“Who matters most?”: Clinician perspectives of influence and recommendation on home dialysis uptake

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Excerpt

Compared with facility dialysis, home dialysis has been associated with improvements in a range of outcomes,1 including survival,4 cost,6 social rehabilitation,7 and quality of life.8 As the international demand for dialysis increases, many countries are exploring options to increase home dialysis rates as a way of improving outcomes and managing costs. The high prevalence of home dialysis in New Zealand (NZ) over the last 30 years has established this country as a leader in this area. Even so, maintaining the uptake of home dialysis remains an ongoing challenge in NZ, as is the case in many other countries.
There are many barriers to home dialysis, including patient‐level factors such as lack of access to education and information, lack of confidence in facing the challenge of home dialysis, and various financial barriers.9 Service‐level barriers have also been reported and include lack of resources, inadequate infrastructure, and unfavorable reimbursement.10 However, even when these conditions are potentially remediable or absent, there remains considerable variation in uptake of home dialysis among centers.12 A large contributor to this residual variation is likely to be the extent to which individual clinicians advocate for or promote home dialysis to their patients. This is an important point for intervention, because under the best circumstances, only 50% of eligible patients choose home dialysis when they are appropriately informed.13 It is possible, or even probable, that effective and consistent clinical advocacy will increase this uptake further.
In the field of dialysis, there is generally a poor understanding of clinical advocacy and no agreed frameworks for quantitative research. As a result, there is little empirical evidence in the literature as to whether clinical advocacy increases home dialysis uptake and which professional groups are most effective in terms of their advocacy. It is important to note that clinicians can influence decision‐making around home dialysis in 2 ways. First, the clinician can influence a team's decision to recommend home dialysis to a patient. Second, they can influence a patient's decision to engage the offer of home dialysis if 1 is made. A good understanding of clinical advocacy is critical for the development of effective initiatives to promote home dialysis. NZ represents a unique opportunity for study in this area. Every center in the country has a home dialysis program, with dedicated pre‐dialysis nurses who deliver pre‐dialysis education and assessment. As in the rest of the world, however, there is still marked variation in home dialysis uptake among centers that is unexplained by patient case mix. This context allows a population‐based study to better understand the effect of clinical advocacy within and from pre‐dialysis teams and assess the extent to which this attribute explains variation in the uptake of home dialysis among centers.
In the social science literature, the ability to influence the recommendations of a decision‐making group or the choices of a consumer is commonly termed “decisional power”.14 The assessment of decisional power is an unfamiliar area for medical researchers and usually the provenance of applied clinical psychology disciplines such as consumer and business‐to‐business (buying team) behavior. In this study, we adopt frameworks and techniques that are utilized in that literature. Among other things, we investigate the distribution of decisional power within pre‐dialysis teams in NZ.
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