Identification of Facilitators and Barriers to Home Dialysis Selection by Canadian Adults with ESRD

Home dialysis (home HD or home PD) remains underutilized in most jurisdictions. Physicians, advanced-practice nurses, and policy makers working with chronic kidney disease populations can provide insights into patient, healthcare professional, and system-level barriers to home dialysis selection by suitable patients. We used in-depth interviews, with a purposive sampling strategy until informational redundancy was achieved, to elicit barriers and facilitators to home dialysis selection from thirteen informants. We triangulated these data against qualitative data collected in a related survey of nephrologist attitudes. We used a modified grounded theory approach to construct a taxonomy of barriers and facilitators. Informants included nephrologists (n=11), an advanced-practice nurse, and a health administrator with a provincial renal care organization. We constructed separate taxonomies of barriers and related facilitators that were specific to PD, specific to home HD, and common to both. We distinguished between factors favoring, modifiable factors opposing, and nonmodifiable factors opposing home dialysis selection. Several major themes emerged, including: medical factors, home physical environment, psychological and cognitive factors (knowledge, attitudes, coping styles), social factors (supports, lifestyle), dialysis program, local hospital or regional factors (expertise, resources, local culture), healthcare professional-related factors (knowledge, attitudes, reimbursement), health system-related factors (funding models), and exogenous factors (late referral, technology). We identified several modifiable practices at the level of patient, healthcare professional, dialysis facility, and healthcare system to increase appropriate use of home dialysis. We discuss potential facilitating factors, knowledge gaps, and priorities for future research, and propose potential applications for this novel taxonomy of determinants of dialysis modality choice.