The American Dialysis Experience: How do we Create Patient Centered Care?
By Peter Laird, MD
I started in-center hemodialysis in February of 2007 and entered a new world of very large needles, headaches, especially after the long weekend and severe restrictions in my diet. It has been a journey that my wife has taken with me, side by side which finally led to our decision to take my treatments home. I am one of the fortunate 1% of hemodialysis patients in America able to create my own patient centered care by being at the forefront of my health care team in the comfort of my own home. Unfortunately, we are leaving too many fellow patients behind in many units that value the payment more than the patient. Many thoughtful, bright and caring advocates have long wondered how we can restore the focus back to the patient as the center of care, instead of the business as usual we see in all too many American dialysis units today. Where do we begin?
Looking at these issues over the last three years not only as a physician but as a dialyzor, I believe we are on the verge of a confluence of trends coming together in rapid fashion that could dramatically change the American dialysis experience very quickly. Focussing on this convergence may yield the greatest rewards in our collective efforts. Categorizing these trends into the framework of Alignment, Avoidance and Enforcement is helpful:
A) ALIGN:
1) The Historical Application: Pioneers of dialysis used rehabilitation as the marker of patient treatment outcomes with more dialysis applied when patients were unable to return to work and life activities.
2) Market Forces: Competition among FMC, Baxter, NxStage and others for the home Hemo market will be fierce. We should align with these forces that will utilize intensive campaigns to increase patient demand for these new machines, thus expanding the home hemodialysis market.
3) Bundle: Align and Reduce per capita health care costs of dialysis by increased utilizing of self-care and home dialysis modalities.
4) Conditions for Coverage, 2008:
Rehab Elements already in place in the regulations.
Mental Health already part of Medicare Part A, B and D
Mental Health evaluations already mandated in the CfC’s
Informed Consent Mandated in the CfC’s
Legally Required
Malpractice potential for not adhering to these regulations
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Medical literature:
Current literature supports more frequent and longer duration dialysis, once again in accord with the original data from the pioneering days of dialysis in the 1960's. FHN and other studies are converging upon a unified approach to optimal dialysis best summarized years ago in the Scribner-Oreopoulos Hemodialysis Product. Duration of dialysis together with frequency of dialysis gives us the best measurement of expected outcomes. -
Focus on CQI driven reviews of current practices to eliminate medical errors and iatrogenic conditions in dialysis centers.
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Reduce unnecessary admissions and readmissions by adhering to best dialysis practices learned in the last fifty years of this lifesaving treatment.
B) AVOID:
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Avoid Re-use of Artificial Kidneys.
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Avoid High Ultrafiltration Rates greater than 10mL/hr/kg.
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Avoid Sodium Modeling.
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Avoid Short Dialysis Times less than 4 hours for thrice weekly hemodialysis .
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Avoid Catheter Use, especially new onset dialysis patients by early referral for fistula placement.
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Avoid the long weekend, support Every Other Day (EOD) petition.
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Avoid Late Referrals:
Improve education of Primary Care Physicians and Patients to optimize referals to Nephrology in a more timely manner.
C) ENFORCE:
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Annual Dialysis Inspections - State and Federal level
QIP CfC’s 2008 Bundle
This will need state legislative or congressional action for enforcement regulations of existing statutes. We already have many excellent regulations and statutes in place, but there are no effective inclusions of true enforcement language in these regulations.
This is my own short list of actions that would restore patient centered care to the American dialysis experience that is only afforded to the smallest percentage of dialyzors. As we move forward with the emerging postitive trends in the market place, I for one do not want to leave anyone behind. With worse survival statistics than breast cancer, prostate cancer and HIV, the American dialysis patient is a vastly underserved population not because of lack of resources, but because of lack of patient centered care that would actually be cost saving as well.