Abstract
Background and Aims
Home hemodialysis (HHD) offers similar, and perhaps even superior clinical outcomes to in-center hemodialysis (HD) at a fraction of the cost. HHD remains underutilized as remote HD patients in the province of Saskatchewan often relocate or travel hundreds of kilometers weekly in order to receive dialysis related care. Many barriers to accessing and utilizing HHD have been described, but the degree to which these factors impact our province’s residents has not been quantified. In quantifying these barriers we can better design better protocols to address the unique barriers leading to low utilization of HHD in our province. The purpose of this study was to determine the barriers to receiving HHD in the province of Saskatchewan.
Method
We conducted a cross sectional survey of in-center HD patients across the province of Saskatchewan, Canada. A total of 740 in-center HD patients (two academic sites, 7 satellite units) were approached by study coordinators. 421 patients (n=268 in the main units and n=153 in the satellite units) agreed to participate in the study. A five-point Likert scale survey was created to identify barriers to HHD with questions addressing HHD awareness and knowledge, accessibility, home constraints, impact on family members, and risks, fears, beliefs surrounding HHD. Responses were anonymous and tabulated using a data collection tool. Survey data were summarized using descriptive statistics.
Results
41.7 % of participants had more than 12 years of formal education. 12% lived on reserve, 18% on farm, and 70% in town/city. The median (interquartile range=IQR) distance of home to in-center dialysis units was 12 (5-80) kilometers. Only 76% of patients were aware of HHD. 46% of patients felt they had no understanding of the benefits or risks of HHD. Despite only 8% of patients being told they were unsuitable for HHD by their nephrologist, only 28% had ever considered it as a treatment option. Other prominent barriers to HHD were: satisfaction with in-center HD (76%), medical supervision during HD (76%), opportunity to socialize with in-center HD patients (73%), increase in utility payments (54%), and fear of having a major health event at home (51%). Other home constraints (space, inability to make modifications to the home) also figured prominently (35%).
Conclusion
In this study, we identified patient specific barriers to HHD in a prevalent cohort of HD patients. Several barriers were identified with a few consistent themes being identified, including deficiencies in knowledge and awareness, home constraints, and perceived benefits of in-center care (satisfaction with current care, socializing with patients and staff, and fear of a catastrophic event at home). The most frequently reported knowledge barrier was a lack of understanding of the benefits and risks of HHD. These findings suggest that not enough patients are receiving formal education, or active involvement in deciding which modality they would be most suitable for them when initiating dialysis. In center dialysis is considered the ‘default’ option for many patients, resulting in limited education on HHD. Changing the culture surrounding in-center dialysis as the ‘default’ method of dialysis requires broader physician, allied health professional, and system level recognition of the potential benefits HHD could offer patients. Differences in remuneration for HHD and in-center HD also pose an obstacle to ensuring patients are making truly informed choices when it comes to in-center HD versus HHD. While the study does not reflect views of all the patients, this information will be valuable in designing an educational program to improve adoption of HHD within our province.
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