by Gary Peterson
As the recent ProPublica articles and NBC stories illustrate, dialysis care in the U.S. needs to be fixed. It is apparent, however, that there are many perspectives, concerns, opinions, and concepts that must be faced in doing so. Here are some thoughts on the things to be considered.
What is/are the goal(s)?
- improved biochemical markers
- more frequent/high frequency hemodialysis treatments
- optimal dialysis
- optimal quality of life
- renal rehabilitation
- individualized care
- individualized rehabilitation
- holistic/whole patient care
- working/employed patients
- longer hemodialysis treatments
- nocturnal dialysis
- home dialysis
- improved survival
- less hospitalizations
- compliance with existing regulations
- lower dialysis costs
- lower overall healthcare costs
- whole system approach
What entities or factors can cause change?
- Reimbursement changes
- Market forces
- Insurance companies
- For-profit corporations
- Non-profit corporations
- Medical professional organizations
- Patient organizations
- Public opinion
- Provider/nephrologist groups
- Individual nephrologists
- Individual patients
- Individual patient0-care staff
- Technological innovations
- Education programs of nephrologists/fellows
- Education programs for patients
- Patient empowerment
What motivations can cause change?
- Improved medical outcomes
- Improved / more efficient system of care
- Improved societal benefits
- Profit motives
- Cost savings
- Moral choices
- Employee profit sharing / stock options
- Peer pressure / corporate culture
- Individual patient health goals
- Individual finances/financial incentives - both patients and caregivers
- Individual patinet psychosocial needs
If dialysis care is individualized, what factors should be considered?
- Optimal quality of life
- Frequency/duration of dialysis treatments
- How the patient feels ( what amount of therapy makes them feel best)
- Treatment schedule
- Psychosocial services
- Rehabilitation choice
- Life goals
- What entities resist/oppose change? Why?
- What entities have the biggest effects on patients? What are those effects?
- What motivations work best?
- What motivations cause the widest change?
- What can cause the most rapid change?
The truth is that we simply have never had discussions about all factors involved in dialysis care. It is time to start.
I believe the greatest good can be done by focusing on patient life outcomes. I believe this is best done by redefining the end-stage renal disease (ESRD) program as a renal rehabilitation program. I think the concept was best put by Denise Eilers in a previous posting:
"I think the overall goal is a rehabilitated patient as defined by the patient himself. This would include optimal treatment to yield the desired quality of life. That would also encompass various modalities and frequencies and would address useful and fulfilling life pursuits, keeping in mind the person's age, culture, education and activity level. When the patient's or family's life circumstances change, their goals may need to change."
To make this happen as quickly as possible, I believe you must change the profit motives for the for-profit corporations that dominate the industry. I believe you must align their interests with the patients' interests.