I Hate Dialysis Message Board
Dialysis Discussion => Dialysis: General Discussion => Topic started by: Hemodoc on December 27, 2010, 03:37:50 PM
-
A Tale of Two Cities: The Story of Dialysis in America
By Peter Laird MD,
The influences of two cities in America during the last fifty years is the tale of two cities taking the technology of dialysis in two different directions. Truly, "It was the best of times, it was the worst of times..." Dr. Scribner in Seattle started the entire field of chronic hemodialysis by his inspiration in the middle of the night for the Scribner Shunt.
Belding Scribner: The Inventor of Shunt Dialysis
Scribner came upon his idea in 1960 after he saw a young man recover briefly following dialysis, only to die a few weeks later. At the time, haemodialysis could only be performed for a few cycles. In a painful procedure, glass tubes were inserted into a patient’s blood vessels, permanently destroying them for further access.
The patient weighed on Scribner’s mind until one night when he suddenly awoke with an idea of how to save patients with end stage kidney disease. He would fashion a loop between an artery and vein, allowing the device—rather than the patient’s own vessels—to be opened and closed with each cycle of dialysis. that it was just like turning on the light from the darkness.”
Dr. Scribner, a patient in his own right from chronic eye problems, immediately freely gave his invention to the medical world for one sole purpose, to save lives, profiteering never entered his mind. This gift followed the example of Wilhelm Kolff, the inventor of the first workable dialysis machine who freely gave his invention to the medical world to save lives as well.
Kolff’s machine is considered the first modern drum dialyzer, and it remained the standard for the next decade. At the time of its creation, Kolff’s goal was to help kidneys recover. The brave doctor had no way of knowing that his invention was one of the foremost life-saving developments in the history of modern medicine.
After World War II ended, Kolff donated the five artificial kidneys he’d made to hospitals around the world, including Mt. Sinai Hospital in New York. Because of this unselfish act, doctors in many countries were able to learn about the practice of dialysis.
Wilhelm Kolff gave the blueprints of his machines to Dr. Thorn at Peter Brent Brigham Hospital in Boston. They shipped 22 of these machines updated at Brigham hospital around the world between 1954 and 1962. Yet, it was not until Dr. Scribner invented his shunt that chronic hemodialysis beyond one or two treatments became a reality. Dr. Scribner immediately set out on his most important mission, to make this new technology widely available and he was the driving force behind the 1973 Medicare legislation initiating the ESRD Medicare program. The Seattle experience brought forth the new field of bioethics and the first dialysis unit opened which still operates now as the Northwest Kidney Center in Seattle, a non-profit organization that is still a leader in dialysis inovation today.
However, in Boston, a new corporation sprang forth from among the Peter Brent Brigham doctors called National Medical Care, Inc. After two years, in 1970, it became the first for-profit dialysis company. The era of altruistic innovations gave way to the era of grand profiteering on a monumental scale. Despite its initial humble beginnings with the Kolff-Brigham machine, Boston would become the most influential center of dialysis making the goals of for-profit dialysis as the standard of care in America.
Dr. Edmund G. Lowrie, in a 1978 Medicare hearing changed the face of dialysis in America from predominantly a home based therapy given three nights a week for a total of 27 hours, into the current ultra-short hemodialysis of 3-4 hours sessions, thrice weekly.
The politics of health cost containment: end-stage renal disease
R.A. Rettig (pages 132-133)
Dr. Edmund Lowrie of Peter Brent Brigham Hospital attacked the Seattle experience directly on two points: "our analysis indicates that the cost of self-care dialysis is not significatly less than limited care dialysis, and that the the indiscriminate use of home dialysis may lead to unacceptable patient mortality." . . . "After careful analysis," Lowrie claimed, "the only obvious reason for this inferior patient survival that we can think of is the indiscriminate use of home dialysis therapy." Lowrie's testimony created the impression that three-year survival ofhome patients in Seattle was unacceptably low. But as Blagg later pointed out, the 58% applied to all Seattle patients, center and home, and inclued elderly and diabetics insignificant numbers.50 "When we look at patient survival on home dialysis ," Blagg wrote, "and exlude the center dialysis patients, the 3-year survival in our program is 74 percent including diabetics; if we exlude diabetics, the 3-year survival rate in pateints aged 55 of less is 81 percent on home dialysis. . .
But the political damage had been done.
The cast was set once again by Edmund Lowrie, et al after the Boston based NCDS ( NCDS: Revisited Three Decades Later) pronounced Kt/V as the best measure of dialysis "adequacy" and for the next thirty years, outcomes in America plummited to the lowest of all developed nations while at the same time, the predominantly home based American therapy given to us from the Seattle model of care passed over to the Boston model of care in for-profit centers giving short, thrice weekly treatments. At the time of the hearings in 1978 on the future of dialysis in America, where the best model we know today of home based, long nocturnal therapies, fell at the hand of what we now know is the incorrect testimony by Edmund Lowrie that in-center care was better, Dr. Lowrie was a high ranking corporate officer in the for-profit dialysis chain, National Medical Care, Inc. Indeed, he later became the president of this corporation. In response to the 1995 Kurt Eichenwald NY Times article, Death and Deficiency in Kidney Treatment, the dialysis industry responded in a letter to the editor: "There is no evidence that an adequate Kt/V delivered in 2.5 hours in[sic] inferior to the same dose delivered inefficiently in 4 or 5 hours. We believe it is to everyone's advantage - patient, provider and payor - to deliver high quality dialysis efficiently at a time of limited resources."
The story of National Medical Care, Inc. in my opinion, is one of obscene profits soon after the ESRD Medicare program began paying for all dialysis care in America . Even Jack Anderson, the prototypical investigative reporter of decades past took notice of the "padding" of dialysis costs by National Medical Care, Inc: Clinics Pad Kidney Dialysis Costs.
The story of dialysis in America truly follows the tale of two cities, that of Seattle giving us chronic hemodialysis, thrice weekly overnight at home for 27 hours weekly, it gave us the first non-profit dialysis center, started the field of bioethics, and has continuously fought against those that have instead turned dialysis into one of the most outlandish profiteering medical schemes in history. Boston, on the other hand ultimately gave us National Medical Care, Inc., the NCDS and those that reduced a life saving technology done best at home into one, in my opinion, of death, despair and disability that we now own today as our American legacy of dialysis for the simple reason, in my opinion, of turning the highest profits. Improving dialysis care in America today can best be accomplished by simply turning time back to the Seattle model of care.
The Boston experiment of dialysis care in America is a failed trial of medical care at best founded on the for-profit industry standards. We can do better here in America, and it is my hope that we shall.
http://www.hemodoc.com/2010/12/a-tale-of-two-cities-the-story-of-dialysis-in-america.html
-
I just posted this query on your blog. What can we patients do, right here right now, to fight this descent into dialysis-for-profit hell? I don't know when I will have to start dialysis, but when it's time, what can I do not only for myself but also for other patients who may have to do incenter D because no other alternative is viable? How do we change the template from what Boston gave us to what Seattle offers?
-
Well written. Thank your for sharing this very interesting prospective. Excellent article. I have no experience with dialysis treatments, or costs in the U.S, but I can say after visiting our center here in Oshawa Ontario, Canada, I was very impressed with the staff, the quality of our facility, and the options offered to patients.
Here in Ontario, OHIP, (Ontario Hospital Insurance Plan) provides all the funding for our dialysis centers. I, like many of my fellow Canadians do not examine health care costs as a factor determining my quality of care. The system here changes your expectations when it comes to health care services. We all pay, its not optional, and we pay dearly. In return, we expect world class care, and we expect our health care system to "spare no expense" if we need care. Money certainly changes the game, and because I live in Canada, its very hard to imagine what life would be like if I couldn't afford to get sick.
Since the frequency and duration of dialysis is known to improve the quality of treatment, it seems many will be looking to change the way they receive their treatments. Please keep the supporting articles that are strengthening this position coming. Your knowledge and experience have given you a very unique opportunity to change the future of dialysis in both Canada and the U.S. Again, great work.
-
So Mark, what is the usual schedule for a typical dialysis patient in Canada? Is it not the thrice weekly in-clinic scenario? Do Canadians get more frequent in-clinic dialysis that's paid for by your health system?
-
Great post Peter. Those of us who have lived long enough to be on both non-profit dialysis and for-profit dialysis can testify to this truth. It has gone to hell and these dialysis centers are making tons of money off Medicare and sick people.
I know my center has fought to keep it's Nocturnal shift but I like it and feel better than just 12 hours a week.
-
Very interesting article, Doc. Thanks.
-
I have heard stories on how the previous clinic I attended changed dramatically after it gobbled up by a huge conglomerate. My friends who went there before the change preferred the non-profit than whats happening now.
-
While I was visiting the center for my pulse treatments, (three days in a row) I met a woman there who told me she comes 3 times a week, but the center was very flexible and she could make adjustments to the schedule as required. It was interesting to me that the center was so accomodating for her. I think most people still do the minimum dialysis routine, since this is what is typically offered. The center I visited did have patients doing more than the typical 3 days a week.
Its probably not going to change overnight, but as more and more people show the benefits of more frequent, slower dialysis, the centers will have to accomodate the patients. The article written here goes a long way to showing how the medical profession has an opportunity to do the right thing, and treat the patient based on their needs, not the cost. I will check with our center on my next visit what schedules they provide to accomodate for patients.
-
mm2010, why do you think that the "minimum dialysis routine" is what is typically offered? Why is optimal dialysis not the "typically offered" way to go?
I don't mean to sound skeptical, but why do Canadian centers have to accomodate the patients? Do dialysis patients have that much power in Canada? If so, that's just wonderful! The benefits of more frequent, slower dialysis are beyond debate, so who in Canada says otherwise (that goes back to my first question of why is this not the typically offered treatment?)?
-
very interesting article...goes along so well with my "soapbox" as to the amounts that are "billed" vs. the amounts that are "allowed" and paid. The difference is a tax write-off for those corporations (we are supported through one of the biggest) and the patient care so often seems to be more affected by the amount that can be billed rather than what is best for the patient.
-
mm2010, why do you think that the "minimum dialysis routine" is what is typically offered? Why is optimal dialysis not the "typically offered" way to go?
I don't mean to sound skeptical, but why do Canadian centers have to accomodate the patients? Do dialysis patients have that much power in Canada? If so, that's just wonderful! The benefits of more frequent, slower dialysis are beyond debate, so who in Canada says otherwise (that goes back to my first question of why is this not the typically offered treatment?)?
There is a puzzle. There is no unit in the world that is open seven days a week, no national system based on units being open seven days a week. To my knowledge every provider closes one day a week. This means that you might be able to get an extra run but it won't be routine, it isn't likely to be at your normal time or at a predictable time because you'll be fit in. To get four treatments in a week you'll need to run two days in a row: M-W-F with Saturday added on. Or T-T-S with an extra Monday for example.
In Australia it is routine to dialyze every other day at home but not incenter. Never incenter. Why? These are health systems where hospitalization and dialysis costs are paid out of the same pocket - there is no Part A/Part B wall as there is with Medicare. I would predict that routine EOD dialysis would save its cost in hospitalizations, yet no health system has tried keeping units open 7 days a week. So, it is a puzzle.
-
I find it fundamentally stupid to close any facility on any day if that facility that gives lifesaving treatment. Why don't we shut hospitals one day a week?
Gosh, department stores are open seven days a week. There are retail outlets that are open 24/7/365. Is shopping more life-sustaining than dialysis? I guess we as a society have decided that is indeed so.
-
Thanks for posting Dr. Laird. I am always shocked by the way Americans stand by their horribly dysfunctional system of care, and even claim that it is superior to other systems. The pursuit of profits can have devastating effects on the quality of medicine. The failure to include a public option in "Obamacare" will ensure that profit seeking corporations will continue to dominate medicine and that America will be permanently bifurcated into medical haves and have-nots. Thoughout the debate on health care reform, Republican scare mongers warned of "Canadian style" health care and its attendant failures. Yet Canadians are overwhelmingly satisfied with their health care and any politician who attempts to fundamentally change the system will soon be voted out of office. The father of Canadian universal health care, Tommy Douglas, was recently voted the "greatest Canadian" in a CBC television series to determine the greatest Canadian of all time.
It will be a long, long time before the United States has anything resembling effective and equitable health care. And if they ever decide to control handguns and discontinue capital punishment they will be well on their way to joining the civilized world.
-
The failure to include a public option in "Obamacare" will ensure that profit seeking corporations will continue to dominate medicine and that America will be permanently bifurcated into medical haves and have-nots.
It's worse than that, though. The current system will continue to ensure that the "haves" can be instantly turned into the "have nots" should they be struck down by a devastating illness or accident.
How the majority of US dialyzors receive dialysis is dictated purely by cost, not by health benefits. We could argue the case of universal health care until the cows come home, but most dialyzors in the US ARE receiving "universal health care", ie Medicare, yet we still are not getting optimal dialysis.
My question remains, then for Canadians...yes, you have universal health care, but does it give you optimal dialysis or just adequate dialysis? Can any dialyzor in Canada have any dialysis they want in whichever setting they want, and if so, will it all be paid for?
-
How the majority of US dialyzors receive dialysis is dictated purely by cost, not by health benefits. We could argue the case of universal health care until the cows come home, but most dialyzors in the US ARE receiving "universal health care", ie Medicare, yet we still are not getting optimal dialysis.
My question remains, then for Canadians...yes, you have universal health care, but does it give you optimal dialysis or just adequate dialysis? Can any dialyzor in Canada have any dialysis they want in whichever setting they want, and if so, will it all be paid for?
Universal dialysis through Medicare is dramatically different from universal health care. My medical team does not just provide dialysis, but is concerned with my long-term health and well being. Once dialysis is economically isolated from the rest of medicine there is no financial incentive to avoid medical complications and hospitalizations. If a dialysis provider is paid the same rate for six hours of treatment as for three and a half, why would they offer the longer treatment? One of the keys to the efficiency of Canadian care is the willingness to act preventatively, at some cost today, to save other higher costs later on. Canadians can't have "any dialysis they want in whichever setting they want", but there are very strong incentives to keeping patients as healthy as possible. In my hospital, the dialysis schedule is often tailored to the patients' needs. For example, a woman who became pregnant while on dialysis was given dialysis six times a week for two and a half hours (her son is now a teenager). There will always be limits to patient care regardless of the structure of the health care system, but unfortunately in the United States such limits are for the benefit of the insurers and medical companies, not for the collective welfare of patients.
-
How the majority of US dialyzors receive dialysis is dictated purely by cost, not by health benefits. We could argue the case of universal health care until the cows come home, but most dialyzors in the US ARE receiving "universal health care", ie Medicare, yet we still are not getting optimal dialysis.
My question remains, then for Canadians...yes, you have universal health care, but does it give you optimal dialysis or just adequate dialysis? Can any dialyzor in Canada have any dialysis they want in whichever setting they want, and if so, will it all be paid for?
Universal dialysis through Medicare is dramatically different from universal health care. My medical team does not just provide dialysis, but is concerned with my long-term health and well being. Once dialysis is economically isolated from the rest of medicine there is no financial incentive to avoid medical complications and hospitalizations. If a dialysis provider is paid the same rate for six hours of treatment as for three and a half, why would they offer the longer treatment? One of the keys to the efficiency of Canadian care is the willingness to act preventatively, at some cost today, to save other higher costs later on. Canadians can't have "any dialysis they want in whichever setting they want", but there are very strong incentives to keeping patients as healthy as possible. In my hospital, the dialysis schedule is often tailored to the patients' needs. For example, a woman who became pregnant while on dialysis was given dialysis six times a week for two and a half hours (her son is now a teenager). There will always be limits to patient care regardless of the structure of the health care system, but unfortunately in the United States such limits are for the benefit of the insurers and medical companies, not for the collective welfare of patients.
And yet the Canadians close their dialysis units once a week just like everyone else. And just like everyone else they see an increase in hospitalizations and sudden deaths during the forced weekend.
-
In my hospital, the dialysis schedule is often tailored to the patients' needs. For example, a woman who became pregnant while on dialysis was given dialysis six times a week for two and a half hours (her son is now a teenager). There will always be limits to patient care regardless of the structure of the health care system, but unfortunately in the United States such limits are for the benefit of the insurers and medical companies, not for the collective welfare of patients.
What you say about the US system is absolutely true. But I would like some clarification on what the Canadian system actually provides. So, in your hospital, the dialysis schedule is "tailored". That's great if you are pregnant and your needs therefore change, but does this tailoring apply to all patients at any time they wish? What if you become an informed dialyzor and come to realize that longer and more frequent sessions are better for your health...will you get those longer and more frequent sessions? And why are there "always limits" to patient care? Why does there have to be a limit to optimal dialysis? Who gets to make that call?
Let's talk about limits. Yep, such limits in the US ARE for the benefit of whoever stands to make a profit, but if you are saying that limits in Canada are for the "collective welfare of patients", well, I need to ask how limiting dialysis is in the collective welfare of said patients.
-
I can remember 25 years ago with the OLD Drake Willock Machines I could only STAND 3 hours! They were LOUD and the blood pump clicked every revolution! The lines would jump with each turn of the blood pump and you could not set the machine to take off a certain amount of fluid so you usually crashed! It was awful.
So it was such a gift to have high flux dialysis. I think that now we have nicer machines and all that we are coming around to longer dialysis.
-
MooseMom, one of the reasons 4hx3d of dialysis is standard for in-centre treatment in Canada as well is that patients do not want to spend more time hooked up. I have met patients who are getting more treatment time in-centre, but it is rare. I don't know if it is available just for the asking.
In the U.S. the limits of health care are determined by the profitability of private medical enterprises and the willingness of Medicare/Mediacade to provide funding. In Canada the limits are determined by the scarcity of resources and the allocation of limited tax dollars toward health. The system works best when money is spent to get the greatest possible value. Limiting dialysis may not be in the best interests of the dialysis patient, but it may enable more spending in other areas where better value can be obtained. It may be in the interests of patients collectively. It would be interesting to know how long term outcomes differ when patients get four, five and six hours of dialysis and what the associated costs are. One of the benefits of longer dialysis is less anemia and therefore less need for EPO preparations, which are costly.
-
MooseMom, one of the reasons 4hx3d of dialysis is standard for in-centre treatment in Canada as well is that patients do not want to spend more time hooked up. I have met patients who are getting more treatment time in-centre, but it is rare. I don't know if it is available just for the asking.
How many Canadian dialyzors know that longer, slower dialysis is better for their long term health? No one wants to be hooked up longer than is necessary, but now many Canadian patients are educated in the benefits of longer dialysis? Do they know they can ask for better treatment? How many patients do you think would ask for better dialysis if they knew it was freely available? What kind of pre-dialysis education does the Canadian system pay for?
In the U.S. the limits of health care are determined by the profitability of private medical enterprises and the willingness of Medicare/Mediacade to provide funding. In Canada the limits are determined by the scarcity of resources and the allocation of limited tax dollars toward health. The system works best when money is spent to get the greatest possible value. Limiting dialysis may not be in the best interests of the dialysis patient, but it may enable more spending in other areas where better value can be obtained. It may be in the interests of patients collectively. It would be interesting to know how long term outcomes differ when patients get four, five and six hours of dialysis and what the associated costs are. One of the benefits of longer dialysis is less anemia and therefore less need for EPO preparations, which are costly.
There are ample studies that prove that longer dialysis gives better results. It only makes sense...longer dialysis more closely replicates normal renal function. I don't think, however, that longer dialysis reduces anemia. Hormone production is not something that a dialysis machine can do. What longer dialysis DOES do, though, is better clear toxins and, more critically, reduces the cardiovascular stresses caused by rapid fluid removal/fluid overload.
It doesn't really matter from where the limits originate, whether it is from corporations or from the public good if you are the one whose life is being undervalued. If you are the one who depends on dialysis to live, I don't think you are going to go to bed at night thinking, "I'm ok with getting less than optimal dialysis because I know there are other people who need tax dollars spent on their health, too. If my treatments are keeping me alive but are causing damage at the same time, I'm ok with that because the public will somehow benefit. And if the public have decided they are willing to risk having to spend even more money on me in the long run rather than a bit more now, that's just fine."
Who gets to decide upon the definition of "better value"? It seems to me that if a patient needs blipomycin to live, but blipomycin gradually causes death after expensive hospitalizations, but by adding flopomycin you can reduce those bad results, you give flopomycin, too, because a bit more money spent now saves a lot of money down the line. That's "better value", but that's not usually the way that politicians think.
-
MooseMom, one of the reasons 4hx3d of dialysis is standard for in-centre treatment in Canada as well is that patients do not want to spend more time hooked up. I have met patients who are getting more treatment time in-centre, but it is rare. I don't know if it is available just for the asking.
In the U.S. the limits of health care are determined by the profitability of private medical enterprises and the willingness of Medicare/Mediacade to provide funding. In Canada the limits are determined by the scarcity of resources and the allocation of limited tax dollars toward health. The system works best when money is spent to get the greatest possible value. Limiting dialysis may not be in the best interests of the dialysis patient, but it may enable more spending in other areas where better value can be obtained. It may be in the interests of patients collectively. It would be interesting to know how long term outcomes differ when patients get four, five and six hours of dialysis and what the associated costs are. One of the benefits of longer dialysis is less anemia and therefore less need for EPO preparations, which are costly.
That doesn't hold up because going every other day should decrease spending on hospitalizations. For a Canadian provence to offer EOD dialysis would cost around $3,000/year. I would bet that an EOD schedule would on average save a hospitalization which on average costs more than $3,000.
It's no use saying patients don't want every other day schedules - it has never been offered other than at home where it is quite popular.
The critique of the Canadian system is that it is not entrepreneurial, it is good at doing what it has always done but it doesn't advance care in the same way the US system does. I think it is fair to say that the world benefits from the innovation produced by the US system. Look at who wins the international awards - Nobel; Lasker. If the US innovated and offered EOD schedules showing the benefits to patients, providers and payers Canada and other first world systems would be quick to follow.
-
MooseMom, one of the reasons 4hx3d of dialysis is standard for in-centre treatment in Canada as well is that patients do not want to spend more time hooked up. I have met patients who are getting more treatment time in-centre, but it is rare. I don't know if it is available just for the asking.
How many Canadian dialyzors know that longer, slower dialysis is better for their long term health? No one wants to be hooked up longer than is necessary, but now many Canadian patients are educated in the benefits of longer dialysis? Do they know they can ask for better treatment? How many patients do you think would ask for better dialysis if they knew it was freely available? What kind of pre-dialysis education does the Canadian system pay for?
I don't think ANY In-Center units anywhere in North America are open 7 days a week. Our unit does advocate home hemodialysis to the patients who show an interest/aptitude in it. I put my own needles in and pretty much take care of all my settings/alarms for the entire run. They jumped to their feet when I asked about the home hemo program. Even home hemo is not 7 nights a week; it is 6 nights and you can choose your night off. Obviously 8 hrs x 6 nights = 48 hours of low and slow dialysis is much better than 15 hours of high flow dialysis.
The home hemo program is fully paid for by the province and they will also provide the RO units and reimburse us for the plumbing and electrical enhancements we have to make to our homes. I would suspect that the main reason they advocate it is 1) it frees up a chair in-center and 2) no cost except the supplies.
In answer to your question: No, in Canada you cannot ask for more that 3 x per week (in-center) regularly. There have been times where I was up a lot of fluid and needed a 4th treatment to get it all off by Friday but that was only a couple of times in my 8 years.
-
Sadly, as much as Canada offers above and beyond what America offers, even Australia and New Zealand with the highest home hemo rates in the world only offer the "ultra-short" 3-4 hour thrice weekly sessions outside of the home program and some nocturnal in-center thrice weekly.
I would also call attention to the fact that this problem eclipses politics. Bill and I are in complete agreement on dialysis issues, yet our political views are not in such agreement. That has never kept either of us from a close and rewarding collaberation to fix dialysis for the last three years. You wouldn't know that if you placed labels on our politics.
I would hope that this example would resolve into common ground of simply doing what is medically correct, since there is NOWHERE in the world right now that offers dialysis 7 days a week no matter how progressive or conservative a government is in place. It is not about being liberal or conservative, democrat of republican, American or Canadian, but simply placing the standard of care of optimal dialysis as a simple humanitarian effort on ALL sides. Sometimes, even gun toting Republicans have a heart and do what is right.
-
I'm sure even gun toting Republicans can develop ESRD.
I am not sure I'd want to rely solely on humanitarianism to achieve access to optimal dialysis for all. That implies "charity", and I for one don't want to be looked at as a charity case. It seems to me that there has to be an economic incentive to keeping people out of the hospital, and if optimal dialysis achieves that, then that's where our resources should go. Hospitalizations are incredibly expensive. Cut down the in-clinic infection rates and offer more dialysis (thus decreasing the risk of cardiovascular problems), and you keep people out of the hospital and you save money. Bingo. I'm sure it's not quite that easy but then again, maybe it is.
-
I'm sure even gun toting Republicans can develop ESRD.
I am not sure I'd want to rely solely on humanitarianism to achieve access to optimal dialysis for all. That implies "charity", and I for one don't want to be looked at as a charity case. It seems to me that there has to be an economic incentive to keeping people out of the hospital, and if optimal dialysis achieves that, then that's where our resources should go. Hospitalizations are incredibly expensive. Cut down the in-clinic infection rates and offer more dialysis (thus decreasing the risk of cardiovascular problems), and you keep people out of the hospital and you save money. Bingo. I'm sure it's not quite that easy but then again, maybe it is.
Dear Moosemom, I think it is just that simple which gives me fits on why we haven't adopted optimal dialysis years ago. It saves hospitalization and direct dialysis costs to place people on optimal regimens. That is quite well demonstrated in many studies. My main point above is that many people like to couch this issue in polarizing terms when it is not about that at all. I don't think that is helpful rhetoric since we will need both sides of the aisle to fix this problem.
I did come across an article out of Canada I believe, calculating how much it would cost to improve survival and their conclusion was that it would bankrupt the system in that specific province. I have always wondered if there was not some sort of survival calculation and the number of dialysis patients that would be in the system if people lived for 10 years instead of 3-5 on dialysis. Perhaps they have done that same calcuation in Washington but would never publicly admit it. In any case, it is complete madness to continue the current substandard care and on top of that to make obscene profits off of our death and suffering at the same time.
-
I plan to write my newly elected GOP Congressman and ask him why, if he is an advocate of reining in spending and personal responsibility, we continue paying for a treatment that ultimately creates risk and almost actively discourages patients from speaking up out of fear of clinic retribution.
Am I wrong? I know that dialysis saves life, but the way it is practiced in the US, it seems that it actively creates risk. And THAT is why I have been so utterly terrified of dialysis...until I learned how to make dialysis far safer and far more effective, ie MORE dialysis. Why do we funnel everyone into a treatment that CREATES MORE RISK? That's what I don't understand.
People believe what they WANT to believe, and too many people, both patients and legislators, WANT to believe that "adequate" dialysis is fine. As one of your posters wrote on your blog, there is no shortcut to living with ESRD if you want to be healthy.
-
MooseMom, when I began dialysis I was anemic and required EPO to maintain an adequate level of red blood cells. After about a year of nocturnal hemo I was able to discontinue the EPO and now, five years later, my hemoglobin is uncomfortably high to my nephrologist. Anemia in ESRD is not always caused by the loss of the kidneys ability to secrete EPO. It is also caused by uremia, which shortens the life of erythrocytes. Conventional dialysis is never sufficient to reduce uremia to the point where erythrocyte survival becomes normal, but nocturnal hemo and peritoneal dialysis are able to achieve such results.
In Canada there are always controversies over which treatments are worthy of funding and which are not. Recently the government of Ontario has struggled with whether to fund early childhood interventions for autism, treatments that can cost as much as $100,000 per child per year. Sex change surgery for transgendered individuals has also raised some heated debate. Cancer treatments which extend life for weeks or months, but at exorbitant costs have also been controversial. In each of these examples there is certain suffering to result from the decision to decline funding, yet funding remains a question. The benefit to the patient is only one factor among many in deciding how health dollars are allocated.
I don't know whether my experience is typical, but I received a great deal of renal education prior to starting dialysis. I knew many years ahead that I would eventually progress to ESRD, and for about a year before I needed dialysis I was placed in a "renal management" program. As my kidneys declined I was encouraged to opt for home nocturnal dialysis, which was an easy choice for me ("You can eat whatever you want"). Keep in mind that it is also common for people to suddenly discover that their kidneys have failed. I've met many people who have been diagnosed with ESRD in the emergency room and then sent directly to dialysis.
It is worth noting that the benefits of longer, slower dialysis have not been known for long. Nocturnal dialysis began in the mid 90's and was not widely adopted until less than a decade ago. Hopefully, the lessons learned in the last ten years will translate into more dialysis for everyone. Dialysis every second day is a great idea, lets hope it catches on. My sister's brother-in-law was a very large man who had difficulty managing his diet and fluid intake. At age 54, after two and a half years on dialysis he suffered heart failure and died. Not surprisingly, he died on a Monday morning. I believe the proximate cause of his death was insufficient dialysis. Strangely enough, when I told this to my sister she was incredulous. "He always reacted badly to dialysis treatments" she said, "more dialysis probably would have been worse".
-
The Australian system is identical to the Canadian and similar to the American in some ways. patients have the option of extended hours but must be prepared to do dialysis, pd or hd, at home but with plenty of support.
The majority do not follow this path for any number of reasons and it is these people who find themselves in a situation identical to Americans...3 sessions weekly each of 5 hours. This is for the same reason - money - in this case lack of it. The government won't or can't provide the funds that will enable more and longer sessions despite the fact that those managing the system know that longer and more frequent dialysis is more beneficial and produces better outcomes. What is happening here is that those who know the score...the younger people, the better educated, those able to access a site like IHD if you like, people willing to self cannulate and some awaiting transplants go to pd or hd...whilst the rest try and fit into a system that is vastly overstressed.
But I ask you all to remember one of the reasons this site was set up, a lot of people hate dialysis and will do as little as possible.
You should see the comment I get when I post on IHD the fact that I do 24 hours of dialysis per week.
-
Mogee, thanks for explaining more about the relationship between anemia and uremia...I did not know this and am pleased to have learned something new. Another reason to do longer dialysis.
I know that in the US when dialysis was first offered, longer sessions of dialysis at home was the norm. It was only once the profit-making corporations got their hands on dialysis that the shorter sessions in clinic became standard practice. So the mantra of more dialysis is actually an old one.
Bruno, you are right...there are plenty of reasons to hate dialysis and to be in that chair for as short a period as possible. My own mother leapt for joy when her neph said she could take 15 minutes off her sessions. But she never really understood the mechanics of dialysis nor the effects of short, violent sessions. No one ever explained to her why she felt rotten so often, why she would cramp up and why her bp would plummet, and even worse, no one told her that it didn't have to be that way. No wonder people hate dialysis! I understand that the more educated and vocal of us are more successful in getting better dialysis, but perhaps we are the people who should advocate for those whose voices are too soft to hear.
-
The Australian system is identical to the Canadian and similar to the American in some ways. patients have the option of extended hours but must be prepared to do dialysis, pd or hd, at home but with plenty of support.
The majority do not follow this path for any number of reasons and it is these people who find themselves in a situation identical to Americans...3 sessions weekly each of 5 hours. This is for the same reason - money - in this case lack of it. The government won't or can't provide the funds that will enable more and longer sessions despite the fact that those managing the system know that longer and more frequent dialysis is more beneficial and produces better outcomes. What is happening here is that those who know the score...the younger people, the better educated, those able to access a site like IHD if you like, people willing to self cannulate and some awaiting transplants go to pd or hd...whilst the rest try and fit into a system that is vastly overstressed.
But I ask you all to remember one of the reasons this site was set up, a lot of people hate dialysis and will do as little as possible.
You should see the comment I get when I post on IHD the fact that I do 24 hours of dialysis per week.
I do about 24 hours of dialysis each week as well, just 5.5 times each week at a little over 4 hour sessions. It is the only true survival strategy with dialysis, more frequent and longer duration.
-
The Australian system is identical to the Canadian and similar to the American in some ways. patients have the option of extended hours but must be prepared to do dialysis, pd or hd, at home but with plenty of support.
The majority do not follow this path for any number of reasons and it is these people who find themselves in a situation identical to Americans...3 sessions weekly each of 5 hours. This is for the same reason - money - in this case lack of it. The government won't or can't provide the funds that will enable more and longer sessions despite the fact that those managing the system know that longer and more frequent dialysis is more beneficial and produces better outcomes. What is happening here is that those who know the score...the younger people, the better educated, those able to access a site like IHD if you like, people willing to self cannulate and some awaiting transplants go to pd or hd...whilst the rest try and fit into a system that is vastly overstressed.
But I ask you all to remember one of the reasons this site was set up, a lot of people hate dialysis and will do as little as possible.
You should see the comment I get when I post on IHD the fact that I do 24 hours of dialysis per week.
The guy who started this site came to see that what he hated was being under dialyzed.
-
Being underdialyzed is what eventually killed my mother.
-
Sadly, being underdialysed is the norm. Even many health professionals do not understand how dramatically superior long, slow dialysis is to conventional dialysis. Those of us fortunate enough to enjoy the benefits of better dialysis should preach the gospel, especially to new patients who may not be getting the straight facts from their dialysis provider.
-
Sadly, being underdialysed is the norm. Even many health professionals do not understand how dramatically superior long, slow dialysis is to conventional dialysis. Those of us fortunate enough to enjoy the benefits of better dialysis should preach the gospel, especially to new patients who may not be getting the straight facts from their dialysis provider.
Exactly. But we can't let "fortune" determine whether or not we or anyone else gets better dialysis.
-
Sadly, being underdialysed is the norm. Even many health professionals do not understand how dramatically superior long, slow dialysis is to conventional dialysis. Those of us fortunate enough to enjoy the benefits of better dialysis should preach the gospel, especially to new patients who may not be getting the straight facts from their dialysis provider.
Sadly, we have failed in that duty as well. We do need to become more vocal but to do so, they have to give us access to the rest of the patients, something they control as well.
-
Well, we have access to patients via IHD, so that's a start! :clap;
-
Actually, if everyone that read IHD would send Dr. Murray and email about her biased report as an example, that would be a start. If we post every positive report in the news on optimal dialysis and criticize every negative report, I believe we have the power to begin making changes just by doing that. Nothing wrong with advocating the right attention to the problem.
-
Actually, if everyone that read IHD would send Dr. Murray and email about her biased report as an example, that would be a start.
I emailed her yesterday. Since it's the holidays, I don't know if she has read it yet, but if she responds, I'll let you all know. I also wrote to NBC.
-
Actually, if everyone that read IHD would send Dr. Murray and email about her biased report as an example, that would be a start.
I emailed her yesterday. Since it's the holidays, I don't know if she has read it yet, but if she responds, I'll let you all know. I also wrote to NBC.
I hope more follow in your example.
God bless,
Peter
-
I think we do a disservice to the professionals (specialists, doctors and nurses) in the system if we think they don't do their best to change the system, I know they do in ours. The fact is some dialysis patients won't take the advice that is offered...if you watch this site you'll see it in action..and I include some of those on home dialysis who do know better. Look folks, some are even unwilling to stick a needle in their arm and to mind that's the start point for extended dialysis, at least it is here in Australia.
Many baulk at even going on dialysis in the first place.
There is a wider discussion going on here and it relates to the advisability of dialysis in certain circumstances...with the elderly for example. If I look at the daycare 3 x 5 hour weekly program at my hospital I see a lot of elderly people in there who are marking time. I've seen people brought to the centre by ambulance so there is no doubt the system needs discussion.
-
I think we do a disservice to the professionals (specialists, doctors and nurses) in the system if we think they don't do their best to change the system, I know they do in ours. The fact is some dialysis patients won't take the advice that is offered...if you watch this site you'll see it in action..and I include some of those on home dialysis who do know better. Look folks, some are even unwilling to stick a needle in their arm and to mind that's the start point for extended dialysis, at least it is here in Australia.
Many baulk at even going on dialysis in the first place.
There is a wider discussion going on here and it relates to the advisability of dialysis in certain circumstances...with the elderly for example. If I look at the daycare 3 x 5 hour weekly program at my hospital I see a lot of elderly people in there who are marking time. I've seen people brought to the centre by ambulance so there is no doubt the system needs discussion.
Dear Bruno, I don't believe we need to include the elderly and infirm nursing home patients in this discussion so much as a need for better informed consent. I was involved in hundreds of cases in my practice of medicine where we withdrew care after a truthful discussion with family members about expected outcomes and futile treatments. Age by itself should not be the discriminator. ALL patients can benefit from better dialysis strategies, such as going to every other day dialysis which eliminates a substantial risk from the long weekend. The other issue is that is one of the largest excuses people use to attack the dialysis program as NBC just did a couple of days ago. Yes, there are indeed patients started on dialysis who probably shouldn't be, but in reality, their individual mortality even with dialysis is excessive. If we exclude deaths in the first three months of initiating dialysis, what impact do these unfortunate folks who have really reached the end of the road have on dialysis outcomes anyway?
http://www.hemodoc.com/2011/01/nbc-commentator-dr-arthur-caplan-calls-dialysis-cruel-and-lousy-care.html
-
I think there is a case for better informed dialysis outcomes with the young and certainly with the elderly and I don't mean to discriminate with the latter, but it is a fact that our western hospital systems are clogged up with older people and some discussion needs to take place even if it is only to keep them working. It makes no sense to refer people to dialysis where the only outcome an over stressed system can provide is to move from 3 x 5 hour to 3 x 4 hour sessions weekly as has been mooted here.
And by the way, we have a six day dialysis week because we need to run at least 2 three day programs each week and it's hard enough to get staff for those programs anyway, let alone a Sunday.
-
I think there is a case for better informed dialysis outcomes with the young and certainly with the elderly and I don't mean to discriminate with the latter, but it is a fact that our western hospital systems are clogged up with older people and some discussion needs to take place even if it is only to keep them working. It makes no sense to refer people to dialysis where the only outcome an over stressed system can provide is to move from 3 x 5 hour to 3 x 4 hour sessions weekly as has been mooted here.
And by the way, we have a six day dialysis week because we need to run at least 2 three day programs each week and it's hard enough to get staff for those programs anyway, let alone a Sunday.
I don't doubt that as a factor, but as a physician and as a patient, that decision is best left between the patient and their doctor. In my opinion, there are people that will use this extreme example to damage the entire program. I don't think we should be complicit with that.
-
I'm sure even gun toting Republicans can develop ESRD.
You talking about me?
Back on the Dialysis topic - I've notice that docs are not very forthcoming with dark side news about "compromises made for cost". My doc confirmed that EOD dialysis is better when asked, and even mentioned that the "third day" is the one with the most heart attacks - but at no point during the process of entering the dialysis system, signing consent forms, etc. was I told "you are getting three days per week which multiple studies conclude is sub-optimal, but is where your payer places you on the cost/benefit curve."
Patients REALLY need to do their own reading to get to the info that will not be automatically shared with them.
-
I'm sure even gun toting Republicans can develop ESRD.
You talking about me?
Back on the Dialysis topic - I've notice that docs are not very forthcoming with dark side news about "compromises made for cost". My doc confirmed that EOD dialysis is better when asked, and even mentioned that the "third day" is the one with the most heart attacks - but at no point during the process of entering the dialysis system, signing consent forms, etc. was I told "you are getting three days per week which multiple studies conclude is sub-optimal, but is where your payer places you on the cost/benefit curve."
Patients REALLY need to do their own reading to get to the info that will not be automatically shared with them.
But this is why it makes no sense - right now it would be profitable to offer EOD schedules (http://www.billpeckham.com/from_the_sharp_end_of_the/2011/10/do-eod-schedules-offer-financial-benefits-to-payers-and-providers.html). Current reimbursement policies mean that the seventh treatment every two weeks would result in about a $70 bonus payment, and yet to my knowledge no unit is routinely offering EOD schedules. I know of one unit where EOD schedules were going to be trialed but in the end it never happened.
Based on financial incentives alone EOD schedules should be widely available.
-
But this is why it makes no sense - right now it would be profitable to offer EOD schedules (http://www.billpeckham.com/from_the_sharp_end_of_the/2011/10/do-eod-schedules-offer-financial-benefits-to-payers-and-providers.html). Current reimbursement policies mean that the seventh treatment every two weeks would result in about a $70 bonus payment, and yet to my knowledge no unit is routinely offering EOD schedules. I know of one unit where EOD schedules were going to be trialed but in the end it never happened.
Based on financial incentives alone EOD schedules should be widely available.
"...meaning in effect the seventh treatment would carry a ~$70 premium. This gain would have to be weighed against the wage premium and possible tenant costs associated with opening on Sunday, but the higher average reimbursement and lower non-labor costs suggests EOD schedules would be viable with relatively few patients." - Labor and associated costs are the highest costs of a clinic, and most states have staff to patient ratios (both techs and nurses) that must be met.
Beyond the straight revenue/cost analysis EOD schedules would be a financial plus if it keeps patients out of the hospital. Dialysis units pay a price when their patients are hospitalized, and they will benefit if EOD schedules keep their patients in their chairs, dialyzing. - Many providers are also contracted by hospitals to run in patient dialysis services. So in actuality, they make MORE profit if clinic patients happen to end up in the hospital. If a few chairs end up being open for the day, the charge nurse will call patients to come in early (which most want to do) and then either close the clinic earlier or let a staff member go home earlier. This is a reality you fail to acknowledge.
"Based on financial incentives alone EOD schedules should be widely available." - I agree, so why won't the DaVita's and Fresenius's offer EOD in some clinics and increase shareholder profits? Maybe because their professional bean counters believe actual costs and an unreliable patient population willing to follow an EOD schedule (just read on IHD the number of patients who don't even want to dialyze 4 hours p/treatment! x 3 weekly) undercut your premise.
There would need to be a massive education/re-education effort put in place for EOD incenter dialysis to become viable. It would need to start with nephrologists and "friendly persuasion" by CMS along the lines of the Fistula First initiative.
-
Not related to cost, I think there could be a lot of confusion with EOD schedules. Right now people can say I know I'm busy on Wed from 11-3. But with EOD you have to know what week you're on and keep track. Then you're trying to schedule a doctor appt for 3 months from now. You've screwed it up and scheduled two things at once. Which do you cancel? Your cardiologist will charge a cancellation fee and not reschedule you for another 3 months and you still might get it wrong. So much of the dialysis population already has a little trouble keeping track of their lives. And then to add the nursing homes trying to keep it straight it would be tough.
In New Jersey, if you want to get a week at a summer home, you have to schedule your dialysis in Jan/Feb. many people would get the days wrong.
I understand the medical benefit of EOD. I just wonder about the practicality of it.
-
Not related to cost, I think there could be a lot of confusion with EOD schedules. Right now people can say I know I'm busy on Wed from 11-3. But with EOD you have to know what week you're on and keep track. Then you're trying to schedule a doctor appt for 3 months from now. You've screwed it up and scheduled two things at once. Which do you cancel? Your cardiologist will charge a cancellation fee and not reschedule you for another 3 months and you still might get it wrong. So much of the dialysis population already has a little trouble keeping track of their lives. And then to add the nursing homes trying to keep it straight it would be tough.
In New Jersey, if you want to get a week at a summer home, you have to schedule your dialysis in Jan/Feb. many people would get the days wrong.
I understand the medical benefit of EOD. I just wonder about the practicality of it.
EOD is most easily implemented in the comfort of your own home where you also have the freedom to adapt to schedule needs.
In center, yes, advance appointments can be an issue, but if concerned, you can keep a calendar marked out in advance to avoid conflicts. I don't see this as a real issue with a modest amount of effort to make it work.