Educational Barriers to the Adoption of Home Hemodialysis as a Primary Modality in the United States

Background: Patients with chronic renal failure in need of dialysis have in-center hemodialysis (ICHD), peritoneal dialysis (PD), and home hemodialysis (HHD) as treatment options. Of the available options, HHD is largely underutilized compared to other modalities despite known advantages including improved treatment outcomes and patient autonomy. In response, a greater emphasis was placed on home modalities via the Advancing American Kidney Health Initiative (AAKHI) in 2019 to increase government subsidization for HHD and overall exposure thereof. This literature review aims to explore barriers, focusing on education, which may improve HHD utilization. Methods: PubMed, Embase, and Scopus were screened for relevant studies in accordance with preferred reporting items for literature review guidelines. All authors conducted a full-text review to assess relevance and extract key study characteristics, including study type, methods, country, purpose, identified barriers, and proposed or studied solutions. Results: Many patients report inadequate pre-dialysis modality education, citing fears of isolation from care teams and needle-related anxieties as reasons for not electing HHD as their primary treatment. These concerns may be reduced through patient education on provider involvement in HHD and training to address needle fears. Knowledge gaps were also noted between senior and training physicians, with nephrology residents and fellows less familiar and less likely to offer HHD. Importantly, discrepancies between provider- and patient-perceived barriers highlight the need for standardized and continued modality education across all levels. Improving HHD education can facilitate comprehensive conversations of all treatment options, encouraging patient autonomy and addressing concerns promptly prior to treatment selection. Conclusion: Educational gaps among both patients and providers remain a key barrier to HHD adoption, despite its well-established clinical benefits. Optimizing education strategies may empower patients and providers alike, fostering greater HHD utilization and improved long-term outcomes in end-stage renal disease.