Patient and Center Factors in Home Dialysis Therapy Uptake: Analysis of a UK Renal Registry Cohort and a National Dialysis Center Survey

Rationale & Objective: Variation in home dialysis therapy (HT) use across centers and geography may reflect the interplay between dialysis center services and patient characteristics. We examined direct and indirect associations between these factors and HT uptake in England.

Study Design: UK Renal Registry (UKRR) cohort linked to a national survey of renal centers.

Setting & Participants: Adults who initiated kidney replacement therapy (KRT) between 2015 and 2019 at 51 English renal centers, totalling 32,400 individuals identified through the UKRR, with center practices captured from a 2022 national survey of dialysis centers.

Exposures: Patient- (demographics and clinical characteristics) and center-level (including availability of assisted peritoneal dialysis, quality improvement initiatives, and fostering staff engagement in research) factors.

Outcomes: Use of HT (home haemodialysis or peritoneal dialysis) within one year of starting KRT.

Analytical Approach: Sequences of regressions, an extension of path analysis, used to examine direct and indirect associations between patient- and center-level factors and the probability of HT uptake.

Results: Both center- and patient-level factors were significantly associated with the probability of HT uptake. Patients at centers conducting quality improvement projects, (OR [95% CI]) 1.94, [1.36-2.76]), offering assisted PD (1.89, [1.39-2.57]), fostering staff research engagement (1.35, [1.03-1.77]) or hosting HT roadshows (1.22, [1.05-1.41]) had higher odds of HT uptake. Centers with greater stress on staff capacity to deliver HT had lower uptake (0.60, [0.45-0.81]). Patients on transplant lists at KRT start (2.55, [2.35-2.77]) or who lived farther from a treatment center (1.10, [1.08-1.12] per 10km) had higher odds of HT uptake. Patients living in areas of higher deprivation or members of minority ethnic groups had lower HT uptake overall. However, some of these associations may have been indirectly mitigated in centers serving more diverse populations, as these centers were more likely to implement practices associated with higher HT uptake.

Limitations: Healthcare professional-reported and aggregated survey data.

Conclusions: This study identified modifiable center-level factors associated with HT uptake, informing potential opportunities to reduce ethnic and area-level disparities.