Author Interview: Dr. Ann M. O’Hare, MD, MA
Renal Dialysis Unit, Veterans Affairs Medical Center
1660 S Columbian Way, Seattle, WA 98109
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Publication:
Author Interview: Dr. Ann M. O’Hare, MD, MA
Trends in Timing of Initiation of Chronic Dialysis in the United States
Ann M. O’Hare, MD, MA; Andy I. Choi, MD, MS†; W. John Boscardin, PhD; Walter L. Clinton, PhD;
Ilan Zawadzki, MD; Paul L. Hebert, PhD; Manjula Kurella Tamura, MD, MPH;
Leslie Taylor, PhD; Eric B. Larson, MD, MPH
Arch Intern Med. 2011;171(18):1663-1669. doi:10.1001/archinternmed.2011.436
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What are the main findings of the study? |
We found that from 1997 to 2007 there was a tendency for patients with chronic kidney disease to initiate chronic dialysis approximately five months earlier in the course of their disease. The trend was more pronounced for older patients: those aged 75 and older initiated dialysis approximately 8 months earlier in 2007 than would have been the case in 1997.
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Were any of the findings unexpected? |
The trend toward dialysis initiation at higher levels of kidney function (or eGFR) over the last decade is known. Our question was what does this mean for patients in terms of additional time spent on dialysis. Our findings are significant in light of recent evidence that earlier initiation of dialysis does not lead to better outcomes, particularly when you consider the cost and intensity of chronic dialysis treatments.
Five months translates into 63 additional hemodialysis treatments, 189 or more hours of treatment and approximately $14,490 in additional payments for dialysis for each patient.
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What should clinicians and patients take away from this study? |
We believe that our findings point to a change in practice over the ten year period from 1997 to 2007 whereby clinicians may have a lower threshold for initiating chronic dialysis than in previous years.
Initiation of chronic dialysis has major implications for both the patient and the health system. Decision-making around chronic dialysis can be very complex and is often fraught with uncertainty. Ultimately, the decision to initiate chronic dialysis should be one that is carefully considered by both the patient (and their family) and the provider.
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What recommendations do you have for nephrology health care providers as a result of your study? |
We believe that our findings call for careful evaluation of contemporary dialysis initiation practices and studies to better understand in detail what is driving recent trends toward initiation of chronic dialysis at higher levels of eGFR.
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| Abstract: |
Background During the past decade, a trend has been observed in the United States toward initiation of chronic dialysis at higher levels of estimated glomerular filtration rate. This likely reflects secular trends in the composition of the dialysis population and a tendency toward initiation of dialysis earlier in the course of kidney disease.
Methods The goal of this study was to generate model-based estimates of the magnitude of changes in the timing of dialysis initiation between 1997 and 2007. We used information from a national registry for end-stage renal disease on estimated glomerular filtration rate at initiation among patients who received their first chronic dialysis treatment in 1997 or 2007. We used information regarding predialysis estimated glomerular filtration rate slope from an integrated health care system.
Results After accounting for changes in the characteristics of new US dialysis patients from 1997 to 2007, we estimate that chronic dialysis was initiated a mean of 147 days earlier (95% confidence interval, 134-160) in the later compared with the earlier year. Differences in timing were consistent across a range of patient subgroups but were most pronounced for those aged 75 years or older; the mean difference in timing in that subgroup was 233 days (95% confidence interval, 206-267).
Conclusions Chronic dialysis appears to have been initiated substantially earlier in the course of kidney disease in 2007 compared with 1997. In the absence of strong evidence to suggest that earlier initiation of chronic dialysis is beneficial, these findings call for careful evaluation of contemporary dialysis initiation practices in the United States.
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| More Author Interview from Hemodialysis.com |
| More on Initiation of Dialysis |
Chronic dialysis for kidney disease patients now initiated substantially earlier - UW-Group Health-led study finds
It has become increasingly clear that patients in the United States are starting dialysis at higher and higher levels of kidney function. A team of researchers, led by Dr. Ann O’Hare, University of Washington associate professor of medicine and affiliate investigator at Group Health Research Institute, set out recently to find out what this means for patients, and how much earlier patients are starting dialysis compared with past practices.
Researchers from Washington state and California found that over a ten-year period, from 1997 to 2007, patients are starting dialysis approximately five months earlier on average. The study, “Trends in timing of initiation of chronic dialysis in the United States,” is published in the Archives of Internal Medicine. Changes in timing are not explained by changes in measured patient characteristics and most likely reflect a shift in dialysis initiation practices over this time period, researchers said.
Dialysis is an intensive, time-consuming and expensive procedure for patients, said O’Hare. “It’s a substantial commitment, taking place three times a week, for three or four hours per treatment, and costing several hundred dollars per treatment. When you look at the overall chronic dialysis population, our findings are significant.”
The research team estimated that the difference in timing translates into 63 additional hemodialysis treatments, 189 or more hours of treatment and approximately $14,490 in additional payments for dialysis for each patient, or more than $1.5 billion if extrapolated to patients in the study who initiated dialysis in 2007.
Researchers used two different data sources for the study: the United States Renal Data System, a national registry of end-stage renal disease and a detailed renal database from the Group Health Research Institute. The national registry contains details on the level of kidney function for patients starting dialysis. The Group Health data contain information on the rate of loss of kidney function prior to dialysis initiation not available in registry data.
O’Hare said the findings are also important in light of other recent research that found starting dialysis earlier did not improve a range of health outcomes. “Patients are starting chronic dialysis significantly earlier, but there is no real evidence that it is beneficial,” she said.
Researchers said the findings call for more careful evaluation of current dialysis initiation practices in the U.S. “We really need to take a good critical look at what we’re doing,” said O’Hare. “Our study did not reveal the rationale for initiating chronic dialysis sooner, nor did it provide details on circumstances, signs and symptoms that might have prompted dialysis initiation . It’s an open question as to why this is happening, but these findings provide a rationale for more detailed study to better understand practices and what’s driving this trend.”
In addition to O’Hare, researchers involved in the study include Drs. Ilan Zawadzki, Walter Clinton and Eric B. Larson of Group Health Cooperative and the Group Health Research Institute; Drs. Andy Choi and John Boscardin of the University of California San Francisco; Dr. Paul Hebert of the University of Washington and the VA Puget Sound Healthcare System; Dr. Leslie Taylor of the VA Puget Sound Healthcare System and Dr. Manjula Tamura of Stanford University and the VA Palo Alto Healthcare System. The study was funded by a Beeson Career Development award from the National Institute on Aging, U.S. National Institutes of Health, to Dr. O’Hare.
The study is dedicated to the memory of Dr. Choi, who made generous and important contributions to this work. Choi died unexpectedly during the final stages of manuscript preparation, leaving behind a wife and two young daughters. O’Hare described him as a “rising star” in his field. |
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Home Dialysis Summit Recommends Policy Changes to Increase Home Dialysis Usage
WASHINGTON, April 25, 2012 /PRNewswire -- On the heels of the first National Summit on Home Dialysis Policy, Summit organizers released a report reflecting the views of the delegates -- leaders in the kidney disease patient, clinician, facility and industry communities -- on federal policy steps to improve utilization of home dialysis for patients who can benefit from this often advantageous form of treatment. Many of the organizers also announced they have formed a new alliance, called the Alliance for Home Dialysis, to advance the recommendations identified at the Summit.
The Summit's "Report of the Delegates" highlights key findings from a March 29th meeting in Washington, DC where experts probed why, despite widely accepted and well-documented benefits of home dialysis -- improved outcomes, enhanced patient satisfaction, improved quality of life, and lower costs-- fewer than ten percent of the more than 390,000 current U.S. dialysis patients receive treatment at home. Current rates of home dialysis utilization reflect a steep decline from the 1970s, when almost 40% of U.S. dialysis patients were treated in-home.
Specifically, delegates found that policymakers should work with stakeholders in the dialysis community to confront three areas:
Accessibility: Patients and clinicians face array of hurdles in education, training, and infrastructure that hinder equalized access to home dialysis.
Accountability: Utilization of home dialysis can be improved through measures within government programs that are designed to recognize and support excellence in the delivery of home dialysis services.
Aligning Incentives: Reimbursement policies, regulation of new technologies and other policy incentives can be realigned to better support federal policy goals of expanding access to home dialysis.
The Report includes 15 recommendations to serve these goals, including that federal policymakers should:
Maintain parity for home and in-center dialysis in Medicare reimbursement;
Support home dialysis mentoring programs, particularly those that use existing patients as mentors; and
Align federal and state regulatory requirements for home therapies, such as revising the Centers for Medicare and Medicaid Services Conditions for Coverage requirements, to reflect differences in home and in-center dialysis.
Summit supporters will begin work through the new Alliance to dialogue with federal policymakers and advance policy improvements in the three consensus areas that emerged at the Summit.
SOURCE National Summit on Home Dialysis Policy
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National Kidney Foundation's Top 10 Things Every Dialysis Patient Should Know.
- You have treatment choices. Options exist for how, where and when you dialyze. Dialysis can be done in a hospital, in a dialysis unit that is not part of a hospital, or at home. You and your doctor will decide which place is best, based on your medical condition and your wishes. There are different types of dialysis - peritoneal and hemodialysis. Work with your health care team to determine a treatment plan that makes you feel comfortable. Recent studies show that the majority of patients beginning in-center hemodialysis (HD) know very little, if anything, about the option to dialyze at home. Once informed, 40% or more of patients are interested in this treatment option, and yet less than 10% actually begin home dialysis. If you're dissatisfied with the type of dialysis treatment that you're receiving, ask your healthcare team if another type of dialysis treatment would be better.
- You can compare in-center dialysis facilities online. Information on over 5,600 US-based dialysis centers is available online through the Medicare website. To help you make choices about your care, you can compare different facilities side-by-side and evaluate each facility based upon clinic characteristics and quality measures. You can search for dialysis facilities by name or geographic proximity. After completing an initial facility comparison to determine which facilities best meet your needs - such as the number of hemodialysis stations at a particular location and whether there are evening shifts available - visit the facilities that you're most interested in. Talk to the staff and other patients, as well as your doctor to ensure that this dialysis facility is a good fit for you.
- There are ways to prepare ahead for an emergency. Ask your dialysis facility about their emergency plan in case of a snow storm, fire, power outage or other natural disaster. As back up, make sure you have the names, locations and phone numbers of other dialysis units and hospitals in your area. Since regular community transportation services may not be working in an emergency, be prepared to make other arrangements for getting to dialysis. You may need to contact the police and Emergency Medical Services (EMS) for assistance. If you dialyze at home, make sure you have at least two weeks' worth of unexpired supplies on hand. If you have to miss a dialysis treatment, begin your emergency meal plan.
- There is an easy way to transfer patient records between clinics. There is an easy, secure way for your health care team to transfer your treatment records online. In 2009, the Centers for Medicare and Medicaid Services (CMS) created a centralized web-based data collection system called CROWNWeb to help reduce and eliminate patient treatment interruptions. This central system helps to streamline patient care regardless of the reason for changing dialysis centers. For example, if you've been admitted to the hospital, or if you needed to relocate during an emergency evacuation, your doctors and health care team can access up-to-date information about your dialysis so that you continue to receive appropriate care no matter where you are.
- You can travel while on dialysis.
Dialysis centers are located in every part of the United States and in many foreign countries. The treatment is standardized, but you need to plan ahead by making an appointment for dialysis at another center before you go. The staff at your center may help you make these appointments.
- You can be your own best advocate. Know what key questions to ask your doctor or other healthcare professionals. Take notes so that you can refer back to them later. Partner with your doctor and decide on a treatment plan together. Advocate for yourself and share how you're feeling.
- You have many rights. You as a patient have a great deal of control over your treatments. Patients have a bill of rights which includes receiving quality care, counseling about your medical information, and an expectation of privacy.
You also have responsibilities. Once you decide on a course of treatment, it's important to follow the recommendations of your health care team. If you decide to receive in-center dialysis, arrive at dialysis on time so that you can receive the full treatment without delays.
- You can receive insurance coverage. If you have end stage renal failure, you are likely eligible for Medicare insurance coverage. Speak with your health care team and social worker for help filling out insurance paperwork.
- You may need to follow a special diet. When your kidneys are not working properly, you may not be able to eat everything you like, and you may need to limit how much you drink. Your diet may vary according to the type of dialysis you receive. It is important to speak with a renal dietitian so that you are able to understand what you can and cannot eat based on your full health history.
- Dialysis patients can work. Many dialysis patients can go back to work or school after they have gotten used to dialysis. After establishing a dialysis routine, many patients have more energy and find that they are able to time to work around this new schedule. Some patients even find creative ways to work remotely from dialysis with the use of a laptop or cell phone, depending on their field of expertise.
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New Book to Help Educate Patients with Chronic Kidney Disease who may be facing Dialysis or Hemodialysis: |
Help, I Need Dialysis!
How to have a good future with kidney disease
By Dori Schatell, MS and Dr. John Agar
An internationally known nephrologist and life-long kidney patient educator explain how dialysis works, each of the ways to do it, and how your treatment choice may affect your diet, energy level, work, travel, sexuality and fertility, sleep, and survival. Comprehensive and fully referenced, this book is a must-read if you face the life-changing choices that come with kidney failure. |
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