Two of the several APD options that patients on PD in the United States have are the AMIA and HomeChoice Pro cyclers, both of which are provided in our home dialysis unit. Features that the technologically advanced AMIA cycler provides that are not present in the HomeChoice Pro cycler include animated graphics, touch screen panel, voice guidance, automated instructions and troubleshooting features as well as remote monitoring through Sharesource. The fact that we found that patients on AMIA – despite their shorter PD vintage – had a lower rate of cycler-related issues compared to their HC counterparts, could be testament to the positive effect that these features have on patients’ hands-on troubleshooting and experience with the cycler. However, despite these capabilities, we found no statistically significant difference between it and the HC cycler in terms of PD-related telephone and office encounters, emergency department visits and hospitalizations.
Our findings differ from a previous study by Sanabria et al [2] where after matching remote patient monitoring (RPM) patients with their non-RPM counterparts, they found significantly lower hospitalization rates and number of in-patient hospital days in the RPM group. There was no reason to suspect that there would be any difference in dialysis adequacy achieved in the two groups, and we found it to be similar as was previously shown [3].
In our retrospective cohort, we found that the number of PD training days required were similar between the two groups. This is in contrast to our previous finding that patients being trained on the AMIA cycler required 33% less time than their HC counterparts [3]. A potential confounder in our study is that the HC patients were younger (although not statistically significant) and had been in PD for much longer than their AMIA counterparts. Moreover, the length of PD training required depends on the individual patient and staff member doing the training. The dialysis unit nursing staff performing the patient PD training was the same during the retrospective period.
In the prospective arm, few patients were on HC during the study period – all of which were prevalent patients. For this reason, we chose to focus on surveying those patients, rather than obtaining the same data that we did for the retrospective arm. We found that despite prevalent AMIA patients reporting higher levels of comfort with their cycler, patients’ overall satisfaction was similar for both prevalent AMIA and HC patients. There was also no difference between these two groups in terms of patient-reported troubleshooting issues requiring assistance.
Creating technically sophisticated cyclers may come at the cost of increased cycler-related issues due to glitches in technology and loss of simplicity. This is something that we did not find to be the case in patients’ reported ability to troubleshoot, change settings of and overall satisfaction with the AMIA cycler.
From a clinician’s perspective, the importance of remote patient treatment monitoring should not be undermined. Daily telemonitoring of home dialysis patients has been previously shown to be cost-effective, allows early detection and resolution of issues, improving dialysis compliance and patients’ quality of life [4]. In this study, we did not specifically explore the effect of remote monitoring on our patients’ outcomes. The experiences of providers across the world and the importance of telenephrology with remote monitoring in caring for their PD patients was also demonstrated during the COVID-19 pandemic [5,6,7]. These benefits, of course, do come with challenges. Data security, reduced staff contact, liability associated with delayed review of alarms, absorbing the higher cost, and the acceptance of technology are amongst the challenges that face providers and healthcare systems when incorporating this technology into common practice [8].
Our study has limitations, the most important of which is the small number of participants. The goal of the retrospective cohort was to examine a time period in which the number of patients on AMIA and HC were similar. With most of our new start PD patients using the AMIA cycler since its FDA-approval in 2015, it was expected that the patients’ time on PD prior to the study period in the HC group would be greater than AMIA. Patients’ time on the cycler increases their familiarity with the nuances of the cycler and their level of comfort in troubleshooting any alarms or issues that may arise. This would skew the data in favor of patients on HC. Given that over 85% of the patients in our home dialysis unit use the AMIA cycler nowadays, it was difficult to obtain a comparable number of patients on HC in the prospective cohort, the best way to clearly compare both therapies. Another confounder is that documentation of the number of telephone encounters to the dialysis unit in our data collection did not include direct patients support calls to Baxter technical support line as we did not have access to this information. Instead, we relied on patient recollection to obtain this information.
A direct comparison of AMIA to HC would require a large cohort of patients who have experience with both cyclers for a prolonged period of time, allowing for the assessment of their clinical outcomes, reported experiences and support needs. Unfortunately, this is something that is difficult to achieve. Of note, this study was conducted prior to the FDA’s approval of HomeChoice Claria in November 2020 – a version of the HC cycler which provides connectivity to the Sharesource platform.
As technological advancements continue to drive our society and medicine forward, so too will the push for their implementation to help maximize patient care. The role of remote monitoring in producing favorable patient outcomes has been previously shown and is something that will continue to be studied closely. Moreover, the coronavirus disease of 2019 (COVID-19) has necessitated further expansion of telehealth services in order to help facilitate social distancing. This was especially relevant for patients on home dialysis modalities who come to the clinic for their monthly visits and assistance with dialysis-related issues [5,6,7].
We were not able to demonstrate a statistically significant difference between the AMIA and HC cyclers in terms of patient overall satisfaction, PD training days, PD-related telephone/office encounters, and PD-related emergency room visits/hospitalizations. These findings demonstrate that our patients adapt to the life-changing event that is PD initiation similarly, irrespective of the PD cycler they are initiated on.
