USING QI AND PATIENT CO-DESIGN TO IMPROVE HOME DIALYSIS UPTAKE AT TRILLIUM HEALTH PARTNERS

End-stage renal disease (ESRD) represents a significant and growing global health challenge with rates of ESRD steadily increasing worldwide. In Canada, patients predominantly undergo in-center hemodialysis (ICHD); however, home hemodialysis (HHD) has been shown to offer numerous advantages, including better quality of life, improved survival rates, and cost-effectiveness. Despite these benefits, HHD remains underutilized at our center and is an area of focus for improvement in our Province. Trillium Health Partners (THP) is a large tertiary care center in Ontario, Canada. We serve one of the most diverse populations in the country and also function as a community teaching site for medical learners.

We used a quality improvement and patient co-design framework as outlined by the Institute for Healthcare Improvement. This included quantitative and qualitative interviews with patients (n = 30) and providers (n = 27) at THP. Providers included nephrologists (n = 12) and nursing/education staff (n = 15). Patients comprised those who had tried HHD but were unsuccessful (n = 10), those who had never tried HHD (n = 10), and those who were currently on HHD (n = 10). Data and feedback from our patients and providers were used to  identify root causes through a quantitative count and a thematic analysis. Patients’ choice of modality was most affected by their physicians’ recommendations, anxiety around HHD and they often noted feeling overwhelmed. Insufficient home support and resources (83%) and apprehension about learning about new equipment (60%) were also common patient barriers.  Providers noted that patients’ anxiety and concerns around self-care as a barrier to HHD, yet 80% of patients of noted that they would do HHD if their physician suggested it regardless of their apprehension.

Our key interventions included; creation of a new assisted HHD program, re-offering HHD to those who failed or had barriers previously along with the creation of new education program focused on HHD and solutions around barriers. We also had ongoing reminders to physicians and nurses about uptake for HHD and created a new simulation area for dialysis where patients could see and touch materials in a home like setting.

The study period was from Jan 1, 2023 to November, 2025. In 2022 we had 31-32 patients in our HHD program, this was 21-23 in 2023. Our interventions began April 2023 and we now have 46 patients in our HHD program (see table below). The rates of ICHD patients in our program remained stable through this period, reflecting a true growth in our HHD rates and not simply new population growth. 

This study led to an almost 50% increase the rate of HHD at our center, with uptake still showing signs of growth. This work shows the benefit of involving patients and front-line staff when designing a new health system to achieve better outcomes. These methods provide a framework on how to engage and empower patients and providers in developing new health systems.