Chronic Kidney Disease
Veterans and Home Dialysis Access: Comprehensive Pre-Kidney Failure Education (CoPE)
Chronic kidney disease (CKD) affects millions of Americans but disproportionately affects US Veterans. An estimated one-third to nearly one-half of Veterans live with CKD, approximately two to three times the rate in the general US population, making it the fourth most common diagnosis within the Department of Veterans Affairs (VA). Additionally, each year thousands of Veterans progress to end-stage kidney disease (ESKD), which requires lifelong dialysis or a kidney transplant. Caring for Veterans with advanced kidney disease costs more than $18 billion annually, while patients often experience poor quality of life and high mortality after beginning dialysis.
Although dialysis is traditionally provided in outpatient dialysis centers several times each week, research has consistently shown that many patients can safely receive treatment at home. Home dialysis (HoD) offers survival rates comparable to in-center dialysis while providing greater independence, improved quality of life, and lower healthcare costs. Further, it reduces travel time, out-of-pocket expenses, and disruptions to the normal rhythms of life. Despite these advantages, only about 7% of Veterans with ESKD currently receive home dialysis.
This study is in partnership with Dr. Ashutosh Shukla at the University of Florida and is intended to correct an important systemic deficit in the care of CKD, VHA’s fourth most common healthcare condition with high mortality and healthcare burden. As many Veterans with CKD are ill-informed of their condition, which adversely affects their care, we anticipate that our proposed comprehensive pre-kidney failure education (CoPE) intervention will enhance Veterans’ knowledge of CKD and its management and increase Veterans’ confidence in making an informed selection of an appropriate dialysis modality. We believe that our strategy will increase Veterans’ utilization of HoD as advocated by the VHA National Kidney Program, improve Veterans' CKD care, access, satisfaction, and decrease VHA and Veteran costs.
The study aligns with the VA Secretary’s three top priorities: 1) “Greater choice for Veterans” in empowering Veterans to make more informed decisions about their healthcare; 2) “Strengthening Foundational Services in the VA”; and 3) “Improving Timeliness of Service” by providing the best access to care for Veterans with CKD. The study also aligns with HSR&D major priorities including “patient-centered care, care management, and health promotion” and “healthcare systems change.”
If successful, the project could transform how Veterans transition from chronic kidney disease to dialysis by making comprehensive education a routine part of kidney care. We believe this patient-centered approach has the potential to increase home dialysis use and ultimately provide Veterans with greater choice and control over their treatment.
The findings may also serve as a model for healthcare systems nationwide, demonstrating how standardized education and telehealth can improve care for patients living with advanced kidney disease.
Expanding Access to Home Dialysis for Rural Veterans Through the ALIGN Initiative
Researchers in the AQUASS Research Lab are leading a nationwide effort to improve kidney care for rural Veterans through the ALIGN for Kidney Failure Care initiative. Chronic kidney disease (CKD) is one of the most common and costly health conditions treated by the Department of Veterans Affairs (VA. More than one-third of Veterans living with CKD reside in rural communities, where access to specialized kidney care can be especially challenging. Caring for Veterans with advanced kidney disease costs the VA almost 20 billion annually, with dialysis representing one of the largest healthcare expenditures.
Although home dialysis has been shown to provide survival outcomes comparable to in-center dialysis while improving quality of life, independence, and patient satisfaction, it remains underused. Home dialysis also reduces healthcare costs by an estimated 15,000 to 20,000 USD per patient each year. National kidney organizations and the VA have identified expanding home dialysis as a priority, recognizing that many patients never receive the education needed to make informed decisions about their treatment options before kidney failure develops.
The ALIGN initiative addresses this challenge by providing Comprehensive Kidney Failure Education (CoPE), a standardized educational program that helps Veterans understand their disease, learn about all available treatment options, and choose the kidney therapy that best aligns with their personal goals and lifestyle. Rather than focusing solely on increasing home dialysis rates, the program emphasizes informed, patient-centered decision-making that empowers Veterans to actively participate in their own care.
Since its launch, the project has enrolled more than 1,500 rural Veterans across five geographically diverse VA healthcare systems in Florida, Utah, and Illinois. The research has demonstrated that while many rural Veterans strongly prefer home dialysis once they understand their options, relatively few ultimately receive it under current models of care. By implementing the ALIGN approach, participating VA healthcare systems have significantly increased Veterans' use of home dialysis while also demonstrating the potential for substantial healthcare savings.
Building on these successful results, our lab is now working with the VA Office of Rural Health to expand the ALIGN model. During the next phase of the project, additional VA healthcare systems will be trained to implement the program, while researchers evaluate barriers and facilitators to adoption through interviews with Veterans, clinicians, and healthcare leaders. These insights will help refine the model and support successful implementation in diverse healthcare settings.