Longer and better lives for patients ... and their centers: a strategy for building a home hemodialysis program

Physicians should prescribe the dialysis mode most likely to result in the best outcome for the end-stage renal disease patient, not leave it to the patient or dialysis center to choose. That prescription, in order of decreasing desirability, should be for frequent home nocturnal hemodialysis, frequent home short-daily, or least efficacious, 3x in-center or peritoneal dialysis. Patient limitations may require prescribing a less than optimal mode. Physician-patient discussions should focus on expected clinical outcomes and health benefits, not patient convenience or "lifestyle." In order to overcome natural fears, qualified patients should participate in a short in-center frequent dialysis personal clinical trial to experience the benefits. The financial health of dialysis centers will be enhanced by shifting continually inflating labor costs from the center to patients and home caregivers. This shift from 3x in-center to frequent (optimally 6x nocturnal) home dialysis may reasonably be expected to enhance the survival and well-being of both the patient and the center.