Trend in dialysis: Automated peritoneal dialysis with remote patient monitoring
Home-based automated peritoneal dialysis (APD) is emerging as an important alternative to haemodialysis, especially in terms of reducing healthcare costs and enhancing patient convenience. APD coupled with a remote patient monitoring (RPM) platform may potentially improve patient outcomes, but uptake remains limited. At a symposium organized by the Hong Kong Association of Renal Nurses, Dr Mitchell Rosner of the University of Virginia in Virginia, US, shared his experience on the use of RPM platforms (eg, Home Choice Claria APD system with Sharesource, Baxter Healthcare) and discussed how these technologies may help improve uptake and outcomes of home dialysis.
Growing burden of ESRD
“End-stage renal disease [ESRD] is increasing worldwide, with Taiwan, the US and Japan reported to have the highest incidence rates between 2000 and 2012,” said Rosner. “This increase is partly due to the ageing population, but is also fueled by the diabetes epidemic.” [Renal Replacement Ther 2016;2:15]
“As the global burden of chronic kidney disease [CKD] and ESRD continues to increase, we expect that the burden of providing maintenance dialysis will also increase, highlighting the need for more efficient and cost-effective renal replacement therapies [RRTs],” he continued.
Uptake trends in peritoneal dialysis
Peritoneal dialysis (PD) provides a safe, convenient, home-based, and cost-effective modality of continuous RRT for patients with ESRD, with clinical outcomes reported to be comparable to or even better than haemodialysis. [Telemed J E Health 2018;24:315-323; Perit Dial Int 2019;39:472-478]
“However, the advantages of home-based PD have not always led to increased use,” noted Rosner.
“The trend in PD uptake varies across Asia,” he added. “In Hong Kong, PD accounts for up to 80 percent of total dialysis use, but the rate is markedly lower elsewhere.” (Figure 1) [Nat Rev Nephrol 2017;13:90-103]
In Hong Kong, reimbursement policy and government initiatives are in place to encourage the use of PD. However, other regions, particularly developing countries, face major challenges and obstacles in increasing the uptake of PD, including prohibitive costs, lack of trained medical personnel and disparities in healthcare provision.
Home-based PD: Benefits and barriers
“RPM and telemedicine are two important components of home-based PD,” explained Rosner. “RPM allows us to acquire treatment parameter data from patients, namely, pulse, blood pressure, temperature and pulse oximetry. These biometric data help guide treatment as well as implementing necessary adjustments to improve outcomes. At the same time, telemedicine enables us to interact with patients through electronic media.” [Clin J Am Soc Nephrol 2017;12:1900-1909]
Potential benefits of home-based RRT with RPM technology and telemedicine include improved outcomes and avoidance of complications, reduction of hospitalizations and readmissions, increased patient satisfaction, enhanced patient independence, decreased in-person care team visits, rapid troubleshooting of problems, as well as cost savings achieved through outcome improvements, and time savings through reduced travel.
Barriers to implementation include the upfront cost for technology, training and programmatic infrastructure, privacy concerns, patient and caregiver acceptance of the technology vs face-to-face visits, limited data showing outcome benefit from telemedicine, and lack of Internet connectivity for some patients. [Clin J Am Soc Nephrol 2017;12:1900-1909]
“While uptake of telemedicine and RPM has been observed for other conditions such as diabetes mellitus and hypertension, their use in home-based RRT has lagged behind,” noted Rosner.
“Adherence to prescribed PD therapy has been poor, with reported rates below 90 percent,” shared Rosner. “Unfortunately, current platforms make it challenging for clinicians to assess nonadherence. New RPM platforms and telemedicine solutions are needed to provide on-demand access to patient data, which may improve outcomes and increase confidence of physicians in offering home-based dialysis, and ultimately improve the uptake and compliance among patients.” [Am J Kidney Dis 2000;35:1104-1110; Am J Kidney Dis 1998;31:101-107]
Experience with Sharesource
APD is an established modality that allows the convenience of dialysis at night when the patient is sleeping. It has also been reported to achieve lower peritonitis rates and higher net ultrafiltration, resulting in improved fluid balance. [Perit Dial Int 2019;39:472-478]
The Home Choice Claria APD system with Sharesource is an APD cycler with RPM capability, which allows two-way communication between the patient and the clinical team that facilitates the provision of high-quality and timely services based on data transmitted from the patient’s home. With real-time support from the clinical team and timely feedback from their doctors, the system may help increase patients’ confidence in performing APD at home. [Kidney Int Rep 2019;4:873-876; Perit Dial Int 2019;39:472-478]
An exploratory study in Colombia evaluated the clinical effects of using the Home Choice Claria APD system with Sharesource for 2 months vs the same APD programme before the introduction of RPM. A total of 49 patients with ESRD were included in the study (mean age, 59.3 years). [Kidney Int Rep 2019;4:873-876]
The introduction of RPM to APD was shown to provide positive early impacts, with significant increases in real-time therapy adjustments (25 percent; p=0.0073) and preemptive patient consultations (29 percent; p=0.0017), as well as a significant decrease in mean diastolic blood pressure (approximately 4 mm Hg; p=0.007) vs APD alone. (Figure 2)
“These results show that RPM enables an early increase in interventions, which can serve as an indicator of better and active monitoring of patients’ health and needs,” said Rosner.
Reduced hospitalization and number of hospital days
A retrospective cohort study in Colombia evaluated the association between APD with RPM use (ie, Home Choice Claria APD system with Sharesource) and clinical outcomes. Upon propensity score matching, APD therapy with RPM (n=63) was associated with 0.36 fewer hospitalizations per patient-year (incidence rate ratio [IRR], 0.61; 95 percent confidence interval [CI], 0.39 to 0.95; p=0.029) and 6.57 fewer hospital days per patient-year (IRR, 0.46; 95 percent CI, 0.23 to 0.92; p=0.028) vs APD alone (n=63). [Perit Dial Int 2019;39:472-478]
Clinical and economic value of RPM
A simulation study estimated the potential impact of RPM/remote therapy management (RTM) on APD patients’ use of healthcare resources and costs in the US, Germany and Italy. Twelve APD patient profiles were developed to reflect potential clinical scenarios of APD therapy. Eleven APD teams (one nephrologist, one nurse) estimated the resources that would be used. [Telemed J E Health 2018;24:315-323]
Across the three countries, results showed that the use of RPM could help avoid 1–2 hospitalizations, 1–4 home visits, 2–5 emergency room visits, and 4–8 unplanned clinic visits, as predicted by the clinician responses. In the US, total healthcare resource utilization that could be avoided represented USD 23,364 in savings for the 12 patient profiles, or USD 1,947 per patient profile. (Figure 2) Savings were the highest for avoided hospitalizations (USD 11,991.74), emergency room visits (USD 5,266.85), and change to haemodialysis (USD 5,025.62). Savings in total healthcare resources were also reported for Germany and Italy.
These results suggest that early intervention enabled by RTM can help reduce healthcare resource utilization and associated costs.
“The promise of home dialysis therapies has not yet been fully realized due to limited uptake and suboptimal outcomes,” noted Rosner. “Moreover, data is still limited with regard to the ability of RPM and telemedicine in enhancing patients’ acceptance of home dialysis as well as optimizing outcomes and adherence. Nevertheless, evolving data and case examples support the likelihood that uptake and outcomes of home dialysis can be improved with recent RPM technologies.”