Looking toward the next 30 years of treating kidney disease


Editor’s note: Nephrology News & Issues is celebrating 30 years of publishing this year. In this series, we are looking to the future. How will treating kidney disease change in the next three decades?

In an industry dedicated to improving the lives of patients with end-stage renal disease, today’s treatments have better clinical outcomes and deliver care for a cost similar to what it was 30 years ago. This is an amazing accomplishment, but the question we have to ask ourselves is: What’s next? Are we positioned to improve the performance, ease of use, safety, and economics of renal care? Are there medical advances in the pipeline that will slow progression of chronic kidney disease? And can we expect radical new technologies to change the way we administer care?

Emerging population, emerging technology

Today there are about five times as many patients with kidney failure receiving treatment as there were when I began my career in renal care almost 30 years ago. Over 460,000 ESRD patients in the United States and 2.6 million ESRD patients worldwide rely on life-sustaining dialysis treatment. As a result, the industry has expanded to support and treat these patients with over 6,100 traditional thrice-weekly dialysis centers in the United States.

Within the U.S., Medicare alone spent almost $31 billion in 2013 in support of ESRD care. The total annual expenditure per patient was estimated at over $83,000. While the industry has made improvements in the standard of care for renal patients over the years, it has taken time to adopt new technological approaches to care that have the potential for better clinical outcomes at a lower overall cost to the health care system. Clearly, cost will affect the future of ESRD care.

I believe that the cost of care will be a significant driver as we move into the future.

One of the biggest opportunities to improve cost efficiency may come from better patient care coordination. Current demonstration projects will provide valuable feedback on how economic incentives and patient-focused networks can improve outcomes while reducing cost. The current model encourages silos of care, which likely leads to higher complication rates and missed opportunities. I believe more integrated care will change how ESRD patients are managed.

I also believe there is a big opportunity to improve the efficiency of care delivery. I believe that the industry needs to focus on transitioning from high labor and overhead sites to lower cost sites of care. Cloud-based information technology can be used to extend the reach of the care team.

Kidney disease will be managed better from the onset.

Experiments with new payment models are beginning to result in new care networks. It’s early, but we’re already seeing an increased focus on pre-ESRD care and education. Better tracking and follow-up have the potential to detect early signs of kidney disease, educate patients about kidney disease, and help them develop care plans earlier in their diease state. Trends like integrated care and total capitation may promote ‘individualized patient care’ where therapy is really customized to meet the patient’s specific clinical and lifestyle needs.

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If we, as an industry, can customize patient care, we can improve outcomes and lower the total cost of care for patients. Better pre-ESRD care to extend the function of kidneys, more patients receiving successful transplants, and improvements in matching therapies to individual patients can improve patient outcomes. Ultimately, this means that patients, their families, and their nephrologists will not only have access to more therapy options but they will also have better awareness of those options so they can make more informed decisions about their care. This could be the pathway to the trifecta: better quality of life, better clinical outcomes, and lower total cost.

Labor costs will influence where and how dialysis is performed.

For over a decade, labor costs associated with dialysis have remained somewhat stable. As labor represents a significant portion of the cost of delivering care, a stable backdrop has allowed dialysis service providers the time and opportunity to aggressively manage and ultimately, optimize their cost structure.

If labor costs go up, however, the cost of in-center dialysis will go up. Providing an option for home treatment represents a path forward that could avoid the impact of increasing labor cost. While it’s impossible to predict the economic and social factors that will drive advancements in renal care, treating at home will likely become more prevalent as economics and technology work together to continuously improve its viability.

In addition, there are situations where the cost of transporting a patient can be higher than providing a caregiver to administer the therapy in the home. As treatment technology becomes easier, safer, and generally more automated, the demands on the caregiver may diminish. This could make it more feasible to bring the therapy to the patient rather than the patient to the therapy, thus eliminating all the disruption and harm that can come from moving the patient.

Telehealth and connectivity will improve patient outcomes and satisfaction.

The cloud revolution has not, to date, had a major impact on ESRD. But, as connectivity becomes universal and people, machines, and clinical data all merge, I believe there is an opportunity to successfully move treatment to lower cost environments and improve patient care. Innovations in connectivity that advance telehealth should also make it much easier for physicians and trained technicians to individualize and manage their patients’ care, wherever patients prefer to perform their treatments.

Read also: An inside look at the UAB home dialysis telemedicine pilot

I imagine technology being used to create very smart systems that can virtualize a dialysis center. We have seen this in other industries that have significantly changed how services are delivered. Advances in technology—from EMRs to more sophisticated sensors, all integrated into intelligent connectivity solutions—will make it easier for the entire health team to track and coordinate care. Doctors will be able to identify and manage problems more quickly, before patients need hospitalization.

Telehealth and smartphones will make it easier to deliver care. Doctors will help dialysis nurses and technicians administer renal care in remote environments.

Technological advances will be based on benefit over burden.

With renal care, we have to look at the benefit versus the burden. Whatever we develop technologically will have to provide a quality of life and health benefit that is extraordinary enough to justify the investment in its creation.

Dialysis has had many years to optimize and refine the delivery model and technology behind it. Changes in the way we deliver therapy will have to be driven by significant benefits in patient comfort, outcomes, or cost efficiency to compete with the current way of doing things. I believe the likely advances will involve less invasive innovations, such as longer nocturnal hemodialysis treatments and more efficient devices that allow patients to treat briefly each day in the location of their choice.

Radical change in approach to care is a few decades away.

The kind of radical developments that excite me are things like transgenetic organs and viable biotechnology alternatives. At some point, we should be in a position to create living tissue that can replace kidney function, but I think it is much further in the future than we would all like or hope.

The cost and performance of these technologies will have to be radically improved to make them viable. However, the technology will get cheaper over time and I expect future generations who suffer from end-stage renal disease will think nothing of having a bio-artificial kidney.

We’re moving forward with a strong foundation.

As we contemplate new changes, it’s important to recognize how far we’ve come since chronic dialysis became a reality in the 1960s. We rarely tout the success of the technology companies, providers, and health care workers who have teamed up to do so much good for patients, using available resources so efficiently.

Thanks to their collective efforts, one of the biggest accomplishments we have made over the last 50 years is making renal care an amazing bargain when compared to other areas of the health care industry. Thanks to all the work done to date, I believe we are perfectly positioned for continued success moving into the future.