From Home Dialysis Access to Home Dialysis Quality

The number and percentage of patients dialyzing at home has steadily increased during the past decade, and federal policy initiatives have driven interest to a new high. However, the mere utilization of home dialysis does not ensure better outcomes for patients and care partners. Although public reporting systems for dialysis quality are mature and robust, the incorporation of home dialysis quality in those systems is immature; the advent of the End-Stage Renal Disease Treatment Choices payment model brings this problem into sharp relief. The home dialysis modalities present both common and unique targets for quality measurement. For both modalities, therapy duration (or its inverse, technique failure) is a potential target. For peritoneal dialysis, peritonitis, catheter complications, and residual kidney function are additional targets; for home hemodialysis, vascular access infections, dialysis adequacy, and treatment adherence are targets. Patient-reported experience measures are also important; this domain is a long-standing disparity, as in-facility hemodialysis patients have been routinely surveyed for several years. The statistical aspect of quality measurement in home dialysis requires some adaptation, as the typical home dialysis program is small, thus presenting a threat to reliability; pooling programs may be necessary. Ultimately, promoting high-quality home dialysis will likely increase utilization of home dialysis.