Background
End-stage renal disease (ESRD) places a considerable burden on healthcare resources [
1]. Over 2 million people worldwide currently require treatment for ESRD [
2]. In 2009, over 1 million patients received renal replacement therapy (RRT) in the USA and Europe combined [
3,
4]. Despite technological advances in haemodialysis (HD) over the past 2 decades, clinical outcomes remain poor and high rates of morbidity and mortality persist [
5]. In the USA, HD patient survival rates have barely improved in more than 25 years and, in 2009, only 50% of dialysis patients were expected to survive 3 years after the start of ESRD therapy [
3]. In addition to the lack of progress in survival rates, the quality of life of patients on HD has not improved [
6].
In-centre HD (ICHD), generally performed thrice-weekly for 4 to 5 hours per session, is the most common dialysis option used by patients worldwide [
3]. However, the latest USRDS report shows that 33.6% of HD patients in the US receive only 180 minutes of dialysis or less per session [
7]. Alternative, home-based dialysis options include peritoneal dialysis (PD) and home HD. While not true for all patients [
8‐
10], generally, PD and conventional home HD offer clinical outcomes that are equivalent, and in some patient groups superior, to those provided by ICHD [
11‐
15]. However, patients using home dialysis benefit from greater independence and autonomy, and less intrusion into their everyday lives [
13,
16,
17]. Furthermore, reduced travel, support, service and collateral costs mean that home dialysis can produce equivalent or greater clinical benefit at reasonable or even reduced costs [
12,
18]. Home HD has the added benefit of facilitating frequent and/or longer ‘high-dose’ HD regimens such as nocturnal HD and short-daily HD. Such regimens lack the long (2-day) interdialytic interval associated with conventional HD, which has been shown to increase patient mortality risk [
19]. In contrast, high-dose HD regimens have shown significant physiological, clinical and patient-reported advantages over conventional ICHD [
20‐
30]. Despite their apparent benefits, home dialysis options remain the less popular choices in many countries [
3]. In light of the apparent disconnect between the possible advantages and actual uptake of home dialysis, a multinational survey of nephrologists was undertaken to determine nephrologists’ views on home dialysis options, with a particular focus on home HD and high-dose HD.
Methods
Nephrologists from Canada, France, Germany, the United Kingdom and the United States were asked to respond to an online questionnaire that took around 45 minutes to complete. The invitation to participate was sent electronically to a list of 1,500 known nephrologists within the participating countries. Questionnaires developed in English and translated into appropriate languages for nephrologists in France and Germany were completed by respondents in the second half of 2010. Respondents were paid a fee to complete the questionnaire in line with currently acceptable standards for such research. The first part of the questionnaire contained questions used to determine whether the responder was eligible to take part in the survey. Only certified nephrologists who had been in practice for 2–35 years and who currently managed more than 25 adult dialysis patients on any modality were eligible for inclusion in the survey analysis. Responders were not included if they currently served as a consultant, advisory board member or employee of a pharmaceutical company, medical device company or other healthcare manufacturer; or had participated in dialysis market research within the past month.
The second part of the questionnaire was designed to obtain nephrologists’ beliefs and attitudes around dialysis modalities and prescriptions, and current treatment goals. Questions were chosen based on previous, unpublished qualitative research performed in the five aforementioned countries. The qualitative research explored the beliefs and values of nephrologists and nurses towards dialysis in general and home dialysis options in particular, and was performed using a variety of research techniques, including in-person, in-depth interviews and in-depth interviews by telephone. Interviews lasted from 45–120 minutes and provided directional information to structure the quantitative questionnaire.
Nephrologists were asked to respond to a variety of statements using the following scale: strongly disagree; disagree; somewhat disagree; somewhat agree; agree; strongly agree. Specifically, questions were asked to discover nephrologists’ personal motivations for treating chronic kidney disease or dialysis patients, treatment goals, attitudes towards new therapies, attitudes towards guidelines and policies, attitudes towards dialysis modalities, and reasons for selecting particular dialysis modalities. In the third section of the questionnaire, the physicians were asked to summarise the dialysis modalities used by their patients, and also general patient capabilities and health profiles. In the final section, different patient profiles were described (relatively healthy; moderately healthy; chronically unhealthy) and nephrologists were asked to provide their dialysis modality recommendations for each profile. This was an extensive survey and the questions most relevant to physicians’ dialysis modality selection are reported herein (see Additional file
1).
Results were analysed using Excel and presented as descriptive statistics. Data are presented as mean numbers ± standard deviation, or as percentages. Unless otherwise stated, all respondents who indicated ‘strongly agreed’ or ‘agreed’ are presented together in the text as the proportion of respondents who agreed with a particular statement.
Ethics approval was not sought for this online survey of healthcare staff; consent to participate in the survey was considered to be implied by a response from the participant.
Discussion
A recent paper has highlighted four areas of benefit to patients from high-dose HD: 1. improved physical and mental wellbeing, 2. increased control over their life, 3. decreased sick role (including return to regular employment) and 4. identification of competencies to undertake self-care [
31]. In support of this, our study showed that most participating nephrologists would prefer to prescribe home dialysis. Most nephrologists who responded to the survey believed that home HD provides a better quality of life than ICHD. In addition, most stated that they would recommend home HD as a dialysis treatment to their family and friends, and felt that home HD, as well as PD, were under-prescribed. Despite such apparently overwhelming support for home dialysis from respondents, this survey also showed that the vast majority of dialysis patients under respondents’ care currently receive ICHD. Furthermore, investigation into which dialysis modality respondents would recommend for patients with different health profiles revealed that, despite preferring home dialysis, most nephrologists in France, Germany, the UK and the USA would still recommend ICHD to patients, regardless of health status or history of dialysis. However, it was noted that a slightly greater proportion of respondents would recommend home HD and PD if the patient was relatively healthy and new to dialysis. Over half of respondents agreed to some extent that they would recommend home HD or PD only to their healthiest patients.
The majority of respondents considered that increasing the frequency of dialysis beyond three times per week and performing longer nocturnal dialysis sessions significantly improves clinical outcomes. These beliefs are consistent with evidence from clinical studies indicating that high-dose HD, i.e. short-daily or nocturnal HD, can improve physiological markers and clinical and patient-reported outcomes versus conventional ICHD. For example, patients on high-dose HD regimens exhibit improved urea clearance [
20‐
22], lower phosphate levels and use of phosphate-binding medications [
22,
25,
26], greater blood pressure control [
22‐
24] and reduced left ventricular mass [
24,
25] versus those on ICHD. Patients receiving high-dose HD also report an improved perception of their general health and mental health and a reduction in the impact of disease on their lives [
27‐
30]. Survival data are relatively scarce, but two small retrospective, observational studies have reported better survival for patients on nocturnal HD versus those on ICHD [
32,
33]. A retrospective matched-cohort study also reported a 45% improvement in survival with high-dose HD in the home versus thrice-weekly ICHD [
34]. Daily home HD has also been associated with a 13% lower risk for all-cause mortality than conventional ICHD performed three times weekly [
35].
Two main questions arise following our survey: why is there a large discrepancy between nephrologists’ treatment preferences and their prescribing habits, and what can be done to reduce it? One likely factor is treatment availability; for example, up to a third of the respondents’ dialysis clinics did not offer home HD, although this reduced to up to a sixth of respondents for PD. In the surveyed countries, ICHD is the standard treatment option, and it may be more difficult for a clinician to prescribe an alternative. One study showed that the use of home HD in the USA was influenced by the number of treatments covered by Medicare [
36]. In an Australian study, lack of physical clinic infrastructure and training facilities were among the reasons cited by nephrologists as barriers to the uptake of home HD [
37]. In some countries PD is the standard method of dialysis and infrastructure is well developed to support this. Therefore, the discrepancy between nephrologists’ home dialysis preferences and prescribing practices in these countries may be less pronounced [
17].
Our results show there appears to be a perception among the respondents that home HD and PD should be used only in patients who are relatively young and healthy. Comorbid conditions can influence the best type of dialysis modality to use. For example, if a patient has multiple comorbidities or suffers from frequent complications during HD, then ICHD under medical supervision may be necessary [
17]. Similarly, patients with diabetes or comorbid heart conditions are more likely to use PD than home HD [
38]. However, it is not always the case that healthier, younger patients are best suited to home dialysis; with adequate support, older patients with comorbidities can fare well on home HD or PD [
39]. Studies further profiling which patients benefit most from home HD may help nephrologists when recommending different dialysis modalities to their patients.
Several studies have been published investigating healthcare provider and patient attitudes towards different methods of HD care and delivery, including home HD [
37,
40‐
42]. A report investigating home HD in the USA categorised the impediments to its effective delivery into educational barriers (for patients and healthcare providers), governmental/regulatory barriers (state and federal), and barriers specifically related to the philosophies and business practices of dialysis providers (e.g. staffing, supplies and continuous quality improvement practices) [
43]. In Australia, nephrologists felt healthcare system factors such as inadequate funding for home therapies in the private sector, lack of financial incentives in the public sector, limited psychological outreach support for patients and carers, lack of training facilities and opportunities for staff and patients, and lack of available simple home dialysis technology prevented the increased uptake of home HD [
37]. Nephrologists and nurses believed that patients might also be worried about the personal costs of home HD, even though many costs (such as the financial burden of travelling to a clinic) are actually reduced with home HD [
12,
17,
37,
40]. Patient attitude and lack of confidence and motivation were also cited as barriers, especially if patients had begun therapy with ICHD and had already been on dialysis for a long time [
37,
40].
In countries such as Australia, Finland and the UK where the uptake of home HD is relatively high, success has been attributed to provision of adequate funding, support, education and training to both service users and service providers in the use of home HD [
17,
44,
45]. In Australia, nephrologists believed that medical and nursing expertise in home dialysis was good, that home HD was available and supported by most units, and that longer hours and/or more frequent regimens offered outcome advantages [
37]. At the Helsinki University Hospital in Finland, adoption of a ‘home first’ policy in predialysis education, close cooperation with other dialysis centres and centralised home HD training to support remote hospitals were cited as key factors for establishing an effective home HD programme [
44]. Strong clinical leadership appears to be key in the UK, with the need to challenge beliefs about who might be suitable for home HD emerging as a consistent theme for improving patient access to home HD [
45]. Additional considerations for successful home HD programmes, raised by the American Society of Nephrology Dialysis Advisory Group, include: selection of appropriate dialysis machines for the treatment regimen, differences in prescribed regimens e.g. dialysate flow; reliable vascular access, preferably arteriovenous fistulas; the potential requirement for remote monitoring, and finally, patient burnout necessitating return to ICHD or a period of ‘respite’ care [
46]. Further initiatives to establish integrated home HD pathways, develop financial incentives and solutions to sustainability challenges, provide support for carers, and capture key indicators of dialysis use and practices within renal registries are also required [
18,
45]. Initiatives such as telemedicine (i.e. telephone support lines and other information technology applications) to provide medical support for patients at home could help improve safety and reassure patients on home HD [
42].
The results of this survey must be interpreted in light of its limitations. Generally speaking, a survey can capture only broad perspectives. Views on complex issues are difficult to compress into simple answers and the questionnaire could not capture all the nuances of nephrologists’ treatment decisions. In France, for example, funding for a nurse to provide assisted PD is available to patients, from which elderly patients who would otherwise be on ICHD can benefit. Therefore, this is likely to influence French nephrologists’ treatment recommendations. It should also be recognised that respondents’ answers to interview questions may differ from their true beliefs. In addition, although encompassing five countries, the study results were biased towards experiences of US nephrologists, as the number of USA respondents was around three times greater than for other countries. Outside the USA, only a relatively small number of respondents (≤50) were recruited from each country. It should also be noted that the survey did not include respondents from Australia and New Zealand, countries where home therapies are most common. Data from a larger, more comprehensive group of nephrologists, along with appropriate statistical analysis, would help further elucidate worldwide practices and preferences in dialysis treatment. Finally, the process of recruiting survey respondents may have itself biased the study population in some way, perhaps recruiting only the most enthusiastic professionals. Therefore, survey results may not fully portray the full spectrum of nephrologists’ attitudes. Of note, in another international survey comprising 544 respondents, physician attitudes toward the evidence for high-dose HD differed significantly between those who typically had patients on high-dose HD and conventional ICHD providers [
47]. High-dose HD providers were significantly more likely to agree with statements that such regimens improve quality of life, improve nutritional status, reduce erythropoietin requirements and are cost effective compared with ICHD providers [
47].
Competing interests
RJF has received lecture and consultancy fees from Baxter, Gambro, Amgen, Ortho Biotech and Roche. DF has received lecture fees from Amgen, Fresenius, Genzyme and Shire, and consulting fees from Abbott, Amgen, Baxter, Danone, Genzyme and Shire. RSL is a member of the Machine Medical Advisory Board of Fresenius Medical Care.
Authors’ contributions
RJF, DF and RSL contributed to the analysis and interpretation of the data, drafting and revising the article, and provided intellectual input. All authors read and approved the final manuscript.