FP672BEYOND COMORBIDITY RELATED BARRIERS: FACTORS TO LIMIT THE ACCESS TO RRT MODALITIES AND CONSERVATIVE CARE

Abstract

Introduction and Aims: Large international differences existin the access to dialysis, kidney transplantation and conservative care for patients with end-stage kidney disease (ESKD). Unfortunately, a number of patients with ESKD may not receive their most suitable treatment. So far, comorbidity related barriers to receive the most suitable treatment have been studied extensively and include for instance patient size, cardiovascular status and manual dexterity. We aimed for the first time to provide a systematic overview of other patient (not comorbidity-related) barriers, healthcare professional related barriers and health system related barriers as experienced by neph-rologists when attempting to provide the most suitable treatment (i.e. different types of dialysis, kidney transplantation and conservative care) to adult patients with ESKD. Methods: Systematic literature search was performedin EMBASE and Medline in June 2017. Publications that represented original research published between 2010 and June 2017, used a quantitative or qualitative cross-sectional design (surveys, interviews or focus groups) and reported other than comorbidity related barriers experienced by nephrologists when providing renal replacement therapy (RRT) or conservative care for adult patients with ESKD were included. All retrieved abstracts were reviewed independently by two authors. Results: Of the 4965 articles screened, 13 articles met the inclusion criteria and provided information on barriers for home haemodialysis (home HD, n=4), peritoneal dialysis (PD, n=3), home HD as well as PD (n=3) kidney transplantation (n=1) and conservative care (n=2). Methodology used consisted of surveys (n=8), focus groups (n=1) and interviews (n=4). Sample sizes varied between 13 and 431 respondents. Most studies were performed in high-income countries. Inadequate (pre-dialysis) education and inadequate funding were reported as barriers for all four modalities. Reported barriers mentioned for home HD, PD as well as conservative care were lack of experience and training for nephrologists, lack of confidence in discussing the treatment option, difficulty in identifying suitable patients and lack of evidence on outcomes. Reported barriers for both PD and home HD included competing alternative programs and easy access to center haemodialysis, lack of skilled staff, fear of complica-tions and therapy specific problems (i.e. with training facilities or PD-catheter placement). Barriers specifically reported for home HD consisted of unsuitable living circumstances (e.g. housing) and demographics, and concerns about burdening patients and carers. Lack of social support was a barrier for both PD and kidney transplantation. Conclusions: This systematic review identified other than comorbidity related barriers as experienced by nephrologists related to education, personal beliefs, reimbursement and practical issues which may limit the access to RRT modalities and conservative care. This overview may help in developing successful interventions aiming to improve access to specific treatment modalities for patients with ESKD.