Virtually all dialysis treatment is paid for by Medicare, even for patients younger than 65 years old. Despite annual federal expenditures of $18 billion, the mortality rate among American hemodialysis patients is the highest in the industrialized world at 23 percent per year. European and Japanese hemodialysis patient mortality rates are much lower at 10 to15 percent per year. The high mortality rate among American patients is in part due to the fact that one-sixth of the 200,000 Americans receiving hemodialysis treatment do not receive an adequate dialysis dose. Hemodialysis is used to treat people with kidney failure. In the process, blood is removed from the body and pumped into a machine that filters out toxic substances from the blood and then returns the purified blood to the person.
The researchers, led by Ashwini Sehgal, M.D., from the Case Western Reserve University School of Medicine, identified three barriers to adequate dialysis, showed that it is possible to overcome the barriers, and demonstrated that overcoming barriers resulted in higher quality treatment. The study, involving 169 patients from 29 hemodialysis facilities, identified and addressed each barrier separately. If dialysis prescriptions were too low, a study coordinator helped physicians improve the prescriptions. If patients received treatment through a catheter, the study coordinator helped patients get grafts or fistulas instead. A graft or fistula is a surgically created connection between an artery and a vein that provides a better blood flow for dialysis. If patients shortened treatment time by coming late or leaving early, the study coordinator educated them about the importance of staying for their full treatment time.
“Dialysis is similar to drugs in that both must be given at an appropriate dose to be effective,” said Sehgal. “Patients getting an inadequate dialysis dose die sooner and are hospitalized more often.”
The federal reimbursement system, which provides a fixed payment per treatment, may act as a financial disincentive to providing high quality treatment. “Using higher efficiency machines or increasing treatment time costs money, but facilities don’t get paid more for these higher costs,” said Sehgal.
“I urge patients to stay for their full treatment time,” said Sehgal. “I urge physicians and dialysis facilities to address the three barriers we identified. I urge policy makers to re-examine how we pay for dialysis treatment.”
The cost of carrying out the intervention was very modest because a single study coordinator educated physicians and patients. Similar inexpensive interventions might be developed to identify and overcome barriers to quality care in other medical areas, said Sehgal.
Sehgal is an associate professor of medicine, biomedical ethics, and epidemiology and biostatistics at CWRU and a member of the Division of Nephrology at MetroHealth Medical Center in Cleveland.
Journal
JAMA