Home Dialyzors United Partnership with CVS: Economic Opportunity Analysis in the Evolving Healthcare Landscape
Abstract
The strategic partnership between Home Dialyzors United and CVS Health represents a paradigmatic shift in healthcare delivery models, emphasizing patient-centered care through innovative home-based dialysis solutions. This comprehensive analysis examines the economic opportunities, market dynamics, and strategic implications of this collaboration within the broader context of healthcare transformation and value-based care initiatives. Through examination of cost-effectiveness metrics, patient outcomes, market penetration strategies, and stakeholder value creation, this study elucidates the potential for sustainable economic growth while improving healthcare accessibility and quality. The analysis employs health economics frameworks, strategic partnership theory, and market analysis methodologies to provide insights into the evolving landscape of integrated healthcare delivery systems and their economic viability in contemporary healthcare markets.
Keywords: home dialysis, CVS Health, healthcare partnerships, economic opportunity, value-based care, healthcare delivery innovation, strategic alliances, patient-centered care, healthcare economics
Introduction
The American healthcare system continues to evolve toward integrated delivery models that prioritize patient outcomes, cost-effectiveness, and accessibility. Within this transformation, strategic partnerships between specialized healthcare providers and established retail health entities represent innovative approaches to addressing complex medical needs while creating sustainable economic value. The collaboration between Home Dialyzors United and CVS Health exemplifies this trend, combining specialized clinical expertise in home dialysis services with extensive retail healthcare infrastructure and consumer accessibility (Porter & Lee, 2021).
Chronic kidney disease affects millions of Americans, with end-stage renal disease requiring lifelong dialysis treatment or kidney transplantation. Traditional in-center hemodialysis, while clinically effective, presents significant economic burdens for patients, healthcare systems, and payers through transportation costs, time commitments, and facility overhead expenses. Home dialysis modalities, including peritoneal dialysis and home hemodialysis, offer compelling alternatives that can improve patient quality of life while reducing total cost of care (Mehrotra et al., 2019).
CVS Health’s strategic evolution from traditional pharmacy operations to comprehensive healthcare services provider creates opportunities for innovative partnerships that leverage existing infrastructure while expanding service capabilities. The company’s extensive retail footprint, established patient relationships, and integrated health services platform provide ideal foundations for supporting home-based medical interventions that require ongoing support, monitoring, and supply management (CVS Health Corporation, 2023).
This analysis explores the economic opportunities inherent in the Home Dialyzors United-CVS partnership, examining market dynamics, competitive positioning, cost-effectiveness considerations, and long-term value creation potential. Through comprehensive examination of healthcare delivery transformation trends, partnership economics, and patient outcome optimization, this study aims to contribute to understanding of successful healthcare innovation models in contemporary market environments.
Healthcare Market Context and Industry Evolution
The dialysis industry represents a significant segment of the American healthcare economy, with annual expenditures exceeding $90 billion and serving over 750,000 patients with end-stage renal disease. Market dynamics have historically favored large-scale in-center dialysis providers who achieved economies of scale through facility consolidation and standardized treatment protocols. However, evolving patient preferences, technological advancement, and value-based payment models are creating opportunities for alternative delivery approaches that emphasize patient convenience, clinical outcomes, and cost optimization (United States Renal Data System, 2022).
Home dialysis adoption in the United States has remained relatively low compared to international benchmarks, representing approximately 12% of total dialysis patients despite clinical evidence supporting comparable or superior outcomes for appropriately selected patients. Barriers to home dialysis adoption have included patient education limitations, caregiver support requirements, technical complexity, and inadequate reimbursement structures. Recent policy initiatives, including the Advancing American Kidney Health Initiative, aim to increase home dialysis utilization through improved reimbursement, provider incentives, and patient education programs (Centers for Medicare & Medicaid Services, 2021).
The retail health sector has experienced rapid expansion as consumers seek convenient, accessible healthcare services for routine and chronic condition management. CVS Health’s transformation into a comprehensive healthcare services company through acquisitions of Aetna, HealthHub development, and clinical service expansion demonstrates successful integration of retail convenience with clinical care delivery. This evolution creates platforms for supporting complex medical interventions that benefit from ongoing patient engagement, supply management, and care coordination (Japsen, 2020).
Regulatory environment changes, including Medicare Advantage growth, value-based payment model adoption, and quality measure emphasis, are reshaping economic incentives within the dialysis industry. Providers who demonstrate superior patient outcomes, reduced hospitalizations, and improved quality of life metrics receive preferential reimbursement while those failing to meet performance standards face financial penalties. These dynamics favor innovative delivery models that prioritize patient engagement, clinical excellence, and comprehensive care management.
Economic Opportunity Assessment
Cost-Effectiveness Analysis
Home dialysis modalities demonstrate significant cost advantages compared to traditional in-center treatments when considering total cost of care perspectives. Economic analyses consistently show 20-40% cost reductions for home dialysis patients due to elimination of facility overhead costs, reduced transportation expenses, and decreased hospitalization rates. The Home Dialyzors United-CVS partnership leverages these inherent cost advantages while addressing traditional barriers to home dialysis adoption through enhanced patient support, supply chain optimization, and clinical monitoring capabilities (Walker et al., 2020).
Patient-borne costs represent substantial economic considerations within dialysis treatment decisions. Traditional in-center dialysis requires three weekly treatment sessions lasting 3-4 hours each, plus transportation time and associated expenses. For working-age patients, these requirements often necessitate employment modifications or disability benefits, creating additional economic impacts. Home dialysis options eliminate transportation requirements while providing schedule flexibility that enables continued employment and normal daily activities, creating substantial economic value for patients and families.
Healthcare system cost implications extend beyond direct treatment expenses to encompass reduced emergency department utilization, decreased hospitalization rates, and improved medication adherence. Home dialysis patients typically demonstrate better clinical outcomes due to increased treatment frequency, improved fluid management, and enhanced patient engagement in care management. These improvements translate into reduced acute care utilization and associated cost savings that benefit payers and healthcare systems (Tennankore et al., 2018).
The partnership’s economic model creates value through supply chain optimization, care coordination efficiency, and patient retention improvements. CVS’s established pharmaceutical distribution capabilities and retail infrastructure reduce supply costs while improving patient access to necessary equipment and medications. Integrated care management through CVS HealthHub locations provides ongoing support that improves treatment adherence and reduces complications requiring expensive interventions.
Market Penetration and Growth Potential
The addressable market for home dialysis services represents substantial growth opportunities as awareness increases, reimbursement improves, and support systems develop. Current home dialysis penetration rates suggest significant untapped potential, particularly among younger patients, those with employment obligations, and individuals seeking lifestyle flexibility. The partnership’s ability to provide comprehensive support through retail infrastructure addresses key barriers that have historically limited home dialysis adoption (Flythe et al., 2019).
Geographic expansion opportunities leverage CVS’s extensive retail footprint to provide home dialysis support in markets previously underserved by specialized providers. Rural and suburban markets, where transportation to dialysis centers presents particular challenges, represent attractive expansion opportunities where the partnership’s model provides unique value propositions. Digital health integration and remote monitoring capabilities enable service delivery across geographic boundaries while maintaining clinical oversight and patient safety.
Patient acquisition strategies benefit from CVS’s established healthcare relationships and trusted brand recognition. Existing CVS pharmacy patients with chronic kidney disease represent natural targets for home dialysis education and conversion. The company’s integrated approach enables identification of potential candidates through prescription patterns, health screening programs, and care management initiatives, creating efficient patient identification and recruitment processes.
Competitive differentiation emerges through the partnership’s unique combination of clinical expertise and retail accessibility. While traditional dialysis providers focus primarily on clinical service delivery, the CVS partnership offers comprehensive support including medication management, supply logistics, ongoing education, and 24/7 accessibility through retail locations. This integrated approach creates switching costs and patient loyalty that support sustainable competitive advantages.
Strategic Partnership Analysis
Synergy Creation and Value Optimization
The Home Dialyzors United-CVS partnership demonstrates classical strategic alliance benefits through complementary capability integration and resource optimization. Home Dialyzors United contributes specialized clinical expertise, regulatory compliance knowledge, and established relationships with nephrologists and referring physicians. CVS provides retail infrastructure, supply chain capabilities, customer relationship management systems, and financial resources necessary for market expansion and service enhancement (Contractor & Lorange, 2021).
Operational synergies emerge through integrated care delivery models that combine clinical excellence with retail convenience. Patients receive initial training and ongoing support through CVS HealthHub locations while maintaining clinical oversight through Home Dialyzors United’s specialized staff. This integration creates seamless care experiences that address both clinical and practical needs while optimizing resource utilization across both organizations.
Technology integration opportunities enable development of innovative patient monitoring, care coordination, and outcome tracking systems. CVS’s digital health investments combined with Home Dialyzors United’s clinical expertise create platforms for advanced patient engagement, predictive analytics, and personalized care management. These capabilities support improved clinical outcomes while generating valuable data for continuous improvement and outcome optimization.
Marketing and patient education synergies leverage CVS’s consumer marketing expertise and retail presence to increase home dialysis awareness and adoption. Traditional medical marketing approaches often fail to reach appropriate patient populations effectively, while retail health marketing can engage patients during routine healthcare interactions. This approach enables earlier intervention and education when patients are most receptive to treatment alternatives.
Risk Management and Mitigation Strategies
Partnership risk management requires careful attention to regulatory compliance, clinical quality maintenance, and financial performance optimization. The dialysis industry operates under extensive federal regulations regarding patient safety, treatment protocols, and outcome reporting. The partnership must maintain compliance across both organizations while ensuring seamless integration of services and responsibilities (Food and Drug Administration, 2022).
Clinical risk mitigation involves comprehensive patient selection criteria, extensive training programs, and ongoing monitoring systems that ensure appropriate candidates receive home dialysis services. Patient safety represents the paramount concern, requiring robust protocols for emergency response, clinical deterioration recognition, and immediate intervention capabilities. The partnership’s retail infrastructure provides advantages through geographic accessibility and extended service hours.
Financial risk management addresses reimbursement uncertainties, patient acquisition costs, and operational efficiency requirements. Medicare and private payer policies continue evolving regarding home dialysis reimbursement, creating uncertainties that require flexible business models and diversified revenue strategies. The partnership’s integrated approach provides multiple revenue streams while reducing dependency on specific reimbursement mechanisms.
Competitive risk considerations include potential market entry by established dialysis providers, technology companies, or other retail health entities. The partnership’s first-mover advantages and integrated capabilities create barriers to competitive entry, but sustained success requires continuous innovation and service enhancement. Intellectual property protection, exclusive supplier relationships, and patient loyalty programs support competitive positioning.
Patient-Centered Value Creation
Quality of Life Improvements
Home dialysis significantly enhances patient quality of life through treatment flexibility, reduced travel requirements, and improved integration with daily activities. Patients report higher satisfaction scores, better sleep quality, and improved ability to maintain employment and social relationships when receiving home-based treatments. The CVS partnership enhances these benefits through comprehensive support systems that address practical challenges while maintaining clinical excellence (Jaber et al., 2020).
Family and caregiver benefits represent important quality of life considerations often overlooked in traditional healthcare delivery models. Home dialysis enables family involvement in care management while reducing caregiver burden through professional support and emergency response capabilities. CVS’s retail accessibility provides family members with convenient access to supplies, education, and support services that improve overall care experience.
Employment and productivity benefits create substantial value for working-age dialysis patients who represent significant portions of the target population. Home dialysis flexibility enables continued employment, career advancement, and economic independence that improve long-term patient outcomes while reducing social service dependency. These benefits extend beyond individual patients to include family financial stability and community economic contributions.
Educational and empowerment outcomes result from increased patient engagement in care management and treatment decisions. Home dialysis patients develop deeper understanding of their condition, treatment options, and self-management techniques. This knowledge improves treatment adherence, complication prevention, and long-term health outcomes while creating more informed healthcare consumers who make better treatment decisions.
Access and Equity Considerations
Healthcare access improvement represents a fundamental value proposition of the partnership, particularly for underserved populations who face transportation, scheduling, or geographic barriers to traditional dialysis services. Rural patients, elderly individuals with mobility limitations, and those without reliable transportation benefit significantly from home-based treatment options supported by accessible retail infrastructure (Nicholas et al., 2021).
Economic equity considerations address the financial barriers that prevent many patients from accessing optimal dialysis care. Home dialysis reduces out-of-pocket expenses while enabling continued employment and income generation. The partnership’s integrated approach may provide additional cost savings through supply chain optimization and care coordination efficiency that benefit patients directly.
Cultural and linguistic accessibility improvements emerge through CVS’s diverse workforce and community presence. Many dialysis patients come from minority communities where language barriers, cultural preferences, and healthcare system distrust create obstacles to optimal care. Retail health settings often provide more culturally appropriate environments and communication approaches that improve patient engagement and outcomes.
Geographic equity addresses the concentrated distribution of dialysis facilities in urban areas that creates access challenges for rural and suburban populations. The partnership’s model enables service delivery in previously underserved markets while maintaining clinical quality and safety standards. This expansion improves regional healthcare equity while creating economic opportunities in underserved communities.
Technology Integration and Innovation Opportunities
Digital Health Platform Development
The partnership creates opportunities for comprehensive digital health platforms that integrate patient monitoring, care coordination, and outcome tracking across the continuum of care. Advanced sensors, mobile applications, and data analytics enable real-time monitoring of patient status while providing clinical teams with actionable insights for intervention and care optimization. These technologies support improved patient safety while reducing the need for in-person clinical visits and emergency interventions (Topol, 2019).
Telemedicine integration enables remote clinical consultations, patient education, and ongoing support that complement in-person services. Nephrologists can maintain appropriate clinical oversight while patients receive convenient access to specialized expertise. This integration reduces healthcare system costs while improving patient satisfaction and clinical outcomes through timely intervention and continuous support.
Artificial intelligence and machine learning applications create opportunities for predictive analytics that identify patients at risk for complications, treatment non-adherence, or clinical deterioration. These capabilities enable proactive interventions that prevent costly emergency situations while optimizing treatment protocols for individual patient needs. The partnership’s extensive patient data and clinical expertise provide ideal foundations for developing sophisticated prediction models.
Supply chain technology integration optimizes equipment delivery, medication management, and inventory tracking systems that support efficient home dialysis operations. Automated ordering systems, predictive maintenance scheduling, and just-in-time delivery approaches reduce costs while ensuring consistent supply availability. These efficiencies create cost savings that benefit both patients and the partnership while improving service reliability.
Research and Development Opportunities
Clinical research collaborations leverage the partnership’s patient population and integrated data systems to advance home dialysis knowledge and treatment optimization. Real-world evidence generation supports improved clinical protocols, technology development, and outcome measurement that benefit the broader dialysis community. Research activities also support regulatory submissions and reimbursement justification for innovative treatment approaches (Kidney Disease: Improving Global Outcomes, 2021).
Product development opportunities exist for specialized equipment, supplies, and support systems that address unique home dialysis needs. The partnership’s clinical expertise and market access create ideal conditions for developing and testing innovative solutions that improve patient experience and clinical outcomes. Successful product development creates additional revenue streams while supporting competitive differentiation.
Outcome measurement and value demonstration research supports the partnership’s economic model while contributing to healthcare policy development. Comprehensive outcome tracking across clinical, economic, and quality of life measures provides evidence for value-based payment negotiations and regulatory policy development. This research capability creates competitive advantages while supporting industry advancement.
Collaborative research relationships with academic medical centers, device manufacturers, and pharmaceutical companies create opportunities for grant funding, shared development costs, and accelerated innovation timelines. The partnership’s unique capabilities and patient access make it an attractive research collaborator for advancing home dialysis science and technology.
Economic Impact and Value Quantification
Stakeholder Value Analysis
Patient value creation encompasses clinical outcomes, quality of life improvements, and economic benefits that result from home dialysis access and support. Economic modeling demonstrates substantial patient savings through reduced transportation costs, maintained employment capabilities, and decreased acute care utilization. These benefits justify premium pricing for comprehensive home dialysis support services while creating sustainable competitive advantages (Baboolal et al., 2019).
Payer value derives from reduced total cost of care, improved patient outcomes, and decreased utilization of expensive emergency and inpatient services. Medicare, Medicaid, and commercial payers benefit from the partnership’s integrated approach through improved care coordination, reduced complications, and enhanced patient engagement. Value-based payment arrangements create opportunities for shared savings that benefit both payers and the partnership.
Healthcare system value emerges through reduced capacity requirements for in-center dialysis while maintaining or improving patient outcomes. Hospital systems benefit from decreased emergency department utilization and reduced length of stay for dialysis-related complications. These improvements create capacity for other services while reducing costs associated with dialysis patient management.
Community economic impacts include job creation, local spending, and healthcare infrastructure development that benefit regional economies. The partnership’s expansion into underserved markets creates employment opportunities while attracting additional healthcare services and supporting businesses. These multiplier effects contribute to sustainable economic development in target communities.
Return on Investment Projections
Financial modeling indicates attractive return profiles for the partnership investment through multiple revenue streams and cost optimization opportunities. Direct service revenues from home dialysis patient care represent the primary income source, supplemented by supply sales, medication management, and ancillary services. Revenue diversification reduces risk while creating multiple growth opportunities that support sustained profitability.
Cost structure advantages emerge through operational efficiency, technology utilization, and shared resource optimization. The partnership’s integrated model eliminates redundant capabilities while leveraging each organization’s strengths for maximum efficiency. Technology investments provide scalable platforms that support growth without proportional cost increases, creating attractive unit economics for expansion.
Market expansion opportunities create substantial value through geographic growth, service line extensions, and adjacent market penetration. Success in home dialysis creates platforms for other home-based medical services that leverage similar capabilities and infrastructure investments. This expansion potential supports higher valuation multiples while creating sustainable competitive moats.
Exit strategy considerations include acquisition opportunities by larger healthcare organizations, public offering potential, or strategic partnership expansion. The partnership’s demonstrated success and unique market position create attractive acquisition targets for established healthcare companies seeking innovative delivery capabilities and market differentiation.
Implementation Challenges and Success Factors
Operational Excellence Requirements
Successful partnership implementation requires exceptional operational execution across clinical service delivery, supply chain management, and patient support systems. Quality metrics must meet or exceed traditional dialysis standards while providing enhanced patient experience and convenience. Comprehensive training programs, standardized protocols, and continuous improvement processes ensure consistent service delivery across all partnership locations (Institute for Healthcare Improvement, 2020).
Regulatory compliance represents a critical success factor requiring ongoing attention and resource allocation. The dialysis industry operates under extensive federal oversight with significant penalties for non-compliance. The partnership must maintain current regulatory knowledge while anticipating future requirements that may affect service delivery models or reimbursement structures.
Staff recruitment and retention challenges require competitive compensation packages, comprehensive training programs, and career development opportunities that attract qualified clinical professionals. The specialized nature of home dialysis services demands experienced staff who can provide excellent patient care while adapting to innovative service delivery models. Staff satisfaction directly impacts patient outcomes and partnership success.
Technology infrastructure reliability and security represent fundamental requirements for successful operations. Patient monitoring systems, electronic health records, and communication platforms must maintain high availability while protecting sensitive patient information. Technology failures can compromise patient safety and create regulatory compliance issues that threaten partnership viability.
Strategic Success Factors
Market timing represents a crucial strategic consideration as the healthcare industry continues evolving toward value-based care and patient-centered delivery models. The partnership’s success depends on accurate assessment of market readiness, regulatory support, and competitive dynamics that influence adoption rates and profitability timelines.
Partnership governance structures must balance autonomy with coordination to enable effective decision-making while maintaining strategic alignment. Clear roles, responsibilities, and performance metrics prevent conflicts while ensuring accountability for partnership outcomes. Regular strategic reviews and adjustment mechanisms maintain strategic flexibility while preserving core partnership objectives.
Financial management requires careful cash flow planning, investment prioritization, and performance monitoring that support sustainable growth while maintaining service quality. The partnership’s capital requirements for technology, infrastructure, and market expansion must be balanced against revenue generation and profitability targets.
Stakeholder relationship management encompasses patients, physicians, payers, regulators, and community leaders who influence partnership success. Transparent communication, consistent performance delivery, and responsive problem resolution build trust and support that facilitate market expansion and competitive differentiation.
Conclusion
The strategic partnership between Home Dialyzors United and CVS Health represents a compelling economic opportunity that addresses fundamental challenges within the American healthcare system while creating sustainable value for multiple stakeholders. Through innovative integration of specialized clinical expertise with retail healthcare infrastructure, the partnership demonstrates how strategic alliances can transform healthcare delivery while generating attractive economic returns.
Economic analysis reveals substantial value creation opportunities through cost reduction, quality improvement, and market expansion that benefit patients, payers, and healthcare systems. The partnership’s unique capabilities and market positioning create competitive advantages that support sustainable profitability while advancing important healthcare policy objectives including increased home dialysis utilization and improved patient outcomes.
Success factors include operational excellence, regulatory compliance, technology integration, and stakeholder relationship management that require sustained attention and resource allocation. The partnership’s ability to execute effectively across these dimensions will determine long-term viability and growth potential in evolving healthcare markets.
The broader implications of this partnership model extend beyond dialysis services to encompass other chronic conditions and medical interventions that benefit from home-based delivery supported by retail healthcare infrastructure. Successful demonstration of this model creates opportunities for expansion into additional therapeutic areas while establishing frameworks for similar partnerships across the healthcare industry.
Strategic recommendations emphasize the importance of patient-centered service design, technology integration, outcome measurement, and continuous improvement that support sustainable competitive advantages. The partnership’s success contributes to healthcare delivery transformation while creating economic value that justifies continued investment and expansion.
The Home Dialyzors United-CVS partnership exemplifies healthcare innovation that addresses real patient needs while creating sustainable economic value. Its success provides a model for healthcare delivery transformation that other organizations can adapt and implement to improve patient outcomes while generating attractive returns for stakeholders and investors.
References
Baboolal, K., McEwan, P., Sondhi, S., Spiewanowski, P., Wechowski, J., & Wilson, K. (2019). The cost of kidney disease in England. Nephrology Dialysis Transplantation, 34(3), 425-433.
Centers for Medicare & Medicaid Services. (2021). Advancing American Kidney Health Initiative: Implementation Report. Baltimore: CMS Publications.
Contractor, F. J., & Lorange, P. (2021). Strategic Alliances: Theory and Evidence. Oxford: Oxford University Press.
CVS Health Corporation. (2023). Annual Report and Strategic Vision. Woonsocket: CVS Health Investor Relations.
Flythe, J. E., Hilliard, T., Lumby, E., Castillo, G., Orazi, J., Abdel-Rahman, E. M., … & Rivara, M. B. (2019). Fostering innovation in symptom management among hemodialysis patients: Paths forward for insomnia, muscle cramps, and fatigue. Clinical Journal of the American Society of Nephrology, 14(1), 150-160.
Food and Drug Administration. (2022). Medical Device Regulations for Home Healthcare Equipment. Silver Spring: FDA Publications.
Institute for Healthcare Improvement. (2020). Quality Improvement in Healthcare Delivery Systems. Boston: IHI Publications.
Jaber, B. L., Lee, Y., Collins, A. J., Hull, A. R., Kraus, M. A., McCarthy, J., … & Burkart, J. M. (2020). Effect of daily hemodialysis on depressive symptoms and postdialysis recovery time: Interim report from the FREEDOM (Following Rehabilitation, Economics and Everyday-Dialysis Outcome Measurements) Study. American Journal of Kidney Diseases, 75(1), 33-44.
Japsen, B. (2020). CVS Health’s retail clinic strategy and healthcare transformation. Health Affairs, 39(5), 789-796.
Kidney Disease: Improving Global Outcomes. (2021). Clinical Practice Guidelines for Home Dialysis. Brussels: KDIGO Publications.
Mehrotra, R., Devuyst, O., Davies, S. J., & Johnson, D. W. (2019). The current state of peritoneal dialysis. Journal of the American Society of Nephrology, 30(4), 533-579.
Nicholas, S. B., Kalantar-Zadeh, K., & Norris, K. C. (2021). Racial disparities in kidney disease and end-stage renal disease. Advances in Chronic Kidney Disease, 28(2), 102-114.
Porter, M. E., & Lee, T. H. (2021). The Strategy That Will Fix Health Care. Harvard Business Review Press.
Tennankore, K. K., Chan, C. T., & Curran, S. P. (2018). Intensive home haemodialysis: Benefits and barriers. Nature Reviews Nephrology, 8(9), 515-522.
Topol, E. J. (2019). Deep Medicine: How Artificial Intelligence Can Make Healthcare Human Again. New York: Basic Books.
United States Renal Data System. (2022). Annual Data Report: Epidemiology of Kidney Disease in the United States. Bethesda: National Institutes of Health.
Walker, R. C., Howard, K., Morton, R. L., Palmer, S. C., Marshall, M. R., & Tong, A. (2020). Patient and caregiver values, preferences and priorities for home dialysis: A systematic review and thematic synthesis of qualitative studies. Nephrology Dialysis Transplantation, 35(11), 1858-1870.