I find it interesting that there is a debate over home hemo. The market is still in its infancy.
There are 350,000 in the U.S. with ESRD (there will be 400,000 in the next few years). Medicare believes there are about 8,000 doing peritoneal dialysis at home. There are a few thousand who have staff-assisted home hemo using regular clinic machines. Aksys has 120 PHD users. NxStage probably has about 150.
Medicare estimates only about 30,000 can dialyze at home, given the restrictions of the current home-hemo machines. Also, many patients are on transplant waiting lists.
NxStage probably can have 3,000 or more patients within the next five years. Aksys is a public corporation with some cash, so it may hang on for a few years. The company has lost millions on the PHD.
NxStage could go public and raise cash, enough to dominate the market. However, new home machines already are being developed in Oregon and the Far East which could challenge NxStage.
At this point, personalized home hemo is insignificant from a market perspective. It does have huge potential, but only if the right technology comes along.
A hundred years form now ESRD patients may just pop a pill to go about their daily lives without dialysis or transplants. Or, there may be a small implant which cleans their blood and removes fluid.
That’s the first time I’ve heard a Medicare projection on home hemo’s potential. Where did you get it? Are you sure Medicare wasn’t referring to the existing PD numbers? According to the renal data system the 2002 numbers are that the prevalent ESRD population includes 281,594 patients on hemodialysis (65 percent), 122,374 with a functioning renal transplant (28 percent), and 24,531 on peritoneal dialysis (6 percent, equally split between CAPD and CCPD). Therefor, ninety-two percent of dialysis patients are treated with hemodialysis and 8 percent with peritoneal dialysis.
I think the debate, such as it is, is about the frequency people should dialyze. Right now more frequent dialysis is available only at home - there are some exceptions but I’d say in general that’s the case - the new machines provide more frequent hemodialysis but there are many people who post to this list who are doing more frequent treatments on “standard” machines - Marty’s Dad, Pierre, Cathy…more the rule than the exception.
And a hundred years? That’s a time frame beyond all our comprehension. I’d say there will be huge changes in the next 10 to 20 years. Maybe not pill form but I’d look for something that does not require needles – (I hope).
The standard machines aren’t that hard to use. I think there’s a big misconception about the level of difficulty.
Even the more conventional hemodialysis machines today have a lot of user-friendliness built-in, mostly achieved via computerization of the user interface, touch screens, etc. It’s not exactly like the machines of old.
The more automated machines save you time and effort in setup and takedown/disinfect. But whatever the machine, there’s still needling and then removing oneself safely afterwards, and the need to watch out for the same things: hemolysis, air in the lines, blood leaks, infection because of contamination, etc. Things that could happen during the treatment itself can happen with any machine.
I guess my message is this:
I don’t think that a person who is interested in the greater independence of home hemo and the better health of daily hemodialysis should shy away from it because they think a modern, conventional hemodialysis machine is too difficult. If I can do it, anyone with motivation, with reasonable dexterity and presence of mind can do it. It’s a lot of work doing it for yourself 6 days a week, but, it has definite rewards. The plumbing and electrical modifications needed for a conventional machine are really trivial in the overall scheme of things. So, don’t let that stop you. It’s less complicated than having a dishwasher put in.
I think that is right Pierre. The message I get from reading this Board and my own experience is that the machine is less important than the act of dialyzing at home and even better more frequently. Is it for everyone? No. Is it doable? Yes. And it is getting easier all the time. Not only do the new macnines make it easier things like this board make it easier. Having access to a wide range of user experiences…I mean being able to easily hear first hand accounts from the “trenches” has to lead to more people seeking these treatments. Sure some people might take a clear eyed look at home and/or more frequent dialysis and decide incenter is the right choice but from what I read and from my own experience the scale is heavily tipped in favor of home and more dialysis, always more.
And I should have noted those were US numbers. Pierre I know sometimes these discussions must seem too US-centric…I really appreciate being able to have reports from another system. ESRD knows no boarders…now back to the US: there is no reason Medicare would limit any dialysis modality. They pay the same regardless (there might be a PD difference - don’t know much about the PD side) of which hemodialysis machine you use.
I’d like to dispel the myth that home hemodialysis or its machinery is in its infancy. Home hemodialysis has been used in the US for over 40 years. I’ve worked with dialysis patients since 1978. Technology has changed tremendously in the last 27 years. It seems like changes in machines are coming even more rapidly now. I’m sure 40 years from now people will look back at how we took care of kidney failure and be as amazed as I was recently when I took a tour through dialysis machines of the past (several before I worked in dialysis) at the Annual Dialysis Conference.
So far as utilization of home dialysis (PD and HD), the ESRD Networks Annual Report for 2003* (the most recent report) states that:
– home hemo patients - 1,417 (up 6% from 2002)
– CAPD patients - 10,645 (down 5% from 2002)
– CCPD patients - 16,604 (up 6% from 2002)
– Other PD patients - 17 (down 50% from 2002)
Total - 28,683 home dialysis patients (HD and PD) of the 311,142 total dialysis patients treated on 12/31/2003. I would love to see more patients do home dialysis, especially longer and more frequent home hemo treatments because of the growing list of clinical and psychosocial benefits these therapies provide.
*Dialysis clinics report data to the Networks and Networks report their data to Medicare and USRDS. To review this and other data reported by Networks, see http://www.cms.hhs.gov/esrd/2k.pdf
You are right. Prior to 1973, when Medicare took over hemodialysis, many patients dialyzed at home. Since then, home hemo has all but disappeared. The market, AS OF TODAY, is tiny. There are only 300 or so doing home hemo, with no outside assistance. Peritoneal is in a separate category, It isn’t home hemo.
Beth was able to find data from a USRDS special study done, I believe in 1996. At that time, fewer than 25% of patients had ever heard of either PD or home hemo. Clearly, if 3 out of 4 patients don’t know a modality exists, they can’t choose to do it. That’s one of the reasons we started Home Dialysis Central–to raise awareness and use of PD and home hemo.
Even today, under the current Conditions for Coverage, clinics are only required to tell patients about treatments they offer THEMSELVES, not all of their other possible options if they were to go elsewhere.
How many patients COULD do PD or home hemo? I personally refuse to believe that US patients are any less capable than patients in Australia and New Zealand, where 50% of patients are home; 35% on PD and 15% on home hemo. Back in the early 70s prior to the Medicare ESRD Program, as has been pointed out here, 40% of US patients did home hemo. They were younger–older patients didn’t get dialysis back then. But even today, 50% of patients are under age 65.
When I provided the Network data I thought people might be interested in how many patients were doing each of the different types of home dialysis, including PD. I realize that home hemo and PD are entirely different types of therapy, but they both require training and a commitment on the part of the patient to take responsibility for his/her care. According to the ESRD Network data for 2003, there were 1,417 patients doing home hemo that year.
Are you saying that 300 patients are doing home hemo without “outside assistance” because you’re counting patients that are using the Aksys and NxStage machines only? Many patients are using other machines to do home hemo. I suspect, for instance, that most Fresenius patients that do home hemo (conventional, daily or nocturnal) use Fresenius machines. Other patients in other clinics may use the B Braun or other machines.
Few dialysis programs in the U.S. offer staff assisted home dialysis. Some durable medical equipment companies offer it. I’ve tried to locate these programs to help patients that don’t have partners get hemo at home. The staff assisted home hemo providers I’ve identified are in FL, MA, and TX. These programs provide staff to dialyze patients on hemodialysis in their homes or in nursing homes.
Other than these few providers, most of the 338 clinics listed on Home Dialysis Central that offer “home hemodialysis” (conventional, daily, or nocturnal), train patients and their partners to do their home hemodialysis. Some have a small number of patients while others have large programs. From the number of presentations at national meetings, the published research studies showing benefits, and the users that visit Home Dialysis Central, I believe that home hemodialysis is making a come back.
You might be interested to know that a survey of US nephrologists published in 2001 reported that that they believed in-center hemo was overutilized, that if 11% of patients did home hemo the US mortality rate would go down and if 14% of patients did home hemo cost effectiveness of the ESRD program would improve. How many people could do home hemo if they were informed about it is anyone’s guess…I’m sure more than currently do it. You who are home hemo patients are the best promoters of the therapy. If it’s working well for you, tell others.
Beth, I have to note that the Northwest Kidney Centers offers a stipend of, I think $40 per treatment, to pay a helper. This is just for people who choose to dialyze at home three days a week on the B Braun. NKC requires a home helper for people who choose the B Braun but on the plus side the stipend is available for family members who train to be a helper as well as unrelated people who are home helpers as a part time job.
I’m on the Aksys system, and I love it, I’ve seen the NxStage, but the Aksys PHD is so much simpler to use, and the monthly supplies are alot less. It’s easy to use and I feel better than I have in years. Been on it for a year and a half now.