandemic—and this inevitably detracts from growth in home dialysis uptake, drawing some ESKD patients away from dialysis altogether. This was reflected in the ORN’s decision to drop its home dialysis target from 28% to 27% midway through the initiative.
Other lessons learned over the past 10 years, according to Blake, include the fact that “nephrologists alone will not grow home dialysis across a region”. And, while they are generally favourable/not hostile to increased home dialysis deployment, only a small percentage are passionate and committed to driving this change. As such, growth is more likely to depend on more widescale initiatives backed by the ‘funding lever’. Here, Blake highlighted examples, including more extreme but ultimately successful PD-first strategies seen in Hong Kong and Thailand, and the USA’s attempts to boost HHD and PD by adding drugs (a “huge profit item”) into dialysis funding bundles from 2011. This constitutes “a very clear example of how the funder can change the game”, Blake asserted.
“The default modality selection is always ICHD, because it is easier to do [and to deliver at short notice],” Blake concluded. “If a region or country wishes to grow home dialysis, the funder has to engage the providers—either with direct financial incentives like in the USA, or by demanding that targets are achieved via performance management, as we have done in Ontario.”