title: Programmatic variation in home hemodialysis in Canada: results from a nationwide survey of practice patterns.
abstract: BACKGROUND
  Over 40% of patients with end stage renal disease in the United States were treated with home hemodialysis (HHD) in the early 1970's. However, this number declined rapidly over the ensuing decades so that the overwhelming majority of patients were treated in-centre 3 times per week on a 3-4 hour schedule. Poor outcomes for patients treated in this fashion led to a renewed interest in home hemodialysis, with more intensive dialysis schedules including short daily (SDHD) and nocturnal (NHD). The relative infancy of these treatment schedules means that there is a paucity of data on 'how to do it'.
  
  
  OBJECTIVE
  We undertook a systematic survey of home hemodialysis programs in Canada to describe current practice patterns.
  
  
  METHODS
  Development and deployment of a qualitative survey instrument.
  
  
  METHODS
  Community and academic HHD programs in Canada.
  
  
  METHODS
  Physicians, nurses and technologists.
  
  
  METHODS
  Programmatic approaches to patient selection, delivery of dialysis, human resources available, and follow up.
  
  
  METHODS
  We developed the survey instrument in three phases. A focus group of Canadian nephrologists with expertise in NHD or SDHD discussed the scope the study and wrote questions on 11 domains. Three nephrologists familiar with all aspects of HHD delivery reviewed this for content validity, followed by further feedback from the whole group. Multidisciplinary teams at three sites pretested the survey and further suggestions were incorporated. In July 2010 we distributed the survey electronically to all renal programs known to offer HHD according to the Canadian Organ Replacement Registry. We compiled the survey results using qualitative and quantitative methods, as appropriate.
  
  
  RESULTS
  Of the academic and community programs that were invited to participate, 80% and 63%, respectively, completed the survey. We observed wide variation in programmatic approaches to patient recruitment, human resources, equipment, water, vascular access, patient training, dialysis prescription, home requirements, patient follow up, medications, and the approach to non-adherent patients.
  
  
  CONCLUSIONS
  Cross-sectional survey, unable to link variation to outcomes. Competition for patients between HHD and home peritoneal dialysis means that case mix for HHD may also vary between centres.
  
  
  CONCLUSIONS
  There is wide variation between programs in all domains of HHD delivery in Canada. We plan further study of the extent to which differences in approach are related to outcomes.
authors.affiliation: Department of Medicine, Division of Nephrology, Northern Alberta Renal Program and the University of Alberta Hospital, University of Alberta, Edmonton, AB Canada.
authors.forename: Robert P
authors.initials: RP
authors.lastname: Pauly
authors.affiliation: Department of Medicine, Section of Nephrology, University of Manitoba, Winnipeg, MB Canada.
authors.forename: Paul
authors.initials: P
authors.lastname: Komenda
authors.affiliation: University Health Network, University of Toronto, Toronto, ON Canada.
authors.forename: Christopher T
authors.initials: CT
authors.lastname: Chan
authors.affiliation: Division of Nephrology, University of British Columbia, Vancouver General Hospital, Vancouver, BC Canada.
authors.forename: Michael
authors.initials: M
authors.lastname: Copland
authors.affiliation: Department of Medicine, Division of Nephrology, McMaster University, Hamilton, ON Canada.
authors.forename: Azim
authors.initials: A
authors.lastname: Gangji
authors.affiliation: Department of Medicine, Division of Nephrology, Dalhousie University, Halifax, NS Canada.
authors.forename: David
authors.initials: D
authors.lastname: Hirsch
authors.affiliation: Director Home Hemodialysis, London Health Sciences Centre, Western University, London, ON Canada.
authors.forename: Robert
authors.initials: R
authors.lastname: Lindsay
authors.affiliation: Division of Nephrology, Horizon Heath, St John Regional Hospital, St John, NB Canada.
authors.forename: Martin
authors.initials: M
authors.lastname: MacKinnon
authors.affiliation: Department of Medicine and Department of Cardiac Sciences, Division of Nephrology, Southern Alberta Renal Program, University of Calgary, Calgary, AB Canada.
authors.forename: Jennifer M
authors.initials: JM
authors.lastname: MacRae
authors.affiliation: Department of Medicine, Division of Nephrology, St Michaels Hospital, Toronto, ON Canada.
authors.forename: Philip
authors.initials: P
authors.lastname: McFarlane
authors.affiliation: The Li Ka Shing Knowledge Institute, Keenan Research Centre, St Michael's Hospital, and Nephrology Program, Humber River Hospital, Toronto, ON Canada.
authors.forename: Gihad
authors.initials: G
authors.lastname: Nesrallah
authors.affiliation: University of Toronto, Humber River Hospital, Toronto, ON Canada.
authors.forename: Andreas
authors.initials: A
authors.lastname: Pierratos
authors.affiliation: Departement de Medecine, Service de Nephrologie, Centre Hospitalier Universitaire de Sherbrooke, Universite de Sherbrooke, Sherbrooke, QC Canada.
authors.forename: Martin
authors.initials: M
authors.lastname: Plaisance
authors.affiliation: Department of Medicine, Division of Nephrology, Northern Alberta Renal Program and the University of Alberta Hospital, University of Alberta, Edmonton, AB Canada.
authors.forename: Frances
authors.initials: F
authors.lastname: Reintjes
authors.affiliation: Department of Medicine, Division of Nephrology, Hopital du Sacre-Coeur de Montreal, University of Montreal, Montreal, QC Canada.
authors.forename: Jean-Philippe
authors.initials: JP
authors.lastname: Rioux
authors.affiliation: Department of Medicine, Division of Nephrology, Health Science Centre, Memorial University of Newfoundland, St Johns, Newfoundland Canada.
authors.forename: John
authors.initials: J
authors.lastname: Shik
authors.affiliation: Division of Nephrology, Lakeridge Health, Oshawa, ON Canada.
authors.forename: Andrew
authors.initials: A
authors.lastname: Steele
authors.affiliation: Department of Medicine, Division of Nephrology, University of Saskachewan, Saskatoon, Saskatchewan Canada.
authors.forename: Rod
authors.initials: R
authors.lastname: Stryker
authors.affiliation: Division of Nephrology, Trillium Health Partners, Mississauga, ON Canada.
authors.forename: George
authors.initials: G
authors.lastname: Wu
authors.affiliation: Department of Medicine, Division of Nephrology, Ottawa Hospital and the University of Ottawa, Ottawa, ON Canada.
authors.forename: Deborah L
authors.initials: DL
authors.lastname: Zimmerman
keywords: Intensive hemodialysis; Nocturnal; Practice patterns; Short daily; Survey