Annotated Barriers to Peritoneal and Home Hemodialysis in the U.S.
Abstract
:1. Introduction
2. Governmental Authoritarianism Through Guidelines
3. Administrative Authoritarianism
- A.
- The choice of antibiotics for exit-site topical prophylactic care, empiric exit-site infection treatment, and empiric peritonitis treatment are medical decisions only. Yet facility administrators weigh in based on expense and availability. Obviously, these are negotiable, but often the medical directors acquiesce to the financial/administrative argument at the expense of medical justification.
- B.
- Icodextrin has a slight cost differential to standard dextrose PD solutions. Once, a Large Dialysis Organization administrator told a PD-savvy nephrologist friend that, if she knew more about how PD works, she would not need to prescribe icodextrin. There are certain patients that benefit from more than one icodextrin exchange per day [15,16,17,18]. Despite being off FDA labeling, this practice is safe and effective and can prolong PD technique survival for many months.
- C.
- Similarly, the use of a certain type of cycler may advantage one clinical situation over another, but, for contracts (read that as expenses), only a certain type of cycler is offered in that clinic. This is relevant for several clinical reasons such as the ability for remote monitoring of the treatment and for addressing drainage issues. Again, medical decisions and opportunities can be and are jeopardized by local administrative decisions.
- D.
- There are patients who would greatly benefit from the hybridization of hemodialysis with PD [19,20,21,22]. This most often occurs while electively transitioning from one to the other, but, in Japan, for example, this is not an infrequently occurring practice. Administrative prohibitions may dominate.
- E.
- Staffing is a component of the quality of care. Some administrators defer to a standard staffing ratio of patients per nurse (social worker, dietician) regardless of the setting. By setting, I refer to location (e.g., urban, dense urban, suburban, rural, distant rural), access to the Internet, experience of the staff, back-up facilities and their proximity, number of clinicians referring and their experience, the expertise of the medical director, and the off-site support from the dialysis organization. What I term “the Godzilla Effect” is that size does matter for many of these settings. It is well described that outcomes are vastly superior in larger PD programs [23,24,25]. The advantages of a larger program are described in Figure 1.
4. Frequency-Related Barriers
5. Special Space and Service Designations
6. Solutions and Opportunities
Funding
Institutional Review Board Statement
Informed Consent Statement
Data Availability Statement
Acknowledgments
Conflicts of Interest
References
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Educational Barriers | Possible Action Plans |
Patient education | Easily accessible Internet resource center, linked sites, chat arrangements |
Physician education | Mandatory training for program certification; ongoing and immersion courses: local, regional, and national |
Dialysis staff education | Designated time and resources; certification; centers of excellence |
Governmental Barriers | Possible Action Plans |
Visit requirements | Local lab services; all frequencies determined by clinical need |
Dialysis access payment | Align payment incentives for the best access for that patient; awareness of retroactive payment for home dialysis initiates |
Partner support | Cost analysis and feasibility study |
Accreditation and certification | Eliminate differences between CMS and The Joint Commission regulations; define precise time frame for certification |
Staff home visits | Clinical judgment defines necessity; use phone photographs |
Make available “state-of-the-art” equipment | FDA to streamline approval process; encourage efficiency research; industry–government collaboration |
Provider Organization Barriers | Possible Action Plans |
Availability of solutions and equipment | Eliminate inappropriate restriction policies; clinical judgment prevails |
Delivery of supplies | Accommodate unique patient needs; local and regional depots |
Pharmacy | Prompt and efficient drug delivery and availability; address and alleviate The Joint Commission restrictions and requirements |
Business conflicts to patient care | Patient care takes priority |
Laboratory services | Improve data sharing; more raid-specific responses |
Quality improvement | Select meaningful data; standardize data collection and reporting |
Independence | Recommended; encourages problem solving andcreativity but does not occur in a vacuum |
Physical environment | Appreciate home programs’ unique requirements |
Staffing | Discourage boilerplate thinking; develop criteria for appropriate staffing ratios; consolidate programs; share staff |
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Golper, T.A. Annotated Barriers to Peritoneal and Home Hemodialysis in the U.S. Kidney Dial. 2025, 5, 18. https://doi.org/10.3390/kidneydial5020018
Golper TA. Annotated Barriers to Peritoneal and Home Hemodialysis in the U.S. Kidney and Dialysis. 2025; 5(2):18. https://doi.org/10.3390/kidneydial5020018
Chicago/Turabian StyleGolper, Thomas A. 2025. "Annotated Barriers to Peritoneal and Home Hemodialysis in the U.S." Kidney and Dialysis 5, no. 2: 18. https://doi.org/10.3390/kidneydial5020018
APA StyleGolper, T. A. (2025). Annotated Barriers to Peritoneal and Home Hemodialysis in the U.S. Kidney and Dialysis, 5(2), 18. https://doi.org/10.3390/kidneydial5020018