CURRENT STATUS OF ALTERNATIVE HEMODIALYSIS REGIMENS
Home Hemodialysis in Australia and New Zealand: How and Why it has been Successful John W. M. Agar,* Carmel M. Hawley,† and Peter G. Kerr‡ *Department of Renal Medicine, Geelong Hospital, Geelong, Victoria, Australia, †Department of Renal Medicine, Princess Alexandra Hospital, Woollongabba, Queensland, Australia, and ‡Department of Nephrology, Monash Medical Centre, Clayton, Victoria, Australia
ABSTRACT After early strong support, home hemodialysis (HHD) has all but disappeared as a viable modality in most western countries––except in Australia and New Zealand (ANZ), where a mean 12.9% of all HD (June 2010) is home-based. The reasons for this unique difference are neither demographic nor geographic; rather, they result from a strong belief held by
ANZ nephrologists, nurses, and funding agencies in the clinical outcome and economic benefits of HHD. This ‘‘hemodialysis is best at home’’ approach has permitted ANZ programs to take full advantage of a renewed interest in extended hour and higher frequency dialysis. This article explores the reasons for the success of HHD in this region.
Historical Perspectives
groups in the South Island. While Seattle may be the HHD cradle, Christchurch is the standard bearer. Continuous ambulatory peritoneal dialysis (CAPD)––a new home therapy characterized by ease of training and lack of capital expense––appeared late in the 1970s. Huge subsequent interest in CAPD led homesuited patients to drift to CAPD and, later, to automated PD (APD). Despite CAPD, APD, and a further challenge through the 1980s from satellite-based facility care, the established HHD training systems, supports, and funding streams remained in place, and HHD remained viable. At the zenith of PD, 32% (Australia) and 62% (New Zealand) dialysis patients were on the modality (3) and, despite a 30-year decline in Australian HHD from 45% to just 11.3% of all dialysis, the combined home therapies were still treating 38.4% (Australia) and 65.3% (New Zealand) of all dialysis patients in 2000 (4). Elsewhere, HHD funding streams had been systematically dismantled or neglected. By 2000, a meager 0.3% of all US dialysis patients remained on HHD with only 7.7% on PD (5). As Australian HHD programs retained a critical ‘‘home’’ mass and were already offering alternate day dialysis to HHD patients, they were ideally placed to take advantage of a renewed interest in higher hour and frequency home-based HD––nocturnal HD (6,7). While longer frequency HHD had been used before (8,9), Canadian reports of a home-based, overnight, slow, frequent ‘‘nocturnal’’ treatment were emerging (10,11). As Australia and New Zealand (ANZ) home training team expertise was still strong, it was relatively simple to transfer conventional HHD patients from daytime to
The impetus to home hemodialysis (HHD) in Australia came largely through one man––a dialysis patient–– who developed renal failure while in Seattle in 1967, trained there for HHD, and introduced the concept to a small, highly motivated, receptive Australian nephrology community. He succeeded in promoting equipment acquisition, reliable technical support, and unrestricted patient access to HHD. Government funding formulas followed. In 1972, the US Congress enacted the Social Security Amendment 1 (Section 2991) (1). This amendment biased US funding toward facility-based care, and HHD began to decline. Conversely, having made an election promise to provide dialysis for all in need, the incoming Australian government (also 1972) proceeded to expand HHD funding to absorb a rapidly rising incident dialysis population. Meanwhile, hospital-based, in-center facilities remained limited. Concurrently, in New Zealand, a National HHD Training Unit was established in Christchurch (2). This unit has continued to provide successful home care (both HD and peritoneal dialysis or PD) without facility-based back-up support, to all socioeconomic and geographic Address correspondence to: John W. M. Agar, Department of Renal Medicine, Geelong Hospital, Barwon Health, PO Box 281, Geelong, Vic. 3220, Australia, or e-mail:
[email protected]. Seminars in Dialysis—Vol 24, No 6 (November–December) 2011 pp. 658–663 DOI: 10.1111/j.1525-139X.2011.00992.x ª 2011 Wiley Periodicals, Inc. 658
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overnight treatment, lengthening the dialysis time to 8–9 hours. From the outset, the Canadian nocturnal programs had included modem-monitored HHD. This permitted central monitoring of real-time treatment data at the parent unit (12). ANZ programs had never monitored HHD and, although unaccompanied home treatments were not encouraged, it was known that many ANZ HHD patients did, indeed, dialyze alone––and safely so. In addition, Australian HHD training had long preferred to train the patient and not a carer. This plus the recognition that longer and more frequent treatments reduce the ultrafiltration rate and risk of intradialytic hypotension reinforced the view that HHD could also be safely performed unmonitored and at night. Where partners were unavailable, unaccompanied overnight HHD was also both condoned and permitted. Overnight rosters of experienced, paid dialysis nurses successfully replaced the more complex Canadian modem-monitoring model, and allowed patients to resolve problems with familiar staff. These factors have combined to extend HHD to a far wider dialysis patient pool. As strong, expert home training teams are widely in place, age and training time have not been particular barriers to successful home transition. Older patients–– assuming suitable dexterity and vision––commonly train as well as or better than their younger counterparts. Older patients commonly have fewer work or family commitments and, if trained at their own pace, train well and safely. As ANZ HHD has been highly cost-efficient (13), it has been easy to increase the sessional frequency to a minimum alternate day therapy, thus abolishing the ‘‘long break.’’ Even 5–6 nights ⁄ week regimens have remained affordable. However, alternate day (3.5 ⁄ week) or four times weekly regimens have predominated in most Australian HHD programs. By December 2008, an estimated 45% of all Australian HHD patients were using overnight therapy (14). By June 2010, 1277 patients (12.9%) of HD patients in ANZ were at home––the majority on nocturnal programs (Personal communication, L. Excell, Interim Registry Data, Australia and New Zealand Dialysis and Transplant Registry, Adelaide, South Australia). Current ANZ Dialysis Modalities The current dialysis modalities in ANZ include in-center (hospital-based) HD; satellite-based HD; home-based HD (both conventional daytime and frequent overnight HHD––the latter now dominant); CAPD; and APD. 1. In-center HD—The Australian and New Zealand Dialysis and Transplant Registry (ANZDATA) records that at December 2009, 28.8% (Australia) and 46.3% (New Zealand) of all HD was center (hospital)-based (14). Most center-based dialysis units provide highlevel acuity care to patients with multiple comorbidities who require on-site medical and nephrology care. However, in-center HD is
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the most expensive modality, and most HD patients do not need intrasessional medical care. Furthermore, center-based environments are thought to dehumanize, institutionalize, and abolish self-determination––all negative influences on quality of life. Rigid hospital work-rosters and thrice weekly travel costs add center-based disadvantages. One further historical footnote regards incenter PD––a small but initially important modality, available in the early 1980s, but now long gone; all PD is now home-based. 2. Satellite HD—An alternative facility-based HD option, commonly administered by trained dialysis nurses in suburban or communitybased centers, or in regional ⁄ rural hospitals distant from the ‘‘parent’’ tertiary in-center service. Distinctively, satellites lack on-site medical or nephrology care. Satellite care provides for 59.4% (Australia) and 28.6% (New Zealand) of all HD (14). By original intent, satellite dialysis required part or full ‘‘selfcare,’’ including machine management and ⁄ or self-needling. Now, while still implying lower acuity care, satellite and in-center margins have blurred: a dwindling number of satellite patients now self-manage within equally rigid treatment schedules and with travel time and costs being dominant issues. 3. Home Dialysis Modalities—In December 2009, 11.8% (Australia) and 25.1% (New Zealand) of all HD was home-based (14); 17.6% (Australia) and 35% (New Zealand) of all dialysis was PD at home. Of PD, CAPD accounted for 40.6% (Australia) and 58.5% (New Zealand) and APD was 59.4% and 41.5%, respectively. This still represented a quantum reduction in PD in both countries from the mid-1990s’ zenith of the modality. It is interesting to speculate on the differences between the HHD and PD uptake in ANZ. Although both countries maintained logarithmic superiority to most other countries in home therapies––Hong Kong being the exception where home-based PD is the dominant modality––New Zealand is where both home modalities have prospered best. Even in New Zealand, there are significant practice differences between the North and South Islands. In the 1970s, Christchurch nephrologists consciously resisted pressures to establish in-center services. With government assistance, all chronic maintenance dialysis was sustained at home. This home-for-all practice is still the Christchurch model and is the single most important factor that differentiates the Christchurch practice (2). From the outset, dialysis services trained, liaised with, and fully involved city, suburban, regional, and rural general practitioners in their home program. Contrary to center-centric practices elsewhere, the Christchurch program continues to champion cooperative management with primary care as the cornerstone of successful home management. As facility-based dialysis numbers
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are rising exponentially, we all might well look to their inspirational program. While the success of home therapies in ANZ has been ascribed to regional geography, this is not so. Australia is one of the most urban countries on earth. Most Australians live in large cities within 50 km of the coast. The 2003 United Nations World Urbanization Report (15) judged Australia to be 92% urban. In comparison, the United States was 80.1%, and Canada was 80.4%. If geography were a factor in home dialysis, Australia might be expected to have less, not more, home patients compared with the United States or Canada. One potential important factor is the attitude of Australians and New Zealanders to their health care, particularly regarding being ‘‘self-caring’’ rather than ‘‘cared-for.’’ While being impossible to quantify, Australians seem to prefer minimal ‘‘state’’ interference in life and health and opt to rely on self-determination. If such perceptions are true, population decisions regarding a complex intervention like home dialysis may be profoundly affected. HHD and Home PD: Competitive or Complementary? Some question whether HHD and PD compete for the same patient population; a recent Canadian study (16) has shown that is not so. Although not specifically studied in ANZ, the Canadian view is supported by the ability of ANZ to sustain high uptake rates for both home-based modalities. Opinions Regarding HHD In 2009, Kidney Health Australia (KHA) surveyed Australian nephrologists, dialysis nurses, and prevalent dialysis patients in three separate but parallel questionnaires. Seventy-one of approximately 300 Australian nephrologists, representing both metropolitan and regional centers and all states (17), reported that 99% of services offered in-center HD, 93% had satellite HD, 98% trained and cared for home PD, and 92% trained and cared for HHD. As continuing funding and infrastructure barriers remained, strong support emerged for up-resourcing both home-based options. The nephrologists believed that medical and nursing expertise in both home therapies was sound; that home PD and HHD were available and supported by most units; and that longer hour and ⁄ or more frequent regimens offered outcome advantages (88% agreed; 10% neutral). Importantly, 93% believed that longer, more frequent regimens were best offered at home. The nursing survey (18) also strongly endorsed the same training, support, and optimal therapy conclusions, but was more strongly critical of training facilities, particularly of infrastructure and staffing ratios. A recently released KHA consumer report (19)––3250 returns from 9223 distributed surveys––concluded that home modality uptake rates might improve with more uniform and consistent education. The patients identi-
fied an educational bias against PD and that following patient acceptance of their modality of first direction–– regardless of that modality––subsequent modality change was uncommon. An earlier educational exposure to the options in and benefits of home therapy seems critical. Interestingly, there was a cumulative increase of >20% of all respondents in a willingness to convert from facility to a home-based therapy, as sequential clinical and financial supports were added. Practical Issues in Program Management HHD suitability assessments, training practices, psychosocial issues, the fears of self-needling, home supports, and the other practical problems routinely encountered when setting up new programs or when training new patients have been described in detail elsewhere (20). Uptake Variability A modality review has been conducted of all 32 Australian dialysis services with >100 patients (December 31, 2008). Assessment by state and by unit showed stark differences in home dialysis uptake, both between states and between units, and both across and within states (21). Home-based, all-modality uptake ranged from 5% to 66%. Home PD uptake ranged from 4% to 43% and HHD uptake ranged from 0% to 26%. The Australian mean all-modality home dialysis uptake was 32%, with 22% PD (CAPD and APD) and 10% HHD. One of Australia’s largest units had 66% at home (46% PD, 20% HHD), while another large service had only 4% at home (3% PD, 1% HHD). Significant state-by-state differences were also seen. The most populous state had the most home patients (42% total: 28% PD and 14% HHD), while the lowest home-performing state recorded only 14% total (10% PD and 4% HHD).The reasons for these discrepancies are likely to be a combination of state demographics, geography, and funding mechanisms. Large, low population states with a high indigent population were least likely to have significant home dialysis. More populous, densely settled states were more home-supportive with formal home funding models and incentive programs being in place. This supports the notion that geography is not the principal reason for a poor home dialysis uptake. Australian core curriculum for nephrology training requires home therapy training––both PD and HD––as an essential training component (22). Trainees are encouraged to experience at least two different programs during their 3-year training, permitting those underexposed to either home therapy in 1 year to up-skill at a different site in a subsequent year. Comparative Costs: HHD, Home PD, and Facility-based HD Multiple studies from differing health structures and funding systems have confirmed HHD as the most cost-efficient HD modality (23–25). Lower medical and nursing requirements, and the absence of
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infrastructure, more than offset the higher equipment and consumable costs––even for high-frequency home programs. Three published Australian studies have shown cost reductions of 15–40% (12,26,27). Even with an HHD frequency of six nights ⁄ week, annual program savings of 10.75% still accrue against conventional thrice-weekly satellite HD (10). Three serial Victorian state funding iterations have confirmed HHD as the cheapest dialysis modality. Furthermore, Victorian funding incentives now encourage home uptake, particularly HHD (28). Using Markov modeling based on the best available published Australian data, a New South Wales study concluded that a 16% saving would accrue to the 2006 national dialysis budget if the national home therapies’ uptake rate had been, within that budget year, at the same level as that achieved by the top home-performing Australian units (26). HHD Incentives Home dialysis patients, whether PD or HD, need strong, effective, and available support to remain confident and safe at home. Home assessments, home visits, ready phone access, a trusted team, and a friendly ‘‘can-do’’ staff––all are essential aspects of good home care. This, however, may still not be enough. While the transfer of dialysis treatment from facility to home dramatically reduces service costs, it simultaneously transfers the cost burden to the patient. This particularly applies to utility costs of water and power, which are currently rapidly escalating in most western countries. Some programs have introduced imaginative rejectwater reuse practices (29). Alternative energy sources have also been trialed (30). Both innovations have reported significant utility cost savings and, if confirmed, bear wider adoption. In the United Kingdom, the National Health Service has established a ‘‘Green Nephrology’’ program. This is already encouraging ‘‘greener’’ practices across 40 renal services in Britain (31). The ‘‘carbon footprint of dialysis’’ has been reported, and incentive programs to reduce the ‘‘footprint’’ are under development (32). At an administrative level, some Australian states now award incentive payments to units that encourage HHD (28). In Victoria, incentive subsidies of A$10,000 (HD) and A$2500 (PD) are directly paid to services for each patient installed at home. Similar subsidies are not directed to facility-based care (28). In addition, patients are annually reimbursed pro-rata for their dialysisrelated water and power expenses. A monthly federal fee for home patient management is also paid to physicians for each HD or PD home-sustained patient (33). Physicians are not paid similar management fees for facility-based patients. While the success of such initiatives remains to be proven, states where incentives are offered are also those states with the greatest home PD and HHD penetration. The budgetary incentive programs in British Columbia are also notable, their initial HHD growth reports, both at state and program levels, being most encouraging (34).
Barriers to HHD Most HHD barriers are perceived and relative, rather than real and absolute. While age is often considered a major HHD restriction, it is not so viewed for home PD. The elderly also train carefully and meticulously for HHD, if allowed to train at their own pace; needle anxiety appears less problematic. If compassionately supported, older patients do well at home. Although comorbidity clearly rises with age, not all comorbidities are HHD contraindications, assuming careful assessment and explanation. More difficult can be the decision to ‘‘evict’’ a home-established patient back to facility care if comorbidities supervene and continued home therapy is deemed unsafe. Venous needle disconnection (VND) is currently a topical issue with several VND detection devices now available. However, VND has not been a significant clinical risk in ANZ, provided strict fixation protocols are followed and self-devised short cuts are avoided. Carer burn-out (20), the risk of access infection (especially using the buttonhole technique) (35), the provision of respite care, and technical failure––are all reported HHD problems, yet none is insuperable in services with well-constructed and managed home programs. ANZ still depends upon single-pass dialysis systems–– systems that are complex to learn, slow to set up, and costly to maintain. When newer, simpler equipment–– unaccountably now available in far less home-friendly countries––or desktop systems currently in development become available, a further expansion of an already successful ANZ HHD milieu seems certain.
HHD Outcomes: ANZ Local enthusiasm and funding support for HHD would be insufficient to sustain HHD unless outcome data were also favorable. While recognizing the limitations of registry data when compared with formal randomized control trial (RCT) data, it has to be recognized that RCTs are rare in dialysis, and will likely remain so despite attempts by the international dialysis community to correct this evidence deficit (36). Already published and current ongoing trials are not powered to establish whether survival benefits are conferred by novel quotidian regimens. Many believe that an undeniable strength exists in complete registry-based data sets. Observational data from ANZDATA suggest that the total hours of dialysis delivered per week confer a strong survival bias to longer hour regimens (see Fig. 1). These unadjusted data demonstrate that dialysis of ‡18 hours ⁄ week shows superior survival over 15–18 hours ⁄ week. This, in turn, is superior to 12–15 hours ⁄ week. All yield superior outcomes ‡12 hours dialysis ⁄ week. As most conventional facilitybased HD is schedule-limited to ±4.5 hours thrice weekly (13.5 hours ⁄ week), it is only the home patients who have access to longer or more frequent HD options. However, residual confounding, particularly related to comorbidity status and other patient-related factors,
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Agar et al. Haemodialysis Patient Survival Australian Patients on HD 1997 - 2009 At 90 days after First Treatment By Hours per Week. Aged >= 19
Percent Survival
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elsewhere. The success of HHD in ANZ is now finally–– and gratifyingly––providing a springboard to a greater global interest in and uptake of HHD modalities.
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References
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