How the COVID-19 Pandemic Hit Home in North America

Introduction During the 1960s, in the United States, home hemodialysis (HD) and peritoneal dialysis (PD) were common maintenance dialysis therapies. In 1972, 40% of US dialysis patients were receiving home HD. In 1972, universal Medicare funding for outpatient dialysis resulted in a major shift to maintenance in-center HD treatment. By 1992, <2% of patients in the United States were treated with home HD.1 Now, the increasing popularity of outcome-based health models coupled with the 2019 signing of the Advancing American Kidney Health Initiative have created a fertile environment for home dialysis growth and improving clinical outcomes in the United States after historical declining home dialysis utilization. The past decade in the United States saw the number of patients initiating maintenance home dialysis increase by 85% and those on home dialysis at 1 year increase by 73%.2 Higher rates of coronavirus disease 2019 (COVID-19)-related hospitalization and mortality were observed in the PD and HD populations compared with the general population.3 The kidney care community must reflect upon lessons learned during the COVID-19 pandemic in home dialysis delivery, including supporting continued growth in home dialysis, virtual education, and dialysis access prioritization; addressing racial disparities in care; and enhancing home-based support for patients. These insights can facilitate implementation of future changes to drive higher quality care, improve patient outcomes, and build greater resiliency against future and emerging threats. COVID-19: A Catalyst for Growth in Home Dialysis Individuals receiving center- over home-based dialysis face higher communicable disease risks, such as viral hepatitis transmission and multidrug-resistant infections.4 Home-based dialysis minimizes these risks by avoiding public transportation and reducing multiple health care provider and patient encounters because the majority perform their own dialysis. Recent data have demonstrated that home dialysis patients (both PD and home HD) were less likely to have been diagnosed with COVID-19 and experienced lower rates of COVID-19–related hospitalization and death, particularly during the early period of the pandemic.5 These findings may relate to differences in patient characteristics between those receiving home- and center-based dialysis and differences in testing. Yet taken together, these findings support shifting a greater proportion of individuals receiving dialysis care at home may reduce the future burden of transmissible diseases. Barriers and Opportunities to Achieve Growth in Home Dialysis Despite a strong impetus to do so, the pandemic did not accelerate overall home dialysis growth; by early 2021, both the number and percentage of home dialysis patients had fallen below forecasts on the basis of prepandemic trends (Figure 1). Drivers for this lack of growth may have been attributable to reduced modality education, limited availability to dialysis access creation, staff shortages, and/or overall higher mortality in patients with CKD and COVID-19.Figure 1.: Actual versus forecasted home dialysis prevalence and utilization from 2018 to mid-2021, with forecasts based on prepandemic growth trends. Forecasted and observed numbers (A) and percentages (B) of patients with end-stage kidney disease undergoing home dialysis, January 2018 to June 2021. The red vertical line is at epidemiologic week 12 of 2020, the first full week after a national emergency was declared. Observed numbers of patients were extracted from the United States Renal Data System 2021 Annual Data Report,2 while forecasted numbers were estimated with a previously described methodology.11Modality education for patients and care partners remains a primary driver for home dialysis choice.6 Virtual CKD education became a focus for providers because in-person sessions were limited. Virtual education may provide additional benefits, such as education in a variety of languages, while reducing geographic and physical barriers at the convenience of the learner at home. Permanent dialysis access creation is critical for successful home dialysis. The pandemic saw the restricted use of operating rooms, reduced availability of surgeons and interventionalists for PD catheter placement, and regulatory restrictions on what procedures are deemed “urgent” or “elective.”7 Because most PD catheters in the United States are inserted laparoscopically, many centers had limited access to operative PD catheter placement, with challenges in obtaining PD access by alternate means. In this regard, percutaneous PD catheter placement (by nephrology or radiology) remains underutilized in the United States compared with centers elsewhere. Beyond the pandemic, exploration of the role of advanced embedded PD catheter placement and availability of percutaneous (nonsurgical) PD catheter placement is needed to facilitate both timely and functional PD access. During the pandemic, some programs had to limit the number of patients in training and reduce the number of home visits performed due to exposure concerns for home nurses. Using virtual training, such as virtual home visits or virtual technique education, may increase knowledge and allow patients and care partners to train at home while minimizing exposure risks. Virtual visits may also allow nurses to work remotely, reduce travel time, and potentially reduce burnout. Enhancing support at home may also help in addressing disparities in care. Although 37% and 19.6% of the current maintenance dialysis population is Black or Hispanic, respectively (compared with only 8.6% that is White), only 7.8% and 7.9% of Black and Hispanic patients are on home dialysis, respectively, compared with 10.8% of White patients.8 These disparities need discrete processes (e.g., culturally sensitive kidney disease education) and support put in place to ensure that all who are facing the need for dialysis are aware of and have access to home dialysis. Telemedicine and Home Dialysis for the Future The 2018 Bipartisan Budget Act allowed providers to use telehealth for home dialysis patients. Yet, telehealth use for home dialysis patients was minimal.9 In 2020, waivers allowed for telehealth visits to occur across state lines, and new and established patients could be seen through telehealth. Any platform (including audio/telephone only) could be used. Telehealth can minimize travel for patients and care partners; limit disruptions to work, school, or childcare; and reduce exposure to other patients. However, the current broadband infrastructure and technology is challenging to patients because of connectivity and cost. More research is needed to evaluate the clinical outcomes with telehealth use while optimizing technology and user experience to improve health outcomes for home dialysis patients. Newer technologies, such as connected home dialysis machines, that transmit information remotely allow a clinician to review the data and respond with any treatment changes. Access to these devices may limit in-person visits, thereby complementing telehealth use to provide comprehensive care. Building Resiliency for Home Patients Many hospitals experienced shortages in dialysis supplies and personnel. Acute HD and continuous KRT were limited in some areas. Hospitals developed protocols for the use of PD to treat AKI, a procedure not performed routinely in the United States.10 Currently, Medicare coverage for patients with AKI requiring outpatient dialysis is only available for center-based HD. The kidney community is advocating for regulatory changes to include outpatient coverage of home PD for AKI. There have been ongoing supply chain disturbances (i.e., masks, hand sanitizer) and product delivery delays leading to challenges for home dialysis patients. Future innovations, such as online product tracking and reducing consumables by in-home and on-demand PD solution generation, may reduce some of this burden for patients. The COVID-19 pandemic highlighted concerns around staffing needs. These include the time required for nurses to be trained as home dialysis nurses (3–6 months) and the use of nurse extenders (e.g., patient care technicians) to help supplement nursing activities. Re-evaluating restrictions on nurse training requirements and dialysis experience before home nurse training may ease this shortage. Ongoing strategies are needed to make home dialysis nursing an attractive career choice for nurses. The clinical benefits seen in home- over center-based dialysis treatment became more apparent during the COVID-19 pandemic, but increased utilization of home dialysis did not occur. We learned to rapidly mobilize technologies, such as telehealth, for educating and providing care to patients at home, but ongoing refinement in this technology is needed. Patients need universal access to technology and broadband internet and support at home to further promote equitable access to home dialysis for all patients. We must increase training in PD catheter placement with various approaches and ensure that PD access creation is prioritized. Additional redundancies for supply chain and staffing are needed, including expanding the scope of some care team members and shortening the time of training required for a home nurse. Additional policy and legislative changes to support these changes highlighted above are needed, including those that seek to reduce racial disparities in access to home dialysis. These lessons learned must be implemented to improve home dialysis utilization and build resiliency against future catastrophic events. Disclosures M.V. Naljayan reports employment with DaVita Kidney Care, ownership interest in DaVita Kidney Care, and other interests or relationships with the National Kidney Foundation of Louisiana. J. Perl reports consultancy agreements with AstraZeneca, Baxter Health Care Canada, Bayer, DaVita Healthcare Partners, Fresenius Medical Care, LiberDi, and Otsuka; grants from the Agency for Healthcare Research and Quality for OPPUS; research funding from Arbor Research Collaborative for Health and AHRQ; honoraria from Amgen Canada, AstraZeneca, Baxter Healthcare USA/Canada, Bayer Canada, DaVita Healthcare partners, DCI, Fresenius Medical Care, Otsuka, and US Renal Care; speakers bureau for Baxter Healthcare and Fresenius Medical Care; salary support from Arbor Research Collaborative for Health; serving on the advisory board for Liberdi Ltd; and other interests or relationships with AHRQ. B. Schiller reports employment with Satellite Healthcare; consultancy agreements with Akebia, CVS, Quanta, and Rockwell Medical; ownership interest in Unicycive Therapeutics Inc.; an advisory or leadership role for the Board of Directors at Unicycive; and speakers bureau for AstraZeneca. S. Watnick reports employment as CMO of Northwest Kidney Centers, a not-for-profit organization; serving as a site PI for Quanta; ownership interest in Cricket Health; honoraria from American Society of Nephrology - BRCU; serving on the CJASN Editorial Board; serving on the ASN Quality Committee and the ASN co-representative to Kidney Care Partners speakers bureau for AstraZeneca; and other interests or relationships as CMO of Northwest Kidney Centers, a not-for-profit organization. E.D. Weinhandl reports employment with Satellite Healthcare; consultancy agreements with Fresenius Medical Care North America, NxStage Medical, Outset Medical, and Quanta Dialysis Technologies; research funding from Dialyze Direct and Outset Medical; honoraria from Quanta Dialysis Technologies; advisory or leadership roles for the Board of Directors of Home Dialyzors United and the Board of Directors of Medical Education Institute; and other interests or relationships with University of Minnesota. Funding None.

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