Analysis of discrepancy between home dialysis and hospital dialysis

Dialysis is defined as the process of getting rid of waste products together with excess fluid from the body (Khanna & Krediet, 2009). It becomes a necessary process when the kidneys are not able to filter blood adequately (Ronco, 2008). The dialysis therefore allows patients suffering from kidney failure the opportunity to live productive lives (Nolph, 2013). It is important to note that there are two types of dialysis; peritoneal and hemodialysis with each bearing advantages and disadvantages (Auer, 2005). Therefore, patients are able to choose the type of long term dialysis perceived to best match their needs.

This essay will focus on analyzing the discrepancy arising from having dialysis at home and in hospital and satellite centers. It will also analyse the long term advantages of a closer alignment between reality and preference, for individual health care and the health system. The process of choosing dialysis modality for patients is perceived as a complex exercise hence requires expertise input from a renal team (Henrich, 2012). There has been a reduction in the uptake of home dialysis in the recent past according to reports (Morfín, et al., 2017). This is because majority of dialysis clients prefer hospital dialysis to home therapies for several reasons. There are some advocates for home dialysis and the reasons cited for such a point of view frequently bear a mixture of utilitarian principle of maximal usage of limited resources and individual clinical indications. However, there are guidelines which broadly recommend that the selection between home dialysis and hospital dialysis should be based on a shared-decision making process mainly between the health -professional and informed patient (Kim & Kawanishi, 2018). The shared-decision making factors in the viable clinical evidence that is available and the values and preferences of the patient. It therefore requires the professionals and patients to understand what is essential to the other party when choosing a treatment plan. A structured pre-dialysis program aimed at increasing the adoption of home dialysis termed as ‘GUIDE’ describes a retrospective analysis of outcomes in patients suffering from advanced chronic kidney disease. In this regard, having home dialysis has been identified as an essential aspect for Australian and New Zealand dialysis clients. This is because based on the GUIDE approach, the programme provides a home focused approach that if it is impossible to have transplantation in a timely fashion, home dialysis is advised over hospital- based treatment particularly by a team who seek to increase the adoption of home therapies. The other difference between home dialysis and center based treatment is that for home dialysis, patients are visited at home conveniently by a case manager who is tasked with the responsibility of reviewing the circumstances of the patient and completes a questionnaire indicating their view of suitability of the patient for home dialysis. The dialysis done at home provides a better position that allows the patient to fit their treatment into their daily schedules (Ho?rl, 2004). This is because studies show that the more a patients knows regarding their treatment and the more they to do on their own, the better they are likely to do on dialysis.

Why hospital dialysis is preferred to home dialysis

This aspect has resulted to the discrepancy being witnessed between the uptake of home dialysis and hospital and satellite dialysis. However, on the other hand in center treatment is preferred by the majority of patients because of the technological complexity of conventional dialysis systems (Kallenbach, 2012). This notion has challenged the prevalence of home dialysis. For instance, in the hospitals, the patients have access to high quality treatment owing to advanced medical facilities put in place (Himmelfarb & Sayegh, 2010). Nevertheless, home dialysis programmes with observational studies have demonstrated greater patient satisfaction, superior control of circulating volume and blood pressure, better patient survival and reduced running costs compared to hospital dialysis. Majority of patients would choose the hospital and satellite dialysis because the patient does not necessarily need to get involved in their treatment apart from taking their medicines and adhering to dietary and restrictions of fluid provided. Since it is conducted on a schedule, usually three or four sessions every week, the patient is able to fit well in the treatment program provided in in centers. It allows them to plan well for other activities that they may be involved in such as work, school etc.

The in center treatment is popular than home dialysis because the latter requires space in the home for the dialysis machine. It requires the patient to connect the dialysis machine to a suitable water supply and draining system hence it is evident that not every patient can afford such support facilities. Therefore, going for hospital based treatment would save them some cost of creating space and draining system in their homes. The other disadvantage that discourages the adoption of home dialysis by patients is that it requires a comprehensive training and good organization and majority of patients may not be ready for such because of its tedious nature (Klahr & Massry, 2012). For instance, not all patients are willing to undertake the necessary pre-dialysis education and training and take responsibility of their own treatment. This is because the patients perceive convenience in putting themselves entirely in the hands of nurses under the hospital based treatment modality. At the end of every treatment the patients ‘walk away and forget’ until the next session. Another reason home dialysis is not popular like the in center dialysis is that many patients do not like the idea that they are always conscious of being kidney patients. This owes to the fact that part of the home is converted into a mini renal unit. This is for the reason of accommodating the dialysis machine for easy accessibility by the patients in home context. The presence of a dialysis machine is also likely to intrude into the consciousness of other members of the family which acts as a constant reminder of the patient’s sickness. Sometimes it can be demoralizing especially to the patient and even result to stigma. An advantage of satellite units as compared to home dialysis is the fact that the former has been associated with improved geographical access together with reduced travel time of patients. In a study that compared home dialysis with regional satellite units, the satisfaction level of patients was higher in satellite units. This is because patients under in center treatment experience less stress attributed to appropriate medical interventions in these facilities.

Why home dialysis is sought after

In an in center treatment approach, the dialysis staff encouragement that seeks to support Patients in coping with the kidney illness which may not be possible in home based dialysis. Sometimes, the patients undergoing dialysis require psychological support because of the distress they may experience in the course of their treatment. It therefore creates a huge discrepancy between the two dialysis modalities. It is important to note that health promotion is the ultimate objective of dialysis treatment hence dialysis staff encouragement has been linked with better compliance. For instance, improved fluid control and enhanced adherence to dialysis treatment. However, the reason why home dialysis is being sought for is because hospital based treatment discourages full time work, uses much time of staff and patient and requires intensive use of health care infrastructure. Therefore, it means that the patient will be forced by the circumstance to sacrifice much of his/ her time in accessing the dialysis treatment in the hospital (Widmer & Malik, 2015). Health care infrastructure is also likely to be restrained owing to the large number of dialysis patients in most of the in center facilities. In contrast, home dialysis time feels productive since the comforts of home life are enjoyed without any unnecessary distractions (Anderton, et al., 2012). Therefore, dialyzing for long, feeding and drinking more makes the patient more energetic hence taking less medication, develop better quality of life and less admissions. Such patients undergoing home dialysis feel more in control unlike their hospital counterparts (Levy, 2013). However, many patients are reluctant to accepting home based treatment because self-needling that requires the skill to carry out the exercise. Others do not have the courage for self-needling. The dialysis machine may also seem sophisticated to operate for majority of the patients who are also scared of a possible break down of the machines in their homes. In incidences where the dialysis machine malfunctions, the consequences can be dire especially in areas where emergency responses are not readily available. It therefore calls for keen and regular monitoring of the machine conditions in order to avert any anticipated operations failure. This makes it costly to use and maintain the dialysis machine in the homes which reduces the capability of many patients to afford it. Therefore, the hospital based treatment becomes the best option for a huge number of dialysis clients. Sometimes the patients are seriously sick such that the chances of them being able to manage their fluid, diet etc. at home are limited and unpredictable. In contrast to hospital and satellite dialysis, a patient under home treatment requires a care giver and it may be a challenge to get a committed care giver especially if the patient is single.

A closer alignment between reality and preference presents several long term advantages for individual health care and the health system. For instance, relating the preference of a medical treatment approach to the actual context of a patient helps in designing the best curative or preventive method of a particular illness. It makes it much easier to choose among various treatment modalities for patients. The patients are able to go through an informative procedure that is aimed at enlightening them on the most viable modality of treatment based on the medical needs assessment. For example, the patients are able to learn about the advantages and disadvantages of the available treatment modalities. Aligning preference and reality in medicine plays a huge role in bridging the gap that is likely to cause safety issues on the part of the patient. For example, the preference of choosing home dialysis over hospital and satellite treatment may pose some safety concerns especially regarding the operation of the dialysis machines and self-needling. This is because of the complexity of the dialysis machine which could also develop some mechanical problems hence compromising the health safety of the patient (Warady, 2014). However, if the home dialysis preference is aligned with the reality of the presenting issues, the patient is able to make an informed decision that suits him/ her the best. The aspect of bringing together reality and preference facilitates the uptake of a specific medication while reinforcing the benefits through a comprehensive health care approach.

It makes lives easier for both health care professionals and patients in the sense that the decisions of the two parties are well informed. The exercise of aligning preference and reality creates a viable platform for sharing information with patients hence being able to inform and change the perceptions of patients in an effort to enhance their health care (Krediet, et al., 2018). The health care system is able to understand and manage the expectations of patients that contributes to improving patient satisfaction. This is done through a comprehensive analysis of the outcomes of a medical condition which is facilitated and made easier through a closer alignment of preference and reality by putting the interests of the patients in the center stage. It also results in optimal compliance by patients to medical prescription and doctor visits in regards to dialysis.

It is important to understand that patients come to a consultation with health care expectations which they may or may not be aware of and reactions to unmet expectations usually range from disappointment to anger. Therefore, aligning the preference and reality in health care system helps create exposure to knowing the expectations of patients. It helps to alleviate these reactions and enhance their health care experience and minimize the health care professionals’ exposure to liability.  

Conclusion:

There is a huge discrepancy being seen between the two modalities of treatment. This is because of varying needs and capabilities of the dialysis patients. It has also been resulting from poor alignment of preference and reality for dialysis treatment. This has made the hospital based treatment more popular than the home dialysis. Efforts to popularize the latter are bearing fruits in the recent past. However, it is important to fully involve the dialysis patients in making the best choice regarding the modalities of treatment through a pre-dialysis education by the health care professionals.

References:

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Widmer, M. K. & Malik, J., 2015. Patient safety in dialysis access. Basel, Switzerland: Karger.