# Home Dialysis Transitions in Canada During the COVID-19 Pandemic: An Interrupted Time Series Analysis

## TL;DR

During the early pandemic, more patients in Canada switched from in-center to home dialysis, but there was also a rise in returning to in-center dialysis, possibly due to pandemic challenges.

## Contribution

This study quantifies the impact of pandemic-related guidelines on dialysis transition rates in Canada using interrupted time-series analysis.

## Key findings

- Transitions to home dialysis increased by 0.60 per 10,000 patients/month during the pandemic.
- Home-to-facility transfers also increased significantly during the pandemic.
- Geographic/resource-related reasons for transfers to facility dialysis doubled during the pandemic.

## Abstract

During the coronavirus disease 2019 (COVID-19) pandemic, nephrology societies recommended transition from facility-based hemodialysis to home dialysis to minimize risks associated with COVID-19 infection. We compared transition rates from facility-based hemodialysis to home dialysis and rates and reasons for transfers from home dialysis to facility-based hemodialysis before and during the pandemic in Canada.

Interrupted time-series analysis.

Using administrative data from the Canadian Organ Replacement Register, our cohort included 31,596 and 22,607 adults with any time receiving hemodialysis during the prepandemic and pandemic study periods, respectively.

Early pandemic (April 1, 2020-September 30, 2021) versus prepandemic (January 1, 2016-December 31, 2019).

Monthly rates of transitions between facility-based hemodialysis and home dialysis as well as reasons for transfer from home to facility.

Segmented linear regression and analysis of covariance.

During the early pandemic, transitions to home dialysis increased by 0.60 per 10,000 patients/month (95% CI, 0.08 to 1.11; P = 0.03), beyond the nonsignificant monthly prepandemic trend of 0.02 per 10,000 (95% CI, –0.10 to 0.13; P = 0.80). Monthly transfers from home dialysis to facility-based hemodialysis per 10,000 home dialysis patients also increased during the pandemic (6.91; 95% CI, 3.42 to 10.40; P < 0.001) versus the prepandemic period (–1.78; 95% CI, –4.31 to0.75; P = 0.20). The rate of increase in home-to-facility transfers during the pandemic was not significantly different than facility-to-home transfers (−0.10 transfers/month; 95% CI, –1.51 to 1.31; P = 0.89). More transfers to facility occurred for geographic/resource-related reasons during the pandemic versus prepandemic (5.8% vs 2.7%; P < 0.0001).

Inability to analyze change in trends by province and ecological bias.

Transitions from facility-based hemodialysis to home dialysis increased, suggesting kidney care programs in Canada implemented recommendations intended to decrease COVID-19-related risks in this population. Reasons for the observed increase in transfers from home to facility during the pandemic are unclear.

During the coronavirus disease 2019 (COVID-19) pandemic, individuals with kidney failure receiving dialysis faced high rates of COVID-19 transmission and severe infection. As a preventive measure, kidney care societies advised increased use of home dialysis. To assess the impact of this directive, we tracked monthly transitions from facility-based hemodialysis to home dialysis before and during the pandemic using data from a large Canadian dialysis database. We found a significant increase in these transitions during the first 18 months of the pandemic compared with the prepandemic period. There was also similar increase in the number of transfers from home to facility dialysis, but it is unclear if this was due to the excess transitions to home dialysis we observed or other pandemic-related factors.