By Bill Peckham
This is Part Two of a five part DSEN series making the case that Every Other Day (EOD) incenter dialysis schedules can be done (Part One); EOD schedules would improve clinical outcomes and support patient choice (Part Two); EOD schedules are implicitly supported by MAC/FIs (Part Three) EOD schedules would improve the clinic's finances and [edit; equivocation] may lower overall Medicare costs  per person, per year (Part Four); EOD schedules would increase the clinic's value (Part Five).
I haven't seen, compared to a conventional schedule, the clinical benefits of an EOD schedule disputed. That the dialysis weekend is risky is well known. Most recently a NEJM paper reviewed the evidence but the data has been consistent since the 1960s. Routinely avoiding the weekend should routinely lead to better clinical outcomes.
The tougher questions to answer are concerns that patients would not want to switch from conventional three day a week schedules to EOD schedules, that patients prefer three day a week schedules.
Unless there is a choice it can not be said that there is a preference. For patients who want to dialyze incenter there is little access to higher frequency dialysis. Incenter patients do not have agency to decide their dialysis frequency. I believe that if there was a choice and the risks that are inherent in the dialysis weekend were well understood a significant number of patients would choose the safer schedule.
Some patients due to transportation issues would not be able to use an EOD schedule. Some patients would prefer the set weekly schedule allowed by conventional three day a week dialysis. Some patients seeing EOD schedules as requiring more from them would feel like they are doing all they can and they just aren't able, at this time, to do any more. This is all to be expected and accommodated.
However, some number of patients would want to use the safer schedule and would choose to dialyze EOD. How many is not a number I can give. Each patient would have to make their own personal cost benefit analysis but I think there is reason to believe that most patients would reckon EOD schedules to be a good value.
We're not use to thinking in terms of weekly dose of dialysis, let alone the biweekly dose of dialysis, but I think we should. Talking about treatment duration alone obscures dangerous anomalies like the dialysis weekend. One way to quantify the impact of the weekly dose of dialysis is the HemoDialysis Product (HDP). The HDP assigns an impact value to various weekly dialysis schedules (D&T just republished the Scribner classic) using a simple formula: HDP = (hrs/dialysis session) x (sessions/wk)2.
My experience supports using HDP as a way to understand the impact of various schedules; how various schedule would make me feel as compared to other schedule options. In order to decide if I would use an EOD schedule I would want to weigh the benefits against the cost. Would I feel better, would the burden of CKD5 be less vs. spending more time dialyzing and taking into account the net effect of additional time getting to and from the clinic and the time spent recovering from the dialysis treatment. The costs are easier to reckon then the benefits, the HDP provides a way to quantify the expected benefits.
A conventional three day a week, four hours per treatment schedule has a HDP=36; keeping treatment length the same but dialyzing once more every two weeks, i.e. going to an EOD schedule, brings the HDP up to 49. Thus, increasing the amount of time dialyzing by 16.6% - from 6 days every two weeks to seven days evey two weeks - will increase the impact of therapy by over 36% - from 36 to 49.
Another way to say it is that going from 12 to 14 hours of treatment per week, in effect, in this way, through frequency, increases the HDP 13 points. If instead you increased your weekly time to 14 hours while keeping frequency the same, i.e. doing four hour forty minute runs three times a week, your HDP would be 41.94, a six point gain. Frequency gives more dialysis 'bang' for a dialyzor's 'buck', paid in time.
The EOD schedule is the better value. There is every reason to believe that if EOD schedules were offered, EOD schedules would be a popular choice.
Think of the very good financial advise to pay your mortgage every two weeks instead of every month. If you pay every month you will make the 12 payments and four times during the year you get an extra week of income between payments. Having an extra paycheck between mortgage payments is pretty great. But if you pay every two weeks you end up taking years off of your mortgage, saving lots of money and you don't really notice that you made a 13th monthly payment during the year. An EOD schedule would be like agreeing to pay your mortgage every two weeks instead of every month. It's the smart move.
Offering EOD schedules improves clinical outcomes. Offering EOD schedules supports patient choice.