ASN Releases Benchmarks for Home Dialysis Training

The American Society of Nephrology (ASN) has developed and released the first benchmarks for training nephrology fellows in home dialysis modalities. The need for these guidelines was identified at the 2012 National Summit on Home Dialysis Policy, where stakeholders recognized inadequate training as a key barrier to utilization of home-centered therapies. These competencies will serve as a roadmap for nephrology training programs to prepare fellows to care for the growing number of patients selecting the home treatment setting.

A gradual shift to the home setting

In 2011, the most recent year for which data was available, 9.6 percent of patients (37,219) with end stage renal disease (ESRD) in the United States chose to dialyze at home. The majority (85 percent) used peritoneal dialysis (PD) (either continuous ambulatory PD or continuous cycling PD) and the remaining 15 percent utilized home hemodialysis. Regardless of modality, the percentage of patients opting for in-home treatment has gradually increased over the past 5 years by 26 percent.

“The Centers for Medicare & Medicaid Services (CMS) has long tried to incentivize a greater use of home dialysis,” said Rajnish Mehrotra, MD, FASN, of the University of Washington School of Medicine. “It is as clinically effective as in-center hemodialysis, offers patients more control over their lives and schedules, and is significantly less expensive (more for PD than for home hemodialysis).”

With the implementation of the expanded bundle (the ESRD prospective payment system [PPS]), CMS expanded financial incentives for home dialysis by offering identical payments to providers of dialysis services for patients treated either in-center or at home, he said. “This spurred a rapid growth in programs for patient and physician education and is changing patterns of care delivery, with more late-referred patients being considered for—and offered—PD than ever before.”

Yet several factors could potentially deter patients from opting for home dialysis. “For many patients isolation is not an incentive to choose a home dialysis setting because they live in close proximity to an in-center facility,” said Nancy Day Adams, MD, of the University of Connecticut School of Medicine. “Patients must have other reasons for choosing a home modality, and providers have to determine and encourage those motivations.” Financial circumstances may also be a disincentive for in-home treatment.

Finally, patients may not have access to providers familiar with home modalities. Adams noted that practicing nephrologists who did not experience much home dialysis during their fellowship may not feel confident in handling some situations that can arise in this setting.

Participants at the Home Dialysis Summit also determined that inadequate training of nephrology fellows in home dialysis delivery inhibited greater home dialysis use in the United States. The summit, organized by the Alliance for Home Dialysis, brought patient groups, health professional societies, academic medical centers, government, and dialysis organizations together to collaborate on ways to improve utilization of home dialysis and expand treatment options for patients with ESRD.

And although fellows may be exposed to PD during their training, fewer gain experience with home hemodialysis. A recent survey of 133 nephrology trainees found 60 percent reported they had little or no training in home hemodialysis and more than 40 percent reported that they had some training in PD but did not feel they were competent (1). “This is in part because most programs neither have access to sufficient patients to ensure adequate training nor are they able to assign enough training time to ensure this competency,” said Mehrotra.

Identifying competencies for in-home treatment

Mehrotra, who attended the summit, noted “ASN took up the challenge and decided to develop standards for training of fellows to ensure competency in the care of home dialysis patients as a resource for training program directors.”

A workgroup composed of members of the ASN Dialysis Advisory Group (DAG) (chaired by Mehrotra), Training Program Directors (TPD) Executive Committee (chaired by Adams), together with home dialysis experts and fellows in training, drafted a list of benchmarks designed to give nephrology trainees a competency-based background in home dialysis methods. After a full review by the DAG and TPD and Education Committees, the final benchmarks were presented to ASN Council in October 2013.

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The benchmarks are comprehensive and contain two important components (see box for a sample of the competencies).

“First, they identify areas for training under each of the six core competencies identified to be important by the Accreditation Council for Graduate Medical Education (ACGME) (medical knowledge, patient care, system-based practice, professionalism, practice-based learning and improvement, and interpersonal and communication skills) for both PD and home hemodialysis,” said Mehrotra. “Second, they offer suggestions on how best to structure the clinical training of fellows to ensure sufficient experience in the care of such patients to achieve clinical competency in delivering that care. Both these components are equally important and meant to be a resource for training program directors.”

The benchmarks also fit within the competency-based milestones being implemented in nephrology and 20 other medical subspecialties beginning this July. “While ACGME Milestones are general in patient care and medical knowledge, these benchmarks address the medical knowledge aspects of home dialysis modalities and the actual care of patients on home dialysis,” said Adams.

However, as the authors point out, the new standards outline the optimal training in PD and home hemodialysis and several of the goals are aspirational. With an increasing number of patients on home therapies, and as more programs introduce more home programs, it will be easier for all fellows to get adequate experience, Adams noted.

“Even in a robust home program it can be difficult to incorporate the fellow into the practical patient interactions. Home patients are independent, which is why they chose home dialysis, and a lack of flexibility in the fellow’s training schedule can make follow-up evaluations with these patients hard to integrate,” said Adams. The practical experience with home dialysis patients is important to preparing fellows for unsupervised practice, she said. “They can do all the reading they can and may have a lot of medical knowledge, but if they haven’t seen patients they won’t be ready.”

To view the complete list of home dialysis training benchmarks, please visit http://www.asn-online.org/education/training/tpd/PD_and_HHD_benchmarks.pdf.

Reference

1. Berns JS. A survey-based evaluation of self-perceived competency after nephrology fellowship training. Clin J Am Soc Nephrol 2010; 5:490–496.