Home care assistance and the utilization of peritoneal dialysis

Peritoneal dialysis (PD) may be declining because the elderly often have barriers to self-care PD. The objective of this study was to determine whether the availability of home care increases utilization of PD. In 134 incident chronic dialysis patients (median age 73), 108 (81%) had at least one medical or social condition, which was a potential barrier to self-care PD. Eighty percent of patients living in regions where home care was available were considered eligible for PD compared to 65% in regions without home care (P=0.01, adjusted). Each barrier reduced the probability of being eligible for PD by 26% (odds ratio 0.74, per condition, P=0.02) adjusted for age, sex, predialysis care, in-patient start, and availability of home care. In regions with and without home care, 59 and 58% of eligible patients choose PD when they were offered it (P=NS). The utilization of PD in the incident end-stage renal disease (ESRD) population living in regions with and without home care was 47 and 37%, respectively (P=0.27). The mean rate of home care visits over the first year was 4.3 per week (maximum available was 14 per week). Of the 22 assisted patients, 15 required chronic support, five graduated to self-care, and two started with self-care but later required assistance. Adverse events were similar between assisted PD and traditional modalities. Barriers to self-care PD are very common in the elderly ESRD population but home care assistance significantly increases the number of patients who can be safely offered PD. Peritoneal dialysis (PD) may be declining because the elderly often have barriers to self-care PD. The objective of this study was to determine whether the availability of home care increases utilization of PD. In 134 incident chronic dialysis patients (median age 73), 108 (81%) had at least one medical or social condition, which was a potential barrier to self-care PD. Eighty percent of patients living in regions where home care was available were considered eligible for PD compared to 65% in regions without home care (P=0.01, adjusted). Each barrier reduced the probability of being eligible for PD by 26% (odds ratio 0.74, per condition, P=0.02) adjusted for age, sex, predialysis care, in-patient start, and availability of home care. In regions with and without home care, 59 and 58% of eligible patients choose PD when they were offered it (P=NS). The utilization of PD in the incident end-stage renal disease (ESRD) population living in regions with and without home care was 47 and 37%, respectively (P=0.27). The mean rate of home care visits over the first year was 4.3 per week (maximum available was 14 per week). Of the 22 assisted patients, 15 required chronic support, five graduated to self-care, and two started with self-care but later required assistance. Adverse events were similar between assisted PD and traditional modalities. Barriers to self-care PD are very common in the elderly ESRD population but home care assistance significantly increases the number of patients who can be safely offered PD. The utilization of peritoneal dialysis (PD) to treat end-stage renal disease (ESRD) is declining in many countries, particularly among the elderly.1.Lee H. Manns B. Taub K. et al.Cost analysis of ongoing care of patients with end-stage renal disease: the impact of dialysis modality and dialysis access.Am J Kidney Dis. 2002; 40: 611-622Abstract Full Text Full Text PDF PubMed Scopus (373) Google Scholar, 2.Harris S.A. Lamping D.L. Brown E.A. Constantinovici N. Clinical outcomes and quality of life in elderly patients on peritoneal dialysis versus hemodialysis.Perit Dial Int. 2002; 22: 463-470PubMed Google Scholar, 3.Canadian Institute of Health Information Dialysis and Renal Transplantation.in: Canadian Organ Replacement Register, 2001 Report Volume 1 The Canadian Institute for Health Information, Ottawa, Ontario2001Google Scholar, 4.Canadian Institute of Health Information Older End-Stage Renal Disease Paitents on Renal Replacement Therapy in Canada: Incidence, Prevalence, and Treatment Patterns. The Canadian Institute for Health Information, Ottawa, Ontario2005Google Scholar, 5.Canadian Organ Replacement Register Treatment of End-Stage Organ Failure in Canada: 2002 and 2003. Canadian Institute for Health Information, Ottawa, Ontario2005Google Scholar In Canada, only 12% of chronic dialysis patients over the age of 75 used PD as their initial treatment modality in 2003.4.Canadian Institute of Health Information Older End-Stage Renal Disease Paitents on Renal Replacement Therapy in Canada: Incidence, Prevalence, and Treatment Patterns. The Canadian Institute for Health Information, Ottawa, Ontario2005Google Scholar One factor contributing to the decline of PD may be the increasing presence of medical or social conditions in the elderly that are barriers to self-care PD.6.Little J. Irwin A. Marshall T. et al.Predicting a patient's choice of dialysis modality: experience in a United Kingdom renal department.Am J Kidney Dis. 2001; 37: 981-986Abstract Full Text PDF PubMed Scopus (128) Google Scholar, 7.McLaughlin K. Manns B. Mortis G. et al.Why patients with ESRD do not select self-care dialysis as a treatment option.Am J Kidney Dis. 2003; 41: 380-385Abstract Full Text PDF PubMed Scopus (132) Google Scholar, 8.Jager K.J. Korevaar J.C. Dekker F.W. et al.The effect of contraindications and patient preference on dialysis modality selection in ESRD patients in The Netherlands.Am J Kidney Dis. 2004; 43: 891-899Abstract Full Text Full Text PDF PubMed Scopus (198) Google Scholar, 9.Lok C.E. Oliver M.J. Rothwell D.M. Hux J.E. The growing volume of diabetes-related dialysis: a population based study.Nephrol Dial Transplant. 2004; 19: 3098-3103Crossref PubMed Scopus (75) Google Scholar In an attempt to overcome these barriers, countries such as Canada, Denmark, and France have provided ‘assisted PD’ using community-based home care.8.Jager K.J. Korevaar J.C. Dekker F.W. et al.The effect of contraindications and patient preference on dialysis modality selection in ESRD patients in The Netherlands.Am J Kidney Dis. 2004; 43: 891-899Abstract Full Text Full Text PDF PubMed Scopus (198) Google Scholar, 10.Brunier G. Gray B. Coulis N. et al.The use of community nurses for home peritoneal dialysis: is it cost-effective?.Perit Dial Int. 1996; 16: S479-S482PubMed Google Scholar, 11.Cuttell K. Gartland C. Five years’ experience of a hospital-based home-care renal nursing service.Adv Perit Dial. 1999; 15: 258-261PubMed Google Scholar, 12.Cascio C. Cabralda T. Wadhwa N.K. et al.Use of private duty nurses for daily CCPD and family relief in pediatric PD patients.Adv Perit Dial. 1994; 10: 304-306PubMed Google Scholar Previous studies of assisted PD are generally small but have reported acceptable rates of peritonitis and hospitalization. However, the cost effectiveness of assisted PD has been questioned, particularly when the rate of home care visits is high. The Government of Ontario recently increased their funding for home care, which provided a new opportunity to implement and study assisted PD. In 2004, a community-based home care assistance program was developed at Sunnybrook Health Sciences Centre in Toronto, Ontario, Canada. The primary objective was to determine if the availability of home care assistance would increase PD utilization in our elderly dialysis population. Secondary objectives included describing the need for home care assistance among PD patients and identifying the frequency of adverse events associated with assisted PD compared to traditional dialysis modalities. One hundred and thirty-four patients started chronic dialysis between 1 January 2004 and 25 May 2006. The median age of the incident population was 73 years old and 58% were male. Seventy-seven percent had received at least 4 months of predialysis care, 48% started dialysis in the hospital, and 62% started on hemodialysis (HD). One hundred and eight (81%) of 134 incident patients had at least one medical or social condition acting as a barrier to PD (Table 1). Medical conditions included a history of multiple abdominal surgeries (4% of population), inoperable hernias (4%), active colitis/diverticulitis (4%), and morbid obesity (4%). Social conditions included small apartments, which had insufficient space for PD supplies (9%) and nursing homes (7%), rehabilitation centres (4%), or retirement homes (3%) that did not permit PD. More prevalent were conditions such as decreased strength to lift PD bags (43%), decreased manual dexterity (37%), decreased vision (25%), immobility (20%), and decreased hearing (17%). Anxiety about performing PD in the home (25%) and living alone and requiring assistance for PD (19%) were also common. The majority of patients had multiple conditions identified with the median number of conditions being 3 and 2 in the region with and without home care, respectively.Table 1Prevalence of conditions in an incident ESRD population that can act as barriers to self-care peritoneal dialysisMedical conditionsNumber (% of population)Decreased strength (to lift PD bags)57 (43)Decreased manual dexterity49 (37)Decreased vision/blindness33 (25)Immobility27 (20)Decreased hearing/deafness23 (17)Previous multiple abdominal surgeries6 (4)Abdominal hernias6 (4)Colitis or diverticulitis6 (4)Morbid obesity5 (4)Mental or psychological conditions AnxietyaPatient expressed anxiety, feeling overwhelmed, fear of isolation, or fear of lack of supervision.34 (25) Decreased cognitionbIncludes dementia, learning disability, or other neurologic condition affecting cognition.11 (8) Psychiatric condition9 (7) History of non-compliance7 (5)Social conditions Lives alone and requires assistance with PD26 (19) Residence does not permit PDcIncludes small living space, no storage space, or no permanent residence.12 (9) Nursing home does not support PD9 (7) Rehabilitation facility does not support PD6 (4) Moving out of region5 (4) Retirement home does not support PD4 (3) OtherdIncludes poor hygiene, insomnia, nocturia, and imminent transplant.4 (3)ESRD, end-stage renal disease; PD, peritoneal dialysis.Conditions were identified by multidisciplinary assessment.a Patient expressed anxiety, feeling overwhelmed, fear of isolation, or fear of lack of supervision.b Includes dementia, learning disability, or other neurologic condition affecting cognition.c Includes small living space, no storage space, or no permanent residence.d Includes poor hygiene, insomnia, nocturia, and imminent transplant. Open table in a new tab ESRD, end-stage renal disease; PD, peritoneal dialysis. Conditions were identified by multidisciplinary assessment. Sixty-six (80%) of the 83 patients living in regions with home care support were considered eligible for PD compared to 33 (65%) of 51 patients living in regions without support (P=0.01) (Table The ratio for a patient being considered eligible for PD was (P=0.01) if they in a region of home care support compared to if they did adjusted for in age, sex, predialysis care, in-patient start, and number of conditions acting as barriers to self-care PD. Each condition acting as barrier reduced the of being eligible for PD by 26% 0.74, per condition, P=0.02) adjusted for age, sex, predialysis care, and home care were significantly to be eligible for PD P=0.02) adjusted for age, sex, predialysis care, number of and home care and use of PD to availability of home with home with no home care, start, acting as barriers, for PD, compared to region with no home care adjusted for in age, sex, predialysis care, and number of conditions acting as barriers to PD between the PD if they were PD as chronic peritoneal dialysis.Conditions to or social conditions that with the of self-care PD was as an attempt or of a PD compared to region with no home care adjusted for in age, sex, predialysis care, and number of conditions acting as barriers to PD between the Open table in a new tab PD, peritoneal dialysis. Conditions to or social conditions that with the of self-care PD. PD was as an attempt or of a PD eligible patients, PD was as their chronic modality by 59 and 58% of patients living in regions with and without home care support for PD, of home care did not significantly increase the of PD in the analysis or for in age, sex, predialysis care, and number of conditions acting as patients and patients predialysis care were to choose PD as their chronic modality adjusted for the other In regions with and without home care, eight of and (19%) of patients who were eligible for PD started on and to PD, The on PD were no between availability of home care and the number of conditions acting as barriers to PD on whether patients PD. The utilization of PD in the incident ESRD population the of and PD use was of the in the regions of home care support compared to of in regions without home care support (P=0.27). The for PD use in regions of home care support was for in age, sex, predialysis care, in-patient and number of conditions acting as PD use was in patients predialysis care and in was a for PD use to be for condition acting as a identified multidisciplinary Of the 83 incident patients who in a region where home care assistance was were eligible for PD, and to One patient out of the region available for patients PD and 15 of the PD patients who PD received assisted PD. One patient who to assisted PD in 22 assisted patients available for were chronic of home care support, graduated to self-care PD, and started as self-care patients and required assistance over In the first year of the mean rate of home care visits was per week in PD patients living in regions of home care support self-care and per week in the patients who received assistance. The rate was and the visits of 14 per week 1). patients received over visits per week at their care. The mean was per Adverse rates were similar in the patients who received assisted PD when compared to patients other self-care PD, 14 two PD in but to (Table PD patients required and per The rate was per of The of in the assisted PD were multiple and of the primary that the were to assisted PD. in the assisted PD with a rate of per when were but the for assisted PD was at 1 of these adverse rates were significantly the who received self-care PD or The rate of peritonitis was months per in the self-care PD patients and months per in the assisted of adverse events between assisted PD and traditional self-care PD patients, 14 patients, and two patients who started on PD in but to dialysis patients peritoneal of the rates are Includes self-care PD patients, 14 patients, and two patients who started on PD in but to Open table in a new tab PD, peritoneal dialysis. of the rates are study that medical and social that act as barriers to self-care PD, were in of an elderly ESRD population. care assistance significantly increased the patients would be considered eligible for PD by the multidisciplinary PD was by the majority of patients it was offered to but home care did not increase the of PD. home care assistance was the majority of PD patients received assisted PD the common modality in patients eligible for PD or patients graduated to self-care and required assistance over the need for support was a the rate of visits was over and the home care was provided as and was not used because it was program to a to increasing PD utilization the ESRD population. Previous studies have reported that of patients were to PD in with a median age to years J. Irwin A. Marshall T. et al.Predicting a patient's choice of dialysis modality: experience in a United Kingdom renal department.Am J Kidney Dis. 2001; 37: 981-986Abstract Full Text PDF PubMed Scopus (128) Google J.C. Dekker F.W. et of with hemodialysis compared with peritoneal dialysis in patients new on dialysis a Int. 2003; Full Text Full Text PDF PubMed Scopus Google Scholar In contraindications are common with increasing J. Irwin A. Marshall T. et al.Predicting a patient's choice of dialysis modality: experience in a United Kingdom renal department.Am J Kidney Dis. 2001; 37: 981-986Abstract Full Text PDF PubMed Scopus (128) Google Scholar, 7.McLaughlin K. Manns B. Mortis G. et al.Why patients with ESRD do not select self-care dialysis as a treatment option.Am J Kidney Dis. 2003; 41: 380-385Abstract Full Text PDF PubMed Scopus (132) Google Scholar, 8.Jager K.J. Korevaar J.C. Dekker F.W. et al.The effect of contraindications and patient preference on dialysis modality selection in ESRD patients in The Netherlands.Am J Kidney Dis. 2004; 43: 891-899Abstract Full Text Full Text PDF PubMed Scopus (198) Google Scholar, of modality selection among incident dialysis a 2002; Google Scholar, et and associated with initial patient Int. 2002; Full Text Full Text PDF PubMed Scopus Google Scholar, et and other associated with modality selection in incident dialysis the for outcomes in for end-stage renal J Kidney Dis. 2002; Full Text Full Text PDF PubMed Scopus Google Scholar but this study only of the population was to PD, a median age of when home care was Previous studies have also associated PD use with renal obesity abdominal and J. Irwin A. Marshall T. et al.Predicting a patient's choice of dialysis modality: experience in a United Kingdom renal department.Am J Kidney Dis. 2001; 37: 981-986Abstract Full Text PDF PubMed Scopus (128) Google Scholar, 7.McLaughlin K. Manns B. Mortis G. et al.Why patients with ESRD do not select self-care dialysis as a treatment option.Am J Kidney Dis. 2003; 41: 380-385Abstract Full Text PDF PubMed Scopus (132) Google Scholar, 8.Jager K.J. Korevaar J.C. Dekker F.W. et al.The effect of contraindications and patient preference on dialysis modality selection in ESRD patients in The Netherlands.Am J Kidney Dis. 2004; 43: 891-899Abstract Full Text Full Text PDF PubMed Scopus (198) Google Scholar, of modality selection among incident dialysis a 2002; Google Scholar, et and associated with initial patient Int. 2002; Full Text Full Text PDF PubMed Scopus Google Scholar, et and other associated with modality selection in incident dialysis the for outcomes in for end-stage renal J Kidney Dis. 2002; Full Text Full Text PDF PubMed Scopus Google Scholar study that elderly patients often in small with storage space or retirement homes and care that do not permit PD. The multidisciplinary by and social was in identifying these social conditions to The multidisciplinary also the other that did not PD but self-care PD a conditions such as decreased vision and hearing were very common. barriers included anxiety, feeling overwhelmed, a fear of social isolation, and a fear of lack of was also care assistance in this was an that overcome not only but also and of in the in where family or a the majority of PD home care may this support out and increasing patients without family or the to a home care may be the support in the these medical and social conditions and support is and may the between predialysis care and PD use that in with of modality selection among incident dialysis a 2002; Google and end-stage renal disease (ESRD) an to ESRD Dial Transplant. 1999; PubMed Scopus (75) Google Scholar a program to a to modality PD have been to increase PD B. use of home Perit Dial. 2003; 19: Google et and of ESRD patients to renal Int. 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Five years’ experience of a hospital-based home-care renal nursing service.Adv Perit Dial. 1999; 15: 258-261PubMed Google C. Cabralda T. Wadhwa N.K. et al.Use of private duty nurses for daily CCPD and family relief in pediatric PD patients.Adv Perit Dial. 1994; 10: 304-306PubMed Google Scholar do that the to with our and of is the effect of home care on PD was not the our PD is in the has had a PD of because our at the of patients, increases PD and an which home A. 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Taub K. et al.Cost analysis of ongoing care of patients with end-stage renal disease: the impact of dialysis modality and dialysis access.Am J Kidney Dis. 2002; 40: 611-622Abstract Full Text Full Text PDF PubMed Scopus (373) Google Scholar The cost of home care visits was because the number of visits was the number care assistance as an for home that patients and have of that assistance is available patients need patients did support, the majority did other in of nurses may the of assisted PD but requires to use nurses in our program because they were available and the our program may choose to nurses or to that do not a would to patient is also to that assisted PD may the required to In our the majority of is provided in the a that is often by lack of In this assisted PD is an when home care is in a where can home care In where dialysis and home care are this may not be as study of the cost effectiveness of assisted PD that for and associated with adverse events such as and is a it would also be to the cost associated with a reduced for when a program of assisted PD is In medical and social which self-care PD are very prevalent among the ESRD population. have assistance to these patients is and increases the number of patients who can be offered PD. 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