I Hate Dialysis Message Board
Dialysis Discussion => Dialysis: News Articles => Topic started by: okarol on August 24, 2009, 09:27:51 AM
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Dialysis treatment in USA: High costs, high death rates
By Rita Rubin, USA TODAY
Deb Lustman was late getting to work a few days every week, and often felt she wasn't thinking as clearly as she once did.
The reason: Lustman, 50, was spending four hours a day, three days a week, undergoing kidney dialysis at a dialysis center, where a machine filtered toxins and fluids from her blood. Normally, that's the job of the kidneys, but for reasons doctors have never figured out, hers had failed.
Nine months into her treatment, as soon as her doctor raised the possibility of home dialysis, Lustman decided to switch. So, in July 2008, after she and her husband learned the ins-and-outs from a nurse, she began dialyzing five evenings a week at her Magnolia, N.J., home, with her two Maltese, Sophie and Jake, often lounging next to her. Now Lustman, an optician, dialyzes on her own schedule, not the center's, and she's not late for work anymore. And, she says, "I'm healthier."
Thanks to more frequent dialysis, totaling 15 or 16 hours a week, "I feel not only physically better but … mentally better" and no longer "loopy," she says.
Lustman is a rarity, however: Only 8% of U.S. dialysis patients treat themselves at home. The vast majority of the more than 350,000 Americans on dialysis are treated in centers, where three treatments a week, three or four hours each, is the norm — not because it's optimal but because that's the way it has been done for nearly four decades.
A growing body of evidence suggests that longer and/or more frequent dialysis treatments, either at home or in a dialysis center, are far superior to the status quo. Although the USA spends more per dialysis patient than other countries, that does not result in higher survival rates or even, many argue, a better quality of life.
"The standard of care is really inappropriate," says Brenda Kurnik, Lustman's doctor, who practices in Marlton, N.J. "Basically, it prevents people from dying, and that's about all it does."
So why doesn't the USA do better? Many blame Medicare's End Stage Renal Disease Program. Launched in 1973, it's the only federal program that entitles people of all ages to health-care coverage on the basis of a single diagnosis: chronic kidney failure. By paying for lifesaving care for hundreds of thousands of Americans, the program is a testament to what health insurance reform might achieve if Congress were to adopt it.
But it also may be a cautionary tale: Its cost has far exceeded initial projections, and some doctors and other analysts question whether Medicare get its money's worth and whether patients get the best treatment. Less than one-quarter of dialysis patients ages 18 to 54 are well enough to work or go to school.
In 2007, Medicare spent $8.6 billion on the treatment and medications of dialysis patients, from babies to the elderly, according to the Medicare Payment Advisory Commission's March report to Congress.
In addition, Medicare pays billions each year for the hospitalization of dialysis patients. Although they are younger on average than most Medicare beneficiaries, who must be 65 to qualify for coverage, "this is an incredibly sick population," says epidemiologist Paul Eggers of the National Institute of Diabetes and Digestive and Kidney Diseases. Such patients, Eggers says, enter the hospital six times more often than Medicare beneficiaries who don't have chronic kidney failure.
Despite the costs, a substantial proportion of dialysis patients die every year. In 2006, 20.1% of U.S. dialysis patients died, most often of heart disease or infections. In Japan, the death rate was about half that; Australia's rate was halfway between the USA's and Japan's.
Explanations for why the USA has the highest dialysis death rate in the world vary. Some U.S. kidney doctors say that countries with national health programs, such as Britain, withhold dialysis from the oldest, sickest patients, while the Medicare program takes all comers. But foreign doctors deny that their countries ration dialysis. They — and many of their U.S. colleagues — attribute the higher U.S. death rate in part to Medicare's own payment system and the resulting "one-size-fits-all" treatment.
The standard of care has become the three treatments a week for which Medicare pays, usually in a dialysis center, and no longer than four hours each. Home dialysis, which allows for longer, more frequent treatments, is more common in most countries with better survival rates.
'Capable of doing better'
The status quo has many critics. In June, a group of nephrologists, or kidney doctors, who had met at a Harvard teaching hospital to discuss the issue sent a letter to White House and Medicare officials urging "substantial changes in the delivery and financing of care … to improve patient outcomes" for those with chronic kidney failure.
"We are capable of doing better," they wrote to White House health policy czar Nancy-Ann DeParle and Barry Straube, chief medical officer at the federal Centers for Medicare & Medicaid Services, or CMS. "Small, incremental improvements in the outcomes for patients with kidney failure are no longer acceptable."
When Medicare's kidney-failure program started in the early 1970s, "the science was such that somewhere between three and six hours of dialysis three days a week was sufficient. Things sort of settled into that pattern," says Dallas nephrologist Thomas Parker III, co-organizer of the conference at Harvard's Beth Israel Deaconess Medical Center.
But normal kidneys work 24/7, not a few shifts a week, so the standard treatment replaces only 10% to 13% of their function, Parker says. How much dialysis is enough isn't clear, he says, because few studies have randomly assigned patients to different amounts to test which approach is more effective.
In his July 22 prime-time press conference, President Obama endorsed the use of such studies, called comparative effectiveness research, to ensure that the U.S. health-care system gets the most value for its money. The economic stimulus package has earmarked $400 million for such research. "If doctors and patients have the best information about what works and what doesn't, then they're going to want to pay for what works," Obama said.
In a report issued June 30, the Institute of Medicine listed its top 100 priorities for comparative effectiveness research. Dialysis and kidney transplantation were high on the list.
Parker said Friday that the nephrologists had received a "very promising" response from Straube, indicating that federal officials "are open to further communications" about the future of dialysis.
Only the wealthy had dialysis
When President Nixon signed the 1972 bill establishing the End Stage Renal Disease Program, only 10,000 Americans were on dialysis, and more than one-third were doing it at home. Only the wealthy could afford long-term treatment.
The world's first outpatient dialysis center, the three-bed Seattle Artificial Kidney Center, predated Medicare by 11 years. There wasn't enough money or machines to go around. So an anonymous committee of Seattle community leaders decided which candidates would get dialysis and live and which would not and die.
The Medicare program opened up treatment to thousands who would have died without it. "We were naive in estimating how much this was going to cost," says Brandeis University professor Stuart Altman, an economist who advised Nixon on health policy and now advises Obama. "People didn't realize how many more people were going to go on it, how much longer we were going to keep these people alive."
It soon became clear: If you pay for it, they will come. "All of a sudden, large numbers of people who were not traditionally on Medicare qualified," Altman says. "We created this giant money machine that made a lot of nephrologists and entrepreneurs rich."
Dialysis became big business, with free-standing centers established in hundreds of cities by corporations, not hospitals. The number of U.S. centers has increased 4% every year, according to a June report by the Medicare Payment Advisory Commission. In 1998, there were 3,394; in 2008, 4,957. About 60% are owned by Denver-based DaVita, a Fortune 500 company, and Fresenius Medical Care North America, a Waltham, Mass.-based subsidiary of a German company that operates centers in 28 countries and also sells dialysis machines and other supplies.
And about 70% of Medicare dollars spent on dialysis and injectable drugs goes to DaVita, which runs more than 1,500 U.S. dialysis centers, and Fresenius, which runs more than 1,700. In the first quarter of this year, DaVita's revenues were $1.45 billion, up more than 8% from the first quarter of 2008. Fresenius' revenues from dialysis in North America were $1.57 billion, up 5% over the first quarter of 2008.
Since 1983, Medicare has paid dialysis providers, whether for-profit centers, non-profit centers or hospitals, a "composite rate" per treatment, which averaged about $155 in 2007. And because Medicare pays the same amount no matter how long the treatment, there's no financial incentive to dialyze patients longer than a few hours at a time.
On top of the composite rate, Medicare pays extra for newer, expensive injectable drugs — namely erythropoietin, or EPO, a hormone that stimulates red blood cell production, and vitamin D, which plays a role in bone health — and lab tests. These extras added an average of $75, or 50%, to the cost of each treatment in 2007. Countries with national health systems don't use the injectables nearly as much. They use less EPO and prescribe oral vitamin D pills that cost about one-quarter of the injectable versions but, their doctors say, are equally effective.
Longer, more frequent dialysis
Longer and/or more frequent dialysis can improve quality of life and survival and reduce hospitalizations, some doctors and patients believe, although the government isn't yet convinced.
"If you ever see patients who are dialyzing six or seven times a week, they are totally different" from those who receive the standard three treatments, says nephrologist Christopher Blagg, a University of Washington professor emeritus who for many years served as director of the Northwest Kidney Centers in Seattle.
Besides improved blood pressure control and lower use of EPO, they generally feel better, with more energy. And chances are they live longer, Blagg says. As he told the House Committee on Ways and Means in March, "dialysis patient deaths and cardiac incidents are significantly more frequent on the day after the two-day gap between treatments that occurs with three dialyses in the seven-day week."
From Medicare's point of view, though, the End Stage Renal Disease Program "is a pretty expensive program, and it needs the best justification imaginable that more dialysis would be better," says Eggers, the kidney disease institute epidemiologist.
Most of the evidence that longer and/or more frequent dialysis is superior has come from observational studies, in which patients decided on their own to try it. Perhaps some characteristic of the patients who choose to dialyze at home or overnight in a center — and not the dialysis itself — explains why they feel better and require less hospitalization than patients at centers.
A randomized trial, in which patients are randomly assigned to a particular therapy, is generally considered the gold standard for comparing treatments. Eggers is the project manager for two such dialysis trials, funded by the National Institutes of Health. One is comparing traditional thrice-weekly, four-hour dialysis treatments with six short daily treatments, adding up to about 16 or 17 hours a week. The other is comparing the traditional in-center approach to six nocturnal, or overnight, treatments a week.
Yet, neither of the trials enrolled as many patients as had been hoped, Eggers says, and he figures he knows why. "You have to go to a patient and say, 'here is something that you do three times a week that you hate,' " he says, and then tell them that they might have to do it twice as often. "It's a pretty significant thing you're asking a patient to do without a huge guarantee."
Because of the studies' limited size, they won't be able to determine conclusively whether more dialysis saves lives, Eggers says. "We might show that patients feel a lot better and have better heart function."
Blagg says he is so convinced of the benefits of more dialysis that he felt it was unethical to enroll patients in Eggers' trials, in which they had a 50-50 chance of getting the standard treatment.
30% could be treated at home
Home is a convenient setting for longer or more frequent treatments. About 30% of U.S. dialysis patients are candidates for home treatment, though only 8% now do it, Blagg says. By comparison, about 55% of dialysis patients in New Zealand dialyze at home, as do 30% in Australia and 20% in Canada.
Some U.S. patients don't even know home dialysis is an option. To fix that, Congress passed a law last year requiring dialysis providers to tell patients about all dialysis methods, beginning Jan. 1.
Home dialysis may also be more cost-effective, according to a May report by the U.S. Government Accountability Office which collected information from the large for-profit chains and non-profit and hospital-based dialysis providers. All of them said their per-treatment costs are lower when patients dialyze at home.
Centers recoup the "serious upfront costs," mainly for the machine they provide, after the patient has been dialyzing at home for a year or 18 months, Blagg says.
J. Michael Lazarus, Fresenius Medical Care North America's chief medical officer, says he wishes more patients would dialyze at home, because it would cut his company's overhead and help it deal with a nursing shortage. But, he says, home dialysis is a hard sell to U.S. patients. "When you build enough dialysis units so there's one on every corner," Lazarus says, patients think " 'why should I go home when I can go to your dialysis unit that's 10 minutes away?' "
Some patients find home dialysis too disruptive for their families. After doctors in 2007 had to remove the kidney her oldest son had donated to her, Michelle Adams-Walton, 46, tried hemodialysis at her Seaside, Calif., home for a couple of months. Her youngest son, now 20, served as her dialysis partner, a requirement for home dialysis.
"That machine did not work out for me," Adams-Walton recalls. "We were both starting to feel the dialysis was taking over our entire lives." However, she says, she had seen enough evidence to convince her that the more dialysis, the better. For her, nocturnal dialysis has been the answer.
On Mondays, Wednesdays and Fridays, Adams-Walton, who works full time as a librarian, drives 90 minutes to one of the few centers set up to provide overnight treatment. She goes on the machine at about 8 p.m. and is taken off at 4 a.m. Then she drives home and tries to catch some more sleep.
Since starting nocturnal dialysis, she says, "I certainly feel so much better." Before, "I was able to function, but just function."
What happens next
Congress has ordered Medicare to revamp the current pricing system. Payments for injectable drugs and lab tests not currently covered by the composite payment are to be "bundled" into it, effective Jan. 1, 2011. Details aren't expected to be released for a few weeks, so the potential impact on dialysis care is difficult to predict.
The open questions:
• Will Medicare keep home dialysis training costs outside the composite payment? Home dialysis advocates fear that rolling such costs into the bundle will discourage centers from offering the home option.
• Will the expanded composite payment be based on what Medicare already pays for dialysis and injectable drugs? That wouldn't result in any savings but could lead to an excessive reduction in the drugs' use, says Bill Peckham, 45, a Seattle dialysis patient and blogger.
• Will Medicare start paying on a weekly or monthly basis, instead of per treatment? Peckham fears that would lead to fewer, not more, treatments.
Straube of CMS emphasizes that a "quality incentive program" will accompany the new payment structure. Instead of paying only on the basis of quantity, he says, Medicare will also begin rewarding dialysis providers on the basis of quality standards, such as how well they manage patients' side effects.
Lazarus, of Fresenius, predicts "a number of (dialysis) units will close because of the bundle. Where are they and who's going to be deprived?" If they're rural, for example, that could greatly impact some patients.
Still, expanding the composite payment is "the right move," Lazarus says. "We have to do something about cost. We have to do something with a system that's out of control. It's a broken system, and we need to fix it."
Find this article at:
http://www.usatoday.com/news/health/2009-08-23-dialysis_N.htm
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okarol, I agree it is a great article. However, I'm not sure it's legal to post it in its entirety. I would suggest that you contact USA Today for permission to post it here. Since there's no money in this site, I wouldn't be surprised if they agreed to it.
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I think the article does a good job explaining the unexplainable. The one issue with the article is that readers might be left to think that the 8% on home dialysis are all doing home hemodialysis since PD isn't mentioned. I think the author made the decision to avoid adding yet another layer of confusion by not bringing up PD but she could have instead said hemodialysis instead of dialysis, then continued by saying over 98% of people on hemodialysis dialyze conventionally incenter. It's a quibble, overall a good article.
okarol, I agree it is a great article. However, I'm not sure it's legal to post it in its entirety. I would suggest that you contact USA Today for permission to post it here. Since there's no money in this site, I wouldn't be surprised if they agreed to it.
USA Today isn't the AP - non commercial use falls under fair use.
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My husband brought the paper home this morning to show me the article. Of course, he had no idea that Bill is one of our members. Great article. :2thumbsup;
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It is a great article. It does not however show how much the CEO's take home in pay. It does not say how much a Nephrologist makes everytime he says "hi - ya doing ok". It does not say how that little visit ignores the HIPPA Rules of privacy.
Too damn much I say! Are they willing to take a 20 million a year cut and only take home 5 million?
Gee, ya think?
If we could start over and have caring people who can live on a medium income, more and better dialysis would be no problem in the current Medicare budget.
Can you say GREED? The article does touch on that and I was glad.
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This article seems to be addressing the fact that under the current system in the US, dialysis treatment is indeed rationed (think of butter and egg rationing during the war). That is to say, we each get some but not as much as is actually enough.
I would also venture to say that this will always be a facet of any health care system since the bottom line is that the demand outstrips the current supply and that gap continues to grow. Each society must address this issue as best they can and the system chosen to deliver this care will be, to a significant degree, reflective of the values of that society.
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Monrein reading the comments (to the article on the USA Today site) it was interesting how many people wrote how: should healthcare reform pass we'll all be given hospice instead of dialysis. I think many of the commenters would be shocked to know that not dialyzing is always presented as an alternative. It has been an alternative since the very earliest days of outpatient treatments.
Knowing what we know about the provision of dialysis is clear how easily change can be misrepresented. How baseless fears can be stoked.
Rerun I think you're right. Greed is at the center of this - no one (private insurers or providers) are interested in keeping costs down because as revenue increases, their margins have to be maintained, so everyone's net revenue increase along with prices. Increasing costs are how everyone involved increases their net income. No one is interested in decreasing total revenue.
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Finally! I'm in the funny papers :clap; I thought that article was never going to appear. I'm sure my family and co-workers thought I was making it all up, hehehe.
Only a little bit of what I said during the interview ended up in the article, but I'm glad I didn't embarrass myself by saying that the techs at my center are so hot I want to "drop trou" each time they want to take my temp. hehehe...
J/K
Seriously, though. I think this is the time to make our voices heard and to put a "human" face on the issues chronic kidney disease patients endure.
Michelle Adams-Walton aka Treasure....
<----------- line forms to the left for autographs. hehehe
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:2thumbsup; Hey treasure - I didn't know that was you!
I'd like an autographed 8 X 10 glossy please! :bandance;
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Which body part, lovey? :rofl;
I really do think I should get a picture of one of my kidneys (I'm sure there are dozens in my medical records) and autograph that and put it up on Ebay...or take PayPal payments. hehehe... But because you were the first request, yours is on the house. hehehe...
Ah, a whole new way of kidney disease fundraising.
Ooooh, how about a fistula calendar!
Sorry, got a bit off track, hehehe.
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Very informative article reaching the masses.
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A Fistula Calendar?
:rofl;
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:2thumbsup; Hey treasure - I didn't know that was you!
I'd like an autographed 8 X 10 glossy please! :bandance;
I didn't know that was you either Treasure. Any idea how the reporter found you? Now I assume the person pictured is an IHD member too but is on the down low.
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A Fistula Calendar?
:rofl;
My fistula is such a sweetie, I get to be Miss February!
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:2thumbsup; Hey treasure - I didn't know that was you!
I'd like an autographed 8 X 10 glossy please! :bandance;
I didn't know that was you either Treasure. Any idea how the reporter found you? Now I assume the person pictured is an IHD member too but is on the down low.
Rita found me through my Nitey Nite Nocturnal Dialysis blog. She emailed me for the first time a couple of months ago, and asked if I would consent to an interview. I think she was amused by my musings.
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Some recent reader's replies to the article:
http://blogs.usatoday.com/oped/2009/08/letters-gentler-dialysis-also-can-help-kidney-failure-patients-.html
'Gentler' dialysis also can help kidney failure patients
William Dickerman - Rindge, N.H.
USA TODAY's article about kidney dialysis failed to mention continuous ambulatory peritoneal dialysis (CAPD), which is both gentler on patients and less expensive than traditional hemodialysis ("Dialysis treatment in USA: High costs, high death rates," Cover story, News, Monday).
I experienced kidney failure in 1987 at age 43. After a short period of hemodialysis, my nephrologist recommended CAPD, a form of dialysis in which the patient "carries" about 2 liters of dialysis fluid in his abdomen at all times. Four times a day, at home or anywhere, the old dialysis fluid is drained out through a permanently implanted plastic tube and replaced by new fluid through the same tube. The fluid exchange is painless and takes about 40 minutes, time that can be used for reading or writing. Because the dialysis is continuous, the patient feels better and can eat a more varied diet than is allowed for hemodialysis patients.
While on CAPD, I was able to work full time at a job that included leading hiking and camping trips, skiing and teaching swimming, activities that aren't possible with the exhausted feeling one often has on hemodialysis. Less than a year after starting dialysis, I was lucky to receive a new kidney.
A transplant is far better than any kind of dialysis, but CAPD is a form of dialysis that can give back an almost-full lifestyle that is out of reach for most hemodialysis patients.
Universal coverage model
Kam Kalantar-Zadeh, M.D., Ph.D. - Torrance, Calif.
USA TODAY's article reported some negative comments about dialysis treatment in the USA, but the Medicare End Stage Renal Disease (ESRD) program is a significant development in U.S. health care and a success.
To be eligible for coverage, patients diagnosed with kidney failure need to be insured under Social Security or a dependent family member of a Social Security beneficiary. Kidney failure patients not yet eligible for Social Security benefits usually are covered by Medicaid. Virtually all of the 400,000 patients with kidney failure in the USA have access to maintenance dialysis treatment and inpatient services regardless of age or other condition. It is unfortunate that the program — established in 1972 remains our nation's only universal health coverage not dependent on age, albeit limited to this diagnosis.
The program has worked well, and its success should provide the impetus for replacing our present fractured health care financing system with one that provides universal coverage for all U.S. residents regardless of age. The Medicare ESRD program has been working. The time has come to expand its universal coverage to the rest of the uninsured population.
Some fall through gaps
Susan Brown - Las Cruces, N.M.
I went to a dialysis center from May 2002 to June 2005 and during that time was covered under the Medicare End Stage Renal Disease program and my personal insurance. I received my transplant June 1, 2005. Medicare covered my anti-rejection drugs for three years.
When I lost that coverage July 1, 2008, I had to put the cost of my anti-rejection drugs, about $965, on my credit card. If you are younger than 65, you lose your Medicare coverage three years after your transplant.
A bill has been introduced in Congress to extend coverage of anti-rejection drugs. A lot of individuals cannot afford to pay for the medication without Medicare. They end up rejecting the transplanted kidney and go back on Medicare-covered dialysis, and the cycle repeats.
It is wrong for Congress to reduce benefits to individuals with chronic kidney ailments.
Access to transplants
Mark Haas, M.D., Ph.D., Renal pathologist - Los Angeles
Unfortunately, USA TODAY's article detailing the high cost, high mortality and low quality of life associated with dialysis treatment in the USA fails to emphasize a viable alternative to dialysis for treatment of patients with end-stage kidney failure: kidney transplantation. Sure, transplantation is expensive, but as the article points out, so is dialysis. Compared with individuals on dialysis, kidney transplant recipients on average live significantly longer and lead higher quality, more productive lives, freed from the dialysis machine.
Furthermore, medical advances make kidney transplantation safer for older individuals and even people who, because of having antibodies to potential donors, could not receive a transplant just a decade ago, and donating a kidney now involves a relatively minor surgical procedure rather than a major operation.
Clearly, doctors and patients need to do better in preventing chronic kidney failure, but for those people already suffering from this condition, perhaps we as a society would be better served by focusing more of our attention — and dollars — on further improvements in kidney transplantation and increasing rates of organ donation, thus making this procedure more accessible.
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hwells (0 friends, send message) wrote:21h 39m ago
I am a 57-year-old living with end-stage renal disease (ESRD). I’ve survived PD (Peritoneal Dialysis), a transplant, in-center thrice weekly hemodialysis, and now I thrive on daily home hemodialysis with the NxStage System One. The difference in my health and quality of life has enabled me to resume normal living.
Over the last two years, along with my two grandsons, I've travelled all over the United States covering over 25,000 miles visiting over 50 dialysis centers in 37 states with my NxStage machine, helping to bring awareness to the availability of more frequent, daily dialysis with this portable therapy.
The problem with dialysis care in the United States is getting the information out there so dialyzers and/or their caregivers are adequately aware of the benefits of each modality and being able to determine which therapy or modality is best for them. I've been fortunate to have good decisions made for me but sadly, this is not the case for a majority of those in the dialysis community.
Last year the Department of Health and Human Services released the Final Rule for Medicare and Medicaid Programs; Conditions for Coverage for End Stage Renal Diseases Facilities that required everyone on dialysis be informed about all treatment modalities even if that particular modality was not available at that particular center. It’s my belief that this is not being done adequately for a variety of reasons.
I’ve experienced the benefits of more frequent, daily dialysis. When I’ve demonstrated the simplicity of home hemodialysis treatment options at dialysis centers the response of nurses, dialysis technicians, administrators, social workers, doctors, staff and patients are almost always very enthusiastic. While the process requires a moderate amount of intensive training, treatment becomes routine over a period of time because you repeat it daily (5 or 6 days a week). Like learning to drive a car, cook or your job, learning how to provide your own dialysis treatments can be done with the support and training of your dialysis center staff.
Thank you for publishing this story and helping to bring awareness to what I believe is better dialysis care. While transplantation is considered to be the optimum therapy of renal replacement today, it’s because the majority of dialysis care is inadequate. Statistical information available today show survival and transplant rates are higher among kidney disease patients doing more frequent therapy. In short, daily more frequent dialysis provides better outcomes and that’s been proven true by almost everyone that’s experienced daily dialysis.
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Cross posted from DSEN
The USA Today article was good but there are nits to pick (http://www.billpeckham.com/from_the_sharp_end_of_the/2009/08/the-usa-today-article-was-good-but-there-are-nits-to-pick.html)
Coming home from the meeting (http://www.billpeckham.com/from_the_sharp_end_of_the/2009/08/talking-dialysis-reimbursement-in-la.html) Saturday, I took Sunday off. I went back to bed after I got off dialysis. Two days of discussing dialysis reimbursement and the politics of healthcare left me spinning and spent. In that state reading the USA Today article by Rita Rubin Dialysis treatment in USA: High costs, high death rates (http://www.usatoday.com/news/health/2009-08-23-dialysis_N.htm) was refreshing. The article was a great overview (http://www.usatoday.com/news/health/2009-08-23-dialysis_N.htm) of a program I just spent two days discussing but one comment in the article seemed out place. It's in the side bar on prevention where I too am quoted:
J. Michael Lazarus, Fresenius' chief medical officer, says: "Every nephrologist would love to see patients earlier. But nobody sends them. … I've seen them in the emergency room at the end." That's because many rarely have seen any kind of doctor, let alone a kidney specialist, he says. End-stage renal disease "is a disease of the indigent," he says. "They show up because nobody treated their hypertension, nobody treated their diabetes."
"renal disease "is a disease of the indigent,"? Really?
I don't think the way that reads reflects what Dr. Lazarus believes. He knows severe CKD is an equal opportunity disease - I know this because I've spent time with him so I know he knows me. Seriously though, I think it's likely he was saying that poverty is a risk factor for severe CKD. That those who are indigent are disproportionately likely to need dialysis. I don't think my quote in that box reads quite right either:
"It's kind of immoral the way it works now," says Bill Peckham, 45, a dialysis patient and blogger in Seattle. Though about one in five dialysis patients die every year, Peckham says, "you keep the chairs filled with new people, because Medicare doesn't show up until you're in the dialysis unit."
I'm don't think I said those statements in proximity to each other.
I believe the immorality was in reference to the way people are funneled into conventional dialysis - the lack of informed consent. And the second part doesn't sound like how I normally state the problem. Those are three points I make but I don't think they are related in the way the sentence makes it out.
If I had to guess Rita Rubin didn't write the side bars.
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"So why doesn't the USA do better? Many blame Medicare's End Stage Renal Disease Program."
I can recall a time period I found in the USRDS stats from '91 to '01 where the number of dialyzors doubled, the costs tripled, and deaths were up 123%. Now what occurred during that time period? Wasn't that about the time the for-profits were taking over? Nah, that couldn't be it, running off RNs and short treatments have been a wonderful thing. Why should I think the for-profits should have part of the blame.