Embedded Files
evidence from generally low-quality studies to suggest no difference in cardiovascular mortality, no difference or improved quality of life with HHD, no difference in access survival, no difference in transplantation rate, and no difference in all-cause hospitalization rate. In 2 studies reporting, a higher percentage of HHD patients switched dialysis modalities over follow-up periods of up to 4 years. · Peritoneal dialysis (PD) versus in-center HD: · We found low strength of evidence (findings from registry studies) that there is no difference in overall mortality between PD to in-center HD (Table 6). However, most studies reporting outcomes over time noted an early survival advantage for PD patients with no difference after 2 to 3 years of treatment. · There were inconsistent findings for quality of life outcomes with studies reporting no differences or higher scores on some elements of quality of life in PD or in-center HD patients. With limited reporting, results were mixed for cardiovascular outcomes, adverse events, transplantation, and hospitalization. Over follow-up periods of 2 to 7 years, higher percentages of PD patients switched dialysis modalities. · Only 2 studies compared HHD and PD with mixed results for mortality. Other outcomes were not reported. · Factors associated with increased selection of home-based dialysis: o Facility factors: larger facility, more years of Medicare certification, providing care for more employed patients or patients in the 18 to 54 year age range, earlier initiation of pre-dialysis care, increased patient/family education; o Patient factors: well-informed about choices, patient preference (more autonomy, more flexible schedule, and less travel to dialysis), family/caregiver support; 56 Home-based versus In-center Dialysis Evidence-based Synthesis Program o Provider factors: team approach (physician, nurse, social worker) to determining patient eligibility (medical and psychosocial). · Factors associated with decreased selection of home-based dialysis: o Facility factors: location in more rural area, location in high density zip code area, availability of an evening shift, higher percentage of black patients; o Patient factors: lack of knowledge, living alone, lack of space in the home, inability to perform PD in the place of residence, fear of social isolation, fear of inability to perform PD, and preference for medical supervision. · Factors associated with technique failure: o Facility factors: lower technique failure if receiving care from larger dialysis facilities; o Patient factors: higher technique failure if lack of caregiver support, caregiver anxiety, medical issues (including diabetes or psychosocial problems), treatment interferes with home life, African-American race (vs white), HD before PD; o Provider factors: none identified. · Costs are lower with HHD and PD compared to in-center HD but costs considered in the analyses and factors that can influence costs (failure rates, patient comorbidity) varied across studies. Table 6. Strength of Evidence for Mortality Outcome Outcome (studies reporting) Results Risk of Bias Consistency Directness Precision Strength of Evidence Overall Mortality HHD vs HD (6 registry studies) 4 of 6 studies reported decreased overall mortality with HHD high consistent direct precise low Overall Mortality PD vs HD (19 registry studies) 4 studies reported decreased mortality with PD 6 studies reported increased mortality with PD 9 studies reported no difference in mortality high inconsistent direct imprecise low HHD = home hemodialysis; HD = in-center hemodialysis; PD = peritoneal dialysis This evidence report summarizes literature on the comparative effectiveness and harms of homebased versus in-center dialysis. Home-based dialysis is a potentially effective option of considerable interest to Veterans and could permit VA to expand internal dialysis capacity. However, it is not well known if this is feasible within the Veteran population, due to in part to a greater prevalence of patients of older age and a greater number of comorbidities in the VA system. None of the included studies were conducted at VA medical centers.
Google Sites
Report abuse