Brenda Kurnik, MD has an article up on KidneyTimes I Want More Dialysis...Please! that is a response to people asking for more dialysis, more than three times a week and/or more than 4 hours a treatment, more than what is typically offered incenter. Dr. Kurnik gives a neutral overview of the situation, giving this history without much comment:
The transition from the long thrice weekly schedule to the current schedule was probably a product of several factors. With the advent of the 1973 Medicare coverage of dialysis there was a proliferation of free standing dialysis units and for-profit dialysis companies. The population changed to include older patients and those with diabetes mellitus as well as other medical conditions. Dialysis times were reduced in order to accommodate three and sometimes four shifts of patients per day with a thrice weekly schedule. High flux/more efficient dialyzers became available and the result was to reduce dialysis time in order to treat more patients in shorter treatments. The patients preferred this also, since it optimized convenience though not necessarily health.
I think a fuller accounting of this period is needed. Dialysis times were cut in persuit of economic efficiencies. There were fine words said about how high flux artificial kidneys would keep the clinical outcomes stable but in fact outcomes deteriorated. Who owned the clinics? Who decided that two hours of dialysis could ever be enough? A lot of money was taken out of the dialysis care system in the 1980s and 1990s; dialyzors are still paying the price for their greed.
Whatever the history I think Peter is right when he says it is his peers, the doctors who prescribe the dose of dialysis; our doctors must put an end to modality neutrality.