Tag Archives: dialysis

Health care ballot measures challenge reporters to separate fact from fiction

Photo: Newslighter via Flickr 

In California, an initiative known as Proposition 8 asks voters to limit the revenue that kidney dialysis clinics can earn. The proposition pits health care unions against the large companies that run dialysis centers.

In Massachusetts, a ballot question asks voters to consider a proposal to limit how many patients a hospital can assign to each registered nurse at hospitals and other health care facilities. Continue reading

Disparities found in hospice care among older dialysis patients

Photo: David Mulder via Flickr

Photo: David Mulder via Flickr

While end-of-life planning may be more common by providers and patients, there are “substantial” racial disparities when it comes to hospice use among some older adults, according to a new study. Researchers found that end-stage renal disease (ESRD) patients who were African American or Native American were 44 percent less likely to take use hospice care than white patients. Asian-Americans were 43 percent less likely to do so. Continue reading

How South Africa rations dialysis

ProPublica’s Sheri Fink, M.D., went to South Africa, where panels in hospitals still decide which patients deserve the scarce dialysis treatments and which must be left with failing, untreated kidneys. Fink was in the room as the assembled physicians gave the final approval or denial, and when they expressed their bitterness that hospital executives required folks on the medical side to make what were, essentially, cost-control decisions. The costs, after all, are not negligible.

In South Africa, only the roughly one out of five patients who have a form of health insurance or the small proportion of patients who can afford pay are able to get dialysis at private clinics or hospitals based on medical need alone. The cost of paying out of pocket—about $20,000 per year— is nearly double the gross domestic product per capita.

Probably in the middle of the last decade we were turning away 50 percent of the patients,” said Dr. Rafique Moosa, a kidney specialist at Tygerberg Hospital and head of the Department of Medicine at the University of Stellenbosch. According to him, as of August they were turning away 80 percent, and in November, only two out of 20 patients were accepted. “We just don’t have the resources to deal with the patients,” Moosa said..

Until relatively recently, there weren’t any formal guidelines for rationing dialysis care, an omission which opened the door for broad racial disparities.

The new general guidelines were drawn up by medical ethicists and emphasize medical criteria, which Fink reports on. It’s a carefully chosen set of criteria, but the enormity of the medical shortage gets in the way of neat formulae like those, Fink writes.

The problem is, few actually are able to get transplants. There are far more good medical candidates than there are dialysis slots. Therefore, the committee falls back on subjective criteria—does the patient seem motivated? Does he or she have a good social support network?

ProPublica releases ratings of 5,000 dialysis providers

On the heels of a successful FOIA request related to Robin Fields’ dialysis investigation, ProPublica has published a database evaluating dialysis clinics on 15 different measures. The information has been available to state health agencies for years, but this is the first time it’s been released for general public consumption, Fields writes.

Patients have long chosen dialysis clinics based only on location or physician recommendation, even though the data shows a wide variation in quality among the 5,000-plus such facilities nationwide.

In more than 200 counties nationwide, the data show, the gap between facilities with the best and worst patient survival, adjusted for case-mix differences, is greater than 50 percent. In areas such as Allegheny County, Pa., or Franklin County, Ohio, each with upwards of two dozen clinics, the differences are even more substantial, exceeding 200 percent.
There is also wide variability in how often patients at different clinics are hospitalized for septicemia. Although septicemia cases can be unrelated to dialysis, it is a significant risk for patients, who typically have their blood cleaned of toxins three times a week. Nationally, the rate was about 12 percent a year for 2006 to 2008. But in dozens of counties, the spread between facilities with the highest and lowest rates was more than 25 percentage points.

Like Dollars for Docs, this new database should provide plenty of ready localizations of of the story.

Dialysis program: Experiment in socialized medicine comes with high costs, risks

ProPublica’s Robin Fields has put together an artful examination of the nation’s Medicare-funded dialysis system. Part history and part investigation, it explains how this massive anomaly of government-run medicine came to be, and how it demonstrates the promise and peril of so-called socialized medicine.

The reporting has had an immediate impact, both upon the dialysis industry (read leaked plans for their response here) and upon the federal government. For health journalists, the federal response is particularly interesting, as it involves the disclosure of previously hidden data, and a classic government excuse.

ProPublica first asked CMS for the clinic-specific outcome data it collects — at taxpayer expense — two years ago under the Freedom of Information Act. The agency declined to say whether it would release the material until last week, as this story neared publication. It subsequently has provided reports for all clinics for 2002 to 2010. ProPublica is reviewing the data and plans to make it available for patients, researchers and the general public.

The reasons CMS has given for withholding the information until now is that some measures are disputed or lack refinement. Regulators and providers can put the data in perspective, officials had said, but patients might misinterpret the information or see it as more than they really want to know.

As befits something destined for publication in The Atlantic, Field’s piece might take more than one sitting to fully digest. And, if you haven’t yet had that second sitting, you’ll have missed some particularly nifty bits of comparative journalism, particularly where Fields compares the U.S. system to that in Italy, where the costs are significantly less and patients “got half the average dose of Epogen given to U.S. patients, perhaps because there’s no profit incentive to give them more.”

In Italy, about one in nine dialysis patients die each year. In the United States, that number is one in five. In dialysis treatment, there’s a trade-off between speed, cost and outcomes. And even high-rated Italy has had to make a few sacrifices, as evidence by comments from an Italian doctor:

“The decision to make dialysis faster wasn’t a scientific decision, it was a managerial decision,” he says. “It’s to allow you to do four shifts a day and make money.” He schedules just two shifts a day to accommodate longer treatment times.

Fields ends the piece on a high note. There’s hope for future efficiency in the dialysis system, thanks to a new program of bundled payments that will supplant the current system in which clinics see the actual dialysis as a “loss leader” and profit instead from heavy use of well-reimbursed drugs.

ProPublica promises more stories about this throughout the week, so be sure to check back its site for developments. Fields discussed dialysis on NPR today, as did Dr. Barry Straube, the chief medical officer at CMS.