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Having dialysis at home has been identified as an important aspect for Australian and New Zealand dialysis clients (Morton et al 2011*). Currently the majority of dialysis clients undertake their dialysis in hospital and satellite centres (ANZDATA 2017**).

Analyse why this discrepancy may occur. What would be the long-term advantages, of a closer alignment between preference and reality, for individual health care and the health system? 

Patient preference for location of dialysis

Patients with end-stage kidney disease depend on dialysis for blood purification and survival. The therapy has flexible location choices and can be received either at home or at hospitals and satellite centers. Most patients prefer home-based dialysis since it confers the convenience of time and finances. Ironically, majority of dialysis patients in both Australia and New Zealand undertake their dialysis in hospitals and satellite centers (ANZDATA, 2018, p.6).

Australia and New Zealand have a moderate prevalence of patients on dialysis with an increasing trend in those seeking therapy at hospitals and satellite centers. Clients between 65 to 74 years have the highest prevalence for dialysis in Australia while in New Zealand dialysis is more common among patients aged 55 to 64 years (ANZDATA, 2018, p.7). Between 2012 and 2016, there was an increase in the number of Australian clients who received dialysis in hospitals and satellite centers and a steady graph for those who received treatment at home. On the contrary, the number of clients who received therapy at hospitals and satellite centers in New Zealand increased between 2012 and 2016, while those on home therapy slightly decreased (ANZDATA, 2018, p.8).

Although the popularity of home-based dialysis seems to be decreasing, most patients and caregivers prefer for the therapy to be administered in the comfort of their homes. According to patients, the most important aspects for dialysis are survival, having dialysis at home and dialysis-free days (Morton et al., 2011, p.4038). While survival is the main goal of treatment, home-based dialysis and dialysis-free days play a significant role in improving the patients’ quality of life. For caregivers, the most important factors are the convenience of dialysis at home, respite and the ability to travel. It is therefore evident that having dialysis at home is a common preference choice for both the patients and caregivers.

The preference for home dialysis can be attributed to the cheaper cost it confers. In the United Kingdom, dialysis at home is 20,000 pounds cheaper than dialysis at hospitals and satellite centers (Morton et al. 2011, p.4038). The extra costs to be covered for travel in form of gasoline and auto-maintenance are saved when dialysis is done at home. Still, the remoteness of both Australia and New Zealand has contributed to the increased popularity of home-based dialysis as most clients strive to avoid the inconvenience of traveling to the dialysis centers (Kerr and Agar, 2016, p.543). Needless to say, dialysis at home has a huge economical advantage.

Advantages of home-based dialysis

Home-based dialysis might also be the preferred choice of treatment since it is associated with better patient outcome. Studies have shown that daily home-based dialysis has numerous cardiovascular benefits including controlled blood pressure and a better quality of life (Nadeau-Fredette et al., 2014, p.6). Through daily and nocturnal home dialysis, patients are able to maintain better fluid control in their body. The frequent dialysis helps to prevent fluid accumulation in the body and is thereby protective against edema, fluid overload, congestive heart failure and cardiomyopathy.

Patients on nocturnal home-based dialysis can also enjoy a near-normal type of diet unlike their counterparts who go to hospitals and satellite centers. Due to less accumulation of toxic substances in the body brought about by frequent dialysis done every night, these clients’ diets are less restricted. (American Association of Kidney Patients, 2016). However, those on home-based dialysis, but not necessarily on the nocturnal plan cannot enjoy this benefit; they have to selectively choose their diet to prevent build-up of wastes in their body.

Also, plenty of time is saved when patients receive therapy at home. Patients are able to do other activities during the sessions, for example, they can surf the internet, watch their favorite television shows, make phone calls or read a novel. According to Glickman, the time that would otherwise be spent travelling to the hospital or satellite centers is saved when dialysis is done at home (n. d). It therefore makes sense that patients would prefer short, daily sessions that enable them to do still engage in their hobbies and other meaningful activities.

More importantly is the fact that home-based therapy is associated with a slower decline of the residual kidney function. The patients are able to partly utilize their renal system for excretion, and this is especially important for the removal of uremic solutes which are not effectively cleared by dialysis (Toth-Manikowski et al., 2017, p.5). If these uremic solutes are not excreted from the body, they contribute to toxicity, morbidity and mortality. The preservation of the residual kidney function therefore increases the patients’ survival rate.

Receiving therapy at home is less likely to make patients depressed. Only 8% of patients on home-based dialysis fall into depression; this is much lower than the 42.3% of those who are depressed from receiving therapy at hospitals and satellite centers (Bennett et al., 2015, p. S128).Clients on home-based dialysis are more positive about the outcome. While at home, they get to interact with their family and friends who make them happy. A combination of a positive attitude, hobbies, happy friends and daily upkeep are effective in preventing derpression.

Costs of home-based dialysis

In addition, the pre-dialysis education given to both the patients and their caregivers plays an important role in improving and promoting home-based dialysis. Studies indicate that multidisciplinary predialysis education reduces the risk of co-morbidities and decreases the overall cost of dialysis (Yu et al., 2014, p. 5). More information about the therapy is also acquired once the sessions are started. The direct involvement of the clients in treatment makes them to better understand their disease and have a positive perspective. This shift of responsibility from healthcare providers to patients makes the patients to personally monitor and take charge of their health.

Once the patients and caregivers have received training on how to use the user-friendly technology, dialysis can be commenced at home while the patient is remotely monitored. Remote patient monitoring is done using technology that virtually connects the dialysis patients to the healthcare providers via smart phones and computers. A doctor or nurse is also able to monitor the vital signs of the patient, whether the patient is compliant with therapy, if they have any significant symptoms and how much fluid is taken off during every dialysis session. Remote patient monitoring therefore has the advantages of cutting down on travel expenses and reducing the time spent to travel to the hospital or satellite centers (Wallace et al., 2017, p.1012).

However, while most patients prefer to receive treatment at home, home-based dialysis can only be started if the patient can effectively care for themselves or has a family support system (Morton et al., 2011, p.4038). As a result, dialysis at hospitals and satellite centers is the recommended option for compromised patients who lack a family support system. For instance, most of the elderly dialysis clients live alone, away from their children. They lack the support system necessary for home-based therapy. Therefore, while they would prefer home dialysis, they have to settle for therapy at hospitals and satellite centers.

Still, a number of clients have perceived barriers and assumptions about home-based dialysis that make them to shy away from it. Many patients believe that dialysis is a complicated procedure that they cannot do without a medical background (Witten, 2018) The truth however is that the process of dialysis can be done by anyone as long as they receive adequate training on how to conduct the procedure.  To help clear this myth, the decision making process for the location of dialysis should include the input of the patient, the doctor and the caregiver. It is only then that the patients’ questions and concerns can easily be addressed by the doctors. Shared decision making also helps to promote understanding between the patients and the doctors.

Importance of Pre-Dialysis education

Although the decision-making process includes patient education on how to use the technology for home-based dialysis, a number of technical complications arise when the therapy is done at home. One of the main complications that arise when the home dialysis technology is not properly used is an increased risk of infections (Nadeau-Fredette et al., 2014, p.6). Patients and caregivers are also likely to mishandle the equipment due to inexperience or simple burn-out. In an attempt to avoid such technical negligence, they patients opt to receive dialysis at the hospital and satellite centers.

A number of co-morbidities also come up when dialysis is done at home. According to ANZDATA (2018, p.9), type II diabetes is the main co-morbidity associated with home-based dialysis. Approximately 45% of dialysis patients who receive therapy at home have diabetes. The high risk of diabetes could be as result of patient non-compliance when it comes to home-based therapy. Most patients would thus rather go to the hospital and satellite centers which have registered a higher compliance rate compared to home-based dialysis.

Given the discrepancies that exist, there is need to closely align the patients’ preference for home-based dialysis and the reality; which is that majority of the clients receive dialysis in hospitals and satellite centers. One of the main long term advantages of a closer alignment between the two is increased patient compliance. Patients should be able to access the services they prefer so that they feel more motivated to comply with their dialysis schedules. Those who receive dialysis at home are likely to be more compliant to their medication and dialysis sessions. In New Zealand, for instance, there are fewer risks of infections in patients receiving dialysis at home as compared to those who go to satellite centers due to better quality of therapy (Marshall et al., 2014, p.10)

Home-based dialysis and facility dialysis can both become more sustainable when they are closely aligned. Sustainable long term programs that fund home-based dialysis can help to closer align the preference for receiving dialysis at home with the advantages conferred by receiving treatment at hospitals and satellite centers. Many patients are discouraged from receiving home-based dialysis by the fact that they have to cater for additional costs while those receiving dialysis at hospitals and satellite centers do not incur out-of-pocket costs (Walker et al., 2017, p. 153). Governments should thus consider providing incentives so as to sustain the long-term use of home-based dialysis globally, and not only the facility dialysis. The patients will thereby be able to use this form of therapy without much financial strain.

Role of remote patient monitoring

In addition, attempts made towards better education of patients and caregivers can help prevent complications brought about by the wrong use of equipment during home-based dialysis. The state and federal governments should both take initiative in championing for better predialysis education. An example of an initiative aimed at improving the life of dialysis patients is the Kidney Health Australia End-Stage Kidney Disease Education Project (Fortnum and Ludlow, 2014, p. 79). The pre-dialysis education should be supplemented with regular education after therapy has commenced. Subsequently, the instruction can be reinforced and follow-up be done with regards to dialysis at home. The use of simulations during the patient education sessions has proven to be effective in making patients better prepared for home-based dialysis (Chan et al., 2015, p. 597).

Better still, a strong and reliable back-up system should be established to support home dialysis. For example, there should be a 24-hour hotline for home-based dialysis patients who wish to make consultations and a visiting team of healthcare practitioners who regularly visit the client and supervise the patient’s condition (Karkar et al., 2015, p. 1102). A medical supply team should also be ready to promptly provide their services in case the patient is facing technical challenges or their equipment breaks down.

Lastly, home-based dialysis can be done at alternating times with dialysis at hospitals and satellite centers. Such an alignment between the two locations would help in preventing excessive strain on one side. The patients can initially enjoy home-based dialysis with the help of their caregivers. Thereafter, the patients can go for dialysis at hospitals and satellite centers for the next few months for what is known as respite dialysis. Respite dialysis enables both the patients and their caregivers to re-energize during the break before home dialysis resumes (Kerr and Agar, 2016, p.543). It is a great way of preventing burnouts on the patients and caregivers side and over-congestion in the facilities.

While the dialysis patients in both Australia and New Zealand prefer to receive therapy at home, they are unable to achieve this due to premade assumptions and a high risk of complications. Since survival remains the main goal for all patients, dialysis patients forego their preference for home-based dialysis and instead go to hospitals and satellite centers where their survival is more guaranteed. Efforts, both monetary and educational, made towards closer alignment of home-based dialysis and dialysis received at hospitals and satellite centers can confer long-term advantages for the use of dialysis as a preferred modality for renal replacement therapy.

Challenges faced by home-based dialysis

References

American Association of Kidney Patients (2016)  Food choices for Home Dialysis. American Association of Kidney Patients [online]. Available at: https://aakp.org/dialysis/food-choices-for-home-hemodialysis/ [Accessed 26th August 2018]

ANZDATA Registry . (2018). 40th Report, Chapter 2: Prevalence of End Stage Kidney Disease. Australia and New Zealand Dialysis and Transplant Registry . Available at: https://www.anzdata.org.au [Accessed 26th August 2018]

Bennett, P.N.,  Schatell, D., & Shah, K.D. (2015) Psychosocial aspects in home homeodialysis: A review. Homeodialysis International [online]. Vol.19, pp. S128-S134 Available from: https://onlinelibrary.wiley.com/doi/pdf/10.1111/hdi.12258 [Accessed 26th August 2018]

Chan, D.T., Faratro, R. & Chan, C.T. (2015) The impact of simulation-based teaching on home hemodialysis patient training. Clinical Kidney Journal [online]. Vol. 8 (5), pp. 594-598 Available from DOI: https://doi.org/10.1093/ckj/sfv067 [Accessed 26th August 2018]

Fortnum, D. & Ludlow, M. (2014) . Improving the uptake of home dialysis in Australia and New  Zealand. Renal Society of Australasia Journal [online]. Vol.10 (2), pp. 75-80. Available from: https://www.researchgate.net/publication/287487422_Improving_the_uptake_of_home_dialysis_in_Australia_and_New_Zealand  [Accessed 26th August 2018]

Glickman, J. (n. d) Home treatments: Home homeodialysis and peritoneal dialysis. Davita Kidney Care [online]. Available from: https://www.davita.com/treatment-services/home-dialysis/home-benefits/home-hemodialysis-and-peritoneal-dialysis-a-look-at-the-two-main-types-of-home-dialysis [Accessed 26th August 2018]

Karkar, A., Hegbrant, J. & Strippoli, G.F.M. (2015) Benefits of Implementation of Home Dialysis: A narrative review. Saudi Journal of Kidney Diseases and Transplantation [online].  Vol. 26 (6),pp .1095-1107. Available from: https://www.sjkdt.org/article.asp?issn=1319-2442;year=2015;volume=26;issue=6;spage=1095;epage=1107;aulast=Karkar Accessed 27th August 2018]Top of Form

Kerr, P.G. & Agar, J.W.M. (2016) Keeping Home Dialysis Patients at Home .  American Journal of Kidney Diseases [online]. Vol. 67 (4), pp. 542-544. Available from DOI:  https://doi.org/10.1053/j.ajkd.2016.01.006 [Accessed 26th August 2018]

Marshall, M.R. , Walker, R.C., Polkinghorne, K.R. & Lynn, K.L. (2014) Survival on home dialysis in New Zealand. PLoS One [online]. Vol.9 (5), p. 10. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4013072/ [Accessed 26th August 2018]

Morton, R., Tong, A ., Webstar, A., Snelling, P., & Howard, K. (2011). Characteristics of dialysis important to patients and family caregivers: a mixed methods approach. Nephrology Dialysis and Transplant . Vol. 26 (12), pp. 4038-4046. Available from DOI: https://doi.org/10.1093/ndt/gfr177 [Accessed 26th August 2018]

Nadeau-Fredette, A., Badve, S.V., & Johnson, D.W . (2014) Daily Home Dialysis: Balancing Cardiovascular Benefits with Infectious Harms. American Journal of Kidney Diseases [online]. Vol. 65 (1), pp. 6-8. Available from DOI:  https://doi.org/10.1053/j.ajkd.2014.08.012 [Accessed 26th August 2018]

Toth-Manikowski, S.M., Mullangi, S., Hwang, & S., Shafi, T. (2017)  Incremental short daily home hemodialysis: a case series. BMC Nephrology [online]. Vol. 18, p. 216. Available from DOI: https://doi.org/10.1186/s12882-017-0651-1 [Accessed 26th August 2018]

Walker, R.C., Howard, K. & Morton, R.L. (2017) Home Dialysis: a comprehensive review of patient-centered and economic considerations. ClinicoEconomics and Outcomes Research [online] .  Vol.9, pp. 149 -169 . Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5317253/pdf/ceor-9-149.pdf  [Accessed 26th August 2018]

Wallace, E.L., Rosner, M.H., Alscher, M.D., Schmitt, C.P., Jain, A., Tentori, F., Firanek, C., Rheuban, K.S., Florez-Arango, J., Jha, V., Foo, M., Blok, K. , Marshall, M.R., Sanabria, M., Kudelka, T. & Sloand, J.A. (2017) Remote Patient Management for Home Dialysis Patients . Kidney International Reports [online]. Vol. 2 (6), pp. 1009-1017. Available from DOI:  https://doi.org/10.1016/j.ekir.2017.07.010  [Accessed 26th August 2018]

Witten, B. (2018). Mythbusting! Do nephrologists really make less money seeing home dialysis patients? Home Dialysis Central [online]. Available from: https://homedialysis.org/news-and-research/blog/238-mythbusting-does-medicare-really-pay-nephrologists-less-to-see-home-dialysis-patients [Accessed 26th August 2018]

Yu, Y., Wu, I., Huang, C., Hsu, K., Lee, C., Sun, C., Hsu, H. & Wu, M. (2014) . Multidisciplinary predialysis education reduced the inpatient and total medical costs of the first 6 months of dialysis in incident hemodialysis patients. PLoS ONE [online]. Vol. 9 (11), p. 5. Available from DOI: https://doi.org/10.1371/journal.pone.0112820 [Accessed 26th August 2018]

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