Background
There is a substantial variation in the use of home dialysis between kidney services, which disproportionally affects people from ethnic minorities and socioeconomically deprived areas.
Objective
To create an evidence-based, user-centred intervention, enabling kidney services to optimise access to home dialysis, thereby eliminating unwarranted centre-level variation in its uptake.
Design and methods
We used exploratory, sequential mixed-methods to understand the centre-level characteristics associated with home dialysis use: an ethnography study to explore the organisational and cultural factors associated with home dialysis use that informed a national survey of centre-level characteristics from all kidney services in England, and quantitative analysis (sequence of regressions) to determine the factors associated with increased odds of going on home dialysis. A multistate model was constructed to determine transitions between dialysis modalities, transplantation and death. A health economic model, drawing upon the multistate model, estimated the quality-adjusted life-years and National Health Service costs over a patient’s lifetime. A user-centred iterative intervention design method to interpret the findings and identify components for a service-level intervention, coproduced with relevant stakeholders (patients, families/carers, doctors, nurses, policy makers and industry).
Setting and participants
Ethnography: Four centres, 43 observations of consultations, meetings and education sessions; 72 patient and staff interviews.
Main outcome measure
Being on dialysis at home within 12 months of starting treatment.
Data source
United Kingdom Renal Registry: Sequence of regressions: 32,400 patients initiating dialysis 2015–20; multistate model: 93,452 initiating dialysis 2005–20; the economic evaluation simulated a cohort of 2000 patients.
Results
Both the ethnography and the national surveys found that organisational culture and leadership were more closely associated home dialysis uptake than how services were organised. Several centre-level factors were found to be important [odds ratio (95% confidence intervals: of being on home dialysis by 1 year)], including: engagement in quality improvement, 1.94 (1.36 to 2.76), availability of assisted peritoneal dialysis, 1.89 (1.39 to 2.57) and a negative association with Home Dialysis staff capacity 0.60 (0.45 to 0.81). Initiating dialysis at home yielded an additional 0.30 quality-adjusted life-years and saved £13,545 compared centre dialysis. Components of the proposed ‘Location of Dialysis Care in Kidney Life’ intervention include engagement with targeted quality improvement, the implementation of leadership roles to embed organisation culture, use of assisted peritoneal dialysis and investing in home dialysis. Economic evaluation found that addressing staff capacity and implementing quality improvement successfully would increase quality-adjusted life-years by 0.22 and 0.08, with cost increases of £8921 and £4547 per patient, respectively.
Limitations and future work
The Location of Dialysis Care in Kidney Life intervention is based on observational evidence and requires evaluating in real clinical settings.
Conclusions
The substantial variation centre use of home dialysis is linked to organisational culture, leadership and resource limitations to innovate practice. The Location of Dialysis Care in Kidney Life intervention proposes a scaffold for embedding leadership roles that support the development of a culture that empowers patients and staff. Redirection of resources to support staff is justified.
Funding
This synopsis presents independent research funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme as award number NIHR128364.
CORE (COnnecting REpositories)
CORE (COnnecting REpositories)