Challenges, Facilitators, and Recommendations for Implementation of Home Dialysis in the Veterans Health Administration: Patient, Caregiver, and Clinician Perceptions.

Background: Home dialysis confers similar survival and greater quality of life than in-center hemodialysis for adults with ESKD but remains underutilized. We examined challenges and facilitators to implementation of home dialysis and identified stakeholder-centered strategies for improving it.
Methods: We conducted a qualitative, cross-sectional, multisite evaluation that included five geographically dispersed Veterans Health Administration (VHA) home dialysis programs. Participants included patients with ESKD receiving home dialysis, their informal caregivers, and home dialysis staff. Semistructured telephone interviews were conducted and audio-recorded from 2017 through 2018, to assess perceived barriers and facilitators to patient home dialysis use in VHA. Transcribed interviews were analyzed thematically by each participant group.
Results: Participants included 22 patients receiving home dialysis (18 on peritoneal dialysis [PD] and four hemodialysis [HD]); 20 informal caregivers, and 19 home dialysis program staff. Ten themes emerged as challenges to implementing home dialysis, of which six (60%) spanned all groups: need for sterility, burden of home dialysis tasks, lack of suitable home environment, physical side effects of home dialysis, negative psychosocial effects of home dialysis, and loss of freedom. Four themes (40%), identified only by staff, were insufficient self-efficacy, diminished peer socialization, geographic barriers, and challenging health status. Twelve themes emerged as facilitators to implementing home dialysis, of which seven (58%) spanned all groups: convenience, freedom, avoidance of in-center HD, preservation of autonomy, adequate support, favorable disposition, and perceptions of improved health. Two themes (17%) common among patients and staff were adequate training and resources, and physical and cognitive skills for home dialysis. Recommendations to promote implementation of home dialysis common to all participant groups entailed incorporating mental health care services, offering peer-to-peer coaching, increasing home visits, providing health data feedback, and reducing patient burden.
Conclusions: Stakeholder-centered challenges were rigorously identified. Facilitators and recommendations can inform efforts to support home dialysis implementation.
Competing Interests: B. Smith reports being a scientific advisor or member of the Journal of Spinal Cord Medicine. E.J. Gordon reports receiving honoraria and travel reimbursements for presentations and meetings from Advisory Committee on Blood and Tissue Safety and Availability (ACBTSA), National Institute of Allergy and Infectious Diseases (NIAID) Data Safety Monitoring Board (DSMB), National Institutes of Health ad hoc study section grant reviewer, and National Heart, Lung, and Blood Institute (NHLBI) DSMB; reports being a scientific advisor or member as Associate Editor for Narrative Inquiry in Bioethics, Associate Editor for American Journal of Transplantation, Member of ACBTSA, National Academies of Sciences, Engineering, and Medicine Committee, NIAID DSMB, and NHLBI DSMB; reports other interests/relationships as a Member of the American Society of Transplantation (AST) Living Donor Community of Practice, Co-Chair of AST Psychosocial and Ethics Community of Practice, Member AST IDEAL Task Force. M.J. Fischer reports being a scientific advisor or member of Department of Veterans Affairs Dialysis Steering Committee, Department of Veterans Affairs VAi2 Renal Information System Technical Expert Panel, National Kidney Foundation of Illinois Scientific Advisory Board and Executive Committee, National Quality Forum Renal Endorsement Maintenance Steering Committee, and Renal Physicians Association Kidney Quality Safety Accountability Committee. All remaining authors have nothing to disclose. This project was supported by a VA Center of Innovation SPARK grant.
(Copyright © 2021 by the American Society of Nephrology.)