Reviewing Implementation Issues in Dialysis:

Challenges and Opportunities

EFTYHIA HELIS, MSc KNOWLEDGE MOBILIZATION

Authorship Presentation authors: Eftyhia Helis, Kristen Moulton, Laura Weeks, Lesley Dunfield, Janet Crain

Presentation based on: Dialysis Modalities for the Treatment of End-Stage Kidney Disease: A Health Technology Assessment. Ottawa: CADTH; 2017. (CADTH Optimal Use Report; vol. 6,no. 2b). Available from: https://www.cadth.ca/sites/default/files/pdf/OP0526_Dialysis_Modalities_Science_Report.pdf

CADTH adheres to the authorship and contribution guidelines established by the International Committee of Medical Journal Editors (ICMJE).

Outline

• Dialysis context in Canada

• CADTH HTA on dialysis and addressing implementation considerations (separate review and HTA chapter)

• Lessons learned and opportunities for future HTA implementation work

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Dialysis in Canada

• Several options for dialysis treatment are available to patients with end-stage kidney disease (ESKD).

• Hemodialysis offered in a clinical setting remains the most frequently used modality.

• Hemodialysis (HD) and peritoneal dialysis (PD) offered in the home are less frequently used.

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cadth.ca/dialysis

What is an HTA? • CADTH: HTA products are evaluations of clinical effectiveness and/or

cost-effectiveness, and may include the ethical, legal, and social implications of health technologies on patient health and the health care system.

• WHO: HTA refers to the systematic evaluation of properties, effects, and/or impacts of health technology. It is a multidisciplinary process to evaluate the social, economic, organizational and ethical issues of a health intervention or health technology.

• INAHTA: HTA is the systematic evaluation of the properties and effects of a health technology, addressing the direct and intended effects of this technology, as well as its indirect and unintended consequences.

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CADTH Dialysis Health Technology Assessment (HTA)

• To inform policy questions regarding the optimal treatment for eligible patients and effective methods of implementation support for the various dialysis options for the treatment of ESKD.

• Reviewed through an assessment of: • clinical effectiveness • cost-effectiveness • patient experiences and perspectives • ethical issues • implementation issues

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Policy Questions

• What is the optimal use, including patient selection and methods of implementation, of self-care or assisted home dialysis (HD or PD) and self-care in-centre HD?

• What strategies could effectively be used to enhance

implementation of self-care or assisted home dialysis (HD or PD) and self-care in-centre HD among eligible patients?

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Implementation

“….the use of strategies to adopt and integrate evidence-based interventions and change practice within specific settings.”

Dissemination and Implementation Science. National Institutes of Health.

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Research questions

• What strategies and processes have been used to implement home-based and self-care in-centre dialysis programs for eligible patients with ESKD?

• What contextual factors contribute to the implementation of

home-based and self-care dialysis programs for eligible patients with ESKD?

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Methods – review

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• Stakeholder Survey • Dialysis program professionals • Nephrologists

• Nesrallah et al (2013)

• Targeted Literature Search • Searched and included Canadian literature only (2000-present)

• Consultations with experts

Implementation of home dialysis (HD or PD) and self-care in-centre HD

• Strategies

• Barriers and Facilitators

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INTEGRATE-HTA Framework

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PFADENHAUER, L., et al (2016) Guidance for the Assessment of Context and Implementation in Health Technology Assessments (HTA) and Systematic Reviews of Complex Interventions: The Context and Implementation of Complex Interventions (CICI) Framework [Online]. Available from: http://www.integrate-hta.eu/downloads/

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What we learned: • Availability of treatment options in Canada is not uniform

• Infrastructure requirements must be in place to support

home-based and self-care modalities

• Facilitators and challenges for remote dialysis (as reported by dialysis stakeholders)

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Purpose of Implementation Reviews (separate chapter in the HTA) 1. To inform HTERP deliberations by bringing attention to

issues that may impact on the implementation of a recommendation

2. To help CADTH customers to implement recommendations developed by HTERP

– To inform dissemination and implementation support strategy for all customers (policy, clinicians, patients)

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Recommendation FOR ESKD PATIENTS DEEMED ELIGIBLE FOR HOME THERAPIES

BY THEIR CARE PROVIDER:

HTERP recommends self-care home-based dialysis in patients diagnosed with end-stage kidney disease, either with home hemodialysis or peritoneal dialysis.

Key Messages

• For patients diagnosed with end-stage kidney disease (ESKD) deemed eligible for home therapies by their care provider, self-care home-based dialysis either with home hemodialysis (HHD) or peritoneal dialysis (PD) is recommended.

• Patient eligibility, available capacity, reimbursement, patient preference, awareness and education about dialysis modalities and quality of life considerations should be considered prior to treatment assignment.

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Implementation Focus

• Education to appropriately address existing knowledge

gaps at various levels of health care decision-making (policy, health administration, medical staff, patients, caregivers)

• Facilitate sharing of successful strategies already underway across Canada.

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Implementation Strategy

Brokering

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Collaborations Leadership

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KM Tools/Activities underway •Project In Brief; Evidence Highlights with “Bottom Line” messages

•Planning webinar for nurses in SK

•Exploring opportunities for a national webinar

•Exploring opportunities for implementation support in PEI

•CMAJ Quizzes; Hospital News Article

•Conference Abstracts

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Strategic partnerships with Canadian networks and partners

• Kidney Foundation of Canada

» Knowledge Translation Committee » Educational tools for providers and patients

• Canadian Society of Nephrology

• Provincial Renal Networks (e.g. ORN, BC Renal Agency)

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Summary and considerations • A review of implementation considerations added a much

needed “context” aspect to the HTA and complemented all other HTA review sections.

– HTERP recommendation; KM strategy for implementation support

• Consultation; literature review; surveys and interviews (as required)

• Do we know what to ask of our experts? What do we want to know?

• Are other methods appropriate? 27

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cadth.ca/dialysis

Dr. Mike Evans https://www.youtube.com/watch?v=mi34xCfmLhw

Next Steps • Indigenous/Rural and Remote

• Business Case offerings?

• INTEGRATE HTA: “this is what we found in your jurisdiction” Then

expand. Target stakeholders from each domain in each province of interest? Identify, prioritize.

•Reinforce messaging with emphasis on economics, ethics and patient perspectives?

•Working with ORN to develop messaging

•Annual conference Kidney Talks (sharing other provinces’ status)

•Complement what already exists

•International aspect – what can we learn from other countries?

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