Empowering Patients: Dr. Graham Abra’s Mission to Expand Home Dialysis
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Graham Abra, MD, is on a mission to optimize access to home dialysis.
The term dialysis frequently brings to mind hours and days sacrificed to sitting in a clinic, hooked up to machinery that does the job of failing kidneys. But many are unaware that home dialysis is available for select patients. Graham Abra, MD, is on a mission to change that. He wants every eligible patient to have the option to dialyze at home, expanding a new frontier in patient care.
Abra is an associate professor of medicine in the Division of Nephrology. With a clinical focus on dialysis care, he has also worked as an administrative physician at Satellite Healthcare, a nonprofit dialysis organization providing services for patients with end-stage kidney disease.
“Many people can thrive and do well on home dialysis,” he says. “Some have more challenges than others in being able to dialyze at home, but that’s part of the job of the clinician – to understand what barriers and challenges might be there and then figure out how to overcome the barriers, to make it a reality for the patient in a safe and effective way. I really love taking care of patients who are on the home modalities. They’re a really nice way to empower people to take on their own care and to really succeed in taking care of their health and taking care of themselves.”
While Stanford has been offering home dialysis for decades, it has taken a long time to fully embrace its benefits, and Abra has worked hard to help overcome the systemic barriers to access, which most affect the socioeconomically disadvantaged. This has included three pillars: education, patient support, and identification of patients who are at high risk of stopping therapy.
“I really love taking care of patients who are on the home modalities. They’re a really nice way to empower people to take on their own care and to really succeed in taking care of their health and taking care of themselves.”
– Graham Abra, MD
Providing Much-Needed Education
Many clinicians need more education on home dialysis than they currently receive to feel comfortable setting it up for their patients. “We piloted a virtual education program on home dialysis, bringing together experts from around the world to lead case-based discussions with learners on home dialysis,” says Abra. “It was a very rich experience that led to a lot of interaction between the learners and the experts in a setting that was different from the classroom.” It was, in fact, so successful that it was picked up as a national program by the American Society of Nephrology, coupled with a long-running live conference called Home Dialysis University. Abra also chairs the Home Dialysis Academy of Excellence, an educational hands-on immersion program created through a collaboration between Stanford Medicine, UC Davis Health, and Satellite Healthcare.
A clinical and patient population that is educated about home dialysis minimizes the risk that patients will be reflexively placed on in-center dialysis without ever fully exploring the at-home option. Once in-center care is established, says Abra, many patients are reluctant to change, even if they are good candidates for home dialysis.
Supporting Patients
With proper training, many patients can dialyze at home without help and achieve the same health and safety outcomes as those who travel to dialysis centers. But some patients, particularly if they are elderly or frail, need help, so Abra helped put together a program that provides trained staff to assist these patients in their homes, either temporarily or permanently, depending on their needs. Abra hopes their success will spearhead greater use of such programs elsewhere in the country.
“There are a number of bills that have been put forth federally to try to provide specific funding for this kind of support because it addresses an important clinical need,” he says. In addition, Abra recently was part of a workgroup for the International Society for Peritoneal Dialysis that released a Position Statement recommending healthcare system funding of assisted peritoneal dialysis to expand the equitable access of the therapy to all patients who wish to receive it.
Identifying High-Risk Patients
To identify patients at high risk of stopping home dialysis, Abra and colleagues ran a simple study in which they asked clinical staff whether they would be surprised if specific patients were to transfer from home- to center-based dialysis. This single question was highly effective at identifying high-risk patients, so that they could then receive the support they needed to continue home dialysis.
Living His Best Life With Home Dialysis
Calvert Polkinda [name changed to protect privacy], a patient of Abra’s, knows exactly what home dialysis can mean for quality of life. Diagnosed in his 30s with an autoimmune disease that attacks his kidneys, he was faced with the specter of dialysis long before most people.
“When it came to that point, I was very emotional,” he says. “After COVID … I wanted to go back to my home country to visit my parents, and I had to stay put. It was an emotional roller coaster. But my friends, my family, my doctors helped me through it.”
Polkinda was extensively educated about dialysis – both at home and in center – before he actually needed it. This left him prepared when the time came, and he found choosing home dialysis a “no-brainer.” But that is not always possible. “We have a situation where 40% to 60% of patients start dialysis acutely in the hospital with very little to no nephrology care,” says Abra. “That’s obviously a medical emergency. But it’s also an educational emergency because they haven’t had the advantage of a relationship with a nephrologist or the luxury of the time, the space to talk about their options.”
If home dialysis were not an option, says Polkinda, “it would definitely affect my career. I’m 45. I still have about 40 more years to work. I maintain at least 85% to 95% of an active life [despite dialysis].”
With home dialysis, he says, “I’m not missing anything. I’m not missing my work. I’m not missing my day activities. In the night, I just put [on my dialysis bag] and go to sleep. So, I’m able to enjoy my life.” Every dialysis patient should have that option.
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