Peritoneal Dialysis among Patients Initiated on Dialysis at a County Hospital: How to Do Better

Background: More than 37 million Americans are living with kidney disease. Approximately 800,000 have chronic kidney failure needing dialysis or kidney transplantation. Several studies have demonstrated the cost-effectiveness of peritoneal dialysis (PD) compared to in-center hemodialysis. Despite multiple interventions increasing awareness and incentives for stakeholders, the overall prevalence of patients on PD in the United States remains at less than 12% of total dialysis patients. Our project aimed to increase the rate of PD initiation among patients starting long-term dialysis at Ben Taub, a 402-bed county hospital in Texas, by 50% from baseline. Methods: An anonymous survey was conducted to assess current understanding of PD among nephrology faculty and trainees at Ben Taub Hospital. The intervention consisted of 1) establishing a screening algorithm to define the eligibility and exclusion criteria for selecting appropriate PD candidates 2) establishing a protocol streamlining the referral process and expediting placement of a PD catheter prior to discharge, and 3) providing an educational session to nephrology faculty and trainees to teach the newly developed algorithm and protocol, bridge knowledge gaps, and address perceived barriers to PD initiation. A chart review study was conducted to collect data on the rates of PD candidacy screening and PD initiation pre- and post-intervention. Results: In the three months prior to the intervention, a total of 29 ESKD patients were initiated on dialysis. Of those 29 patients, only 8 (27.5%) were screened for PD candidacy and 1 (3.5%) was initiated on PD. At 6 months post-intervention, a total of 78 patients were initiated on dialysis. The percentage of patients initiated on PD increased to 19% (15 of 78 total patients) which reflects nearly a 5-fold increase from baseline. Additionally, the rate of screening improved to 75.6% (59 of 78 total patients). Conclusion: The results of this study show that simple interventions consisting of providing clinical education on PD to nephrology trainees and faculty and streamlining the referral and initiation process can increase the proportion of ESKD patients screened for PD candidacy and successfully initiated on PD in a county hospital setting.