Despite Benefits, Taiwan Lags on Home-Based Dialysis

While Taiwan has seen a surge in the adoption of telemedicine in recent months, its utilization rate of home-based dialysis is less than half that of the Asia Pacific average.

The COVID-19 pandemic has accelerated the digitalization of healthcare and increased the market for telemedicine. As a result of capacity-saving efforts and swift innovation during the past year-and-a-half, telehealth utilization is around 38 times higher today than before the pandemic, according to management consulting firm McKinsey & Company.

In many countries, the pandemic has also brought with it an increased number of patients using home-based dialysis, the potential benefits of which include convenience and shortened recovery times. Yet for Taiwanese patients with kidney disease, in-center treatment remains the preferred option.

Patients with chronic kidney disease (CKD) can generally choose one of two main treatment options: hemodialysis, in which a machine and special filter cleanse the blood, or peritoneal dialysis (PD), which involves an implanted catheter and is a popular option for treatment at home.

While the technology for PD has existed for decades, recent developments have increased the accessibility and effectiveness of the treatment. Healthcare professionals can now access patient data following a session and adjust the therapy remotely using cloud technology.

Multinational healthcare company Baxter International is a proponent of PD as an alternative for patients and has developed its own connectivity platform, called Sharesource, for the remote patient monitoring of PD. According to Baxter, remote patient monitoring will save the global healthcare industry up to US$36 billion in the future.

“We expect to continue seeing improvements in digital capabilities for the treatment of chronic kidney disease,” says Gary Wong, general manager of Baxter Hong Kong & Taiwan. “This brings with it an opportunity to enhance productivity and profitability for the healthcare service providers and improve patient outcomes, which is the ultimate value.”

Gary Wong, general manager of Baxter Hong Kong & Taiwan, says Taiwan has big potential to catch up with the Asia Pacific utilization rate of home-based dialysis. Photo: Baxter International

Baxter’s portfolio includes devices for ICU, multiple organ failures, and medical products used in operating theatres, but its most prominent area of expertise lies in dialysis and the treatment of CKD. Wong manages two outliers in the Asia-Pacific region: Taiwan, with one of the lowest numbers of PD patients, and Hong Kong, with the world’s highest.

The benefits of opting for home-based PD, says Wong, are threefold. The first is improvement in the quality of patients’ lives. With hemodialysis, a patient needs to visit the hospital or clinic three times per week for around four to six hours each time.

Meanwhile, PD patients can choose between continuous ambulatory peritoneal dialysis (CAPD) and automated peritoneal dialysis (APD). CAPD does not require a machine – patients can conduct fluid exchanges by hand for 30 to 40 minutes, four times per day, while performing other non-physical activities. With APD, a cycler fills and empties the patient’s stomach three to five times at night, enabling them to study, work, or engage in other activities during the day.

The second advantage of using home-based PD is a significantly decreased burden on the healthcare system. Lee Wui-Chiang, director of Medical Affairs and Planning at Taipei Veterans General Hospital, notes that Taiwan has the highest number of dialysis patients per capita in the world – around 90,000 at present.

“In terms of instance rate and prevalence rate, we are number one in the world,” he says. “This may be because of the high prevalence of both diabetes and hypertension. Lifestyle choices also make an impact – many people in Taiwan purchase and take medications at a high rate.”

Around 13,000 people die of kidney disease in Taiwan every year, according to government data. Due to a lack of donors, only around 200 of the 70,000 patients on the waiting list in Taiwan receive successful kidney transplants annually. This results in staggering costs of over NT$53 billion (US$1.9 billion) annually, making CKD Taiwan’s most expensive disease.

Moving some treatment from hospitals and clinics to the home could reduce this number. According to the 2016 Annual Report on Kidney Disease in Taiwan, hemodialysis patients had higher NHI expenses (NT$70,000 per month) than PD patients (NT$51,000 per month).

The third reason for increasing home-based PD is the risk of exposure for chronically ill patients when visiting hospitals. Patients with kidney failure suffer from immune dysfunction, which puts them at high risk of contracting viral infections.

“During COVID-19, nothing is more important or safer than staying home, even for healthy people,” says Wong. “For dialysis patients, staying home drastically reduces the risk of infection. In fact, some countries like the UK are recommending that patients choose home-based PD during the pandemic.”

Taiwan has in the past few years implemented some policies favoring home-based PD. The National Health Insurance scheme covers all costs related to both hemodialysis and PD treatment, and in 2012 the Department of Health (precursor to the Ministry of Health and Welfare) set a goal of having 14% of patients use PD by 2016, though that objective was not achieved.

Due to the accessibility of healthcare in Taiwan, many patients choose center-based hemodialysis over home-based peritoneal dialysis.

Wong notes that less than 10% choose PD over traditional dialysis in Taiwan – half of the APAC average of around 20% and much lower than the outlier Hong Kong, where approximately 70% of patients use PD. In order for Taiwan to avoid falling behind, improvements in patient education, as well as incentives and reimbursements for doctors, are needed to increase the penetration of PD.

While stressing the potential benefits of this treatment, Wong points out that it is still just one of the options for patients with kidney disease, and many patients are better suited to use hemodialysis. The key, he notes, is finding a balance.

“No single treatment can fit all patients,” he says. “But less than 10% is too little. For many patients, PD is the preferred option. Based on clinical evidence, this includes patients with cardiovascular diseases, those with kidney residual functions, and those who plan to undergo transplantations.”

Lee agrees that while elderly patients and those with impaired eyesight, poor health, and low technical literacy might not be the best candidates for PD, the government could offer incentives to encourage doctors to recommend and implement home-based dialysis for younger patients. “We should especially encourage the young and the educated, who are likely to be able to manage the dialysis at home, to do that,” he says. “If they are still healthy enough to be walking around, they can use PD and live a normal life.”