The effect of bundling on peritoneal dialysis: Challenges and opportunities to improve outcomes and change the “default”

Dramatic changes in the end-stage renal disease (ESRD) prospective payment system (PPS) were enacted in 2011. Among the multiple changes brought about by the bundling of ESRD services, modifications were made explicitly “to encourage the use of home peritoneal dialysis (PD) among dialysis patients where feasible.”1 Peritoneal dialysis generally utilizes fewer overall healthcare resources, a fact that should have a favorable impact for dialysis facilities in the fixed payment environment of bundled ESRD services. It is anticipated that facilities will encourage PD and make it more accessible to nephrologists and their patients. But is PD always a viable option for patients who both want and are suitable for it? What factors should be evaluated in determining feasibility?

The incentive provided to facilities by the new PPS should afford nephrologists, and the patients they care for, the opportunities for an equally effective, less costly, and in some instances, a safer form of renal replacement therapy (RRT). It should enhance the likelihood of an additional option being offered to many individuals with ESRD as they decide how dialysis will impact their lifestyle. But a number of challenges need to be addressed, given the limited clinical use of PD in the past 15 years.

The use of peritoneal dialysis in the United States peaked at 16% in 1985, remained at a plateau of 14-15% through 1993,2 and has steadily eroded to a current 8% of Americans receiving dialysis today.3 With 92% of dialysis patients receiving hemodialysis (HD), the latter is the RRT “default.” There are many reasons for the decline of PD, but the lack of infrastructure and clinical support in current dialysis facilities certainly compromised the capacity to deliver full, quality care.2, 4 Nephrologists and patients must make the life-sustaining, clinical “choice” of therapies based on tangible, current services and expertise. When there is great disparity in support and expertise, there really isn't much of a choice.

To do something well, we must do it often. The knowledge and skill necessary to develop expertise requires frequency and focus. Logically, it would seem that PD outcomes would have suffered as the proportion of dialysis patients using this therapy declined. However, this was not the case. Fully adjusted patient and technique survival outcomes have improved.2, 5 This may be attributed to the centralization of expertise in larger centers,2-4, 6 but results could undoubtedly be replicated elsewhere if sufficient resources and focus are provided.

Should dialysis facilities adopt measures to support PD, nephrologists may modify prescriptive RRT guidance in a way that could improve the outcomes for a significant number of their patients. Currently four of every five patients starting HD do so with a central venous catheter (CVC).7 Yet this practice places them at significant, unnecessary risk.

A recent analysis of the Canadian Organ Replacement Register by Perl et al.8 demonstrated that patients starting HD with a CVC as their means of vascular access had a clear, sustained survival disadvantage. They were more likely to die within 90 days of dialysis initiation compared with patients starting on PD or HD with a fistula or graft. Perl et al. conclude that “PD offers the opportunity to avoid HD initiation with a CVC” in patients with “late referral, ineligibility for a surgical vascular access, or who defer a dialysis modality choice or access creation.”

In a document defining the “Role of Nephrologists in Access Placement in Patients with CKD Stages 4-5,” the Renal Physicians Association has suggested that both pre-emptive transplant and peritoneal dialysis (particularly as a bridge to HD using a permanent vascular access) be considered a priority in those patients presenting in need of dialysis with a glomerular filtration rate (GFR) < 10 mL/min in order to avoid CVC-associated risks and poor outcomes.9 Several prominent U.S. nephrologists have suggested that the use of PD as “a preferred mode of therapy for incident patients without a functioning arteriovenous fistula might mitigate some of the downsides of vascular catheter use for HD.”10 Whether treating acutely discovered ESRD with PD can improve outcomes is yet to be tested; however, fewer complications from CVCs would certainly be welcome.

Peritoneal dialysis may present a significant advantage for patients—or not. Poor outcomes are a distinct possibility if the cart is placed before the horse. Expanding PD requires a strong team of well-educated nurses applying best-demonstrated principles and practices in caring for patients in all environments: the hospital, the home, and assisted living facilities. Training and treatment protocols supported by a robust continuous quality improvement (CQI) process must be in place. To ensure optimal care, a home program must not be allowed to outpace or outstrip the resources provided it.

Peritoneal catheters must be viewed by surgeons and interventionalists as being more than “a tube in a hole.”11-13 There are proven, specific techniques for insertion that significantly improve function and minimize both mechanical and infectious complications.12, 14 Advancements and adoption of best demonstrated practices (BDP) in catheter placement are needed. The first International Society for Peritoneal Dialysis (ISPD)-sponsored Surgeons' Catheter University held last fall, with at least two more scheduled for 2011, provided a significant step in this direction. Given the shortage of willing and available surgeons capable of meeting local and/or more acute dialysis needs, a similar structured, “hands-on” BDP initiative for interventionalists is needed.

Most U.S. nephrologists who completed their training in the past 15 years have had little exposure to PD clinical management. There must be therapeutic acumen and acquired experience in addressing the prescriptive, adequacy, volume, and metabolic challenges unique to the PD patient population.15-18 Knowledge of the pharmacokinetic principles of antibiotics, specifically as they apply to automated PD, is key to the management of infectious complications to avoid refractory, relapsing, and repeat episodes of peritonitis.14

Patients need to be educated and to participate in their dialysis therapy choice.19 Persuasion to elect PD when an individual is either unwilling or unable to perform their care in a safe and correct manner will certainly lead to failure. As with any other disease process addressed in medicine, the focus must be to provide the right treatment to the right patient at the right time. The collaborative relationship between physician and patient must entail objective information, accurate understanding, and individualized guidance in order to achieve an informed choice and a therapy that best accommodates preferences, lifestyles, and survival.

The changes made by the Centers for Medicare & Medicaid Services will certainly drive a stronger consideration of PD as a dialysis modality. There are many opportunities to improve the care of U.S. dialysis patients while concurrently conserving costs of care. However, there is a clear risk of PD going from “boom to bust” if the measures, tools, and protocols needed to guarantee quality of care and excellent outcomes are not in place. As nephrologists, optimizing the care of patients with kidney disease is our central charge. The onus is on us to prepare ourselves and direct the improvements necessary to ensure the best possible healthcare for our patients.