Nephrology Advanced Practice Providers in Home Dialysis

In 1972, nearly 40% of all patients on dialysis in the United States were on home dialysis. The next year, the Medicare End Stage Renal Disease (ESRD) Program began, and as a result, the use of home dialysis decreased dramatically. Over the years that have followed the establishment of the Medicare ESRD Program, there has been a resurgence of home dialysis, and research demonstrates that more frequent dialysis has better health outcomes than dialysis administered three times per week (1). U.S. Renal Data System (USRDS) data from 2019 reveal that 13.1% of prevalent patients with end stage kidney disease were engaged in home dialysis (Figure 1), including 1.9% with home hemodialysis and 11.2% with peritoneal dialysis (PD) (2). The advanced practice provider (APP) plays a vital role in increasing the number of patients on home dialysis.

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Utilization of home dialysis, 2009−2019

Citation: Kidney News 14, 9

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I have been a practicing APP for the past 22 years at Washington University School of Medicine in St. Louis, MO. I was fortunate to be exposed early on in my career to home dialysis. In 2004, the role of APPs expanded secondary to the decision of the Centers for Medicare & Medicaid Services (CMS) to allow APPs to perform at least three of the required dialysis visits. This jumpstarted the awareness that APPs can play a big part in the management of kidney diseases. One of the primary reasons patients do not choose home dialysis is lack of education regarding this option. APPs can increase home dialysis use by educating patients and their care partners. The University of Florida initiated a comprehensive kidney disease education (KDE) program that demonstrated success, as 70% of patients who engaged in the program choose home dialysis (3).

APPs see patients during home training and in clinic. According to billing guidelines, the nephrologist must see his or her patients in person at least once each quarter. APPs can perform up to 2 visits per quarter on their own with documentation and billing. If the patient is seen with the APP and nephrologist, the visit is billed under the APP. For the training visit, the note by the APP can be billed at 100%, as it is not part of the monthly visit. An online survey in 2022 with 293 respondents was conducted by the National Kidney Foundation/Council of Advanced Practice Providers (NKF/CAPP) and the American Academy of Nephrology Physician Assistants (AANPA), which revealed that 37% of APPs are involved in taking care of PD patients. The survey did not specify home hemodialysis (4).

In recognition of the vital role APPs play in nephrology, the CMS initiated a KDE benefit in 2010 for stage 4 chronic kidney disease with six billable sessions. In review of USRDS data, Johansen et al. (5) discovered that 3% of patients received KDE between 2013 and 2017 (n = 106,456 patients). The authors observed that receipt of KDE was associated with a greater likelihood of initiating dialysis on a home-based modality (18% vs. 11.5%) (5).

APPs can fill many roles in the management of home dialysis, and increasing the exposure of APPs to home dialysis can be vital to the growth of home programs.