Davita is bad!!!

[Bill Peckham]

In Japan CAPD is you only option. If you fail at that then you have to do hemo. And thats only if there is a machine. Same in Europe. Its not like here where every corner is  a clinic.Thats why they have less mortality rates. The pts dont have a choice like they do in the USA.  NOT ALL pts can do CAPD or home hemo but I bet 50% could but wont. So whats up with that??? Americans dont want responsibility for their own care. If that was the case they would do it.  Then they wouldnt have nothing to complain about.... I personally would do CAPD to preserve my residual renal function as long as I could and to have a more normal way of life and to continue to work and be productive.  I think the US is lacking in education for our patients. I do a real good job in educating and trying to get people to do self care, but I hear every excuse in the book why they cant. I think the US needs to start everyone out one CAPD unless of course they are elderly and alone, or in a SNF.  My CAPD pts are happy, travel, work, and feel normal. Sometimes I think its easier to blame then take responsibility.  Cant blame dialysis companies for poor pt outcomes like potassium, albumin, phosporus and KT/V. Those on the pts non compliance with diet and signing off and refusing to get a fistula.

I've never dialyzed in Japan but I can tell you that the provision of dialysis in Europe is available as widely as it is here - and unless you have some data I'll go with the DOPPS. The main difference I have observed is more dialysis time per kilogram being delivered in Europe and Singapore.

As far as self care explaining mortality rate differences that is not supported by the data. The DOPPS provides a pretty clear picture, we in the US  should be doing better. As John Maynard Keynes said, "When the facts change, I change my mind - what do you do, sir?"

[Wattle]

I personally would do CAPD to preserve my residual renal function as long as I could and to have a more normal way of life and to continue to work and be productive. 

You are NOT a dialysis patient are you? There are many members here on Hemo that work are are still productive members of there community. You should not judge someone for not wanting to do home care. It is a personal choice that shouldn't alter their level of treatment. No patient should have to put up with incompetent techs and substandard treatment just because they want to do incenter dialysis. Self care is just not for everyone. It doesn't mean they are non compliant. Non compliance is another issue.

oh... I am a home APD dialysis patient that is very compliant   

[Black]

I'll say better. Apples to apples the US mortality rate is 20% higher than it would be if it met European standards of care.

What are the European standards for deciding who gets dialysis and who doesn't?

They're about the same. ...

Have a link to that info?  TIA

[Black]

... I think the US needs to start everyone out one CAPD unless of course they are elderly and alone, or in a SNF.  My CAPD patients are happy, travel, work, and feel normal. Sometimes I think its easier to blame than take responsibility.  Cant blame dialysis companies for poor patient outcomes like potassium, albumin, phosphorus and KT/V. Those on the patients non compliance with diet and signing off and refusing to get a fistula.

What is "SNF"?

Many patients cannot do any kind of PD due to health issues - abdominal scarring, hernias, large kidneys (PKD), and  many diabetics.  Most patients who live long enough have to switch to HD.  The life expectancy of PD patients is shorter than those on HD.  There is not ONE clinic within a 20 mile radius of where we live which offered my husband home hemo.  His kidneys are huge and PD was NOT an option for him, but even if it were, he would not have chosen PD.

I most certainly can blame some dialysis centers for poor outcomes like potassium, albumin, phosphorous, and KT/V.  All clinics are not as proactive in patient education as you apparently are with your patients.  There are patients here who have dietary problems and they have to come here to get answers and help.  There are also some here who have signed off early due to neglect or abuse by center staff, and some because they had other commitments, such as a job, because they were started late.

The low percentage of fistulas is most likely NOT the patients fault.  Many in the medical community are often not forthcoming with information and support which patients need to make the best choice for their access.  Check out the threads and questions here about fistulas.  If we had listened to my husband's nephrologist and the first surgeon he saw, he'd most likely have a graft.

If all nephrologists and all center staff were proactive in educating patients, the life span and quality of life for dialysis patients would be better, and this forum would not have been so successful.

[Bill Peckham]

Skilled Nursing Facility  what we use to call nursing homes

[Bill Peckham]

I'll say better. Apples to apples the US mortality rate is 20% higher than it would be if it met European standards of care.

What are the European standards for deciding who gets dialysis and who doesn't?

They're about the same. ...

Have a link to that info?  TIA

Here is a link to an article by one of the high profile deniers of a high US mortality rate http://www.aakp.org/aakp-library/Comparison-ESRD-Therapy-United-States-Overseas/

This was written in 2000, before the DOPPS results. I doubt he would write this article today, I've not seen criticism of the DOPPS on the basis of selection bias, etc. With the DOPPS data you can look at just one demographic - youngish, non-diabetic males - people who have complete access to care abroad, and in the US, and see the same persistent mortality bias.

We can try to figure out the reasons - I spend a lot of time thinking about it - but the discussion has moved past the access to care question.

Even before DOPPS I knew the access to care issue was a red herring. I've dialyzed in over 20 units throughout Europe, going every year from 1996 to 2005, I've talked to the staff, and to the dialyzors. They're doing a better job over there. Dialysis is in my experience better on average in Europe than the US (I've been to dozens, maybe scores, of US units in 16 years of treatment). I think this is indisputable.

My primary theory about mortality is that they get more dialysis per kilo, something all units, for profit and non-profit units alike could offer but do not. If your unit does not offer the option of 6 hour runs they could be doing more but they don't because of money. Max five hours? I've seen four hour maximums. When those go away then we'll talk about "compliance" or more correctly what providers can do to help dialyzors better accommodate CKD5.

[kitkatz]

You know I am glad to see a dialysis patient is up in arms over our care and really working to do something about it.   Thanks Bill P.

[Black]

Here is a link to an article by one of the high profile deniers of a high US mortality rate http://www.aakp.org/aakp-library/Comparison-ESRD-Therapy-United-States-Overseas/

This was written in 2000, before the DOPPS results. I doubt he would write this article today, I've not seen criticism of the DOPPS on the basis of selection bias, etc. With the DOPPS data you can look at just one demographic - youngish, non-diabetic males - people who have complete access to care abroad, and in the US, and see the same persistent mortality bias.

We can try to figure out the reasons - I spend a lot of time thinking about it - but the discussion has moved past the access to care question.

Even before DOPPS I knew the access to care issue was a red herring. I've dialyzed in over 20 units throughout Europe, going every year from 1996 to 2005, I've talked to the staff, and to the dialyzors. They're doing a better job over there. Dialysis is in my experience better on average in Europe than the US (I've been to dozens, maybe scores, of US units in 16 years of treatment). I think this is indisputable. ...

Thanks so much, Bill.  I was under the impression that other countries were turning away medically fragile patients and the elderly who would be put on dialysis in the US, and that accounted for the difference in  mortality rates.

... My primary theory about mortality is that they get more dialysis per kilo, something all units, for profit and non-profit units alike could offer but do not. If your unit does not offer the option of 6 hour runs they could be doing more but they don't because of money. Max five hours? I've seen four hour maximums. When those go away then we'll talk about "compliance" or more correctly what providers can do to help dialyzors better accommodate CKD5.

Bravo!

  Until home dialysis is the norm and in center the exception, the majority of dialyzors will continue to receive inadequate treatment.

[bdpoe]

Fixin' To Die Rag Revisited:

" And it's one, two, three, what are we suffering for?"
"That Corporation don't give a damn"
" That Quality O' Care pledge is just a scam"
"we're just doing the best that we can"
" unlike some congressman"
"Whoopie sometime we're all gonna die"

In A Getto Duh Vita

Goin' to Duh Vita this morning Baby
Don't know if I'll be comming home
Gotta go to Duh Vita Honey
How I wish that it wasn't so.

I think theiy're gonna kill me.
I can barely do my time.
When it comes to being stuck with needles
I could just lose my mind

Please won't you just come with me
Don't let go there alone again
In A Getto Duh Vita Honey
Don't you know i miss you so.

( Pardon me for this )
......bd

[kitkatz]

I loved that rhyme time !

[gr8fulrn]

Im all for longer dialysis treatments at lower blood flow rate. I feel its more gentle on the body and of course the patient feels better. No Im not a patient, but Im very proactive for my patients because I could be a patient someday. And I know how I would want to be treated. I remind the staff many times to rememember that we or our families could be here at dialysis and would we want the best. So I expect that every patient be treated like their most loved family member. I dont tolerated incompetentece, sure people make mistakes and must admitt to them.  To work in dialysis is a hard job and to meet the standards is also very hard. So the key is education and support. Of course you always get the few patients that no matter what you preach, they just dont listen. And I agree with al of you, no one should have mediocor care. But I can tell you from my own experience with health care, my  father died in a hospital,(even though Im a nurse and was very proactive in his care) He got a MRSA infection, and in his advance directives he wanted only CPR no life support. The nurse did not read the chart right and she did have him coded. To me that is gross negligence. So I am all for qailty care. The problem is not the dialysis companies, its the management of your clinics. They ned to hire, train and keep the good ones and let the losers leave. Thats were the care is.

[Hawkeye]

They need to hire, train and keep the good ones and let the losers leave. Thats were the care is.

They are getting rid of the bad staff and keeping the good staff as best as they can, but with so many bad techs out there the good techs are overworked and burn out.  Turnover of staff is one of the biggest problems the clinics face when it comes to quality care of the patients.

[Hawkeye]

Fixin' To Die Rag Revisited:

" And it's one, two, three, what are we suffering for?"
"That Corporation don't give a damn"
" That Quality O' Care pledge is just a scam"
"we're just doing the best that we can"
" unlike some congressman"
"Whoopie sometime we're all gonna die"
( Pardon me for this )

A little Country Joe And The Fish parody gotta love it.

[Bill Peckham]

What are the maximum run lengths at your units?

[Hawkeye]

What are the maximum run lengths at your units?

I don't know about the run times at gr8fulrn's clinic, but the most I have ever seen someone run was 5hrs and that was a temporary thing.  Most run an average of 4hrs.

[bdpoe]

Huh? What? Longer run times at a lower blood flow rate? I thought higher blood flow rates were more desireable.
In six years of Hemo, with the exception of a few nurses, I havent seen the kind of management or care that you speak
of here in Florida.

I can barely make it through three and a half hours in chair. Five to six hours seems impossible for me.
How can anyone do that?

I agree that a lot of things are contingent on a good manager and regional manager but these seem
to be exceptions to the norm as do you.
....bd

Im all for longer dialysis treatments at lower blood flow rate. I feel its more gentle on the body and of course the patient feels better. No Im not a patient, but Im very proactive for my patients because I could be a patient someday. And I know how I would want to be treated. I remind the staff many times to rememember that we or our families could be here at dialysis and would we want the best. So I expect that every patient be treated like their most loved family member. I dont tolerated incompetentece, sure people make mistakes and must admitt to them.  To work in dialysis is a hard job and to meet the standards is also very hard. So the key is education and support. Of course you always get the few patients that no matter what you preach, they just dont listen. And I agree with al of you, no one should have mediocor care. But I can tell you from my own experience with health care, my  father died in a hospital,(even though Im a nurse and was very proactive in his care) He got a MRSA infection, and in his advance directives he wanted only CPR no life support. The nurse did not read the chart right and she did have him coded. To me that is gross negligence. So I am all for qailty care. The problem is not the dialysis companies, its the management of your clinics. They ned to hire, train and keep the good ones and let the losers leave. Thats were the care is.

[Bill Peckham]

What are the maximum run lengths at your units?

I don't know about the run times at gr8fulrn's clinic, but the most I have ever seen someone run was 5hrs and that was a temporary thing.  Most run an average of 4hrs.

I thought you were at FMC? FMC offers incenter nocturnal at a number of their units. There is one by my Mom's house that I use when I visit her and run incenter.

[Hawkeye]

I thought you were at FMC? FMC offers incenter nocturnal at a number of their units. There is one by my Mom's house that I use when I visit her and run incenter.

You are correct I do work for Fresenius but none of the centers in my area offer incenter nocturnal dialysis so I have no experience with that.

[Bill Peckham]

What are the maximum run lengths at your units?

I don't know about the run times at gr8fulrn's clinic, but the most I have ever seen someone run was 5hrs and that was a temporary thing.  Most run an average of 4hrs.

I am concerned when a sizable dialyzor population has no one running 5 hours (or more. But I use to run only 4.75) or 4 times a week. Some Fiscal Intermediaries are more lenient than others but I think four day a week schedules should be a standard menu item. Does your unit provide four day a week schedules?

[bdpoe]

I've never heard of one that offers 4 times a week. What is a "Fiscal Intermediary?"
How do you deal with being in the chair that long?
..............bd

What are the maximum run lengths at your units?

I don't know about the run times at gr8fulrn's clinic, but the most I have ever seen someone run was 5hrs and that was a temporary thing. Most run an average of 4hrs.

I am concerned when a sizable dialyzor population has no one running 5 hours (or more. But I use to run only 4.75) or 4 times a week. Some Fiscal Intermediaries are more lenient than others but I think four day a week schedules should be a standard menu item. Does your unit provide four day a week schedules?

[Zach]

How do you deal with being in the chair that long?

It's tough, no question about that.  A good book or DVD can really help pass the time.
The Renalist   

[goofynina]

How do you deal with being in the chair that long?

It's tough, no question about that.  A good book or DVD can really help pass the time.
The Renalist   

A good dose of Benadryl helped me pass a good couple of hours 

[kitkatz]

Oh Yes Benadryl helps me through the hours in the chair!

[Bill Peckham]

I've never heard of one that offers 4 times a week. What is a "Fiscal Intermediary?"
How do you deal with being in the chair that long?
..............bd

Providers don't really bill Medicare directly, they send their bills to a Medicare Fiscal Intermediary. There are I think 18 FIs, each covers a region of the country.

They make the decision on what is covered, it is the FIs that decide if something is reimbursable by Medicare and those decisions vary from one FI to the next.

For instance, the actual law around how many treatments per week is reimbursable is vague. Some FIs reimburse for a forth treatment under very narrow circumstances, while other FIs will reimburse for every treatment.  I  believe that units should be open seven days a week and routinely offer forth treatments because it is logistically difficult to accommodate forth treatments with units closed one day a week. If FIs routinely reimbursed for forth treatments I think units would be open seven days a week.

[Hawkeye]

Does your unit provide four day a week schedules?

No clinics that I am aware of offer a 4 day a week schedule.  Your choices are M-W-F or T-Th-S.  Depending on your remaining renal function you may only go 2 days a week instead of 3.  The only time you may dialyze more than 3 time in one week is if you are going to miss your first treatment the following week, or there is a holiday that the clinic is closed for so they opened on a Sun. instead of that holiday.