3 Nephrologists Explain 3 Keys to Growing Home Dialysis

Since 2019, home dialysis utilization in the U.S. has seen a significant uptick, according to data released at the American Society of Nephrology Kidney Week 2021 conference. At the heart of this proportionately small but rapidly growing patient population are end-stage kidney disease (ESKD, also referred to as an end-stage renal disease or ESRD) patients who are educated by their care teams, starting with their nephrologist. Recently, three of these physicians, representing hospital systems from around the U.S., were brought together to discuss three key ways to successfully build on the current momentum for sending patients home.

The discussion participants included:

• Vikram Aggarwal, MD, DNB, FASN, Assistant Professor, Department of Nephrology & Hypertension, Northwestern University & Feinberg School of Medicine, Chicago, IL
• Varshi Broumand, MD, FASN, Physician, South Texas Renal Care Group, Dialysis Medical Director, CHRISTUS Health
• Naveed Masani, MD, FACP, FASN, Medical Director of Diabetes Services, NYU Langone Hospital – Long Island
• Moderator: Michael Aragon, MD, CMO, Outset Medical

Dr. Masani set the stage for the unique and complex environment in which nephrologists and other healthcare professionals are managing kidney disease patients across the care continuum today. “Nephrology is one of the very few specialties that see patients across all sites of care—from the ER to the ICU, to fetal medicine in preeclampsia cases [a cause of acute kidney injury], to the hospital dialysis unit, along with bedside cases, the clinic, home, and office visits. And chronic kidney disease patient management is definitely not one-size-fits-all in every case. Nephrology is the most highly individualized care that you can think of. This is what makes it fun, but also challenging at the same time,” he says.

Here’s what this group of seasoned physicians say needs to happen for home dialysis to gain a foothold as a standard of care, with their advice representing a call to action for the kidney disease community.

1. It All Starts with Education

The three discussed that as nephrologists, they ensure that the patient is educated about their treatment options, and recognize the important role that the nurse educator and other care team members play in a patient’s decision to go home. Ultimately though, they agree that it needs to be the patient’s choice.

In Dr. Broumand’s view, the nurse educator who is teaching the patient in an unbiased way about different modality choices, taking into consideration the person’s specific needs and lifestyle, has a major influence on their decision. “The patient gets to spend two to three hours with that individual. Nurses are very influential,” he says.

Dr. Masani adds that the home nurse, in particular, is critical in helping the home patient succeed. “As a nephrologist, there’s a lot that you fundamentally don’t know. For example, you don’t do the home visit. Your nurses do. I listen to my nurses about what’s working or not, for the patient and their family.”

“I need to have buy-in from my nurses, and that’s what is so special about home. We all just want to make sure the patient is safe,” adds Dr. Broumand.

Dr. Aggarwal says that nurses serve a key role in instilling confidence in the patient. “With dialysis, if the nurse is educated and confident about the various therapeutic options, including home, they can then pass that confidence on to the patient,” he says. “Nurses can even be compared to trusted, respected parental figures, who are working alongside the nephrologist to make sure the patient is safe and well taken care of. We will need more of these care teams in the future in order to support growth in home hemodialysis.”

Dr. Broumand explains that hands-on patient education prior to them going home with a device is key as well. “Transitional care is a good opportunity for patients to train and use home hemodialysis for a few sessions. In that way, they can make an educated decision on whether that modality is realistically going to work for them. This includes vascular access and cannulation education, as you have to make sure they are comfortable,” he says. “In terms of PD [peritoneal dialysis] versus home hemo, I like to iterate that dialysis at home with the Tablo Hemodialysis System is much more of an easy-to-use and flexible option, and takes much less of their time,” he continues.

(Note that there is now an added incentive for providers to send patients home on Tablo, after CMS recently announced its first-ever approval for a Transitional Add-on Payment Adjustment for New and Innovative Equipment and Supplies [TPNIES], with Tablo deemed a substantial clinical improvement over other existing home hemodialysis technology.)

Another important component in moving patients home is having peer advocates, says Dr. Aggarwal. “It’s helpful to be able to learn from others who are also going through kidney disease, and who are successfully treating at home. This can help build their confidence and trust, and overcome fears that treating at home is something that they can achieve.”

2. Pandemic-Driven Telehealth and Remote Monitoring

All three nephrologists mentioned that connected and intelligent device innovation will be crucial to sending more patients home, and the future certainly looks bright in that arena, with the Tablo system available for home use. “What if, several times a week, you could have an RN remotely check-in and see the patients. Would that give the nephrologist a little more comfort level? I say yes, especially with your sicker and more vulnerable patients, as we learned during this pandemic,” says Dr. Masani.

(For more information on the Tablo device’s digital ecosystem of intuitive tools to simplify dialysis, including remote monitoring and two-way communication with the cloud, see the Providers page and recent data on the Outset Medical website.To read more about the utility of Tablo during the pandemic, review our recent blog posts.)

3. Incentives

“Whether we like it or not, it’s all about finances, as the world of nephrology becomes more familiar with value-based medicine, the ETC Model, and the incentives. Value-based medicine has been used across many other areas of healthcare for a while. As we learn more about home dialysis, as we’re incentivized more, we’ll see more movement in that direction,” says Dr. Broumand.

“I think home therapy has to be incentivized in creative new ways. An example could be tax credits to the patients who are going home, for assisted home hemodialysis,” adds Dr. Aggarwal.

“I think that we need for many different pieces of this complex puzzle to come together, to make home dialysis the preferred modality,” says Dr. Masani. “Education for physicians, nurses, kidney disease patients, and populations at high risk of kidney disease, preventing crash-starts, added reimbursement or incentives, and preemptive transplants where we can. We need these elements to work in concert, and there’s awareness of this now.”

Additional Resources:

Outset Medical’s Tablo Hemodialysis System Receives Landmark TPNIES Approval From CMS

A Pivotal Moment for Nephrology Nursing

Nephrologist Spotlight on Luis Alvarez, MD, PhD: Catalyzing System Change in ESRD Care