Barriers and enablers of Home Haemodialysis

  • Anuradha Jayanti

Student thesis: Phd


Background: Chronic Kidney Disease is a global health problem. In the United Kingdom, there is impetus for self-management of long term conditions. In 2002, the National Institute for Health and Clinical Excellence' technology appraisal guideline on haemodialysis suggested that 10%-15% of the centre's dialysis population should undertake home haemodialysis. The clinical community is yet to rise to this challenge. In this study, we seek to explore patient-related clinical and psychosocial predictors and provider beliefs and attitudes which determine the choice of self-care dialysis, particularly, home haemodialysis. Design and methods: The design is a combined cross-sectional and longitudinal study employing an integrated mixed methodology (convergent, parallel design). Study participants include patients and multidisciplinary staff. The three patient cohorts (n = 535) include pre-dialysis (222), hospital (213) and self-care haemodialysis patients (100) from geographically distinct NHS sites, and with variable prevalence of home haemodialysis (low 8%). The pre-dialysis patients were followed up for a period of 12 months from study entry. Quantitative data ascertained include biomarkers, clinical, psychosocial quantitative and neuropsychometric-cognitive tests in the study cohorts. Organizational attitudes and dialysis unit practices were gathered from a survey of the participating units. Semi-structured interviews were carried out for patients and care-providers. The datasets were analysed independently and the findings mixed at the stage of interpretation. Statistical tests appropriate to the specific questions were considered for the quantitative data and qualitative data was analysed using thematic analysis.Results: Home haemodialysis has a high composite (training+home) technique survival rate of 90.2%, 87.4% & 81.5% at 1, 2 and 5-years respectively in a death and transplantation censored analysis. The key predictors of self-care dialysis, especially home haemodialysis, are self-perceived higher cognitive ability (metaconcentration), lower comorbidity score, home ownership, and white ethnicity background. There are 20% lower odds of choosing self-care dialysis over fully-assisted dialysis for every unit reduction in metaconcentration score and this is significantly associated with trails making test B, an objective test of executive brain function. Perceived inability to self-cannulate was a significant predictor of the choice of peritoneal dialysis over home haemodialysis amongst CKD-5, predialysis patients. However, approximately 1 in 3 patients from the predialysis and hospital haemodialysis groups feel able to consider self-cannulation. The centre to which the patient belonged had an impact on the choice of dialysis modality, with greater proportion opting for home haemodialysis in a centre with greater home haemodialysis prevalence. Amongst predialysis patients who made a modality choice, the experience of their interaction with healthcare teams and dialysis counselling, self-efficacy, personal fulfilment through work and social engagements, and their views of the modality's impact on their significant others, influenced the choice of home or hospital-based haemodialysis. 45% of all respondents in a survey of healthcare practitioners felt that staff knowledge and bias influenced the offer of home haemodialysis therapy. At a policy level, the tariff for home haemodialysis was not a clear incentive for its adoption due to uncertainty about operational costs. Conclusions: There exists a perception of lack of uniformity in practice pertaining to offer of home haemodialysis across the study centres. The impact of financial incentives designed at a policy level is influenced by the understanding of cost and benefits at the local operational level. Most barriers are surmountable and patients should be able to consider self-care therapies option in all but the most limiting physical and cognitive states
Date of Award31 Dec 2016
Original languageEnglish
Awarding Institution
  • The University of Manchester
SupervisorSandip Mitra (Supervisor), Alison Wearden (Supervisor) & Paul Brenchley (Supervisor)


  • Self-care dialysis
  • Home Haemodialysis

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