Utilization of Home Dialysis and Permanent Vascular Access at Dialysis Initiation Following a Structured CKD Education Program

RATIONALE & OBJECTIVE: Treatment options for kidney failure are complex, and the majority of patients transitioning to dialysis lack important information about treatment options and are not prepared to make informed decisions about their care. Correspondingly, the majority of patients who start dialysis default to in-center hemodialysis using a central venous catheter for vascular access as the initial modality; furthermore, hospital admissions, mortality, and infections are exceedingly common over the first few months. STUDY DESIGN: Matched retrospective cohort study. SETTING & PATIENTS: 2,398 adult patients with chronic kidney disease (CKD) who attended a structured CKD education program and pair-matched control patients who did not receive education before starting dialysis between January 2018 and June 2019. EXPOSURE: CKD education attendance documented from 2 months (60 days)-3 years before dialysis initiation. CKD education consisted of a 1-time, 90-minute, inperson or virtual class. OUTCOME: Primary outcomes were dialysis modality and vascular access type on the first day of dialysis (day 0) and at day 90 after dialysis initiation. Secondary outcomes included hospitalizations and deaths during the first year of receiving dialysis. ANALYTICAL APPROACH: Generalized linear models were used to compare outcomes between patients receiving CKD education and controls. RESULTS: Compared with controls, CKD education patients were more frequently receiving home dialysis (38.5% vs 12.6%, P < 0.001) and used a permanent vascular access (57.9% vs 33.8%, P < 0.001) at dialysis initiation; differences were minimally attenuated and remained statistically significant at day 90. Hospitalization rates were lower among CKD education patients than among controls during the first year of receiving dialysis (1.00 vs 1.38 admissions per patient-year; P < 0.001). CKD education patients also had lower mortality over the first year of receiving dialysis (P < 0.001). LIMITATIONS: Bias and confounding cannot fully be accounted for in an observational study. Analyses only included patients with commercial and Medicare insurance who received CKD care before dialysis initiation and may not be generalizable to other patient populations. CONCLUSIONS: Our findings indicate that attending a CKD education class before starting dialysis resulted in positive clinical outcomes, including reduction in hospitalization and mortality rates. Broad implementation of structured CKD education may result in more patients choosing home dialysis as their first treatment option and reduce the risk of adverse outcomes in the crucial early period after dialysis initiation.