Dialysis from the sharp end of the needle

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.

The Every Other Day Dialysis Clinic

By Bill Peckham

My contribution to the excellent discussion taking place on The Kidney Doctor (spring boarding off the Atlantic article) puts forward incenter every other day dialysis schedules as one of the solutions needed to improve the clinical outcomes of those who use dialysis. I am an advocate for incenter every other day dialysis (e.g. the petition, here, here), I have not heard anyone dispute that this would be better clinically but some might question this, the push back I have heard has been that it is impractical. Not that it shouldn't be done, but that it can't be done. Or it can only be done at too high a financial cost. 

I say 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 will make my case in five parts. Part I -

EOD incenter dialysis schedules can be done along side conventional schedules

The most specific concern that I have read is that you couldn't do EOD dialysis schedules for some patients but not others. "You can't be a little bit pregnant" the skeptics remind, contending that a unit would have to go entirely to an EOD schedule to offer anyone an EOD schedule. "They'd have to be 100% in or 100% out", "What clinic can accommodate its entire pt population for an additional treatment day?".

I would not advocate switching entire incenter populations over to EOD schedules but I think all patients should be offered EOD schedules. Transportation to the unit, specifically funded transportation, is an issue outside the control of units and represents a real barrier to EOD schedule access. I don't see EOD schedules being used by a majority of patients but I do believe it would be a popular choice if it was widely available.

What follows is an example of how a unit could operate with some patients using an EOD schedule, while other patients, the majority of patients continue to use a conventional three day a week schedule.

Consider a 24 station unit - operating six shifts Monday through Saturday at 80% capacity, a unit with 115 patients dialyzing 3x/week on average for 3.5 hours.

The unit would have to have in mind the minimum number of patients they would need to have dialyzing on Sunday to open the unit (the unit conventionally runs Mon to Sat). And then double that number to find how many patients the unit would need to start EOD schedules. It's a question of staffing.

Staffing a Sunday shift would be more costly than an average conventional shift but the treatments provided would carry more reimbursement. There would be different staffing requirements for different units, depending on case mix among other factors. For ours the number is 12, the unit would need 12 patients to make opening the unit on Sunday viable. Thus, the unit needs 24 patients to want EOD schedules for it to make sense to start their EOD program.

36 patients have agreed to switch to EOD schedules (there will need to be another post on how it might come to pass that a third of a unit's census would agree to switch but it would start with buy in from the patient's MCP physicians).

The first step to make this work is to divide the EODers into two groups of 18 (a number well over the 12 patient threshold). Instead of calling them MWF and TTS we'll call them Group 1 (G1) and Group 2 (G2). At this unit the interest in EOD skewed to the evening shift.

To accommodate the EODer's shift preferences the unit manager has to have 8 stations on the evening shift (16 wanted EOD) and 5 stations on both the morning and mid day shifts (10 patients on each wanted EOD schedules). As the EOD census grows or contracts G1 and G2 have to stay in balance, just as the shifts generally have to remain in balance. However, unlike MWF & TTS, G1 & G2 are indistinguishable from the dialyzor's point of view so switching between the groups should not represent a problem but it will mean that there will be times when patients have to shift from G1 to G2 or vise versa - as long as the number of patients on G1 and G2 is greater than 24 (12+12) the program remains viable at this unit.

Day One
It's Monday and G1's turn to dialyze. The patients get themselves to treatment and arrive at their appointed times, receiving their treatments normally. If they use ESAs they receive their dose. This continues through the day. From an operational stand point it should look like any other Monday even as this tectonic shift in the provision of dialysis is taking place.

Day Two
G2 comes in for their dialysis. As with G1 this looks like any other Tuesday from an operational stand point. Unless you looked at their charts you wouldn't be able to tell G2 patients from the conventional TTS patients. But as a group they do skew towards the units younger and healthier patients. Many of the unit's older and sicker patients rely on funded transportation to get to and from dialysis and it has not yet been worked out how to make funded transportation compatible with EOD schedules. This reality does mean that as a group the EODers are younger, healthier and have better insurance than the unit's patients generally.

Day Three to Six
The unit would continue to operate per usual, without any unique staffing requirements. In gathering supplies and preparing stations, staff would know they were getting ready for Wednesday and G1 or Thursday and G2. If it was time for labs they'd be drawn, iron would be given, visits with doctors and staff, nutritionists and social workers would take place normally.

Day Seven
On Sunday G1 would come in for dialysis. From the patient's point of view Sundays would be different. On every other day of the week you'd come in at your normal time but if dialysis fell on a Sunday you'd come in, most likely, at a different time. Having a special Sunday time for dialysis, different from dialysis on conventional days, is what allows EOD schedules to embed in a unit with a majority of patients using conventional schedules. 

It might be that on Sunday G1 and G2's dialysis is always during a window from 8AM to 2PM or it could be that G1's Sunday is from 10AM to 6PM and G2's is from 8AM to 2PM. The options would need to be evaluated based on patient and staff preferences and availability but ultimately most patients would need to accommodate a time outside their conventional time. Until the EOD census grows it will be necessary to operate the unit for just part of the day on Sunday. Additionally by operating the unit for only six or eight hours the unit would still be available for maintenance tasks typically done during off hours.

It's 10AM, G1 arrives in waves of four, 20 minutes apart. The four techs and one nurse get 18 patients dialyzing by noon. At the height of operation the unit operates 18 stations at once with a slightly higher staff/patient ratio then their conventional standard, since no medications, labs or ongoing education is taking place and there are no deliveries and few phone calls. The patients have event free treatments, they are generally healthier than the average unit patient and they have not had two days off. Note that no formerly separately billable services are provided on Sunday but payment is the same, resulting in the ~$70 included in the bundle for formerly separately billable services to be available for increased staffing costs.

Day Eight
G2 comes in for dialysis. From an operational perspective it should look the same, setting up treatments based on a patient's prescription. Staff would know to set up for Monday and G2. The only difference I would expect to be apparent is that G2 would not show the effects of taking two days off while the conventional Monday patients would continue to show the symptoms associated with the break in their routine renal replacement.

Day Nine to thirteen
Lather, rinse, repeat.

Incenter every other day dialysis can be done along side conventional dialysis schedules.