The number of incident dialysis patients in the United States continues to climb annually, reaching more than 120,000 in 2016 with a prevalence close to 750,000 according to data provided by the USRDS ESRD Annual Report. Modality choices followed are hemodialysis, peritoneal dialysis and transplant. Observation of the relatively linear graphs reveals that the later two have remained horizontal during the data collection period, accounting for less than 10% receiving peritoneal dialysis (PD) and far fewer (5%) opting for pre-emptive kidney transplant.
Total expenditures for ESKD (End Stage Kidney Disease) patients in 2016 has approached $60 billion or about 7% of the total Medicare budget. Cost per person per modality divulges hemodialysis as the most costly at about $90,000 per patient per year, whereas peritoneal dialysis approached $65,000 and transplant about $35,000. As payers become more scrupulous, a taste for PD or out-of-center HD becomes more palatable. The difference in cost is related to access creation and maintenance, frequent nursing involvement and supplies needed for HD topping a longer list. With PD a less expensive alternative, payer inquiry has come to the forefront.
Self-assessment of dialysis entails comparison to other countries. If we survey in center HD vs. Home PD, Hong Kong ranks number one with close to 70% performing PD. Mexico is second with about 60% followed by Guatamala at 55%, New Zealand 30% (with an additional 20% of total on Home HD) and Thailand at 25%. China does not report their numbers and the US is at a dismal 10%. Thus, a small increase in PD could result in significant reduction in spending.
There are multiple barriers to the pursuit of PD. We must address all aspects of care of the ESKD patient, starting with the primary care physician. Prior to reporting of the GFR (glomerular filtration rate), physicians relied mainly on the serum creatinine. As we age, the muscle mass of individuals declines, and so should the creatinine. If there is loss of muscle mass, the fall in creatinine could mislead the physician. This led to late nephrology referrals. Some current models in ACO (Accountable Care Organizations) and Hospitalist run practices are the new barriers to nephrology referral. Some of these physicians may be compensated differently if nephrology or general consults are requested.
Approximately 50% of the number of nephrology fellowship positions have remained unfilled for more than 15 years. This uncovers a deeper issue; fewer doctors are opting to pursue nephrology due to its unattractiveness. Two additional years of training are required for a modest increase in reimbursement compared to primary care physicians. Couple that with the challenging lifestyle of a nephrologist, comprehension of lack of suitable workforce is understandable. The Nephrologist must cover office patients, dialysis clinics, hospitals and nursing homes. Compound this with administrative duties and excess driving time between facilities, the choice becomes simpler when deciding on a specialty field.
For more than 20 years, the drive for “Fistula First” has created awareness for those managing CKD (chronic kidney disease patients). When a GFR of 20 – 25 cc/min is reached, the powers-that-be have requested the patient obtain a fistula in preparation for hemodialysis. This creates automatic assumption that the patient will be pursuing hemodialysis. Bias within the system is born. Although Fistula First assists in preparation for dialysis, it has not resulted in continued increases in fistulas in those with ESKD. In fact, the percentage of individuals on dialysis with a fistula has remained relatively flat over the past ten years. What Fistula First created was the “Don’t look over here” with respect to the alternative PD segment of care.
When pollings are performed, given adequate information more than 50% of people would choose PD. Some nephrologists avoid fistula creation, thus once transplanted, no surgical remnant of dialysis exists. Unfortunately, most dialysis treatments initiated are likely to be hemodialysis via a temporary or tunneled catheter. The patient suddenly has a change of heart, not pursuing the option initially sought. Reality shines on daily therapy. PD requires space for solution storage and significant involvement of spouse or family member along with self-responsibility. While on HD, a nurse or technician administers the treatment and the lone responsibility for the patient is literally habeas corpus.
Many nephrologists are exposed to little or no PD during training. They do not visit with the patients often, as they are seen only monthly. Compare this to HD where the nephrologist knows the patients whereabouts almost EVERY OTHER DAY of their life. Knowing where and what your patient is doing fuels the controlling engine. In addition, the blood taken from PD patients may not be as close to that from an HD patient. A BUN (blood urea nitrogen) of 80 mg/dL on a PD patient may infuriate a nephrologist. Although one should not compare blood tests between patients on different modalities, one cannot help but do so. Acceptance of higher numbers may be difficult for the untrained eye, or less trained nephrologist.
Success in Other Countries
The success other countries enjoy in having more patients on PD affirms the height of the bar. Some countries may encourage the patient to pursue PD first. If the US wishes to compete with these countries, we may inadvertently reduce true patient choice. The “I know what’s best for you” approach may not be a digestible edible for the American consumer, even if the modality is as efficacious and allows for avoidance of fistula creation. Multiple sessions with nurses, educators, physicians and most importantly, other patients who have traveled the PD road will provide valuable information that cannot be obtained from a video, book or internet search.
If an aging populous is added to a sedentary adolescent cohort and unified with expected longevity, the results are social and financial strain. If we do not change our approach, the ESKD population will follow an exponential path, leading us to crippling outcomes. Altering the percentages in favor of more PD, may only dampen the strain; but it is a step along the correct path.