US Dialysis Mortality Rates High but Vary Widely Between Centers

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http://www.medscape.com/viewarticle/732938

November 22, 2010 (Denver, Colorado) — Editor's note: Recent media attention has compared the quality of dialysis care in the United States with that in other developed countries, and has illuminated issues such as Medicare reimbursement for dialysis providers and federal oversight of dialysis clinics.

Jonathan Himmelfarb, MD, is director of the Kidney Research Institute and professor of medicine, Division of Nephrology, at the University of Washington, Seattle. In an interview with Medscape Medical News, he addressed some of the recently publicized issues at this year's Renal Week 2010: American Society of Nephrology 43rd Annual Meeting, being held November 16 to 21 in Denver, Colorado.

Medscape: The United States has one of the highest dialysis-care mortality rates in the world, with some reports citing 1 death in every 5 patients and others noting that, since 1990, only Taiwan and Mexico have had higher increases in kidney failure than the United States. What do you see as the top 1 or 2 near-term measures that can be implemented in the clinic or in the regulatory sphere to improve dialysis outcomes?


Dr. Jonathan Himmelfarb

Dr. Himmelfarb: People come to dialysis now with a lot of established disease — with diabetes, with vascular disease, with other medical complications — and it's increasingly a frail, more elderly population. So some of the high mortality that we see is associated with the comorbidities that people have. For some of the comparisons from around the world, there really are major differences in the kinds of people that are receiving dialysis therapy in different places. That's one factor that we have to take into account when we think of the high mortality that's associated with dialysis.

Some of the high mortality in kidney patients is of major concern to the nephrology profession. It's the focus of a great deal of research. We're looking for ways to improve outcomes for dialysis patients with new innovations, with adjuncts to dialysis therapy, and by improving dialysis therapy. That said, even with the way we deliver dialysis now, there are probably things that can be done better in the United States. One of those is the type of access that is used for dialysis — what's called vascular access. Many would say that the Achilles' heel of hemodialysis is that you have to have access to the circulation so that you can take blood out, put it through the dialysis filter, and clean the blood of many toxins.

We know that dialysis using the arteriovenous fistula is preferred, in that it tends not to develop clots and is resistant to infection. So that's the best type of dialysis access. The earlier that people are identified as needing dialysis and have a fistula created surgically, the better off they are when they start dialysis. Early referral and placement of the fistula is an important quality measure.

Medscape: Aside from those suggestions, what are the most promising recommendations or messages being sent to the dialysis community as part of Renal Week 2010?

Dr. Himmelfarb: This is the premier kidney disease conference in the world, year in and year out. It attracts more people, and the quality of the science is better than any nephrology meeting in the world. It's always, for a kidney specialist like myself, an exciting time. There are literally thousands of scientific presentations that are available in the course of 3 or 4 days.

There are a number of presentations on how we can reduce catheter use and how we can improve vascular health, because most people who die on dialysis die of cardiovascular complications. We know that the treatment of dialysis patients from a cardiovascular standpoint is very complicated. There will be reports in a late-breaking clinical trial session on important National Institutes of Health–funded studies that are examining whether more frequent dialysis, up to 6 times a week, will result in better outcomes.

We are also focusing this year on developing a strong biomedical research component for kidney research — novel approaches that are very different from what we do right now — with nanotechnology and miniaturization. There may also be completely different ways to deliver similar therapies, or maybe improvements in membrane technology.

Medscape: To what degree can American mortality rates be attributed to factors such as higher rates of diabetes and heart disease?

Dr. Himmelfarb: Most studies show that the number of people accepted into dialysis programs, per million population, adjusted, is higher than in many parts of the world. It's very hard to do these transnational comparisons, because the foreign-care patterns are different and the patients are different. Having said that, . . . it still looks like mortality may be higher in the United States than in other parts of the world.

Medscape: How did the discussion regarding potential improvements in dialysis care fare during the recent debates over healthcare reform?

Dr. Himmelfarb: Actually, there was a great deal of discussion about dialysis care in healthcare reform. The recent legislation, the Accountable Care Act, has provisions related to end-stage kidney disease and the way dialysis is delivered. You have to keep in mind that care for dialysis patients is about 7% of Medicare's total budget. It definitely has policy makers' attention.

Medscape: Is dialysis care better attuned to independent clinics and small chains, or is it better attuned to large corporate chains?

Dr. Himmelfarb: We have seen, in the past 5 to 8 years, a major change in dialysis in the sense that there has been consolidation in the dialysis providers, largely through mergers. It's important when there is consolidation to make sure that there is a focus on physician autonomy and the highest levels of quality. There are some advantages to mergers, in the sense that there are economies of scale and the ability to have large databases from which one can analyze the data. But there are some disadvantages, and we have to watch that corporate models do not impinge on individualized treatment for patients.

Medscape: What is the Centers for Medicare and Medicaid Services (CMS) doing right with regard to dialysis clinic oversight, and what is it doing wrong?

Dr. Himmelfarb: It happens that this industry has been blessed to have, for the past 6 years of CMS, a chief medical officer who is a nephrologist. He's well attuned to the many issues of the end-stage kidney disease program. During that time, there has been a lot of innovation on the part of CMS, much of it reflected in the healthcare reform legislation. Many of the issues that were raised in recent news stories have more to do with local and state inspection authority. I think the federal government under Barry Straube has really done a good job of being innovative and trying to improve care.

Medscape: Can dialysis care can be improved by offering financial incentives for superior outcomes?

Dr. Himmelfarb: The dialysis field is going to be one of the earliest in which the federal government will to try to implement some pay for performance or pay for quality. It's an innovative area in terms of healthcare policy. We'll probably be the first area in all of what the federal government does to implement pay for quality. You get paid better if your outcomes are better, according to a variety of different quality metrics, which are all being actively developed.