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Systematic review of the effectiveness of home versus hospital or satellite unit hemodialysis for people with end-stage renal failure

Published online by Cambridge University Press:  01 August 2004

Graham Mowatt ,
Luke Vale  and
Alison MacLeod
Graham Mowatt
Affiliation:
University of Aberdeen
Luke Vale
Affiliation:
University of Aberdeen
Alison MacLeod
Affiliation:
University of Aberdeen
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Abstract

Background: Home hemodialysis offers potential advantages over hospital hemodialysis, including the opportunity for more frequent and/or longer dialysis sessions. Expanding home hemodialysis services may help cope with the increasing numbers of people requiring hemodialysis.

Methods: We sought comparative studies or systematic reviews of home versus hospital/satellite unit hemodialysis for people with end-stage renal failure (ESRF). Outcomes included quality of life and survival. We searched MEDLINE, EMBASE, HealthSTAR, CINAHL, PREMEDLINE, and BIOSIS. Two reviewers independently extracted data and assessed the quality of the studies included.

Results: Twenty-seven studies of variable quality were included. People on home hemodialysis generally experienced a better quality of life and lived longer than those on hospital hemodialysis. Their partners, however, found home hemodialysis more stressful. Four studies using a Cox proportional hazards model to compare home with hospital hemodialysis reported a lower mortality risk for home hemodialysis. Of two studies using a Cox model to compare home with satellite unit hemodialysis, one reported a similar mortality risk, whereas the other reported a lower mortality risk for home hemodialysis.

Conclusions: Home hemodialysis was generally associated with better outcomes than hospital hemodialysis and (more modestly so) satellite unit hemodialysis, in terms of quality of life, survival, and other measures of effectiveness. People on home hemodialysis, however, are a highly selected group. Home hemodialysis also provides the opportunity for more frequent and/or longer dialysis sessions than would otherwise be possible. It is difficult to disentangle the true effects of home hemodialysis from such influencing factors.

Keywords

Home hemodialysisHospital hemodialysisSatellite unit hemodialysisRenal replacement therapyEnd-stage renal failure
Type
GENERAL ESSAYS
Information
International Journal of Technology Assessment in Health Care , Volume 20 , Issue 3 , August 2004 , pp. 258 - 268
Copyright
© 2004 Cambridge University Press

In recent years, the number of people with end-stage renal failure (ESRF) on renal replacement therapy (RRT) has increased substantially. For example, the incidence of those on RRT in England, Wales, and Scotland, respectively, rose from 82, 109, and 87 per million population in 1995 to 92, 128, and 105 per million population in 1998 (30). Over the same period, the total number of people on RRT in England increased from 22,300 to 25,890 with similar proportional increases in Wales and Scotland (28;30). Hemodialysis is the most frequently used modality of dialysis. In 1998 in England and Wales, 62 percent of those on dialysis received hemodialysis (70 percent in Scotland), predominantly in a hospital or satellite unit (28;30). Of the thirty-four hemodialysis units in the United Kingdom, twenty-four also support a home hemodialysis program, but in only six units does home hemodialysis account for more than 10 percent of their hemodialysis populations (30). Overall, only 2 percent of patients receiving hemodialysis do so at home (30).

In the 1970s and 1980s, home hemodialysis was used more frequently (28) but the hemodialysis population was younger, had fewer comorbidities, and was more likely to have a relative at home able to provide assistance. The adoption of techniques such as continuous ambulatory peritoneal dialysis and increased use of transplantation, as well as changes in the patient population, led to a decline in the use of home hemodialysis as a form of treatment for those requiring RRT.

Given the limited capacity of hospital and satellite units and the unmet need for dialysis (28), expanding home hemodialysis services may allow more people to receive dialysis. Furthermore, home hemodialysis offers potential advantages over hospital hemodialysis as it removes the need to travel for treatment and it may aid the adoption of more frequent/longer dialysis or more convenient scheduling of sessions than would be possible, due to capacity constraints, in a hospital setting. Home hemodialysis does, however, require a relative or friend to help and may put pressure on family relationships. Because of this requirement, home hemodialysis is predominantly used to treat younger patients, whose spouses or parents are prepared to act as the dialysis assistant.

Because of the uncertainty surrounding the outcomes for patients, we conducted a systematic review of the effectiveness, in terms of quality of life, survival, and other outcomes, of home versus hospital or satellite unit hemodialysis for people with ESRF.

SUBJECTS AND METHODS

Inclusion Criteria

The systematic review included randomized controlled trials (RCTs), controlled clinical trials (in which the participants are assigned to alternative forms of health care using a quasirandom method, for example alternation), comparative observational studies (in which the participants are assigned to alternative forms of health care in a nonrandom manner), and systematic reviews comparing home with hospital or satellite hemodialysis for people with ESRF. Outcomes sought were quality of life, survival, technique failure, access failure, hospitalization rates, employment/school status, measures of anemia, erythropoietin use, biochemical indices of renal disease, dialysis adequacy, blood pressure, and complications.

Search Strategy

The following electronic sources were searched: MEDLINE 1966 to October 2001; EMBASE 1980 to week 46 2001; HealthSTAR 1975 to December 2000; CINAHL 1982 to October 2001; PREMEDLINE (Ovid) 13 December 2001; BIOSIS (Edina) 1985 to October 2001; Science Citation Index (Web of Science) 1981 to October 2001; The Cochrane Library (Issue 3 2001); National Research Register (Issue 3 2001); Health Management Information Consortium (HCN) 1979 to 2001; BL Inside (December 2001); NLM Gateway (for HSRProj, Health Services Research Meetings and Locatorplus); Current Controlled Trials; Clinical Trials; DH Research Findings Register; and World Wide Web. Reference lists of retrieved articles were also checked. Further details of the search strategy are available from the authors.

Methods of Systematic Review

All titles and abstracts identified were screened, and full-text reports of potentially relevant studies were obtained and assessed for inclusion independently by two reviewers. Two reviewers independently assessed the quality of, and extracted data from, the included studies. The quality of the systematic reviews was assessed using a ten-item checklist developed by Oxman and Guyatt (19;20). The primary studies were assessed using a checklist developed by Downs and Black (8) that was designed to assess both randomized and nonrandomized studies. The checklist contained 27 questions in total, covering the following subscales: reporting, external validity, internal validity—bias, internal validity—confounding, power. The question on power was amended to simply check whether the study had provided an indication of statistical power.

RESULTS

Description of Studies

Twenty-seven studies met the inclusion criteria, including four systematic reviews (3;13;18;22), one RCT (concerning blood pressure control) (17), and 22 comparative observational studies (1;2;4–7;10–12;14–16;21;23–27;29;31–33). Of the primary studies, one compared home with both hospital and satellite hemodialysis (2), nineteen compared home with hospital hemodialysis (4–7;11;12;14–17;21;23–25;27;29;31–33), and three compared home with satellite hemodialysis (1;10;26). The majority of the primary studies (14) were performed in the United States (2;4;6;10–12;15;16;21;23;26;31–33), with two each from Canada (5;24), Germany (25;27), the United Kingdom (7;14), and one each from France (1), Israel (29), and New Zealand (17). Three studies provided information on the length of follow-up of participants (15;32;33), ranging from 1 to 6 years.

The quality of the primary studies was variable, in terms of reporting (how well various aspects of the study were described), with limited internal and external validity. Overall, the mean score was 12 of a maximum achievable score of 27. The quality of the systematic reviews also varied; based on the extent to which the items on the checklist had been met, on an overall score from 1 (extensive flaws) to 7 (minimal flaws), one review scored 5 (minor flaws) (3), one review scored 4 (22), and two reviews scored 3 (major flaws) (13;18).

Across all the studies, 1,760 patients had been dialyzed at home, 8,380 in hospital, and 1,258 in satellite units. Eleven studies had less than 100 participants. Sociodemographic characteristics and comorbidities were not evenly balanced between the treatment groups; in general, home hemodialysis patients had fewer comorbidities than those receiving dialysis in hospital or in satellite units (as would be predicted from the selection criteria used in most units). For example, fewer patients on home hemodialysis had diabetes (Table 1).

In many studies, the intervention, particularly the equipment used and the duration and frequency of dialysis, was poorly described. Five studies gave details of the type of equipment used (1;4;10;17;26). Nine studies provided information on the frequency and/or duration of dialysis (Table 2).

Outcomes

Quality of Life

Sixteen studies reported data on quality of life (Table 3), which covered aspects of general health, psychological health, or social activities. Six studies (2;5;11;18;22;31) assessed general quality of life using a variety of generic measures. In all studies, the quality of life of home hemodialysis patients was higher and they were better able to engage in activities of daily living. The systematic review by Mohr et al. (18) concluded that the evidence of improved quality of life with daily dialysis was convincing, despite the limitations in study designs (which appear to favor home hemodialysis), the use of diverse instruments, and small sample sizes.

Seven studies (3;6;14;21;23;27;29) reported various aspects of the psychological well-being of patients and carers. Although a variety of measures were used, all but one study (14) noted less psychological distress amongst home hemodialysis patients. However, in the study by Schreiber and Huber (27), those receiving hemodialysis at home were described as more nervous, tense, and irritable, but also more self-confident and less anxious, than those receiving hospital hemodialysis. In the study by Soskolne and De Nour (29) the spouses of the home group reported better adjustment than those of the hospital group.

Four studies (16;21;25;33) considered social aspects related to quality of life. Two studies (21;25) reported that home hemodialysis was less disruptive for patients but more disruptive for their families than hospital dialysis. Page and Weisberg (21) found that home hemodialysis patients and their partners demonstrated higher levels of marital relationship satisfaction than hospital dialysis patients and families. McGee (16), however, found that spouses of the home hemodialysis patients were less satisfied with the location of dialysis than spouses of the hospital dialysis patients and also believed that their partners were more dependent on them. In the study by Woods et al. (33) although a higher percentage of the home hemodialysis patients were unable to eat independently compared with the hospital dialysis patients, a higher percentage of hospital dialysis patients were unable to transfer independently or walk independently.

Survival

Eight primary studies and one systematic review reported data on patient survival (Table 4). Six studies used the Cox proportional hazards regression model, four comparing home with hospital hemodialysis (4;15;32;33) and two comparing home with satellite unit hemodialysis (1;26). The Cox model, a regression technique often used in survival analysis, was used to statistically adjust for differences in baseline characteristics between groups. In varying combinations, the factors controlled for were age at start of treatment, ethnicity, diabetes, renal vascular disease, chronic glomerulonephritis, chronic interstitial nephritis, arrhythmia, congestive heart failure, myocardial infarction, peripheral vascular disease, stroke, obesity, hypertension, pre-existing cardiac disease, low serum albumin, and whether the patient was an active smoker.

Home Versus Hospital Hemodialysis

Three studies using the Cox model showed that home hemodialysis had a mortality rate 37 percent (32), 42 percent (33), and 51 percent (15) lower than hospital hemodialysis. In the study by Capelli et al. (4), the home hemodialysis group had a dramatically lower risk of death in the first 18 months on RRT, although median lifetime survival was similar in both groups.

In those studies that reported survival in matched groups (matched on the basis of age, diagnosis, length of time on dialysis), the survival was higher for home hemodialysis patients (12;15;33). Hellerstedt et al. (12) also reported a higher survival on home hemodialysis for those with diabetes.

A systematic review on the development of RRT in France between 1982 to 1992 (13) reported that, for those 15 to 34 years of age at the start of RRT, home hemodialysis had a slightly lower 5-year survival (93.4 percent versus 96 percent) but higher survival at 10 years (90.3 percent versus 86 percent). For those 55 to 64 years of age at the start of RRT, home hemodialysis had higher survival rates (78~percent at 5 years, 56 percent at 10 years, compared with 59 percent at 5 years, 32 percent at 10 years for hospital hemodialysis).

Home Versus Satellite Hemodialysis

Two studies used the Cox model to compare survival on home and satellite unit hemodialysis. One study (1) found that home and satellite unit hemodialysis were associated with similar survival (hazard ratio, 0.65; 95 percent confidence interval; 0.30 to 1.39), whereas the other, larger, study (26) reported statistically significant greater survival for home hemodialysis (hazard ratio, 1.39; p=.003).

Other Outcomes

Hospitalization

Bremer et al. (2) reported a higher mean hospitalization rate for the home hemodialysis group compared with the self-care, in–center (satellite unit) group, whereas the staff-assisted (hospital unit) in–center group had the highest hospitalization rate. Mohr et al. (18), comparing short daily or nocturnal hemodialysis with three times per week in-center hemodialysis, reported a reduction in hospital days associated with daily or nocturnal hemodialysis.

Employment and School Status

Six studies reported employment status (2;6;9;22;23;29; the primary reference for 9 is 11), and all, apart from the study by Courts and Boyette (6), found that home hemodialysis patients were more likely to be employed compared with those being dialyzed in-center or in satellite units. A small study by Reichwald-Klugger et al. (25) of children on home or hospital hemodialysis reported variable results in terms of school activities, with no definite benefit to either group.

Technique Survival

One study (26) reported technique survival. It found that patients receiving satellite hemodialysis had a longer median technique survival time (9.7 years) compared with those in the home hemodialysis program (7.5 years). Any transfer from one dialysis therapy to another that lasted longer than 4 months was considered as technique failure. Patient data were censored at the time of transfer from the program or if renal function returned. For patients receiving a renal transplant, their data were censored at the time of transplantation and were not re-entered into the analysis if the patients returned to dialysis.

Measures of Anemia

In a randomized cross-over trial of nine patients (17), a higher mean hematocrit (percent) was found after long home hemodialysis compared with short in–center dialysis. A similar finding was reported by Covic (7), who compared the mean hemoglobin for patients receiving 8-hour home hemodialysis with standard 4-hour hospital hemodialysis. A further study reported higher hematocrit levels for home hemodialysis patients (31). Mohr et al. (18) reported a substantially reduced (41 percent) erythropoietin dosage for patients receiving nocturnal/daily hemodialysis compared with those receiving standard hospital dialysis.

Biochemical Indices of Renal Disease

Two studies reported lower phosphate values for home hemodialysis compared with hospital hemodialysis (10;17). Mean values of albumin were higher in home hemodialysis patients in two studies (17;31), although Woods et al. (33) reported that, at the beginning of treatment, albumin levels were lower for the home hemodialysis group. Two studies also reported that calcium values were higher for home hemodialysis patients compared with those undergoing hospital hemodialysis (17;31). In the study by Westlie et al. (31), the home hemodialysis patients had higher potassium levels than those undergoing hospital dialysis.

Dialysis Adequacy

In two studies comparing long home hemodialysis with standard hospital hemodialysis (7;17;), Kt/V was higher for patients undergoing long home dialysis. To be eligible for the study by McGregor et al. (17), patients had to have been on home hemodialysis for more than 6 months. Before commencing the study, each patient had a trial run of short hemodialysis to ensure a similar equilibrated Kt/V to their dialysis at home, and throughout the study equilibrated Kt/V was measured for a midweek dialysis every 2 weeks.

Blood Pressure Control

In both a randomized cross-over trial (17) and an observational study (31) reporting blood pressure. measurements, the home hemodialysis group achieved better control both pre- and postdialysis.

Adverse Events

Two studies comparing home with in–center hemodialysis provided information on adverse events (17;31), and both reported fewer episodes of hypotension for home hemodialysis patients. Westlie et al. (31) also reported data on the incidence of other adverse events (vomiting, cramps, arrhythmia, and headaches) that suggested better outcomes for home hemodialysis patients. None of the included studies gave details of access failure.

DISCUSSION

Home hemodialysis was associated with better outcomes than both hospital dialysis and (more modestly so) satellite unit dialysis in most of the studies included and for almost all measures of effectiveness considered. There were some exceptions. Parents of children on home hemodialysis have reported reduced social contacts compared with parents of children receiving dialysis in hospital (25). In addition, partners of those on home hemodialysis are reported to have found the treatment process and the increased dependency placed upon them to be more stressful than partners of those receiving dialysis in hospital (16).

The extent to which the associations with better outcome are causally linked to home dialysis, however, is difficult to judge. The evidence base is almost entirely observational studies. The single randomized controlled trial (17) had a cross-over design, involving only nine participants and, hence, contributed very little to the review. Unless adjusted for, confounding factors in the twenty-two observational studies (and in the four systematic reviews) are likely to strongly favor home dialysis. People offered hemodialysis at home are a deliberately highly selected group. They are generally younger and with fewer comorbidities than those receiving dialysis in hospital or in satellite units.

Another factor that makes interpretation difficult is that, in some studies, the primary comparison was actually between different durations/frequencies of hemodialysis rather than specifically comparing settings for hemodialysis. For practical purposes, it was more appropriate for some interventions such as longer, more frequent, or overnight dialysis to take place at home rather than in a hospital or satellite unit, and this option is a potential advantage of this setting.

In an attempt to control for potential confounders, six studies with survival as an outcome used the Cox proportional hazards regression model (1;4;15;26;32;33). Generally, these six studies appeared to have included appropriate risk factors, although only three studies reported that the frequency and duration of dialysis sessions were the same for both groups (1;4;26). In the other three (15;32;33), covariates reflecting differences in the process of treatment, for example, dose prescribed and achieved, compliance, and any local patterns of practice were not included. It is likely, therefore, that the results of these three studies may be confounded by differences in treatment characteristics, despite adjusting for other potential confounders. With regard to the review's other outcomes, nearly all the results of the included studies suggest superior outcomes for home hemodialysis, although the one study that reported technique survival (26) suggested that this outcome was shorter on home hemodialysis.

A new generation of home hemodialysis machines is under development. These machines should improve ease of use for those undertaking hemodialysis at home, reducing the rate of complications and also the burden of care on partners/carers. This new generation of machines, for appropriate groups, may increase the advantages offered by home hemodialysis over hospital hemodialysis and may also lead to a situation of clearer advantage over satellite hemodialysis.

For those without a carer but who might otherwise be considered potentially eligible for home hemodialysis, community carers could be trained to fulfill this role. Although this possibility would add to the cost of home hemodialysis, it might be considered appropriate for people living in remote areas who were unsuitable for peritoneal dialysis.

Implications for Practice

Although the data on outcomes are almost all from nonrandomized studies and, hence, potentially confounded by other differences between the groups than the setting of dialysis, the results suggest that, for appropriate groups, use of home hemodialysis may help to alleviate the increasing pressure on hospital units. However, account needs to be taken of the burden not only on those directly involved but also on their partners/carers, requiring the availability of suitable support and respite systems. The increasing number of elderly dialysis patients may mean that fewer are considered suitable for this form of therapy if a relative or friend (unpaid) is needed to assist them. If carers (paid) were provided, more people would become eligible for home hemodialysis.

Implications for Future Research

Further prospective comparative studies are required on the effectiveness of home versus satellite unit hemodialysis. These results would provide a much more reliable evidence base if the choice of setting were based on random allocation. These studies should consider outcomes such as quality of life of patients and their partners/carers, acceptability of the treatment to patients and their partners/carers, survival, technique failure, access failure, hospitalization rates, employment/school status, measures of anemia, biochemical indices of renal disease, and adverse events. Analysis of the newer generation of home hemodialysis machines with respect to the above outcomes should be undertaken as part of this research.

This manuscript is based on the following systematic review that was commissioned by the NHS R&D HTA Programme on behalf of the National Institute for Clinical Excellence (NICE): Mowatt G, Vale L, Perez J, Wyness L, Fraser C, MacLeod A, et al. Systematic review of the effectiveness and cost-effectiveness, and economic evaluation, of home versus hospital or satellite unit hemodialysis for people with end-stage renal failure. Health Technol Assess 2003;7(2). We are grateful to Adrian Grant and Cairns Smith for their advice and comments on earlier drafts of this manuscript and to Neil Scott for statistical advice. The Health Services Research Unit and Health Economics Research Unit are funded by the Chief Scientist Office of the Scottish Executive Department of Health.

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Figure 0

Primary Studies Reporting Percentage of Participants with Diabetes

Figure 1

Primary Studies Reporting Duration and Frequency of Hemodialysis

Figure 2

Quality of Life: Summary of Results of Studies Comparing Home with Hospital or Satellite Unit Hemodialysis

Figure 3

Survival: Summary of Results of Studies Comparing Home with Hospital or Satellite Unit Hemodialysis