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Original Investigation
September 9, 2019

Trends Associated With Large-scale Expansion of Peritoneal Dialysis Within an Integrated Care Delivery Model

Author Affiliations
  • 1Regional Nephrology Service Line, The Permanente Medical Group, Oakland, California
  • 2Department of Nephrology, Kaiser Permanente Oakland Medical Center, Oakland, California
  • 3Division of Research, Kaiser Permanente Northern California, Oakland
  • 4Department of Nephrology, Kaiser Permanente Hayward Medical Center, Hayward, California
  • 5Department of Nephrology, Kaiser Permanente Santa Clara Medical Center, Santa Clara, California
  • 6Regional Renal Services, Kaiser Permanente Northern California, Oakland
  • 7Department of Nephrology, Kaiser Permanente San Francisco Medical Center, San Francisco, California
  • 8Department of Epidemiology and Biostatistics, University of California, San Francisco
  • 9Department of Medicine, University of California, San Francisco
  • 10Department of Medicine (Nephrology) and Health Research and Policy, Stanford University School of Medicine, Stanford, California
JAMA Intern Med. Published online September 9, 2019. doi:10.1001/jamainternmed.2019.3155
Key Points

Question  What are the feasibility and outcomes of a system-level approach to expand the use of peritoneal dialysis as the preferred initial modality for advanced kidney disease?

Findings  This cohort study of 13 500 eligible patients describes a large-scale program implemented within an integrated health care delivery system that was followed by an increase in the proportion of new peritoneal dialysis initiation from 15.2% to 33.8% among patients starting dialysis during an 11-year period that was substantially higher than national rates. In addition, 331 of 394 patients (84.2%) who started peritoneal dialysis in 2017 were still receiving it at 1 year.

Meaning  Large-scale expansion of peritoneal dialysis for advanced kidney disease appears to be feasible through a coordinated, integrated health care delivery framework that applies a multidisciplinary system-level approach.


Importance  Despite favorable national trends in the incidence of end-stage renal disease (ESRD) from 2008 to 2011, ESRD incidence has been increasing recently, and less than 10% of patients with ESRD start renal replacement therapy with peritoneal dialysis (PD) in the United States. Given known and potential advantages of PD over hemodialysis, the Kaiser Permanente Northern California integrated health care delivery system implemented a program to expand use of PD.

Objectives  To describe the system-level approach to expansion of PD use and temporal trends in initiation and persistence of PD and its associated mortality.

Design, Setting, and Participants  This retrospective cohort study included adult members of a large integrated health care delivery system in Northern California who initiated chronic dialysis therapy from January 1, 2008, through December 31, 2018. Data were analyzed from March 1, 2018, through May 31, 2019.

Exposure  From 2008 to 2018, Kaiser Permanente Northern California implemented a multidisciplinary, system-wide approach to increase use of PD that included patient and caregiver education, education and support tools for health care professionals, streamlined system-level processes, monitoring, and continuous quality improvement.

Main Outcomes and Measures  Temporal trends in the proportion of patients starting chronic dialysis with PD vs hemodialysis compared with national trends. Secondary outcomes included persistence of PD at 1 year in those initiating it and standardized 1-year mortality rates in those initiating PD or hemodialysis.

Results  Among 13 500 eligible health plan members in the study population (7840 men [58.1%] and 5660 women [41.9%]; mean [SD] age, 64.3 [14.4] years), initiation of PD increased from 165 of 1089 all new dialysis patients (15.2%) in 2008 to 486 of 1438 (33.8%) in 2018, which was substantially higher than national trends (6.1% in 2008 and 9.7% in 2016). Among the 2974 patients who initiated PD from 2008 to 2017, 2387 (80.3%) continued PD at 1 year after initiation, with a significant increase in age-, sex-, and race-standardized rates from 2008 (69.1%) to 2017 (84.2%). Age-, sex-, and race-standardized 1-year mortality for patients receiving PD and hemodialysis did not change significantly across this 10-year period (17.3% to 15.5% for hemodialysis, P = 0.89 for trend; and 5.5% to 7.3% for PD, P = 0.12 for trend).

Conclusions and Relevance  This study suggests that large-scale expansion of PD is feasible using a multidisciplinary, integrated, coordinated care approach; we believe these findings represent a national opportunity to improve outcomes for patients with advanced kidney disease.

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