A Province-Wide Home Dialysis Program Review: Challenges,Strengths,and Future Strategies

Abstract

Purpose of review:

British Columbia (BC) has a robust provincial kidney care program emphasizing patient-centered and goal-oriented dialysis care. Despite maintaining a home dialysis prevalence of approximately 30%, consistently above the national average, a review was conducted to examine intake and attrition rates and optimize these outcomes within a learning health system context.

Sources of information:

This review draws on published articles, program reports, and insights from the provincial kidney care program framework. Key components include funding models, multidisciplinary committees, administrative support, and comprehensive training resources for staff and patients.

Methods:

A structured analysis was conducted to evaluate factors influencing home dialysis rates. The approach focused on health care system dynamics, professional practices, and patient characteristics, emphasizing identifying barriers and opportunities for program optimization.

Key findings:

Challenges identified include ongoing biases among health care professionals and logistical barriers in remote areas. Future initiatives aim to standardize patient screening, promote home dialysis champions, adopt environmentally friendly practices, and expand peer support networks.

Limitations:

The review is constrained by potential regional variability within BC and limited generalizability to other provinces or countries. In addition, patient preferences and broader societal influences require further exploration.

Implications:

A systematic approach to assessing and optimizing home dialysis programs is essential. The findings highlight the need to address health care system barriers, improve professional education, and promote patient engagement to increase home dialysis uptake and sustainability.

Introduction

British Columbia (BC) is fortunate to have a well-established, multidisciplinary, and comprehensive provincial kidney care program that is effectively organized in terms of geography and resources. Funding for outpatient kidney services, in-center and home-based dialysis, and transplantation is part of an accountable and transparent provincial funding model. ¹ With an overarching goal of patient-centered, goal-orientated dialysis care in BC, the growth of the dialysis population has motivated, as in many jurisdictions and countries, an emphasis on peritoneal dialysis (PD) and home hemodialysis (HHD) as effective and cost-conscious options to pursue.^{2 -4} Home dialysis modalities offer many advantages to in-center dialysis options with clinical, lifestyle,^3,5,6 and planetary health benefits.^7,8 BC has a higher proportion of patients on home dialysis than other Canadian provinces; despite this, the prevalence of home dialysis has remained stagnant over time. The absence of significant changes has prompted an evaluation of the program’s past and future direction. A thorough assessment of historical and current activities, including all home dialysis publications, projects and patient and staff surveys from the last 10 years, will inform future initiatives to enhance independent dialysis modalities’ uptake.

The British Columbia Home Dialysis Program: Current State and Challenges

The expansion of home dialysis within a given system is a complex process influenced by various factors. Typically, countries such as Hong Kong, which has high utilization of and favorable outcomes from home dialysis, have implemented PD-first policies and built PD expertise over decades. ⁵ Canada, Australia, New Zealand, and multiple Scandinavian countries have a home dialysis-preferred policy (versus a mandatory PD-first policy). Across Canada, there is significant variation in home dialysis use by province, ranging from 30% in BC to 9% in Newfoundland. ⁹ Dialysis modality selection is ultimately considered a personal choice as patients can access established PD, HHD, and in-center HD. ¹⁰ Despite BC’s active home dialysis program, home dialysis intake has plateaued over the last 10 years (Figure 1). Home dialysis attrition has risen (Figure 1), resulting in more patients undergoing in-center HD and declining home dialysis prevalence (Figure 1). Demographic factors such as the older median age of incident dialysis patients cannot explain this increase. While older patients are less likely to initiate independent dialysis, ⁵ the median ages of BC’s in-center and home dialysis patients have remained similar over the past 10 years, as indicated by the provincial renal database in British Columbia (PROMIS), which tracks all kidney patients across the province.

Figure 1.

Home dialysis trend lines (intake, prevalence, yearly attrition) 2014-2024.

With in-center dialysis units often exceeding recommended capacity targets and persistent staffing challenges exacerbated by the impact of the COVID-19 pandemic, the need to increase independent dialysis numbers has become a renewed priority.^4,5,11 This initiative would be part of an integrated care model in which patients and their health care providers collaborate to develop a detailed care plan. This plan is intended to guide essential decisions about initial and future treatment methods, ultimately affecting clinical outcomes and overall quality of life. ¹² Various components comprise the BC home dialysis landscape and have been targeted with initiatives at different levels (program, staff, patient) to enhance home dialysis for our patients and increase the uptake of and reduce attrition from home dialysis (Figure 2).

Figure 2.

General provincial initiatives to support home dialysis in recent years.

Program/Funding

Government funding in Canada varies; in BC, it primarily covers home dialysis costs (excluding utilities), minimizing financial barriers for patients. ¹⁰ In BC, patient care is delivered through 6 health authorities (HAs), while funding is administered by BC Renal (BCR), the provincial renal agency, using an activity-based funding model. ¹ BCR provides supplies, equipment, and funds for home renovation to support patients who opt for home dialysis. The program’s guiding principles highlight offering the highest quality dialysis within the most appropriate location for the individual patient. Since funding for home dialysis is activity-based, not volume-based, smaller programs in more remote communities are not disadvantaged financially in favor of large hospital-based programs. As such, patients in all programs have access to high-quality home dialysis care in their local facilities rather than needing to be transferred to a PD or HHD hospital, keeping individuals within their local communities. ³ Other advantages of this model include the uniformity of equipment, standardized educational and training materials, and establishing province-wide best practices. Additional strategies to support the program include provincial home dialysis committees with representation from allied health disciplines, patient partners, HAs, provincial medical and administrative director roles for PD and HHD, human resources and funds dedicated to home dialysis and a provincial database and metrics, which provide focused data to support home dialysis reporting to the BC Ministry of Health and for research and quality improvement initiatives. ¹³

Support for patients living in remote areas has included a backup machine for HHD and a resource launched in 2020 to assist with PD care. This resource features videos of essential PD procedures, clinical algorithms, and a clinician competency module (Figure 2). The uptake of home dialysis in rural and remote communities, despite climate and infrastructure challenges, is high. Due to geographic location, when faced with the prospect of relocating to a major center to dialyze or choosing home dialysis, many patients welcome the opportunity to do so at home (Figure 3). ¹⁴ However, challenges persist with PD tube insertions despite efforts to train providers and a 2017 ministry-supported provincial PD catheter access strategy that prioritizes dialysis access in the provincial surgical plan. ¹⁵ In addition, training for home dialysis occurs at regional centers, placing financial, travel, and time burdens on patients.

Figure 3.

Map of BC with dialysis modality percentage prevalence by health authority (March 2024).

Staff

From the perspective of facilities and providers, biases and misperceptions about modality selection and absolute contraindications for home dialysis endure among BC providers, as seen internationally. ¹⁶ A 2021 cross-sectional survey of 334 BC kidney care providers found substantial differences in perceptions toward home dialysis candidacy. It proposed various solutions, including a standardized list of absolute contraindications and structured maintenance provider education sessions to address this. ¹⁷ BCR has facilitated numerous education and quality improvement projects (Figure 2), including BCR sponsoring new staff to take the BC Institute of Technology PD Basic course, as many new employees in specific nursing roles provide modality education to patients with limited knowledge of or exposure to PD. Similarly, unlike in-center HD, nephrologists vary in comfort levels and clinical exposure to home dialysis, influencing patient guidance. ¹² ,^{17 -19} A US survey of nephrology trainees from 2004-2008 showed that 80% felt competent with in-center HD. Still, only 56% and 16% felt competent with PD and HHD, respectively, due to factors like inadequate curriculum, limited clinical exposure, and a lack of experienced mentors. ²⁰ A 2021 pilot study found that a virtual program with lectures, literature reviews, and case discussions significantly increased nephrologists’ confidence in home dialysis. Program graduates were 53% more likely to recommend home dialysis.^20,21 As such, In BC, Nephrology fellows rotate through the home dialysis program; in their core training, extra training via a dedicated home fellowship program is also offered to local and international trainees.

Patient

Specific patient-level data on modality selection factors must be included in local jurisdictions, considering socioeconomic status, home environment, support availability, personal preferences, and cultural beliefs and practices.^5,6,^{22 -24} Multiple patient resources have been developed and translated to accommodate BC’s linguistically diverse patient population and assist with modality decision-making and transitions. Within the Kidney Care Clinics, multidisciplinary non-dialysis chronic kidney disease care clinics throughout the province, and in partnership with the home dialysis care teams, annual home dialysis patient webinars are hosted and made available on the BCR Web site. These webinars have been well received as valuable, pragmatic resources, mainly due to the sharing of lived experiences from patient peers and visual representation of the modalities (Box 1). Transition guidebooks for PD and HHD were introduced in 2018 (Figure 2). They clearly outline the steps of transitioning to home dialysis, aiding patients and the medical staff supporting them. ²⁵ In addition, trained peer mentors are accessible via the Kidney Foundation of Canada (KFOC)-BC and Yukon branch. Drawing on their experiences, peer mentors provide a unique and relatable perspective for newly diagnosed patients, addressing their questions more effectively than general health care professionals. However, despite the essential role of peer support in home dialysis modality decision-making, it has not yet been systematically integrated into pre-dialysis care in BC.^5,26

Box 1.

Verbatim Patient Perspectives on Annual Home Therapies Webinars (2021-2023).

What did you find most valuable?

Hearing perspectives from those with lived experience: -[The] PD patient was excellent—[They were] clear, active, honest regarding challenges and overcoming issues -[It was beneficial] Having someone on the treatment talk about their experience -“I appreciated hearing from patients who have gone through the process themselves” -“Hearing from the man who has been doing home hemodialysis for 3 years . . . his talk was exceptionally informative” -“Hearing personal experiences and stories from actual patients” -“[They were] honest and reassuring, although the journey can be bumpy, with the help of staff, [one] can gain the confidence to succeed.”

Visuals of the modality practicalities: -“The photos on the storage space of supplies gave me an idea of the storage space required” -I liked the hands-on information -The dummy visual . . . and how the catheter works made me understand PD for the first time -“Seeing the equipment and supplies . . . The images of the different machines, home set up and storage for supplies were good”

Due to age-related changes and diverse care goals, dialysis treatment decisions can be particularly complex for older adults. Peritoneal dialysis is suitable for some elderly patients due to its less invasive nature and cardiovascular benefits in this population,^27,28 but it can be challenging without physical assistance. The Peritoneal Dialysis Assist (PDA) program supports these patients with daily home visits from trained caregivers. The program offers patient-focused support with clear referral criteria, providing daily home visits from trained caregivers. This enables patients with physical, cognitive, and social challenges to use an independent dialysis method. BC’s PDA program has demonstrated positive patient-centered outcomes, facilitating more patients to dialyze at home and avoid in-center dialysis until the end of life. ²⁸ As with the majority of programs in Canada, BC has no assisted HHD programs. This approach could improve accessibility, enhance patient autonomy, and reduce the burden on in-center dialysis resources, though it requires additional funding and workforce planning. ²⁹

A Project to Standardize Screening and Identification of Patients for Home Dialysis

A province-wide current state review of home dialysis conducted in 2022 uncovered common themes from patient and staff discussions. It was noted that different programs use varying methods for screening and referral of patients to home dialysis, leading to potential disparities in access and opportunities. This finding aligns with previous research using our province-wide registry, which includes all patients attending Kidney Care Clinics and on dialysis, identifying missed opportunities to recruit many potentially suitable patients for home dialysis. ²⁶ The 2022 patient experience survey data further highlighted communication gaps between kidney providers, patients, and their caregivers during the referral process to home dialysis. Recognizing these discrepancies, the need for a standardized provincial process was identified to ensure consistency and clarity in the patient’s pathway to home dialysis, ensuring no patient who may benefit from a home dialysis referral is overlooked. Consequently, after discussions with PD and HHD committees, assessing and improving BC’s referral process to home dialysis was established as a primary provincial project for 2023-2024.

To address these issues, a diverse working group guided a mixed-method quality improvement initiative in collaboration with the BCR PD and HHD committees. Launched in April 2023, this initiative involved developing and administering semi-structured surveys (for providers and patient partners) as part of a provincial environmental scan. The broad project goals include standardizing patient screening and referral and minimizing practice variations for home dialysis across all regional HAs.

Developing a consistent provincial referral pathway with specific tools aims to increase the uptake of home dialysis provincially through:

1. Equitably and comprehensively identify all eligible candidates from in-center HD (both new starts and previously overlooked patient populations such as pandemic parachute patients);

2. Ensuring that each patient is allowed to advance as far as possible through the education and assessment process;

3. Providing required support to patients and their care partners (for example, trained peer mentors) in the decision-making process;

4. Enhancing staff (nurses and allied health professionals) confidence in the entire process and equipping them with tools to discuss home dialysis options with patients efficiently;

5. Implementing the standardized provincial list of absolute contraindications for home dialysis increases awareness of home dialysis candidacy and reduces misperceptions about which barriers are truly insurmountable.

The following steps in this 18-month project are to identify core themes from the surveys and develop and implement, following a quality improvement framework, a standardized referral guide for determining patients’ accurate eligibility for home dialysis. Upon completion, the findings from this project will be published in a separate publication.

Future Initiatives

Generally, there is not one solution for expanding the use of home dialysis. In BC, various important considerations and priorities are being considered for incorporation into future projects and planned evaluation to help build an evidence base. However, the relative value of initiatives (in any jurisdiction) needs to be weighed against the resources and efforts required for implementation in the local context.

Program

Build a positive organizational culture and home dialysis champions

A supportive and receptive organizational culture is needed to facilitate home dialysis uptake. This can be accomplished by fostering collaboration and knowledge-sharing for continuous quality improvement, having supportive clinical leadership, and positively engaging staff with home dialysis.^5,26,30,31 The referral project will promote home dialysis and staff education; opportunities continue to be offered at various levels. Home dialysis champions are identified as staff who are supportive and knowledgeable in home dialysis and have been critical internationally in helping programs flourish by motivating teams, building programs and keeping local practices up-to-date.^32,33 Therefore, cultivating a pool of home dialysis clinical champions in each center could significantly contribute to driving implementation initiatives and overcoming potential resistance at the organizational level.

Adopting a Green Approach to Home Dialysis

Adopting more home therapies aligns with a planetary health approach supported by BCR and the Ministry of Health. Home dialysis has environmental benefits, including reduced impact on patient and staff transportation and reduced energy and water requirements.^8,34 As we advance, this understanding is fundamental for improved environmental stewardship, climate change mitigation, resource efficiency, and sustainable reputation.

Staff

Provider education and eliminating bias

Enhancing existing education initiatives for those involved in modality education and decision-making processes is crucial to fostering open discussions with patients. Existing efforts will hopefully increase provider comfort levels in discussing home dialysis with patients in a culturally appropriate manner to cater for BC’s diverse patient population. However, developing and testing tools to identify and address potential biases among physicians and health care teams in modality selection is essential. Multi-modal educational interventions should then be tailored based on these assessments. ³⁵

Patient

Building a peer support network for home dialysis

In partnership with the KFOC, we aim to cultivate our peer support network actively, fostering mentorship and mentee relationships. This process is instrumental in alleviating fears and uncertainties linked to decision-making, ultimately bolstering decisional self-efficacy and preparedness. ³⁶ Timely peer support, integrated with modality education for pre-dialysis patients, could increase the uptake of home dialysis by allowing patients more time to process information in a relatable way. ²¹ ,^{36 -38}

Conclusion

In 2024, with few absolute contraindications for home dialysis, all individuals needing maintenance dialysis should be considered for this option. A systematic approach should be used to identify those unable to undergo home-based treatment and document the reasons. This information could explain to payers why numbers have plateaued and help develop strategies to address modifiable barriers. Key priorities include educating health care professionals on various home modalities, emphasizing individualized care, multi-modal and culturally relevant patient education, and shared decision-making in choosing the most suitable treatment. This collaborative approach empowers patients, reduces bias, and effectively identifies those ideal for home dialysis, ultimately aiming for optimal outcomes.