Tuesday, November 16, 2010

The US dialysis program -- How good and how bad?

A recent article in ProPublica by Robin Fields contains a number of strong criticisms of the US dialysis program for people with kidney disease. Here's an excerpt:

Now, almost four decades later, a program once envisioned as a model for a national health care system has evolved into a hulking monster. Taxpayers spend more than $20 billion a year to care for those on dialysis -- about $77,000 per patient, more, by some accounts, than any other nation. Yet the United States continues to have one of the industrialized world's highest mortality rates for dialysis care. Even taking into account differences in patient characteristics, studies suggest that if our system performed as well as Italy's, or France's, or Japan's, thousands fewer patients would die each year.

NPR's Terry Gross recently interviewed both Robin Fields and Barry Straube, Chief Medical Officer for Medicare. The interviews are worth hearing or reading. Here's an excerpt from Dr. Straube's interview:

I believe that Robin's article, although pointing up some very important issues that this agency and the Department of Health and Human Services is aware of and trying its best to fix, that it overstates significantly the degree of the problem out in the real world. It makes it sound like any dialysis unit that a patient would walk into is subject to these problems and that's simply not true. The vast, vast majority of the units are not as described in the several examples, which are completely true examples but not illustrative of most dialysis units.

I think my main quibble with the article is that it sounds as though one would not want to have dialysis in the United States. This is a life-saving treatment that the vast majority of people are being treated very well in very clean facilities that hopefully make very few mistakes. And the examples there are not indicative of most dialysis units.

I conclude, having read and heard both, that there are elements of truth in the article about this kind of care and need for improvement. However, the magnitude of the problem seems to me to be less than reported. I welcome your thoughts.


A nephrologist said...

I read the Atlantic article and I agree with the points you make.
Dialysis is not perfect, but it keeps people alive. The medical directors at most units are highly committed to taking good care of kidney failure patients.

Of course, the ultimate solution to this problem is not making dialysis better, but preventing and treating kidney disease before it progresses to "end-stage" kidney failure. Polio was not cured by improving the iron lung!

BM said...

As I was first employed as a hospital administrator in the early 1970's the Nephrology industry got Congress to approve Medicare payments to Dialysis doctors and paid for the patients on a per Dialysis basis.

On the other hand (I sound like Tevye in Fiddler on the Roof), my grandfather died of kidney disease at age 54 in 1954, when there was no treatment.

Anonymous said...

Regina Herzlinger of HBS discusses the dialysis industry in her book WHO KILLED HEALTHCARE? The contrast of practice specialization based on a technology (e.g. dialysis, MRIs) vs. condition (e.g. kidney disease, breast cancer) is important. The latter model is more patient-centered and comprehensive and lends itself to treating patients rather than organs.

Anonymous said...

To dismiss the Pro Publica article out of hand is a great disservice to people like myself on dialysis at present. The take home message is showing how America is an outlier compared to other developed nations on how we deliver dialysis to our patients.

Our poor outcomes are based on our profit driven practices that have been universally rejected by the other nations. Longer, slower and more frequent hemodialysis saves lives and returns people to higher function. Home, nocturnal dialysis has equal outcomes to cadaveric transplant, yet less than 1% of patients use this modality in America. Yet in New Zealand, they have over 25% of their patients on home, nocturnal dialysis. It is time for America to grasp that we have poor outcomes because we have the worst approach to dialysis as a developed nation.