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Increasing adoption of at-home dialysis

Patients who undergo home dialysis tend to fare better than their in-clinic counterparts. So why is this an exception and not the norm?

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Dialysis can be a life-sustaining treatment for people with end-stage renal disease (ESRD). It can also be a long and costly treatment. A patient who lands in a clinic dialysis chair may expect to spend as much as five hours per session there, with three sessions each week, for an average of five to 10 years.1 The spend associated with all that treatment time? The average monthly cost is $3,364 for Medicare patients, according to a 2021 report in JAMA Internal Medicine. For non-Medicare patients, the monthly average is more than three times higher, at $10,149.2

With more than half a million Americans now receiving dialysis,3 the total costs are staggering. ESRD patients make up less than 1% (0.1%) of the individual health care market, but account for 3.3% of total non-group-plan health care spending.4 In other words, the average monthly spending on all services for these patients is 33 times higher than spending for those without ESRD.5

In 2019, the U.S. Department of Health and Human Services launched a program called Advancing American Kidney Health to increase the number of U.S. patients with kidney failure treated at home, whether by peritoneal dialysis or home hemodialysis.6 At that time, Alex M. Azar II, then Secretary of Health and Human Services, called dialysis “one of the most burdensome, draining long-term treatments modern medicine has to offer,” saying it’s “far from sustainable.”7

But there is another option. For patients reluctant to spend hours in a clinic dialysis chair, and for payers looking to bring renal-related care costs under control, at-home dialysis is well worth exploring.

The upsides of outpatient dialysis

Health care costs tend to be far lower when people pursue home dialysis than in-center options. But that’s hardly the only reason why this option is becoming more popular.8 Quality of life is a central concern for ESRD patients. When researchers asked those on or near dialysis to share their most pressing questions about managing kidney failure, the vast majority of responses related to quality of life, such as depression, poor sleep, low energy and sexual side effects.9 In another study, researchers found that patients on dialysis would be willing to give up seven months of life expectancy to reduce their number of hospital visits and 15 months to decrease their travel restrictions.10

Shifting dialysis to the home can offer huge quality-of-life improvements for the patient, sparing them the scheduling, travel and restricted mobility of in-clinic dialysis. Home dialysis also often means patients can administer the treatment more often, which can lead to fewer dietary restrictions and fewer side effects (like headaches and cramping).11 ESRD patients who receive dialysis at home also report better post-dialysis recovery time,12 better sleep quality,13 and fewer low blood pressure episodes.14

At the same time, research shows that survival rates tend to be higher when patients receive dialysis at home, compared with those who receive in-center hemodialysis treatment.15 In a large study in the American Journal of Kidney Disease, home hemodialysis was associated with an 8% lower risk of hospitalization and a 20% lower risk of all-cause mortality.16 No wonder, then, that more than 90% of nephrologists said they would choose a home therapy for themselves, if faced with dialysis.17

Pushing for more at-home options

Roughly 85% of ESRD patients are eligible for in-home dialysis.18 Yet, of those on hemodialysis, only 2% use home dialysis.19 Clearly, the current model — in which educating patients about their options falls to providers and dialysis clinics themselves — isn’t working.

ESRD patients choose the default treatment setting for many reasons. One is that many ESRD patients have little time to research their options. Instead, they may be diagnosed with renal disease only once they learn they need dialysis. This unplanned start (also called “crashing” into dialysis) can be a time of stress and fear, which may make a clinical setting more appealing. Another factor may be intimidation, as patients assume they’d be on their own to figure out how to navigate at-home treatment. Or they might simply be unsure of where to turn for help.

Patient-centric education and support can ease all three barriers. But handing out a brochure or posting details on a website isn’t enough. To truly empower patients to make an informed decision, a more tailored approach is needed. Imagine, for instance, a clinical specialist highly trained not only in renal disease management but the treatment landscape. This dedicated support system would educate the patient on their dialysis options whether they’re getting ready to book their very first treatment or have already had sessions in a clinical setting.

And for those who opt for home dialysis, a kidney care manager can help make the transition more seamless. They’d train the patient and the patient’s support partner on how to conduct the treatment at home, solicit patients’ questions or concerns, and provide ongoing monitoring to ensure treatments are proceeding apace.

As noted in Kidney Medicine, “unstable living situations and limited space for storage, poor health literacy, and limited family support” can all be barriers for home dialysis among certain patient populations.20 But here, too, a kidney management program can help. Depending on the patient and their situation, a kidney specialist could connect with a social worker to provide tailored solutions. Too little space for supplies at home might be best solved by increasing the frequency of supply deliveries, for instance. Limited family or social support might be best solved through funding patient care assistants.21

Home dialysis isn’t an ideal fit for everyone. But given the health benefits and improved quality of life associated with this form of treatment, it’s worthwhile for more ESRD patients to choose this path. By taking a more patient-centric approach to kidney care management, payers and health systems can turn the tide toward home dialysis, resulting in better health outcomes, bigger savings, and a true feat of public health.

  1. University of California San Francisco. The Kidney Project. Accessed September 29, 2022.
  2. Trish E, Fiedler M, et al. Payment for dialysis services in the individual market. JAMA Internal Medicine. March 22, 2021.
  3. National Institute of Diabetes and Digestive and Kidney Diseases. Kidney disease statistics for the United States. Last reviewed September 2021.
  4. Trish E, Fiedler M, et al. Payment for dialysis services in the individual market. JAMA Internal Medicine. March 22, 2021.
  5. Ibid.
  6. U.S. Department of Health and Human Services. Advancing American kidney health. 2019.
  7. Ibid.
  8. National Kidney Foundation. Have you thought about dialysis at home?
  9. Manns B, Hemmelgarn B, Lillie E, Dip SC, Cyr A, Gladish M, Large C, Silverman H, Toth B, Wolfs W, Laupacis A. Setting research priorities for patients on or nearing dialysis. Clin J Am Soc Nephrol. 2014; 9(10):1813–21. doi: 10.2215/CJN.01610214. Epub 2014 May 15.
  10. Morton RL, Snelling P, Webster AC, et al. Factors influencing patient choice of dialysis versus conservative care to treat end-stage kidney disease. March 20, 2012.
  11. Ibid.
  12. Jaber BL, Lee Y, Collins AJ, et al. Effect of daily hemodialysis: A comprehensive review of patient-centered and economic considerations. Clinicoecon Outcomes Res. 2017;16(9):140–161.
  13. Jaber BL, Schiller B, Burkart JM, et al. Impact of short daily hemodialysis on restless legs symptoms and sleep disturbances. Clin J Am Soc Nephrol. 2011;6(5):1049–1056.
  14. The FHN Trial Group. In-center hemodialysis six times per week versus three times per week. N Engl J Md. 2010;363(24):2287–2300.
  15. U.S. Department of Health and Human Services. Advancing American kidney health. 2019.
  16. Weinhandl ED, Gilbertson DT, Collins AJ. Mortality, hospitalization, and technique failure in daily home hemodialysis and matched peritoneal dialysis patients: A matched cohort study. Am J Kidney Dis. 2016;67:98–110.
  17. Merighi JR, Schatell DR, Bragg-Gresham JL, Witten B, Mehrotra R. Insights into nephrologist training, clinical practice, and dialysis choice. Hemodial Int. 2012;16(2):242–251.
  18. U.S. Department of Health and Human Services. Advancing American kidney health. 2019.
  19. Ibid.
  20. Weiner DE, Meyer KB. Home dialysis in the United States: To increase utilization, address disparities. Kidney Med. February 2020.
  21. Ibid.