Comparative Effectiveness of Home-based Kidney Dialysis versus In-center or Other Outpatient Kidney Dialysis Locations: A Systematic Review

Home-based dialysis (defined for this review as in-home hemodialysis [HHD] or peritoneal dialysis [PD] outside of a dialysis facility) may offer advantages over in-center hemodialysis (HD). Advantages can include patient convenience, expanded capacity for VA to deliver fully integrated care to Veterans with end-stage renal disease, a reduction in costs, as well as improved patient quality of life, fewer hospitalizations, and greater survival. As the number of patients requiring renal replacement therapy increases, there is need for a current review of the benefits and harms of home-based dialysis (HHD or PD) versus in-center HD, the benefits and harms of different home-based dialysis modalities, and the predictors of successful home-based dialysis to allow VA to better serve the needs of their patients.

Investigators with the VA Evidence-Based Synthesis Program located in Minneapolis, MN, reviewed the evidence from studies of adults with chronic kidney disease requiring dialysis – and compared home-based and in-center HD, focusing on studies most relevant to the VA, such as those conducted in North America, Europe, Australia, or New Zealand. Investigators reviewed the literature from 1995 to December 2014 and identified 130 articles that met inclusion criteria.

Summary of Review
Low-strength evidence suggests that home-based dialysis may provide similar health outcomes – and at similar or lower costs for many patients compared to in-center hemodialysis. Therefore, home-based dialysis may be an acceptable and sometimes preferred alternative to in-center hemodialysis. However, information is limited on factors important in addressing selection of and barriers to home-based dialysis, thus this remains an area of important research and healthcare policy.

Results
Below are some of the key findings:

• There were few randomized or controlled clinical trials – or prospective clinical cohort studies – that compared home-based and in-center HD. Available clinical trials were small in size and had short follow-up durations.
• Most of the data on mortality (primary outcome for the evidence review) is from registry studies. Results from these studies should be interpreted with caution, as patients who select home-based therapies are different from those who select in-center therapies.
  • There was low strength of evidence that HHD is associated with improved overall survival compared to in-center HD, and there were few studies of variations of HHD (e.g., longer duration or more frequent sessions).
  • There is evidence from generally low-quality studies to suggest no difference between HHD and in-center HD regarding cardiovascular mortality, transplantation rate, or all-cause hospitalization rate with mixed results for quality of life.
• There was no difference in overall mortality between PD and in-center HD (low strength of evidence). Most studies reporting outcomes over time noted an early survival advantage for PD patient (up to 2 years), then no difference after 2 to 3 years of treatment. In addition, studies showing increased mortality with PD compared to in-center HD were generally published before 2003, while studies showing no difference or reduced mortality with PD were generally published after 2003. There were inconsistent findings for quality of life, cardiovascular outcomes, adverse events, transplantation, and hospitalization.
• Costs were lower with HHD and PD compared to in-center HD, but costs considered in the analyses and factors that can influence costs (i.e., failure rates and patient comorbidity) varied across studies.
• Factors associated with increased selection of home-based dialysis include:
  • Larger dialysis facility,
  • Dialysis facilities providing care for more employed patients or patients 18 to 54 years old,
  • Earlier initiation of pre-dialysis care,
  • Increased patient/family education about the different dialysis modalities,
  • Family/caregiver support, and
  • Team approach to determining patient eligibility for home based dialysis.
• Factors associated with decreased selection of home-based dialysis include:
  • Rural location,
  • Patient's lack of knowledge about the dialysis procedure, and
  • Patient's preference for medical supervision during dialysis.

Implications
Home-based dialysis is a potentially effective option of considerable interest to Veterans, and could permit VA to expand internal dialysis capacity. However, it is not well known if this is feasible within the Veteran population, due, in part, to a greater prevalence of patients of older age and a greater number of comorbidities among patients in the VA healthcare system. Moreover, none of the included studies were conducted at VA medical centers.

Future Research
Despite the large number of studies included in this report, considerable gaps exist. The comparative effectiveness of HHD or PD to in-center HD (including outcomes of mortality, hospitalizations, quality of life, patient satisfaction, and adverse events), and whether treatment choice and technique success vary by modality, patient, provider, or facility factors remains relatively unknown. This is predominately because considerable differences likely exist among individuals selected for (or selecting) different treatment modalities. While difficult to undertake, a large randomized trial comparing different modalities would be useful. Other research needs would be evaluating methods to understand barriers to and improve implementation of HHD or PD – and providing individuals with sufficient skill-building and caregiver support in attempts to maximize benefits. Of note, HHD and PD are widely used as treatment options of choice in other developed countries.

Reference
Ishani A, Slinin Y, Greer N, MacDonald R, Messana J, Rutks I, and Wilt TJ. Comparative Effectiveness of Home-based Kidney Dialysis versus In-center or Other Outpatient Kidney Dialysis Locations - A Systematic Review. VA ESP Project #09-009; 2015.

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This report is a product of VA/HSR&D's Quality Enhancement Research Initiative's (QUERI) Evidence-Based Synthesis Program (ESP), which was established to provide timely and accurate synthesis of targeted healthcare topics of particular importance to VA managers and policymakers – and to disseminate these reports throughout VA.

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