Peritoneal dialysis (PD) was developed in the 1920s as a therapy for patients with acute kidney failure. It was introduced as a therapy for kidney failure in the 1970s, and by the 1980s, PD was routine and expected to reverse trends in in-center and home hemodialysis treatment.1 However, PD remains a minority modality in the United States. Policy efforts to increase PD utilization have been met with tepid response, which highlights important considerations in current initiatives to promote a patient-centered (i.e., aligning with clinical appropriateness, patient's capacity and preferences) and value-based (i.e., less costly care that improves health) transformation of kidney care.

As primary payer for most patients with kidney failure, the Centers for Medicare & Medicaid Services is in the best position to encourage the adoption of PD. In 1983, Medicare waived the 3-month enrollment period for patients initiating home dialysis and instituted a two-part payment for dialysis: (1) modality-agnostic prospective payment, on the basis of a composite of PD and in-center hemodialysis operating costs furnished to dialysis facilities and (2) fee-for-service payment for drugs and ancillary services. With lower operating costs for PD, the composite system was intended to favor PD. But with the rise of industrialized, profit-driven efficiencies in hemodialysis practice and pharmaceutical innovations, this reimbursement structure favored hemodialysis (e.g., drugs more frequently used among patients on hemodialysis, limited reimbursement for PD training). Over time, patient PD utilization and dialysis facility PD service offerings diminished.2,3 Medicare further revised reimbursement in 2011 by bundling dialysis, medications, and ancillary services into a single payment and providing an add-on payment for home dialysis training. Observational studies detected modest nudges in dialysis facility supply and PD uptake in the years leading up to and after passage of bundled payment.4

More recently, the US Department of Health and Human Services oversees efforts in the 2019 Advancing American Kidney Health Initiative to improve outcomes at lower cost for Americans with kidney disease,5 including investment in kidney care innovations (e.g., KidneyX) and Medicare payment reforms (e.g., ESRD Seamless Care Organizations, Kidney Care Choices Model, and ESRD Treatment Choices Model). Payment reform initiatives seek to enhance patient access and the quality of patient-centered treatment options and to reduce costs through increased use of home dialysis or transplantation. With ongoing development of innovations such as wearable kidneys, biomedical materials, and equipment (i.e., home hemodialysis6), and the time required for subsequent implementation and routine use, there is renewed hope in greater utilization of PD.

In many ways, achieving patient-centered and value-based care through PD expansion may be low-hanging fruit that aligns with what proponents of PD have long endorsed. Data from patient-reported preference and dialysis outcomes studies indicate positive associations between PD and treatment preference (if offered), physical function, autonomy, and satisfaction—factors that may improve quality of life. Self-treatment confers logistical flexibilities for patients to maintain employment and travel and may thus appeal to working age and rural/remote-dwelling patients, for whom thrice-weekly in-center hemodialysis treatments are restrictive. Clinically, PD is physiologically gentler and generally no different than for hemodialysis (e.g., infection) in the short term; however, safety remains a concern in the long term (e.g., undertreated fluid overload, metabolic effects, or breakdown of the peritoneum). As a first-line treatment, PD may preserve residual kidney function and vasculature for later transition to hemodialysis. There are few randomized control trials of PD, and evidence on the comparative effectiveness of PD versus hemodialysis is largely drawn from observational studies that may be confounded by baseline differences between PD and hemodialysis patients (e.g., health status). Contemporary studies, designed to account for bias, show equivalent to better rates of complications (e.g., infection) among patients undergoing PD, fewer dialysis-related hospitalizations, and better rates of survival when PD is used in patients' first years of dialysis compared with hemodialysis. For insurers and health systems, ESRD-related and overall health care spending is lower among patients initiating dialysis with PD. Despite the many reasons for the health care community to be excited about the potential value of PD, history gives us many reasons to pause and consider the challenges in realizing these goals.

Trends belie the evidence and promise of PD because adoption of PD has floundered in the United States7 and in contrast to the classic S-shaped curve of innovation diffusion (Figure 1) and the higher rates of PD use in other developed countries7 (with markedly different health system structures). PD is not clinically suitable for all patients, but data indicate that PD is appropriate for more patients than is reflected in current utilization rates. Previous research evaluating predialysis education and patient decision making suggests many patients prefer PD but also that many patients do not recall being informed of their treatment options by clinicians.

Figure 1:

Trends in PD utilization in the United States, by year. According to diffusion of innovations theory, cumulative adoption of PD would ideally follow an S-shaped curve shown in the blue dotted line, reflecting initially slow and subsequent faster adoption as the number of adopted or incident users increase, and eventually reaching a plateau. Actual utilization of PD shown in the solid red line does not follow the typical innovation trajectory. Policy initiatives enacted in 1983 and 2011 to alter dialysis facility payments intended to encourage greater PD utilization have resulted in modest impacts. Data Source: United States Renal Data System Annual Data Reports 2012, 2022. FFS, fee for service; PD, peritoneal dialysis PPS, prospective payment system.

Furthermore, there has been a failure to offer PD to all patients appropriate for it. Racial disparities have been reported, and PD prevalence remains consistently unequal between race groups.7,8 Lower PD use and higher technique failure persist among patients bearing socioeconomic characteristics of disadvantage, including patients with language barriers, Medicaid–Medicare insurance coverage, and rural patients with limited access to facilities offering PD.8 Payment reforms have not worsened these geographic, socioeconomic, and racial differences in PD utilization, but it is no surprise that gaps and disparities persist.9,10 Payment models and the newer value-based payment systems were designed to reduce costs and improve health outcomes, not necessarily to promote equitable PD use. Payment alone has been an inadequate lever to increase utilization of PD.

There is reason to be skeptical about efforts in payment reform to foment reversal of trends in PD in the United States. Greater investment in evidence-based policies and practices is needed to set the stage for realizing value through PD expansion. This begins with a focus on preconditions for PD utilization, which include better predialysis education and awareness, development of disease surveillance and protocols to better and more equitably identify patients eligible for PD, peer-learning programs to enhance self-efficacy, and annual patient–provider assessment of kidney failure treatment plans and options. These efforts stand a greater chance at promoting PD adoption when initially applied in areas with greatest demand and adequate supply to support broad PD use. Optimizing the value of PD also includes patients' sustained use of PD. With roughly one in five PD patients converting to in-center hemodialysis in the initial years of dialysis,4,7 efforts to prevent PD attrition are critical. Establishment of provider-assisted telehealth and home visits (i.e., assisted PD); continuing education and home dialysis support systems for clinicians, patients, and caregivers; and patient peer mentoring networks could provide timely education and support to people with urgent clinical needs and limited social resources to combat inequities in attrition. Underlying these approaches, it will be essential to improve data collection of patient characteristics, including social determinants of health, to enhance identification of patients suitable for PD and patient–provider shared decision making on treatment decisions. Altogether, these approaches focus on clinical and social factors of PD utilization for all patients and may, in turn, address the racial and sociodemographic disparities in PD we observe today.

To hold health care professionals and organizations accountable for informed decision making and patient education/access to PD therapies, explicitly tying payment to actionable performance metrics on provider practices related to increasing and sustaining PD use (e.g., in-center Consumer Assessment of Healthcare Providers and Systems [CAHPS] survey items regarding education counseling and discussions about treatment options with dialysis clinic staff) might encourage investment in the infrastructure and practices necessary for PD expansion and, more broadly, deliver better kidney disease management and high-value care to all communities. Finally, understanding the contexts in which current successful and equitable PD programs operate provides opportunities for shared learning to lift all boats in efforts to increase PD and home dialysis utilization, in general. Achieving value in kidney care—care that is patient-centered, less expensive, and optimizes patient outcomes—necessitates restructuring traditional delivery of care for patients with kidney failure and renders value-based payment an important opportunity to reset the future for PD.

Disclosures

V. Wang reports employment with Durham VA Health Care System and research grants and funding from AHRQ, NHLBI, NIDDK, PCORI, Robert Wood Johnson Foundation, and the Department of Veterans Affairs.

Funding

V. Wang: Durham Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT) at the Durham VA Health Care System (CIN 13-410).

Acknowledgments

The author is grateful to Dr. Jenny Flythe and the anonymous reviewers for helpful comments on this manuscript. The information and opinions reported here is the responsibility of the author and in no way should be seen as official policy or interpretation of the US Department of Veterans Affairs or Duke University. This is dedicated to the memory of Celeste Castillo Lee. The content of this article reflects the personal experience and views of the author and should not be considered medical advice or recommendation. The content does not reflect the views or opinions of the American Society of Nephrology (ASN) or CJASN. Responsibility for the information and views expressed herein lies entirely with the author.

Author Contributions

Conceptualization: Virginia Wang.

Data curation: Virginia Wang.

Resources: Virginia Wang.

Visualization: Virginia Wang.

Writing – original draft: Virginia Wang.

Writing – review & editing: Virginia Wang.

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