4121 — Identifying Major Barriers to Home Dialysis (The IM-HOME Study): Findings from a National Survey of Patients and Providers

Lead/Presenter: Yuvaram Reddy,  COIN - Pittsburgh/Philadelphia
All Authors: Reddy YN (Center for Health Equity Research and Promotion, Philadelphia), Kearney M (Perelman School of Medicine, University of Pennsylvania, Philadelphia) Ward M (Perelman School of Medicine, University of Pennsylvania, Philadelphia) Reese PP (Perelman School of Medicine, University of Pennsylvania, Philadelphia) Lane-Fall MB (Perelman School of Medicine, University of Pennsylvania, Philadelphia) Burke RE (Center for Health Equity Research and Promotion, Philadelphia)

Objectives:
Increasing home dialysis use from 13% towards 80% of patients with kidney failure by 2025—a goal of the federal Advancing American Kidney Health initiative that aligns with the 2022 Veterans Health Administration’s priority to improve home care for older Veterans—requires a comprehensive understanding of home dialysis barriers. In this national survey, we sought to identify major home dialysis barriers from the perspective of patients and providers to inform home dialysis implementation strategies within VA.

Methods:
We used the modified Delphi method—a technique that iteratively leverages stakeholder feedback in multiple stages to reach consensus. First, each of the 7 members of our advisory board of providers and patients (including Veterans) listed barriers to home dialysis. Then, the advisory board met as a group to discuss these barriers and compiled a final list of 12 patient-perceived and 9 provider-perceived barriers. Finally, this list of barriers was distributed as a survey to patients and providers across the US through the American Association of Kidney Patients and the National Kidney Foundation. The survey asked participants to rank their top 3 barriers to home dialysis from the list provided by the advisory board. The survey also provided participants with the option to describe additional barriers that were important to them. We aggregated participants’ scores to identify the top 3 patient-perceived and top 3 provider-perceived barriers to home dialysis. We also conducted a directed content analysis of the additional barriers listed by participants. The survey was informed by the Systems Engineering Initiative for Patient Safety 3.0 conceptual model.

Results:
There were 522 complete responses (289 patients and 223 providers). Patients perceived their top 3 barriers as fear of performing dialysis at home, limited space at home, and lack of home-based support—all of which occur at home. Providers perceived their top 3 barriers as poor education within the clinic, lack of reimbursable mechanisms for additional clinic-based support, and limited staff with experience in home dialysis—all of which occur in clinic. From the open-ended responses, we derived three new themes related to home dialysis that were not previously identified by the advisory board: 1) patient perceptions of inequities in access to home dialysis, 2) provider biases against the patient that limit the patient’s ability to perform home dialysis, and 3) resiliency as an underrecognized skillset that enables patients and providers to receive home dialysis.

Implications:
While patients perceived major barriers at home, providers perceived major barriers in the home dialysis clinic. Further, patients and providers recognized inequitable access to home dialysis, provider bias, and resiliency as contextual factors to consider when addressing barriers to home dialysis. These findings highlight the need for VA to evaluate the feasibility of novel strategies that simultaneously address barriers at home and in the clinic, such as assisted dialysis (where healthcare workers visit the patient’s home to assist with dialysis) or peer mentorship (for patients and providers).

Impacts:
To improve home dialysis use within VA, stakeholders should support implementation strategies that simultaneously address barriers at home and in the home dialysis clinic.