Developed Countries Lag in Use of Cheaper and Easier Peritoneal Dialysis

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Medical News And Perspectives | June 13, 2012
Developed Countries Lag in Use of Cheaper and Easier Peritoneal Dialysis
Mike Mitka
JAMA. 2012;307(22):2360-2361. doi:10.1001/jama.2012.5761 Text Size: A A A
Article

Peritoneal dialysis is less costly than in-center hemodialysis and offers equal mortality risk and improved quality of life. Still, such therapy for patients with end-stage renal disease has not been widely embraced in the United States and other developed countries.

Worldwide, an estimated 1.8 million patients receive some form of dialysis, with only about 11% undergoing peritoneal dialysis. In the United States, of more than 390 000 patients who received dialysis in 2010, only about 7% were treated with peritoneal dialysis—down from peak usage in 1995, when 14.4% of US dialysis use was peritoneal.

The low utilization rates of peritoneal dialysis prompted leaders in the field of kidney dialysis in the United States to meet at a National Summit on Home Dialysis Policy on March 29 in Washington, DC. This summit served as the impetus for the launching on April 25 of the Alliance for Home Dialysis to advance the recommendations identified at the summit to federal policy makers (http://tinyurl.com/82q95rp). The alliance said that stakeholders in the dialysis community should work with policy makers to ease accessibility to peritoneal dialysis, improve accountability of those delivering home dialysis services, and align incentives to expand access to home dialysis.

Rajnish Mehrotra, MD, a professor of medicine at the University of California, Los Angeles, and a panelist at the summit, said the reasons for low US utilization of peritoneal dialysis are complex and interrelated. Because the United States has developed an infrastructure to support hemodialysis but not peritoneal dialysis, there have been fewer peritoneal dialysis patients in the clinics. “That means that physicians in training get little or no training in treating patients with peritoneal dialysis,” said Mehrotra. “And in part, because of this lack of training, most patients starting dialysis are not informed by their physicians of the possibility of doing peritoneal dialysis.”

According to presenters at the summit, only about half of surveyed nephrologists following fellowship training felt “comfortable, well trained, and competent” in the use of peritoneal dialysis as a treatment modality. Another survey presented found that less than half of patients receiving hemodialysis were provided information about peritoneal dialysis; yet another survey found that 45% of patients who received education about both options before starting dialysis chose peritoneal dialysis. In contrast, another study presented suggested that among US nephrologists, more than 90% would choose home dialysis for themselves.

Other developed nations also are having trouble boosting use of peritoneal dialysis, but its use relative to the use of hemodialysis has remained stable in the developing world. A recent study involving data from 130 countries found that over a 12-year period ending in 2008, the number of patients receiving peritoneal dialysis increased in developing countries by 24.9 patients per million population and in developed countries by 21.8 per million population. However, the proportion of all patients treated with peritoneal dialysis declined by 5.3% in developed countries but did not change in developing countries (Jain AK et al. J Am Soc Nephrol. 2012;23[3]:533-544).

The study's lead author, Arsh Jain, MD, an assistant professor at the University of Western Ontario in London, Canada, suggested that the number of hemodialysis units available for treating patients, as well as differing regulations, may explain why developing countries seem more likely to offer peritoneal dialysis. “In the United States, you have built hemodialysis centers, and there is an incentive to keep those units filled,” Jain said. “In developing countries, it is very different; some places have mandates where you have to be on peritoneal dialysis.”

Christopher R. Blagg, MD, professor emeritus of medicine at the University of Washington in Seattle and editor in chief of Hemodialysis International, is optimistic that peritoneal dialysis use will continue to grow in the United States because the financial incentives by Medicare (which pays for about 95% of all hemodialysis costs) are in place. Before 2011, dialysis firms received roughly the same payment for treatment through either hemodialysis or peritoneal dialysis. They could make more money, however, by administering injectable end-stage renal disease drugs such as erythropoiesis-stimulating agents to treat anemia while a patient sat in a center undergoing hemodialysis; such patients typically lose some blood during their thrice-weekly treatments, thus requiring more of the agents to maintain similar hemoglobin concentrations as seen in patients receiving peritoneal dialysis. But beginning in 2011, Medicare started bundling dialysis payments to cover sessions regardless of the amount of injectable drugs administered. This bundling should tilt the playing field in favor of peritoneal dialysis because this method costs about $20 000 less per year per patient.

“It has been easy to make money for a long time with hemodialysis, but now it is getting more difficult,” Blagg said. “There is another benefit; physicians are supposed to talk to patients starting treatment about all the modalities available to them, but it has not happened. It is happening more often now, however, with the new conditions of Medicare coverage.”

http://jama.jamanetwork.com/article.aspx?articleID=1182854