These doctors say: Ration dialysis for health care reform

September 21, 2009

Kidney doctors suggest limits on dialysis

By RITA RUBIN
USA Today

One way to rein in Medicare spending on chronic kidney failure would be to ration dialysis, which "would almost certainly be politically unacceptable," a pair of Yale kidney doctors write in the October issue of one of their top professional journals.

Through Medicare's End Stage Renal Disease Program, the U.S. spends more on kidney dialysis than any other country, but that doesn't translate into higher survival rates. In 2007, Medicare spent $8.6 billion on treatment and medications for dialysis patients, plus billions more on hospitalizing them.

In their commentary in the Journal of the American Society of Nephrology, Felix Knauf and Peter Aronson write that the fastest-growing group of patients starting dialysis in the USA is 75 and older. And the average age at which an American goes on dialysis is now older than 64.

Some critics of universal health care argue that countries with national health programs, such as the United Kingdom, have set age limits for lifesaving care such as dialysis, which is not the case.

"Nobody would say there should be some criterion just based on age," Aronson said in an interview. But he and Knauf question the wisdom of paying for dialysis for patients who are likely to die soon of diseases other than kidney failure.

Among patients who begin dialyzing in their 80s and 90s, nearly half are suffering from congestive heart failure and one-third from diabetes or cardiovascular disease, Knauf and Aronson write.

When Medicare first started paying for dialysis in 1973, though, Aronson says, patients with other serious diseases were excluded. The thought was that the End Stage Renal Disease Program, which covers kidney transplants as well as dialysis, would be limited to patients for whom treatment would extend high-quality life, he and Knauf write.

Today, though, "physicians are often willing to provide dialysis care to patients with greatly diminished quality of life," they write. One survey of nephrologists, or kidney doctors, found that nearly half would be willing to continue dialysis in a patient who develops severe dementia.

Yet research suggests that dialysis provides little benefit to the oldest, sickest patients, the doctors write. Its main effect: increasing the chance that the patients will die in a hospital instead of at home or in a hospice. "Many physicians are not well-trained in end-of-life care," Aronson says. "When doctors don't know about it, I think it is very hard for patients to know about it."

http://www.thedailyjournal.com/article/20090921/LIFESTYLE/909210325