Great article by Mel H

Special Article

Longer and better lives for patients … and their centers: A strategy for building a home hemodialysis program

I need still need to read it but my quick scan (and Mel’s posts to this board and others) makes me think this in an instant classic.

These two posts are cross posted from billpeckham.com. I liked the article.

I’m trying to write shorter posts on the blog - it takes two of these to make one HDC posts.

“Live longer and better through home nocturnal dialysis.”

Mel Hodge who is known to the denizens of Home Dialysis Central’s forums, has an article in the most recent issue of Hemodialysis International: Longer and better lives for patients … and their centers: A strategy for building a home hemodialysis program. Mel makes good points about how renal replacement options are presented to patients. At the root the issue is inappropriate modality neutrality.

Mel compares the approaches of the nephrologist and the oncologist as they explain the treatment options; for kidney disease, incenter is presented as the norm and home modalities are presented as after thoughts, rather than as presented by the oncologist, in the terms of stark outcomes . By Mel’s reckoning too often home modalities are presented as lifestyle options rather than impactful treatment choices, the impact being a difference in expected mortality. This is modality neutrality - the idea that the only difference among the choices is different logistics or phsyco/social factors rather than life or death options. Mel suggest nephrologists take the lead in prescribing home nocturnal hemodialysis when ever possible.

I have one quibble with Mel’s framework and it’s his evaluation of PD. I would rank PD ahead of incenter hemo, on par with short, more frequent treatments. Otherwise, I think his excellent article accurately represents the calculus that should be occurring to all nephrologists and indeed all dialysis providers. Daily nocturnal is that much better.

Getting buy-in and closing the sale

In the most recent issue of Hemodialysis International: Longer and better lives for patients … and their centers: A strategy for building a home hemodialysis program by Mel Hodge offers an approach and a marketing strategy to increase the demand for daily nocturnal hemodialysis. Letting people try it out, just as a smart business lets their customers try something on or take a test drive.

Dialyzor buy in would, I think, increase using Mel’s suggested techniques and there is a role for dialysis reimbursement too. CMS’s reimbursement rules could help spread the availability and use of daily home nocturnal hemodialysis as Mel suggests. One other way is to fairly reimburse during patient training.

Currently Medicare reimburses during home hemodialysis training just as they do normally - three days per week. During training, when there is a great deal of one on one time spent by staff with patients, Medicare should reimburse for each of the usual five training sessions/week. This would amount to a few millions dollars a year in additional Medicare spending - 7 extra treatments on average for 2,000 or so people - but enough to help new programs to startup and to help existing programs grow. This would not require very much money.

I agree, Bill, and especially liked Hodge’s “Top 10 list” of reasons to use home dialysis. On the plane to Orlando for the Annual Dialysis Conference, I sat next to a woman who works for the airline–and has an employee who is on standard, in-center HD. When I went through the common sense explanation of why you wouldn’t want kidney replacement just 3 times a week for 3-4 hours (homeostasis; kidneys work 24/7…) her response was, “Why don’t more people do home treatment?!” Folks can clearly grasp this if it’s presented. The problem is, all too often, it’s not.

I too like Mel’s top 10… and agree that the problem seems (is) to be that patients are “not”
given all the options…and when explained properly I think that most dialysis patients would opt for daily/home/nocturnal dialysis

I also agree with Mel.
But we also need to get the DR’s on board!
And the Center’s on Board!
Pat

I appreciate the kind comments on my article. They won’t go to my head as I have been raked over the coals by the first nephrologist I have heard from who believes that for a nephrologist to prescribe the modality he believes would best serve the patient would “violate the basic priniple of patient autonomy” which he finds “repugnant.”

I particularly like Bill’s description of the apparent reigning theology among some nephrolgists and centers as “modality neutrality.” To me, modality neutrality makes no more sense for nephrologists than “antibiotic neutrality” for internists. ESRD is a serious, life threatening condition, and the patient deserves the very best judgement of the nephrologist in weighing the multitude of complex issues and then prescribing the specific modality that will give that specific patient the longest, highest quality life. Pretending it’s a “lifestyle” choice best left to the patient strikes me as just plain irrespomsible.

If my wife’s nephrologist had not told us at the outset nearly six years ago that 6x nocturnal dialysis at home was our best option and worked to help us realize it, I calculate there is less than a 15% chance she would be alive today if he had just passed her off to the center.

I just wish every new ESRD patient could be given the very best shot at life by their physician. That’s what motivates me to write articles.

Mel

[QUOTE=Mel;15632]I appreciate the kind comments on my article. They won’t go to my head as I have been raked over the coals by the first nephrologist I have heard from who believes that for a nephrologist to prescribe the modality he believes would best serve the patient would “violate the basic priniple of patient autonomy” which he finds “repugnant.”

I particularly like Bill’s description of the apparent reigning theology among some nephrolgists and centers as “modality neutrality.” To me, modality neutrality makes no more sense for nephrologists than “antibiotic neutrality” for internists. ESRD is a serious, life threatening condition, and the patient deserves the very best judgement of the nephrologist in weighing the multitude of complex issues and then prescribing the specific modality that will give that specific patient the longest, highest quality life. Pretending it’s a “lifestyle” choice best left to the patient strikes me as just plain irrespomsible.

If my wife’s nephrologist had not told us at the outset nearly six years ago that 6x nocturnal dialysis at home was our best option and worked to help us realize it, I calculate there is less than a 15% chance she would be alive today if he had just passed her off to the center.

I just wish every new ESRD patient could be given the very best shot at life by their physician. That’s what motivates me to write articles.

Mel[/QUOTE]

Great article Mel! It is really great that one of our own was in the position to write this much needed article out of your first-hand experience as a caregiver to one on nocturnal dialysis. This is the type article that will open eyes and pave the way to better txs for more of the dialysis population. This is what it means to make the world a better place. Keep writing those articles- if even one nephrologist listens and acts, accordingly, you will have saved lives.

As far as the comment by the nephrologist, is he saying that far be it from him to suggest a superior tx to his patients as it would negate their autonomy? How great that your neph counseled you appropriately, and more than that, supported you fully in getting to the best tx. I would trade all 7 nephs I have had thus far for one like yours. Tell him I said thanks : )