Study of Home-Embedded Palliative Care for Hemodialysis- (and Peritoneal-) Dependent End-Stage Renal Disease (SHEPHERD)

Patients with end-stage renal disease (ESRD, i.e., stage 5 chronic kidney disease requiring hemodialysis or peritoneal dialysis) experience morbidity and mortality that equal or exceed those in advanced cancer and heart failure. Despite this, patients with ESRD have insufficient and inequitable access to palliative care (PC). Our pilot feasibility clinical trial found that nudging clinical teams to make referrals for home PC significantly increased home PC use, but most patients still did not receive this service. We identified actionable barriers to improved uptake, including that only approximately one-third of patients lived in neighborhoods consistently serviced by home PC. These underserviced neighborhoods were lower income, more deprived, and home to more patients who identify as Black. For these and other reasons, Penn Medicine established a new Home PC Nurse Practitioner Program in 2022 that is not geographically limited. As the next step toward our long-term goal of ensuring that patients with ESRD have equitable access to effective PC services, we will engage stakeholders to identify opportunities to improve the SHEPHERD intervention (Aim 1). We will then conduct a pragmatic clinical trial among 400 hospitalized patients to test the refined intervention’s effectiveness in improving patient-centered outcomes and barriers/facilitators to its uptake and effectiveness (Aim 2). The primary outcome of the hybrid effectiveness-implementation clinical trial is the number of acute-care encounters over 6 months. Finally, we will assess the impact of nudging referrals to the home PC Nurse Practitioner Program on disparities in PC access (Aim 3). The SHEPHERD study will generate evidence adaptable by all U.S. health systems to improve equity and outcomes for patients with ESRD.

Penn Leonard Davis Institute CKD Research Initiative, funded by a gift from Monogram Health