Yesterday RenalWeb linked to a Molly Cahill article in the Nephrology Nursing Journal November-December 2007 issue (Volume 34, Number 6) A Change in Adequacy Standards Could Create a Nightmare: Is It Necessary? which is wide ranging but primarily takes on two issues - the potential and practicality for improving the US' relatively poor dialysis mortality outcomes through longer more frequent dialysis and the practicality of home hemodialysis. Cahill writes:
According to the United States Renal Data System (USRDS) (2006) Report, 0.6% or 1,954 patients on hemodialysis receive their treatment at home. If daily dialysis, either home hemodialysis (HHD) or peritoneal dialysis (PD), is necessary to improve mortality, is it possible that many of our patients on hemodialysis are under-dialyzed and that their prescriptions are therefore inadequate? Is this malpractice? I believe that if our treatment is based on the best available evidence based standards, then no.
The article seems to be in response to Diaz-Buxo and Crawford-Bonadio December 2006 article in Blood Purification (2007;25:48–52) Major Difficulties the US Nephrologist Faces in Providing Adequate Dialysis. Here the authors, after reviewing DOPPS data, offer that the US' poor by international standards dialysis mortality rate can be improved by providing more dialysis:
Increasing time and frequency of HD should improve adequacy. However, three principal obstacles have been identified that impede its implementation:
- the complex logistics with the present infrastructure required to increase the frequency and/or time of dialysis sessions;
- the higher cost mostly associated with the additional personnel time,
- resistance from nurses and patients.
Diaz-Buxo and Crawford-Bonadio do not suggest that limiting dose constitutes malpractice. They present evidence that "many of our patients on hemodialysis are under-dialyzed and that their prescriptions are therefore inadequate". Cahill doesn't address the evidence of chronic renal under dialysis (CRUD) but acknowledging the evidence and addressing the US' wide spread CRUD prevalence does not imply malpractice, just as adding airbags to cars did not imply car makers where previously negligent in selling cars without airbags.
Cahill is making many of the same arguments once made by car manufacturers. For years car companies said that it would be too hard or too expensive to make airbags standard and that in any case people didn't want them and that the best available evidence showed that cars were safe. And if airbags were made standard did that imply that previously the cars were unsafe? In the case of airbags it turned out that these fears were not valid.
Cahill's writes that besides being a bad idea it is impractical; that Diaz-Buxo and Crawford-Bonadio
offer all of the same obstacles with economics, staffing, education, and also added cultural issues. The obstacles are large and difficult and right now we are prescribing and providing dialysis based on what is practical for the population under the standards that rely on the best evidence.
Well yes. Offering more frequent dialysis routinely would be hard. There are obstacles. But obstacles can be overcome and some times the best route is the hardest. Dialysis units have one day of the week when they are idle. Staying open seven days a week is not impractical - many health providers operate 24/7. Cahill's point that KDOQI KT/V standards call for achieving a 1.2 minimum is not a reason to stop trying to improve the provision of dialysis.
As Dr. Agar's articles Fluid and solute removal: how and why (par 1; part 2) pointed the clear problems with basing dialysis dose adequacy on the easiest to remove molecule - urea - which is in itself nontoxic. Putting aside the questions about the measure, it is important to keep in mind that a KT/V of 1.2 is a floor, it is a minimum acceptable dose of dialysis.
Whether to achieve a minimum dose or an optimal dose is a question for the dialyzor, the choice should not be limited by what is simpler for the program to provide. Cahill also suggests that there is an ethical dilemmas relating to scheduling but those same issues are a part of the provision of dialysis today; I think she misses the real dilemma. In 2008 the ethical question is: should access to this healthier modality depend on ones zip code? Should access depend on ones ability to dialyze at home?
Finally Cahill offers a broad brush economic analysis of the provision of dialysis and like car makers and airbags she contends the costs would be too great. Cahill writes that "In 2004, Medicare spent over $19 billion dollars on the ESRD program" however she does not note that her figure is total ESRD spending. According to the USRDS Annual Dialysis Report (PDF link):
Of the total Medicare dollars spent on ESRD in 2005, inpatient and outpatient services each accounted for 36–37 percent— $6.96 and $7.15 billion, respectively—while physician/supplier costs were slightly more than one-fifth of the total, at $4.1 billion (Figure 11.6). Skilled nursing, home health, and hospice together accounted for less than 6 percent of overall costs.
Part B Spending is less than 40% of overall spending (excluding those in skilled nursing, home health, and hospice it's about a 50/50 split between Part A and Part B). Clearly there is plenty of room to save Part A money through additional Part B spending. The solution to CRUD is more dialysis.
We don't know what the entire economic impact would be if we offered additional dialysis but we do have evidence that additional dialysis would improve mortality and hospitalization outcomes. That there are obstacles and that it would be hard is not enough of a reason to dismiss potential clinical and economic benefits; if there is one benefit and not the other then we will have an ethical dilemma but today that is not the issue, today the issue is inertia. As far as home dialysis not being a part of the solution she lost me.
Home hemodialysis, frequent or otherwise, require fewer staff. Home hemodialysis offers economic efficiencies on the Part B side alone. If Part A savings were included the discussion would shift to who has a medical necessity to dialyze in a center.
Today airbags are a widespread and touted feature. Like airbags, I hope some day soon higher doses of dialysis will become a widespread and touted feature of the provision of dialysis in the US