Patient and Center Factors in Home Dialysis Therapy Uptake: Analysis of a UK Renal Registry Cohort and a National Dialysis Center Survey

RATIONALE & OBJECTIVE: Variation in home dialysis therapy (HT) use across centers and geography may reflect the interplay between dialysis center services and patient characteristics. We examined direct and indirect associations between these factors and HT uptake in England. STUDY DESIGN: UK Renal Registry (UKRR) cohort linked to a national survey of renal centers. SETTING & PARTICIPANTS: Adults who initiated kidney replacement therapy (KRT) between 2015 and 2019 at 51 English renal centers, totaling 32,400 individuals identified through the UKRR with center practices captured from a 2022 national survey of dialysis centers. EXPOSURE: Patient-level (demographics and clinical characteristics) and center-level (including availability of assisted peritoneal dialysis, quality improvement initiatives, and fostering staff engagement in research) factors. OUTCOME: Use of HT (home hemodialysis or peritoneal dialysis) within 1 year of starting KRT. ANALYTICAL APPROACH: Sequences of regressions, an extension of path analysis, used to examine direct and indirect associations between patient-level and center-level factors and the probability of HT uptake. RESULTS: Both center-level and patient-level factors were significantly associated with the probability of HT uptake. Patients at centers conducting quality improvement projects (odds ratio OR, 1.94 95% CI, 1.36-2.76), offering assisted peritoneal dialysis (OR, 1.89 95% CI, 1.39-2.57), fostering staff research engagement (OR, 1.35 95% CI, 1.03-1.77), or hosting HT roadshows (OR, 1.22 95% CI, 1.05-1.41) had higher odds of HT uptake. Centers with greater stress on staff capacity to deliver HT had lower uptake (OR, 0.60 95% CI, 0.45-0.81). Patients on transplant lists at KRT start (OR, 2.55 95% CI, 2.35-2.77) or who lived farther from a treatment center (OR, 1.10 95% CI, 1.08-1.12 per 10 km) had higher odds of HT uptake. Patients living in areas of higher deprivation or members of minoritized ethnic groups had lower HT uptake overall. However, some of these associations may have been indirectly mitigated in centers serving more diverse populations because these centers were more likely to implement practices associated with higher HT uptake. LIMITATIONS: Health care professional-reported and aggregated survey data. CONCLUSIONS: This study identified modifiable center-level factors associated with HT uptake, informing potential opportunities to reduce ethnic and area-level disparities. PLAIN-LANGUAGE SUMMARY: Some patients are less likely to use home dialysis, possibly due to both patient characteristics and how dialysis centers operate. We studied over 32,000 patients who began kidney replacement therapy between 2015 and 2019, linking national patient data with a 2022 survey of English dialysis centers. Using advanced statistical methods, we uncovered direct and indirect links between patient and center factors and home therapy use. Patients were more likely to use home dialysis if their center offered supportive practices like assisted dialysis, staff-led improvement projects, or home dialysis educational roadshows. Notably, centers serving diverse populations were more likely to implement such practices. This study highlights how center practices may contribute to improving and reducing disparities in access to home therapy.