Today, self-care (home) dialysis therapies, including peritoneal dialysis and home hemodialysis, are receiving significant attention within the chronic kidney disease (CKD) field and adoption of these therapies as treatments for patients with end stage renal disease (ESRD) is increasing. However, even as we see more patients initiate treatment with these therapies than in previous years, there is still a widely held belief that self-care dialysis options are significantly underutilized. In fact, industry figures estimate that only nine percent of U.S. dialysis patients are being treated with a selfcare dialysis therapy. As we work to drive increases in the number of ESRD patients that embrace self-care therapies, it is important that we educate patients and their families on these innovative treatments.
The Benefits of Self-Care Dialysis:
There is an expanding body of scientific evidence that demonstrates that patients on selfcare dialysis achieve superior clinical outcomes as compared to those who are not. Findings from various studies within the industry have shown that when compared to traditional incenter hemodialysis, self-care dialysis therapies lead to important health improvements in:
• Dialysis Adequacy/Effectiveness
• Anemia Status
• Blood Pressure
• Hospitalization Rates
• Fluid and Dietary Restrictions
• Prescription Drug Use
If the benefits of self-care ended here then it would still be considered a remarkable therapy option. However, this extensive list does not reflect the broad quality of life benefits also experienced by self-care patients. These include enhanced energy/vitality, improved appetite, reduction in sleep disorders, improved sexual function, greater independence, more flexible schedules, increased involvement in and control of their health, and increased rate of employment. For many patients, these quality of life improvements are just as, if not more, important than the clinical advantages outlined before. That is because these benefits are tangible and easy to recognize in their day-to-day lives.
Equally important is that these quality of life benefits highlight the fact that self-care therapies are now finally beginning to fulfill the original promise of dialysis treatment. In 1972, the U.S. government decided to provide coverage for ESRD care partially based on the belief that dialysis could be an enabling therapy for patients, allowing them to continue to live productive lives, including the flexibility to remain employed. While in-center hemodialysis has had a difficult time meeting this goal, self-care therapies are finally making it a reality for many patients.
The Underutilization of Self- Care Dialysis:
With the long list of advantages offered by selfcare therapies, one must consider why adoption rates remain relatively low. One explanation for the underutilization of self-care therapies may be found in the results of the 1997 U.S. Renal Data System Dialysis Morbidity and Mortality Study. Findings from this study showed that only 25 percent of patients receiving in-center hemodialysis were presented self-care therapies such as peritoneal dialysis or home hemodialysis as initial therapy options.
Compounding this situation, industry studies have shown patients would consider a self-care therapy almost 50 percent of the time if they have been properly educated on all dialysis treatment options. Through its own clinical experience, WellBound, an affiliate of Satellite Healthcare, has corroborated this information, presenting its latest findings at the 2007 Annual Dialysis Conference. These results showed that approximately 46 percent of the 986 Stage 4 CKD patients who were provided with dialysis options education had selected a self-care therapy after they received early education on all available treatment options including conventional in-center hemodialysis (HD), peritoneal dialysis (either CAPD or CCPD), renal transplant and various home hemodialysis regiments.
This disparity between the number of patients that have selected self-care and the number that indicate they would select self-care highlights the critical unmet need of proper pre-dialysis patient education, particularly as it relates to treatment options. To combat this problem, some home dialysis programs have strategically incorporated an aggressive, proactive pre-dialysis patient education focus into its programs. It is believed by providing pre-dialysis patients with comprehensive information on all therapy options, we can help increase the number of individuals that experience the benefits that self-care therapies offer.
Identifying Patients for Self-Care Dialysis:
With all of the health and life style benefits afforded by self-care, it is important to note these therapies may not be right for all patients. The reality is, self-care therapies require a patient to be a more active participant in his or her healthcare and treatment. This is the trade-off required for patients to experience the advantages of self-care dialysis.
With that in mind, there are several characteristics that make some patients more appropriate for self-care therapies than others. Specifically, selfcare treatments should be strongly considered by patients who are willing and able to:
• Take responsibility for their own healthcare and understand the serious commitment of self administering their therapies
• Dedicate the time and effort required to learn about self-care therapies, how they are administered and the importance of adhering to their treatments
• Vigilantly follow the procedures and guidelines established for their specific self-care therapy, including maintenance of supplies and completion of treatment related paperwork
• Work collaboratively with their healthcare team to provide updates on treatment, discuss therapy challenges and solutions, and consider modifications to treatment programs as appropriate
While this list may make self-care therapies appear intimidating, it is critical that patients understand the benefits afforded by these innovative treatments. Patients that are motivated, responsible, and conscientious, can achieve significant health and quality of life benefits through self-care dialysis.
Pre-Dialysis Education: Preparing Patients for Therapy:
One of the best avenues for identifying patients for self-care dialysis and preparing them for the time they need therapy is through proactive pre-dialysis wellness education. For many chronic kidney disease (CKD) patients, diagnosis is a traumatic event that can lead to stress and depression. Managing these emotions, which can prevent patients from taking the immediate and appropriate steps to best address their disease, is possible if appropriate and sensitive education programs are administered around the time of diagnosis. These programs can assist patients in addressing the emotional burdens of diagnosis and empower them to address their long-term health at the earliest possible stage.
While breaking through the realities of stress and depression is an important initial role for education, the ultimate goal of these programs is promoting “health literacy” for patients. Health literacy has been defined as the ability to read, comprehend and act on medical instructions. For patients with a disease such as CKD, it refers to their ability to understand the disease and the best way to manage it. There are a wide variety of studies that have demonstrated the ability of pre-dialysis patient education and health literacy to result in an array of key patient benefits including:
• Delaying chronic renal failure and the need for dialysis
• Reducing early mortality
• Managing cardiovascular risk factors and other co-morbid conditions
• Improving anemia control
• Fostering higher serum albumin
• Initiating dialysis with higher residual renal function
By driving these improvements in clinical outcomes, pre-dialysis patient education is assisting CKD patients in stabilizing and maintaining their health while also prolonging their need for dialysis. This places CKD patients in the best health possible at the time they begin their self-care dialysis regimens, allowing them to continue to lead the healthiest lifestyle possible.
While not all patients are appropriate candidates for self-care therapies, industry research clearly indicates that these treatments are significantly underutilized. This is particularly tragic in light of the broad health and quality of life benefits afforded by self-care dialysis. In order to remedy this situation, it is important that patients are exposed to comprehensive therapy options education programs prior to requiring dialysis. By actively educating CKD patients on all dialysis options, we can best position those who are the best candidates for self-care to select these therapies as their first-line of treatment. Furthermore, providing these patients with broad wellness education programs prior to their need for dialysis positions them to initiate dialysis in the optimal state of health.
Maureen Holland, RN, CNN and Ginger Myers, RN are the Northern California Regional Directors for WellBound. WellBound is an affiliate of Satellite Healthcare.
This article originally appeared in the March 2008 issue of At Home with AAKP.