By Jody A. Charnow via Renal and Urology News

Shaminder Gupta, MD, is a nephrologist who practices in Houma, Louisiana.  He serves as the section chief at his hospital and also as Corporate Medical Director at Monogram Health, a renal disease care management company. He tells Renal & Urology News how he developed and manages a home dialysis program in which approximately 40% of his patients with end-stage kidney disease (ESKD) participate, far above the national average in the United States. As of December 31, 2017, only 2% of hemodialysis (HD) patients used home HD, according to the US Renal Data 2019 Annual Data Report. Another 7.1% of ESKD patients used peritoneal dialysis, which is a home dialysis modality.

How are you able to care for such a relatively high proportion of your patients receiving home dialysis?

Dr Gupta: I practice in a rural part of Louisiana. On the first pass, it may seem that home dialysis would be challenging in these patients for multiple reasons: poor socioeconomic status, large distances from patient to dialysis unit, lower education. I have found that this patient cohort is extremely resilient and capable of self-care. They are willing to learn and care for themselves, and there is a deep sense of family.

Our nurses are the key to having patients choose home options by constant encouragement and support. We do not promise patients it will be easy in the beginning, but we do promise it will be better. Once the home program matures past a critical mass, it is actually easier for the nurses as a team because of the self-care that patients do. Many patients only come in for the monthly visit and we do check-ins. The ones who need more attention can usually be managed by phone or telehealth.

What prompted you to establish a home dialysis program?

Dr. Gupta: Our part of the state is also very prone to weather events, and this makes home options very attractive. I started this program in 2008 with the idea that all patients can do home dialysis and they all should be offered home dialysis. I do not let my own biases get in the way, and I want all patients to consider home dialysis as a first option. For some, it is easy. They have support and are engaged. Others are very reluctant, but we continue to encourage and push them from early CKD stage 4 to consider this option. 

How big a role does telemedicine play in your ability to manage these patients?

Dr. Gupta: For my practice, telemedicine has not been a large component. We sometimes utilize it, but most patients are stable and enjoy coming for their monthly visit. I believe the face-to-face encounter is still very important and crucial to patient success.

Reimbursement issues (ie, lack of reimbursement) have been noted as an impediment to adoption of home dialysis. Has this been a problem for you and, if so, how have you been able to manage such a large home dialysis population from a financial perspective?

Dr Gupta: Reimbursement issues can be a hurdle when first starting. The dialysis companies have to dedicate a nurse to the program, and these programs can take a few years to mature. There are some positive reimbursements in terms of training of the patients that go to the dialysis center, and there are training payments that go the physicians as well. Ultimately, the reimbursements are good and when computed in a payment for time spent, they are fair. 

Do you make house calls?

Dr Gupta: I do not do house calls, but our nurses do in-home visits to assess the environments and often check on patients on their own.  I would welcome the chance to do them, but have not yet.

Do you think the COVID-19 pandemic will accelerate adoption of home dialysis nationally?

Dr Gupta: COVID-19 provides a unique opportunity to further interest and choice in home dialysis options. Patients are rightfully worried about being in environments where there are chances of exposure to COVID-19 and other communicable diseases. Home dialysis eliminates this possibility, and the current COVID-19 crisis is making patients realize this. I have found that patients are much more open to listening to these options now, and I have had some patients commit to conversion to peritoneal dialysis or home hemodialysis over the past few weeks. A strategy for home dialysis growth has always been to approach patients at moments when they are feeling stress about in-center therapies, and this is one of those moments.