Anuradha Wadhwa, MDa,b; Linda F. Fried, MDc,d; Kerri Cavanaugh, MDe,f; Karen MacKichan, MDg,h; Arjun D. Sinha, MD, MSi,j; Sarah Adam, MSWa; Laurie Hippensteel, RNk; Scott Ruele, MDl,m; Susan T. Crowley, MDn,o; Ashutosh M. Shukla, MBBS, MDp,q
iRichard L. Roudebush Veterans Affairs Medical Center, Indianapolis, Indiana
jIndiana University School of Medicine, Indianapolis
kKansas City Veterans Affairs Medical Center, Missouri
lUniversity of Minnesota Medical Center, Minneapolis
mMinneapolis Veterans Affairs Health Care System, Minnesota
nVeterans Affairs Connecticut Healthcare System, New Haven
oYale University, New Haven, Connecticut
pNorth Florida/South Georgia Veterans Health System, Gainesville
qUniversity of Florida, Gainesville
Author disclosures
The authors report no outside sources of funding with regard to this article.
Disclaimer
The opinions expressed herein are those of the authors and do not necessarily reflect those of Federal Practitioner, Frontline Medical Communications Inc., the US Government, or any of its agencies.
Ethics and consent
No research activities were conducted; hence, ethics approval was not required.
Background: Home dialysis utilization is lower among veterans than in the general US population. Several sociodemographic factors and comorbidities contribute to peritoneal dialysis (PD) underutilization. In 2019, the Veterans Health Administration (VHA) Kidney Disease Program Office convened a PD workgroup to address this concern.
Observations: The PD workgroup was explicitly concerned by the limited availability of PD within the VHA, which frequently requires veterans to transition kidney disease care from US Department of Veterans Affairs medical centers (VAMCs) to non-VHA facilities when they progress from chronic kidney disease to end-stage kidney disease, causing fragmentation of care. Since the administrative requirements and infrastructure of VAMCs vary, the workgroup focused its deliberations on synthesizing a standard process for evaluating the feasibility and establishing a new PD program within any individual VAMC. A 3-phased approach was envisioned, beginning with ascertainment of prerequisites, leading to an examination of the clinical and financial feasibility through the process of data gathering and synthesis, culminating in a business plan that translates the previous 2 steps into an administrative document necessary for obtaining VHA approvals.
Conclusions: VAMCs can use the guide presented here to improve therapeutic options for veterans with kidney failure by establishing a new or restructured PD program.
Compared with hemodialysis (HD), peritoneal dialysis (PD) offers comparable survival and superior patient-centered and health services outcomes.1,2 This has prompted repeated calls over the past 2 decades for policies to increase the use of home dialysis and, more specifically, for PD in the United States.3,4
Veterans comprise nearly 10% of the population with end-stage kidney disease (ESKD) burden; > 50,000 US veterans are currently on dialysis.5,6 A majority of these veterans receive their chronic kidney disease (CKD) care through their affiliated US Department of Veterans Affairs (VA) medical centers (VAMCs).
However, there are only 71 hospital-affiliated or free-standing HD and 28 outpatient PD units within the Veterans Health Administration (VHA) (Figure 1). Together, these units serve only about 3500 veterans on HD and about 300 veterans with PD. More than 90% of veterans receive their dialysis care from non-VA facilities. Thus, veterans progressing from CKD to ESKD commonly need to transition their VA-based nephrology care to non-VA facilities, causing fragmentation of care during a medically fragile period. Such transitions adversely impact the quality of ESKD care and reduce the probability of PD use. PD use among veterans is lower (~7%) compared with the general ESKD population (~12%).7
To address these needs, the VHA National Kidney Disease Program (NKDP) formed a 4-member PD workgroup in 2019. Considering the breadth of challenges involved, the PD workgroup broadly designed its approach based on the I CARE (Integrity, Commitment, Advocacy, Respect, and Excellence) VA Core Values.
The workgroup devised a conceptual model with 3 focus areas, each comprising a subgroup led by a workgroup member: respecting the veteran’s choice for PD, advocating for universal access to PD, and providing excellence in PD care within the VHA (Figure 2). While the passage of the Choice Act (2014) and the Mission Act (2018) was recognized to have increased access to PD for veterans through non-VA purchased care, lack of availability within the VA infrastructure was considered a significant residual limitation to greater PD use.8
This review focuses on the initial deliberations of the PD access subgroup and provides a guide to establishing a new local VA PD program.
We describe the process by dividing it into 3 operational phases: examining the prerequisites, analyzing clinical and financial feasibility, and outlining the process of administrative approval (Figure 3).
