EOD schedules would improve clinical outcomes, and support patient choice

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 [edit] 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.

Comments

[Bill Peckham]

I'm saying the HDP works as a tool to compare one treatment schedule against another for a dialyzor, not a tool to compare treatment impact between or among dialyzors.

Keeping everything else the same - the machine, Qb, Qd, the patient - the HDP will give the patient some idea what a change in schedule will feel like.

If you know what it feels like to dialyze 5 hours a time 3 days a week, you'll know you'll feel about the same, maybe a little better dialyzing three hours a time 4 days a week. An HDP of 45 vs HDP of 48. HDP is way to predict what a change in schedule will feel like if all else is kept the same.

Ultimately dialysis does have an impact. Some dialysis schedules have more impact than others. We don't have a way to measure this, it certainly isn't measured by urea.

The HDP offers a simple way to compare the impact of various schedules. As someone who has tried a lot of schedules, I think it does as good a job as any measure. It definitely provides a guide to what might be the perceived value of EOD schedules but until EOD is offered we won't know.

[theodore patrick]

Mr Peckham I completely support your EOD solution.I dialyze 3x's per week and after 4 yrs i stiil can't comply with the industries standards for fluid gain on the weekend.I come in on monday weighing about 5 to 6+ kilos over my dry weight. During the mid week sessions i average about 2 to 4 kilos.I have developed set routines for controling fluid intake during the week.When the weekend comes those routines don't work because of the extra day between sessions. After some thought about my situation i came to the conclusion that the EOD schedule would be the way to go.However that would be an industry change and is seems that it might be to much trouble to implement.My other option is to extend the time of my treatments to where 6 kilo removal is not a problem.I am totally frustrated with the current standards that they expect us to adhere to.I will have to do something soon because the constant struggle with the technicians is unproductive and not worth the stress that their pressure puts me through.It was encouraging to see that someone like you has already come up with a solution that matches with what i was thinking.Now know i can speak with some confidence behind me when i talk to my clinic about my problem.thank you

[Bill Peckham]

Best of luck Theodore, please update us if there is news. Taking these posts together I feel confident that every other day schedules should be offered and if an EOD schedule was offered I would predict a 20 to 30% initial uptake. There is no reason to deny you the choice.

We'll find out if this would work when a unit tries an EOD schedule (and units will try this in 2012), the verdict will be delivered depending on: does the EOD census grow or shrink after the initial roll out?

[jack]

Why doesn't anyone talk about recovery? Just curious.

[Bill Peckham]

You mean no one besides me? It is widely discussed - talking to Dori Schatell at Home Dialysis Central is how I developed a lot of my thinking. I do agree that in the unit it is rarely mentioned and it is too often overlooked when talking about alternative dialysis schedules or even longer treatments leaving frequency alone.

I think in general many units have a blind spot concerning things that happen outside the unit. When these units think of treatment burden they only consider what happens during treatment e.g. cramps, nausea ignoring or not giving adequate weight to the treatment burden once we get home.

[Theodore patrick]

Hello Bill
I finally got the doctors to prescribe 4x a wk. dialysis i go in Sat. for 2 1/2 HR.s My fluid gains are out of control so they okayed the extra session. I noticed that on Sat after i'm done i feel like i got spring in my step and i'm ready to go out and do something. I still have problems sleeping and they tell me that with the 4th session that i'm getting that it will get better. I'm only sleep 2 or 3 hr at a time. I presented your articles to them on EOD schedules and they were interested but they said that at this particular time that it would take a industry wide change for that to occur. I have concluded that the system wants to give us enough dialysis to keep us alive but when it comes to giving us enough to live as normal a life as possible,You have to fight for it and most people that are in-center are not educated enough about dialysis or doo not feel well enough to do this. I am not one of those people.I am one of two people in my clinic that run 14 guage needles and i am the only one that runs with a 550 flow during dialysis.I found that i get a little cleaner that way. Before that i was having itching problems after dialysis and the doctors were telling me that they did not know what it was from. Well it was from left over toxins that dialysis did not remove. So i figured out how to improve that thru education on the internet and then i went and fought for it and got what i needed. I learned alot during the last 5 yrs since i started dialysis. It seems that i have had to educate my doctors. Luckily i have a good working relationship with the head nephrologist and am able to talk to her on a one to one basis.