Benefits and Challenges When Implementing Incremental Hemodialysis: A Qualitative Study of Patients and Providers.

Background: In 2022, we implemented an incremental hemodialysis (iHD) protocol to initiate twice-weekly treatment for eligible patients. This patient-centered approach aims to ease the transition to dialysis and enhance quality of life. However, limited data exists on how iHD is experienced by patients and health care providers (HCPs). Objective: The aim of the study was to explore the benefits and challenges of iHD from patients' and HCPs' perspectives, and to generate practical considerations for its implementation. Study Design: We conducted an exploratory descriptive qualitative study, guided by an interpretivist-constructivist paradigm, using semi-structured interviews (March-May 2024). Setting: The study was conducted in a tertiary care center. Participants: Participants included patients who were actively or had previously received iHD and HCPs caring for iHD patients. Methods: Interview data was analyzed thematically using inductive thematic analysis. Results: Ten patients and five HCPs were interviewed. Six major themes were identified: (1) better quality of life than conventional hemodialysis, (2) travel and financial benefits, (3) psychosocial and emotional impact similar to conventional hemodialysis, (4) coordination of care and logistics, (5) knowledge and training challenges, and (6) challenges when switching modality. Patients preferred iHD because it afforded them more time for participation in daily life activities. However, the start of a dialysis treatment remained "traumatic" for some patients. While HCPs recognized the greater quality of life for iHD patients, HCPs expressed a need for increased monitoring to ensure adequate care. Patients noticed an inconsistency in care coordination and reduced opportunities to see nephrologists. Some HCPs reported a lack of guidance on iHD. Finally, HCPs observed patients negotiating to stay on iHD even when it became unsafe. Limitations: The small sample size and single-center setting may limit the findings' transferability. Conclusions: IHD was shown to offer quality of life advantages. However, the transition to iHD remained emotionally challenging for patients. Patients often exhibited resistance when moving from twice-weekly to a thrice-weekly schedule. Logistical issues for HCPs and educational barriers must be addressed to optimize delivery of iHD.