Consolidation in dialysis Markets—Causes,consequences, and the role of policy

The dialysis industry is one of the most highly concentrated healthcare sectors in the United States. Despite decades of growth in the number of patients with end-stage renal disease and in the size of dialysis markets, two large dialysis organizations currently care for more than two-thirds of the dialysis population. Economies of scale, bargaining leverage with suppliers and private insurers, barriers to entry, and government regulations have contributed to highly concentrated dialysis markets by conferring advantages to larger organizations. Consolidated dialysis markets have coincided with both positive and negative trends in healthcare costs and outcomes. Costs per patient receiving dialysis have grown at a slower rate than per capita Medicare costs, while access to dialysis care remains available across a wide socioeconomic range. Mortality rates have declined despite a sicker dialysis patient population. Yet, concerns remain about the cost and quality of dialysis care. Evidence suggests that chain ownership, for profit status, and less market competition may negatively impact health outcomes. Future policies and innovations involving kidney health may temporarily disrupt consolidation. However, if the underlying mechanisms that contributed to past consolidation persist, dialysis markets may remain highly concentrated over the long term.     

Aging and ESRD Demographics: Consequences for the Practice of Dialysis

The disproportionate increase in the prevalence of chronic kidney disease (CKD) and end‐stage renal disease (ESRD) in the elderly is now recognized as a national and global reality. Among the major contributing factors are the aging of the population, a growing prevalence of CKD, greater access to care, and increased comorbidities. The utilization of renal replacement therapy in the geriatric population has concomitantly increased. It is imposing enormous challenges to the practice of ESRD care, the largest of which may be to determine the best application of clinical performance targets to a population with limitations in life expectancy. Concurrently, increased focus on quality of life will be required. The effective dialysis practitioner will need to adapt to the aging ESRD demographics with an increased focus on physical and mental well‐being of the geriatric patient.     

Identification of Facilitators and Barriers to Home Dialysis Selection by Canadian Adults with ESRD

Home dialysis (home HD or home PD) remains underutilized in most jurisdictions. Physicians, advanced‐practice nurses, and policy makers working with chronic kidney disease populations can provide insights into patient, healthcare professional, and system‐level barriers to home dialysis selection by suitable patients. We used in‐depth interviews, with a purposive sampling strategy until informational redundancy was achieved, to elicit barriers and facilitators to home dialysis selection from thirteen informants. We triangulated these data against qualitative data collected in a related survey of nephrologist attitudes. We used a modified grounded theory approach to construct a taxonomy of barriers and facilitators. Informants included nephrologists (n = 11), an advanced‐practice nurse, and a health administrator with a provincial renal care organization. We constructed separate taxonomies of barriers and related facilitators that were specific to PD, specific to home HD, and common to both. We distinguished between factors favoring, modifiable factors opposing, and nonmodifiable factors opposing home dialysis selection. Several major themes emerged, including: medical factors, home physical environment, psychological and cognitive factors (knowledge, attitudes, coping styles), social factors (supports, lifestyle), dialysis program, local hospital or regional factors (expertise, resources, local culture), healthcare professional‐related factors (knowledge, attitudes, reimbursement), health system‐related factors (funding models), and exogenous factors (late referral, technology). We identified several modifiable practices at the level of patient, healthcare professional, dialysis facility, and healthcare system to increase appropriate use of home dialysis. We discuss potential facilitating factors, knowledge gaps, and priorities for future research, and propose potential applications for this novel taxonomy of determinants of dialysis modality choice.     

Using an Electronic Self‐Management Tool to Support Patients with Chronic Kidney Disease (CKD): A CKD Clinic Self‐Care Model

New healthcare delivery models are needed to enhance the patient experience and improve quality of care for individuals with chronic conditions such as kidney disease. One potential avenue is to implement self‐management strategies. There is growing evidence that self‐management interventions help optimize various aspects of chronic disease management. With the increasing use of information technology (IT) in health care, chronic disease management programs are incorporating IT solutions to support patient self‐management practices. IT solutions have the ability to promote key principles of self‐management, namely education, empowerment, and collaboration. Positive clinical outcomes have been demonstrated for a number of chronic conditions when IT solutions were incorporated into self‐management programs. There is a paucity of evidence for self‐management in chronic kidney disease (CKD) patients. Furthermore, IT strategies have not been tested in this patient population to the same extent as other chronic conditions (e.g., diabetes, hypertension). Therefore, it is currently unknown if IT strategies will promote self‐management behaviors and lead to improvements in overall patient care. We designed and developed an IT solution called My KidneyCare Centre to support self‐management strategies for patients with CKD. In this review, we discuss the rationale and vision of incorporating an electronic self‐management tool to support the care of patients with CKD.     

Outcomes research in dialysis

Worldwide, the number of patients with end stage renal disease (ESRD) and the number of ESRD patients receiving renal replacement therapy is growing. In the United States the number of patients enrolled in the Medicare-funded ESRD program has grown substantially, from approximately 10000 beneficiaries in 1973 to 340261 as of December 31, 1999. United States has the highest incidence ESRD of 317 per million population. Despite the magnitude of resources committed to the treatment of ESRD and the substantial improvements in the quality of dialysis therapy, these patients continue to experience significant mortality and morbidity, and reduced quality of life. Moreover, 50% of dialysis patients have 3 or more comorbid conditions, the mean number of hospital days per year is approximately 14 per patient, and self reported quality of life is far lower in dialysis patients than in general population. The most desirable interventions are those that specifically target measurable global outcomes such as mortality, morbidity, and health care costs. Nevertheless, patient outcomes that have shown links with these global outcomes may also be appropriate targets for intervention. This article will briefly review the available literature to discuss the role of important clinical indicators on dialysis outcomes and their impact on continuing care of ESRD population.     

In Quality We Trust; but Quality of Life or Quality of Care?

The ESRD program provides medical care to a diverse and medically complex patient population. The care for the ESRD patient population has become increasingly benchmarked with process of care measures. These measures include dialysis adequacy, anemia, nutrition, and vascular access outcomes. These process‐related dialysis measures may not improve the care of the individual patient as care relates to the individual's goals and values. There is also evidence that these process measures may not be causally related to quality of life, hospitalization, and survival. The adoption of patient‐reported outcomes may shift the balance toward more patient‐centered care. However, the extent to which mandated measures of health‐related quality of life and patient satisfaction result in improved outcomes remains unclear.     

A Description of the Costs of Living and Standard Criteria Deceased Donor Kidney Transplantation

Kidney transplantation improves quality of life and survival and is associated with lower health care costs compared with dialysis. We described and compared the costs of living and standard criteria for deceased donor kidney transplantation. Patients included adult recipients of a first kidney‐only transplant between April 1, 1998, and March 31, 2006, as well as their donor information. All costs (outpatient care, diagnostic imaging, inpatient care, physician claims, laboratory tests and transplant medications) for 2 years after transplant for recipients and transplant‐related costs prior to transplant (donor workup and management) were included. Complete cost information was available for 357 recipients. The mean total 2‐year cost of transplantation, including donor costs, for recipients of living and deceased donors was $118 347 (95% confidence interval [CI], 110 395–126 299) and $121 121 (95% CI 114 287–127 956), respectively (p = 0.7). The mean cost for a living donor was $18 129 (95% CI 16 845–19 414) and for a deceased donor was $36 989 (95% CI 34 421–39 558). Living donor kidney transplantation has similar costs at 2 years compared with deceased donor transplantation. These results can be used by health care decision makers to inform strategies to increase donation.     

Approaches to Self‐Management in Chronic Illness

Management of a chronic medical condition is a complex process and requires coordinated action between healthcare providers and patients. This process is further complicated by the fact that an increasing number of patients suffer from multiple chronic conditions. Self‐management involves active participation of the patients in the everyday care of the symptoms of their illness(es) and medical treatments, as well as maintaining general health and prevention of progression of medical conditions. Managing the psychosocial consequences of illness is also an important component of self‐management. Data have demonstrated that enhancing self‐management improves quality of life, coping, symptom management, disability, and reduces healthcare expenditures and service utilization. To foster self‐management, potential barriers to implementation as well as facilitators and supports for this approach must be acknowledged. In this article, we review various aspects of self‐management in chronic illness, focusing on chronic kidney disease. Better understanding of these concepts will facilitate patient–provider collaboration, improve patient care with increased patient and staff satisfaction, and may ultimately result in better clinical outcomes and enhanced quality of life for both the patients and their families.     

Patient‐reported outcome measures and their utility in the management of patients with advanced chronic kidney disease

Symptom and quality of life (QOL) measures in patients with advanced chronic kidney disease are recognized indicators of patient‐centred care and represent important research, quality and clinical measures. This study examined relationships between symptom burden, QOL and functional status and associations of symptoms and mortality risk. A multisite longitudinal cohort analysis was undertaken in chronic kidney disease stage 4/5 (no dialysis) and dialysis patients. Patients completed symptom and QOL measures (Palliative Care Outcome Symptom Score renal), World Health Organisation QOL Brief Version) and Karnofsky Performance scale. Clinical and demographic data were recorded.     

Integrating kidney transplantation into value‐based care for people with renal failure

Healthcare reimbursement is increasingly tied to value instead of volume, with special attention paid to resource‐intensive populations such as patients with renal disease. To this end, Medicare has sponsored pilot projects to encourage providers to develop care coordination and population health management strategies to provide quality care while reducing resource utilization. In this Personal Viewpoint essay, we argue in favor of expanding one such pilot project—the Comprehensive ESRD Care (CEC) initiative—to include patients with advanced chronic kidney disease and kidney transplant recipients. The implementation of the Medicare Access and CHIP Reauthorization Act (MACRA) offers a time‐sensitive incentive for transplant centers in particular to align with extant CECs. An “expanded” CEC model proffers opportunity for robust cooperation between general nephrology practices, dialysis providers, and transplant centers to develop care coordination strategies for all patients with renal disease, realign incentives for all clinical stakeholders to increase kidney transplantation rates, and reduce total costs of care.     

Postoperative recovery: the importance of the team

An ageing population and rising healthcare costs are challenging cost-efficient hospital systems wanting to adapt, employing novel organisational structures designed to merge diverse skill sets. This needs not only physician and nursing leadership but also new models of care. Anaesthetists have expanded their role into the broader multidisciplinary field of peri-operative medicine, emphasising collaboration and safety in health teams. A greater focus on patient-centred care and shared decision making, along with validated metrics to quantify quality improvement activities, have emphasised the importance of comfort, patient satisfaction and quality of life after surgery. Shared decision-making is more likely to be manifest in a flat hierarchy in which each member of the team brings their own experience and skills to optimise patient care. Successful surgery is best achieved by a coordinated, multidisciplinary team, embedded in a culture of collaboration and safety.     

Accountable care organizations and ESRD: the time has come

Accountable care organizations (ACOs) are a newly proposed vehicle for improving or maintaining high-quality patient care while controlling costs. They are meant to achieve the goals of the Medicare Shared Savings Program mandated by the Patient Protection and Affordable Care Act (PPACA) of 2010. ACOs are voluntary groups of hospitals, physicians, and health care teams that provide care for a defined group of Medicare beneficiaries and assume responsibility for providing high-quality care through defined quality measures at a cost below what would have been expected. If an ACO succeeds in achieving both the quality measures and reduced costs, the ACO will share in Medicare's cost savings. Health care for patients with end-stage renal disease is complex due to multiple patient comorbid conditions, expensive, and often poorly coordinated. Due to the unique needs of patients with end-stage renal disease receiving dialysis, ACOs may be unable to provide the highly specialized quality care these patients require. We discuss the benefits and risks of a renal-focused ACO for dialysis patients, as well as the kidney community's prior experience with an ACO-like demonstration project.     

Health‐related quality of life in peritoneal dialysis patients: A narrative review

Health‐related quality of life (HRQOL) is an important aspect of patients´ health that should be an integral part of the evaluation of patient‐centered outcomes, not least because HRQOL associates with patients´ morbidity and mortality. This applies also to chronic kidney disease patients, including those dependent on renal replacement therapies, the type of which may influence patients´ perception of HRQOL. Several studies have addressed HRQOL in chronic kidney disease patients undergoing renal replacement therapies, especially transplanted patients and hemodialysis patients, while publications concerning peritoneal dialysis (PD) patients are scarcer. This review describes some of the methods used to assess HRQOL, factors influencing HRQOL in PD patients, HRQOL in PD vs hemodialysis, and the relation between HRQOL and patient outcomes. We conclude that assessment of HRQOL–often neglected at present–should be included as a standard measure of patient‐centered outcomes and when monitoring the quality and effectiveness of renal care including PD treatment.     

Psychosocial factors in people with chronic kidney disease prior to renal replacement therapy

Increasing evidence implicates psychosocial factors including depression, anxiety, perceived social support and health‐related quality of life in the pathophysiology of various chronic diseases. Research examining the psychosocial aspects of kidney disease has focussed predominantly on depressive disorders in dialysis patients where they are independently associated with increased risk of mortality and poor health‐related quality of life. In contrast, studies examining the influence of psychosocial factors in people with chronic kidney disease (CKD) prior to the initiation of renal replacement therapy are sparse. Limited data indicate that clinical depression and depressive symptoms are common and may independently predict progression to dialysis, hospitalization and death. In contrast, the influence of anxiety disorders, lower perceived social support and impaired health‐related quality of life on the clinical course of CKD have received little attention. Large‐scale prospective cohort studies are needed to clarify the burden and prognostic impact of these factors in this vulnerable population. Given the escalating burden of CKD worldwide examining the role of these potentially modifiable risk factors is crucial. Identifying and implementing targeted interventions in order to prevent or delay the progression of CKD and improve quality of life will be a major challenge.     

Incorporating patient-reported outcomes (PROs) into dialysis policy: Current initiatives,challenges, and opportunities

Governments at national and state levels regulate dialysis care in the United States to ensure safe practices, and continually elevate the quality of care. An objective of these regulatory policies is the independent evaluation of dialysis unit outcomes by patients, caregivers, and the community to facilitate choices as well as to advance equal access to high quality dialysis care. These polices recognized decades ago that it was fundamental to include the patient perspective in the assessment and evaluation of dialysis care quality by requiring both individual and aggregate patient reported outcomes (PROs). Although there is support for integrating the patient perspective, concerns persist about the implementation of these polices including selection of PRO measures, administration timing and reach, as well as interpretation of results including benchmarking to permit comparisons across organizations. The experience from the early adoption of PROs into dialysis policies in conjunction with advances in electronic health records, personal data capture and monitoring, and analytics is poised to address these concerns. The dialysis community has the opportunity to lead the way in innovation related to PRO implementation not only in kidney disease care, but also for other healthcare conditions or contexts such as oncology, surgical, and acute care.     

Outcomes of Kidney Transplants Under the Philippine Health Insurance Corporation's Z Benefit Package at the University of the Philippines-Philippine General Hospital from 2015 to 2021

End-stage renal disease is one of the most burdensome diseases, particularly in developing countries such as the Philippines, with dialysis and kidney transplant commonly being a source of out-of-pocket expenditure among patients. To address the burgeoning health inequity, the Philippine Health Insurance Corporation (Philhealth) launched in 2012 its Z Benefit Package for kidney transplantation providing a substantial amount to subsidize the transplant with the aim of increasing financial risk protection of its members, especially the marginalized sector. The University of the Philippines-Philippine General Hospital is a government hospital that was one of the contracted hospitals to provide this benefit package since 2015. Herein we report our initial experience with 29 primary, low immunologic risk, living donor kidney transplants. Recipients mostly had chronic glomerulonephritis with a median discharge creatinine of 1.04 mg/dL. One, 3-, and 5-year graft survival was 100%, 96%, and 85%, respectively, with a median graft survival of 65 months. Donors were mostly male with a median discharge creatinine of 1.0 mg/dL. One, 3-, and 5-year patient survival was 100%, 91%, and 81%, respectively. Complications were mostly urinary tract infections. In conclusion, the Philippine Health Insurance Corporation Z Benefit Package for transplant seems to be achieving its goals of providing quality care particularly for the poor with catastrophic diseases such as end-stage renal disease. Optimal patient selection and management are essential in attaining excellent graft and patient outcomes. Furthermore, it is hoped that with this program, there will be increased awareness of the at-risk population, transplanting them preemptively, ensuring a better overall survival.     

Prioritizing Patient‐Centered Care Implementation and Research for Patients with Kidney Disease

Patient‐centered care is upheld as one of the fundamental components of high quality health care. Although a deceptively easy concept, patient‐centered care is an elusive goal in clinical practice. A core objective for patient‐centered care is a collaboration between health care providers and patients that aligns therapy with patients' values and preferences through shared decision making. Advances in communication training that are tailored to the specific requirements of nephrology care are promising methods for enhancing the skill‐set of our providers. However, patient‐centered care extends beyond shared decision‐making and also involves attention to patients' physical and emotional symptoms, care coordination, and the inclusion of family members. Research about patient‐centered care processes, interventions and outcomes among patients with kidney disease is sparse. Recent discussions among nephrology experts name patient‐centered care as a priority for research and quality improvement in care. Given recent advances in methods for quantifying patient‐centered care as well as patient reported outcomes, now is the time to prioritize our resources to evolve our health system and meet the needs of all patients with kidney disease.     

Treatment of End‐stage Kidney Failure without Renal Replacement Therapy

For the majority of patients with end‐stage kidney failure (ESKF) replacement of excretory renal function by dialysis or transplantation (RRT) can extend life and alleviate symptoms. Historically, the availability of RRT has been insufficient and this remains the case for much of the world. However, RRT is now widely available in healthcare systems of higher income countries. Increasing numbers of elderly patients are developing ESKF. RRT in this population is largely by dialysis, comorbidity is high and life expectancy short. Evidence of effectiveness coupled with the burden of treatment among these individuals has raised concerns that health services in high‐income countries may have moved from an era of unmet need into one of potential over‐treatment. Alongside the requirement to make treatment more patient‐centered, this has driven the development of comprehensive conservative care as an alternative approach for older comorbid individuals with ESKF, with the potential for acceptable symptom control and reduced treatment burden. This paper provides a largely UK‐perspective on treating ESKF without RRT. Emphasis is on the need for high‐quality evidence to inform treatment decisions. Complexities of defining, delivering and improving treatment of ESKF without dialysis care are explored. Quantitative and qualitative evidence are summarized and the relationship with palliative and terminal care examined. A framework is suggested for classifying management of ESKF and recommendations made to improve delivery of nondialysis care in the future. For patients with a poor prognosis, such treatment may not result in significantly different survival or quality of life when compared with dialysis. There is a key need to generate the best possible evidence of person‐centered health outcomes associated with the various treatment options for ESKF and to present this to patients in a balanced, personalized way that allows them to make the treatment decision most appropriate for them.