Optimal Dialysis: Are we losing the Battle in America?

December 24, 2009
Optimal Dialysis: Are we losing the Battle in America?
By Peter Laird, MD

A little over a week ago I had my home dialysis monthly check-in with a nephrologist that I was meeting for the first time. I found him very knowledgeable and supportive of alternative dialysis strategies including the NxStage System One as well as nocturnal dialysis in its various forms. He recently opened his unit to incenter nocturnal dialysis patients, achieving excellent results with several of those patients who transferred from conventional dialysis care. Unfortunately, one of those patients is now at jeopardy of returning to conventional dialysis care by the decision of their HMO. This, despite the widespread acceptance of the benefits of incenter nocturnal dialysis especially in Canada just to the north and down south in Australia, America continues to dismiss the overwhelming evidence of improved outcomes with this modality.

Remarkably, despite the widespread knowledge that dialysis pioneers originally used eight hour sessions nearly fifty years ago instead of the conventional 3-4 hours sessions we are now familiar with, many health insurance providers perversely consider these alternative strategies unproven and experimental and will not pay for them. They continue to insist upon randomized controlled trials as the only standard of proof which at this time still do not exist. They fail to acknowledge that the current standard of care, 3-4 hours sessions thrice a week, was a business decision unsupported by any randomized controlled trials as well.

A little over a year ago, I contacted the physician overseeing the committee at Southern California Kaiser that evaluates new and evolving technologies after hearing that they were considering nocturnal hemodialysis at that time. After reviewing the available literature mainly from Canada and Australia, they determined that that data was insufficient to support adopting it as a covered benefit for all patients, but they did recommend setting a pilot study which is now in progress. Yet there are many such as Dr. Carl Kjellstrand and Dr. Christopher Blagg who have advocated for optimal dialysis here in America for decades citing the improved outcomes in several other nations that have been able to incorporate this in dialysis practice.

The case of my fellow patient at my center now battling for coverage of optimal dialysis through a well run incenter nocturnal dialysis program takes me back to the current status of many patients in America who still do not have access to these life saving modalities. After observing the positively changing mindset among many in the nephrology community over the last two years that I have been involved in dialysis advocacy, this case reminds us that the battle is not yet won here in America. With the uncertainties that the new prospective payment system could bring to American dialysis patients and these alternative treatment options, I can only wonder whether we are winning or losing this battle. Dr. Belding Scribner spent the last two decades of his life fighting this battle only to tragically die in 2003 before he saw it come to fruition.
Certainly, in the nearly seven years since Dr. Scribner death, dozens of studies have brought forth the profound benefits of daily hemodialysis, especially in regard to daily nocturnal hemodialysis. Many who support these modalities continue to wage the battle against this American dialysis hegemony hoping that we shall never again hear that a patient was denied access to these life changing treatments. It is a battle that one of our fellow dialyzors is waging today, unfortunately it seems, with very little chance of success. A vocal dialysis advocate that I asked to assist in this case summed it up by simply saying, “That's truly appalling!” I agree. The battle continues locally and nationally.

http://www.billpeckham.com/from_the_sharp_end_of_the/2009/12/optimal-dialysis-in-america.html