Barriers and Opportunities in Access to Peritoneal Dialysis across Veterans Healthcare Administration

Peritoneal dialysis (PD) use among the United States (US) Veteran population is lower than in the non-Veteran kidney failure population. Enhancing access to PD within the Veteran Healthcare Administration (VHA) may be crucial for achieving the Advancing American Kidney Health Executive Order goals. The VHA Home Dialysis Committee conducted a nationwide survey of nephrology stakeholders to assess Veterans' access to PD across the VHA and identify barriers and opportunities for the growth of VHA-affiliated PD services. Participants were invited via email and completed an electronic questionnaire consisting of seventeen PD access items and fifteen respondent characteristic items. Of the 141 eligible centers, 117 (83%) responded, including 97 facilities that provide nephrology services. Respondents indicated that PD could ideally serve 25% (interquartile range IQR: 15%, 40%) of Veterans with kidney failure. Most (62%) of the nephrology service-providing centers offered outpatient hemodialysis; however, only 28% reported providing outpatient PD services, with a median census of 10 Veterans. Among those lacking, 30% expressed a desire to establish outpatient PD services. The availability of comprehensive kidney replacement therapy KRT-directed pre-kidney failure education, an inpatient PD program, or respondents' perceptions of Veteran interest in PD were positively associated (p<0.05) with their desire to establish outpatient PD services. System-related challenges, such as limited space and capital costs of establishing a program, alongside staff-related issues like insufficient availability of trained nurses and support staff, were frequently cited barriers to PD programs. Respondents commonly cited the need for formal VHA-specific policies and procedural standards, administrative guides to establish local PD and patient education programs, and VHA-based PD nurse training assistance as strategies to address PD underutilization. Our findings suggest that the Veterans' lack of access to VHA-based PD programs may be an underrecognized barrier to their PD utilization. VHA nephrology stakeholders have a high desire to establish PD services but require local and system-based support to address PD underuse across the VHA.