Initial home dialysis is increased for rural patients by accessing urban facilities

Background: The 240,000 rural patients with end stage kidney disease in the United States have less access to nephrology care and higher mortality than those in urban settings. The Advancing American Kidney Health initiative aims to increase the use of home renal replacement therapy. Little is known about how rural patients access home dialysis and the availability and quality of rural dialysis facilities. Methods: Incident dialysis patients in 2017 and their facilities were identified in the United States Renal Data System. Facility quality and service availability was analyzed with descriptive statistics. We assessed the availability of home dialysis methods depending on rural versus urban counties, and then we used multivariate logistic regression to identify the likelihood of rural patients with home dialysis as their initial modality and the likelihood of rural patients changing to home dialysis within 90 days. Finally, we assessed mortality after dialysis initiation based on patient home location. Results: Of the 97,930 dialysis initiates, 15,310 (15.6%) were rural. Rural dialysis facilities were less likely to offer home dialysis (51.4% vs 54.1%, P<0.001). While a greater proportion of rural patients (9.2 vs 8.2%, P<0.001) were on home dialysis, this was achieved by traveling to urban facilities to obtain home dialysis (OR 2.74, P<0.001). After adjusting for patient and facility factors, rural patients had a higher risk of mortality (HR 1.06, P=0.004). Conclusions: Despite having fewer facilities that offer home dialysis, rural patients were more often on home dialysis methods because they traveled to urban facilities, representing an access gap. Even if rural patients accessed home dialysis at urban facilities, rural patients still suffered worse mortality. Future dialysis policy should address this access gap to improve care and overall mortality for rural patients.

A Web-based, Provider-driven Mobile App to Enhance Patient Care Coordination between Dialysis Facilities and Hospitals: Development and Pilot Implementation Study (Preprint)

BACKGROUND To fill the communication and care coordination gap between hospitals and dialysis facilities, we piloted a web-based, provider-driven mobile app (“DialysisConnect”). Here, we describe its development and pilot implementation. OBJECTIVE . METHODS DialysisConnect was developed iteratively, with focus group and user testing feedback, and made available to 106 potential users at one hospital [hospitalists, advanced practice providers (APPs), care coordinator] and four affiliated dialysis facilities (nephrologists, APPs, nurses/nurse managers) prior to the start of the pilot (11/1/20-5/31/21). Mid- and end-of-pilot online surveys of potential users were performed. Descriptive statistics were used to describe system usage patterns, ratings on multiple satisfaction items (1=not at all; 3=to a great extent), and provider-selected motivators and barriers to using DialysisConnect. RESULTS The pilot version of DialysisConnect included automatically uploaded clinical information from dialysis facilities, forms for entering critical admission and discharge information, and a direct communications channel. While physicians comprised most of the potential users of DialysisConnect, APPs and dialysis nurses were the most active users. Activity was unevenly distributed: e.g., one hospital-based APP recorded most of the admissions (n=225, 89%) and discharges (n=226, 93%) among patients treated at the pilot dialysis facilities. End-of-pilot ratings of DialysisConnect were generally higher for users vs. non-users: e.g., “I can see the potential value of DialysisConnect for my work with dialysis patients” [mean (SD): 2.8 (0.4) vs 2.3 (0.6), P=0.02]. Providers most commonly selected reduced time and energy spent gathering information as a motivator (42.3%) and lack of time to use the system as a barrier (30.8%). CONCLUSIONS In this pilot, we found that APPs and nurses were most likely to engage with the system. Survey participants generally viewed the system favorably, while identifying substantial barriers to its use. These results inform how best to motivate providers to use this and similar systems and inform future pragmatic research in care coordination in this and other populations.

Using Focus Groups to Understand Dialysis Staff Perspectives on Delivering Transplant Education

Introduction Kidney transplant education in dialysis facilities could be optimized with internet resources, like videos, but most qualitative research predates widespread availability of online video education about kidney transplantation. To improve understanding of dialysis staff transplant education practices, as well as the potential value of video, we conducted focus groups of dialysis center staff members in Buffalo, NY. Methods/Approach Seventeen focus groups (97 participants: 53 nurses, 10 dialysis technicians, 6 social workers, 6 dieticians, 7 administrative personnel, 2 trainees, and 1 insurance coordinator) from 8 dialysis facilities in Buffalo, NY, were conducted, audio-recorded, transcribed, and analyzed. After thematic data analysis, a diverse patient and caregiver community advisory board was invited to comment, and their voices were integrated. Findings: Five key themes were identified that captured barriers to transplant education delivery and how online video could be a facilitator: (1) delivery of transplant education was reliant on one person, (2) other dialysis staff had time to answer transplant questions but felt uninformed, (3) patient lack of interest in existing supplementary transplant education, (4) patient disinterest in transplantation education was due to education timing, feeling overwhelmed, and transplant fear/ambivalence, and (5) video education could be flexible, low effort, and spark transplant interest. Study limitations are potential selection bias and inclusion of English-speaking participants only. Discussion Dialysis staff barriers of time, insufficient knowledge, and limited resources to provide education to patients and their care partners may be mitigated with online educational videos without increasing staff workload.

The association between prevalence of peritoneal dialysis vs hemodialysis and patients' distance to dialysis-providing facilities

Background: Accessibility to dialysis facilities plays a central role when deciding on a patient's long-term dialysis modality. Studies investigating the effect of distance to nearest dialysis-providing unit on modality choice have yielded conflicting results. We set out to investigate the association between patients' dialysis modality and both the driving and straight-line distances to the closest HD- and PD-providing units. Methods: All end stage kidney disease patients who initiated in-center HD and PD in 2017, 18-90 years old, and on dialysis for ≥30 days were included. Patients in residence zip codes in non-conterminous United States or lived >90 miles from the nearest HD-providing unit were excluded. Results: 102,247 patients in the United States initiated in-center HD and PD in 2017. Compared to HD patients, PD patients had longer driving distances to their nearest PD unit (4.4 vs 3.4 miles; p <0.001). Patients who lived >30 miles from the nearest HD unit were more likely to be on PD if the nearest PD unit was a distance equal to/less than the HD unit. PD utilization increased with increasing distance from patients' homes to the nearest HD unit. No change in this association was found regardless of if the PD unit was farther/closer than the nearest HD unit. This association was not seen with straight line distance analysis. Conclusions: With increasing distances from the nearest dialysis providing units (HD or PD), PD utilization increased. Using driving distance rather than straight line distance affects data analysis and outcomes. Increasing the number of PD units may have a limited impact on increasing PD utilization.

Covid-19 in 40 dialysis facilities. A prospective multicenter cohort study in Spain

Aims: Assess the incidence of COVID-19 during the first wave of the pandemic in 40 hemodialysis units in Spain. Material and methods: We analyzed 396 Rt-PCR performed March 14th to April 28th, 2020 in a cohort of 2398 hemodialysis (HD) patients corresponding to 19 hospital units and 21 satellite centers. Results: We performed Rt-PCR in 14% of the patients, with a marked variability depending on the location. The overall COVID-19 incidence was 3.2% (range 0-15.9%). It was significantly higher in the hospital units (4.5%) than in the satellite units (1.9%) (p=0.0003). There was a positive and significant correlation between the COVID-19 incidence in the units and their proximity to Madrid (R2=0.6235, p=0.0013), which was the main epidemic focus. Conclusion: Our study showed a low incidence of COVID-19 in HD, higher in hospital units and closer to Madrid.

Fixed Effects High-Dimensional Profiling Models in Low Information Context

Profiling or evaluation of health care providers, including hospitals or dialysis facilities, involves the application of hierarchical regression models to compare each provider’s performance with respect to a patient outcome, such as unplanned 30-day hospital readmission. This is achieved by comparing a specific provider’s estimate of unplanned readmission rate, adjusted for patient case-mix, to a normative standard, typically defined as an “average” national readmission rate across all providers. Profiling is of national importance in the United States because the Centers for Medicare and Medicaid Services (CMS) policy for payment to providers is dependent on providers’ performance, which is part of a national strategy to improve delivery and quality of patient care. Novel high dimensional fixed effects (FE) models have been proposed for profiling dialysis facilities and are more focused towards inference on the tail of the distribution of provider outcomes, which is well-suited for the objective of identifying sub-standard (“extreme”) performance. However, the extent to which estimation and inference procedures for FE profiling models are effective when the outcome is sparse and/or when there are relatively few patients within a provider, referred to as the “low information” context, have not been examined. This scenario is common in practice when the patient outcome of interest is cause-specific 30-day readmissions, such as 30-day readmission due to infections in patients on dialysis, which is only about ~ 8% compared to the > 30% for all-cause 30-day readmission. Thus, we examine the feasibility and effectiveness of profiling models under the low information context in simulation studies and propose a novel correction method to FE profiling models to better handle sparse outcome data.

Clinical Course of SARS-CoV-2 Infection in Adults with ESKD Receiving Outpatient Hemodialysis

BackgroundPatients with ESKD on maintenance dialysis receive dialysis in common spaces with other patients and have a higher risk of severe SARS-CoV-2 infections. They may have persistently or intermittently positive SARS-CoV-2 RT-PCR tests after infection. We describe the clinical course of SARS-CoV-2 infection and the serologic response in a convenience sample of patients with ESKD to understand the duration of infectivity.MethodsFrom August to November 2020, we enrolled patients on maintenance dialysis with SARS-CoV-2 infections from outpatient dialysis facilities in Atlanta, Georgia. We followed participants for approximately 42 days. We assessed COVID-19 symptoms and collected specimens. Oropharyngeal (OP), anterior nasal (AN), and saliva (SA) specimens were tested for the presence of SARS-CoV-2 RNA, using RT-PCR, and sent for viral culture. Serology, including neutralizing antibodies, was measured in blood specimens.ResultsFifteen participants, with a median age of 58 (range, 37‒77) years, were enrolled. Median duration of RT-PCR positivity from diagnosis was 18 days (interquartile range [IQR], 8‒24 days). Ten participants had at least one, for a total of 41, positive RT-PCR specimens ≥10 days after symptoms onset. Of these 41 specimens, 21 underwent viral culture; one (5%) was positive 14 days after symptom onset. Thirteen participants developed SARS-CoV-2–specific antibodies, 11 of which included neutralizing antibodies. RT-PCRs remained positive after seroconversion in eight participants and after detection of neutralizing antibodies in four participants; however, all of these samples were culture negative.ConclusionsPatients with ESKD on maintenance dialysis remained persistently and intermittently SARS-CoV-2–RT-PCR positive. However, of the 15 participants, only one had infectious virus, on day 14 after symptom onset. Most participants mounted an antibody response, including neutralizing antibodies. Participants continued having RT-PCR–positive results in the presence of SARS-CoV-2–specific antibodies, but without replication-competent virus detected.

Effective approach to manage COVID-19 challenges in Hamad General Hospital dialysis facilities

Background: Hamad Medical Corporation (HMC) is providing dialysis treatment to approximately 1050 patients. COVID-19 started from China in December 2019, and the first case in Qatar was confirmed on 27th February 2020. There were challenges to provide dialysis treatment for COVID-19 positive and negative patients during the pandemic due to severe staff shortage, staff fear and psychological distress, workload, lack of dialysis slots, prolonged working hours and staff fatigue. Some staff were even deployed to COVID-19 facilities (modular dialysis services, hotel and quarantine facilities) to provide treatment. Methods: 1) A COVID-19 management committee was established 2) An on-call team was assigned to manage new cases and review dialysis slots availability. 3) Staff performance and adherence to safety measures was monitored. 4) A hierarchy model was implemented for COVID-19. A) Elimination: – Confirmed COVID-19 patients were not to receive dialysis at Ambulatory Dialysis centres. – Unit meetings were only held online. B) Substitution: – Dialysis services were to be provided in HMC dialysis facilities, COVID-19 hospitals, and isolation/quarantine facilities (home/hotels). – Administrators with chronic disease worked from home. C) Engineering: – Reduce number of chairs in tearoom and waiting area – Rearrange offices, working spaces, and conference room to keep everyone 2 meters apart. D) Administrative: – Staff, patient and family education – Screening by using visual triaging scale – Deployment of staff – Managing staff mental health and psychosocial well-being Results: 76 dialysis patients and 30 dialysis staff were infected. 900 hemodialysis sessions were provided inside quarantine and isolation facilities (home, hotel, Bu-Sidra, and other locations) and Hazm Mebaireek General Hospital (HMGH) Modular Dialysis Unit from March to October 2020 . The number of COVID-19 positive patients reduced from 39 in May 2020 to 12 in July 2020 (p = 0002). Conclusion: Thanks to our approach, we were able to provide a high quality and safe dialysis service for in-centre dialysis and in COVID-19 facilities and quarantine centres (home/hotels).