Home Dialysis Curriculum Implementation for Healthcare Workers Using Project ECHO (Extension for Community Healthcare Outcome) Principles: A Feasibility Report From NKF-KDOQI

The National Kidney Foundation facilitated a series of NKF-KDOQI conferences with the aim to remove barriers towards home dialysis adoption in the United States1Chan C.T. Collins K. Ditschman E.P. Koester-Wiedemann L. Saffer T.L. Wallace E. Rocco M.V. Overcoming Barriers for Uptake and Continued Use of Home Dialysis: An NKF-KDOQI Conference Report.Am J Kidney Dis. 2020; Abstract Full Text Full Text PDF Scopus (32) Google Scholar. Given that knowledge base and provider awareness continued to be limited, a home dialysis project ECHO (Extension for Community Healthcare Outcome) was proposed as an important and implementable strategy. The rationale of our home dialysis project ECHO was previously published1Chan C.T. Collins K. Ditschman E.P. Koester-Wiedemann L. Saffer T.L. Wallace E. Rocco M.V. Overcoming Barriers for Uptake and Continued Use of Home Dialysis: An NKF-KDOQI Conference Report.Am J Kidney Dis. 2020; Abstract Full Text Full Text PDF Scopus (32) Google Scholar. Project ECHO is a known remote health educational model that uses videoconferencing technology to connect clinicians across multiple geographical settings with different areas of expertise. The NKF home dialysis project ECHO was registered through the University of New Mexico ECHO project repository in November 2020. Curriculum topics are presented in Table S1. Our overall goal was to assess the feasibility of implementing a sustainable ECHO model in home dialysis. In brief, our project is based on a hub and spokes model. The home dialysis clinical hub faculty team consisted of nephrologists, a home dialysis nurse, a certified biomedical dialysis technician, a social worker, a dietitian and a patient representative. Our hub team was charged to cover a broad scope of clinical topics and scenarios. On a bi-weekly basis, audience pre-determined clinical scenarios were presented to the clinical hub team. The faculty members facilitated informal case discussion which mimicked that of residency training followed by a short didactic session. An open invitation to participate was sent to all dialysis facilities within ESRD Networks 16 and 18. Baseline and exit surveys were created to assess the aforementioned domains. A secure video conferencing platform was developed with standardized forms which facilitated case submission to encourage a learning community for informal case discussion. Each session included informal case presentation and didactic curriculum topic discussion. NKF Home Dialysis Project ECHO was conducted from March 11, 2021 to March 24, 2022. 107 healthcare workers registered (including 19 faculty and facility administrators) for our home dialysis ECHO project. The median number of participated sessions was 1.5 (range = 16). The registrants represented a diverse background (including: dietitian [n = 15], facility administrator [n = 19], nurse [n=36] and social worker [n=17], fellow [n=2], physician [n=10], technician [n=1], other [n=6]). Home Dialysis Project ECHO sessions were consistently well received. Ninety-four percent of our participants agreed or strongly agreed that the learning objectives were met. 99% of participants reported that they would recommend the activity to their peers. Participants (93%) confirmed that the project assisted in the clinical management of home dialysis and enhanced inter-professional team dynamics and will make changes to their daily clinical practice. Sessional participants’ survey results are summarized in Tables 1 and 2. Our program is not designed nor powered to ascertain the impact of home dialysis ECHO on adoption of home dialysis. Descriptively, at baseline, the participating centers’ median home dialysis rate was 9.3% (0.0 – 18.5%) [25-75% Interquartile range] and was 12.8% (0.0 – 24.6%) at the end of 12 months of the implementation of Home Dialysis Project ECHO.Table 1Survey Results – changes to practiceI plan to make changes in my practice based on the information in this activity.YESNOHow to Establish A Culture of Promoting Home Dialysis121Assumptions about Barriers to PD Summary Evaluation90Modality Education101Infection Prevention70Patient/Family/Home Assessment81Psychosocial Adjustment121Best Practice Training Techniques80Ingredients for a Successful Home Dialysis Team61Clinical Strategies to Help Patients Feel Comfortable Performing Dialysis at Home30PD Catheter Placement & Growing Relationship with PD Catheter Surgeons60Involving the Family/Support People in Training and Follow Up70Hernias and Leaks in Peritoneal Dialysis50Transitional Units50Nutrition and Home Dialysis81Home Hemodialysis Prescription Using Various Platforms22Troubleshooting the PD Prescription51Improvement of Technique Survival30Technological Safety20Co-Management with the Patient20Acute PD, Urgent Start PD20 Open table in a new tab Table 2Survey results – activity evaluationActivity Evaluation: This activity will assist to improve my: (Select all that apply)CompetenceCommunicationSkills/StrategiesPatient OutcomesPerformanceHow to Establish A Culture of Promoting Home Dialysis38764Assumptions about Barriers to PD Summary Evaluation35450Modality Education46963Infection Prevention33332Patient/Family/Home Assessment42332Psychosocial Adjustment59974Best Practice Training Techniques55764Ingredients for a Successful Home Dialysis Team33334Clinical Strategies to Help Patients Feel Comfortable Performing Dialysis at Home12222PD Catheter Placement & Growing Relationship with PD Catheter Surgeons36331Involving the Family/Support People in Training and Follow Up33453Hernias and Leaks in Peritoneal Dialysis31221Transitional Units21344Nutrition and Home Dialysis53451Home Hemodialysis Prescription Using Various Platforms42121Troubleshooting the PD Prescription53342Improvement of Technique Survival33323Technological Safety11100Co-Management with the Patient11101Acute PD, Urgent Start PD00201 Open table in a new tab The NKF – Home Dialysis Project ECHO was a feasible virtual educational program. We are encouraged to see the potential of our strategy to be a sustainable program. Project ECHO has been implemented across multiple clinical disciplines with different levels of success2Addala A. Filipp S.L. Figg L.E. Anez-Zabala C. Lal R.A. Gurka M.J. Haller M.J. Maahs D.M. Walker A.F. Project E.D.R.T. Tele-education model for primary care providers to advance diabetes equity: Findings from Project ECHO Diabetes.Front Endocrinol (Lausanne). 2022; 131066521Crossref Scopus (1) Google Scholar, 3Hodge A. Manson J. McTague L. Kyeremateng S. Taylor P. Creating virtual communities of practice for ambulance paramedics: a qualitative evaluation of the use of Project ECHO in end-of-life care.Br Paramed J. 2022; 7: 51-58Crossref PubMed Google Scholar, 4Panjwani S. Porto A. Motz R. Morris M. Grzejszczak L. Dimartino A. Ashley K. Participation in Project ECHO to advance rural primary care providers' ability to address patient mental health needs.Med Educ Online. 2023; 282164470Crossref PubMed Scopus (1) Google Scholar, 5Tilmon S.J. Lee K.K. Gower P.A. West K.S.H. Mittal K. Ogle M.B. Rodriguez I.M. Johnson D. Impact of an Urban Project ECHO: Safety-Net Clinician Self-Efficacy Across Conditions.Am J Prev Med. 2023; Abstract Full Text Full Text PDF PubMed Scopus (0) Google Scholar. Most studies have reported improvements in knowledge awareness, enhancement in team dynamics or integration and providers’ self efficacy. We are limited in our observational design and hence are unable to discern any potential causal link between our educational efforts and change in home dialysis rate. Additionally, there are other residual confounders including changes in dialysis policy and/or reimbursement which may also impact on home dialysis uptake6Bhat J.G. Weiss S. ETC Model: How One Small Dialysis Organization Is Navigating Uncharted Policy Waters.Adv Chronic Kidney Dis. 2022; 29: 45-51Abstract Full Text Full Text PDF PubMed Google Scholar, 7Reddy Y.N.V. Mendu M.L. Weinhandl E.D. Funding Innovative Dialysis Technology in the United States: Home Dialysis and the ESRD Transitional Add-on Payment for New and Innovative Equipment and Supplies (TPNIES).Am J Kidney Dis. 2021; 78: 892-896Abstract Full Text Full Text PDF PubMed Scopus (0) Google Scholar, 8Reddy Y.N.V. Tummalapalli S.L. Mendu M.L. Ensuring the Equitable Advancement of American Kidney Health-the Need to Account for Socioeconomic Disparities in the ESRD Treatment Choices Model.J Am Soc Nephrol. 2021; 32: 265-267Crossref PubMed Scopus (0) Google Scholar. Finally, given that we conducted our project during COVID-19 pandemic, the likelihood of home dialysis adoption has also varied and may represent a secular trend9Truong T. Dittmar M. Ghaffari A. Lin E. Policy and Pandemic: The Changing Practice of Nephrology During the Coronavirus Disease-2019 Outbreak.Adv Chronic Kidney Dis. 2020; 27: 390-396Abstract Full Text Full Text PDF PubMed Scopus (0) Google Scholar. Our project ECHO was able to disseminate a virtual education program to a relatively large number of clinicians. However, similar to previously published reports, the need for outreach poses a challenge for sustained recruitment10Sockalingam S. Rajaratnam T. Gambin A. Soklaridis S. Serhal E. Crawford A. Interprofessional continuing professional development programs can foster lifelong learning in healthcare professionals: experiences from the Project ECHO model.BMC Med Educ. 2022; 22: 432Crossref PubMed Scopus (0) Google Scholar,11Abra G. Poyan Mehr A. Chan C.T. Schiller B. The Implementation of a Virtual Home Dialysis Mentoring Program for Nephrologists.Kidney360. 2022; 3: 734-736Crossref PubMed Scopus (0) Google Scholar. We noted that our project ECHO had a median attendance of 1.5 sessions with a large range. In order for our project ECHO to operate, ongoing communication is required to engage our audience. Removal of barriers to attend may also facilitate participation. However, a second year Home Dialysis Project ECHO program has expanded participation across four ESRD Networks, resulting in over double the attendance and participation as the pilot year. Home dialysis is generally underutilized in the United States compared to other Western countries. Overall, it is widely perceived that lack of easily accessible broad based clinical education for clinicians and patients may be one of the foundational elements contributing to the present distribution of dialysis modalities12Morita P.P. Huynh K. Zakir A. Cafazzo J.A. McQuillan R.F. Bargman J.M. Chan C.T.M. Supporting the Establishment of New Home Dialysis Programs Through the Explore Home Dialysis Program.Kidney Int Rep. 2019; 4: 293-300Abstract Full Text Full Text PDF PubMed Scopus (0) Google Scholar. The NKF – Home Dialysis Project ECHO fulfills the perquisites for an accessible, broad based virtual clinical education platform13Ashley J. Abra G. Schiller B. Bennett P.N. Mehr A.P. Bargman J.M. Chan C.T. The use of virtual physician mentoring to enhance home dialysis knowledge and uptake.Nephrology (Carlton). 2021; 26: 569-577Crossref PubMed Scopus (5) Google Scholar. Authors’ Contributions: Research idea and study design: CTC, BDB, JC, RC, KC, DC, SH, JJ, RM, GM, NP, MBR, KW; data acquisition: JC, JJ; data analysis/interpretation: JC, JJ, CTC; statistical analysis: JC, JJ CTC; Each author contributed important intellectual content during manuscript drafting or revision and accepts accountability for the overall work by ensuring that questions pertaining to the accuracy or integrity of any portion of the work are appropriately investigated and resolved. Support: Financial support of this project was provided by Comagine Health and the National Kidney Foundation. Financial Disclosure: Mr. Concepcion serves on the editorial advisory boards for Nephrology News and Issues (Healio) and sole proprietor and owner of Renal Logistics. Dr. Mehrotra serves as a consultant for Lightline Medical, is the editor-in-chief of Clinical Journal of the American Society of Nephrology, and is the Chair of the Board of Trustees of the Northwest Kidney Centers. The remaining authors declare that they have no relevant financial interests. Acknowledgements: The NKF would like to thank Comagine Health for their collaboration and partnership on this project. Peer Review: Received April 21, 2023 as a submission to the expedited consideration track with 2 external peer reviews. Direct editorial input from the Editor-in-Chief. Accepted in revised form August 2, 2023. Download .pdf (.09 MB) Help with pdf files