US adoption of peritoneal dialysis limited by “misconceptions” of clinicians, study suggests

The use of peritoneal dialysis (PD) in treating chronic kidney disease (CKD) patients is limited in the USA by the mistaken assumptions of clinicians, in part a result of insufficient education by healthcare providers, claims a new study published in the Cureus Journal of Medical Science.

DESPITE AN “ENCOURAGING” programme from the US government aimed at improving public understanding of end-stage kidney disease (ESKD), the study authors say that “misconceptions and differing attitudes about PD among physicians” remain “important barriers” to its further implementation.

The study, led by Hussan S Lalani (Brigham and Women’s Hospital, Boston, USA) and assisted by corresponding author Ramesh Saxena (UT Southwestern Medical Center, Dallas, USA), employed a survey of 10 questions “to assess the knowledge and attitudes around peritoneal dialysis and haemodialysis among internal medicine faculty at the University of Texas Southwestern Medical Center” in Dallas, USA. Lalani et al stress that, despite the “well-established benefits of PD”, including a “lower adjusted mortality rate” and its lower cost compared to in-centre haemodialysis, it is still unclear why PD has not further supplanted in-centre.

Lalani et al distributed their survey to both nephrologists and non-nephrologists, with 83 recipients fully completing it. Of those, 10 were nephrologists and the remaining 73 were from other disciplines. Both groups reported “increased perceived knowledge and comfort with caring for patients on haemodialysis compared to patients on PD”. Nephrologists “scored 30% correct responses regarding medical contraindications and 48% regarding psychosocial contraindications to PD”. The authors describe it as “interesting”, meanwhile, that “non-nephrologists scored higher regarding medical contraindications” even though they reported “lower comfort and perceived knowledge (42.5% and 20.5%) of PD”. tives were implemented and 211 to a control group where they were not. The primary outcome was the percentage of patients receiving home dialysis in their first 90 days of treatment.

In their discussion, the authors state that the results suggest there is a clinician “knowledge gap” between haemodialysis and PD. They state the results suggest “disproportionate hesitancy” towards PD among nephrologists, though are quick to stipulate that their study had its limitations, including its small sample size. The subject requires further study on a larger scale, they argue.

The authors are firm in their concluding emphasis on “the importance of basic education regarding PD candidacy and the subversion of misconceptions regarding PD” among both nephrologists and non-nephrologists. Finally, they propose a solution to the issues they raise in the form of regional centres of excellence dedicated to training physicians and other health professionals on PD.

The study’s analysis found no meaningful difference in rates of home dialysis after those first 90 days between the two groups. The control HRRs saw a rate of 20.60% while the treatment group saw one of 20.72%.

This lack of difference leads the study authors to suggest that larger financial incentives may be required to deliver a significantly higher uptake of home dialysis treatment. It is noted that the 90-day period examined by the study limited it from assessing the effect of larger incentives, which were implemented in later years of the programme.

An accompanying editorial on the study led by Sri Lekha Tummalapalli (Cornell University, New York, USA) suggests that lack of increase in home dialysis rates may be a result of the fact that “care redesign to shift dialysis into the home is complex and time-consuming,” while “many frontline nephrologists may still be unaware of the ETC model.” Future studies, the editorial states, should also account for the fact that “randomised payment models operate pragmatically in real-world settings that are not fully controlled.”