LAUSR

Home dialysis has been shown to deliver both survival and quality-of-life benefits to patients (1–3). In this issue, we learn that African American and Hispanic patients utilize home dialysis therapies less frequently than patients from other races and that this holds true throughout the United States (4). Is this disparity justified by the health circumstances of these patients or is this another example of racial inequality in access to high-quality healthcare? African American patients in the US are less likely to use high-quality dialysis units than their Caucasian counterparts despite living closer to those high-quality units (5), are less likely to receive a deceased or living donor kidney transplant (6), and are more likely to dialyze in units with worse than expected survival outcomes (7). About 1 in 8 dialysis units in the US offers home hemodialysis and 45% offer peritoneal dialysis (PD) (8). Units without home dialysis programs are disproportionately used by African American and Hispanic patients. Presumably, accessing good-quality information, encouragement, and support for home dialysis is much harder if it is not available where you receive treatment 3 times per week. Wallace and colleagues suggest there is no good evidence of differential outcomes by race with the use of home dialysis which leads to the conclusion that this variation in use is “preference sensitive,” as Wennberg describes it in his Dartmouth Atlas and multiple publications (9). There are well described factors associated with the uptake of home therapies such as education level, home environment, having a spouse, level of patient activation, and coping style (10,11). These all focus on characteristics of individual patients, and it could simply be said that these are unmodifiable aspects of the patient group that, as they are more often found among African American and Hispanic patients, may explain the lower utilization of home dialysis. However, some centers that have a built-in additional support infrastructure are able to overcome these potential barriers and deliver home therapies to patients with these characteristics. There are also many modifiable factors at play in determining the type of dialysis treatment patients receive. At the level of the individual patient, these are broadly targeted by patient education. Patient decision aids are gaining momentum in assisting patients to make an informed choice about which treatment they prefer and ensuring they end up receiving it (12,13). Sadly, patients often still perceive they have not been allowed to make their own choice about treatment (14). Providing education inside patients’ own homes has been associated with higher uptake of home dialysis in the UK (15). Taking part in education within their own homes was associated with higher rates of living donor kidney transplantation in a recent study (16) of African American patients, and so it is conceivable this may apply to home dialysis also. At a renal center level it has been suggested that various modifiable aspects of care delivery can influence the rate of home dialysis use. An efficient service for PD catheter insertion (17,18) and the use of acute PD for unplanned starts on dialysis have been seen to result in more patients receiving home dialysis (18,19). Providing home visits to patients once they are using PD was also shown to encourage patients to choose this treatment (18). Physician enthusiasm for home dialysis has been shown to be among the strongest determinants of the rate of home dialysis use by the patients they care for (18). This physiciangenerated variation in care has also been seen with rates of tonsillectomy (20) and carotid endarterectomy (21), amongst others, and is clearly modifiable. One facet of physician enthusiasm is the level of training physicians have received in home therapies and the degree of confidence gained to provide high-quality care in this area (22). Wallace et al. have shown in their paper that the lower uptake of home dialysis amongst African American and Hispanic patients is present in almost all states in the US and the effect of individual physician enthusiasm is therefore not seen here (4). Recent physician payment reforms have been associated with a reduction in home hemodialysis use, particularly in high-volume dialysis units, where African American/Hispanic patients are more likely to dialyze, as in-center hemodialysis becomes more lucrative (23). It may be this type of driver which results in the nationwide underrepresentation of African American/Hispanic patients on home hemodialysis. Payment reforms for PD have resulted in a financial incentive for these therapies, however, so this does not explain lower rates of PD. Health service level determinants of variation in home dialysis use such as insurance arrangements (24) and expected patient contributions toward care are also likely to disproportionately affect African American and Hispanic patients, who are more likely to have lower socioeconomic status and no private medical insurance (25). This has been shown in New Zealand (26), where reforms in insurance and co-pay arrangements are being implemented to minimize the disparity in home dialysis use associated with socioeconomic status. Insurance status may also affect the ability of an individual to perform home HD, as even though all types of dialysis are