The way the Uncle Sam treats end-stage renal disease (ESRD) is—as close as anything else—socialized medicine.
The federal government picks up the tab for dialysis, medications, hospitalization, lab, and physicians' supplies for at least 453,000 patients who lack private insurance, at an average cost of between $57,639 and $77,506 per patient per year as of 2008, according to the U.S. Renal Data System.
In 2008, ESRD costs were $26.8 billion, 5.9% of the total Medicare budget and a 13.2% increase over 2007.
Despite all this spending, however, the disease is plagued by enormously high death rates that average one in five patients undergoing dialysis a year. In other words, for every 10 patients who get dialysis on January 1, only eight will still be alive on Dec. 31.
To confound the issue further, the risk of dying varies greatly among the 5,000 dialysis centers around the country.
You would think Uncle Sam would want to count on good quality care for his money no matter where the care was provided. But that is not the case.
In some centers, risk-adjusted mortality rate is as low as 10%, while in others it is as high as 30% annually. That means that in some centers, nine people walk out after a year, whereas in other centers, only seven.
That's a lot of deaths, despite an awful lot of money being spent, and without any good explanation for the wide variation, says Kamyar Kalantar-Zadeh, MD, PhD, a researcher and Director of Off-Campus Dialysis Expansion Program and Epidemiology at the UCLA David Geffen School of Medicine. Something else is obviously going on.
"We want to find the secret of survival in dialysis centers with lower mortality. What is it? We just don't know," he says.
One new approach that seeks to address this disparity came this week in a study published by the American Society of Nephrology. Researchers in Los Angeles, San Francisco, Palo Alto, Albuquerque and Denver surveyed 423 personnel at 90 dialysis centers—both for profit and not-for-profit—to find out whether specific center practices might be influencing lower or higher death rates.
The researchers found 19 very specific conditions or factors present in centers with low ESRD mortality at higher levels than at centers with high patient mortality.
For example, low-mortality centers had better "patient engagement" manifested by patients' ability to stay for the entirety of their prescribed dialysis session; they didn't leave prematurely as some patients do. They also found greater willingness among patients' willingness to learn from staff.
Also, the number of patients considered to have good compliance with dietary advice was greater in centers with low mortality than it was in centers with high mortality, the staff surveys said. In short, it sounds like these lower mortality centers offer a friendlier environment for the long hours patients must be there each week.
Likewise, physicians' interaction with patients was in a respectful manner, and dieticians addressed patients' cultural issues in preparing nutritional plans, two other factors seen as more likely at centers with lower mortality.
And there were more multi-disciplinary conferences among staff after a patient returned from a hospitalization, which "may be associated with improved mortality," the authors wrote.
Lastly, they wrote, that in lower mortality dialysis centers, personnel "perceive a higher quality of staff management and education. Specifically, top units are more likely to call for per diem help if there is unexpected short staffing, and have a higher perceived quality of continuing medical education programs for staff." In short, they have "a more staff-oriented and friendly environment."
"We found that personnel in facilities with low mortality rates perceive their patients to be more cooperative, willing to learn, compliant, self-efficacious, independent, and accountable compared with patients in high mortality units," the authors wrote.
"We identified many factors that may enhance survival in dialysis, and we hope our findings can pave the way for future quality improvement initiatives," Brennan M.R. Spiegel, MD, of the Greater Los Angeles Healthcare System and lead author of the report said in a statement.
Of course it's possible, Spiegel and his co-authors wrote, that accepted criteria to adjust for risk in these patients, age, sex, race, disease duration, co-morbidities, nursing home status and BMI, is inadequate or faulty. There may be numerous other indicators.
Kalantar-Zadeh, a member of the Dialysis Advisory Group for the American Society of Nephrology, says that at his two centers, which provide dialysis treatment to about 300 patients, those who have higher protein intake and higher serum albumin levels tend to live longer. That seems to make the most difference, he says.
That's not inconsistent with the Spiegel study, he adds. "If you have better interaction between the physicians and staff with the patients, and more dieticians counseling the patients, you may see better nutritional status," Kalantar-Zadeh says. "Patients who say 'my appetite is good' tend to be happier and live longer."
Also at his center, he says, patients are advised to be on dialysis a bit longer, usually 4 to 4.5 hours, instead of the usual 3.5.
It's obvious that the federal government wants to get a better handle on costs and quality with ESRD centers. On July 30, it announced a new bundled payment system for all renal dialysis services.
Since this disease represents such an enormous burden on hospitals, physicians, and Uncle Sam, not to mention the patients who are dying, it's well worth the effort to figure out what may be working.