Population-level barriers to home hemodialysis implementation: a public health systems analysis of adoption readiness, health equity, and policy implications in China.

BACKGROUND

Home hemodialysis (HHD) can improve clinical outcomes and reduce system costs, yet utilization remains negligible in mainland China. This study quantified population-level willingness to adopt HHD and identified multilevel determinants with direct relevance to service delivery, equity, and implementation.

METHODS

A cross-sectional survey was conducted at a tertiary dialysis center in Huzhou, China (February 2022-November 2025) among consecutive adults receiving thrice-weekly in-center hemodialysis for ≥3 months. The primary outcome was high HHD adoption intent (Likert 4-5). Multivariable logistic regression, with bootstrap validation, estimated independent associations across sociodemographic, clinical, psychosocial, infrastructural, economic, and health-system engagement domains.

RESULTS

Of 2,847 participants (72% response rate), 717 (25.2%) reported high adoption intent. High-intent patients were younger (54.8 ± 13.7 vs. 59.6 ± 14.3 years), more often male (61.6% vs. 54.3%), employed (58.7% vs. 44.4%), and university-educated (18.1% vs. 14.5%). Favorable clinical, psychosocial, and system-readiness profiles were observed, including arteriovenous fistula use (71.4% vs. 61.5%), higher Kt/V (1.35 ± 0.27 vs. 1.26 ± 0.28), greater knowledge (9.0 vs. 5.0), and prior HHD discussion. The model showed strong discrimination (optimism-corrected AUC = 0.82). Independent facilitators included prior HHD discussion (OR 2.18, 95% CI: 1.78-2.67), university education (2.12, 1.58-2.84), arteriovenous fistula (1.87, 1.41-2.48), and perceived effectiveness (1.52 per point, 1.32-1.75); age, comorbidity, and perceived risk were deterrents. High-intent patients had fewer emergency visits, better adherence, and lower total dialysis costs.

CONCLUSION

A quarter of Chinese dialysis patients are interested in HHD, revealing significant latent demand. Adoption can be boosted by addressing key facilitators such as provider education, patient knowledge, vascular access, and cannulation anxiety. Since HHD-ready patients have better outcomes and lower healthcare costs, targeted expansion offers an evidence-based strategy to improve health equity, reduce the burden on the health system, and strengthen financial protection for vulnerable populations.