Home Dialysis Training Needs for Fellows: A Survey of Nephrology Program Directors and Division Chiefs in the United States

The Advancing American Kidney Health initiative aims to substantially increase home dialysis utilization in the United States.1Mehrotra R. Advancing American Kidney Health: an introduction.Clin J Am Soc Nephrol. 2019; 14: 1788Crossref PubMed Scopus (38) Google Scholar To align with this goal, the American Society of Nephrology (ASN) convened a Home Dialysis Task Force to improve home dialysis education and advocate for policies that improve modality choice.2List of Home Dialysis Task Force MembersAmerican Society of Nephrology Excellence in Patient Care.https://epc.asn-online.org/projects/hdp/home-dialysis-membership/Date accessed: September 7, 2022Google Scholar As a first step, the Task Force surveyed nephrology fellowship programs to evaluate the following: (1) the current landscape of fellowship training in home dialysis, (2) perceptions of the minimum amount of home dialysis training fellows should receive, and (3) additional resources ASN should create to support home dialysis training. We created 2 distinct surveys—one each for program directors and division chiefs (Item S1 and Item S2)—using themes derived from literature review3Berns J.S. A survey-based evaluation of self-perceived competency after nephrology fellowship training.Clin J Am Soc Nephrol. 2010; 5: 490-496Crossref PubMed Scopus (127) Google Scholar, 4Rope R.W. Pivert K.A. Parker M.G. Sozio S.M. Merell S.B. Education in nephrology fellowship: a survey-based needs assessment.J Am Soc Nephrol. 2017; 28: 1983-1990Crossref PubMed Scopus (55) Google Scholar, 5Gupta N. Miller B.W. Training nephrology fellows in home dialysis in the United States.Clin J Am Soc Nephrol. 2021; 16: 1749-1751Crossref PubMed Scopus (3) Google Scholar and the 2020 ASN Home Dialysis Focus Group. Surveys asked participants to describe the following: (1) whether fellows could practice home dialysis independently on graduation and (2) the amount of home dialysis training fellows should receive (quantitatively defined as the number of clinic sessions attended and patients seen, based on expert opinion). Program directors were asked to describe the home dialysis training resources they used and training resources they wanted ASN to create. Division chiefs were asked to rank the value of different training resources on a scale of 1-5 (with 1 being the least important). Before dissemination, we revised the surveys through an iterative process involving feedback from the ASN’s Workforce and Training Committee and the ASN’s Data Subcommittee. To improve response rates, the surveys were revised to be brief, that is, they did not capture demographic data or determine the home dialysis competencies that should be achieved during training. We distributed the survey through REDCap on March 4, 2022, to program directors and division chiefs listed in ASN’s database, sent 2 reminders (on March 14 and 23), and closed the survey on April 5, 2022.6Harris P.A. Taylor R. Thielke R. Payne J. Gonzalez N. Conde J.G. Research Electronic Data Capture (REDCap)—a metadata-driven methodology and workflow process for providing translational research informatics support.J Biomed Inform. 2009; 42: 377-381Crossref PubMed Scopus (26546) Google Scholar Consent was waived, and the University of Pennsylvania institutional review board deemed this study exempt (protocol #849893). The surveys followed the American Association for Public Opinion Research reporting guidelines for survey studies.7Best Practices for Survey Research. American Association for Public Opinion Research.https://www.aapor.org/Standards-Ethics/Best-Practices.aspxDate accessed: September 7, 2022Google Scholar Forty-three program directors and 31 division chiefs responded to the surveys (response rates: 27% and 18%, respectively). Tables S1 and S2 list respondent demographics, overall and stratified by program size (<4 or ≥4 fellows per year). Only 72% and 30% of program directors reported that, on graduation, every fellow in their fellowship program could provide peritoneal dialysis and home hemodialysis without supervision, respectively. When asked about the minimum training fellows should receive in peritoneal dialysis, the most common answers were 10-12 clinic sessions (53% of program directors and 35% of division chiefs) and 11-15 patients (33% of program directors and 29% of division chiefs). When asked about the minimum training fellows should receive in home hemodialysis, the most common answers were 10-12 clinic sessions (56% of program directors), <4 clinic sessions (26% of division chiefs), and 3-5 patients (30% of program directors and 26% of division chiefs). Seventy-four percent of the program directors requested a virtual home dialysis mentorship program. Only 12% requested assistance with coordinating home dialysis rotations outside their institution. For additional details, see Table 1, Table S3, and Item S3.Table 1Survey Responses: Home Dialysis Training in Adult Nephrology Fellowship Programs (n=74)Survey QuestionProgram Directors (n=43)Division Chiefs (n=31)On graduation, how many of your fellows can provide home dialysis without supervision?Peritoneal dialysis, n (%) All31 (72)22 (71) Most8 (19)6 (19) Some4 (9)3 (10)Home hemodialysis, n (%) All13 (30)14 (45) Most14 (33)6 (19) Some12 (28)5 (16) None3 (7)6 (19) Missing1 (2)0 (0)What is the minimum number of patients receiving home dialysis that a fellow should see before they can provide home dialysis without supervision?Peritoneal dialysis, n (%) 3-54 (9)2 (6) 6-1010 (23)3 (10) 11-1514 (33)9 (29) 16-208 (19)5 (16) 21-301 (2)7 (23) >306 (14)5 (16)Home hemodialysis, n (%) 1-21 (2)6 (19) 3-513 (30)8 (26) 6-1012 (28)6 (19) 11-1510 (23)6 (19) 16-203 (7)1 (3) 21-302 (5)1 (3) >302 (5)3 (10)How many home dialysis clinics should a fellow attend before they can provide home dialysis without supervision?Peritoneal dialysis, n (%) <42 (5)1 (3) 4-63 (7)6 (19) 7-94 (9)3 (10) 10-1223 (53)11 (35) 13-183 (7)5 (16) 19-246 (14)2 (6) >242 (5)3 (10)Home hemodialysis, n (%) <43 (7)8 (26) 4-65 (12)5 (16) 7-93 (7)4 (13) 10-1224 (56)7 (23) 13-183 (7)3 (10) 19-244 (9)1 (3) >241 (2)3 (10)Does your program use any of the following resources? n (%) Home dialysis rotation within the program36 (84) National home dialysis conference23 (53) Home dialysis rotation at an outside academic or private practice setting5 (12)Would your program want ASN to facilitate the creation of the following training resources? n (%) Home dialysis rotation at an outside academic/private practice setting5 (12) Year-long virtual case-based home dialysis mentorship program32 (74)Division chief’s perspective on the value of home dialysis resourcesaDivision chiefs rated each training resource on a scale of 1-5, with 1 meaning it had no influence and 5 meaning it had a major influence on whether the division chief would hire a graduating fellow to practice home dialysis. (Median [IQR]) National home dialysis conference (eg, Home Dialysis University, Home Dialysis Academy of Excellence)-3 (3-4) Year-long virtual case-based home dialysis mentorship program-3 (3-4) 1-month rotation at a large home dialysis program-4 (3-4) 3-month rotation at a large home dialysis program-4 (3-5) Additional year of home dialysis training (ie, a dedicated home dialysis fellowship)-4 (3-5)Abbreviations: ASN, American Society of Nephrology; IQR, interquartile range.a Division chiefs rated each training resource on a scale of 1-5, with 1 meaning it had no influence and 5 meaning it had a major influence on whether the division chief would hire a graduating fellow to practice home dialysis. Open table in a new tab Abbreviations: ASN, American Society of Nephrology; IQR, interquartile range. There were 3 main findings, which are as follows. First, 70% of surveyed program directors reported that their program graduated fellows who could not provide home hemodialysis without supervision, marking the need to drastically reform fellowship training. Second, although there was no clear consensus regarding the ideal amount of home dialysis training, collectively, fellows who attended 10-12 peritoneal dialysis clinic sessions met or exceeded the expectations of 74% and 67% of surveyed program directors and division chiefs, respectively (Fig 1). Similarly, fellows who attended 10-12 home hemodialysis clinic sessions met or exceeded the expectations of 82% and 78% of surveyed program directors and division chiefs, respectively. Finally, most program directors desired longitudinal home dialysis mentorship programs; these results informed ASN’s decision to support a new longitudinal home dialysis virtual mentorship program in 2023. Although this study sought to establish a minimum quantity of home dialysis training for fellows, quantity alone does not ensure competency. Future research should evaluate whether raising the minimum amount of training to 10-12 clinic sessions improves attainment of core competencies in home dialysis, such as the management of fungal peritonitis and catheter dysfunction. Other survey limitations include the low response rates, although these response rates are higher than recently published ASN surveys.8Alvarado F. Crews D.C. Delgado C. Neyra J.A. International medical graduates in nephrology: impressions of the implications of visa status in a cohort of program directors and division chiefs.Kidney Med. 2021; 3: 451-453Abstract Full Text Full Text PDF PubMed Scopus (2) Google Scholar In conclusion, most surveyed fellowship programs: (1) are unable to provide adequate home hemodialysis training, (2) felt that graduating fellows who attend 10-12 home dialysis clinic sessions could provide home dialysis without supervision, and (3) desire a virtual case-based home dialysis mentorship program. The United States needs a major restructuring of home dialysis education; as a first step, the ASN Home Dialysis Task Force recommends increasing the “floor” of fellowship home dialysis training to 10-12 clinic sessions, while prospectively evaluating whether this change improves training in the core competencies of home dialysis. Study concept: YNVR, JP, EG; study design: YNVR, JSB, SB, JFS, RM; data acquisition: YNVR, MJ, RM; data analysis/interpretation: all authors; statistical analysis: YNVR. Each author contributed important intellectual content during manuscript drafting or revision and accepts accountability for the overall work by ensuring that questions pertaining to the accuracy or integrity of any portion of the work are appropriately investigated and resolved. Research reported in this publication was supported by the Agency for Healthcare Research & Quality under Award K12HS026372 supporting Dr Reddy. The funders of this study had no role in study design; collection, analysis, and interpretation of data; writing the report; or the decision to submit the report for publication. The authors declare that they have no relevant financial interests. The authors would like to acknowledge the American Society of Nephrology for their support in creating the American Society of Nephrology Home Dialysis Task Force’s Training and Fellowship Workgroup. The authors would also like to acknowledge Drs Christopher Chan, Janice Lea, Eric Wallace, and Suzanne Watnick, who serve on the American Society of Nephrology’s Home Dialysis Task Force. This content is solely the responsibility of the authors and does not necessarily represent the official views of the Agency for Healthcare Research & Quality. Received November 2, 2022, as a submission to the expedited consideration track with 3 external peer reviews. Direct editorial input from the Editor-in-Chief. Accepted in revised form January 17, 2023. Download .pdf (.31 MB) Help with pdf files Supplementary File (PDF)Items S1-S3, Tables S1-S3.