Rationale & Objective Disparities in home dialysis therapy (HT) use may stem from the interplay between dialysis centre services and patient characteristics. We analysed how these factors directly and indirectly affect HT uptake in England.

Study design Linked UK Renal Registry (UKRR) cohort to a national survey of renal centres informed by ethnographic observation.

Setting & Participants Adults who initiated kidney replacement therapy (KRT) between 2015 and 2019 at 51 English renal centres, totalling 32,400 individuals identified through the UKRR, with centre practices captured from a 2022 national survey.

Exposures or predictors Patient- and centre-level factors

Outcomes Use of HT (home haemodialysis or peritoneal dialysis) within one year of starting KRT.

Analytical Approach Sequences of regressions, an extension of path analysis, were used to examine the direct and indirect associations between patient- and centre-level factors and the probability of HT uptake.

Results Direct associations revealed that both centre- and patient-factors significantly influenced the probability of HT uptake. Patients at centres conducting quality improvement projects, (OR [95% CI]) 1.94, [1.36-2.76]), offering assisted PD (1.89, [1.39-2.57]), fostering staff research engagement (1.35, [1.03-1.77]) or hosting HT roadshows (1.22, [1.05-1.41]) had higher odds of HT uptake. Centres with staff capacity stress had lower uptake (0.60, [0.45-0.81]). Patients on transplant lists at KRT start (2.55, [2.35-2.77]) or living further from a treatment centre (1.10, [1.08-1.12] per 10km) had higher odds of HT uptake. Patients from more deprived areas or minority ethnic groups had lower HT uptake. However, an indirect association was observed through centre practices, as certain centres serving ethnically diverse populations implemented practices that directly increased HT uptake, potentially mitigating disparities.

Limitations Healthcare professional-reported and aggregated survey data

Conclusions This study identified modifiable centre-level factors that could improve equity in HT access and uptake by mitigating ethnic and area-level disparities in diverse populations.

SJD has received research funding and lecture fees from Baxter Healthcare and Fresenius Medical Care (both companies deliver dialysis treatments, including home dialysis). ML has received research funding from Baxter Healthcare and speaker honoraria from Baxter Healthcare and Fresenius Medical Care. SJD and ML are members of the Behring LLC POSIBIL6ESKD steering committee. JF has received research funding from Baxter Healthcare.

This study was funded by the National Institute for Health Research (NIHR) (Health and Social Care Delivery Research, Grant Reference Number NIHR 128364). The NIHR had no input in in study design, data collection, analysis, reporting, or the decision to submit for publication. For the purpose of Open Access, the author has applied a CC BY public copyright licence to any Author Accepted Manuscript version arising from this submission.

I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained.

Yes

The details of the IRB/oversight body that provided approval or exemption for the research described are given below:

Ethical approval for this study was granted by the UK Health Research Authority (Ref: 20-WA-0249). Centre survey participants provided informed consent via an embedded form at the start of the survey. Pseudonymised patient data were provided by the UKRR under study approval (Ref: DSA93). The UKRR holds Section 251 approval under the NHS Act 2006 to process and share confidential patient data for research, with ethics approval from the Research Ethics Committee (Ref: 16/NE/0042).

I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals.

Yes

I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance).

Yes

I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable.

Yes

The data used in this study were obtained by linking centre survey data with registry data provided by the UKRR. Access to UKRR data is governed by strict data protection regulations, and the data cannot be made publicly available. To apply for access to UKRR data for research purposes visit https://www.ukkidney.org/audit-research/how-access-data/ukrr-data/apply-access-ukrr-data. The deidentified and aggregated survey data underlying the results presented in this manuscript are available by contacting the survey lead at University of Birmingham (Sarah Damery) on reasonable request from bona fide researchers with a methodologically sound proposal and the appropriate ethnical approvals. Any relevant analysis can be done on these data, which will be available for five years following manuscript publication.