Improving Home Dialysis Education and Fellowship Training

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

1. Statement about increase in incidence and prevalence of ESRD (note term ESKD is now generally preferred) seems unnecessary.
2. Would suggest finding better references than 2 and 3 for benefits of home dialysis and make sure covers both HHD and PD.
3. Suggest citing this recent survey data: Reddy YNV, Berns JS, Bansal S, Simon JF, Murray R, Jacob M, Perl J, Gould E. Home Dialysis Training Needs for Fellows: A Survey of Nephrology Program Directors and Division Chiefs in the United States. Kidney Med. 2023 Mar 20;5(5):100629. doi: 10.1016/j.xkme.2023.100629. PMID: 37229444; PMCID: PMC10202772.
4. In general it would be helpful if the authors could identify any programs, activities, etc. that have been demonstrated to increase trainee competency in home dialysis and have led to increased use of home dialysis in practice.
5. I believe University of Toronto also has a home dialysis fellowship program.
6. Worth mentioning ACGME and ABIM requirements regarding home dialysis training and competency and then note any specific data on program compliance with these requirements.

Author Response

Dear Reviewer,

Thank you for reviewing our manuscript and providing your valuable comments and suggestions. Please see our responses to your suggestions here in red. The changes in the manuscript are highlighted in yellow.

1. Statement about increase in incidence and prevalence of ESRD (note term ESKD is now generally preferred) seems unnecessary.

Thank you for this suggestion. We have removed the sentence “There has been a rapid rise…..two decades” from the Introduction. We have also changed ESRD to ESKD.

2. Would suggest finding better references than 2 and 3 for benefits of home dialysis and make sure covers both HHD and PD.

We have removed references 2 and 3 and added new references 2-9 to highlight the benefits of home dialysis.

3. Suggest citing this recent survey data: Reddy YNV, Berns JS, Bansal S, Simon JF, Murray R, Jacob M, Perl J, Gould E. Home Dialysis Training Needs for Fellows: A Survey of Nephrology Program Directors and Division Chiefs in the United States. Kidney Med. 2023 Mar 20;5(5):100629. doi: 10.1016/j.xkme.2023.100629. PMID: 37229444; PMCID: PMC10202772.

Thank you very much for this suggestion. We have added a paragraph under “Educational gaps in Nephrology Training Programs” highlighting the findings of the survey. (Line 99-109)

4. In general it would be helpful if the authors could identify any programs, activities, etc. that have been demonstrated to increase trainee competency in home dialysis and have led to increased use of home dialysis in practice.

Thank you for this comment. Upon our research, we could not find any programs or tests evaluating the competency of trainees and further correlating it to change in utilization of home dialysis.

5. I believe University of Toronto also has a home dialysis fellowship program.

Thank you for this comment. We have included Canadian institutions offering home dialysis fellowship in our manuscript. (Line 231-234)

6. Worth mentioning ACGME and ABIM requirements regarding home dialysis training and competency and then note any specific data on program compliance with these requirements.

Thank you very much for this suggestion. We have included the ACGME and ABIM requirements for home dialysis training and competency in our manuscript. (Line 180-198)

 

Thank you again for your time and consideration. We look forward to hearing back from you.

Best Regards,

Shuchita Sharma

Reviewer 2 Report

Comments and Suggestions for Authors

This is essentially a position paper on the need for and requirements of a training programme in Home Dialysis for professionals (specifically MDs) in the form of a narrative review. The authors have synthesised the existing literature rather than undertaking a structured research approach, drawing on the findings of surveys. As such they make a number of ‘didactic’ statements, which I largely agree with – e.g. “To address the educational gaps in current nephrology training programs, a multi-faceted approach is needed”. It is a nicely written article.

 

I have some comments:

 

Introduction/Educational gaps: I appreciate the intended audience of this manuscript is the US, where re-imbursement plays a significant role by creating levers that can ensure that policy changes lead to action, but even where there are no financial disincentives and/or incentives for home dialysis, achieving this ‘change’ is challenging. While part of this gap is education, there are other factors here that should be mentioned, in particular ‘organisational culture’ is an important component of growing and maintaining home dialysis programmes. [ e.g. Castledine CI, et al. Renal centre characteristics and physician practice patterns associated with home dialysis use. Nephrol Dial Transplant. 2013 Aug;28(8):2169-80. doi: 10.1093/ndt/gft196 and Allen K, et al. How does organisational culture facilitate uptake of home dialysis? An ethnographic study of kidney centres in England. BMJ Open. 2024 Dec 27;14(12):e085754. doi: 10.1136/bmjopen-2024-085754. Of course education is one of the tools by which a favourable organisational culture can be developed, but the emphasis here has to be not just on the individual trainees (which is the focus of this review as I see it) but also on how a whole home dialysis service needs to be involved in the process through service development, quality improvement – and importantly, educating of those members of the service that are not specialists in home dialysis (e.g. centre HD staff, surgeons, administrators etc.) It is clear at Mount Sinai, where the delivery of home dialysis has an excellent track record, the institutional culture is well developed (and possibly taken for granted) but I am certain this is not the case universally. I think that while the focus of this review is education of trainees, effectively supporting the concept of sub-speciality training, (which I would strongly support) it is important to at least mention that there is training to do at an organisational level.

 

I was pleased to see that a core curriculum should be developed. I am less clear as to whether the recommendation here is that this should be developed nationally, at the training programme level or internationally. I am not sufficiently familiar with how this works in the US – so this is probably my ignorance, but if the proposal here is that it should be a compulsory component of a national curriculum, of this is what is intended could be stated more forcefully.

Author Response

Dear Reviewer,

Thank you for reviewing our manuscript and providing your encouraging and valuable comments and suggestions. Please see our responses below in red. The changes in the manuscript are highlighted in yellow.

1. Introduction/Educational gaps: I appreciate the intended audience of this manuscript is the US, where re-imbursement plays a significant role by creating levers that can ensure that policy changes lead to action, but even where there are no financial disincentives and/or incentives for home dialysis, achieving this ‘change’ is challenging. While part of this gap is education, there are other factors here that should be mentioned, in particular ‘organisational culture’ is an important component of growing and maintaining home dialysis programmes. [ e.g. Castledine CI, et al. Renal centre characteristics and physician practice patterns associated with home dialysis use. Nephrol Dial Transplant. 2013 Aug;28(8):2169-80. doi: 10.1093/ndt/gft196 and Allen K, et al. How does organisational culture facilitate uptake of home dialysis? An ethnographic study of kidney centres in England. BMJ Open. 2024 Dec 27;14(12):e085754. doi: 10.1136/bmjopen-2024-085754. Of course education is one of the tools by which a favourable organisational culture can be developed, but the emphasis here has to be not just on the individual trainees (which is the focus of this review as I see it) but also on how a whole home dialysis service needs to be involved in the process through service development, quality improvement – and importantly, educating of those members of the service that are not specialists in home dialysis (e.g. centre HD staff, surgeons, administrators etc.) It is clear at Mount Sinai, where the delivery of home dialysis has an excellent track record, the institutional culture is well developed (and possibly taken for granted) but I am certain this is not the case universally. I think that while the focus of this review is education of trainees, effectively supporting the concept of sub-speciality training, (which I would strongly support) it is important to at least mention that there is training to do at an organisational level.

Thank you for this suggestion. We agree that organizational culture plays a big role in the uptake of home dialysis and educating the other members of the team is equally important. While our review paper was mostly centered around the home dialysis education for fellows and nephrologists, we have added a section on education and changing the organizational culture as a strategy for improving home dialysis utilization.

2. I was pleased to see that a core curriculum should be developed. I am less clear as to whether the recommendation here is that this should be developed nationally, at the training programme level or internationally. I am not sufficiently familiar with how this works in the US – so this is probably my ignorance, but if the proposal here is that it should be a compulsory component of a national curriculum, of this is what is intended could be stated more forcefully.

Thank you for this comment. We believe ideally, there should be a national consensus on core curriculum for home dialysis fellowship to standardize the training and competency. There are some basic ACGME and ABIM requirements for fellows regarding home dialysis education which we have added in the manuscript (Line 180-198).

Thank you again for your time and consideration. We look forward to hearing back from you.

Best regards,

Shuchita Sharma

Round 2

Reviewer 1 Report

Comments and Suggestions for Authors

Ok as is 

Reviewer 2 Report

Comments and Suggestions for Authors

Thank you for incorporating my suggestions. I have nothing further to add.