Repeating Arguments Does Not Make Them Sound
When it comes to saving money in the care of end-stage kidney disease patients there are a number of oft-repeated statements that may not be true. In 2019, the White House announced the “Advancing American Kidney Health Initiative” aiming to “better outcomes, often at lower cost, for millions of Americans,” by having 80% of incident dialysis patients treated at home or by transplantation. But, as noted by Quinn and associates, the number of patients in the US treated by home dialysis and transplantation currently ranks third in the world as a function of population. The reason these therapies are thought to be underused in the US reflects the high rates of acceptance of patients for renal replacement therapy, (RRT), which, by default, means in-center hemodialysis.
“…We believe this target cannot be plausibly reached by increasing the numbers of individuals who receive home dialysis or transplantation. In fact, the most plausible way to hit the target is to reduce the total number of patients treated by RRT by restricting access to facility-based hemodialysis (HD), increasing the proportion of elderly patients who choose conservative (palliative) care, and limiting the ability of patients to choose their dialysis modality.”
The authors are under no illusion that this will happen spontaneously, nor do they think it likely to be incorporated as a policy goal.
“As for the likelihood of this happening in clinical practice, it is somewhat dependent on the motivation to improve performance and the consequences of not hitting the targets.”
The very next article was by Baerman and associates, which examined the costs involved in treating patients with peritoneal dialysis (PD), the dominant form of home dialysis in the US.
“According to one estimate, even modest annual increases over 5 years of home hemodialysis from 1% to 4%, and PD from 8%-16% could save an estimated US $233 million…
Interest among US policymakers in promoting more widespread use of PD is not new…Yet, despite decades of advocacy efforts and potential economic and quality of life advantages from PD, its use in the United States has generally decreased and remains less than other high-income countries. Between 1988 anad 2008, the proportion of patients with ESKD receiving dialysis at home decreased from 16% to 9%. Only recently has this downward trajectory reversed.”
The authors estimate from Medicare cost reports that 82% of the costs of care are shared equally by both PD and HD patients. Injectable drugs, which are now included in the in-center costs, accounts for another 4%, so realistically the remaining 14% of potential savings is from less time in the hospital. But the authors point out that increasing use of PD means less selectivity of patients. Currently the annual “switch rate” from PD to HD is on the order of 35%, and there are no cost savings associated with patients who switched.
From my purely clinical perspective, both papers, and the Federal policy, ignore the fact that both transplantation and home dialysis are selected populations of patients. Those with significant barriers—either medical co-morbidity, or adverse social determinants of health—are defaulted to in-center hemodialysis, so those accepted for transplant or home dialysis would do better no matter which form of therapy they choose. As a practical matter, it usually boils down to life-style choices and patient preference. With national targets, it is easy to predict more patients will be started on PD training with more switching, at cost to both patients and payers.
Quinn and associates’ observations deserve some additional comment. First, limiting in-center hemodialysis availability is not something providers will do willingly, but as I explored earlier this year, increasing staff shortages will have the effect of rationing slots. And we aren’t prepared for the implications of this, but, again, it will have the effect of putting more pressure to start patients on PD, only to have them fail, as they weren’t really suitable by current standards.
Are nephrologists prepared to push palliative (no-dialysis) options? Wong and associates conducted a survey in 2017, which I participated in, trying to ascertain the state of the art qualitatively. Based on their prior research, Dr. Wong had developed the notion that her participants were “pioneers.” I had to point out that I was not pioneering, I was just one of the last physicians to come into the field when facilities were limited and not everyone was automatically accepted for dialysis. As a result of this study, she noted her subjects were trying to present dialysis as an explicit choice and were improvising care systems to help them manage their patients. The authors concluded that such practices were going to be hard to generalize, a notion I agree with.
So, we have a new government initiative that will work only if more patients, in the words of former Governor of Colorado Richard Lamm, accept “a social duty to die.” In the meantime, much effort will be expended starting patients, perhaps involuntarily, on peritoneal dialysis, only to have them fail and end up on in-center hemodialysis anyway. To me, the more compassionate approach is to present PD as a “bridge therapy” to be used for a few years as a transition to either a transplant or HD. And patients with transplants that fail can be transferred back to dialysis. The “either-or” approach implicit in this initiative is wrong. I am reminded of my nine-year old grandson, whose approach to arguing with someone who doesn’t agree with him is to restate his conclusions at the top of his voice. I keep telling him saying it louder does not make the argument more persuasive, and neither does repeating it ad nauseum.
14 June 2022
 Quinn RR, Lam NN, Rovani P, Oliver MJ, Blake PG, Tonelli M. The Advancing American Kidney Health Initiative: The Challenge of Measuring Success. JASN 2022;33:1060-1062. doi:10.1681/ASN.2021121619.
 Baerman EA, Kaplan J, Shen JI, Winkelmayer WC, Erickson KF. Cost Barriers to More Widespread Use of Peritoneal Dialysis in the United States. JASN 2022;33:1063-1072. doi:10.1681/ASN.2021060854.
 Wong SPY, Boyapati S, Engelberg RA, Thorsteindottir B, Taylor JS, O’Hare AM. Experiences of US Nephrologists in the Delivery of Conservative Care to Patients with Advanced Kidney Disease: A National Qualitative Survey. Am J Kidney Dis 2020 (Feb);75(2):167-176. doi:10.1053/j.AJKD.2019.07.006.
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