Nephrology: forerunner in the search for care in the right place

Note: This article has been translated from fmtgezodheidszorg.nl. The text is written by Dietske van der Brugge and published in edition 5/6 2019 of FMT Gezondheidszorg (in Dutch). In all editions of FMT Gezondheidszorg, you can read about new developments in medical technology.

The desire to provide ‘the right care in the right place’ requires a radical transition of care, which must be based more on network connections. Even before the political outline agreement of 2018, “nephrology” sought sector-wide options for home treatment of patients with renal failure.

The Kidney Foundation started more than ten years ago with a project to develop a “portable” artificial kidney. Patients are eager for technology that makes dialysis less stressful. […] In the meantime, the percentage of patients dialyzing at home declined. The desire to find out the resulting and put home dialysis back on the map was shared by all sector partners. The DOMESTICO study (Dutch nOcturnal and hoME dialysis study to improve clinical outcomes) was started, and the researchers and participating hospitals rejoiced in collaboration with quality agency Nefrovisie, the Dutch Federation of Nephrology, Kidney Foundation and NVN patient association.

Development of artificial kidney

Since 2014, the Kidney Foundation has been working with Debiotech in Switzerland on the realization of a portable hemodialysis device. The Singaporean company Dialyss is responsible for the further development of sorbent technology, and focuses on its large-scale production. Jasper Boomker, Innovation Manager at the Kidney Foundation: “It is essential that patients do not have to bring in a “small hospital” and that they can take the device with them in order to be able to dialyze older people. With the device that we are currently developing, we will succeed.”

Trials artificial kidney

“The device has a closed system: the dialysate is reused, which means that only 7 liters of water per dialysis is needed,” continues Boomker. “The concept of recycling dialysis now meets the standards for safe, responsible dialysis. Until 2021 there are animal and lab tests with the sorbent cartridge. If all goes well, a small-scale phase I (first-in-human) clinical trial will start in 2021 at the UMC Utrecht. In the first instance, the emphasis will be on the safety and functionality of the sorbent cartridges that we will use to recycle the dialysate. In particular, it will be examined whether the waste is sufficiently removed and whether the composition of the dialysate remains within the established limits. In 2022 we hope to test the entire system, to make sure that the blood pump, for example, leaves the blood cells intact, and whether the system responds adequately to blood pressure drops, for example. So there is still a long way to go, but the availability of a small, easy-to-carry device will certainly remove a hurdle for home dialysis for a number of patients. By the way, you are not nearly finished with that if you want to realize a substantial transfer from center dialysis to home dialysis or even “dialysis everywhere”.”

Own direction

Boomker refers to the conditions that the “dialysis everywhere” treatment option must meet in order to be feasible and interesting. The most important gain that can be achieved is the company’s own control over dialysis. If patients can choose for themselves how often and for how long they dialyze, that is an enormous quality gain. Getting free from the dialysis center, with a fixed schedule of dialysis sessions, is a necessary, but not yet sufficient condition.

Dialysis assistance

“The added value of home hemodialysis is therefore highly dependent on how the therapy is offered,” says Jasper Boomker. “Could you offer a treatment modality without a nurse dialysis assistant (VDA), or with someone who can be deployed flexibly? A small number of patients are already working with a specially trained VDA from their own circle, but usually the practice is that a VDA comes home from the dialysis center, and it stays with you throughout the entire session. That is, in terms of cost and labor input, not really efficient. It is therefore important to consider whether the assistance with connection and disconnection can be done differently, for example by bringing in trained home care staff, who can simply go to other patients in the neighborhood in the intervening hours. You can then organize the monitoring of the process with telecare. It is technically possible, but it still requires a lot of care.”

Decrease in home treatment

“Our big question is what is needed to make the best use of all treatment options,” says DOMESTICO physician-researcher Anita van Eck van der Sluijs. The number of patients who are on dialysis at home has fallen sharply in the last fifteen years: almost half by half. The cause is partly known. Peritoneal dialysis is also part of the dialysis modalities you can do at home. Patients change the dialysis fluid in the abdominal cavity several times a day. Anita van Eck van der Sluijs: “The choice of treatment was previously often made by younger patients. Since there are better possibilities for kidney transplantation with an organ from a living donor, it is precisely these young people who often receive a pre-emptive transplant: before they have to start dialysis. That is of course only good news, but does not explain the entire decline in the proportion of home dialysis patients. So there is more going on, and we need to get an idea of ​​that in order to reverse that trend.”

DOMESTICO

The DOMESTICO research program studies the factors that determine the variance between different treatment centers. Anita van Eck van der Sluijs: “We see that one center can keep almost all patients who start it in the home dialysis, while elsewhere many patients go back from home treatment to center dialysis. We want to be able to explain that. ” DOMESTICO is based on three pillars. The first is retrospective research into technology failure or dialysis treatment, which analyzes data from 1,200 home dialysis patients from the 2012-2017 period. We also conduct prospective research into clinical treatment outcomes, quality of life on the basis of PROMs (patient reported outcome measures) and cost effectiveness of home versus center dialysis. Finally, there is a project called “Good Practices & Shared Decision Making”. Anita van Eck van der Sluijs: “We ultimately want to gain insight into which treatment modality is suitable for what reason for offering to an individual patient. And then ensuring that the care structure is well equipped to weigh the options together with that patient. That is a matter of knowledge and expertise, and of course good decision-making skills. We really think there is more in it; certainly when a handy dialysis device for home treatment will become available in the future. And it’s really worth it. People often think in terms of healthcare costs. We think in terms of 100% freedom of choice for patients, and think that this is always beneficial.”

The right care in the right place

In the spring of 2018, insurers, health care providers, insurers and the Ministry of Health, Welfare and Sport signed the “Negotiation agreement for specialist medical care 2019 to 2022”. In this outline agreement, they committed themselves to work to achieve healthcare “in the right place” more than before.

The care transition involved in this involves a 3 tactics:  preventing more expensive care, transfer of care from second to first line, and replacement of care with other care with a better quality.

King Willem Alexander announced in the 2019 Throne Speech that the government will present a contour outline of the future care organization before the summer of 2020.