Dialysis in the U.S. and Abroad

[okarol]

Dialysis in the U.S. and Abroad
Delicia Honen Yard
September 09 2011

Taking all comers may be the best thing about the U.S. end-stage renal disease (ESRD) program—but it could also be the program's downfall. Providing such costly services for so many beneficiaries calls for more intense use of treatments that fall outside the walls of traditional in-center hemodialysis, according to nephrologists both within and outside of the United States who shared with Renal & Urology News their opinions on the management of kidney failure here and abroad.


By the end of 2007 (the most recent year for which the National Kidney and Urologic Disease Information Clearinghouse (NKUDIC) makes the following statistics available), 527,283 U.S. residents were under treatment for end-stage renal disease (ESRD) (http://kidney.niddk.nih.gov/KUDiseases/pubs/kustats/index.aspx). A total of 87,812 such patients died that year, with 157.3 deaths per 1,000 patient years.

“There is a difference in reported survival of treated patients with kidney failure in the United States as compared with Europe or other industrialized nations,” declares Eli A. Friedman, MD, MACP, Distinguished Teaching Professor of Medicine and former Chief of the Division of Nephrology at SUNY Downstate Medical Center in Brooklyn, N.Y. “The difference could be that we treat patients who shouldn't be treated, and they have poor prognosis and they die; or that Europe doesn't treat patients who should be treated, and therefore they've taken out patients with the worst prognosis, altering their survival for the treated cohort.”

The economics of the situation may be far more telling than the health conditions of the given patient populations. “If we look at the per-person parity for countries with more than 2 billion people, it's $5,370 per year in China, $2,740 in India—and $45,850 in the United States,” Dr. Friedman reports. “According to the World Bank, in 2010, 82 countries had a per-person parity of less than $5,000 a year, and 52 countries with less than $1,000 per year. So, can these 134 countries afford uremia therapy? The answer is no.”

With the United States topping the list for most kidney transplants performed in persons aged 65 to 74 years, “we treat more high-risk people and older people than any other country,” Dr. Friedman observes. “If you look at Canada, there's no rule that says, ‘Don't dialyze patients who are over the age of 75.' But if you try to find patients over the age of 75 in Canada who are on dialysis, they're almost nonexistent. That's because they're not referred from the general practitioner to the nephrologist. The argument is that the apparent difference in selection therapy represents the ability of the country to support the population who would benefit from therapy.”

Mexico also serves as an example of this, according to Dr. Friedman. “Of the patients treated there—very few—about 80% are on peritoneal dialysis. [The country] can only afford hemodialysis for the wealthy or the politically connected.”

Diabetes brings the masses to dialysis

Dr. Friedman was practicing at Downstate Medical Center when the first federally funded dialysis unit was established there in 1963. “But when [maintenance-dialysis pioneer Dr. Belding] Scribner began in 1960 telling us how to dialyze, we excluded diabetic patients,” he recalls. “Now the CDC [Centers for Disease Control and Prevention] predicts that by 2050, 1 in 3 Americans is going to have diabetes. And the biggest cause of kidney failure treated in the United States is diabetes.”

Along with his Downstate colleagues as well as researchers at the Mayo Clinic and several other institutions, Dr. Friedman is investigating less expensive replacements for dialysis or kidney transplantation. The group is focusing on specially manufactured probiotic bacteria that consume uric acid and other waste products of kidney failure. The technique already has been shown to extend life in animal studies, and trials with dialysis patients are now starting.

“We'll first see what happens if patients get these bacteria with three-times-a-week dialysis, and then try to reduce dialysis to twice a week, and then once a week,” Dr. Friedman explains. “The point is not whether this works, but that there's room for fresh ideas about how to treat patients with kidney failure without bankrupting the country.”

“A good job” is relative

In comparing the conservative delivery of dialysis services in other countries to the more inclusive use in the United States, Dr. Friedman acknowledges that differences do indeed exist. “But there's nothing for American doctors to apologize for. We do a good job and we should be proud of it.”

Christopher Blagg, MD, Professor Emeritus of Medicine, University of Washington and Executive Director Emeritus, Northwest Kidney Centers, Seattle, is not convinced. “I don't often agree with Eli on that point,” he says. “We're doing a great job in the sense that we treat everyone, but I think we can treat many of them better than we do. The thing is, whatever [change] is going to come, it's going to come slowly.”

A major difference between the United States and other nations stems from Medicare, Dr. Blagg contends. “Most first-world countries provide what they regard as universal coverage, but this is not like an entitlement program as the Medicare ESRD Program is. We're the only country that entitles almost anyone to renal replacement therapy whatever their complications”

The fact that Medicare's ESRD program is an entitlement may, at times, be more harmful than helpful when offered to a patient who probably won't benefit from dialysis. “For example,” Dr. Blagg recalls, “one day a nephrologist in private practice asked me for some advice about a patient—a 75-year-old woman with medical complications and Alzheimer's disease who was being referred to him for dialysis treatment. He told me, ‘I don't think putting her through dialysis is the right choice, but her family tells me she's entitled to it, so what can I do?'”

There was little Dr. Blagg could say. “I told him, ‘That's right, it's an entitlement. And unless you can talk the patient and the family out of it, there's nothing you can do.'”

Dr. Blagg came from England in the early 1960s to practice at the University of Washington, and ran Northwest Kidney Centers in Seattle from 1971 until 1998. A longtime supporter of home hemodialysis [home HD], Dr. Blagg trained the second patient in Seattle to use such a system, in 1964.

“As far back as 1973, the government had intentions of encouraging kidney transplantation and home dialysis, and in the 1980s even made the payments for home dialysis and in-center dialysis equivalent –the composite rate,” he recalls.

As of December 31, 2008, 354,600 patients were receiving HD and 26,517 were on peritoneal dialysis, according to the U.S. Renal Data System. The home HD population was 3,826 individuals.

The for-profit dialysis providers have had a strong influence on such matters, Dr. Blagg says. “If you're going to run a dialysis unit, the easiest thing to do is in-center dialysis,” he comments. “And in the early days of the program Medicare paid so well for center dialysis, and private insurers paid incredible amounts, so if you were a for-profit provider and were interested in money and wanted to please your stockholders, why would you set up a home-dialysis program with all the issues and difficulties? Now with the new bundling and so on, there may be a bit more pressure on the idea of using home dialysis or PD [peritoneal dialysis] because it's less expensive.”

The tide may already be turning: Dr. Blagg is pleased to note that over the past few years, for-profit dialysis units appear to becoming more interested in setting up not only home HD and PD, but also nocturnal dialysis—a practice popular in Australia and New Zealand and championed by Dr. Blagg, who believes that longer and/or more frequent dialysis is easier on and safer for the patient than is undergoing the treatment for a few hours a day, a few days a week, and feeling wiped out after every session.

 “I think it's a process that's going to take quite a time to change,” Dr. Blagg says. He said he believes the interest in more frequent dialysis, the development of home-use machines that are more specifically patient-friendly, and an increase in talks about home HD and PD in the last few years bodes well for the future of these alternative dialysis delivery systems.

An outside critique of U.S. dialysis

John Agar, OAM, MBBS, is a self-described enthusiast for home dialysis. In fact, he states exactly that on www.NocturnalDialysis.org, the Web site he helps maintain for Geelong Hospital in Victoria, Australia, where he is also Director of Renal Services. As Dr. Agar makes clear on the Web site, he is no fan of the way dialysis services are delivered in the United States:

In Geelong, we sustain >40% of our total dialysis patient pool at home … currently 22% of all our patients are on home haemodialysis and 18% on home peritoneal dialysis (both manual  [continuous ambulatory] PD and automated PD). Of our haemodialysis patient group alone, 28% are currently at home. This compares with ~14% in Australia and New Zealand as a whole and with less than 1% in the US! I think we have a good balance in our program and that the US, in theirs, does not—though this is a personal view.

“The poor performance of the U.S. in dialysis—and this is not just home dialysis but all dialysis—is steeped in the history of how dialysis was originally funded in the U.S.,” Dr. Agar tells Renal & Urology News.

The for-profit model in the U.S.

Dialysis in Australia and New Zealand (ANZ) is provided free of all charge to patients by accredited renal units established through the public, tertiary hospital system. For example, Dr. Agar has been the director of his institution's central renal unit for the past 30 years; the director is always a practicing nephrologist. In this “hub and spoke” setup, each central in-center service administers and staffs multiple suburban, regional, and—where appropriate—remote satellites.

Except for a small number of barely profitable or even loss-producing private satellite services in one or two Australian states, Dr. Agar notes, companies do not provide dialysis services there. Conversely, in the United States, dialysis services are provided by for-profit companies. “Companies are, in the end—and as companies should be—beholden to profit-making for their shareholders,” Dr. Agar says. “This is a huge and fundamental difference. Again and broadly, we in ANZ provide, prescribe, and support dialysis as we believe it to be best suited to each individual patient.”

Whereas the U.S. dialysis patient is responsible for a 20% copayment—which may be covered under a Medicare Advantage Plan or Medigap policy (www.medicare.gov/publications/pubs/pdf/10128.pdf) —dialysis is free to the ANZ patient. “This is also true in the main for their physicians and dialysis teams who are salaried and, as a result, make their decisions about their patient's best interests—home or otherwise—with the patient and his/her family but without the income pressures that might occur if a ‘fee'—read income—is gained or lost depending on the site of dialysis,” Dr. Agar adds.

But not only is home dialysis better for the patient, Dr. Agar says, it is far less expensive for the government. “The costs of home HD and home PD have consistently been shown to come in at anywhere from 15% to 30% cheaper in a range of studies here [ANZ], in Canada, and elsewhere,” he states. “If it is better for the patient and better for the national accounts, why wouldn't you encourage, support, and even incentivize it?”

On the other hand, Dr. Agar argues, “If funding is for-profit, and profits are best likely to be made in a center under a ‘Henry Ford' production-line model of care and are not likely to be made at home under a patient self-care program model, where is the incentive to devise and support the home-care model?”

Dr. Agar believes that about half of dialysis patients are capable of home self-care. “In ANZ, many dialysis services sustain a comfy 40% to 50% of patients at home, with some units doing even better than that.”

Unlike nephrologists in the United States, ANZ nephrology trainees are required to be trained in and aware of home-dialysis practices. “How can you expect to grow a healthy home program when your U.S. nephrologists remain blissfully unaware of its benefits or its possibilities?” Dr. Agar asks.

Medicolegal issues can bias decision-making, Dr. Agar acknowledges. However, “It is our view and experience that no one cares better for the patient than the patient. Things will, from time to time, go wrong at home; the patient understands this by going home at all. But, again, in our experience, a well-trained home patient makes fewer mistakes and has less go wrong, than do their counterparts in centers.

“So, we do not fear medicolegality. We do not monitor home patients. We train well, we support strongly, we sustain help-lines, and we put trust and faith in our patients. They, in turn, reward us through dialysis well done, with rehabilitation to family and work, with lives better lived than their counterparts in-center.”

Dr. Agar sees signs that the viability of more frequent and longer administration of dialysis is infiltrating the U.S. dialysis psyche. “More hours of dialysis per week just can't be managed in your centers—at least not as they are currently structured,” he insists. “This will force a slow but steady imperative to rethink and redesign programs. At least, that is my belief. And, for the outcomes for your U.S. dialysis patients ... those changes can't come fast enough.”

Home-care modalities underused in Israel

With more than 70 dialysis centers in a small country, HD access is not an issue in Israel. HD is the main form of dialysis delivered there, with the use of PD on the decline.

“The misconception among patients and families is that HD is more efficient and confers survival advantage,” explains Suheir Assady, MD, PhD, Director of the Department of Nephrology at Rambam-Health Care Campus in Haifa. “But HD and PD each has a place within the practice of nephrology, and they are complementary. Each modality is considered the best modality when it meets patient expectations and fits his or her medical condition.”

Although Dr. Assady said she believes that HD is appropriate for the majority of ESRD patients in Israel, she also finds self-care dialysis modalities to be underutilized, and says they should be encouraged. “Potentially, it may reduce the economic burden, both direct and indirect medical expenditures, and provide many benefits for patients—mainly improved quality of life, more freedom, fewer hospital visits, and so forth,” she remarks. “Of course, in Israel—as in other countries—kidney transplantation is the most cost-effective therapy, offering obvious survival advantage for our ESRD patients.”

Dr. Assady summarizes the main medical and nonmedical factors that inhibit the widespread use of PD in Israel:

Health providers generally offer low reimbursement for PD.
Late referral of chronic kidney disease patients to nephrologists limits time available for iterative dialysis modality education.
The country has a limited number of PD training programs, qualified nephrologists, and skilled dialysis nurses.
Patient-related factors, such as poor education and housing conditions nonconductive to home care, restrict the use of PD.
At least some of those obstacles will no doubt sound familiar to U.S. nephrologists, as will the following statement from Dr. Assady:

“Some patients are not willing to bring their illness back home, but unfortunately, some patients are not even aware of alternatives to in-center HD.”

Part 2 of this feature, which will appear next week, discusses differing practice patterns in prostate cancer screening and management in Europe and the United States.

http://www.renalandurologynews.com/dialysis-in-the-us-and-abroad/article/211603/